Clinical Exercise Pathophysiology For: Physical Therapy

Coglianese
Clinical Exercise Pathophysiology

for Physical Therapy Clinical Exercise
Examination, Testing, and Exercise Prescription Pathophysiology for
Clinical Exercise Pathophysiology for Physical Therapy

Examination, Testing, and Exercise Prescription for Movement-Related Disorders
for Movement-Related Disorders
In order to effectively examine, test, and treat patients with exercise, physical therapists need to understand
Physical Therapy
how physiology from the cellular to the systems level provides the basis for normal responses to exercise,
but that is not enough. Knowledge about pathophysiology, the changes that lead to abnormal responses to
exercise in different patient populations, is also essential.
Clinical Exercise Pathophysiology for Physical Therapy: Examination, Testing, and Exercise Prescription
for Movement-Related Disorders is a comprehensive reference created to answer the “why” and the “how”
to treat patients with exercise by offering both comprehensive information from the research literature as
well as original patient cases.
Dr. Debra Coglianese, along with her contributors, have arranged Clinical Exercise Pathophysiology for
Physical Therapy into three parts: foundations of physiological responses, pathophysiology of deconditioning
and physiology of training, and pathophysiology considerations and clinical practice. The chapters present
the physiology and pathophysiology for defined patient populations consistent with the American Physical
Therapy Association’s Guide to Physical Therapy Practice.
Patient cases also supplement each chapter to illustrate how understanding the content of the chapter
informs physical therapy examination, testing, and treatment. The patient/client management model from
the Guide to Physical Therapy Practice defines the structure of the patient cases, and the International
Classification of Function, Disability, and Health (ICF) model of disablement has been inserted into each
patient case. Highlighted Clinician Comments appear throughout each patient case to point out the critical
Examination, Testing, and Exercise Prescription
thinking considerations.
Instructors in educational settings can visit www.efacultylounge.com for additional materials to be used for
for Movement-Related Disorders
teaching in the classroom.
Clinical Exercise Pathophysiology for Physical Therapy: Examination, Testing, and Exercise Prescription
for Movement-Related Disorders is a groundbreaking reference for the physical therapy student or clinician
looking to understand how physiology and pathophysiology relate to responses to exercise in different
patient populations.
Debra Coglianese SLACK Incorporated

MEDICAL/Allied Health Services/Physical Therapy
Editor
Debra Coglianese, PT, DPT, OCS, ATC

Clinical Specialist
Mercy Rehab & Wellness Center at Havertown
Havertown, Pennsylvania
Mentor for Professional Development and Portfolios
Rehabilitation Services
Mercy Fitzgerald Hospital
Darby, Pennsylvania
www.Healio.com/books
Copyright © 2015 by SLACK Incorporated
Clinical Exercise Pathophysiology for Physical Therapy: Examination, Testing, and Exercise Prescription for
Movement-Related Disorders includes ancillary materials specifically available for faculty use. Included are PowerPoint
Slides. Please visit http://www.efacultylounge.com to obtain access.
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Library of Congress Cataloging-in-Publication Data
Clinical exercise pathophysiology for physical therapy : examination, testing, and exercise prescription for movement-related
disorders / [edited by] Debra Coglianese.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-61711-645-2 (hardback : alk. paper)
I. Coglianese, Debra, - editor.
[DNLM: 1. Exercise--physiology--Case Reports. 2. Physical Therapy Modalities--Case Reports. WB 460]
RM725
615.8’2--dc23
2014011379
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CONTENTS
Contributing Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
About the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Foreword by Cynthia Coffin-Zadai, DPT, MS, FAPTA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xv
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Section I Foundations of Physiological Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 1 Cardiovascular and Pulmonary System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Daniel Malone, PT, PhD, CCS
Chapter 2 Developing Systems: Birth to Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
David Chapman, PT, PhD
Case Study 2-1 (Jill) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58
Joanell A. Bohmert, PT, DPT, MS
Case Study 2-2 (Jack) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78
Kathleen Coultes, PT, PCS
Chapter 3 System Changes in the Aging Adult . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95
Alison L. Squadrito, PT, DPT, GCS, CEEAA
Case Study 3-1 (Ms. Arbor) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .122
Section II Pathophysiology of Deconditioning and Physiology of Training . . . . . . . . . . . . 135

Chapter 4 Fatigue and Deconditioning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137
LeeAnne Carrothers, PT, PhD
Case Study 4-1 (Mr. Biscotti) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155
Kerri Lang, PT, DPT
Chapter 5 Principles of Training and Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Skye Donovan, PT, PhD, OCS and LeeAnne Carrothers, PT, PhD
Case Study 5-1 (Mr. Cedar) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .188
Lola Sicard Rosenbaum, PT, DPT, MHS
Case Study 5-2 (Ms. Caster) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .197
Mary Jane Myslinski, PT, EdD
Section III Pathophysiological Considerations and Clinical Practice . . . . . . . . . . . . . . . . . . 209

Chapter 6 Individuals With Cardiovascular Pump Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Daniel Malone, PT, PhD, CCS and Scot Irwin, PT, DPT, CCS
Case Study 6-1 (Ms. Damask) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .236
Scot Irwin, PT, DPT, CCS
Chapter 7 Individuals With Peripheral Vascular Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .247
Cheryl L. Brunelle, PT, MS, CCS, CLT
Case Study 7-1 (Mr. Eagle) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .271
Cheryl L. Brunelle, PT, MS, CCS, CLT; Paul D. Gaspar, PT, DPT, CCS; and
Robert M. Snow, PT, DPT, OCS, ATC
Chapter 8 Individuals With Ventilatory Pump Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .283
Jane L. Wetzel, PT, PhD
Case Study 8-1 (Mr. Fortnight) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
vi Contents
Chapter 9 Individuals With Gas-Exchange Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .337
Jane L. Wetzel, PT, PhD and Brian D. Roy, PT, DPT, MS, CCS
Case Study 9-1 (Ms. Garden) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .373
Brian D. Roy, PT, DPT, MS, CCS
Chapter 10 Individuals With Localized Musculoskeletal and Connective Tissue Disorders . . . . . . . . . . . . . . . . . . . . . . . .385
Case Study 10-1 (Mr. Halo) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .432
Chapter 11 Individuals With Systemic Musculoskeletal and Connective Tissue Disorders . . . . . . . . . . . . . . . . . . . . . . . . .443
Susan L. Edmond, PT, DSc, OCS
Case Study 11-1 (Ms. Icon) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .455
Chapter 12 Individuals With Motor Control and Motor Function Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .465
Lisa Brown, PT, DPT, NCS
Case Study 12-1 (Mr. Julep) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .497
Laura Klassen, DipPT, BPT, MSc
Case Study 12-2 (Mrs. Jelly) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
Vanina Dal Bello-Haas, PT, PhD
Chapter 13 Individuals With Multi-System Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .533
Melanie A. Gillar, PT, DPT, MA
Case Study 13-1 (Dr. Lacrosse) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .553
Case Study 13-2 (Ms. Ledger) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .562
Melanie A. Gillar, PT, DPT, MA and Nancy Gage, PT, DPT
Financial Disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .575
Clinical Exercise Pathophysiology for Physical Therapy: Examination, Testing, and Exercise Prescription for
Movement-Related Disorders includes ancillary materials specifically available for faculty use. Included are PowerPoint
Slides. Please visit http://www.efacultylounge.com to obtain access.
CONTRIBUTING AUTHORS
Joanell A. Bohmert, PT, DPT, MS (Case Study 2-1) Skye Donovan, PT, PhD, OCS (Chapter 5)
Physical Therapist Associate Professor
Anoka-Hennepin Independent School District No. 11 Department of Physical Therapy
Anoka, Minnesota Marymount University
Arlington, Virginia
Lisa Brown, PT, DPT, NCS (Chapter 12)
Clinical Assistant Professor Susan L. Edmond, PT, DSc, OCS (Chapter 11, Case Study 11-1)
Boston University Professor
Sargent College of Health and Rehabilitation Science School of Health Related Professions
Boston, Massachusetts Department of Movement Sciences
Rutgers, The State University of New Jersey
Cheryl L. Brunelle, PT, MS, CCS, CLT (Chapter 7, Case Study Newark, New Jersey
7-1)
Clinical Specialist, Physical Therapy Services Nancy Gage, PT, DPT (Case Study 13-2)
Massachusetts General Hospital Director Rehabilitation Services
Boston, Massachusetts Beth Israel Deaconess Hospital-Plymouth
Plymouth, Massachusetts
LeeAnne Carrothers, PT, PhD (Chapter 4, Chapter 5)
Program Director, Physical Therapist Assistant Program Paul D. Gaspar, PT, DPT, CCS (Case Study 7-1)
Term Assistant Professor Founder/President
University of Alaska Anchorage Gaspar Doctors of Physical Therapy, APC
Anchorage, Alaska Carlsbad, California
David Chapman, PT, PhD (Chapter 2) Melanie A. Gillar, PT, DPT, MA (Chapter 13, Case Study 13-1,
Associate Professor Case Study 13-2)
Physical Therapy Program Owner/President
St. Catherine University Gillar Physical Therapy
Minneapolis, Minnesota New York, New York
Debra Coglianese, PT, DPT, OCS, ATC (Chapter 10, Case Scot Irwin, PT, DPT, CCS (Chapter 6, Case Study 6-1)
Study 10-1) Deceased
Clinical Specialist
Mercy Rehab & Wellness Center at Havertown Laura Klassen, DipPT, BPT, MSc (Case Study 12-1)
Havertown, Pennsylvania Clinical Associate
Mentor for Professional Development and Portfolios Bourassa & Associates Rehabilitation Centre
Rehabilitation Services Adjunct Professor
Mercy Fitzgerald Hospital School of Physical Therapy
Darby, Pennsylvania University of Saskatchewan
Saskatoon, Saskatchewan, Canada
Kathleen Coultes, PT, PCS (Case Study 2-2)
Pediatric Clinical Specialist Kerri Lang, PT, DPT (Case Study 4-1)
Rehabilitation Services Physical Therapist
Mercy Fitzgerald Hospital Advantage Sports Medicine
Darby, Pennsylvania Stoneham, Massachusetts
Vanina Dal Bello-Haas, PT, PhD (Case Study 12-2) Daniel Malone, PT, PhD, CCS (Chapter 1, Chapter 6)
Associate Professor Assistant Professor
Assistant Dean, Physiotherapy Program Physical Therapy Program
School of Rehabilitation Science Department of Physical Medicine and Rehabilitation
McMaster University University of Colorado Denver
Hamilton, Ontario, Canada Aurora, Colorado
viii Contributing Authors
Mary Jane Myslinski, PT, EdD (Case Study 5-2) Robert M. Snow, PT, DPT, OCS, ATC (Case Study 7-1)
Associate Professor CEO
Doctoral Program in Physical Therapy Gaspar Doctors of Physical Therapy, APC
School of Health Related Professions Carlsbad, California
Rutgers, The State University of New Jersey
Newark, New Jersey Alison L. Squadrito, PT, DPT, GCS, CEEAA (Chapter 3,
Case Study 3-1)
Lola Sicard Rosenbaum, PT, DPT, MHS (Case Study 5-1) Clinical Specialist
Physical Therapist Physical Therapy Services
Cantrell Center for Physical Therapy Massachusetts General Hospital
Warner Robins, Georgia Boston, Massachusetts
Brian D. Roy, PT, DPT, MS, CCS (Chapter 9, Case Study 9-1) Jane L. Wetzel, PT, PhD (Chapter 8, Case Study 8-1,
Cardiovascular and Pulmonary Clinical Specialist Chapter 9)
Acute Therapies Associate Professor
University of Vermont Medical Center Department of Physical Therapy
Adjunct Faculty College of Health and Human Services
The University of Vermont Youngstown State University
Burlington, Vermont Youngstown, Ohio
ABOUT THE EDITOR
Debra Coglianese, PT, DPT, OCS, ATC is a clinical specialist with the Mercy Health System, with over three decades’
experience. She holds her Doctor of Physical Therapy from the MGH Institute of Health Professions and her MS in physi-
cal therapy from the University of Southern California. After initially practicing in a thoracic surgery ICU, Dr. Coglianese
focused on treating musculoskeletal patients in outpatient settings and is specialty board certified in orthopedics. She has
lectured nationally, taught for four years as a section leader for the Comprehensive Case course for entry-level DPT students at
MGH Institute of Health Professions, and frequently supervised students in clinical training. Prior to her current practice in
Pennsylvania, she practiced with the University of Michigan Health System, Massachusetts General Hospital, and Beth Israel
Deaconess Medical Center. Still earlier, she served as a physical therapist assistant at the Idaho State School and Hospital and
then as an athletic trainer at the College of Idaho. Dr. Coglianese has previously been published in the Journal of Orthopaedic
& Sports Physical Therapy and as a regular abstractor and book reviewer for the Journal of Physical Therapy. She continues
to be certified as an athletic trainer.
DEDICATION
For teachers and mentors who lit the way,

colleagues with whom we share the path,
and future physical therapists yet to begin the journey.
FOREWORD
Dr. Scot Irwin, PT, DPT, CCS had a unique perspective on the practice of physical therapy (PT). While most PT prac-
titioners consider the multiple facets of human movement response to pathology from a biomechanical or motor function
perspective, Scot consistently focused on the scientific principles of oxygen uptake and delivery as crucial factors in human
performance. This perspective, possibly borne of an undergraduate degree in exercise physiology followed by two graduate
degrees in PT, led him into a relatively new practice area in the mid-1970s—cardiac rehabilitation.
During the 1960s and early 1970s, conventional wisdom in medical practice managed an individual’s post-cardiac event
with rest to preserve the injured myocardial tissue from experiencing further damage. Exercise in a general form was discour-
aged, and prescribed exercise for these “at risk” patients was not yet recognized as a therapeutic intervention. The recognition
and physiologic description of deconditioning, or the “deleterious effects of bed rest” on normal individuals, had only begun
to evolve in the late 1960s,1 so the application of these concepts to patient populations was not yet common.
It was into this evolving intersection of basic science knowledge and clinical practice protocols that Scot began developing
his career as a “cardiopulmonary physical therapist.” He joined several PT colleagues to form Specialized Cardiac Outpatient
Rehabilitation (SCOR), a PT practice focused on diagnostic exercise testing and training of individuals with history and risk
of coronary artery disease (CAD). They were at the forefront of the cardiac rehabilitation trend, and by the late 1970s, they
had collected substantial population data. Scot and his partners presented and published their findings on the safety and effi-
cacy of exercise testing and training patients with CAD at their angina threshold—a whole new way of managing patients by
documenting their pathophysiologic response to activity, identifying abnormalities, and then using the information to safely
prescribe exercise for effective rehabilitation.2
Scot and his colleagues were not simply advancing clinical practice and disseminating their work through publication,
they were teaching these cutting-edge concepts in academic and continuing education settings nationally. Their fundamental
message relied heavily on the background science of exercise physiology, the human movement science database from PT,
and descriptive and experimental research in the current literature. As a result, the suggested reading list for the courses
they taught required the participants to either purchase multiple textbooks, spend days in a medical library, or both. To
remedy that inefficient situation, Scot partnered with another colleague to develop the first and definitive text on the physi-
cal therapist’s management of individuals with cardiovascular and pulmonary disorders. Cardiopulmonary Physical Therapy
by Irwin and Tecklin was first published in 1985, and in its fourth edition,3 it remains one of the most comprehensive and
well-referenced texts on the subject.
As practical a clinical reference as that text has been, it addressed only “half of the problem” from Scot’s perspective.
Despite his seemingly narrow cardiopulmonary clinical practice specialty, Scot’s very early practice experiences with broad
rehabilitation populations, including those with amputation, spinal cord injury, or other neuromusculoskeletal disorders,
produced a clinician who always addressed the entire patient. His physiologic mindset and physical therapist’s clinical per-
spective on functional human movement combined to produce patient evaluations that considered both the cellular and
systemic aspects of human movement as carefully as the functional or task performance. The diagnostic exercise testing Scot
performed was intended to measure the oxygen cost of an activity such as ambulation simultaneously with the gait abnor-
mality. Similarly, biomechanical analysis of workload could be measured with the physiologic cost of movement. From his
vantage point, accurate evaluation of human movement to diagnose limitations required assessment of performance elements
from the cellular to the person level.4
Scot fundamentally believed that a broad pathophysiologic perspective is truly essential for all professionals managing
humans and their desire to move. He recognized there was a large gap between the science of exercise in normal human
movement and the science of exercise associated with prevention or remediation of human movement abnormalities. In the
mid-1990s, Scot set out to rectify that gap by locating clinical scientists who practiced PT by considering the cellular through
systemic physiologic principles governing human motion. The clinicians, researchers, and academicians he approached
spanned the spectrum of neurologic, orthopedic, cardiovascular-pulmonary, pediatric, and geriatric specialties. He chal-
lenged them to reflect on the scientific basis of their practice and attempt to describe the primary texts that served as their
reference points. Individually and collectively, they could easily cite anatomic and physiologic references for the normal
resting state or exercise physiology references for the same. Similarly, all could name favorite general or focused pathology
texts. None could cite a single exercise text focusing on the pathophysiologic response to increased workload across systems.
As a result, Scot set out to remediate the situation by creating a text for that “missing link” in the exercise science scope.
Preliminary research demonstrated that the essential science existed and was being well-used by PT practitioners who
accessed it one article at a time, mostly focusing on their clinical specialty. However, there was no summary compilation of
the information to be accessed by PT practitioners and students alike. Additionally, there were other health practitioners who
could similarly benefit from understanding the demarcation between normal and abnormal response to increased oxygen
demand or workload across systems.
xiv Foreword
This book was subsequently started as a project more than a decade ago. Its production was stalled by Scot’s early and
untimely death mid-production. However, the information that has been assembled here is a testament to the importance of
the work. Many of these authors are members of the originally assembled group, and they have persevered to fulfill promises
made as the need for the dissemination of this information has not diminished. Some of the newer authors were taught by
Scot and have become knowledgeable, authoritatively informed, professional resources in their own right. They too believe in
the value of this assembled evidence. Collectively, we remain grateful for the vision and leadership Dr. Scot Irwin, PT, DPT,
CCS demonstrated over the full trajectory of his career. I believe this work honors his memory and fulfills his expectation.
References
1. Saltin B, Blomqvist G, Mitchell JH, Johnson RL Jr, Wildenthal K, Chapman CB. Response to exercise after bed rest and after training.
Circulation. 1968;38(5 Suppl):1-78.
2. Blessey R, et al. Therapeutic effects and safety of exercising coronary patients at their angina threshold. Med Sci Sports Exer. 1979;11:110
(abstract).
3. Irwin S, Tecklin J. Cardiopulmonary Physical Therapy. 4th ed. St Louis, MO: Mosby; 2004.
4. Hislop HJ. Tenth Mary McMillan lecture. The not-so impossible dream. Phys Ther. 1975;55(10):1069-1080.
Cynthia Coffin-Zadai, DPT, MS, FAPTA

Professor Emerita
MGH Institute of Health Professions Charlestown Navy Yard
Boston, Massachusetts
PREFACE
To effectively examine, test, and treat patients with exercise, physical therapists need to understand how physiology from
the cellular to systems level provides the basis for normal responses to exercise. But that is not enough. Knowledge about
pathophysiology—the changes that lead to abnormal responses to exercise in different patient populations—is also essential.
Other texts cover normal exercise physiology well. Information about abnormal responses to exercise, however, has to be
gathered from a variety of sources for different patient populations. Examination and testing information can be found in
articles and texts for some specific patient populations, but for not all. In addition, a smattering of case studies can be found
in the literature. Until now, though, no text has compiled all of this information together for physical therapists.
Clinical Exercise Pathophysiology for Physical Therapy: Examination, Testing and Exercise Prescription for Movement-
Related Disorders shows why, and offers examples of how, to treat patients with exercise, offering comprehensive information
from the research literature as well as original patient cases. Its coverage is broad, ranging from a cellular metabolism review
to the discharge summary—with all of the connections in between.
To ensure that this exceptional sweep of information would not overwhelm the reader, the talented authors contributing
to this book have created chapters that follow a consistent format. That alone is a remarkable feat for a text with different
contributors. Further, the authors have distilled and refined the content for clarity to further assist the reader.
This book’s chapters are arranged into 3 distinct sections: Foundations of Physiological Responses; Pathophysiology of
Deconditioning and Physiology of Training; and Pathophysiological Considerations and Clinical Practice.
In Section I, the first chapter, “Cardiovascular and Pulmonary System,” begins with a review of cellular metabolic path-
ways as the basis for why a delivery system in the form of the cardiovascular and pulmonary system even exists. The chapter
presents the structure and physiology for each component of this essential system. The chapter then discusses the normal
physiological responses of the components to show how the system responds as a whole during an exercise session. The next
2 chapters in Section 1 show the normal physiology in developing and aging systems, respectively. These 2 chapters have been
placed early in this text rather than toward the end because it is not a pathology to be young or old. Along with presenting
the normal physiology associated with development and aging, however, these chapters do identify the pathophysiology that
can occur simultaneously with each phase of life.
Section II of this book provides chapters exploring the changes that occur from decreased, and then increased, physiologi-
cal demands. A clarification needs to be made at the outset about the dual routes to a deconditioned status. Is it decondition-
ing when a high-performance athlete follows a much lighter-than-usual workout for several weeks, or is deconditioning
what occurs when a person who has been functioning adequately with daily activities experiences a drop in activity level?
Chapter 4, entitled “Fatigue and Deconditioning,” offers the true physiologic definition of a deconditioned status that applies
to both situations. In the groundbreaking collection of information that makes up that chapter, however, the emphasis is on
the latter scenario. Chapter 5, “Principles of Training and Exercise Prescription,” summarizes the training information many
readers will recognize from previous exposure to exercise physiology content. Here again, though, the focus of the chapter is
to highlight the principles for patient—not athlete—applications.
In Section III of this book, the chapters present the physiology and pathophysiology for defined patient populations con-
sistent with the American Physical Therapy Association (APTA) Guide to Physical Therapy Practice. For clarity, the chapters
in Section 3 follow a consistent organizational structure. Each chapter begins with a presentation of the basic physiology
principles appropriate for the systems involved. This information then serves as the foundation to link to the pathophysiol-
ogy that occurs in the defined patient population. The pathophysiology content then spans the components to be included,
or considered, in therapists’ examination, testing, evaluation, and treatment of these patients. It is worth repeating that these
chapters have the same structure: basic physiology, pathophysiology, and the impact on clinical practice.
The order of chapter topics reflects, as does this text as a whole, a view of patients through a cardiovascular and pulmonary
system lens. As such, chapters on cardiovascular and pump dysfunctions, peripheral vascular disorders, ventilatory pump
dysfunctions, and gas exchange disorders appear first in Section 3. Next, the musculoskeletal system is introduced with
chapters on localized, and then systemic, musculoskeletal disorders. Similarly, the neuromuscular system is introduced and
associated disorders presented in the next chapter. The text concludes with a chapter that considers multi-system disorders.
Throughout this book, all of the chapters except the first are followed by at least one patient case. The cases serve to illus-
trate how understanding the content in each chapter informs physical therapy examination, testing, and treatment. Just as the
chapters follow a consistent structure, so do the patient cases. The patient/client management model from the Guide defines
the structure. Three exciting upgrades from the Guide enhance the cases in this book.
First, the Guide recommends a list of pathology, impairments, functional limitations, and disability in the diagnosis por-
tion of the evaluation. Although there are plans to upgrade the Guide language to be consistent with that identified in the
International Classification of Function, Disability and Health (ICF), the APTA had yet to make this upgrade at the time
this book was submitted for publication. To better reflect the profession’s acceptance of ICF language, and prepare physical
xvi Preface
therapists for anticipated changes in the Guide, the ICF model of disablement has been inserted into the patient case presen-
tations in this text.
Second, special attention has been paid in the patient cases to the writing of the exercise prescriptions. The Guide does
mention that physical therapists prescribe exercise as a therapeutic intervention. The APTA has more recently highlighted
exercise and physical activity prescription as a component of the tasks physical therapists perform as the health service
delivery providers of choice. The patient cases in this book, therefore, model taking exercise prescription to a higher level.
Any exercise recommended in a patient case here is accompanied by an exercise prescription that contains a specified mode,
intensity, duration, and frequency, along with a description of the intervention.
Finally, the third innovative upgrade distinguishes the patient cases in this book and enhances their educational value. A
defined format for writing a case report exists that renders the case suitable for publication, or poster presentation, but might
not be the best form for teaching. For one thing, when students are asked to write cases about “average” patients encountered
in clinical affiliations, the defined format for the journal and posters focuses on novel cases. For another, this format, or one
that presents bulleted facts following the Guide structure, does not allow an “in the moment” identification of the critical
thinking involved during a patient encounter. It can be useful to know more about what a patient’s therapist is thinking,
moment by moment. We think these limitations have now been solved with the introduction here of a “Clinician Comments”
feature that emphasizes critical thinking and moves beyond the “just the facts” structure of case presentations.
Highlighted “Clinician Comments” appear throughout each patient case in this book to point out the critical thinking
considerations. The reporting of information from the patient case is periodically interspersed with “Clinician Comments”
that allow the case author to step outside the traditional narration of the case, so to speak, to summarize what is now known
about the patient or what additional information needs to be gathered or clarified. The evidence to support the interpreta-
tion of the case facts also appears in these comments, as well as the decisions being made by the physical therapist as the case
unfolds. Once the critical thinking required for this portion of the case is completed, the highlighted “Clinician Comments”
section ends and the case reporting resumes. Various “Clinician Comments” are inserted into the cases to explain the deci-
sion making about matters such as the selection of the tests and measures to be used, the practice pattern chosen, and the
mode of exercise selected, to list a few examples. Further, “Clinician Comments” are included to bring forward chapter con-
tent to aid in patient management.
Clinical Exercise Pathophysiology for Physical Therapy will be an effective resource tool for physical therapists at many
levels. Entry-level Doctor of Physical Therapy (DPT) students will be well-guided by the scope and depth of content in this
book when used as the primary text for a clinical exercise pathophysiology course. Advanced master’s students will find the
extensive pathophysiology content to be an exemplary supplement to any clinical research inquiry.
The extensive patient cases illustrate not only the application of physiological and pathophysiological principles for patient
management, but the critical thinking employed as well. The information in the cases will inform future clinical practice for
students at all levels. In addition, entry-level and transitional DPT students will find the format used for patient cases to be
an invaluable model as they prepare their own patient cases in comprehensive case classes.
Constant retooling is required to maintain competency in physical therapy. Knowledge of the various physical therapy
practice areas can only enhance the skills of the experienced and well-rounded practitioner. For this reason, all physical
therapists who desire a single reference to update their knowledge base will find this text useful. The content provides a clear
delineation of the physiology, pathophysiology, and research evidence that supports therapeutic exercise intervention across
the scope of physical therapy practice.

ACKNOWLEDGMENTS
When much is owed to the contributions of many, it can be difficult to know where to start. Let me begin with the talented
chapter and case authors whose work built this text. I cannot possibly express adequate gratitude for the countless hours and
expertise each put into their respective chapters and cases. Although their previous experience with published writing varied,
all approached the writing assignments with fresh eyes and infectious enthusiasm. We needed that spirit to keep up resolve
when the exhausting “breaking trail” nature of the writing proved daunting at times.
Some of the authors have been with this project from the beginning. That meant that they accepted the assignment of
periodic rewriting of their work to provide updated evidence and references as the project spread out over years. As challeng-
ing as it can be to write a chapter or case the first time, the task of rewriting can seem a punishment for being prompt with
the first deadline. Other authors, brought on board late in the project, delivered on short writing deadlines so that the entire
project would not have to be subjected to another updating. Heroes, all.
It was not just the incredible expertise that the authors brought to their work. They were, to a person, a pleasure to work
with. Countless times I benefited from individual and collective goodwill. No group could have been more supportive. I
will always be grateful for the experience of working with them. It has been a privilege to promote their work to successful
publication.
Initially, I was asked to join this project to provide support to a few authors working to finish chapters. Cyndi Coffin-Zadai
appealed to my regard for Scot Irwin to help her complete the project he had started. It was not a tough sell. She did not know
it at the time, but, to paraphrase the line from the movie, Jerry Maguire, the project “had me” at the idea of incorporating
“Clinician Comments” into the book’s patient cases.
After taking a comprehensive case course in the transitional Doctor of Physical Therapy (DPT) program at the MGH
Institute of Health Professions (IHP) and serving as adjunct faculty for 4 years in the same course for entry-level DPT stu-
dents, I knew that patient cases were my interest. Specifically, I had hoped to identify the process of writing a case in a manner
that would be accessible for all physical therapists who wanted to write one. I tabled my how-to book idea to help with this
project and, in the process, gained an insight into case writing that I might not have discovered on my own. Cyndi’s brilliant
creation of the “Clinician Comments” tool was key to the effective educational form the cases have taken in this book. Once
again, the profession owes her much appreciation for coming up with a solution to a perplexing situation. I am grateful to her
for the opportunity to be involved with this project. I am appreciative of her confidence in me to ultimately carry on as the
editor when the demand for her extensive professional skills spread her time too thinly to allow her to continue.
There will be those who may question a text that views patients from a cardiovascular and pulmonary perspective being
edited by a physical therapist with a predominant expertise in orthopedics. It is a reasonable question and one I have con-
sidered also. However, as I look back over my career thus far, the influence of cardiovascular and pulmonary concerns for
patients has always appeared as a broadening correction to my focus in rehabilitation of athletes and patients with musculo-
skeletal disorders.
During the first year as a physical therapy assistant student, a serendipitous opportunity led me to Bob Moore and the
training room at San Diego State University. Once we had the athletes ready for practice and out of the training room in the
late afternoon, I was equally curious about the participants in the cardiac rehab group who gathered in the area outside the
training room. During my second year, John Iames arranged a class field trip to Rancho Los Amigos. There I was oriented to,
and then observed, cardiac stress testing by Scot Irwin and cardiac rehab by Ray Blessey. While providing athletic training
services at a youth John Wooden Basketball Camp, I spent a week of mornings talking with Coach Wooden during the time
he cooled down from his own cardiac rehab walking program. Events such as these leave an impression.
Even with subsequent moves to other parts of the country, the trend of pursuing musculoskeletal rehabilitation with an
awareness of cardiovascular/pulmonary concerns continued to be reinforced by the professionals from whom I had the good
fortune to learn. My practice in Idaho as a physical therapist assistant and then athletic trainer benefited from the knowledge
I gained from Sheri Robison, Ron Pfeiffer, Ross Vaughn, and Bob Murray. As an entry-level master’s physical therapy student
at the University of Southern California, exposure to the wisdom of Joan Walker, Ray Blessey, and Cyndi Coffin-Zadai was
invaluable. In Michigan, as a member of the chest team in my first year of practice as a physical therapist, I was fortunate to
learn from Peg Clough, and later from Steve Goldstein, Jim Goulet, and Pete Loubert.
A move to Massachusetts provided the truly amazing opportunity to work with the extraordinarily talented physical
therapists at Massachusetts General Hospital, Beth Israel Deaconess Medical Center, and Mount Auburn Hospital. Do you
think a physical therapist would be allowed to ignore cardiovascular and pulmonary considerations in orthopedic patients
when working in a department headed by Cyndi Coffin-Zadai? Of course not.
I am grateful to have had the opportunity to meet and learn from the gifted clinicians, teachers, and researchers named
above. To the countless others, including patients, who have influenced my patient care, I give thanks.
This project benefited from the generous assistance of many. Ellen Abramowitz, the medical librarian at Mercy Fitzgerald
Hospital, was an incredible resource herself in tracking down elusive references. Megan Fennell provided much development
xviii Acknowledgments
expertise to the manuscript. I am grateful to Mike Johnson for stepping in to make an introduction for me when it became
clear that Dan Malone held the solution for the first chapter. I owe Dan Malone more pies than I could possibly provide. Not
only did Dan contribute a wonderful chapter and update a second one, he also provided invaluable advice at various points
in the manuscript construction. Dan, in turn, made an introduction for me to Brien Cummings, the Acquisitions Editor at
SLACK Incorporated.
I appreciate Brien for his wonderful encouragement when he was first shown this manuscript. He deftly steered the project
through all the required steps for approval. His unfailing optimism is a gift to all who have the opportunity to work with him.
Thank you, Brien, for all you did to ensure that our manuscript would become a book we can hold in our hands.
Many thanks as well to the members of the SLACK team whose dynamic work launched the project to new heights. Brien
and his assistant, Katherine Rola, each stepped outside their usual job duties and offered assistance with the permission pro-
cess. John Bond, Chief Content Officer at SLACK, championed our project and adjusted the budget to allow the project to
move forward. Special thanks to April Billick, the Managing Editor, for lining up such great talent for the book’s production.
The artists at SLACK induced smiles all around the country when the authors saw the masterful cover design for the first
time. An equally beautiful interior design by Jean-Marc Yee will greet and guide readers. The new illustrations will further
enhance the readers’ experience. Also, April found us Dani Malady, Senior Project Editor. Working with Dani has been a joy.
She managed us more gently than one would expect for a project this size. Thank you, Dani, for your diligent attention to
detail—the book is better for it.
I am grateful to the continued team effort for the published book. Tony Schiavo competently stepped in to fill big
shoes when Brien Cummings accepted broader duties at SLACK. The book is in good hands with Michelle Gatt, SLACK
Incorporated’s Marketing Communications Director; Trevor Hirsh for the marketing campaign; and Jim Clark, who will
promote the book in his duties as SLACK’s sales representative for physical therapy.
Cyndi gave me Laurie Hack’s contact information when I moved from Boston to Pennsylvania. Little did I know that
Laurie, my first physical therapy contact in Pennsylvania, would be such an amazing source of wisdom and lovely friendship.
My colleagues in Havertown, Pennsylvania—Linda Price, Nathalie Wilson, and Janet Buckley—were so nice to me during this
project. No colleagues have had to witness more editorial hand-wringing than them, yet they consistently provided encourag-
ing responses in return. There is not enough chocolate in the world to repay them for their kindness.
With the ease of social media, I am fairly certain that my children, on more than one occasion, sent text warnings to each
other such as, “Unless you want an earful, don’t ask Mom about the book.” I would like to thank Patrick, John, and Anne—
and now my lovely daughter-in-law, Erin—for their patience when birthdays, holidays, and general home life seemed to be
given a backseat constantly to this project—not to mention all the space taken up at home with piles.
To my amazing husband, Cary Coglianese, I owe much. From my time studying in physical therapy school to the extra
hours I continue to need to complete documentation at work, he has been wonderfully supportive of my career. Countless
times during this project, I benefited from Cary’s well-informed advice. I am especially appreciative that he understood my
desire to see the authors’ work published despite the never-ending quest it seemed at times. Through it all, he bore every bit
of angst to which he was exposed with good cheer. Thank you.
DC
2014
SECTION I
FOUNDATIONS OF
PHYSIOLOGICAL RESPONSES
Cardiovascular and Pulmonary System
1
Daniel Malone, PT, PhD, CCS
▪ Cardiac Component
CHAPTER OBJECTIVES ▫ Cardiac Pump
• Identify the central and peripheral cardiovascular ▫ Cardiac Muscle
responses that occur during an acute exercise session. ▫ Generation of Heart Rate: The Cardiac
• Identify the pulmonary responses during an acute exer- Conduction System
cise session and relate these responses to the homeostasis ▫ Neurohumoral Control: Autonomic
of oxygen (O2) and carbon dioxide (CO2) concentrations Innervation of the Heart
within the blood.
▫ The Cardiac Cycle
• Discuss the interrelationships between the cardiac, vas-
▫ Common Cardiac Reflexes
cular and pulmonary systems as it relates to human
movement and exercise training. - Frank-Starling Mechanism
• List abnormal exercise responses using the concepts of - Bainbridge Reflex
normal exercise physiology as a guideline to prevent - Baroreceptor Reflex
untoward patient responses during a physical therapy
- Force-Frequency Relationship (Bowditch
session.
Effect)
▪ Vasculature Component
CHAPTER OUTLINE ▫ Structure and Network
▫ Neurohumoral Control of Blood Flow
• Mortality and Survivorship ▫ Blood Flow
• Interdependence of Systems ▫ Blood Pressure
• Cellular Metabolism ◦ Pulmonary Component
◦ Adenosine Triphosphate ▪ Overview
▪ Resynthesis of Adenosine Triphosphate ▪ Ventilatory Pump
◦ Cellular Respiration ▫ Structure
◦ One-Celled to Multi-Celled Organisms: ▫ Properties
Development of Transport Systems
▫ Ventilation
• Cardiovascular and Pulmonary Systems
▫ Control of Ventilation
◦ Overview
▫ Ventilation Volumes and Flow
◦ The Cardiovascular System
▪ Overview
Coglianese D, ed. Clinical Exercise Pathophysiology for

Physical Therapy: Examination, Testing, and Exercise
Prescription for Movement-Related Disorders (pp 3-26).
-3- © 2015 SLACK Incorporated.
4 Chapter 1
▪ Gas Exchange
▫ Perfusion
- Blood Flow to Lungs
- Properties of Perfusion
- Ventilation to Perfusion Ratio
▫ Properties of Gas Exchange, Including Surface
Area
▫ Gas Partial Pressures
◦ Blood
▪ Oxygen in Blood/Oxygen Delivery
▪ Hemoglobin Saturation Curve
• Exercise Physiology: Tying It All Together
◦ Overview
◦ Maximal Oxygen Consumption and Metabolic
Equivalents Figure 1-1. Relative risks of death from any cause among subjects
with various risk factors who achieved an exercise capacity of less than
◦ Energy Utilization
5 metabolic equivalents (MET) or 5 to 8 MET, as compared with subjects
◦ Normal Response to Increasing Loads whose exercise capacity was more than 8 MET. Numbers in parentheses
are 95% confidence intervals for the relative risks. BMI, body mass index.
▪ The Cardiovascular Responses (Reprinted with permission from Myers J, Prakash M, Froelicher V, Do D,
Partington S, Atwood JE. Exercise capacity and mortality among men
▫ Cardiac Output and Stroke Volume
referred for exercise testing. N Engl J Med. 2002;346(11):793-801.)
▫ Heart Rate
▫ Blood Pressure
The patient’s case history may appear straightforward
▪ Pulmonary Responses initially. She will primarily be viewed as an orthopedic
▫ Overview patient, but the subjective comments add complexity and
question this treatment approach. The physical therapist
▫ Minute Ventilation (Respiratory Rate × Tidal
(PT) starts the examination process not knowing where the
Volume
patient sits on a continuum of activity tolerance. Knowing
▫ Gas Exchange the fundamentals of normal exercise physiology will allow
• Summary the PT to compare and contrast this patient’s physiologic and
symptomatic responses to the normal or expected responses.
• References
Through the examination and evaluation process, the PT
must determine the potential causes of the patient’s limited
Mrs. Mason is a 73-year-old female who was referred to exercise capacity in order to design the most efficacious and
outpatient physical therapy for evaluation and treatment safe treatment plan as well as determine the patient’s prog-
of a left-sided pelvic fracture sustained 10 weeks prior nosis for attaining anticipated goals and expected outcomes.
when she fell in her doctor’s waiting room. She reported
pain in her left groin, left buttock, and anterior left thigh
with standing transfers and stair climbing. Her chief com-
plaint is that it takes her twice as long to bathe and dress
MORTALITY AND SURVIVORSHIP
herself because she gets severely short of breath. Her past
medical history is significant for pulmonary sarcoidosis, A common physical therapy goal is to improve the patient’s
myocardial infarction, hypertension, osteopenia, and a activity tolerance, and this is most often accomplished by
significant leg length difference. exercise training. Research has shown that physical activity is
associated with a marked decrease in cardiovascular and all-
Is she a candidate for physical therapy? If so, how do
cause mortality in men and women.1-3 Physically fit patients
we identify which of the possible underlying pathologies is
have excellent prognoses even if they have significant heart
affecting her breathing, thus her functional status, most?
disease, risk factors for heart disease, and other comorbid
Is there evidence in the literature to support exercise
conditions (Figure 1-1).4-7 Additionally, improvements in
training for this patient? Are there long-term benefits if
exercise capacity, even modest advances in physical fitness,
she begins an exercise program? Should she be referred to
are associated with a significantly lowered risk of death.3,8 It
another health care practitioner before initiating physical
is imperative, therefore, that an attempt be made to improve
therapy?
the exercise tolerance of patients.
Cardiovascular and Pulmonary System 5
Figure 1-2. The gas transport mechanisms coupling cellular (internal) Figure 1-3. Direction of net solute flux crossing a membrane by diffusion
respiration of muscle to pulmonary (external) respiration by way of the (high to low concentration) and active transport (low to high concentra-
cardiovascular system. The movement system relies on each of these tion with energy expenditure). (Reprinted with permission from Vander A,
linked systems during activities of daily living and exercise. (Reprinted Sherman J, Luciano D. Human Physiology: The Mechanism of Body Function.
with permission from Wasserman K, Hansen JE, Sue DY, et al. Principles 7th ed. New York, NY: McGraw-Hill; 1999:118. Copyright The McGraw-Hill
of Exercise Testing and Interpretation. 3rd ed. Philadelphia, PA: Lippincott Companies, Inc.)
Williams & Wilkins; 1999.)
physiologic responses and fully appreciate the pathophysi-

INTERDEPENDENCE OF SYSTEMS ology of disease and the negative impact on the movement
system.
The challenge is to carefully assess the patient’s status and
begin exercise, being aware of a desired outcome but equally
mindful of the patient’s ability and potential risks for an
untoward event. These clinical decisions are guided by an CELLULAR METABOLISM
understanding of cellular metabolism, properties of organ
and system function, and the overarching interdependence All biological systems share common cellular process in
of the involved body systems. This overarching interdepen- their quest to function and survive. These common features
dency of systems has been conceptualized by Wasserman et include the following:
al (Figure 1-2).9 The muscular, cardiovascular, pulmonary, • Exchange of essential materials between the internal
and bioenergetic systems are represented as gears depicting environment of a cell and its external environment
how alterations in one system lead to changes in the others. • Production of energy from organic compounds
This model highlights the functional interdependence of the
• Synthesis of complex proteins
physiological components that are responsible for energy
production, waste elimination, and O2 delivery and trans- • Replication of the cell itself
port. • Detection of, and response to, signals in the external
Viewing the Wasserman schematic starting on the left, environment
the model shows the link between internal cellular respira- A single-celled organism low in essential nutrients can
tion at the mitochondria level and external respiration of the obtain nutrients from the relatively more abundant supply in
lungs by way of the circulation. As the human body begins to the external environment. Simple diffusion allows nutrients
move, energy derived from O2 is used to fuel muscle contrac- to pass through the cell’s membrane down a concentration
tion and results in the production of a waste product, CO2. If gradient from the external environment into the cell. Waste
additional O2 is not provided, energy production slows and products from the cell will follow the reverse path and dif-
activity will stop. If waste products increase without adequate fuse from a higher concentration within the cell to a lower
removal, activity will stop. Providing transport of O2 as well concentration in the external environment. Fluid move-
as providing waste removal from the working muscle is the ment across semipermeable cell membranes by osmosis is
role of the cardiovascular and pulmonary systems. similarly driven by equalizing concentrations on either side
It is necessary that the practicing PT and PT assis- of the cell membrane. However, cells cannot rely on simple
tant (PTA) have an understanding of the basic physiologic diffusion for the movement of all nutrients and waste prod-
mechanisms underlying normal functioning of the human ucts. Movement of nutrients or fluids against concentration
body. This understanding of normal physiology and exercise gradients requires active transport by the cell (Figure 1-3).
physiology allows the clinician to compare and contrast Active transport, as well as other common cellular functions,
6 Chapter 1
(Figure 1-5). A cell that needs to resynthesize ATP rapidly
requires the ability to quickly obtain greater quantities of
O2. This requirement partially explains the evolutionary
development of complex organizational structures of the
cardiovascular and pulmonary systems as well as the internal
structure of the mitochondria.
The synthesis of ATP in the presence of O2 relies on meta-
bolic pathways that can utilize carbohydrates, lipids, and
proteins. Though not immediate sources of energy, oxidative
pathways lead to increased ATP production compared to
anaerobic pathways (Figure 1-6). Oxidative pathways limit
the accumulation of lactic acid because its chemical precur-
sor, pyruvic acid, is metabolized in the presence of O2. The
body’s use of oxidative pathways in muscle work delays the
onset of muscle fatigue (see Figure 1-6).
For shorter duration activity, ATP can be resynthesized
without O2 by nonoxidative, or anaerobic, metabolic path-
ways to give the muscles another immediate source of energy.
Anaerobic pathways are useful for short-duration activity
because ATP production is limited and the accumulation
of the metabolic byproduct, lactic acid, leads to muscular
Figure 1-4. Chemical structure of ATP. Its breakdown to ADP and Pi is fatigue. Nonoxidative pathways use only glucose or its stor-
accompanied by the release of energy that is used to fuel cellular pro- age form, glycogen.
cesses. (Adapted from Widmaier EP, Hershel R, Strang KT. Vander, Sherman
& Luciano’s Human Physiology: The Mechanism of Body Function. 9th ed.
New York, NY: McGraw-Hill; 2004:46.) Cellular Respiration
As stated previously, cellular respiration is the use of O2 to
requires a ready supply of energy to allow prolonged cellular resynthesize ATP and results in the production of CO2. The
function and survival. rate of cellular respiration reflects the extent of the metabolic
work being performed by the cell. When the amount of O2
Adenosine Triphosphate used by the cell (QO2) is proportional to the CO2 produced
(QCO2), the cell is functioning in a steady-state condition.
The basic unit of fuel used by cells is adenosine triphos- The cell remains in steady state as long as respiration remains
phate (ATP). ATP is a complex molecule made up of adenos- balanced with waste removal.
ine and 3 phosphate groups. The usefulness of ATP lies in the
energy released when the high-energy bond holding the third One-Celled to Multi-Celled Organisms:
phosphate is broken, forming adenosine diphosphate (ADP),
inorganic phosphate (Pi): ATP → ADP + Pi + energy (Figure Development of Transport Systems
1-4). This energy is used by the cell to perform work such as
In single-celled organisms, a cell membrane separates the
active transport and protein synthesis. Unfortunately, cells
internal environment of the cell from the external environ-
have limited ATP stores. When cellular energy demands
ment of H2O, O2, and organic molecules. Needed O2 dif-
exceed the available free ATP molecules, these energy stores
fuses across the cell membrane and the produced H2O and
need to be replaced to maintain ongoing cellular activity.
CO2 diffuse out to the external environment. The limits of
Resynthesis of Adenosine Triphosphate simple diffusion, however, dictate the distance that molecules
ATP is created and restored by sequences of enzyme- can cover, thereby dictating the size and complexity of cells
mediated reactions known as metabolic pathways. For (Figure 1-7).
example, in skeletal muscle, there are limited stores of a As single-cell organisms evolved into multi-cell organ-
high-energy phosphate compound, phosphocreatine (PC), isms, cells and organelles would no longer be exposed to
which can be used to immediately resynthesize ATP from the external environment. As multi-cell organisms evolved
ADP and inorganic phosphates (ADP + PC → ATP + C). Use with differentiation of cells into specialized tissues and
of PC preserves the levels of ATP during short-duration, organs, transport mechanisms also evolved. These transport
quick bursts of muscle activity. systems carried essential nutrients and wastes to and from
For longer duration activity, ATP is resynthesized by the external environment to each cell. Over time, through
oxidation. At rest or with submaximal activities, the optimal exoskeletons, gills, and primitive hearts and lungs, transport
restoration of ATP occurs via oxidation in the mitochon- mechanisms evolved into cardiovascular and pulmonary
dria, leaving CO2 and water (H2O) as the waste products organ systems of increasing complexity.
Figure 1-5. Simplified schema of glycolysis and oxidative
phosphorylation in a cell. Anaerobic glycolysis results in
forming 2 ATP from each glucose molecule while aerobic
respiration yields 38 ATP highlighting the efficiency of aer-
obic metabolism. (Reprinted by permission from MacMillan
Publishers Ltd: Sitkovsky M, Lukashev D. Regulation of
immune cells by local-tissue oxygen tension: HIF1 alpha
and adenosine receptors. Nat Rev Immunol. 2005;5:712-721.
Copyright 2005.)
Figure 1-7. The time required for diffusion to raise the concentration of
Figure 1-6. Interrelations between the pathways for the metabolism of glucose at a point 10 μ (about one cell diameter) away from a blood vessel
carbohydrate, fat, and protein. (Adapted from Widmaier EP, Hershel R, to 90% of the blood glucose concentration is about 3.5 sec, while it will
Strang KT. Vander, Sherman & Luciano’s Human Physiology: The Mechanism take more than 11 years for the glucose to reach that same concentration
of Body Function. 9th ed. New York, NY: McGraw-Hill; 2004:104.) at a point 10 cm away (3.9 in). (Reprinted with permission from Vander A,
Sherman J, Luciano D. Human Physiology: The Mechanism of Body Function.
7th ed. New York, NY: McGraw-Hill; 1999:44. Copyright The McGraw-Hill
Companies, Inc.)
CARDIOVASCULAR AND
PULMONARY SYSTEMS regions of higher concentration to regions of lower concen-
tration. Bulk flow defines the movement of substances under
the influence of pressure.10,11
Overview Bulk flow of air occurs through the activity of the ven-
In its simplest description, the pulmonary system extracts tilatory pump of the lungs while bulk flow of blood occurs
air from the external environment and the cardiovascular through activity of the cardiac pump. Bulk flow of air and
system delivers O2 to the internal environment of cells for blood must be continuous. In the transition from the cardiac
metabolism. The transport of air and blood occurs by 2 dis- pump or ventilatory pump to the tubes of the vascular and
tinct mechanisms: diffusion and bulk flow. Diffusion defines bronchial tree, flow is ultimately dependent on the amount of
the movement of particles through random motion from pressure generated by the pump and limited by the resistance
8 Chapter 1
Figure 1-8. Schematic view of the cardiovascular system indicating the heart and the pulmonary and systemic vascular
circuits. Red shading depicts oxygen-rich arterial blood; blue shading denotes deoxygenated venous blood. The situ-
ation reverses in the pulmonary circuit; oxygenated blood returns to the heart in the right and left pulmonary veins.
of the tubes. Diffusion occurs across capillary membranes at heart pumps to the lungs and is referred to as the pulmonary
the alveolar-capillary membrane of the lung, and the capil- circuit, while the left heart is the systemic circuit pumping to
lary networks of skeletal muscle and other organ systems. the remainder of the body.
The energy requirements of repetitively contracting skel- Cardiac Component
etal muscle cells exceed the energy that can be supplied by
the cell’s stored ATP. The efficient transport of O2 to exercis- Cardiac Pump
ing muscle and removal of CO2 and other metabolic acids is Though sitting side-by-side and joined by the intraventric-
integral to improving activity tolerance at the muscle level. ular septum, the 4-chambered human heart can be viewed as
Fortunately, the O2 transport system is able to adjust to the a 2-sided pump of similar structure—each side with a primer
varied demands of each individual. pump (the atrium) and a more powerful pump (the ventricle;
Figure 1-9A). The 2 pumps often referred to as the right and
The Cardiovascular System left heart are aligned in a series occupying different locations
in the vascular circuit. In brief, deoxygenated blood from
Overview the peripheral circulation fills the right atrium (RA), which
Distilled down to its basic elements, the human cardiovas- guides and pumps the blood through the tricuspid valve to
cular system is a circuit of tubes with 2 interspersed pumps the right ventricle (RV). The RV pumps the blood through
whose primary purpose is to deliver adequate amounts of the pulmonary valve to the lungs via the main pulmonary
O2 and remove wastes from the body (Figure 1-8). The right artery. The main pulmonary artery divides into the right
A TABLE 1-1. ABSOLUTE AND PERCENTAGE

DISTRIBUTION OF TOTAL BLOOD VOLUME IN
THE PULMONARY AND SYSTEMIC VASCULAR
CIRCUITS OF A TYPICAL ADULT MALE AT REST
BODY AREA BLOOD VOLUME
mL Percentage
Heart 360 7.2
Lungs
Arteries 130 2.6
Capillaries 110 2.2
Veins 200 4.0
Systemic
Aorta, large arteries 300 6.0
Small arteries 400 8.0
Capillaries 300 6.0
B Small veins 2300 46.0
Large veins 900 18.0
Total 5000 100.0
Reprinted with permission from McArdle WD, Katch FI, Katch VL.
Exercise Physiology: Nutrition, Energy and Human Performance.
7th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2010:305.
Although each ventricle contracts and propels an equal

volume of blood, the distribution of the blood volume and
pressures developed are markedly different (Table 1-1). These
differences are reflected in the structure of the RV and LV.
The pulmonary circuit is a low-pressure, high-capacity sys-
tem that receives the entire cardiac output (CO) while main-
taining pressures that are usually 20% to 25% of the systemic
circulation. The RV has a thicker myocardium than the atria
but is approximately one-third the thickness of the LV. The
thicker LV myocardium is related to the higher afterload, the
resistance to ventricular ejection, within the systemic circuit
Figure 1-9. (A) Structure of the heart and course of blood flow through
the heart chambers. (B) The anatomical relationship of the RV to the LV,
compared to the afterload of the pulmonary circuit.
showing the thicker globular shape of the LV and the half-moon shape Cardiac Muscle
of the RV as it drapes around the LV. (Adapted from Hall J. Guyton and
Hall Textbook of Medical Physiology. 12th ed. Philadelphia, PA: Saunders; The heart is composed of connective tissue and cardiac
2010:101, 289.) muscle, an involuntary striated muscle tissue. Cardiac muscle
is 1 of the 3 major types of muscle, the others being skeletal
muscle and smooth muscle. Though all 3 muscle types share
and left pulmonary arteries, supplying blood via the pulmo- monofilament sliding for contraction, their morphology and
nary circulation to each lung. The blood is oxygenated at the activation patterns differ (Figure 1-10). Cardiac muscle is
alveolar-capillary interface surrounding the alveoli and then multinucleated, differing from skeletal muscle but having
returns to the left atrium (LA) via the pulmonary veins. The a striated arrangement of the filaments similar to skeletal
LA pumps the oxygenated blood through the mitral valve muscle promoting forceful contractions. Cardiac muscle cells
into the left ventricle (LV), which, in turn, pumps the oxy- (myocytes) are connected via intercalated discs that couple
genated blood through the aortic valve into the aorta to be the cells both mechanically and electrically. This conductiv-
distributed to the rest of the body. The continuous pumping ity defines the ability of the myocytes to transmit impulses
of the heart ensures that blood continues moving through rapidly to successive cells, allowing the heart to contract as a
the circulatory system by bulk flow. unit, a functional syncytium. The interconnectedness of the
10 Chapter 1
Figure 1-10. Structure of the 3 different types of muscle fibers.
(A) Skeletal muscle consists of long, parallel multinucleated
fibers that provide rapid, forceful contraction. (B) Cardiac muscle
A
fibers are irregular, branched fibers connected by interca-
lated discs with a central nuclei; contraction is a variable rhythm.
(C) Smooth muscle fibers are spindle shaped with a single central
nucleus and contraction is slow, sustained, or rhythmic in nature.
cardiac muscle filaments—different from skeletal muscle but Generation of Heart Rate: The
similar to smooth muscle—leads to a sequential contraction Cardiac Conduction System
of a muscle sheet when one muscle fiber is stimulated (ie, “all The average resting adult heart contracts 72 beats per
or none” phenomenon). minute (bpm). The contraction is generated by the special-
All 3 muscle types will contract with nerve stimulation, ized cardiac muscle fibers of the SA node located in the
but cardiac and smooth muscle can be directly stimulated by muscle wall of the RA. The electrical signal from the SA node
circulating hormones, while only cardiac muscle can gener- travels throughout the muscle sheet of the RA and LA. It
ate its own stimulus for rhythmic contraction. This unique then travels to the AV node, located at midline just above the
property of cardiac muscle, termed automaticity, refers to the junction of the atria and ventricles. While the atria contract,
ability of a cardiac myocyte to discharge an electrical current the transmitted electrical signal is slightly delayed in the AV
without stimulation from the nervous system. The pace- node before traveling along the bundle of fibers (AV bundle).
maker cells of the sinoatrial (SA) node, atrioventricular (AV) The delay in the signal at the AV node allows the atria to
node, and Purkinje system highlight this property, but other contract and complete ventricular filling before the ventricles
regions of the myocardium can initiate electrical impulses contract and eject the blood out of the heart.15,16 The signal
and take over pacemaker function as seen in various heart then travels along the 2 large bundle branches of the Purkinje
dysrhythmias (eg, atrial fibrillation/flutter). system that transmit the electrical stimulus for contraction to
The walls of the heart are made up of 3 layers: an inner the ventricles (Figure 1-12).
layer (endocardium), an outer protective layer (epicardium), The SA node, known as the pacemaker of the heart, gener-
and muscular middle layer (myocardium; Figure 1-11). The ally sets the rate of heart contraction. Its rate (72 bpm) over-
innermost layer, the endocardium, is a thin layer of endo- rides the self-generating rate of the AV node (40 to 60 bpm)
thelial cells supported by underlying connective tissue that and the Purkinje system (15 to 40 bpm). However, the heart
repeatedly folds on itself to form the valves of the heart and rate (HR) can be stimulated to increase with a stretch of the
is continuous with the innermost layer of the large blood heart muscle walls due to an increased arrival of blood vol-
vessels (tunica intima). The conduction pathways are found ume to the heart (see the Bainbridge Reflex section on p 13)
beneath the endocardium in the subendocardial layer.12 The as well as by hormone and autonomic nervous system (ANS)
middle layer, the myocardium, is the contractile layer of the input.
heart and is composed primarily of cardiac muscle fibers.
The outer layer, the epicardium, is a thin membrane that Neurohumoral Control: Autonomic
encases the myocardium and is the root of the great vessels. Innervation of the Heart
The epicardium turns back on itself to form a sac that sur- The heart and vascular systems receive neurologic input
rounds the heart (the pericardium).13,14 from the ANS. Specifically, the heart is innervated by cra-
nial nerve X (the vagus nerve) and sympathetic fibers arise
Figure 1-11. Layers of the heart wall from innermost (the
endocardium), through the middle layer (the myocardium), to
the exterior (the epicardium). The epicardium is continuous
with the visceral or serous pericardium that lubricates and
reduces friction during contraction. The outermost covering,
the parietal or fibrous pericardium, is a dense fibrous sac
that limits its distension and retains the heart in its anatomic
position.
Figure 1-12. Sinus node and the Purkinje system of the

heart, also showing the AV node, atrial internodal path-
ways, and ventricular bundle branches. (Adapted from Hall
J. Guyton and Hall Textbook of Medical Physiology. 12th ed.
Philadelphia, PA: Saunders; 2010.)
from the sympathetic chain ganglia from the thoracolumbar with release of NE increases HR (positive chronotropy),
region of the spinal cord (levels T1 to L2; Figure 1-13). The increases the strength of ventricular contraction (positive
medulla, located in the brainstem, is the primary site in the inotropy), and increases the velocity of the action potential
brain for regulating sympathetic and vagal outflow to the throughout the conduction system (positive dromotropy),
heart and blood vessels. The sympathetic nervous system whereas parasympathetic stimulation with release of ace-
(SNS) uses norepinephrine (NE) and the parasympathetic tylcholine has opposite effects (eg, negative chronotropy).
nervous system uses acetylcholine as neurotransmitters. The adrenal glands located superior to the kidneys are also
Sympathetic and parasympathetic effects on heart function stimulated by the SNS and will release epinephrine (EPI) into
are mediated by beta-adrenoceptors and muscarinic recep- the circulation. Although this response is delayed, EPI has
tors, respectively (Table 1-2).10,17 Sympathetic stimulation similar effects on heart and vascular function as NE.
12 Chapter 1
Figure 1-13. The ANS showing distribution of sympa-
thetic and parasympathetic nerve fibers to the myo-
cardium. (Adapted from McArdle WD, Katch FI, Katch
VL. Exercise Physiology: Nutrition, Energy and Human
Performance. 7th ed. Philadelphia, PA: Lippincott,
Williams & Wilkins; 2010:330.)
TABLE 1-2. AUTONOMIC NERVOUS SYSTEM INFLUENCES ON CARDIOVASCULAR SYSTEM

NEUROTRANSMITTER RECEPTOR LOCATION RESPONSE
TYPE
Parasympathetic nervous Muscarinic Airway smooth muscle Contraction
system (bronchi/bronchioles)
Cholinergic: acetylcholine Vasculature of genitalia Dilation
SA node; AV node Decreased rate (‒ chronotropy),
Atria conductive velocity (‒ dromotropy),
and force of contraction (‒ inotropy)
SNS Alpha1 Vascular smooth muscle Contraction
Adrenergic: NE/EPI Beta1 SA node and AV node Increased rate (+ chronotropy),
Atria and ventricle conductive velocity (+ dromotropy),
and force of contraction (+ inotropy)
Beta2 Airway smooth muscle Dilation
(bronchi/bronchioles)
Skeletal muscle and hepatic Dilation
vascular smooth muscle
The Cardiac Cycle ultimately CO are influenced by multiple factors, including

The cardiac cycle defines the combined electrical and the end-diastolic volume (EDV), ventricular contractility,
mechanical forces acting within the heart to complete one afterload, and HR.18
heartbeat. It includes a phase of contraction (systole) and The EDV is the maximal filling volume in the ventricle
a phase of relaxation or filling (diastole). Systole begins prior to ejection. The EDV in the normal adult averages
with the contraction of the ventricle resulting from electri- 120 mL, representing the ventricular preload. The SV math-
cal stimulation by the pacemaker of the heart transmitted ematically is expressed as the difference between the EDV
through the conduction system. The amount of blood ejected and the end-systolic volume (ESV) volume of blood remain-
from the heart with each ventricular contraction is called ing in the heart at the end of ejection (SV = EDV – ESV). The
the stroke volume (SV). The amount of blood ejected from ejection fraction (EF) is the fraction of blood pumped out
the ventricles per minute defines the CO. At rest, the adult of the ventricles with each heartbeat and compares the fill-
heart pumps about 5 to 8 liters of blood each minute. This ing volume of the ventricle to the volume ejected with each
volume of blood (the CO) is the product of the SV. The rate of beat. EF is SV divided by EDV where: EF = EDV – ESV/EDV
heart contractions per minute (the HR) is expressed as bpm. or SV/EDV. Normal EF is approximately 55% to 70% and
CO is represented by the equation CO = SV × HR. SV and is widely considered an index of contractility.19 Since the
Figure 1-14. Diagram showing the major factors that influence cardiac Figure 1-15. Diagram of the Frank-Starling curve. This curve relates
contractility. These factors will elevate (+) or depress (–) left ventricular ventricular filling (EDV) to ventricular performance. Factors that increase
performance at any given level of ventricular filling (ie, EDV). (Adapted EDV will stretch the myocardium and increase ventricular performance
from Braunwald E, Ross J, Sonnenblick H. Mechanisms of contraction of leading, to enhanced SV. Factors that reduce EDV decrease ventricular
the normal and failing heart. N Engl J Med. 1967;277:1012-1022.) performance and SV. (Adapted from Braunwald E, Ross J, Sonnenblick H.
Mechanisms of contraction of the normal and failing heart. N Engl J Med.
1967;277:1012-1022.)
cardiovascular system is a closed pressure and closed volume

system, the heart can eject only what enters it during diastole. return augments the EDV, leading to an increased stretch of
It is evident that the SV is highly dependent on the EDV. the cardiac myocytes prior to contraction. Myocyte stretch-
Changes in the EDV will directly change the SV as described ing increases the sarcomere length, optimizing actin and
by the Frank-Starling mechanism (see the Common Cardiac myosin overlap and resulting in enhanced force production
Reflexes section next). and, therefore, an increased SV. Reducing EDV will have a
Afterload is the resistance to ejection and is defined as reverse response. This mechanism enables the heart to eject
the force against which the ventricle must contract to eject the additional venous return that accompanies exercise even
blood.10 Afterload will directly affect the SV. For example, an though the filling time is reduced, thereby increasing SV and
increase in afterload (eg, increased aortic pressure as seen in CO during activity (Figure 1-15).
hypertension and aortic valve stenosis) will increase the resis- Bainbridge Reflex
tance to ejection and may decrease SV. Conversely, a decrease The Bainbridge reflex is also called the RA stretch reflex.
in afterload (eg, anti-hypertension medications; aortic valve This reflex occurs when an increased blood volume reaches
replacement) enhances SV. It is important to note, however, the RA and stretches the wall of the RA. The RA contains
that the SV in a normal, nondiseased ventricle is not strongly stretch receptors that respond by a reflex arc increasing HR.
influenced by afterload. In contrast, the SV of hearts that are As the increased right ventricular output reaches the left
failing is very sensitive to changes in afterload.17 heart, the left ventricular EDV is increased, which increases
Contractility, or inotropy, is often defined as the strength the CO (see Frank-Starling Mechanism section).
of ventricular contraction and refers to the ventricular per- Baroreceptor Reflex
formance at a given preload and afterload. The heart can
The baroreceptor reflex is mediated by stretch receptors in
increase its SV with reductions in afterload or increases in
the walls of the aortic arch and carotid sinus. These mecha-
preload. The heart, however, can also modify its contractile
noreceptors are called baroreceptors because they respond to
performance for any given EDV or afterload. For example,
changes in pressure, and the role of the arterial baroreflex
consider the “fight or flight response.” Activation of the SNS
is to prevent excessive fluctuations of arterial blood pres-
will increase the calcium released in the myocardium, which
sure (BP). For example, as BP decreases, which may be seen
increases the force of ventricular contractions independent of
in conditions such as dehydration and heart failure, these
the EDV (Figure 1-14). Conversely, a decrease in inotropy as
receptors respond by inducing a sympathetic reflex that
seen in heart failure reduces SV and limits CO.
increases HR and contractility and promotes vasoconstric-
Common Cardiac Reflexes tion in the periphery. These factors will increase CO and
Frank-Starling Mechanism total peripheral resistance (TPR), leading to an increased BP.
The Frank-Starling mechanism or Starling’s Law of the Failure of this reflex may lead to orthostatic hypotension, the
Heart is mechanically similar to the length-tension rela- sudden fall in BP upon standing—a potential manifestation
tionship defining skeletal muscular contraction. The heart of prolonged immobility and bed rest. Baroreceptor reflex
can change its force of contraction and therefore its SV in failure, although infrequent, can be manifested as wide
response to changes in venous return. Increased venous changes in BP and HR.20,21
14 Chapter 1
TABLE 1-3. VASOACTIVE INFLUENCES ON

PERIPHERAL ARTERIES AND VEINS
VASODILATION VASOCONSTRICTION
Nitric oxide Adrenergic stimulation
Adenosine (NE/EPI)
Bradykinin Endothelin
Low oxygen concentration Angiotensin II
High CO2 concentration Aldosterone
Decreased blood pH (ie,
acidosis)
the contraction or relaxation of the smooth muscle within

blood vessels. The middle layer (the media) consists of mul-
tiple layers of smooth muscle cells and elastic tissue. The
media is the site of vasoconstriction/dilation through chemi-
cal, mechanical, and neurologic stimuli (see Tables 1-2 and
1-3). The outer layer (the adventitia) consists of collagen and
loose connective tissues providing a supportive structure to
the vessel as well as containing nerves and small blood ves-
sels, the vasa vasorum that provides nutrients to the vessels
themselves.14
Figure 1-16. Schematic highlighting the structure of arteries, veins, and The blood vessels provide the conduit for the distribution
capillaries. Lining the interior of all blood vessels is a continuous endo- and return of blood and waste products to their appropriate
thelial cell layer. The arteries, arterioles, and veins have additional smooth
destinations. Under normal circumstances, the resistances
muscle that spirals around the blood vessels. The aorta and other large
arteries contain large amounts of elastic tissue. (Adapted from Carroll RG. throughout the vascular system adjust to regulate the pres-
Integrated Physiology. Philadelphia, PA: Mosby Elsevier; 2007.) sure and flow through the various organ systems, resulting
in increased or reduced flow to match metabolic needs.
Structurally, the pulmonary circulation and the systemic
Force-Frequency Relationship (Bowditch Effect) vasculature continually branch into vessels of progressively
The “treppe” or Bowditch effect defines the positive rela- smaller diameters (the arteries, arterioles, and capillaries)
tionship between ventricular force production and frequency to form parallel circuits that provide nutrient-rich blood
of stimulation. An increased frequency of stimulation leads to the organ systems of the body. This change in the tube
to an increased force of contraction of the heart. In other structure reduces vascular resistance and aids diffusion of
words, an increasing HR increases cardiac contractility. This necessary respiratory gases and nutrients down their respec-
is an important reflex when we consider exercise or stress tive concentration gradients. Blood returns to the heart from
responses. As the HR accelerates, the duration of diastolic the capillaries passing through vessels of progressively larger
filling decreases; however, the reduced filling time is normal- diameters called venules and veins.
ly compensated by an enhanced ventricular contractility. It
should also be noted that the Bowditch effect does not apply Neurohumoral Control of Blood Flow
to patients with severe heart failure, which may contribute to Blood flow is the movement of blood through the ves-
poor exercise performance.22,23 sels. It is pulsatile in the large arteries and diminishes in
amplitude as it approaches the capillaries. The blood vessels
Vasculature Component actively control the flow and distribution of blood through-
Structure and Network out the body by smooth muscle vasoconstriction or dilation
that results from the influences of vasoactive substances,
All vessels larger than the capillaries consist of 3 distinct
hormones, and neurologic input.
layers: the tunica intima, the media, and the adventitia
(Figure 1-16). The innermost layer (the tunica intima) con- The blood vessels are innervated by SNS within the tuni-
sists of a smooth layer of endothelial cells, isolated smooth ca adventitia and mediated by alpha-adrenergic receptors.
muscle cells, and loose connective tissue. The endothelium Activation of vascular sympathetic nerves causes vasocon-
promotes smooth laminar blood flow and is selectively per- striction of the arteries and veins.17 Interestingly, capillaries
meable to many different molecules (eg, low-density lipopro- are not innervated and the capacitance vessels (the veins)
tein cholesterol). Additionally, the endothelium secretes and are more responsive to sympathetic stimulation than the
responds to a variety of vasoactive substances that influence resistance vessels (arterioles).22 Venous constriction reduces
blood storage in the venous system, increasing venous
return to the heart during periods of stress and exercise.
Parasympathetic fibers are only found associated with blood
vessels in certain organs such as salivary glands, gastrointes-
tinal glands, and erectile tissue of the genitalia. The release of
acetylcholine from these parasympathetic nerves has a direct
vasodilatory action.17
Blood Flow
Blood flow relies on ventricular ejection to provide a driv-
ing pressure that must overcome vascular resistance. The
flow in arteries is the result of SV, as well as the elastic recoil
of the large arteries. Venous blood flow is nonpulsatile and Figure 1-17. Interrelationships of pressure, resistance, and blood flow.
results from several factors, including residual arterial pres- (Adapted from Hall J. Guyton and Hall Textbook of Medical Physiology. 12th
ed. Philadelphia, PA: Saunders; 2010.)
sure, pressure fluctuations due to respiratory movements,
and muscle compression of the veins aided by one-way valves.
Blood flow (Q) is directly proportional to the pressure differ- delivery would be impaired, ATP would fail to be produced,
ences across the vasculature (ΔP = P1 – P2 [ΔP = upstream and muscle fatigue would necessitate stopping the exercise
pressure – downstream pressure]) and inversely proportional session.
to the resistance (R) within the vessels. Quantitatively, this is
expressed as Q = ΔP/R (Figure 1-17).19 Blood Pressure
Blood flow can be viewed across the entire circulatory sys- BP is defined by the CO of the heart and the TPR of the
tem, where the pressure difference is left ventricular pressure vascular system: BP = CO × TPR. Since the CO from the LV
minus right atrial pressure, or across a single capillary bed, and RV is similar, the differences in pressures that need
where the pressure gradient is defined by the arterial pres- to be generated by the right and left sides of the heart are
sure minus venous pressure. The greater the pressure differ- explained by the differences in the peripheral resistances. On
ence (ie, ΔP), the greater the blood flow. Opposing blood flow the right, the resistance of only the pulmonary circulatory
is the vascular resistances. Again, this can be viewed across system needs to be countered, while the LV needs to gener-
the entire circulatory system, where the sum of all vascular ate pressure to overcome the resistances of multiple vascular
resistances is the TPR, or it can be viewed across a single cap- systems, including the skeletal, hepatic, renal, cerebral, and
illary bed, where vascular resistance is defined by the resis- the heart muscle itself, to name just a few.
tances in the artery and arterioles supplying the capillary. BP is the pressure exerted by circulating blood upon the
The 3 primary factors that determine the resistance to walls of blood vessels. During each heartbeat, BP varies
blood flow within a vessel include vessel diameter or radius between a maximum (systolic) and a minimum (diastolic)
(r), vessel length (L), and blood viscosity (η). The relation- pressure. It should be remembered that systolic and diastolic
ship between these factors is described by Poiseuille’s equa- arterial BPs are not static but undergo natural variations
tion, where resistance (R) is: R ~ η × L/r4. A 2-fold decrease from one heartbeat to another, and measurements will reflect
in radius (ie, vasoconstriction) increases resistance 16-fold this variation. The mean arterial pressure (MAP) is the aver-
(24 = 2 × 2 × 2 × 2), but a 2-fold increase in vessel length or age pressure over a cardiac cycle and is determined by the
blood viscosity (eg, increased hematocrit; polycythemia) will CO, systemic vascular resistance (SVR), and central venous
increase resistance only 2-fold. The most important factor pressure (CVP): MAP:MAP = (CO × SVR) + CVP. Clinically,
impacting vascular resistance quantitatively and physiologi- MAP can be estimated by adding the diastolic BP to the
cally is vessel radius and vessel radius changes because of pulse pressure (PP = SBP – DBP) in the following equation:
contraction and relaxation of the vascular smooth muscle MAP ~ DP + 1/3 (PP) (Figure 1-18).
within the tunica media of the blood vessel. The PP fluctuates because of the pulsatile nature of the
Considering the equation Q = ΔP/R, the concept of auto- cardiac cycle and is directly proportional to SV and inversely
regulation is explained. Autoregulation is the intrinsic ability proportional to the compliance (ability to expand) of the
of an organ to maintain a constant blood flow despite chang- aorta. For example, a widened PP would be seen during
es in arterial perfusion pressure. The ability to autoregulate exercise because of an increased SV, or it could be seen in
is intrinsic to the small arteries and arterioles and is most atherosclerosis of the aorta because of stiffening of this usu-
readily identified in the cerebral and renal vascular systems ally highly elastic artery. A narrowed PP may signify a poor
but is also believed to occur in skeletal muscle, termed the SV as seen in heart failure.
myogenic reflex. For example, if arterial perfusion pressure MAP is an important variable to consider because it
would decrease to exercising muscle, vasodilation of the reflects the perfusion pressure of the organ systems of
arteries and arterioles will reduce vascular resistance, allow- the body, and it is generally accepted that a MAP greater
ing adequate blood flow to be maintained to the muscle.19 than 60 mm Hg is necessary to maintain sufficient blood
If the vasculature did not dilate, muscle perfusion and O2 flow to meet an organ’s metabolic needs. If the MAP falls
16 Chapter 1
the external environment and into the lungs. The respiratory
muscles develop force to overcome the resistances of the
airways, lung tissue, and chest wall to create the negative
intrathoracic pressure.26 The forces produced by the muscu-
loskeletal pump may be considered the “work of breathing”
(WOB).
The primary muscle of inspiration, the diaphragm,
accounts for approximately 60% of quiet breathing, and
this dome-shaped muscle separates the abdomen from the
thoracic cavity. The diaphragm consists of 2 separate halves
(ie, right and left) with 3 distinct portions.27,28 The costal
diaphragm fans out to originate within the inner surfaces
Figure 1-18. The arterial pressure waveform highlighting SBP, DBP, MAP of the costal cartilages and adjacent portions of the lower
and PP in relation to the cardiac cycle. (Reprinted with permission from 6 ribs; the xiphoid portion attaches on the posterior surface
Carroll RG. Integrated Physiology. Philadelphia, PA: Mosby Elsevier; 2007.) of the xiphoid process; and the crural diaphragm inserts into
a central tendon that attaches to the lumbar vertebrae.29 The
phrenic nerve, originating from cervical nerve roots C3 to
significantly below 55 mm Hg for an extended time, the
C5, innervates the diaphragm, activating the muscle.
organ will not have sufficient blood flow, resulting in isch-
emia and organ dysfunction. Properties
BP drops most rapidly along the small arteries and arte- Contraction of the diaphragm pulls the central tendon
rioles and continues to decrease as the blood moves through downward, combining with the rib cage attachments pro-
the capillaries and back to the heart through the veins. The moting thoracic expansion in both the lateral and vertical
pressure drop in the arterioles is due to increased vascular plane. The accessory muscles of inspiration (the sternoclei-
resistance in this region of the circulatory system. It is the domastoid, erector spinae, trapezius, and scalenes) activate
alterations in vascular contraction and relaxation of the arte- during tasks that require increased ventilation, allowing
rioles that regulates organ blood flow and primarily dictates greater elevation of the rib cage. Expiration is normally a
the arterial BP.24 passive process. The inspiratory muscles relax, allowing the
rib cage and the diaphragm to return to their resting posi-
Pulmonary Component tions. This combines with the elastic recoil of the lungs and
airways, resulting in a reduced thoracic volume and higher
Overview intrathoracic pressures compared to the environment.10
Exceptions to the passive nature of expiration are forced
A simple way to conceptualize the respiratory system
expirations such as coughing, sneezing, and exercise as well
is to divide the system into the gas-exchanging organ and
as expiration for patients with increased airway resistance
the musculoskeletal ventilatory pump. The gas-exchanging
(eg, chronic obstructive pulmonary disease [COPD]). Forced
organ is composed of the lung tissue and airways that con-
exhalation combines the activities of the abdominals, the
duct airflow from the external environment to the alveoli
primary expiratory muscles, with the postural back, cervical,
and the specialized interface between inspired air and the
and pelvic muscles to contribute to force development.27
circulation—the alveolar-capillary membrane. Additionally,
the gas-exchanging organ includes the pulmonary and bron- Ventilation
chial circulations.25 The musculoskeletal pump consists of Air enters through the mouth and nose and travels via
the thoracic rib cage, cervical and thoracic spine, and upper the trachea through the repeatedly branching conducting
pelvic area and the muscles of respiration. The bony struc- airways to the sites of gas exchange. The airflow divides at
tures allow for the origin and insertion of the respiratory the level of the 2 mainstem bronchi to enter the right and left
muscles and also provide protection and support of the lung lungs. The right lung divides into 3 lobes: the middle, upper,
tissue. The muscles of ventilation alter the configuration of and lower. The left lung is divided into 2 lobes: the upper and
the thoracic cage by contracting and relaxing in synchrony, lower. Part of the left upper lobe, the lingula, is considered
creating the pressure fluctuations that result in inspiration anatomically similar to the right middle lobe. The left lung is
and expiration. These 2 systems (the gas-exchanging organ slightly smaller than the right because of the space occupied
and musculoskeletal pump) must work in concert to main- in the left thorax by the heart. Air moves from large bronchi
tain adequate O2 supply and CO2 removal, allowing meta- to smaller branches (the bronchioles) to reach the air-filled
bolic processes to continue. sacks (the alveoli). The tree-like branching structure of the
airways, branching upwards of 28 times, greatly increases the
Ventilatory Pump
surface area for gas exchange (Figure 1-19). The conducting
Structure airways extend from the oral and nasal pharynx to the 17th
The ventilatory pump creates a vacuum, a lower intratho- generation of branching bronchi (the terminal bronchioles).
racic pressure that draws air down a pressure gradient, from The transitional zone consists of respiratory bronchioles,
alveolar ducts, and the alveolar sacs, and is the site of gas
exchange. Gas exchange occurs by diffusion through the cell
membranes of the alveoli and the capillaries of the cardio-
vascular system.
Control of Ventilation
Breathing is largely regulated by the respiratory center
in the medulla of the brainstem. The breathing rhythm is
driven by neurons originating in the inspiratory area of
the respiratory center.11,30 Changes in ventilation rate and
breathing pattern can occur with a variety of stimuli, includ-
ing blood gases. Central and peripheral chemoreceptors will
detect the changing amounts of O2, CO2, and pH in the
blood and will stimulate an adaptive change in respiratory
rate (RR).30,31 Additional factors that alter the breathing
pattern include stimuli from the cerebral cortex (eg, breath
holding, volitional hyperventilation, phonation), hypothala-
mus and limbic systems (eg, emotional states), and irritant
and pain receptors within the lung and muscle spindle recep-
tors of the chest wall and extremities.10,11,29 For example, at
the onset of increased activity, skeletal muscle can provide
input that will lead to an increase in ventilatory pump force
and frequency.32
Figure 1-19. The conducting and respiratory zones of the respiratory
Ventilation Volumes and Flow system. Note the increased cross-sectional area with each airway genera-
tion and airway branching. (Reprinted with permission from Levitzky M.
At rest, the volume of air that enters the lungs in 1 min- Pulmonary Physiology. 8th ed. New York, NY: McGraw- Hill; 2013. Copyright
ute in the average adult is 4 to 8 liters. This volume of air The McGraw-Hill Companies, Inc.)
(the minute ventilation [VE]) is determined by the volume
of air that is inspired in one normal resting breath (the
tidal volume [VT]) and the number of breaths in 1 minute airflow occurs primarily in the larger airways (eg, trachea
(the RR). VE, therefore, can be represented by the equation to the fourth or fifth generation of bronchi), requiring an
VE = VT × RR. An average RR of 10 to 16 breaths per minute increased driving pressure (an increased WOB) to maintain
with an average VT at rest of 500 mL yields the average adult flow down the tracheobronchial tree. Compliance defines
VE noted previously. the ease of lung and chest wall expansion. Compliance is
Since ventilation is the volume of inspired gas that enters the ability of the lung or chest wall to change volume rela-
and leaves the lungs but not all of the inspired volume par- tive to an applied change in pressure and is defined by the
ticipates in gas exchange, the VT and VE can be further equation C = ΔV/ΔP. As compliance decreases, expansion
divided. The VT consists of air that reaches the alveoli (alve- is resisted and greater force is required by the musculoskel-
olar ventilation [VA]) and the volume of air in the conducting etal pump to promote a volume change. Lung compliance is
zones at the level of the mouth to the terminal bronchioles, influenced by the fluid content of pulmonary tissues and the
termed anatomic dead space (VD), or the volume of air that structural components of the lung parenchyma. For example,
does not contribute to gas exchange. VE, therefore, consists pulmonary edema and fibrosis of the lung will decrease lung
of both alveolar ventilation and dead space ventilation and compliance, leading to an increased demand on the musculo-
can be represented by the following equation: VT = VA + VD. skeletal pump and increasing the WOB. The musculoskeletal
On average, dead space volume is approximately one-third pump will also be influenced by the structural make-up of
of the resting VT and is usually in the range of 150 mL.11 the soft tissues and the mechanical alignment of the rib cage.
Hypothetically, if the VT was the same as the VD volume, Chest wall compliance would be reduced by fibrosis of the
minimal gas exchange would occur since the inspired vol- costovertebral joints (eg, ankylosing spondylitis) or a hori-
ume of air would not reach the level of the alveoli. A vital zontal rib alignment (eg, COPD), resulting in an increased
task of the musculoskeletal pump is to provide VT breaths WOB.
that exceed the VD. Ventilation is influenced by many factors and will not be
Ventilation is influenced by multiple factors, including uniform throughout the lung. For example, the lung is often
lung and chest wall compliance, and the frictional forces compared to the childhood toy, the Slinky (Figure 1-20).
within the airways. Airway friction or airway resistance is The alveoli in the upper part of the upright lung (the apex)
affected by the geometry of the airways (bronchodilation ver- are more expanded because of the weight of the dependent
sus bronchoconstriction; see discussion of Poiseuille’s equa- portion of the lung (the base). These alveoli will be stiffer
tion on p 15) and velocity and type of airflow (laminar versus and have a lower lung compliance compared to the smaller
turbulent, slow versus rapid breathing frequency). Turbulent alveoli at the base. Therefore, as the individual breathes,
18 Chapter 1
Figure 1-20. Diagram of the “Slinky” analogy of the lung,
where the apical alveoli are larger and more distended
compared with alveoli at the base at resting volume (ie,
functional residual capacity). (Adapted from Grippi MA.
Pulmonary Pathophysiology. Philadelphia, PA: Lippincott Co.;
1995, and Leff AR, Schumacker PT. Respiratory Physiology:
Basics and Application. Philadelphia, PA: W.B. Saunders
Company; 1993.)
the majority of the VT will take the path of least resistance which carries oxygenated blood to the LA via the pulmonary
and airflow will be directed to the base of the lung. Disease veins. Just as ventilation is not uniform, lung perfusion is het-
processes can lead to regional alterations in lung compliance erogeneous. CO, gravity, and the pulmonary vascular resis-
that can result in regional changes in ventilation. Consider tance (PVR) affect blood flow, creating regional differences
the patient with right lower lobe pneumonia. In this case, that are classically defined as 3 separate “Zones of West”:
inflammation and hypersecretion of mucus lead to lung con- 1. Zone 1 defines the upper one-third of the lung
solidation and decrease lung compliance in the right lower
2. Zone 2 defines the middle
lobe. Airflow will be restricted to this region and redistrib-
uted to the higher compliant middle and upper lobes. 3. Zone 3 defines the lower one-third
Gas Exchange Recall that the alveoli in the apex are more distended
compared with alveoli in the basilar portions of the lung. The
Perfusion pressure from these air-filled alveoli compresses the capillar-
Blood Flow to Lungs ies, leading to an increase in the PVR. The increased PVR
Blood flow to the lungs occurs via 2 separate circulations: combined with the resistive force of gravity will limit blood
the pulmonary circulation and the bronchial circulation. The flow to the apical regions. The result is relatively greater
bronchial circulation arises from the aorta or from intercos- ventilation (V) compared to perfusion (Q), V > Q, and this is
tal arteries and supplies oxygenated blood to the conducting termed dead space physiology. The alveoli in the lower one-
airways, pulmonary vessels, nerves, interstitium, and pleura. third of the lung have greater compliance and will receive the
The pulmonary circulation is responsible for bringing the majority of the ventilation. However, gravity and a decreased
systemic venous blood into contact with the alveoli, allowing PVR will preferentially allow greater blood flow at the base
gas exchange. Additionally, the pulmonary circulation filters of the lung. Even though more airflow goes to the base com-
the blood, serves as a blood reservoir, provides nutrients to pared to the apex (approximately 3 times more air), blood
the lungs, and metabolizes many blood-borne chemicals. flow is much greater in the base (approximately 10 times
Properties of Perfusion greater), resulting in perfusion exceeding ventilation (Q > V).
The pulmonary circulation is a high-capacity, low-resis- When Q > V, this is termed shunt physiology.
tance circuit allowing pulmonary BP to remain low even Ventilation to Perfusion Ratio
though the lung receives the entire CO. Anatomically, blood The V/Q ratio defines the relationship between airflow
enters the pulmonary circulation at the main pulmonary and blood flow, and the physiologic coupling of these 2 fac-
artery after being ejected from the RV. Just as the airways tors determines the gas-exchanging function of the lung.
repeatedly divide into smaller but more numerous units, the Regions of low V/Q (ie, shunt physiology) result in decreased
pulmonary circulation follows a similar tree-like pattern of partial pressure of O2 in arterial blood (PaO2) and elevated
branching until forming the alveolar-capillary membrane arterial concentrations of CO2 (PaCO2). The concentra-
and then converging into the pulmonary venous system, tions of the respiratory gases in the blood in a low V/Q state
A B
Figure 1-21. (A) Major pulmonary structures within the thoracic cavity. (B) General overview of the ventilatory system showing the respiratory pas-
sages, alveoli, pulmonary circulation, and gas exchange function in an alveolus. (Adapted from McArdle WD, Katch FI, Katch VL. Exercise Physiology:
Nutrition, Energy and Human Performance. 7th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2010:254.)
resemble venous blood even though the blood has passed Properties of Gas Exchange,
through the pulmonary circulation. It is as if the blood Including Surface Area
exited the RV, bypassed the lungs, and entered the LV (ie, a The alveolar-capillary junction plays a critical role in gas
right-to-left shunt). Shunt refers to the entry of blood into the exchange. The lungs and the cardiovascular system directly
systemic arterial system without going through ventilated connect when the pulmonary arteries branch into single-
areas of lung. This mismatch between ventilation and perfu- cell walled capillaries that surround the alveoli of the lungs
sion is a common cause of hypoxemia in adult patients.31,33 (Figure 1-21). The O2 requirements for all of the other cells
To compensate for V/Q mismatch, the pulmonary vascula- in the body, and CO2 removal, rely on the successful diffu-
ture is sensitive to low O2 and high CO2 tensions as seen in sion of respiratory gases across the cell membranes at this
poorly ventilated lung regions. The vasculature will adapt by juncture.
“shunting” blood to better ventilated areas of the lungs for
Diffusion within the lung is defined by the Fick equation
gas exchange by the process of hypoxic vasoconstriction.25
(Fick’s Law of Diffusion): V = d A × (P1 – P2)/T. This equation
Increased PVR in poorly ventilated regions enhances blood
states that the diffusion of a volume of gas (V) is directly
flow to normally ventilated regions. Blood flow will take
proportional to the gas constant (d), the surface area avail-
the path of least resistance, and this adaptive mechanism
able for gas exchange (A), and the difference of the partial
optimizes V/Q matching. This may become pathologic when
pressures of the specific gas across the alveolar capillary
there is extensive tissue destruction of the lung or alterations
membrane (P1 – P2). Diffusion is inversely proportional to
of the pulmonary vascular bed leading to increased PVR,
the tissue thickness across the alveolar capillary membrane
pulmonary hypertension, and right heart failure. Regions of
(T). The diffusion constant (d) represents the solubility of the
high V/Q are termed dead space and result in reduced PaCO2
gas within the membrane. The respiratory gases are highly
and insignificant changes in PaO2 (eg, hyperventilation).
soluble in lipids and therefore pass through cell membranes
An example of ventilation exceeding perfusion would be a
easily.11 CO2 is approximately 20 times more soluble than O2
patient with a pulmonary embolism restricting pulmonary
and will more readily diffuse in the lung.
blood flow.
20 Chapter 1
The adult lung contains approximately 300 million alveo- normally. This defines the perfusion limit for gas exchange
li, creating a large surface area (A) for gas exchange (approxi- in the normal lung.
mately 100 m2 or the area of 2 tennis courts).10 The alveolar
capillary membrane (T) is thin and in some places less than Blood
0.5 μm (10-6 meters; one-millionth of a meter), which aides in
diffusion of respiratory of O2 and CO2.10,14 For comparison, Oxygen in Blood/Oxygen Delivery
a single strand of human hair usually has a diameter of 20 to
The erythrocyte or RBCs’ primary functions are the
180 μm while red blood cells (RBCs) are approximately 8 μm
delivery of O2 to tissues, the uptake of cellular metabolic
in diameter.14
byproducts (specifically CO2 and H+), and maintenance of
With consideration of Fick’s equation, it is easy to under-
acid-base balance. A single RBC contains 4 hemoglobin mol-
stand how various lung pathologies affect gas exchange. For
ecules and can carry 4 molecules of O2 when fully saturated,
example, the thickness of the alveolar-capillary junction
for a total O2 content of approximately 20 mL/dL of blood.
(T) may be increased with pulmonary edema or pulmonary
RBCs last 120 days in the bloodstream and are removed by
fibrosis, reducing gas diffusion. The surface area (A) could
macrophages in the liver and spleen.14 Only 3% of the O2 in
be reduced when alveoli are destroyed, as seen in emphy-
the pulmonary capillaries remains dissolved in the blood.
sema. If a patient has a gas-exchange defect and is provided
The remaining molecules, the majority at 97%, are loosely
supplemental O2, the inhaled O2 increases the partial pres-
bound to hemoglobin molecules within RBCs.
sure gradient (↑ ΔP) for this gas across the alveolar-capillary
The number of RBCs and the volume of blood that is
membrane, increasing diffusion of O2 from the alveoli into
RBCs will vary with age and gender. The numbers of RBCs
the bloodstream (see Chapter 9).
are carefully regulated by the body to ensure there is an ade-
Gas Partial Pressures quate supply to deliver O2 to the cells of the body. Hypoxia,
At standard temperature and pressure, the composi- low O2 tensions in the blood due to pulmonary disease,
tion of atmospheric air is 21% O2 (a fraction of inspired O2 heart failure, or altitude, may upregulate RBC production in
[FiO2] = 0.21) and 79% nitrogen (FiN2 = 0.79). At sea level, response to the production of the hormone erythropoietin
1 atmosphere of pressure is 760 mm Hg. The partial pressure from the kidneys. RBC production is also regulated to avoid
of O2 (PO2) in air is equal to its portion in the mixture, thus an excessive concentration that would increase blood viscos-
21% of 760 mm Hg. Therefore, the PO2 in atmospheric air, ity, thereby increasing resistance and impeding blood flow.
inhaled into the lungs, would be 160 mm Hg. However, as we
Hemoglobin Saturation Curve
breathe, the air is humidified and warmed as it passes through
the mouth, nose, and conducting airways. Saturating the dry The oxyhemoglobin dissociation curve defines how our
atmospheric air with water vapor effectively lowers the PO2 RBCs acquire and release O2. Specifically, the oxyhemoglo-
to 149.13 mm Hg, or just more than 19.5%.11 Additionally, bin dissociation curve relates O2 saturation (SpO2) measur-
inspired air will mix with air already in the tracheobronchial able by pulse oximetry on the “X” axis and PaO2 on the “Y”
tree, further reducing the concentration of O2 and raising axis. The sigmoid shape of the curve relates to the reversible
the concentration of CO2. The PO2 becomes 104 mm Hg, or binding properties of hemoglobin itself (Figure 1-22). For
13.6%. This pressure of O2 becomes the driving force for the example, consider the saturation of hemoglobin at a PaO2 of
diffusion of O2 across the alveolar capillary membrane (see 60 mm Hg. Hemoglobin’s affinity for O2 increases as succes-
ΔP—Fick’s Law of Diffusion). sive molecules of O2 bind and more molecules of O2 bind as
O2 diffusing from the alveoli into capillaries follows a the PaO2 increases. Each RBC can carry 4 O2 molecules, and
pressure gradient. The relatively higher concentration of as this limit is approached, hemoglobin is fully saturated and
O2 in the alveoli (~100 mm Hg) contrasts with the lower additional binding cannot occur, regardless of an increase
O2 concentration in the venous blood (40 mm Hg) arriv- in PaO2, and the curve plateaus. This process occurs in the
ing from the pulmonary arteries and arterioles into the lung.
pulmonary capillaries. The net rate of O2 diffusion through Consider the shape of the curve as O2 partial pressure
the cell membranes of the alveoli and blood capillaries is decreases below 50 mm Hg. This is the process that occurs in
proportional to the concentration difference on either side peripheral tissues such as exercising skeletal muscle. In this
(P1 – P2 = ΔP or 100 mm Hg – 40 mm Hg = 60 mm Hg). The steep area of the curve, O2 is unloaded to peripheral tissue as
PO2 in the capillary blood rises rapidly and quickly combines the hemoglobin’s affinity diminishes and O2 is released into
with hemoglobin of the RBCs. Under normal circumstances, the surrounding plasma. The O2 molecules will diffuse into
the total transit time of an RBC within a pulmonary capil- the skeletal muscle and will ultimately be available for meta-
lary is approximately 0.75 seconds. However, when an RBC bolic pathways to create ATP.
is about one-third of the way through the capillary, PaO2 Complicating the understanding of the oxyhemoglobin
equilibrates and matches that of the alveoli. O2 tensions dissociation curve is the fact that hemoglobin-O2 binding
equilibrate in approximately 0.25 seconds, and hemoglobin can be affected by several factors, and this is represented
will fully saturate with O2. As long as there is normal perfu- by the curve shifting to the left or right. A rightward shift
sion through the pulmonary circulation and the alveolar cap- occurs in states of lower pH (acidosis), high CO2, fever,
illary membrane is not altered, gas exchange will continue and increased 2,3-diphosphoglycerate (DPG). 2,3-DPG is a
substance created during glycolysis in RBCs during periods
of inadequate O2 availability such as hypoxemia and inade-
quate O2 delivery such as heart disease, and facilitates hemo-
globin’s release of O2. A rightward shift defines a reduced
affinity of hemoglobin for O2. In other words, hemoglobin
will release the O2 it is carrying and hemoglobin’s saturation
will be reduced for a given PaO2 compared to normal.10,11,34
Consider the case of exercising muscle. This muscle will
need greater O2 to maintain energy production. As a result
of exercise, heat is produced, CO2 and lactic acid are released,
and this will promote hemoglobin release of O2, making it
available for ATP production within the exercising muscle.
Pathologically, a rightward shift may accompany many dis-
ease processes such as respiratory failure in COPD, reducing
binding of O2 and hemoglobin, which will decrease the deliv-
ery of O2 to peripheral tissues.
Conversely, a leftward shift defines an increased affinity
of hemoglobin for O2; hemoglobin holds onto O2, limiting
its availability for metabolic processes. This occurs in states
where pH is higher (alkalosis), and when CO2 and 2,3-DPG
are reduced, as is seen in the resting state or pathologically
during sepsis (see Chapter 9).
EXERCISE PHYSIOLOGY:
Figure 1-22. Hemoglobin affinity for O2 can be altered. The hemoglobin
TYING IT ALL TOGETHER affinity for O2 is decreased by factors that occur during exercise: a decrease
in pH, an increase in PCO2, or an increase in temperature. Prolonged
hypoxia generates 2,3-DPG, which also decreases hemoglobin affinity for
Overview O2. Each of these changes allows a greater proportion of the bound O2 to
dissociate from hemoglobin and be delivered to the tissues. The decrease
The transition from rest to exercise involves the coordi- hemoglobin affinity for O2 is called a shift to the right of the oxyhemoglo-
bin dissociation curve, or an increase in P50, the PO2 at which 50% of the
nated functioning of the cardiovascular, respiratory, mus- hemoglobin is saturated with O2. (Reprinted with permission from Carroll
culoskeletal, neurologic systems, and bioenergetic systems. RG. Integrated Physiology. Philadelphia, PA: Mosby Elsevier; 2007.)
Successful completion of any exercise or activity is based on
adequate O2 transport and waste removal (see Figure 1-2).
Ultimately, the movement system is limited by the weakest Accurately measuring VO2max involves a physical effort
link in this “interdependent” chain, and this weakest link sufficient in duration and intensity to overload the aerobic
or combination of impairments will be the cause of activity energy system. This typically involves a graded exercise test
intolerance and functional limitations. performed on either a treadmill or a cycle ergometer. Testing
requires an exercise intensity that is progressively increased
while measuring vital signs including HR and rhythm (ie,
Maximal Oxygen Consumption and electrocardiogram), BP, RR, VTs, VE, pulse oximetry, as
Metabolic Equivalents well O2 and CO2 concentration of the inhaled and exhaled
air.35,36 VO2max is achieved when O2 consumption plateaus
The maximal capacity to transport and utilize O2 during and the HR and BP fail to increase despite an increase in
exercise is considered the “gold standard” measurement of workload. The point during exercise where CO2 production
cardiorespiratory fitness. This measurement, VO2 maximum rises disproportionately to O2 consumed (VCO2 > VO2) or
(also called maximal O2 consumption, maximum O2 uptake, lactate accumulates in the blood are termed the ventilatory
or aerobic capacity), implies that an individual’s physiologi- or lactate threshold, respectively. The lactate threshold may
cal limit has been reached. Conceptually, VO2max is defined also be referred to as the onset of blood lactate accumula-
by O2 delivery and O2 extraction (VO2 = O2 delivery × O2 tion.32 Technically, this is a challenging test to perform and
extraction). Mathematically, this is represented by Fick’s requires a highly motivated subject. Few patients will achieve
equation: VO2 = CO × (A – V) O2 difference. O2 delivery is a true maximum, however, and the highest achieved workload
function of the CO (HR × SV) while O2 extraction is a func- is termed peak. VO2max is expressed either as an absolute rate
tion of the arterial-venous O2 difference, or the ability of in liters of O2 per minute (L/min), or it can be normalized
peripheral tissues to extract O2 and create ATP by aerobic to the patient’s body weight in milliliters of O2 per kilogram
metabolism. (mL/kg/min).
22 Chapter 1
TABLE 1-4. ACTIVITIES OF DAILY LIVING AND METABOLIC EQUIVALENTS

ACTIVITY METHOD METS AVERAGE HR RESPONSE (ELEVATED
FROM RESTING HR)
Toileting Bed pan 1.0 to 2.0 5 to 15 bpm
Commode
Urinal (in bed)
Urinal (standing)
Bathing Bed bath 2.0 to 3.0 10 to 20 bpm
Tub bath
Shower
Walking (flat surface) 2 mph 2.0 to 2.5 5 to 15 bpm
2.5 mph 2.5 to 2.9 5 to 15 bpm
3 mph 3.0 to 3.3 5 to 15 bpm
Stair climbing Down 1 flight of stairs 2.5 10 bpm
(1 flight = 12 steps) Up 1 flight of stairs 4.0 10 to 25 bpm
Down 1 flight of stairs carrying 5.0 15 to 30 bpm
objects (25 to 49 pounds)
Upper body exercise Upper extremity 2.0 to 2.2 10 to 20 bpm
(while standing)
Leg calisthenics 2.5 to 4.5 15 to 25 bpm
Adapted from Ainsworth BE, Haskell WL, Herrmann SD, et al. 2011 Compendium of Physical Activities: a second update of codes and
MET values. Med Sci Sports Exerc. 2011;43(8):1575-1581; and National Cancer Institute. Metabolic equivalent (MET) values for activities in
American time use survey (ATUS). Applied Research Cancer Control and Population Sciences. http://appliedresearch.cancer.gov/atus-met/
met.php. Accessed August 6, 2014.
Another method to express patients’ aerobic capacity is of inspired VO2 and expired VCO2 measured at the mouth
the metabolic equivalent (MET). The measured O2 consump- accurately reflect the extent of cellular work at a particular
tion of a 70-kg man at rest is approximately 3.5 mL/kg/min, level of exercise.35 The ratio of VCO2/VO2 is called the respi-
and this value is used as the standard unit for setting the rest- ratory exchange ratio (RER) or is sometimes referred to as
ing energy expenditure, or 1 MET. Therefore, any physical the respiratory quotient (RQ) if measured at the tissue level.
activity can be viewed as a multiple of this unit. For example, Although related, the RER and RQ are not completely inter-
most activities of daily living require an energy expenditure changeable.36 Normally, blood and gas transport systems are
of approximately 1.5 to 4 METs, moderate work and typical keeping pace with tissue metabolism and the RER can be
sexual activities require an energy expenditure of approxi- used as an index of metabolic events or RQ. Additionally, the
mately 3 to 6 METs, and heavy work or high-level sport ratio of VO2 to VCO2 will reflect the energy substrate used to
activities require an energy expenditure of 5 to 15 METs create ATP. For example, an RQ of 1.0 indicates metabolism
(Table 1-4).37 Since exercise testing will reveal the highest of primarily carbohydrates, whereas an RER < 1.0 indicates
achievable workload and vital sign responses to progressive a mixture of carbohydrates and fat (RER ~ 0.7) or protein
activity, clinicians can use this information to determine if a (RER ~ 0.8). RER greater than 1.0 could be caused by CO2
patient can safely participate and complete various activities. derived from lactic acid or by hyperventilation, and this
For example, if a patient had a peak achieved O2 consump- value is used to determine whether the patient has achieved
tion of 35 mL/kg/min (10 METs), it would be risky for him the anaerobic threshold.35,36,38
to return to work as a firefighter since this job requires an
estimated energy expenditure of 12 METs. Energy Utilization
Measurements during exercise testing assume a steady-
state condition. Steady state occurs when the amounts of O2 Energy utilization will depend on the exercise duration
and CO2 exchanged in cellular respiration is in balance, and and intensity. Short-duration, high-intensity exercise pri-
this is balanced by the inspired O2 (VO2) and expired CO2 marily utilizes anaerobic metabolic pathways. For example,
(VCO2) from the lungs. A steady state assumes the amounts exercise lasting less than 10 seconds primarily relies on the
ATP-PC system, between 10 seconds to 1 minute will rely
on ATP created from glycolysis, and longer than 45 seconds
will utilize a combination of anaerobic (ATP-PC; glycolysis)
and aerobic systems. Longer-duration activities, especially
submaximal exercises at moderate intensity, will use ATP
generated from aerobic metabolism. However, as exercise
intensity increases toward maximum as in an incremental or
graded exercise test, there is increased reliance on anaerobic
pathways. This switch is identified by the rise in lactic acid
in the plasma as well as increased VE with increased CO2
elimination (RER > 1.0, where VCO2 > VO2). The switch from
aerobic to more anaerobic metabolism is termed the anaero-
bic threshold, lactate or ventilatory threshold or the onset of
blood lactic acidosis.11,13 During endurance tasks, anaerobic
metabolism is triggered when the preferable aerobic system
can no longer match the demand for ATP production and
fatigue and the cessation of activity will soon occur.
Normal Response to Increasing Loads

The Cardiovascular Responses
The cardiovascular changes associated with exercise will
increase O2 delivery to working muscle, allowing aerobic
metabolism to continue. Consider the case of running on a
treadmill or a patient performing gait training. At the start
of the therapy session, the patient’s HR increases. This initial
increase in HR is due to inhibition of tonic parasympathetic
tone. Vagus nerve activity is reduced, acetylcholine levels
decline, and the heart is released from this negative chrono-
tropic influence and HR begins to accelerate. As workload
increases, sympathetic activity increases. NE and later EPI
are released and combine with the beta1-type receptors, lead-
ing to an increased HR and increased cardiac contractility,
while stimulation of the alpha1 receptors promotes vasocon-
striction of the peripheral vasculature, increasing peripheral
resistance (see Table 1-2). The increased HR and contractility
will promote an increased SV and CO, thus increasing O2
delivery, and the increased CO and TPR will increase BP.35,36
TPR will later decrease as exercise continues because of local
mediators as described next.
Cardiac Output and Stroke Volume
CO increases in direct proportion to work rate and results
from both an increase in HR and SV (Figure 1-23). As noted
previously, SV is influenced by the changes in contractility,
afterload, HR, and preload.39 SNS activation will enhance
contractility and HR, increasing CO. Vasoconstriction of
nonworking vasculature, most notably the splanchnic cir-
culation (vasculature of the abdominal viscera—mesenteric,
splenic and hepatic circulations), combined with ongoing Figure 1-23. Cardiovascular responses to graded exercise for a healthy
muscle contraction and the increased rate and depth of sedentary individual. Values are plotted against specific work rates and
breathing will support venous return and increase the EDV percentage of VO2max. The shaded area represents the lactate threshold.
(Reprinted with permission from ACSM’s Resource Manual for Guidelines for
(see Bainbridge reflex and Frank-Starling mechanism on Exercise Testing and Prescription. 2nd ed. Malvern, PA: Lea & Febiger; 1993.)
p 13), leading to elevations in SV and, consequently, the CO.
SV, however, will plateau in the untrained or moderately
trained at approximately 40% to 60% of VO2max.40,41 During session.42 This implies that the increase in CO at higher
progressive exercise, SV will increase by as much as 50%, workloads is due primarily to increases in HR. Maximal CO
with the greatest change occurring earlier in the exercise tends to decrease in both men and women after 30 years of
24 Chapter 1
age, but the age-related decline in CO is still uncertain.41,43 to working muscle as the resistance falls. Enhanced blood
Challenging this traditional view of SV changes with increas- flow ensures O2 delivery and CO2 removal, supporting the
ing exercise intensity is recent evidence demonstrating that metabolic demands of the muscle. The observed increase in
SV may progressively increase throughout the exercise ses- BP results from marked increases in CO that counteracts the
sion. However, this finding requires further research as it decrease in TPR. As a result of the increase in CO, systolic
appears SV may be influenced by multiple factors, including and MAP increase with a progressive increase in workload.
training status, age, mode of training, and gender.44-46 Systolic BP will continue to rise until maximal workload
Heart Rate with little change in diastolic BP (+10 to 15 mm Hg; see
Figure 1-23). Exercise-induced hypotension is an abnormal
HR increases nearly linearly with increasing workload but
finding, and the clinician should terminate the exercise ses-
plateaus as exercise approaches maximum, as noted in Figure
sion if this is observed. Knowing that BP relies on CO and
1-23. The HR acceleration will increase the CO, especially
TPR, it is not surprising that abnormal BP responses are due
at higher workloads, and is primarily due to SNS stimula-
to alterations in CO such as aortic valve or other outflow
tion of the beta adrenergic receptors, but cardiac reflexes
obstruction, impaired LV function, global severe myocardial
(eg, Bainbridge reflex) also contribute to the rise in HR.
ischemia, and/or alterations in TPR, most notably an exag-
Maximal HR declines in a linear fashion in men and women
gerated peripheral vasodilation.36,52 Each factor increases
after 30 years of age.47,48 It should also be noted that peak
the risk for an exercise-related untoward event, and the clini-
HR is reduced in many, but not all, patients with different
cian should immediately stop the exercise and evaluate the
cardiovascular and/or pulmonary diseases (either because
patient. Exercise-induced hypotension, as a general rule, is
of the disease itself or because of medications used to treat
associated with a poor prognosis and should raise emergent
the disease), and therapists should modify their expecta-
consideration of significant cardiac disease.36
tions while patients perform therapeutic interventions.33
Conversely, an excessive rise in BP is often seen in patients
Common equations to determine the age-predicted maximal
with known resting hypertension, but an abnormal rise with
HR include 220 – age and 208 – (age × 0.7). Both give similar
exercise in the face of normal resting BP is also indicative of
values for people younger than 40 years. However, the first
abnormal BP control.35 It is also important to consider the
equation appears to underestimate the maximal HR in older
site of BP measurements. For measurements taken in the
people and variability of 10 to 15 bpm within an age group
lower extremities, the diastolic pressure in the legs is usually
is expected.35,48 Determining the HR reserve (HRR) is clini-
similar to that in the arms, while the systolic pressure may be
cally important since it provides information regarding an
20 to 30 mm Hg higher in normal individuals.53
individual’s potential reserve capacity and may allow the
clinician to set exercise parameters. HRR is calculated by Pulmonary Responses
subtracting the resting and measured or age-predicted maxi-
mum HR (HRR = HR max – HR rest). Overview
Another concept related to the exercise HR response is Exercise increases the metabolism of the working muscles,
the HR recovery following exercise. HR recovery refers to leading to increased O2 consumption, CO2, and lactic acid
the early deceleration of the HR following an exercise session production. The respiratory system, in combination with
and is believed to be associated with vagal tone reactiva- the cardiovascular system, responds to these demands by
tion.36 HR recovery has generated interest in recent years increasing the volume of O2 supplied to the exercising tissues
because studies have demonstrated that the longer the HR and increasing the removal of CO2 and hydrogen ions (H+)
remains elevated following an exercise test, there is increased from the body. Although the lungs and heart are coupled in
cardiovascular risk of death.49,50 Vagal reactivation is an gas exchange, they differ with regard to physiologic reserve
important cardiac deceleration mechanism after exercise; it during maximal exercise. Under normal circumstances, the
is accelerated in well-trained athletes but may be blunted in respiratory system has a larger reserve capacity and normally
deconditioned and/or “medically ill” patients.51 The reasons exceeds the demands of maximal exercise. For example, VE
why patients are at increased risk is poorly understood and is can increase 20 times in healthy subjects to meet the needs
still under investigation. of O2 uptake and CO2 removal. Exercising subjects will
usually reach maximum O2 consumption (VO2max) when
Blood Pressure pulmonary ventilation is 60% to 70% of maximal breath-
BP, as previously noted, is dependent on CO and TPR. As ing capacity, reflecting a 30% to 40% breathing reserve.40
the working muscle continues to contract, waste products This highlights that maximal exercise is normally limited by
build and the local mediators cause intense vasodilation restricted O2 delivery from the cardiovascular system and
(see Table 1-3). The vasodilation overrides the sympathetic- not limited by a lack of pulmonary reserve.
derived vasoconstriction and lowers TPR (see Figure 1-23).
Minute Ventilation (Respiratory
Although generalized vasoconstriction occurs, local vasore-
laxation reduces peripheral resistance and diverts blood flow Rate × Tidal Volume)
from low-demand visceral areas to the skeletal muscles.52 During exercise, the increase in depth and rate of breath-
Remember that blood flow is inversely proportional to ing are early signs for the clinician to observe (Figure 1-24).
vascular resistance (Q = P/R) and blood flow will increase The stimulus to increase ventilation results from feedback
loops emerging from the respiratory centers in the brainstem
and volitional activity from the motor cortex, and through
feedback from the proprioceptors in the muscles and joints
of the working muscles.11,13,31 Bronchial dilation due to SNS
stimulation of beta2 adrenergic receptors within the airways
leads to reduced airway resistance, promoting increased air-
flow (see Poiseuille’s equation on p 15 and Table 1-2). During
prolonged and/or intense exercise, CO2 production and H+
from lactic acid will stimulate the central and peripheral
chemoreceptors associated with respiratory control, further
increasing the rate and depth of breathing. The increases
in VT and RR increase VE, specifically alveolar ventilation.
The initial increase in ventilation is due to an increase in VT
greater than RR. However, with increasing exercise intensity
(typically 70% to 80% of peak exercise), increases in RR pre-
dominate due to greater resistive and elastic loads on the lung
with large VTs (> 75% of vital capacity).31,35 Considering that
the normal RR is 10 breaths per minute, RR can increase 1- to
3-fold (25 to 45 breaths/minute) in most adult subjects, but in
athletes, it may be increased by 6- to 7-fold (60 to 70 breaths/
minute).35
Gas Exchange
Efficient pulmonary gas exchange function is impor-
tant for a normal exercise response. The increases in CO
in combination with increased pulmonary ventilation will
lead to improved matching of ventilation and perfusion.
The increased pulmonary perfusion due to the enhanced
CO, especially of apical lung units, will decrease dead space,
and increases in alveolar ventilation in basilar regions
will reduce shunting, thereby optimizing gas exchange.
Normally, oxygenation is well-maintained during an exercise
session. However, a decrease of > 5% in the pulse oximeter
Figure 1-24. Ventilatory responses to graded exercise for a healthy
estimate of arterial saturation during exercise is suggestive sedentary individual. Values are plotted against specific work rates and
of abnormal exercise-induced hypoxemia likely due to a V/Q percentage of VO2max. The shaded area represents the lactate threshold.
mismatch, most notably Q > V (ie, shunt physiology).36 True (Reprinted with permission from ACSM’s Resource Manual for Guidelines for
arterial desaturation of 5% to 10% from baseline can occur Exercise Testing and Prescription. 2nd ed. Malvern, PA: Lea & Febiger; 1993.)
in extremely fit healthy individuals but is uncommon in the
general population. In fit individuals, desaturation occurs
during sustained high-intensity exercise because of a dif-
fusion limitation resulting from rapid pulmonary vascular
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Blair SN, Kohl HW 3rd, Barlow CE, Paffenbarger RS Jr, Gibbons
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Lippincott Co.; 1995.
Developing Systems
2
Birth to Adolescence
David Chapman, PT, PhD
▫ Endochondral Ossification
CHAPTER OBJECTIVES ▪ Prenatal Muscle Development
• List the mature tissues and anatomical structures that ◦ Prenatal Cardiovascular Development
arise from the ectoderm, mesoderm, and endoderm. ▪ Prenatal Heart Development
• Outline the developmental changes that occur in the ▪ Prenatal Circulatory System Development
musculoskeletal system during the germinal, embry-
◦ Prenatal Lung Development
onic, and fetal periods of prenatal development.
◦ Development of the Endocrine System
• Describe typical development of the cardiovascular/pul-
monary system during prenatal development, infancy, ◦ Neuromotor Development and Motor Control
childhood, and adolescence. ▪ Neurological Changes in Neuromotor
• Explain the age-related changes that occur in motor con- Development and Control
trol during infancy, childhood, and adolescence. ▪ Development of Motor Milestones
• Outline the impact that training has on the development ▪ Development of Fundamental Motor Skills
of aerobic endurance and muscular strength during
◦ Summary: Using this Information to Guide the
childhood and adolescence.
Physical Therapy Examination
• Explain the protective role the nervous systems plays
• Development of Systems That Influence Aerobic
when children and adolescents participate in training
Capacity During Infancy, Childhood, and Adolescence
programs.
◦ Heart Development During Infancy, Childhood, and
• Identify the age-related changes in the cardiovascular/
Adolescence
pulmonary system to consider during the physical
therapy examination process. ◦ Circulatory System Development During Infancy,
Childhood, and Adolescence
◦ Lung Development During Infancy, Childhood, and
CHAPTER OUTLINE Adolescence
◦ Support System/Structures
• Overview of Embryogenesis and Prenatal Development ◦ Developmental Changes in Aerobic Capacity and
◦ Prenatal Nervous System Development Endurance Training
◦ Prenatal Musculoskeletal System Development ◦ Summary: Using this Information to Guide the
▪ Prenatal Skeletal Development Physical Therapy Examination
▫ Intramembranous Ossification

- 27 - Prescription for Movement-Related Disorders (pp 27-93).
© 2015 SLACK Incorporated.
28 Chapter 2
• Development of Muscle Performance Systems During that boys will not. In fact, certain physical abilities will begin
Infancy, Childhood, and Adolescence to plateau as she reaches physical maturity. Alternatively,
◦ Development of Muscle Tissue her male counterparts will continue to develop increasingly
higher levels of muscle performance and aerobic capacity
◦ Development of Bony Tissue as they grow and develop. Adolescents of both genders will
◦ Developmental Changes in Muscle Performance and continue to develop and refine their cognitive, language, and
Strength Training social skills as they seek to develop their own identity and
◦ Summary: Using this Information to Guide the sense of purpose in the world.
Physical Therapy Examination The behaviors we observe during infancy, childhood, and
adolescence reflect the developmental status of multiple body
• Integumentary System Development
systems and structures. Our “everyday” observations of these
• Summary traits, however, may mask the underlying complexity of the
• References developmental trajectories for each of these systems. For
instance, why do infants have higher heart rates (HRs), but
lower blood pressure (BP) values compared to children and
Physical therapists (PTs) who treat or work with pediatric
adolescents? What changes occur within an infant or child’s
patients usually begin an episode of care by completing an
system(s) that allow him or her to demonstrate improved
in-depth history and thorough systems review with the child
neuromotor control over time? Why are prepubescent girls
and his or her parent or caregiver. These essential first steps
and boys able to increase their muscle strength in the
enable the PT to establish a productive working relationship
absence of androgens and without showing any hypertrophy
with the child and parent/caregiver as well as develop an
of their muscle tissues? Why do boys show a positive rela-
understanding of the reason(s) for this episode of care. The
tionship between their growth spurt and improvements in
results of this initial interview and systems review can be
muscle performance and aerobic capacity while girls do not?
used by the PT to guide the examination process and proce-
Answers to these questions can be established by examining
dures that will be implemented with this particular child and
the influence typical development of selected body systems
his or her family.
has on observable traits, such as aerobic capacity and muscle
Ideally, the PT will recognize that each child develops performance. This type of knowledge will enable us, as PTs,
holistically in real time and that clinical observations of how to provide effective examinations, evaluations, and interven-
a child moves and functions are a reflection of the complex tions with infants, children, and adolescents who may pres-
interactions of his or her multiple systems at that point in ent in the clinic for known or suspected impairments in one
development. For example, when an infant leaves the com- or more of these body structures and functions.
pact and supportive environment of the womb at birth, she
In light of the PT’s need to interpret a child’s movement
“comes with” certain characteristics and faces multiple devel-
patterns and accurately predict how he or she will respond to
opmental tasks. Her joints are used to being flexed, she has
prescribed therapeutic exercises, the purposes of this chapter
relatively weak muscles, and her head is quite large in relation
are to (1) describe typical development of the cardiovascular-
to her body. In addition, she has a nervous system that will
pulmonary musculoskeletal, neurological, integument, and
continue to develop for nearly 2 decades, lungs that need to
endocrine systems during prenatal development, infancy,
mature, and virtually no experience with gravity. And yet,
childhood, and adolescence and (2) review the developmen-
during the first year of life, she will learn to suck and chew
tal changes that occur in aerobic capacity, muscle perfor-
for nutrition, bond with her parents and other caregivers, as
mance, and neuromotor development/motor control during
well as coordinate her musculoskeletal system as she prepares
infancy, childhood, and adolescence. Suggestions regarding
to walk and manipulate objects with her hands.
how this information can be used to guide the physical ther-
Then, during childhood, as her nervous system matures apy examination and evaluation process for infants, children,
and her muscles gain strength, she will learn to explore her and adolescents will also be offered.
environment physically as she develops a variety of complex
The chapter begins with an overview of embryogenesis
neuromotor skills, such as running, hopping, skipping, and
and prenatal development. This information is followed by
galloping. Simultaneously, she will develop the cognitive
a review of the endocrine system and neuromotor develop-
skills needed to solve basic problems and begin to reason
ment/control. A comprehensive review of how the subsys-
abstractly. Her development of oral and written language
tems that support aerobic capacity and muscle performance
skills will enable her to interact with and understand the
typically develop will then be offered. This section will also
world around her and the people in it. As her social skills
include a review of how these traits respond to training. How
expand, her ability to comprehend nonverbal communication
this knowledge can be used to guide the physical therapy
and the emotional aspects of relationships will continue to
examination and evaluation process for infants, children,
grow, as will her need to be independent at home and school.
and adolescents will be presented next. Finally, 2 patient cases
With the arrival of adolescence and the changes associ- will be offered as a means to integrate how the development
ated with puberty, she will develop secondary sexual char- of these various systems affect typical and atypical responses
acteristics and experience changes in her body composition to exercise during infancy, childhood, and adolescence.
Developing Systems: Birth to Adolescence 29
Figure 2-1. Human development begins with cleavage
A B C D of the fertilized egg. (A) The fertilized egg at day 0 with
2 pronuclei and the polar bodies. (B) A 2-cell embryo at day
1 after fertilization. (C) A 4-cell embryo at day 2. (D) The
8-cell embryo at day 3. (E) The 16-cell stage later in day 3,
followed by the phenomenon of compaction, whereby the
embryo is now termed a morula. (F) Day 4. (G) The forma-
tion of the blastocyst at day 5, with the inner cell mass indi-
cated by the arrow. (H) Finally, the embryo (arrow) hatches
from the zona pellucida. (Adapted from Ogilvie CM, Braude
E F G H PR, Scriven PN. Preimplantation diagnosis—an overview.
J Histochem Cytochem. 2005;53:255-260.)
since the mother’s LNMP began approximately 14 days prior

OVERVIEW OF EMBRYOGENESIS AND to conception. Here, we will use developmental age when
PRENATAL DEVELOPMENT referring to the age of the embryo or fetus during prenatal
development.
Embryology commonly refers to the study of prenatal Cell division begins approximately 30 hours after concep-
development but literally means the study of embryos.1 tion.1,2 At this point, the zygote begins to travel through the
Examining the developmental changes that occur during fallopian tube on its week-long journey to the womb. During
gestation allows therapists to acquire knowledge regarding this time, the zygote becomes a morula—a raspberry like
how life begins as well as typical and atypical development structure—that consists of 16 identical cells. Note, cell dif-
of the anatomical structures and function(s) we treat in ferentiation has yet to begin (see Figure 2-1E).1,2
patients. Perhaps more importantly, it provides us with the Cell differentiation begins near the end of the first week
knowledge needed to answer the questions that parents and of gestation with the zygote developing into a blastocyst (see
caregivers often express regarding, “How did this happen?” Figure 2-1G).1,2 The blastocyst consists of an outer cell layer
and “What can we do about it now?”1 known as the trophoblast and an inner cell layer called the
A typical human pregnancy lasts approximately 280 days, embryoblast. The trophoblast becomes the placenta, which
or 40 weeks, and consists of 3 trimesters that encompass will attach to the uterine wall, and the embryoblast becomes
3 periods of prenatal development. The first trimester is the the embryo. Full implantation into the uterine wall generally
most critical trimester and includes the germinal and embry- occurs by the tenth day following fertilization.2
onic periods of gestation as well as the first month of the fetal The next phase of gestation is known as the embryonic
period. This is when all systems, organs, appendages, and period.1,2 As mentioned earlier, it begins at the end of week 2
sense organs develop. It is known as the most critical trimes- and continues through the eighth week of gestation. During
ter because the embryo/fetus is the most vulnerable to the this time, the blastocyst undergoes rapid cell differentiation,
potentially negative effects of drugs, viruses, nutritional defi- known as gastrulation, and change that includes develop-
cits, and the impact of radiation.2 The germinal period lasts ment of multiple body systems and organs, including the
approximately 2 weeks from conception to full implantation head, vertebrae, arm and leg buds, a heart that beats, internal
in the uterine wall. This is followed by the embryonic period, organs such as the liver and kidneys, and sense organs (eg,
which begins at the end of the second week of gestation and eyes and ears).
continues through the eighth week of prenatal development. Gastrulation continues throughout the embryonic period.
The fetal period begins with the onset of the ninth week of Specifically, development of the 3 germ layers known as
gestation and continues until the baby is born. the ectoderm, mesoderm, and endoderm takes place during
Human development begins when an egg or ovum is weeks 2 and 3 of embryonic development as is illustrated in
fertilized by a sperm cell and is defined as change over time Figure 2-2. These 3 layers of tissue are known as germ layers
(Figure 2-1).1,3 Thus, the developmental age of the zygote, because all other tissues arise or germinate from them. Each
embryo, and developing fetus can be calculated from the day will continue to undergo cell differentiation as well as fur-
of conception, which is assumed to be approximately 14 days ther growth and development during the embryonic period.
after the first day of the mother’s last normal menstrual As we will see, each layer contributes to the development of
period (LNMP). Alternatively, gestational age is calculated more specialized structures and systems that will support
from the first day of the mother’s LNMP. This approach the development of neuromotor control, aerobic capacity,
usually over estimates developmental age by about 2 weeks and muscle performance during infancy, childhood, and
adolescence.
30 Chapter 2
Figure 2-2. A cross-sectional view of an
embryonic diagram at 16 days of gesta-
tion showing the endoderm, mesoderm,
A B
and ectoderm. (Adapted from Moore KL,
Persaud TVN. Before We Are Born: Essentials
of Embryology and Birth Defects. 7th ed.
W.B. Saunders Company; 2007.)
C D
E F
G H
The ectoderm forms the dorsal or posterior layer of the within the ectoderm give rise to the neural plate.1,2 The
embryo.1,2 Cells from the ectoderm develop into the neural neural plate develops thickened neural folds superiorly and
tube, spinal cord, brain, sensory organs, and epidermal por- a longitudinal groove surrounded by neural folds inferiorly.2
tion of the integumentary system.1,2 The spinal cord, brain, Cells in the thickened neural folds located at the superior
and sensory organs provide structures and systems that sup- end of the neural plate then fuse to form the prosencepha-
port typical development of neuromotor control as well as lon, or forebrain; the mesencephalon, or midbrain; and the
influence muscle performance and aerobic capacity during rhombencephalon, or hindbrain. A complete discussion of
infancy, childhood, and adolescence. Prenatal development brain development, which continues well into the second
of the brain and spinal cord is presented next. decade of life, is beyond the scope of this chapter. However,
Table 2-1 identifies the relationship between these primitive
Prenatal Nervous System Development brain structures and the corresponding area or region of the
mature brain.2
The brain and spinal cord begin to develop during the The neural folds that surround the longitudinal groove
third week of gestation when thickening mesenchyme cells also fuse to form the neural tube (Figure 2-3). At this point
TABLE 2-1. THE RELATIONSHIP BETWEEN EMBRYONIC AND MATURE BRAIN STRUCTURES
PRIMARY BRAIN VESICLES SECONDARY BRAIN VESICLES AREA OF THE MATURE BRAIN
Hindbrain Myelencephalon Medulla
Metencephalon Pons and cerebellum
Midbrain Mesencephalon Midbrain
Forebrain Diencephalon Thalamus, epithalamus, hypothalamus,
subthalamus
Telencephalon Cerebral hemispheres: cortex, medullary
center, corpus striatum, and olfactory system
Adapted with permission from Moore KL. Essentials of Human Embryology. Burlington, Ontario: B.C. Decker Inc; 1988.
in development, cells deep within the neural tube begin to the development of neuromotor control and muscle perfor-
divide and produce neuroblasts and glioblasts.1,2 Neuroblasts mance in the developing infant, child, and adolescent.
develop into nerve cells, while glioblasts become neuroglial
or supporting cells. In addition, select cells from the neural Prenatal Musculoskeletal System
folds cluster to form the neural crest. These cells eventually
give rise to dorsal root ganglia, autonomic nervous system Development
ganglia, some cranial nerve ganglia, and peripheral nerve
sheaths.1,2 Simultaneously, a shallow groove known as the Prenatal Skeletal Development
sulcus limitans develops along the midline of the neural tube. Skeletal development also begins during the third week of
This developmental process results in 2 groups of nerve cells. gestation via gastrulation, when mesenchymal cells condense
One is located dorsally to the sulcus limitans and is known as to form fibrous membrane and hyaline cartilage templates
the alar plate. The second is recognized as the basal plate and for later skeletal development.1,2 Initially, somites—a series
is ventral to the sulcus limitans. Nerve cells that develop from of paired block cells—form from the mesoderm approxi-
the alar plate are predominantly sensory or afferent neurons. mately 22 days after gestation. The ventral or anterior seg-
These cells lead to the formation of the dorsal or posterior ment of each pair of somites develops into the cartilage and
horn of the gray matter within the spinal cord and function bone of the vertebral columns and ribs. The posterior or
to receive sensory information from the periphery. Nerve dorsal portion gives rise to the dermis of the back and to the
cells that come from the basal plate become organized in the skeletal muscles of the body and limbs. Figure 2-5 illustrates
ventral or anterior horn of the gray matter and are typically somites at 22 days of gestation.2
motor or efferent neurons. These cells eventually provide the The embryo consists of fibrous membranes and hya-
motor signals needed for skeletal muscles to function. line cartilage until approximately 6 to 7 weeks of gesta-
During the first 12 weeks of prenatal development, the tion. Cartilaginous upper limb buds begin to form during
spinal cord is essentially the same length as the vertebral week 4 of gestation, with the lower limb buds appearing
column. This enables the nerve roots to exit directly through 1 to 2 days later (Figure 2-6A).1,2 The digits of the hands
the corresponding intervertebral foramen. Later in prenatal and feet develop during weeks 6 and 7 of prenatal develop-
development and after birth, the vertebral column grows ment (Figure 2-6B).1,2 By the end of the seventh week of
faster in length than the spinal cord itself and the caudal or gestation, all 206 bones have been “set down” as cartilage.
inferior end of the spinal cord degenerates. These 2 processes Synovial joints then develop during weeks 8 and 9 of gesta-
coupled with the fact that the cranial end of the spinal cord is tion. Osteogenesis/ossification begins during this same time
attached to the brain cause the caudal end of the spinal cord period and will continue throughout life.
to ascend within the vertebral canal. Eventually, the conus There are 2 types of human osteogenesis/ossification.
medullaris, or tapered end of the spinal cord, resides at the Intramembranous (IM) ossification leads to the formation of
end of the third lumbar vertebrae in newborn infants. These flat bones including the skull, a portion of the mandible, and
events and structures are represented in Figure 2-4.1 the clavicles. Endochondral (EC) ossification results in the
The middle germ layer, or mesoderm, is the origin of the long and short bones of the upper (UE) and lower extremi-
muscles, bones, cartilage, tendons, and ligaments; dermal ties (LE) as well as the vertebrae (irregular bones). Days
layer of the integumentary system; and the circulatory sys- 24 to 36 of embryonic development are especially critical
tem.1,2 As we will observe, the circulatory system plays a for healthy bone development. It is during this time—weeks
vital role in the development of aerobic capacity throughout 4 through 7—that the embryo is most sensitive to terato-
infancy, childhood, and adolescence. The connective tissues gens and/or genetic mutations that may affect typical bone
listed previously will be reviewed next as they contribute to development.
32 Chapter 2
A B
G
C D H
E
I
Figure 2-3. The neural plate and its folding to form the neural tube. (A) Dorsal view of an embryo at approximately 18 days, exposed by removing the
amnion. (B) Transverse section of the embryo, showing the neural plate and early development of the neural groove and neural folds. (C) Dorsal view
of an embryo at approximately 22 days. The neural folds have fused opposite the fourth to sixth somites, but are spread apart at both ends. (D) to (F)
Transverse sections of this embryo at the levels shown in (C), showing the formation of the neural tube and its detachment from the surface ectoderm.
Note that some neuroectodermal cells are not included in the neural tube but remain between it and the surface ectoderm as the neural crest. (G) to (I)
Development of the spinal cord. (G) Transverse section of the neural tube of an embryo at approximately 23 days. (H) and (C) Similar sections in 6- and
9-week embryos, respectively. (D) Section of the wall of the neural tube shown in (G). (I) Section of the wall of the developing spinal cord, showing its
3 zones. In (G) to (I), note that the neural canal of the neural tube is converted into the central canal of the spinal cord. (Adapted from Boron WF. Medical
Physiology, Updated Edition. St. Louis, MO: Saunders; 2005.)
Intramembranous Ossification development that is typically observed in the skull, man-

IM ossification means that bony tissue develops within dible, and clavicles. Over time, more and more osteoblasts
flat membranes. This process begins after connective tis- are formed from sheets of connective tissue and become
sue has formed sheets of mesenchymal cells, where the flat layers of osteocytes that build up at the edge of spongy bone.
bones will be located. These cells are highly vascularized Osteocytes continue to lay down more hard matrix that
and differentiate into osteoblasts. Osteoblasts “lay down” becomes compact over time and enables flat bones to develop
spongy bone cells that get trapped in a hard matrix. They are to an appropriate level of thickness. IM ossification is illus-
known as osteocytes and provide the basis for compact bone trated in Figure 2-7.
A B C D
Figure 2-4. Spinal cord development (A) at 8 weeks of gestation, (B) at 24 weeks of gestation, (C) at the time of delivery,
and (D) in an adult. Note the relationship of the vertebra with the spinal cord itself, including the conus medullaris, and how
the spinal cord tapers throughout development. (Adapted from Moore KL, Persaud TVN. Before We Are Born: Essentials of
Embryology and Birth Defects. 7th ed. W.B. Saunders Company; 2007.)
Figure 2-5. (A) A microphotograph of a

A 22-day-old embryo from the dorsal view
that illustrates 5 paired somites with a cor-
responding drawing of the same-aged
embryo in (B). Note these are the first pairs
of somites that will give rise to the dermis
of the back and the skeletal muscles of the
body and limbs. (Adapted from Moore KL,
Persaud TVN. Before We Are Born: Essentials
of Embryology and Birth Defects. 7th ed. W.B.
Saunders Company; 2007.)
B
34 Chapter 2
A B
Figure 2-6. (A) A 4-week-old embryo showing UE and LE limb buds. (B) A 6- to 7-week-old embryo displaying the early development
of the UEs and LEs, including the hands and feet. (Adapted from Moore KL, Persaud TVN. The Developing Human: Clinically Oriented
Embryology. 7th ed. Philadelphia, PA: Saunders; 2003.)
Endochondral Ossification
EC ossification occurs when bony tissue replaces a hya-
line cartilage model (Figure 2-8). Chondrocytes within the
cartilage begin to die off and a layer of periosteum forms
on the outside of the cartilaginous model. The periosteum
provides the osteoblasts needed for bony tissue to develop.
Chondrocytes die first in the middle of the diaphysis, which
is the primary ossification center and is where spongy bone
develops. The next set of chondrocytes to die are found in the
secondary ossification centers known as the epiphyses. The
epiphyses are typically located near the end of long bones
and are also known as the growth plate. While osteoblasts
make hard extracellular matrix, the periosteum produces
osteoblasts that get “laid down” as compact bone along the
edges of the long, short, and irregular bones. Note that carti-
lage near the epiphyses is retained and functions as articular
cartilage within the synovial joints.
Prenatal joint development begins during the sixth week
of gestation and is complete 2 weeks later.1,2 Synovial joints
form when interzonal mesenchyme cells that are located
between the long bones differentiate to form the joint capsule
and ligaments in the peripheral areas of the developing joint
Figure 2-7. A light micrograph illustrating IM ossification. The arrows on (Figure 2-9). Centrally, these cells disappear, which leads to
the left side of the micrograph point out the trabeculae of bone that is
being formed by osteoblasts lining their surface. The arrowheads in the
the development of the joint space.2 These cells also form the
upper middle portion of the micrograph are pointing out the osteocytes synovial membrane that lines the joint capsule and articular
that are being trapped in the lacune. (Adapted from Gartner LP, Hiatt JL. surfaces. Fibrous joints develop as the interzonal mesen-
Color Textbook of Histology. 2nd ed. Philadelphia, PA: Saunders; 2001.) chyme cells differentiate into the dense fibrous cartilage that
exists between the developing bones, such as the suture joints
C D
Figure 2-8. Drawings that illustrate the EC ossification process that begins at approximately 5 weeks of gestation.
(Adapted from Moore KL, Persaud TVN. Before We Are Born: Essentials of Embryology and Birth Defects. 7th ed. W.B.
in the skull.2 The hyaline cartilage of the costochondral somites located on the posterior aspect of the embryo and
joints and the fibrocartilage of the pubic symphysis develop become myoblasts (Figure 2-10). These fibers fuse to form
in the same manner. That is, the interzonal mesenchyme multinucleated muscle fibers. Soon after, myofibrils appear
cells differentiate into hyaline cartilage and fibrocartilage. By in the cytoplasm of the developing muscle cells. This process
the end of the eighth week of gestation, the developing joints is followed by the development of cross striations that leads
resemble those of an adult.2 to the formation of striated muscle fibers. From the antero-
lateral body walls of the embryo, mesenchyme cells from the
Prenatal Muscle Development
somatic layer of the mesoderm give rise to striated muscle
Prenatal skeletal muscle development begins during the fibers for the body walls and limbs.
fourth week of gestation. Most skeletal muscle tissue devel- The ventral or anterior layer of the embryo is composed
ops before birth from embryonic mesoderm with the excep- of the endoderm, which gives rise to the endocrine system,
tion of the dilator and sphincter papillae muscles of the gut, liver, pancreas, respiratory system, gastrointestinal tract,
iris.1,2 These muscles develop from the ectoderm. In general, and genitourinary system. The respiratory system along with
mesenchymal cells migrate from myotome regions of the the circulatory system that develops from the mesoderm
36 Chapter 2
A D A
C
Figure 2-9. Schematic drawings of synovial joints and fibrous joints.
(Adapted from Moore KL, Persaud TVN. Before We Are Born: Essentials of
Embryology and Birth Defects. 7th ed. W.B. Saunders Company; 2007.)
play key roles in the development of aerobic capacity, while

the endocrine system heavily influences the development of
muscle performance and aerobic capacity during puberty.
The prenatal development of circulatory and respiratory sys-
tem components will be presented next.
Figure 2-10. Drawings illustrating early prenatal muscular development
Prenatal Cardiovascular Development at approximately 41 days of gestation. Note the myotomes in (A) as
well as the transverse section of the developing embryo in (B) and (C),
respectively. The embryo represented in drawing (C) is now 7 weeks old.
Prenatal Heart Development (Adapted from Moore KL, Persaud TVN. Before We Are Born: Essentials of
The heart is the central pump that supplies blood to the Embryology and Birth Defects. 7th ed. W.B. Saunders Company; 2007.)
pulmonary or venous blood transport loop and the periph-
eral or arterial blood transport loop. Heart development
begins with the appearance of cardiogenic cords of cells venosus, primitive atrium, primitive ventricle, bulbus cordis,
that are located in the cardiogenic area of the fetus (Figure and truncus arteriosus are formed.1
2-11).1,2 These consist of mesenchymal cells that become The sinus venosus is located in the caudal region of the
canalized and form a primitive tube. This original structure primitive heart. Initially, it functions to receive blood that
develops into a thin-walled, 2-tube structure by the end of is returning to the heart from the common cardinal veins,
the third week of gestation. This primitive heart begins to vitelline veins, and umbilical vein and later is incorporated
beat at approximately 22 days of gestation and connects to into the right atrium. The truncus arteriosus dilates to form
blood vessels in the embryo, connective stalk, chorion, and the aortic sac, which eventually develops into the aortic arch-
yolk sac to form a primitive cardiovascular system. Then, es. The primitive ventricle becomes the left ventricle while
through a series of constrictions and dilations, the sinus the bulbus cordis develops into the right ventricle.2
A B C
D
E
Figure 2-11. Ventral views of the developing heart and the pericardial region (22 to 35 days). The ventral pericardial wall has been
removed to show (A) the developing myocardium and fusion of the 2 heart tubes to form (B) a single heart tube. (C) Fusion begins
at the cranial ends of the tubes and extends caudally until a single tubular heart is formed. (D) As the heart elongates, it bends on
itself, forming (E) an S-shaped heart. (F) The embryonic cardiovascular system (at approximately 26 days), showing vessels on the
left side only. The umbilical vein carries well-oxygenated blood and nutrients from the chorion (the embryonic part of the placenta)
to the embryo. The umbilical arteries carry poorly oxygenated blood and waste products from the embryo to the chorion. (Adapted
from Moore KL, Persaud TVN. Before We Are Born: Essentials of Embryology and Birth Defects. 7th ed. W.B. Saunders Company; 2007.)
38 Chapter 2
Figure 2-12. Schematic drawings of the
developing heart from 28 days of gesta-
tion through 8 weeks (56 days) of prenatal
A B
development. Note the plane cutting
through the heart in drawing (A) that is the
basis for drawings (B) through (E). Drawing
(E) represents a typical 4-chambered heart
at 56 days of gestation. (F) Sonogram of
a second trimester fetus showing the
4 chambers of the heart. Note the sep-
tum secundum (arrow) and the descending
aorta. (Adapted from Moore KL, Persaud
TVN. Before We Are Born: Essentials of
Embryology and Birth Defects. 7th ed. W.B. C D
E F
During days 22 to 24, the primitive heart begins to bend to in the embryo join those in the yolk sac, connecting stalk
the right and folds back on itself (see Figure 2-11B) to create a and chorion to form a primitive vascular system. In particu-
left- and right-sided double-chambered pump for each of the lar, the cardinal veins return blood from the embryo while
2 circulatory loops mentioned previously.1,2 During weeks 4 the vitelline veins return blood from the yolk sac, and the
and 5, the primitive heart divides into the typical 4-cham- umbilical veins return oxygenated blood from the placenta
bered heart with 2 atria and 2 ventricles. The formation of the (see Figure 2-11F).1,2
atrioventricular pumping chambers is complete by 8 weeks of Prenatally, a majority of fetal blood moves from the right
gestation (Figure 2-12).1,2 atrium through the foramen ovale—a small opening located
Prenatal Circulatory System Development between the right and left atria—into the left atrium to the
left ventricle and then to the body via the aorta.1 A small
The circulatory/vascular system begins to develop during amount of fetal blood also flows from the right atrium to the
the third week of gestation in the extra-embryonic meso- right ventricle through the ductus arteriosus, located in the
derm of the yolk sac, connecting stalk, and chorion.1,2 Blood pulmonary trunk that connects to the aorta.1 This allows a
vessels begin to appear when groups of mesenchymal cells, portion of the fetal blood supply to flow out to the body. The
known as angioblasts, located in the yolk sac form “blood ductus arteriosus is a small opening that connects the right
islands.” Cavities then form within these islands. Next, mes- ventricle with the arterial circulation. These openings pro-
enchymal cells begin to arrange themselves around these vide for intrauterine circulation of the arterialized placenta
cavities to form the endothelium of the primitive blood blood directly through the heart and into the arterial tree,
vessels. These primitive vessels begin to fuse and form a net- essentially bypassing the lungs (Figure 2-13A). In neonatal
works of vessels within the wall of the yolk sac. This process circulation, the lungs are now involved because of closure of
is also repeated in the connecting stalk and chorion as well the foramen ovale and ductus arteriosus shortly after birth
as within the embryo itself. All of these vessels extend into (Figure 2-13B).
adjacent areas and fuse with other vessels. The blood vessels
Figure 2-13. (A) Prenatal and (B) neonatal circulation. It is important to note the foramen ovale and the ductus arteriosus. Both con-
tribute to the observation that intrauterine circulation bypasses the lungs completely. Note that both the foramen ovale and ductus
arteriosus are now closed in the neonate, which allows the infant to circulate blood between the heart, body, and lungs for typical
perfusion of all body tissues. (Adapted from Moore KL, Persaud TVN. Before We Are Born: Essentials of Embryology and Birth Defects. 7th
ed. W.B. Saunders Company; 2007.) (continued)
Prenatal Lung Development laryngotracheal tube, a single lung bud develops during week
4 of gestation. A tracheoesophageal septum develops that
Development of the lungs begins at approximately divides the single lung bud into 2 lung buds (Figure 2-14).
4 weeks of gestation via the primitive endoderm and meso- Figure 2-15 highlights the development of the bronchial
derm tissues mentioned previously. Endoderm from the buds, bronchi, and lungs between 28 and 56 days of gesta-
pharynx develops into the epithelial lining with the meso- tion. By 16 weeks of gestation, the bronchi, bronchioles, and
derm surrounding the lung buds, developing into smooth terminal bronchioles develop (Figure 2-16). The respiratory
muscle, connective tissue, and cartilage. At the end of the bronchioles and alveolar ducts develop next, with a large
40 Chapter 2
Figure 2-13 (continued). (A) Prenatal and (B) neonatal circulation. It is important to note the foramen ovale and the ductus arte-
riosus. Both contribute to the observation that intrauterine circulation bypasses the lungs completely. Note that both the foramen
ovale and ductus arteriosus are now closed in the neonate, which allows the infant to circulate blood between the heart, body, and
lungs for typical perfusion of all body tissues. (Adapted from Moore KL, Persaud TVN. Before We Are Born: Essentials of Embryology
and Birth Defects. 7th ed. W.B. Saunders Company; 2007.)
number in place by week 24 of gestation. From 24 weeks development. However, it normally takes 36 weeks of gesta-
of gestation until birth, terminal respiratory units continue tion for the prenatal lungs to develop fully. Approximately
to form alveoli. The alveolar sacculi are the last to develop, 75% of infants born between 26 and 28 weeks of gestation
with only one-third of alveoli developed at birth. Surfactant will experience respiratory distress syndrome due to a lack of
also begins to be produced at approximately 24 weeks of surfactant. Thus, it is important to recognize that the num-
gestation. By weeks 26 to 28, there are enough vascularized ber of vascularized terminal sacs multiplies rapidly during
terminal sacs developed and appropriate levels of surfactant the last few weeks of fetal life and that the number of alveoli
for the fetus to survive if he or she is born at this point in will continue to increase following birth.
Figure 2-14. Early development of the upper
A B C and lower respiratory system during the
fourth and fifth weeks of gestation. Note the
tracheal bud in drawing (B) and how it then
divides into the primary bronchial buds in (C).
(Adapted from Moore KL, Persaud TVN. Before
We Are Born: Essentials of Embryology and Birth
Defects. 7th ed. W.B. Saunders Company;
2007.)
D E F
Figure 2-15. Stages of development of the bronchial buds, bronchi, and lungs between 28 and 56 days of prenatal development. (Adapted from Moore
KL, Persaud TVN. Before We Are Born: Essentials of Embryology and Birth Defects. 7th ed. W.B. Saunders Company; 2007.)
The final segment of prenatal development is the fetal minute (bpm) during the last trimester of pregnancy.5 The
period. The fetal period, as noted previously, begins during integument becomes coarser during the final trimester, while
the ninth week of gestation and continues until the infant is the fetus grows by approximately 8 inches in length and
delivered. During this period, the brain cells begin to mature. gains nearly 6 pounds on average during the final 3 months
The fetus also begins to demonstrate early neuromuscular of gestation.2
system function as is evidenced by his or her ability to kick Underlying many of the changes observed in the develop-
legs, curl toes and fingers, as well as squint with his or her ment of aerobic capacity and muscle performance during
eyes.4 In addition, the heartbeat is stronger than earlier in infancy, childhood, and adolescence are the all-encompass-
development with a typical range of 120 to 160 beats per ing influences of the endocrine system, as well as changes
42 Chapter 2
Figure 2-16. An illustration of the histologi-
cal development of the terminal bronchi-
oles, saccules, and alveoli between 6 weeks
A B
of gestation and 8 years of age. (Adapted
from Moore KL, Persaud TVN. Before We
Are Born: Essentials of Embryology and Birth
Defects. 7th ed. W.B. Saunders Company;
2007.)
C D
in the child’s level of neuromotor development and motor These chemical messengers influence or target very specific
control. Because both of these systems have fundamental tissues while selectively bypassing most body structures. For
effects on the development of aerobic capacity and muscle example, in females, the ovaries secrete progesterone and
performance for typically developing infants, children, and estrogen. Progesterone functions to support pregnancy, min-
adolescents, they will be reviewed next. imize inflammation within the body, and assists the thyroid
in promoting bone growth, while estrogen influences the
Development of the Endocrine System development of secondary sexual characteristics in women,
including the percentage of body fat in females, the rate of
The endocrine system begins to develop approximately growth in height in girls, and bone formation in children of
24 days after fertilization when the thyroid gland begins to both genders. In addition, estrogen alters serotonin activity,
form from the endoderm.1 All 3 germ layers contribute to which changes the perception of pain during the follicular
the development of the endocrine system. For instance, the phase of the menstrual cycle when estrogen is at its low-
pituitary gland develops from the ectoderm, the adrenal cor- est level during the menstrual cycle.6 This may change the
tex develops from the mesoderm, and the thyroid and para- motivation levels of adolescent females when they are train-
thyroid originates in the endoderm. The testes in boys and ing. Alternatively, the testes in boys impact the development
ovaries in girls develop from the mesoderm, mesenchyme of their secondary sexual characteristics and enhance the
cells, and primordial germ cells.1 development of muscle mass, strength, height, and bone den-
Figure 2-17 illustrates the endocrine system, which con- sity during puberty. Testosterone has also been linked to an
sists of ductless glands that are located throughout the increase in aggressive behaviors in mature males, which may
body.6 The primary tasks of the endocrine system are to change their levels of motivation when they train to enhance
integrate the various metabolic activities needed to sustain their aerobic capacity and muscle performance. In addition,
life; influence growth and development of the body, includ- the thyroid secretes thyroxine, which functions to stimulate
ing the development of secondary sexual characteristics; and oxygen (O2) and energy consumption that influences the
regulate internal body functions in light of environmental child’s metabolic rate at rest and during activity. Finally, the
and activity-based demands. They accomplish these primary pituitary gland secretes growth hormone (GH), which influ-
tasks by secreting hormones (ie, chemical messengers that ences the growth of the body and body tissues throughout
are circulated throughout the body via the bloodstream). infancy, childhood, and adolescence.
Figure 2-17. A schematic drawing of the endocrine sys-
tem. (Adapted from LaFleur Brooks M. Exploring Medical
Language: A Student-Directed Approach. 7th ed. St. Louis,
MO: Mosby; 2009.)
Although a complete discussion of endocrine system with age-related norms, gain insight into their ability to coor-
development and function is beyond the scope of this chap- dinate their movements, develop preliminary hypotheses
ter, it is important to recognize the comprehensive integrat- regarding how efficiently they move, and determine which of
ing role and influence these hormones play throughout life in their many subsystems may be preventing them from moving
the ongoing development of aerobic capacity and muscle per- in a more functional or adaptive manner.
formance. As we will see, the development of aerobic capacity By definition, motor development means changes in
and muscle performance are significantly influenced by the motor behavior over the lifespan and the process(es) that
effects of the endocrine system.6 underlie these changes.3 The development of motor skills
at every age is the result of the interaction of the individual
Neuromotor Development and mover, the task(s), and the environment(s) in which he or
she is placed.13 Motor control has been defined as an area of
Motor Control study that attempts to understand the neural, physical, and
The neuromotor skills demonstrated by the infants, chil- behavioral aspects of movement.14 Motor learning is fre-
dren, and adolescents that we examine in the clinic reflect quently thought to be synonymous with motor development
the developmental status and cooperative interactions of and motor control but has been defined as an area of study
their multiple subsystems (eg, muscles, nervous, and ves- that focuses on the acquisition of skilled movements as a
tibular systems) in a given environment as they attempt to result of practice.14 Given these definitions and the purposes
meet the demands of a specific task.7-13 These “snapshot” of this chapter, our focus here will be on neuromotor devel-
views of their neuromotor development afford us with the opment, motor control, and the developmental processes,
opportunity to compare their current level of performance including those within the nervous system, that influence
these 2 characteristics.
44 Chapter 2
Figure 2-18. An illustration of an unmyelinated and
myelinated nerve fiber. (Adapted from Purves D,
Augustine GJ, Fitzpatrick D, et al, eds. Neuroscience. 4th
ed. Sunderland, MA: Sinauer Associates Inc; 2008.)
Neurological Changes in Neuromotor how the developing infant relies on experience to “learn” how
Development and Control to move and control his or her body.
Myelination is the formation of myelin sheaths around
As mentioned in the embryogenesis and prenatal develop- the axons by glial cells (Figure 2-18).15 Myelin is a fatty
ment section of this chapter, nervous system development insulating material that consists of select lipids and proteins
begins during the third week of gestation and may not be that function to insulate the nerve fibers and enhance nerve
complete, depending on the child, until sometime during conduction velocities in the PNS and CNS. Schwann cells
the third decade of life. This is because there are multiple accomplish this task in the PNS while oligodendrocytes
developmental processes within the nervous system itself do so in the CNS. Myelination begins about 24 weeks after
that literally continue throughout life. Here, however, we conception in the spinal cord and moves to the primitive
are concerned only with those changes that occur during hind-, fore-, and midbrain and the periphery during prenatal
infancy, childhood, and adolescence. Thus, concepts such as development. Following delivery, there is an intense period
neural migration, myelination, and neuroplasticity as they of central and peripheral myelination that occurs early in the
affect the child’s developing levels of motor development and infant’s life and continues through adolescence. In fact, mag-
control will be reviewed next. netic resonance images of 111 living children and adolescents
Neural migration occurs in both the peripheral (PNS) and indicate that myelination of the nerve fibers that support
central nervous systems (CNS). Neural migration within the motor functions continues through late childhood and into
embryo and developing child involves chemical processes at adolescence.16 Functionally, this neural maturation process
the cellular and extra-cellular levels and physical relocation explains, in part, why children and adolescents are able to
of various types of neurons and their developing axons. For refine their motor skills and learn to move more efficiently
example, motor neurons are able to move into close proxim- throughout childhood and adolescence. As we will observe,
ity with each other as well as their “target” tissue(s), in this the ability to move more efficiently over time influences
case muscle fibers, because of peptide hormones, cell surface a child’s ability to improve his or her aerobic capacity and
ligands and receptors, extracellular matrix molecules, exist- muscle performance.
ing axons within the CNS, and radial glial cells.15 This allows Neuroplasticity is the brain’s ability to organize itself
them to interact in an appropriate manner during develop- during development or reorganize itself as a consequence of
ment and facilitates the physical relationship needed between a brain injury through the formation of new neural connec-
neurons and their targeted receptors for the child to display tions that result from novel experiences.17 During develop-
typical levels of neuromotor development and control. This ment, as the brain grows and neurons mature, they send out
physical proximity is assumed to be particularly important multiple axons and dendrites that increase the number of
because it enables the developing nervous system to organize synaptic connections within the brain. (Note: Axons send
itself in a manner that is consistent with the neural map(s) out neural signals and dendrites receive information back
needed to generate functional and adaptive motor behaviors from the periphery.) This process increases the number of
over time.15 For example, when infants spontaneously gener- synapses within the brain from approximately 2500 at birth
ate leg movements that involve flexion and extension of their to nearly 15,000 by age 2 or 3.18 Because of genetics and as a
legs at the hip and knee, they strengthen the muscles used to result of evolutionary development of the human brain, new
move their legs at those joints, the efferent neural signals that information coming into the brain via the sensory receptors
result in leg kicks, and the afferent fibers that send sensory “finds” its way to the correct area of the brain. For example,
information back to their brain and cerebellum about the information that excites nerve cells within the eye gets sent to
consequences of those movements.10,11 This is an example of the primary visual area in the occipital lobe of the brain and
not to another area of the brain, such as the motor cortex.
In this way, neural connections between neurons in the eye TABLE 2-2. DEVELOPMENTAL
and the primary visual area of the brain are strengthened. MOTOR MILESTONES DURING THE
If a child is born without vision and the ability to see, then
these connections would not be strengthened over time. FIRST YEAR OF DEVELOPMENT
Instead, they would become weakened and eventually die AVERAGE AGE MOTOR MILESTONE
out. This process is known as synaptic pruning.17 During AGE IN RANGE IN
development, synapses can be selectively strengthened or
MONTHS MONTHS
weakened depending on the experiences the child is pro-
vided. This suggests that the child and his or her developing 0.1 Lateral head movements
nervous system will benefit from a variety of movement 0.8 0.3 to 3.0 Arm and leg thrusts in
experiences throughout infancy, childhood, and adolescence. play
Multiple movement experiences will optimize his or her abil-
ity to strengthen the neural connections that will support a 1.6 0.7 to 4.0 Head erect and steady
relatively rich and diverse movement repertoire during these 1.8 0.7 to 5.0 Turns from side to back
developmental periods.
2.3 1.0 to 5.0 Sits with slight support
Development of Motor Milestones
4.4 2.0 to 7.0 Turns from back to side
To be able to interpret the motor performance of an infant,
child, or adolescent, the examining PT must be knowledge- 4.9 4.0 to 8.0 Partial thumb opposition
able about when in development most children demonstrate 5.3 4.0 to 8.0 Sits alone momentarily
particular motor skills, like rolling over, pulling to a stand,
5.4 4.0 to 8.0 Unilateral reaching
and walking. During the first year of life, developing infants
typically learn to perform a number of gross and fine motor 6.4 4.0 to 10.0 Rolls from back to front
skills.19 These are summarized in Table 2-2. 6.6 5.0 to 9.0 Sits alone steadily
Development of Fundamental Motor Skills 6.9 5.0 to 9.0 Complete thumb
Throughout childhood, the developing child will then opposition
learn to walk, run, and perform a number of other funda-
7.4 6.0 to 10.0 Partial finger prehension
mental locomotor and object control skills.20 These skills
will be refined during childhood depending on the child’s 8.1 5.0 to 12.0 Pulls to a stand
movement experiences and will enable him or her to success- 8.6 6.0 to 12.0 Stand by furniture
fully participate in recreational and sport activities of his or
her choice during late childhood and throughout adolescence 8.8 6.0 to 12.0 Stepping movements
(Table 2-3). Recreational sport and athletic experiences will 9.6 7.0 to 12.0 Walks with help
allow the child to continue to refine his or her movement
repertoire as well as strengthen the neural connections that 11.0 9.0 to 16.0 Stand alone
support his or her well-developed set of movement skills. 11.7 9.0 to 17.0 Walks alone
14.6 11.0 to 20.0 Walks backward
Summary: Using This Information 16.1 12.0 to 23.0 Walks up stairs with help
to Guide the Physical Therapy 16.4 13.0 to 23.0 Walks down stairs with
Examination help
During the initial physical therapy examination, the 23.4 17.0 to 30.0 Jumps off floor, both feet
PT should keep in mind that how the child moves reflects 24.8 19.0 to 30.0+ Jumps from bottom step
the developmental status of his or her neuromuscular and
musculoskeletal systems as well as the integrity of his or her
nervous system and the impact of his or her previous move- In the presence of a known or suspected functional limi-
ment experiences. While it is important to be mindful of tation or participation restriction, the PT needs to uncover
when selected motor milestones are typically achieved, there during examination which system(s) is/are preventing the
is a great deal of variability as to when a given child demon- child from moving more effectively. This will allow the PT
strates a particular skill. As a result, it is equally important to design intervention strategies that will minimize the level
to recognize that each child develops at his or her own rate. of impairment of the involved system(s), expand the child’s
Thus, it becomes our responsibility to facilitate that process movement repertoire, and take advantage of the intrinsic
in light of the child’s strengths and weaknesses. plasticity that exists in all of his or her developing systems.
46 Chapter 2
in ventilation and gas delivery include the nose, pharynx,
TABLE 2-3. DEVELOPMENT OF larynx, trachea, bronchi, bronchioles, and terminal units or
FUNDAMENTAL LOCOMOTOR AND respiratory bronchioles and alveoli.
The aerobic capacity of infants, children, and adolescents
OBJECT CONTROL SKILLS reflects the developmental status of and changes in the heart,
LOCOMOTOR AGE IN YEARS WHEN circulatory system, and lungs. As will be shown, each system
SKILLS CHILDREN DEMONSTRATE affects the relative efficiency of aerobic capacity at rest and
MATURE FORM OF SKILL during exercise throughout these developmental periods.
In addition, these systems also influence how children and
Running 5 adolescents respond to endurance training.
Hopping 8
Skipping 7 Heart Development During Infancy,
Galloping 8 Childhood, and Adolescence
Side slide 5 At birth, a typically developing infant is born with an
intact, fully functional heart. It is, however, considerably
Horizontal jump 9
smaller than it will be later in childhood and adolescence. As
Leap 8 a result, an infant’s heart is able to pump less blood per beat
when compared to the amount of blood pumped per beat by
OBJECT
a child, adolescent, or adult. The amount of blood pumped
CONTROL SKILLS
per beat is known as stroke volume (SV) and depends on
Two-hand strike 8 the size of the left ventricle and myocardial contractility.21
Overhand throw 8 Myocardial contractility does not change over time or with
growth.21 Thus, SV is the primary factory that affects cardiac
Kick 10 output (CO) throughout life. CO generally increases during
Catch 7 development and is the amount of blood pumped by the
heart in 1 minute. It is the product of HR multiplied by SV.
Bouncing ball 7 In equation format it appears like: CO = HR × SV.
Adapted from Ulrich DA. Test of Gross Motor Development 2. A newborn infant’s HR is generally higher at rest and dur-
Austin, TX: PRO-Ed Publishers; 2000. ing activity when compared to a child, adolescent, or adult.
This is because an infant’s heart and left ventricle are rela-
tively small compared to his or her basal metabolic needs and
DEVELOPMENT OF SYSTEMS the energy he or she needs to grow. In fact, a newborn infant’s
average resting HR is 120 bpm.22 This figure can reach as
THAT INFLUENCE AEROBIC CAPACITY high as 190 bpm when the infant is crying and generally will
be higher if the infant is ill, especially if he or she has a fever
DURING INFANCY, CHILDHOOD, AND and/or is fighting an infection.22
ADOLESCENCE Following birth, the heart continues to grow in size
throughout infancy, childhood, and adolescence parallel to
the individual’s body growth and development until matu-
The cardiovascular system is the first organ system
rity is reached. This results in a larger left ventricle, which
to reach a functional state and includes the heart, veins,
results in an increase in SV and CO, and ensures adequate
and arteries, which are all connected in a continuous
perfusion of the body throughout development.
loop system.1,2 The pulmonary system includes the lungs
As children get older, their HRs at rest and with activity
and musculoskeletal structures that support these organs
decrease. For example, at 2 years of age, the average resting
and participate in their physiologic function. The skeletal
HR has dropped to 110 bpm because of the increased size of
system, which provides specific structural support to the
the heart/left ventricle and a corresponding increase in SV
cardiovascular and pulmonary systems, includes the verte-
and CO compared to a newborn infant.22 Throughout child-
bral column, ribs, and sternum, collectively known as the
hood and adolescence, resting HR values continue to decline
thorax. The muscular system contributing to physiologic
so that an average 10 year old’s resting HR is 90 bpm.22 By
function includes the primary and accessory muscles of res-
age 14, the typical resting HR for females is 85 bpm and for
piration/ventilation as well as the muscles that provide for
males is 80 bpm.22 By age 16, the average resting HR has
stabilization of this system. These include the diaphragm,
dropped to 80 bpm for females and 75 bpm for males.22
intercostal muscles, sternocleidomastoid, scalenes, serratus
anterior, pectoralis major, pectoralis minor, trapezius, erec- The resting HR values observed during childhood and
tor spinae, and abdominal wall (rectus, obliques, transverses) adolescence parallel the increase in SV and CO experienced
muscles. The pulmonary system structures that participate by these individuals. Typically, developing children have an
average SV of 3 to 4 mL per ventricular contraction compared
to 40 to 60 mL per ventricular contraction for adolescents.23 TABLE 2-4. NORMAL VALUES FOR
Although SV is generally greater in boys than in girls, this HEART RATE, STROKE VOLUME,
10-fold increase in SV for both genders directly facilitates
the observed lower resting HR and corresponding higher CO CARDIAC OUTPUT, AND BLOOD PRESSURE
values in children and adolescents compared to infants and DURING DEVELOPMENT
newborns.23 Alternatively, maximum HR values for children
and adolescents have been reported to range from 195 to AGE HEART RESPIRA- BLOOD
215 bpm and then begin to decrease by 0.7 to 0.8 bpm every RATE TION RATE PRESSURE
year after maturity has been reached.21 The resting HR, SV, Newborn 120 30 to 40 60 to 90/20 to 60
and CO values during infancy, childhood, and adolescence
are presented in Table 2-4. 1 year 120 20 to 40 74 to 100/50 to 70
2 years 110 25 to 32 80 to 112/50 to 80
Circulatory System Development 4 years 100 23 to 30 82 to 110/50 to 78
During Infancy, Childhood, and 6 years 100 21 to 26 84 to 120/54 to 80
Adolescence 8 years 90 20 to 26 84 to 120/54 to 80
At birth, the lungs expand, which allows for a rapid 10 years 90 20 to 26 84 to 120/54 to 80
increase in blood flow to and from the lungs. Typically, the 12 years
foramen ovale and ductus arteriosus close when the umbili-
cal cord is cut because circulation to the placenta is termi- Female 90 18 to 22 84 to 120/54 to 80
nated, which causes a change in blood flow and an increase Male 85 18 to 22 84 to 120/54 to 80
in BP within the chambers of the heart. This results in the
14 years
reflex closure of the ductus arteriosus and foramen ovale.1
This phenomenon is presented in Figure 2-19. Female 85 18 to 22 94 to 120/62 to 80
If the foramen ovale does not close spontaneously, O2-rich Male 80 18 to 22 94 to 120/62 to 80
blood will leak from the left atrium into the right atrium
instead of moving to the left ventricle and then out to the 16 years
aorta and body. Minor atrial septal defects (ASDs) will Female 80 16-20 94 to 120/62 to 80
present without symptoms, but larger ASDs will need to be
Male 75 16-20 94 to 120/62 to 80
repaired surgically. In a similar manner, if the ductus arte-
riosus remains patent or open, some blood that should flow 18 years
through the body will go to the lungs. This may lead to heart
Female 75 12 to 20 90 to 120/60 to 80
failure and/or cardiac infections. Infants with this condition
are usually treated with medications, while older children Male 70 12 to 20 90 to 120/60 to 80
and adults have their ASDs repaired surgically. These condi-
tions are illustrated in Figure 2-19.
Following delivery, infants and children have hypoki- males will have an easier time delivering O2 to their working
netic circulation.24 This means that their CO is less when muscles.21
compared with adults. This is primarily because infants and BP is the amount of pressure exerted by the blood on the
children have smaller left ventricles and hearts than adults, walls of the blood vessels.24 It is influenced by an individual’s
so their SV—the amount of blood pumped per beat—is less HR, volume of blood, resistance to blood flow due to the
than adults. Thus, as noted earlier, when compared to adults, radius and length of the blood vessels, and the viscosity of
infants and children will have higher/faster HRs at rest and at the blood itself.21 Resting systolic, diastolic, and systemic BP
a given level of work. In addition, infants and children have values all rise during infancy, childhood, and adolescence.
lower levels of hemoglobin in their blood compared to adults. For instance, a healthy full-term newborn infant’s average BP
For example, the total hemoglobin concentration in adults is is on average 60 to 90/20 to 60. By age 10, it will rise to 84 to
approximately 22% greater than in typical 11- and 12-year- 120/54 to 80 and will be 94 to 120/62 to 80 for the average
old children.25 This suggests that they have a decreased 15 year old.21 (These values are summarized in Table 2-4.)
ability to carry O2 in their blood. Fortunately, their lower This trend reflects the increase in SV children and adoles-
hemoglobin levels are offset by an enhanced ability to extract cents demonstrate as well as changes in peripheral resistance
O2 when compared with adults.26,27 Hemoglobin concentra- that are likely due to changes in sympathetic innervation,
tions plateau in females during adolescence but continue to blood viscosity, arteriolar radius, and blood vessels that
rise in males throughout adolescence, which suggests that continue to lengthen as the child grows and develops into
maturity.21
48 Chapter 2
Figure 2-19. Neonatal circulation is illustrated in this figure. Note that both the foramen ovale and ductus arteriosus are now closed,
which allows the infant to circulate blood between the heart, body, and lungs for typical perfusion of all body tissues. (Adapted
from Moore KL, Persaud TVN. The Developing Human: Clinically Oriented Embryology. 7th ed. Philadelphia, PA: Saunders; 2003.)
Lung Development During Infancy, collapsed and the lungs are filled with amniotic fluid. Then,
during the birthing process, the amniotic fluid is expressed
Childhood, and Adolescence from the lungs in 3 ways as they convert to managing gas
exchange and supplying the O2 transport system. Fifty per-
Lung development, similar to heart development and
cent is reabsorbed by the lymph system, and 25% is pressed
function, improves as the child and his or her lungs get big-
out as the infant’s thorax is significantly compressed as it
ger during infancy, childhood, and adolescence. Initially, the
passes through the birth canal. Of course, this does not take
lungs develop as an organ that participates in the production
place if the baby is born via caesarian section; the remain-
and drainage of the amniotic fluid that also fills the devel-
ing 25% is absorbed into the circulatory system through
oping air spaces. Just prior to birth, the existing alveoli are
the capillaries.28 This complex system for expressing fluid
is essential for the conversion to successful gas exchange in
the neonate as the high surface tension in the relatively wet
alveoli causes them to continually collapse.
The 2 physiologic mechanisms that combat alveolar col-
lapse are the filling of the alveoli with air and the production
of surfactant by type II alveolar cells. At birth, the neonate
has a low arterial pH and low partial pressure of arterial O2
that will both drive the respiratory rate and increase ventila-
tory pump action to result in a higher level of ventilation.
Simultaneously, the stretch of alveoli enhances the produc-
tion of surfactant to lower intra-alveolar surface tension.
Consequently, the inhalation of air and the reduction in alve-
olar surface tension by surfactant results in gradually more
and more alveoli unfolding to participate in gas exchange.
During the first 6 months of life, there is a rapid increase
in the number of alveoli, with the process continuing until
the baby is approximately 18 months old. A significant
increase in the size of the alveoli and an increase in the num-
ber of alveoli continue through adolescence.1,2
Support System/Structures
The function of the cardiovascular/pulmonary sys-
tem is interdependent with the musculoskeletal system.
Development of ventilatory pump, gas exchange, and cardio-
vascular pump functional capacity depends not only on the
growth and development of the heart and lungs, but also on
Figure 2-20. Chest wall motions. (Adapted from Massery M. Multisystem
the musculoskeletal system’s increasing structural strength clinical implications of impaired breathing mechanics and postural con-
and endurance capacity as this will impact the ability of the trol. In: Frownfelter D, Dean E, eds. Cardiovascular and Pulmonary Physical
child to perform work against gravity. Therapy: Evidence to Practice. 4th ed. St. Louis, MO: Elsevier-Mosby; 2006.)
The thorax as a structure has been biomechanically
described as having 3 degrees of movement freedom that
allow it to expand in 3 dimensions: anteroposterior, supero- breathing pattern is essential to allow for ventilation during
inferior, and transverse or lateral.29 Expansion and compres- feeding. The intercostal muscles are also immature and are
sion of the chest wall boundaries or surfaces may be assisted unable to produce force for movement of the ribs. The lungs
or resisted by the forces of gravity, strength of supporting have formed with large bronchi and few alveoli. As a result,
muscles, or a support surface. Figure 2-20 shows the 3 chest they have limited vital capacity (VC) and their breathing is
wall motions. shallow and rapid. The typical respiration rate for newborns
At birth, all of the infant’s systems have been influenced and infants up to 6 months of age is 30 to 40 breaths per min-
by the limited space available in the womb. The anterior ute, while infants between 6 and 12 months of age breathe
chest wall is shortened and the connective tissues are short between 20 and 40 times per minute.24 As infants begin to
and tight because of the forward flexed position of the fetus move against gravity and change positions, they strengthen
in the womb. The thorax is triangular-shaped at birth, taking the muscles of respiration, which facilitates migration of the
up only one-third of the trunk. The ribs are positioned hori- ribs in a downward direction. Increased extensor activity
zontally with limited intercostal space and there is sternal relative to their flexed in utero position facilitates the “open-
instability primarily because the skeletal tissue is composed ing up” of the anterior chest wall.
entirely of cartilage. The lack of skeletal rigidity is what Between 6 and 12 months of age, the infant transitions
allows for the compression of the thorax as it passes through to moving against gravity while in an upright position. The
the birth canal and the minimal resistance or load the venti- general muscle strength increases that occur during this
latory muscles face to perform the work of breathing.29 time allow for a downward pull and expansion of the ribs
The work of breathing in the infant is accomplished pri- from the abdominals, diaphragm, and intercostals muscles.
marily through the piston action of the diaphragm.30 The Head control is gained, resulting in elongation of the neck.
diaphragm works by contracting against the load of the The thorax becomes more rectangular in shape and takes
abdominal contents to displace the fluid volume and create up one-half of the trunk cavity.30 Intra-abdominal pressure
the negative inspiratory pressure for inhalation. increases as the diaphragm achieves a more optimal position
Infants at birth are obligatory nose breathers, so the resis- supported by the abdominal viscera and downward pull of
tance of the upper airways has to be overcome. This immature the ribs by the abdominals. The intercostals muscles stabilize
50 Chapter 2
Figure 2-21. Chest wall shape at birth. Figure 2-22. Chest wall shape at 6 months.
age. Further changes occur with growth spurts through bone

growth and lengthening of muscles. The rib cage continues
to rotate downward and does not fully ossify until the mid-
20s.31 Figures 2-21 to 2-23 depict the shape of the chest at
birth, 6 months, and 12 months of age, respectively.
During childhood and early adolescence, there is a marked
increase in total lung capacity. Starting at age 5 years, total
lung capacity is estimated to be approximately 1400 cm3.
By age 14 years, total lung capacity will triple to nearly
4500 cm3. This increase in total lung capacity parallels the
child’s growth in stature and is positively correlated with
the height and weight of the child.32 This increase in lung
capacity results in a slowing of respiration from an average
of 24 breaths per minute at age 6 years to 13 breaths per min-
ute on average at age 17 years.33 Note that this phenomenon
parallels what we observed with heart development; that
is, as the child grows and develops, his or her left ventricle
increases in size, enabling the heart to pump more blood per
beat and minute, which allows his or her HR to slow. Thus,
as children get older and bigger, they tend to show decreased
rates of respiration as well as slower HRs.
Although breathing rates decline during childhood and
adolescence, tidal volume (VT) and VC both increase during
these same periods of development. VT is the amount of air
Figure 2-23. Chest wall shape at 12 months.
that is moved into and out of the lungs during normal inspi-
ration and expiration.21 VC is the greatest amount of air that
the chest wall, allowing for changes in the dimensions of the can be expelled in one single maximum expiratory effort.21
chest during inhalation and exhalation. The general shape of Both increase with lung growth and body size. VC per kilo-
the thorax and chest cavity are established by 12 months of gram (kg) of body weight has been found to be greater in
boys than girls.34 Research has shown that VC per kg to be her cardiovascular system. During infancy, childhood, and
2.5 L for 11-year-old boys and 2.19 L for 11-year-old girls adolescence, aerobic capacity is also affected by developmen-
when mass and height are controlled.34 tal changes in the heart, circulatory system, and lungs as
It is important to note that VT at rest decreases with reviewed earlier. Thus, the development of aerobic capacity
respect to mass and surface area during childhood. For is a dynamic trait that needs to be thoughtfully considered
example, 6- to 8-year-old girls demonstrate VTs of 321 mL/m2 by the PT.
of body surface compared to 297 mL/m2 for 8- to 12-year- Aerobic capacity is often associated with the concept
old females and 242 mL/m2 for 12- to 17-year-old females, of physical fitness. Physical fitness consists of motor fit-
respectively.35 This suggests that the percentage of VC used ness and health-related fitness.38 Motor fitness focuses on
for VT decreases (ie, breathing becomes more efficient as the skills and abilities needed to participate and compete
children develop and mature). This is thought to be the result in athletics. Health-related fitness includes having enough
of improved lung compliance and reduced airway resistance energy to complete activities of daily living (ADL) in an
demonstrated by late childhood.21 appropriate manner and maintaining a low level of risk for
Resting minute ventilation (VE) also decreases during prematurely developing diseases related to being inactive (eg,
childhood but is consistently higher in children than adults hypertension, coronary artery disease, and obesity).39 Four
at all activity levels. VE is the volume of air inhaled or basic components of health-related fitness have been identi-
exhaled in 1 minute and reflects both the rate or frequency fied.40 These include cardiorespiratory endurance (ie, aero-
of breaths taken and VT expressed relative to body size.21 bic capacity), muscular strength and endurance, flexibility,
In equation format, it appears as: VE = VT × respiration rate and body composition. Muscle strength and endurance will
Typically, developing 10-year-old children show VE values be addressed later in the muscle performance section of this
of 200 mL ∙ kg-1 ∙ min-1 while typical 16-year-old adolescents chapter. Developmental changes in aerobic capacity at rest
have VE values of 158 mL ∙ kg-1 ∙ min-1.21 As such, it makes and with exercise during infancy, childhood, and adoles-
logical sense that resting VE would decrease as a result of cence as influenced by development of the heart, circulatory
the decreases observed during childhood for respiration rate system, and lungs will be presented next. The focus here is on
and VT. aerobic activity rather than anaerobic activity.
Maximal VE (VEmax) reflects maximal metabolic activity Aerobic fitness is usually measured by maximum O2
and the influence of excessive carbon dioxide (CO2) pro- consumption (VO2max), which equals the amount of O2 con-
duced during activity and the need to modulate metabolic sumed in mL or L per minute. VO2max expressed in L/min is
waste products, such as lactate, during peak levels of activ- an absolute measure of O2 consumed. It can be normalized to
ity.36 Unfortunately, no normative values exist for VEmax in body weight (mL/min/kg) by dividing the absolute measure
children.21 In spite of this gap in our knowledge, it is thought by the child’s weight in kg.21 Either measure represents the
that VE increases during maximal exercise because of the highest rate that O2 can be delivered and used by working
observed increase in total lung capacity throughout child- skeletal muscle.21 Functionally, it can be thought of as the
hood. It is important for PTs to keep in mind that VEmax time it takes to walk, run, or bike a given distance.21 VO2max
reflects the metabolic rate of the exercising child or adoles- is influenced by multiple factors and generally improves
cent and is influenced by cellular level metabolic processes, throughout childhood and adolescence.21
like lactate production and levels of CO2 in the blood. The factors that influence the development of VO2max
To summarize, as a child gets older, he or she typically include SV, skeletal muscle mass (lean body mass), percent-
experiences an increase in size that parallels the growth he age of body fat, oxidative enzymatic activity within skeletal
or she experiences in his or her heart, circulatory system, muscle cells, the level of hemoglobin in the blood, endur-
and lungs. These changes enable the child’s heart to pump ance training, and nervous system activity.21 VO2max is
more blood per beat and beat less often at rest and with activ- approximately 200 mL ∙ kg-1 ∙ min-1 greater for boys than for
ity; levels of circulating hemoglobin increase and the child girls throughout childhood, but both genders demonstrate
breathes more efficiently as he or she grows and develops. improved VO2max values as they grow and their SV improves
With these thoughts in mind, we can now focus on the devel- over time. For instance, a typical 6-year-old boy will demon-
opmental changes in aerobic capacity demonstrated during strate a VO2max of 1.2 L/min-1 and by age 12 years, and this
childhood and adolescence. will rise to 2.7 L/min-1.41-43 This trend continues to approxi-
mately 16 years of age for boys, but only age 14 years for typi-
cally developing girls.41-43 Girls actually experience a plateau
Developmental Changes in Aerobic or decline in VO2max beginning at the time of puberty, and
Capacity and Endurance Training by age 16 years, their VO2max will be 32% lower than boys
their age.41-43
Aerobic capacity is the amount of physiologic work that
SV has been found to be sensitive to endurance training in
a person can perform as measured by how much O2 he or
prepubescent children. Mobert et al reported a 20% increase
she consumes during activity.37 This ability is influenced by
in SV from 55 to 66 mL for twelve 13- to 14-year-old boys
a person’s age, gender, genetics, experiences, social factors
who completed 7 months of an aerobic training program.44
such as economic status, and the relative condition of his or
52 Chapter 2
Obert et al reported similar results for 10 girls and 9 boys training protocols with adequate levels of frequency, dura-
who were 10 years old after they finished a 13-week aerobic tion, and intensity with nontrained boys and girls have
training program.45 These researchers documented a 15% been completed.44-58 These studies examined the impact of
increase in SV for the boys and an 11% increase in SV for the endurance training on VO2max, resting HR, ventricular size,
girls who participated in this study. plasma volume, and VE in prepubescent children.
Skeletal muscle mass and percentage of body fat have a Improvements in VO2max ranged from 0% to 10% across
positive and negative effect on VO2max depending on the the 15 studies, with an average improvement of 5.8%. Two
gender of the child. Boys show an 11% increase in skeletal experiments specifically examined gender differences in
muscle mass, from 42% to 53%, as a percentage of their body VO2max after completing a 12- or 13-week training program
weight during puberty because of the influence of testos- but did not reveal any gender differences for this trait.46,47
terone.26 Females experience only a 1% increase in skeletal Two additional studies reported that 11-year-old girls had
muscle mass as a percentage of their body weight during greater gains in VO2max than boys of the same age after
puberty.26 Thus, they will have nearly the same amount of they completed an endurance training program.46,48 These
skeletal muscle mass as a percentage of their body weight by authors suggested that the observed post-training gender dif-
the end of puberty as they did at the beginning of puberty. ferences were due to the fact that the girls had lower pretrain-
They will, however, experience a significant increase in ing VO2max values than did the boys.
body fat as a percentage of their total body weight. A typical Resting HR and vascular resistance to blood flow were con-
female gains nearly twice as much body fat during puberty sistently observed to be lower after these children completed
compared to a typical boy.26 This trend reflects gender dif- the required endurance training program.49 Concurrently,
ferences that began prior to birth (eg, newborn baby boys left ventricle size (volume) and plasma volume were found to
average 11% body fat, while infant girls are born with 14% be improved as a result of participating in an aerobic training
body fat) and are observed during childhood, then accelerate program.49
throughout adolescence.21 Ultimately, when a female reaches The length of the training program (duration) did not
maturity, she will, on average, have twice the amount of body show a significant overall impact on any of the variables mea-
fat as a percentage of her total body weight that a boy has sured in this set of studies. However, the 3 longest programs
when he reaches maturity.26 This is due to an increase in the showed the greatest gains in VO2max. These program were
number and size of her fat cells. Functionally, it means that run for 15, 28, and 72 weeks and obtained VO2max increases
her cardiovascular system has become relatively less efficient of 10.3%, 12.2%, and 18.9%, respectively.44,50,51
during puberty, especially when compared to a boy her age. Collectively, these studies suggest that VO2max and the
Oxidative enzymatic activity within skeletal muscle cells traits related to VO2max can be improved in prepubescent
appears to limit the development of and absolute values children. However, the training program must last for a
at maturity for VO2max for adults and children.21 This is sufficient period of time, be frequent enough, and require
because cellular-level aerobic enzyme function decreases at the children to work at high enough levels of intensity to
rest as body mass increases.21 Currently, it is assumed that obtain these benefits. They also show, but do not explain,
this “rule” also applies to when children and adults are work- why children’s gains in VO2max with training are 15% to
ing at peak levels of activity. Unfortunately, it is not known 30% less than those enjoyed by adults who complete similar
whether oxidative enzymatic activity in children improves types of programs, nor do they address how the nervous
with training, nor is it clear why this mechanism functions system affects the development of VO2max in children and
in this manner. adolescents.21
Hemoglobin levels range from 11.5 to 15.5 grams/deciliter The nervous system may affect the development of VO2max
(g/dL) in boys and girls prior to puberty and cannot be used in children and adolescents in several ways. The brain exerts
to explain the gender differences observed in VO2max in pre- a protective influence on exercising children by sending neu-
pubescent children.22,44 However, as noted previously, adults ral signals to the child that lets him or her know that he or
have approximately 22% greater levels of hemoglobin in she is feeling uncomfortable, nauseated, light headed, and/
their blood compared to children.25 These differences occur or is experiencing excessive leg fatigue.21 The perception of
during puberty as boys’ hemoglobin levels rise to 14 to 18 g/ these “fatigue signals” may function to prevent myocardial
dL, while girls experience a smaller increase to 12 to 16 g/ ischemia and cardiogenic shock when the child exercises at
dL on average.22 As result, this difference explains, in part, maximum levels of intensity.21 The autonomic nervous sys-
the greater VO2max values observed in adults compared with tem also influences aerobic capacity by controlling regional
children and why adolescent boys begin to show increased blood flow, perspiration rates, bronchodilation, and myo-
VO2max values when compared with girls their age. cardial contractility. Beyond these protective mechanisms,
Endurance training is the next factor to consider as we it is not clear if these neural activities limit the development
explore the developmental changes observed in VO2max dur- of VO2max or simply function to keep the exercising child
ing childhood and adolescence. Fifteen well-designed stud- safe.21
ies that employed appropriate control groups and sufficient
38
these types of traits. Strength refers to a person’s ability
Summary: Using This Information to generate maximal contractile force. Muscular endurance
to Guide the Physical Therapy depends, in part, on muscular strength and is the abil-
ity of the muscle(s) to perform work when work is equal
Examination to force multiplied by distance. The equation for work is:
Health-related fitness is influenced by multiple factors, work = force × distance.
including aerobic capacity, which is frequently associated For example, if a child moves a 5-pound dumbbell 2 feet,
with physical fitness. Typically, as the child grows and devel- he or she would have performed 10 pounds-feet of work. In
ops, components of his or her cardiovascular and pulmonary equation form, this would appear as: work = 5 pounds × 2 feet =
systems also grow to ensure adequate perfusion of his or her 10 pounds-feet.
body tissues at rest and during activity. It is important for the Muscular power is the ability to generate maximal mus-
examining PT to realize that none of these systems will be cular force in a specified time. In an equation, muscular
mature until the child has completed puberty and reaches a power presents as Power = (force × distance)/time; with power
mature physical state. Until that time, the child’s HR, respira- being defined as the amount of work completed per unit of
tion rate, and VE will usually get lower as he or she develops. time. In the previous example, if a child moves the 5-pound
Simultaneously, BP, SV, CO, VT, and VC will all increase dumbbell 2 feet in 1 second, he or she would have completed
over time. To complete a thorough systems review during 10 pounds-feet per second of work. Likewise, if a child moves
the initial physical therapy examination and subsequent the 5-pound dumbbell 2 feet in 0.5 seconds, he or she would
treatment sessions, it is imperative that the examining PT be have generated 20 pounds-feet per second of work. In equa-
aware of the normal values for HR, BP, and respiration rate. tion format, these examples would look like the following:
This knowledge will allow the PT to rule in or rule out any • Power = (5 pounds × 2 feet)/1 second = 10 pounds-feet/
impairment that may exist in one or more of these functions. second
It is also important for the involved PT to recognize • Power = (5 pounds × 2 feet)/0.5 seconds = 20 pounds-feet/
that, prior to puberty, boys and girls have similar levels of second
aerobic capacity and respond to aerobic training programs
in a comparable manner with the exception that girls often As a result, muscular power increases when velocity
show greater gains in VO2max after completing an endurance increases or time decreases. Because muscular endurance
training program when compared with boys of the same and power are dependent on muscular strength, strength will
age. During puberty, the aerobic capacity of girls plateaus, be the focus of the information presented here.
while the ability of boys to deliver and use O2 during activity
improves. Children of all ages and both genders experience Development of Muscle Tissue
less improvement in VO2max as a result of participating in
The number of muscle fibers that each child possesses is
endurance training programs than adults. In spite of the lim-
established at or shortly after birth. Following birth, muscle
ited impact endurance training programs have on VO2max
tissue enlarges in size because of an increase in the diameter
in children, they do result in lower HRs, less vascular resis-
of individual muscle cells secondary to more myofilaments
tance, and greater SVs and plasma levels after an endurance
within each fiber and an increase in the protein content with
training program has been completed. Thus, aerobic train-
the muscle fibers themselves.59 The skeletal muscle mass
ing programs that are of sufficient frequency, duration, and
of all children, under the influence of GH and insulin-like
intensity are considered to be beneficial to most children.
growth factor I (IGF-I), increases linearly with age until
Finally, the treating PT must keep in mind the protective
puberty. This is because GH and IGF-I promote the devel-
role the nervous system plays in letting the child know when
opment of muscle mass and greater levels of strength by
she is becoming fatigued, feeling nauseated, light-headed, or
promoting muscle protein synthesis during childhood.59-61
otherwise uncomfortable. This is nature’s way of letting her
Prepubescent boys tend to demonstrate relatively larger
know is it time to take a break.
muscles than girls of the same age.21 During puberty, boys
experience a marked increase in muscle mass (11%), while
girls show only a 1% gain in muscle mass during this same
DEVELOPMENT OF time period.21 It has been observed that boys experience this
MUSCLE PERFORMANCE SYSTEMS marked increase in muscle mass and strength approximately
1 year after their peak change in height.59-61 Unfortunately,
DURING INFANCY, CHILDHOOD, there are no data that describe this type of effect in females.21
AND ADOLESCENCE Development of Bony Tissue

Muscle performance reflects the developmental status of There is a gradual increase in bone density throughout
an individual’s muscular strength, endurance, and power childhood for children of both genders prior to puberty.62-67
as well as the influence of his or her nervous system on During puberty, bone density increases from 17% to 70% in
54 Chapter 2
girls.68 These influences may shape when in development the
long bones stop growing for boys and girls. Skeletal devel-
opment is also shaped by movement and the forces exerted
on the bones during movement as well as injuries that may
occur in or near the growth plates located at the end of the
long bones.69 A schematic drawing of a mature long bone is
presented in Figure 2-24.
Developmental Changes in Muscle

Performance and Strength Training
Little is known about the development of strength prior
to age 6 years, but cross-sectional and longitudinal stud-
ies of muscle strength show that children of both genders
safely demonstrate, with no injuries, an increase in isometric
and isokinetic strength when they are trained on weight
machines, free weights, calisthenics, and sport-specific activ-
ities.70-73 These studies examined the effects of strength
training in prepubescent boys and girls and showed that
children demonstrated a 30% to 40% increase in strength
following an 8- to 12-week training program without a con-
comitant hypertrophy of muscle tissue.70-73 The authors of
these studies have suggested that the increases in strength
demonstrated by prepubescent children with training may
be due to learning effects as well as developmental changes in
motor unit firing, motor unit recruitment, nerve conduction
velocity, modulation in CNS inhibition, and/or an increase in
the contractile forces of skeletal muscle. Each of these influ-
ences will be examined next.
A motor unit consists of one motor neuron in the ante-
rior horn of the spinal cord and its axons that synapse with
a number of muscle fibers. The number of muscle fibers
innervated by one motor neuron, depending on the area of
the body involved, may range from 3 to 2000 fibers.21 Note
that motor units fire on an all-or-nothing principle. As a
result, the increase in strength observed in children in the
Figure 2-24. A schematic drawing of a mature long bone. (Adapted
from Whiting WC, Zernicke RF. Biomechanics of Musculoskeletal Injury.
absence of muscle hypertrophy may be due to an increase in
Champaign, IL: Human Kinetics; 1998.) the frequency of firing by a given motor unit and/or recruit-
ment of more motor units during the execution of a given
task. In other words, a given motor unit may fire more often
girls and 11% to 75% in boys, depending on the source.62-67 and/or a child may be able to selectively recruit more motor
Researchers doubt the accuracy of these values because of units while performing a particular task. Both would enable
variations caused by the dual energy X-ray absorptiometry the child to demonstrate more strength without an increase
method of measurement that was employed in each of these in the muscle fibers themselves.
studies. There is, however, general consensus that there is a A second neurological influence on strength develop-
large gain in bone density during adolescence. Several studies ment in childhood is nerve conduction velocity. Research
suggest that peak bone density development occurs between has shown that motor nerve and sensory nerve conduction
the ages of 16 and 26 years for females and 16 and 25 years velocities increase between birth and 4 to 5 years of age.71-73
for males.62-67 Adults demonstrate nerve conduction velocities that are
Several factors influence skeletal development throughout 2 times faster than neonates.73 However, these researchers
childhood and adolescence. For example, hormonal factors noted that nerve conduction velocities are similar between
influence how fast and how much the long bones grow. In 4 to 5 year olds and adults.71-73 Other researchers have found
particular, testosterone, thyroxin, and GH stimulate cell dif- that nerve conduction velocities continue to increase until
ferentiation of the cartilage within the growth plate of long age 20 years.73 As a result, it is possible then that the increas-
bones.68 Simultaneously, estrogen acts to suppress growth of es in strength shown by adolescents may also be due to neu-
the cartilage but stimulates bone growth both in boys and rological factors in addition to the influence of testosterone
in males. Corticospinal tract conduction velocities (motor than muscular endurance or power during childhood and
nerve conduction velocities) have also been found to increase adolescence. In general, muscle mass and strength improves
between children aged 6 to 9 years and young adults between linearly throughout childhood because of the effects of
22 and 26 years old.74 Collectively, these lines of research GH and IGI-I. During puberty, boys naturally experience a
show that increases in strength can be due, in part, to neuro- greater gain in muscle mass and strength than girls do dur-
logical factors into early adulthood. ing this period of development. Concurrently, females will
The final neurological factor to consider is the role of experience a marked increase in their percentage of body
the CNS in the development of strength during childhood fat, which implies from a movement perspective that their
and adolescence. The CNS influences the development of systems will become relatively less efficient as they mature
strength via cognitive, autonomic, and reflexive processes. during puberty.
In particular, the CNS sends signals from the brain through Bone density also increases linearly for boys and girls dur-
the spinal cord that affect the relative contractile force ing childhood. Throughout adolescence, bone density con-
demonstrated by the child as he or she exercises.21 At a tinues to increase for boys and girls because of the influence
conscious level, the CNS can also influence the child or ado- of several hormones. Skeletal development is also sensitive to
lescent’s level of motivation when performing a given task. movement and the forces that are exerted on the bones as the
Subconsciously, the CNS modulates the child’s HR and BP at child and adolescent moves.
rest and during activity. In addition, the autonomic portion Little is known about how children younger than age
of the CNS affects how the child or adolescent may perform 6 years respond to strength training programs, but the
because of its influences on how efficiently he or she loses literature clearly documents that prepubescent children of
heat during exercise via perspiration and controls regional both genders can safely increase their isometric and iso-
blood flow to the muscles, internal organs, integument, and kinetic strength when they complete training programs that
bronchodilation that may or may not enhance the child’s involve free weights, weight machines, calisthenics, and sport
ability to exercise at a given level of intensity during exercise. activities under supervision. These gains are due primarily
For clinicians, it is perhaps most important to realize to neurological factors, so the treating PT needs to recognize
that the CNS exerts a powerful protective influence on the that, prior to adolescence, children may gain strength with-
exercising child and/or adolescent. The relative threshold of out an observable increase in the size of their muscles. With
this central inhibitory function may change during child- training, of course, adolescent boys and girls will continue
hood, but it will always exert this protective function.21 It is to demonstrate increases in muscle size and strength, but it
through this mechanism that the child will sense that he or is essential that the involved PT recognize that the skeleton
she is becoming fatigued and that it is time to stop working. is usually immature prior to and during adolescence, which
This may limit the development of strength but will prevent suggests that children and skeletally immature adolescents
damage to exercising muscles.21 Evidence of this effect is should not perform one-repetition maximum lifts.
observable in the clinic and occurs when the child reports Finally, as we observed in the development of aerobic
feeling nauseated, light headed, or uncomfortable, and/or capacity, the involved PT needs to be aware that the nervous
reports, “I need to stop.” system exerts a protective role in the development of muscle
Currently, it is not clear whether the contractile proper- strength. As such, intensity levels that cause the child to
ties of skeletal muscle cells change during development. feel nauseated, light headed, or unduly fatigued should be
Although this may change during childhood, it is more likely avoided.
that individual muscle fiber architecture improves during
childhood and adolescence.21 This suggests that the angle of
pennation (ie, the angle of the muscle fibers themselves) in INTEGUMENTARY
relation to the direction of the insertion of the muscle tendon
into the bone may facilitate the increase in strength observed SYSTEM DEVELOPMENT
in children. If this relationship improves during childhood
and adolescence, then it would enable the child to show The integumentary system includes the skin and its
greater strength without showing an increase in the size of appendages, such as hair, glands, and fingernails and toe-
the muscle fiber under study. nails, as well as the mammary glands and teeth. Because of
space constraints, only the skin will be examined in detail
Summary: Using This Information here. The epidermis develops from the ectoderm of the fetus
and the dermis arises from the mesoderm.1,2 Initially, the
to Guide the Physical Therapy epidermis consists of only one layer of ectodermal cells.
Examination By week 7 of gestation, a second layer has formed so that
the fetus is covered by a superficial layer of dermal tissue
Muscle performance consists of strength, endurance, known as periderm and a deeper layer called the basal layer.
and power. Because muscular endurance and power are During the remainder of gestation, the periderm is continu-
dependent on strength, it is most appropriate for practic- ously sloughed off. These cells become mixed with hair and
ing PTs to focus on the development of strength rather sebaceous gland secretions to form vernix caseosa.1,2 Vernix
56 Chapter 2
caseosa is a greasy, whitish material that is thought to protect important cardiovascular functions in prepubescent chil-
the skin of the fetus while surrounded by the amniotic fluid dren. The nervous system plays an important and sometimes
in utero. The basal layer serves as a germinal layer that leads protective role in influencing the development of aerobic
to the development of the mature epidermis.1,2 capacity of children and adolescents.
In the absence of significant scar tissue, the skin will not Muscle performance includes strength, muscular endur-
biomechanically limit an infant or child’s movement or abil- ance, and power. An examination of the developmental
ity to exercise. It may, however, affect how a child responds changes that children and adolescents experience in muscle
to exercise if the skin’s ability to generate perspiration is and bony development as well as how they respond to resis-
impaired and limits the child’s ability to lose body heat. tance training indicates that prepubescent children usually
experience linear growth of their muscle mass and strength.
They may safely participate in resistance training programs
SUMMARY that are designed to improve their isometric and isokinetic
strength with multiple types of equipment. They should not,
The purposes of this chapter were to describe typical however, complete any activities that require a one-repetition
development of the cardiovascular-pulmonary, musculo- maximum effort. During adolescence, boys demonstrate
skeletal, neurological, integument, and endocrine systems marked increases in their muscle mass and strength with and
from conception through adolescence and review the devel- without training, but girls do not show similar gains as they
opmental changes that occur in aerobic capacity, muscle mature during puberty.
performance, and neuromotor development/motor control It is recommended that the evaluating and treating PT
during infancy, childhood, and adolescence. To achieve these recognize the important role a thorough systems review plays
purposes, the literature was reviewed in each of these areas in conducting an effective physical therapy examination for
with regard to the PT’s need to be able to understand a child’s children and adolescents. This necessary first step provides
movement patterns and then correctly predict how he or she the basis for completing a comprehensive examination of
will respond to therapeutic interventions. the child or adolescent that will reveal his or her individual
Our review of embryology and prenatal development strengths and weaknesses and current levels of development.
revealed that the first trimester is the most critical or sen- Then, an effective and efficient treatment program can be
sitive period for typical development of all body organs, implemented.
systems, and structures. This area of study provides us with
the foundation needed to understand the beginning of devel-
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58 Chapter 2
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growth parameters. J Clin Endocrinol Metab. 1990;70:1330-1333. specialized instruction, or demonstrates an educational
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1988;43:260-262
in general education. Physical therapy is a related service
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72. Carter DR, Fyhrie CB, Whalen RT. Trabecular bone density and cal therapy is available to a special education student who
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Fitness. 2002;42:267-273.
Social History/Environment
CASE 2-1 Jill lived with her mother, stepfather, and 2 brothers aged
5 and 9 years in a 3-bedroom split-entry home. Her mother
worked at a law office as an administrative assistant. Her
Joanell A. Bohmert, PT, DPT, MS stepfather was a department store manager. Her father lived
2 hours away and worked in construction. Jill would spend
holidays and 1 month in the summer with her father.
EXAMINATION Jill was a ninth-grade student at her neighborhood high
school. To accommodate the large number of students, the
History school building was large and multilevel with elevators. She
used a manual wheelchair for her primary mobility. She was,
Current Condition/Chief Complaint however, able to walk for short, in-room distances by holding
onto objects or with the assistance of a classmate or teacher.
Jill, a 15-year-old female with cerebral palsy (CP), was
Jill had an Individual Education Plan (IEP) that listed accom-
referred to physical therapy for an evaluation as part of her
modations and program modifications that she needed while
comprehensive 3-year reevaluation for special education ser-
at school. The accommodations included the following:
vices. She was a general education ninth-grader at her local
public high school. • A table/desk close to the classroom exit door
• Shortened or modified assignments
Clinician Comment CP is a nonprogres- • Copy of teacher’s notes
sive neurological condition that results from an insult to • Extra set of textbooks to keep at home
the CNS in utero, at birth, or within the first 2 years that
• Early release from classes to avoid congestion in hallways
results in a movement disorder.1 Cognition, learning abil-
ity, vision, and hearing may also be affected. The term CP • A locker on the end of a row
covers a wide array of symptoms that have been classified • Assistance for getting lunch and carrying a tray
by area of body affected, type of movement disorder, or
• Use of handicapped-accessible bathroom with rails and
functional movement abilities.
large enough to accommodate her wheelchair
While the pathology in the CNS does not progress, it has
• Special transportation
ongoing impact on development, growth, and movement.
CP affects motor coordination, postural control, and the • An evacuation plan
use of muscles in a smooth, efficient manner. The ability of Jill was reported to be a good self-advocate by informing
the muscle to relax, extend, or contract easily and smoothly her teachers of her abilities and needs.
may also be affected. Spasticity may be present and may
interfere or assist with movement and posture.2
from this surgery was to be removed in the upcoming sum-
Clinician Comment Transition to high school mer. She had solid ankle-foot orthoses (AFOs) following sur-
is a major event. Students typically move from a smaller gery to assist in maintaining length of her Achilles tendons.
middle school to a larger high school. In Jill’s case, she went
from a single-level middle school with 1240 students to a
large, multilevel high school with 2870 students. Clinician Comment Spasticity is a symptom
The physical environment at home, school, and in the com- of an upper motor neuron insult that presents as muscle
munity may be a challenge for Jill when using her wheel- hyperactivity to a velocity-dependent passive stretch.2,5,6
chair or when walking. The environment can aid or hinder It can interfere with the ability of the muscles to function
movement. She also needed to be aware of how the envi- appropriately and may affect range of motion (ROM) and
ronment changed when people were added and it became movement.7 It can also provide tension in the muscle that
highly variable and unpredictable. An open hallway was allows the performance of functional activities.2,8 Spasticity
easy to wheel through when empty but quite challeng- has been viewed as a major contributor to the difficulties
ing when filled with students going in multiple directions with movement and function in children with CP and is
or just standing still, talking, and passing time. Jill also frequently managed with pharmacological agents, surgery,
needed to be aware of routes to exit her home or school for orthotics, and therapy.2,8-10
emergency evacuation as the designated route may not be Botox, or botulinum toxin, is a medication that provides
accessible to her. a chemical denervation of the motor unit within a specific
muscle, decreasing its ability to contract.2 It is adminis-
tered through injection into the muscle at the motor unit
Social/Health Habits endplate, causing inhibition of acetylcholine release at
the synaptic cleft.11 It has been used in children with CP
Jill and her family were very active in school and commu-
to decrease muscle tightness and improve movement by
nity activities. Jill enjoyed going out with friends, shopping,
decreasing the ability of the muscle to contract. There has
movies, and reading. The family had a family membership to
been debate about spasticity and how it actually affects
a community health club. She enjoyed using the pool at the
movement, which has resulted in reconsideration of Botox
health club. She hadn’t used the weight machines because she
as an appropriate method of improving function.2,7,9,10
didn’t think she could get on and off or lift the weights.
An ITBP is an implanted device that provides baclofen
medication directly into the intrathecal space of the spinal
Clinician Comment Jill enjoyed going out column.8,12 It provides a more general impact on overall
in the community and participating in activities with her limb or trunk spasticity and is removable if it is not effective
brothers and friends. Membership at the community health for the individual.2 The ITBP is about the size and shape of
club allowed her to incorporate fitness into her weekly a hockey puck that is inserted through an incision over the
routine. lateral aspect of the abdomen. It is secured in place under
the skin, over the abdominal muscles. A catheter is attached
to the pump and runs internally to the spine. Through a
Medical/Surgical History small incision along the spine, the tip of the catheter is
inserted into the intrathecal space of the spinal column. The
Jill was diagnosed with CP, spastic diplegia, as an infant.
vertebral level at which the catheter is inserted is dependent
Jill was born at 28 weeks weighing 2 pounds, 6 ounces. She
on the functional effect that is desired. For example, place-
had delays in gross and fine motor skills, while language and
ment at T10 or lower will affect the legs more than the arms,
cognition followed appropriate developmental milestones.
while placement at C5 to T2 will affect the arms more than
Jill had multiple orthopedic surgeries to correct the align-
the legs.8,12
ment of her legs. Jill’s spasticity had been managed with
Botox injections to specific leg muscles at various times Orthopedic surgeries are used to correct alignment issues
throughout her childhood. Jill reported that the injections that may be present because of imbalance in muscle ten-
were not successful, so she had an intrathecal baclofen pump sion, flexibility, and decreased strength. The purpose of
(ITBP) implanted 4 years prior. Jill reported she felt her legs SEMLS of the LEs is to decrease crouch and prevent future
were “looser” and it was easier to move since she had received complications of crouch including arthritis, pain, contrac-
the pump. tures, and loss of walking ability as an adult.13,14
Her most recent orthopedic surgery was a single-event A proximal femoral derotation osteotomy is performed
multilevel surgery (SEMLS) 2 years prior and included bilat- to correct excessive femoral anteversion that leads to hip
eral proximal femoral derotation osteotomy, bilateral distal internal rotation and subluxation. It involves removing a
femoral extension osteotomies, bilateral patellar tendon wedge of bone of the proximal femur then rotating the bone
advancements, right distal tibial derotation osteotomy, and to the desired angle of alignment. The new bone location is
bilateral Vulpius Achilles tendon lengthening. Her hardware secured with pins, screws, and/or plates.
60 Chapter 2
A distal femoral extension osteotomy is performed to devices such as forearm crutches, walking sticks, or various
increase knee extension lost because of excessive crouch canes as these could be easily attached to the wheelchair.
when standing and walking.14 It involves removing a wedge Jill would like to be more independent. She would like to be
of the distal femur from the anterior surface then realigning able to do more with her friends but has difficulty getting
bone and securing it in place with screws and plates. into their vans or trucks. She also would like to be able to
A patellar tendon advancement is performed to correct for walk up and down stairs instead of scooting on her seat. At
an over-lengthened patella tendon as a result of a crouched school, she would like to be able to change into shorts and a
stance/gait.14 If the epiphyseal plate is still present, only the T-shirt for physical education.
tendon is moved. If it is closed, then a wedge of bone with
the tendon attached is cut out of the proximal tibia and
moved lower and reattached with plates, screws, wire, or Medications
sutures.
Jill had an ITBP implanted 4 years ago. Her baclofen
The Vulpius Achilles tendon lengthening is performed to dosage was monitored at her medical facility. She had an
lengthen the Achilles tendon and correct pull on the cal- increased dose before bed to aid in sleeping and a smaller dose
caneous.13,15 It is performed through a longitudinal inci- throughout her day. She did not take any other medications.
sion over the Achilles tendon, which is then cut to allow
lengthening.
Clinician Comment ITBPs are used to deliver
a specific dosage of baclofen directly into the intrathecal
Reported Functional Status space of the spinal column. The pump holds a reserve of
medication, in this case baclofen, which is released based
Jill reported that she was fairly independent getting
on the programming of the pump. The pump is refilled
dressed at home but needed help getting her shoes on over
using a transdermal needle puncture.12 How frequent the
her AFOs. She did her own hair and makeup. She was inde-
pump needs to be refilled is dependent on the dosage and
pendent with bathing, including getting in and out of tub
the size of the pump. Baclofen is used to decrease muscle
with the use of a bath chair outside of the tub to assist her
tone. It can be taken orally; however, it is more effective
transfer. She was able to do simple cooking. She had con-
when delivered directly into the spinal fluid. Baclofen, act-
cerns about using the stove and oven because her impaired
ing prior to the synapse, inhibits and suppresses the excit-
balance might compromise her safety handling hot items. Jill
atory neurotransmitters at the synaptic junction.16 When
reported she needed some assistance with dressing at school,
the desired outcome is to have more effect on the legs, the
such as getting her coat on and changing for physical educa-
catheter is commonly placed between T8 and T12. While
tion. At home, she walked up stairs using the wall and hand
this level will affect the legs, it will also affect the activity
railing, but she would often scoot down on her seat as she felt
of the abdominals, which may make it difficult to gain
safer and it was faster.
strength to stabilize the core for weight shifting through the
Jill reported she used her wheelchair at school because pelvis. Adjusting dosage and delivery times to allow more
she did not think she could walk safely in the congested activity for strengthening and use of muscles may be ben-
hallways. She left class early, which helped her avoid crowds. eficial. Reviews on use of ITBPs in children and adolescents
Jill reported she would like to be more independent in her with spasticity who can walk indicate that it may improve
mobility and daily routine. She wanted to be able to be more their ability to move, but it does not change their level of
active in her community. She especially wanted to go to her functional walking.2,8,17 Possible loss of function needs to
friends’ houses. This was difficult because it required trans- be considered if the individual is using her spasticity to
porting her wheelchair, and her friends’ homes might not be stand or transfer.
accessible. Jill wanted to improve her ability and confidence
with walking.
Other Clinical Tests

Clinician Comment Students with CP who
were walkers in elementary and middle school frequently Additional educational testing took place as part of this
transition to using a wheelchair as they age as the amount comprehensive educational evaluation. Cognition and aca-
of energy needed to walk greater distances in shorter peri- demic status were assessed by the school psychologist; com-
ods is too high. It is also challenging to use a wheelchair in munication by the speech and language pathologist; impact
the halls and a walker in the classroom as it is difficult to of disability on education by the special education teacher for
transport a walker while wheeling. Staff could transport a students with physical and health disabilities; and motor skill
walker; however, this is not reality in future settings or in development and abilities by the adapted physical education
current community settings. Jill needed to bring one or the teacher. Jill qualified for special education under the category
other. It would be appropriate to explore other assistive of Physically Impaired. She also qualified for adapted physi-
cal education.
Clinician Comment Jill had a diagnosis that first in the fit of orthotics, so they should be monitored on a
was known to affect movement and ability to participate in regular basis. Pressure-relieving strategies need to be used
home, school, work, and community activities. She had a throughout the day.
supportive family and school program and was interested
in becoming more independent. She reported decreased
strength and endurance and safety concerns. Musculoskeletal
Next, in the examination portion of the evaluation, was Gross Symmetry/Posture
the systems review. The limited examination of the systems
Jill’s standing posture was asymmetrical with shoulders
review aided in the identification of indicated tests and
rounded forward, increased lumbar lordosis, and internally
measures as the examination moved forward as well as
rotated and flexed hips and knees. Her sitting posture in the
establishing that there were no contraindications for Jill to
wheelchair was asymmetrical. She sat with her trunk leaning
be seen in physical therapy. As Jill had a diagnosis that was
to the left with rounded back and shoulder girdle posture and
known to affect her systems, it was expected that her results
her pelvis rotated forward on the left, causing the left knee to
would vary from typical.
be further forward than the right.
Gross Range of Motion
Limitations in gross active shoulder, hip, and knee
Systems Review motions.
Cardiovascular/Pulmonary Gross Strength
HR (resting): 94 bpm Limitations noted in extremities and trunk.
Respiration rate: 24 bpm Height/Weight
BP: 100/70 mm Hg 61 inches; 108 pounds
Edema: no edema present
Clinician Comment Jill demonstrated vital

Clinician Comment It is common to have
asymmetry and postural deviations with CP. Changes in
signs within the normal range for typical adolescents
posture may be due to multiple factors, including decreased
when at rest. CP frequently results in difficulty moving in
strength, limited ROM, contractures, and difficulty with
an efficient manner, so it was important to measure Jill’s
movement.
response to activity and exercise to determine not only
how she responded to movement, but also how quickly she
recovered.
Neuromuscular
Balance
Integumentary
With her AFOs, Jill was unable to stand still in one place,
Skin Integrity requiring stepping to avoid falling. She tended to weave and
Jill had mild acne on her face. She wore bilateral solid- used increased trunk movements to maintain her balance.
ankle AFOs. Her skin was calloused over the medial mal- She reported falling whenever she was bumped while in class
leolus, bilaterally, especially on the right. She reported no or tripped herself.
problems with skin breakdown from sitting. She relieved Locomotion
pressure by getting out of her wheelchair or doing wheelchair She was able to wheel her manual wheelchair indepen-
pushups. dently for distance. She walked in classrooms using the wall
Presence of Scar Formation or objects for balance. Observed lateral sway when walking
Jill had well-healed incision scars bilaterally on hips, in class with or without hand support.
thighs, knees, and over her Achilles tendons from previ- Transfers
ous orthopedic and soft tissue surgeries. Also, she had a Reported independent from wheelchair to/from walker,
well-healed incision scar on her right lower abdomen and desk, and toilet.
posterior spine from placement of the intrathecal pump and
catheter. Transitions
Movements were slow and deliberate. Jill had difficulty
ascending and descending stairs and needed to use the
Clinician Comment Use of orthotics and handrail going up or down. She had difficulty with eccentric
assistive devices can result in pressure on bony promi-
control and sustaining postures when moving. This was seen
nences, which can affect alignment and position of feet,
when she was descending stairs and when she lowered herself
legs, and body. Changes as a result of growth are often seen
to sit in her wheelchair or desk.
62 Chapter 2
Clinician Comment Observation of move- Tests and Measures

ment provided valuable information that helped to decide
what needed further testing. Jill demonstrated ability to Aerobic Capacity/Endurance
move independently using natural supports. While this Energy Expenditure Index (EEI): Jill was asked to walk
type of movement may be considered functional for CP, it independently at a fast pace for 2 minutes. She was able to
was not performed with the speed or efficiency of her peers. walk the entire time but would periodically veer toward the
wall, touching it to maintain her balance. The following mea-
sures were recorded:
Communication, Affect, Cognition,
Language, and Learning Style HEART OXYGEN
Jill reported she got As and Bs in her classes. English RATE (BPM) SATURATION %
was her first language. She preferred demonstration and Starting 103 98
picture diagrams for learning movement. She reported that
she learned better by listening and discussing in classes. Jill Stopping, after 188 100
was alert and oriented to person, place, time, and situation. 2 minutes
She demonstrated selective attention typical for her age. MINUTES OF RECOVERY
Interested in becoming more active and fit, she was moti-
1 132 96
vated to improve her movement.
2 110 97
Clinician Comment Jill demonstrated charac- 3 107 97
teristics that were consistent with a diagnosis of CP spastic 4 106 97
diplegia. While her resting vitals were within an acceptable
range, it needed to be known how she responded to activity. 5 103 96
Testing of her aerobic capacity and endurance was needed.
Since children with CP tend to grow at a slower rate, it was
important to have baseline measurements for height and EEI in Heartbeats/Meter
weight as well as other anthropometric measures to docu-
ment rate of change. Her ROM was limited actively and her Wheeling regular pace 0.168
posture suggested potential contractures.
Wheeling at fast pace 0.334
Individuals with CP have difficulty moving as part of their
condition; it was important, therefore, to determine what Walking independently at regular pace 1.24
was interfering with her movement and mobility indepen- Walking independently at fast pace 1.80
dence. Her muscle performance was decreased as demon-
strated in posture and gait deviations and difficulty with
balance. Her motor function needed further examination Clinician Comment The EEI measures the
looking at how she planned and varied movement. amount of energy used over a 2-minute walk or run. It is
Fit and functional use of her wheelchair and assistive easy to use in a school setting and is based on change in HR
device needed to be evaluated. The integumentary screen over distance walked per minute (walking HR – resting HR/
identified a number of scars; however, all were healed and distance in meters/minute).18-20 The result is a ratio that
did not require further examination. Her orthotics did need provides the heart bpm walked. Resting HR was measured
further examination to assess their fit in relation to her after sitting for 5 minutes. Walking HR was the HR taken
growth as well as the impact on her function. immediately upon stopping the walk. Rate of recovery can
also be measured by tracking HR each minute for 5 minutes
Jill was 15 years old and in high school, so areas of transi-
after stopping. O2 saturation may also be measured when
tion needed to be assessed to further address her function-
a pulse oximeter is used. A measurement wheel is used to
ing in self-care and home management, as well as work
measure distance walked; an advantage of this instrument
and leisure integration. Environmental, home, and work
is you can follow the path walked by the student rather than
barriers as they limit or aid function needed to be assessed.
just a straight line.
In typically developing adolescents, 0.4 bpm is common for
walking at a preferred pace, while running is 0.7 bpm.18,20
Jill’s EEI demonstrated she was very efficient when wheel-
ing on a flat, smooth indoor surface. When walking, how-
ever, her energy use spiked, indicating she was using a lot
of energy to walk, even when walking at her preferred rate. Body Measurements/Circumference
She walked farther in her first minute compared to the sec-
ond, indicating she had little reserves from which to draw. AREA MEASURED MEASUREMENT (INCHES)
The EEI requires walking for only 2 minutes, which is too *All measurements are circumfer-
short of a time period for Jill to get to most of her classes. ence except height and weight
In addition to improving her aerobic capacity and endur-
ance, Jill needed a method to conserve her energy to allow LEFT RIGHT
optimal academic performance throughout her school day. Height 61
Whether to use the wheelchair or to walk still needed to be
Weight 108 pounds
determined.
Shoulders 34
Chest (under arms) 32
Anthropometric Characteristics
Bicep (flexed) 97/8 101/4
Body Fat Composition Forearm (wrist 9 95/8
flexed)
SKINFOLD CALIPER MEASUREMENT
Waist 28
Side (Dominant) Area Measurement (mm)
Hips 347/8
Right Tricep 16
Thigh (midpoint) 173/8 173/4
Right Bicep 6
Thigh (widest point) 187/8 191/8
Right Subscapular 12
Calf (widest when 113/8 113/8
Right Suprailiac 16 flexed)
Total mm measured 50
% body fat 26.5
Clinician Comment Body circumference is
measured using a standard flexible tape measure. The
purpose of measurement is to evaluate how interventions
Body Fat Percentage
affect changes in body dimensions. Body circumference is
frequently used to monitor weight loss as it more accurately
Body fat handheld analyzer 27.4% measures change than weighing. The comparison is against
Skinfold measurement 26.5% self and not other adolescents as there are no standard-
ized measures. Circumference measurements are often
Height/weight formula (kg/m2) 20.43%
motivated as they show the student how his or her body
has changed with exercise that may be attributed to weight
loss and/or muscle gain. It is important to take height and
Clinician Comment Body composition may weight measurements at the same time as circumference
be measured in many ways. For body fat, it has become
since changes in circumference may also be from growth or
popular to use an impedance device such as a handheld
weight gain/loss.
analyzer or a scale as it is easy to administer and takes
age, weight, height, and gender into consideration. Another Overall, Jill appeared healthy with weight appropriate for
method is the use of a skinfold caliper in which the skin in height. It was noted that the widest part of calf was just
4 specific locations (tricep, bicep, subscapular, suprailiac) below her knee joint and stopped on top of where her AFO
is pinched and measured with the specifically designed ended. Her lower leg was very flat under the area covered
caliper. The last method is to calculate the body mass index by the AFO. Her feet also appeared flat with little muscle
(BMI) using height and weight. There are a variety of for- development and definition.
mulas that attempt to take age, gender, and muscle mass Jill demonstrated body dimensions for her right arm and
into account; however, this calculation may overestimate leg (her dominant side) that were slightly larger on the left.
or underestimate the actual percentage of body fat. While Lack of lower leg and foot muscular development is typical
none of these methods are totally accurate, they are easily when AFOs, especially solid ankle, are worn. An AFO is
available and easy to use in the clinic or school setting and designed to restrict unwanted movement and may, there-
give an estimation of body fat. Because of the impact of fore, limit muscle development. It can impose a “ forced
the endocrine system on body composition at puberty, it disuse” of the lower leg, ankle, and foot. The gastrocnemius,
is important to use a scale that differentiates males and being a 2-joint muscle, will develop above the brace but is
females. limited in how much it can develop because of the constraint
64 Chapter 2
of the brace around the leg and the limited (or no) motion the lower leg is to full knee extension, or 0 degrees, the lon-
at the ankle. For development of ankle and foot muscles, ger the hamstrings.
the ankle needs to be allowed to move. Consideration needs Jill had limitations in hip extension and external rota-
to be given to the benefits and limitations of orthotics in tion with excessive motion in internal rotation. Her knee
relation to the development of strength while maintaining extension lacked full ROM while her hamstring length
appropriate alignment. was decreased (more on the left than right). Passive range
of motion (PROM) is greater than active range of motion
(AROM) due in part to decreased strength to actively move
Range of Motion (Including Muscle the joint. This was especially seen in ankle motions.
Length)
Joint ROM was measured with Jill lying supine on an
Muscle Performance (Including Strength,
examination table. Measurements were taken at the end
of available passive motion using a 360-degree goniom- Power, and Endurance)
eter. Motion was provided at a slow, steady pace to decrease Hip flexion, knee extension, knee flexion, and hip abduc-
changes in muscle tension during movement. tion strength were measured using a handheld dynamom-
eter (HHD) in a “make” test. Hip flexion, knee extension,
and knee flexion were measured sitting on a leg extension
JOINT MOTION LEFT RIGHT
machine with a seat belt around the pelvis with the hip and
(DEGREES) (DEGREES)
knee at 90 degrees. The dynamometer was placed 2 inches
Hip flexion 0 to 123 0 to 127 from the top of the patella for hip flexion, 2 inches above
Hip extension -15 -10 the bend in the ankle for knee extension, and 2 inches from
the base of the heel on the heel cord for knee flexion. Hip
Hip external rotation 0 to 20 0 to 30 abduction was measured with Jill lying on her side on a mat
Hip internal rotation 0 to 60 0 to 50 with her pelvis and trunk stabilized by one examiner. The
dynamometer was placed on the lateral aspect of the femur
Hip abduction 0 to 30 0 to 40 2 inches above the knee joint. Each muscle group was mea-
Hip adduction 0 to 40 0 to 30 sured 3 times, with each trial lasting 4 seconds. The highest
force produced was recorded.
Knee flexion 18 to 153 15 to 156
Knee extension -18 -15
MUSCLE LEFT RIGHT
Ankle dorsiflexion 0 to 25 0 to 27 GROUP (POUNDS) (POUNDS)
Ankle plantarflexion 0 to 31 0 to 35 Hip flexion 29 39
Hamstring length̶ 37 short of 25 short of Knee extension 30 48
popliteal angle full extension full extension
Knee flexion 4.0 6.3
Hip abduction 8.9 12.1
Clinician Comment When measuring hip
motions, it is important to note the position of the pelvis.21
Individuals with CP often have an anterior tilt of the pelvis Ankle plantarflexion was measured standing using the
even when supine. This anterior tilt can result in an inac- number of toe raises performed with the knee straight and
curate measurement of the hamstrings. They will measure then bent. Single leg (20 considered Normal; 19 to 10, Good;
shorter than they actually are as they are already in a par- 9 to 1, Fair) Right (R): 2 able to lift heel 1 inch (not full range);
tially lengthened position due to the tilt of the pelvis. Left (L): 1 able to lift heel 0.5 inch (not full range). Ankle
dorsiflexion: unable to lift toes in standing; when supine,
Hamstring length is traditionally measured using a straight
note minimal movement of ankle and toe extensors R greater
leg raise. This may be difficult to measure in individuals
than L.
with CP because of increased stiffness, difficulty isolating
Abdominal strength was measured with Jill supine on
leg motions, and increased anterior tilt of the pelvis. An
a mat performing a sit-up. With her arms crossed over her
alternate measure, the popliteal angle, is often used.22 This
chest, she had difficulty lifting her head and shoulders off the
is performed by holding one leg in extension on the mat,
mat. She was unable to isolate and use her transverse abdom-
then placing the other hip in 90 degrees of flexion with the
inals (maximal inhalation then forced exhalation causing
knee in 90 degrees of flexion. The lower leg is then raised
stomach to flatten toward spine), or obliques or rectus.
while keeping the hip at 90 degrees. The measurement is
taken when the lower leg can no longer be raised. The closer Functional strength: When going up the stairs and wear-
ing her AFOs, Jill had difficulty flexing either hip enough to
place her foot on the next step. Without her AFOs, she had
force over a period of time. Functionally, she was limited in
adequate hip flexion but had difficulty dorsiflexing her foot
activities that required sustained as well as controlled con-
to clear her toe. With and without her AFOs, she had poor
traction. She was able to complete short bursts of strength
eccentric control for going down the stairs and lowering
but did not have the reserves to sustain anaerobic or aerobic
herself from standing to sitting, and slow controlled move-
activities. The majority of activities that Jill needed to per-
ments. Jill had poor contraction around her hip and pelvis for
form required power moves versus endurance: sit to stand,
single-leg stance. In regular standing, Jill stood with her hips
transfers, stair ascending/descending, and single-leg stance.
and knees flexed and internally rotated and had difficulty
It was critical that her intervention program included
externally rotating her hips and straightening her knees. Jill
training specifically for anaerobic muscle use.
had difficulty keeping her pelvis and legs forward while side-
stepping. She was unable to sustain trunk and leg strength Jill’s difficulty with core strength (abdominals) may be
for activities such as transfers into vans and trucks. She was related to placement of the ITBP catheter at T8-10. Baclofen
unable to produce enough force to lift moderate-to-heavy may also affect the strength of hip muscles, especially
objects in sitting or standing. She was also unable to sustain smaller muscles around the hip used for stabilization and
strength to maintain a stable posture to lift her wheelchair. external rotation.
Clinician Comment In adolescents, manual Posture

muscle testing (MMT) may be used to assess strength.
However, in individuals with CP, it may be difficult for Jill stood in a crouched (hip and knee flexion with hip
the student to isolate movement because of difficulties internal rotation) pattern. She had increased lordosis in
with motor control and spasticity. MMT may be beneficial her low back and kyphosis in her mid-back. Her head was
to determine strength that is below normal, but having forward and her shoulders rounded. When wearing her
a normal grade of strength may not translate to having AFOs, she stood forward on the ball of her foot, heels off the
enough strength or force generation to perform functional ground. This threw her trunk forward, so to counterbalance,
tasks. Hislop and Montgomery23 provide a description of she had to pull her upper trunk posterior, which increased
muscle activity pattern for typical functional activities for her lumbar lordosis.
infants and children that may also be used when examining When sitting, Jill had more weight on the right hip with
functional strength in older children and adolescents. In her legs windswept to the right and her trunk leaning to the
adolescents, it is important to be aware of the relationship left to counterbalance. Her trunk was also collapsed into
between the strength of the examiner to that of the student. flexion. Jill stated her preferred posture felt “normal” or in
It is also important to standardize tester, position, and any centered alignment. She was not aware of her posture or
other conditions to improve reliability between measures. how to correct her posture so that she was in midline and
MMT, functional skills, or dynamometry, depending on the symmetrical.
purpose of examination, may be used to measure muscle
strength.
Clinician Comment With CP, there are differ-
An HHD is an objective method for measurement force ences within a limb or the trunk as well as between limbs.
production in the school or clinic setting. It is a valid and Muscle stiffness, joint contractures, and difficulty with tim-
reliable way of measuring isometric strength of a muscle ing and sequencing may all contribute to poor alignment.
group at a specific joint angle that is used to measure the Changes in visual spatial perception, righting reactions,
impact of the strengthening program. When using an HHD, and somatosensory may also impact alignment. Movement
it is important to standardize the position of the individual, and the ability to use functional strength to initiate move-
placement of the HHD, type of test (make or break), length ment and sustain postures also influence posture.
of each trial (2 to 6 seconds), and examiner administering
Jill’s posture was consistent with her limitations in joint
the test.24 A make test requires the individual to push as
ROM and decreased muscle strength. She demonstrated
hard as he or she can against the HHD while it is held in
a lack of awareness of where her body was in relation to
one place. The break test requires the examiner to exert
upright midline positions. This made it difficult for her to
tension against the individual while he or she attempts to
correct or fix her alignment on her own.
hold the position. Either test has been shown to be appro-
priate with children, with the break test resulting in higher
force production values and the make test being easier for
children to understand and perform.24 Gait, Locomotion, and Balance
Jill demonstrated deficits in muscle strength, power, and Gait
endurance. It was important to consider not only the Jill had 2 forms of mobility: she could walk for short dis-
patient’s ability to produce force for a few seconds (test- tances in her classroom or at home, and she wheeled herself
ing situation), but also the ability to produce and sustain in her manual wheelchair for moderate and long distances.
66 Chapter 2
She was independent in propelling herself in her manual
wheelchair throughout her school and home environments. Clinician Comment The Gross Motor
She reported she had difficulty wheeling or walking on grass, Function Classification System-Expanded and Revised
rough terrains, snow, and ice. When going up or down stairs, (GMFCS-E&R) was developed to categorize children with
Jill would go one step at a time, leading with her right leg. She CP based on their self-initiated movement in daily life.25
was able to go up and down a standard curb but would stop The 5 levels emphasize what abilities can currently be
before stepping off it. performed in typical environments such as home, school,
When walking in the hall, Jill trailed the wall (walked and community. It is different from other tests in that it is
with one hand sliding along the wall) to keep her balance interested in what individuals do versus the quality of how
and decrease the amount of energy she used. She could walk they do it. The GMFCS includes youths aged 12 to 18 years
3 to 10 feet without touching a support surface or object. She as well as the concepts of the World Health Organization’s
had used a reverse walker in the past but preferred to now International Classification of Functioning, Disability and
walk without an assistive device. Her gait was different when Health (ICF). It is a common classification for individuals
wearing her AFOs compared with not wearing them. When with CP and reports at what level the individual is function-
wearing her AFOs, her hips were internally rotated and ing.26 For example, Level I is Walks Without Limitations,
flexed with her knees turned in. She would lurch from side while Level V is Transported in a Manual Wheelchair. Jill
to side, shifting her weight through her shoulders instead of was classified as Level III as she was capable of walking
her pelvis. with a handheld device even though she chose to not use
one. In addition, she used a manual wheelchair for mobility
Locomotion at school and in community and required a support surface
Jill reported she crawled or walked using a support surface or physical assistance to get up from the floor.
to get around her house. She was able to get down to the floor Jill had difficulty with balance, which appeared to be relat-
from sitting or standing and vice versa using a support sured to decreased strength in her legs and trunk. This was
face or physical assistance. She was able to move from sitting determined as she was able to balance on 2 feet with eyes
on the floor to lying and then back to sitting by rolling to her open or closed for 5 minutes but had difficulty with single-
side and pushing up with her arms. leg balance. In addition, when wearing her AFOs, she was
Balance unable to use ankle strategies for balance and was forced to
Standing balance: Standing balance was tested without use either hip or stepping strategies.
AFOs, on 2 feet with feet together and in single-leg stance.
Both tests were conducted under 2 conditions: eyes open
and eyes closed. During testing, Jill was allowed to crouch or Motor Function
move her arms to assist her balance. For the single-leg stance, Jill was able to initiate, vary speed, and stop movement
the timing was started when her nonsupporting foot lifted of her arms without difficulty. She was also able to initiate
off the ground. For double-leg and single-leg stance, timing movement of her trunk and legs but had difficulty varying
was stopped when her supporting foot lifted off the ground. speed and stopping movement. She tended to move quickly
and had difficulty with timing and sequencing of muscles for
CONDITION BOTH LEFT RIGHT slow, controlled movements, especially for eccentric control.
FEET (MIN/SEC) (MIN/SEC) Her ability to start, stop, and change directions improved
(MIN/SEC) when she was not wearing her AFOs.
Jill was able to anticipate and set her body for movement
Eyes open 05.00.00 00.01.62 00.03.50 when sitting but had difficulty when she was standing. For
Eyes closed 05.00.00 00.02.00 00.02.46 example, when sitting, she was able to catch and throw a
large ball with 2 hands, but when standing, she was unable to
set her body to allow movement of her arms away from her
Jill was very crouched during the 5-minute balance trial body, especially over her head to throw. She demonstrated
with her eyes open or closed. Her balance on a single leg was difficulty stabilizing her pelvis and weight shifting through
not more than the time needed to take a step. She had dif- pelvis when standing and walking without support, with or
ficulty shifting her weight through her hips onto the stance without her AFOs.
leg and, as a result, was off balance before lifting her opposite
leg. Jill tended to lower herself into a crouch rather than use
ankle strategies to maintain her balance on 2 feet when bal- Clinician Comment Individuals with CP fre-
ancing without her AFOs. When wearing her AFOs, Jill was quently have difficulties with planning, initiating, modu-
forced to use either a hip or stepping strategy, as her ankles lating, and stopping movement. Depending on the area of
were not able to bend in the AFOs. the brain affected, movement may be minimally or signifi-
cantly affected.
Jill’s difficulties with movement were not severe, but they • Balance strategies: When the ankle is free, Jill is able
contributed to a lack of variability in movement and to use ankle, hip, and stepping strategies. These allow
the development of muscle strength and endurance. Her her to maintain static balance without swaying and to
difficulty with movement appeared to be related to mus- stand in one place.
cle weakness or fatigue rather than spasticity or motor • Development of muscles of the lower leg: When the
planning. ankle is allowed to move, the muscles are able to work
and can be strengthened. An AFO not only restricts
ankle motion, it restricts the ability of the leg muscles
Assistive and Adaptive Devices to expand because of the tight fit of the cuff.
Jill used a manual, ultra-light folding wheelchair with • Neuromotor learning: Ankle motion allows for learn-
swing-away leg rests and a 2-inch foam cushion. Her wheeling appropriate motor programs and timing and
chair was in good condition and the fit was appropriate. Jill sequencing for mobility. It also allows for brain map-
used a backpack that she hung on the push handles of her ping of the ankle and foot.
wheelchair. She also used a small pouch placed next to her • Functional use: Ankle motion allows for forced use
right thigh for items she needed quick and easy access to, such instead of forced disuse of ankle and foot in functional
as her cell phone, pens, pencils, and student identification. activities. It allows for the use of new patterns of move-
ment and strength that allow external rotation of hips,
increased hip and knee extension, ankle plantar and
Clinician Comment Assessment of the type, dorsiflexion, movement of the leg over the foot that
condition, and use of a wheelchair was completed by look-
decreases crouch, circumduction, and excessive inter-
ing at the wheelchair and observing Jill’s use of it in various
nal rotation of hip due to compensation to clear the
activities and environments. In addition, how Jill used the
foot when wearing braces.
wheelchair needed to be considered so she had one that
would allow her to participate in her preferred activities. Jill was able to perform toe raises bilaterally and clear her
foot when walking. She had baseline strength for movement
The lighter the wheelchair, the easier it is to self-propel.
and was an excellent candidate for a trial without wearing
Swing-away leg rests allow closer access to furniture or
AFOs. These devices are also considered assistive technol-
vehicles for transfers. Seating provides a base for posture
ogy in the educational setting.
as well as pressure relief for skin. The ease of wheeling and
the ability to transfer or manage the wheelchair indepen-
dently—including loading the wheelchair into and out of a
car—are important considerations in wheelchair selection. Self-Care and Home Management
A folding wheelchair provides more flexibility over a solid Additional information was obtained through observa-
frame manual wheelchair or power wheelchair as it can be tion and interview with Jill, her mother, and the school staff.
easily folded and put in most vehicles for transportation. Jill was independent in most activities of self-care and home
In the educational setting, these devices would be included management. She had to allow for the increased time it took
under the category of assistive technology. her to complete these activities. She got up 2.5 hours before
she needed to meet her bus in order to get ready for school
and eat breakfast. She bathed and washed her hair in the
Orthotic, Protective, and Supportive evening instead of the morning to save time.
Devices Jill reported she was more independent in dressing at
home because she would lie down on the floor or her bed
Jill wore bilateral, solid-ankle AFOs to support her ankle
to dress. This, however, was not an option at school or in
and foot in standing, to prevent crouched standing, and to
community settings. She was independent in toileting with
assist her in walking. The fit was appropriate and the AFOs
the exception of needing assistance with pulling some of her
were in good condition.
pants up all the way.
Clinician Comment Individuals with CP

frequently use orthotics to improve alignment, support and Clinician Comment Jill was independent in
protect joints, and improve gait and functional abilities. most self-care activities; however, it would take her at least
With CP spastic diplegia, AFOs are frequently prescribed twice as long to complete tasks compared with her peers.
to prevent a crouched posture in standing and walking with Jill’s difficulty with ADL appeared to be related to a lack
hopes of enabling the individual to continue to walk as she of flexibility and strength. Strategies that worked at home
ages. There are, however, implications to wearing orthotics were not effective in other settings. This made it more dif-
that limit ankle motion. These include the following: ficult for her to participate in desired settings, such as at a
friend’s home or at school, and being independent at the
community health club.
68 Chapter 2
Work, Community, and Leisure Integration EVALUATION
Jill completed simple chores at home. She did not yet
have an after-school job. She reported she attended church
and was a member of the youth group. She enjoyed shop- Diagnosis
ping with friends. She reported that she was not able to go as Jill was a 15-year-old girl attending ninth grade in her
often as she would like because she needed help getting the local high school. She had a medical diagnosis of CP, spastic
wheelchair into and out of a car. She reported she was able to diplegia with a history of multiple orthopedic surgeries, and
wheel herself at the mall but friends would also push her. Jill an ITBP to manage spasticity. She participated in general
wanted to get her driver’s license so she could drive herself to education with support from special education and related
activities and work. services. She was referred as part of her 3-year special edu-
Jill was looking for a job that could be performed sitting. cation reevaluation. Jill and her family expressed concerns
Jill was able to transport light materials on her lap but would about being more independent in transfers and mobility. Jill
have difficulty with heavy materials. She was able to tolerate was also interested in getting stronger.
a full day of school. She was also able to stand and take breaks Jill had limitations in strength, endurance, coordination,
to relieve pressure and stiffness from sitting for extended balance, and flexibility that interfered with her ability to
periods of time. She would be able to stock shelves that were move. She had some difficulty with timing and sequencing of
within her reach with light- to moderate-weight stock. muscles for movement but was able to effectively plan move-
ment. She had decreased physical capacity that affected her
Clinician Comment Jill was a typical teen- walking and participating in activities with her friends. Her
ager who wanted to hang out with her friends, get a job, primary problem appeared to be a lack of sufficient strength
and drive a car. Having CP affected her physical capacity to perform movements and activities. Jill was diagnosed with
and mobility as well as speed and efficiency for performing impaired muscle performance.
movement activities. Increased physical capacity would Practice Pattern
allow her to perform tasks at a competitive rate for employ-
ment as well as make it easier for her to do social activities. Based on the history, systems review, and tests and mea-
sures, this patient was classified into the Preferred Practice
Pattern: Musculoskeletal Practice Pattern 4C: Impaired
Muscle Performance.
Environmental, Home, and Work Barriers
Additional information was obtained through observa-
tion and interview with Jill, her mother, and the school staff. Clinician Comment While the framework for
Her kitchen was not accessible from a wheelchair, but she Jill’s evaluation was the practice pattern of Neuromuscular
could stand at the counter and reach with one hand. She was Impaired Motor Function and Sensory Integrity Associated
able to get in and out of a car independently but needed assis- with Nonprogressive Disorders of the Central Nervous
tance getting in and out of a van or truck. She was unable to System-Congenital Origin or Acquired in Infancy or
place her wheelchair in any vehicle without help. Childhood 5C, it was not the pattern that described her
Jill was able to use the elevator at school independently. assessed impairments best. Jill’s function was limited most
She was unable to safely or efficiently use the stairs at school. by impaired muscle performance, not motor function. It is
She was able to evacuate the building with her class when important to put the client in the Preferred Practice Pattern
on the ground floor and used an evacuation chair or sling that is appropriate for the primary problem identified for
for evacuation from other levels. Jill was unable to ascend or that client, not the client’s identified medical diagnosis.
descend bus steps because of difficulty lifting her legs high
enough to accommodate the increased height of the bus
steps. Jill needed a wheelchair-accessible bathroom and lift International Classification of Functioning,
bus for transportation. Disability and Health Model of Disability
Jill was interested in a job when she got older. She would See ICF Model on page 69.
need a work environment that was accessible and allowed
work from a sitting position.
Prognosis
Jill’s goals were to attain her highest level of fitness and
Clinician Comment Jill would benefit from
function through participation in an individualized, high-
education on how to evaluate community settings for access
intensity strength-training class. While Jill demonstrated
and strategies for evacuation.
limitations in joint ROM and decreased strength, she also
demonstrated good motor planning skills, motivation, and
an excellent work ethic. Her spasticity did not interfere with
movement. Her primary problem was decreased strength or
ICF Model of Disablement for Jill

Health Status
• Cerebral palsy—spastic diplegia
• Spasticity
Body Structure/ Activity Participation

Function
• Crouched gait • Used manual wheelchair as
• Decreased strength in trunk • Walking limited by primary mobility
and lower extremities strength, balance, physical • Difficulty with mobility in
• Decreased aerobic capacity capacity crowds
• Decreased physical capacity • Difficulty transferring into • Increased time required for
• Decreased ROM vans, trucks ADL to get ready for school
• Decreased static and • Difficulty ascending and • Difficulty going to friends
dynamic balance descending stairs houses
• Support surface needed for • Unsure of which machines
dressing to use in community health
club
Personal Factors Environmental Factors

• Age = 15 years • Supportive parents and siblings
• Appropriate height and weight • Supportive peers
• Outgoing, enjoys being social • Supportive educators and staff at her school
• Enjoys activity, working out • Elevators at school
• Would like to be more independent • Accessible school weight room
• Would like to walk better • Family membership at community health club
• Good self advocate
• Good student
70 Chapter 2
force production. Jill was an excellent candidate for high- canes, to determine the feasibility of use in an educa-
intensity strength and agility training, from which she sig- tional setting (12 weeks).
nificantly improved her strength, balance, alignment, and 5. Jill would improve her ability to walk up and down a
movement patterns. Jill had excellent rehabilitation potential. flight of stairs using one handrail and walking forward
alternating steps up and down with standby supervision
(12 weeks).
PLAN OF CARE 6. Jill would improve her ability to transfer in and out of a
variety of vehicles from needing physical assistance to
Intervention needing standby assistance (20 weeks).
7. Jill would demonstrate a clear understanding of her cur-
Proposed Frequency and Duration of rent and changing evacuation plan and be able to direct
Physical Therapy Visits staff in all emergencies of drills during the school year
(2 weeks).
Jill participated in the strength-training class offered
through the physical education department at her high
school. The class met daily for one class period, 65 min- Clinician Comment In the educational set-
utes, with strength training on Monday, Wednesday, and ting, goals and outcomes are based on the needs identified
Friday, and cardio, agility, and gait training on Tuesday in the evaluation. Jill had the following identified special
and Thursday. Her school-based PT developed her program education needs:
and provided direct, face-to-face service at least 3 days per • Jill needs to use assistive technology and modifications
week. A high school special education paraprofessional with in her environment to move safely and independently
knowledge and background in strength training provided in the home, school, and community.
daily direct service. Jill was able to take this class each semes-
ter for an entire school year. • Jill needs to improve her overall level of fitness in the
areas of flexibility, strength, muscular and cardiovas-
cular endurance, and agility and balance.
Clinician Comment Fitness programs are safe • Jill needs to improve her mobility in her current and
and beneficial for children and adolescents with CP.19,27-30
future environments.
Concerns about strengthening activities making spasticity
worse are unsubstantiated.30,31 Physical education classes • Jill needs to improve her ability to transfer in and out
offered at the student’s school allow for intervention in the of a variety of vehicles and manage her wheelchair with
natural setting and are often preferred to exercising at a less assistance.
physical therapy clinic.32-34 • Jill needs an evacuation plan.
Many high schools offer strength training classes as part of From these needs, specific outcomes and goals were devel-
their physical education curriculum. Working with general oped, after which her IEP team determined that the exper-
and special education staff, the PT is able to develop and tise of a PT was needed for Jill to attain her fitness and
provide an individualized program for Jill. In addition to mobility outcomes and goals.
addressing Jill’s physical needs, participation in a general
physical education class with her peers provided Jill with
social interaction that is frequently difficult for adolescents
with CP.35 Expected Outcomes (39 Weeks or One
School Year)
1. Jill would complete a high-intensity strength training
Anticipated Goals protocol 3 days per week, increasing her weights weekly.
1. Jill would improve the flexibility of her hips and knees 2. Jill would increase the flexibility in her hips to allow her
by 10% over baseline measurements taken at the begin- to put her foot on the opposite leg while sitting in her
ning of the next 2 semesters (14 weeks). wheelchair in order to put her shoe on her foot.
2. Jill would increase the amount of weight she lifted in the 3. Jill would dress independently for physical education
weight room by 20% over baseline measurements taken class.
at the beginning of the next 2 semesters (14 weeks).
4. Jill would pull her pants up independently after toileting.
3. Jill would improve her endurance when walking by 20%
5. Jill would walk up or down stairs using a railing to
as measured by the EEI baseline taken at the beginning
evacuate the building.
of the next 2 semesters (14 weeks).
6. Jill would walk in her classroom without using any sup-
4. Jill would explore walking with a variety of assistive
port surface or assistance from students or staff.
devices, including walking sticks, forearm crutches, and
7. Jill would walk between close classes.
8. Jill would get in and out of a variety of vans or trucks
Clinician Comment It is important to commu-
nicate and coordinate care with Jill’s medical team. Before
with standby assistance.
beginning a high-intensity, strength-training program, it is
9. Jill would no longer wear AFOs. important to make sure there are no contraindications to
10. Jill would participate in her fitness program at her com- training. Consulting with her physician regarding program-
munity health club 2 times per week. ming and interventions at school informed the physician
11. Jill would maintain or increase her level of fitness of interventions provided outside the traditional medical
through her home fitness program. model. Requesting a trial is an effective way to evaluate the
effectiveness of a proposed intervention, especially when it
Discharge Plan may be different from the typical course of care.
It was anticipated that Jill would participate in an indi- When working with a community health club, it is impor-
vidualized strength training program for the current school tant to obtain permission not only from the family, but also
year. These classes met her high school’s graduation credit the health club. Since the health club was not a part of the
requirement for physical education. Her IEP was in effect school district or the PT’s practice, licensure, liability, and
for 1 calendar year. Her needs and goals would be updated other legal aspects need to be considered before going on
in 1 year. If Jill decided to continue her participation in site.
strength training, PT services would be available to establish
and implement her program during each semester she took
the class. Physical therapy services would be discontinued Patient-/Client-Related Instruction
through the educational due process when the educational
team determined there was no longer an educational need. Jill received information on general fitness and fitness as
related to her CP in education sessions with the evaluating
PT. She learned how to manage her energy throughout her
INTERVENTION day so she could fully participate in her desired activities.
She was able to understand how her diagnosis may affect her
various body systems and activities as she aged. Following
Coordination, Communication, and the education sessions, she developed a list of job-demand
considerations related to her physical abilities and her mobil-
Documentation ity. She was instructed in how to evaluate different environ-
Communication occurred with Jill’s family regarding her ments for access, barriers, and evacuation routes.
mobility and fitness needs. They discussed a plan to commu-
nicate with her physician regarding a trial of Jill not wearing Procedural Interventions
her AFOs. They also discussed a plan for Jill to participate
in a fitness program outside of school at their community Therapeutic Exercise
health club. Aerobic Capacity/Endurance
Communication occurred with Jill’s case manager and Conditioning or Reconditioning
teachers regarding accommodations needed for accessing Mode
their classrooms, participation in class, and early release. Walking on treadmill; stationary bike; aerobic activities
Communication occurred with the school nurse regard- Intensity
ing transfers and management of clothing for toileting.
High-intensity interval training
Documentation would include all aspects of care, including
Duration
initial evaluation, progress reports, reexaminations, and
discharge summary. Educational requirements were met as 10 to 20 minutes depending on activity
described in Jill’s IEP. Frequency
Coordination and communication with Jill’s doc- 1 to 2 times per week
tor regarding a 2-month trial without wearing her AFOs Description of the Intervention
occurred with the doctor approving the trial. The trial With high-intensity interval-training (HIIT), the focus
allowed time for Jill to strengthen her calf and foot muscles would be on alternating bursts of intense activity with lighter
and use new movement patterns throughout her day to deter- activities. Jill would walk or wheel for 30 seconds at a quick
mine if strengthening would make a difference for her. pace and then walk/wheel at a regular pace for 30 seconds.
With the family’s permission, coordination and commu- She would continue to alternate between the exercise intensi-
nication of Jill’s fitness program occurred with their com- ties for 5 and 10 minutes. She would work up to a total work-
munity health club. out time of 20 minutes.
72 Chapter 2
Flexibility Exercises Duration
Mode 10 to 12 repetitions times one set to failure
Stander (standing frame); proprioceptive neuromuscular Frequency
facilitation (PNF) patterns; yoga patterns 3 times per week—Monday, Wednesday, Friday
Description of the Intervention
Clinician Comment It is important to start Completion of a one-set sequence to failure lifting strategy
at a level and intensity that the student can manage before was used for each lift performed. Focus was on high-intensity
increasing the length of the total activity or the length of work while performing quality repetitions to momentary
the interval. Monitor the student’s HR while participating. muscular failure. Weight or amount of resistance was high,
Walk on a treadmill with hand support, and begin with 80%, one repetition maximum.
a slight incline and a slower walking speed for warm-up.
Increase intensity by increasing the incline and/or speed.
Walk at an intense rate for 30 seconds, slow speed down
Clinician Comment Strengthening has been
demonstrated to be effective for children and adolescents
and walk for 30 seconds, increase speed for 30 seconds,
with CP.32,33 However, controversy was recently raised as a
then decrease for 30 seconds and continue for 5 minutes.
result of a systematic review that determined the evidence
Monitor HR to determine need for increasing or decreas-
demonstrated that muscle strengthening was not effec-
ing intensity. Can also do HIIT with throwing activities,
tive.36 While others debated the findings of the review,36-40
circuits, and agility activities.
Verschuren et al proposed that the reason for the lack of
evidence was a result of the training protocols used in the
Intensity studies.40 They suggest that children and adolescents with
Low to moderate CP could use the same guidelines developed by the National
Strength and Conditioning Association for those developing
Duration
typically. Use of higher intensity is needed to obtain gains in
Stander 15 to 20 minutes; other activities 2 to 5 minutes
strength.40,41 The National Center on Physical Activity and
Frequency Disability Exercise/Fitness agrees and has developed a fact
Stander 2 to 3 times per month; other activities daily sheet for High-Intensity Weight Training for People with
Description of the Intervention Disabilities to guide intervention.28
The standing frame would support Jill at her hips and There are a number of methods for performing strength
knees while also providing a prolonged stretch to hips, knees, training.42-44 High-intensity strength training is recom-
and ankles in a weightbearing position. Movements using mended as the method to build strength.40,41,45 When
PNF patterns or yoga patterns provide inhibition and move- using variable resistant machines or manual resistance
ment of joints that is slow and gentle. for high-intensity strength training, movement is through
Strength, Power, and Endurance Training the full available ROM with tension throughout the range.
for Head, Neck, Limb, and Trunk Muscles Movement is slow and controlled in the best alignment
Mode possible. Work large muscle groups first, then small muscle
Stander (standing frame) groups, then grips followed by abdominals. Begin with
Intensity either the legs or arms, completing one set before starting
the other. Alignment for each lift is critical; physically hold
Progressive resistance exercise
or assist the student to maintain alignment through the
Duration
entire lift. Technique and form used while lifting are also
10 to 12 repetitions critical. Whenever possible, DO NOT wear orthotics that
Frequency limit joint movement or muscle contraction.
2 to 3 times per month
A 7-second repetition was used for each repetition that
Description of the Intervention included the following:
While standing, the upper body is free to perform
strengthening or aerobic activities, such as forward bends • 2 seconds to lift concentrically—positive phase
with light weights progressing to heavier kettle bells, rotation • 1-second pause at end of positive phase
activities for core strengthening, or medicine ball tossing • 4 seconds to lower weight eccentrically—negative phase
from overhead. A 1-set sequence was used to reach failure on each
Strength, Power, and Endurance Training lift28,43-45:
for Head, Neck, Limb, and Trunk Muscles • Completed one set of 8 to 12 seven-second repetitions
Mode • Worked to muscle failure in positive phase of lift (con-
Variable resistant machines, manual resistance centric)
Intensity
High intensity to failure for each lift
placing other foot on step. Progress from doing one step at a
• Once reached failure, begin forced repetitions
time to alternating steps. When descending stairs, focus on
◦ Assist with positive phase slow, controlled movement to lower self to next step, keeping
◦ Resist negative phase alignment with feet and knees straight ahead.
• Amount of weight lifted is what student can lift with- Balance, Coordination, and Agility Training
out assistance for 8 to 12 repetitions Mode
• Weight is increased for the next session when reach Balance activities
12 repetitions Intensity
• Weight is decreased for the next session when lift 7 or Activities should be performed slowly and controlled with
less repetitions correct alignment of trunk and LE, then increase speed as
• Limit rest between lifts control improves.
• Need 48 hours’ rest between workouts for same muscle Duration
groups 10 to 20 minutes
Frequency
Once per week
Strength, Power, and Endurance Training Description of the Intervention
for Core and Ventilatory Muscles Balance activities initially using walking sticks, then
Mode progressing to no-hand support while standing with both
Active isometric and isotonic progressive exercises feet or one foot on a variety of surfaces, including foam, bal-
Intensity ance boards, and inflated disc. Start with 2 feet on a stable
Slow, controlled movements through concentric and surface, focusing on alignment and weight shifting through
eccentric phase pelvis. Jill would have a mirror available to allow her to see
and correct her alignment. Coordination and agility activi-
Duration
ties using walking sticks or the PT’s hands for balance while
10 to 12 repetitions times one set to failure
performing basic stepping drills, speed ladder, and dot drills.
Frequency Begin with simple activities working on accurate placement,
3 times per week—Monday, Wednesday, Friday changing direction, and varying speed. Speed ladder and
Description of the Intervention dot drills are performed slowly at first to learn patterns and
A series of core strengthening exercises were developed increase accuracy.
with progressive intensity. Training included learning how
to activate core muscles to set the pelvis when performing
other activities. Breathing exercises were also included as a Clinician Comment The examination showed
component of core strengthening as well as to aid appropriate that Jill’s perception of her alignment was not accurate.
breathing when lifting. Using the mirror would provide Jill the opportunity to use
visual feedback to self-evaluate her alignment and then
Gait and Locomotion Training correct.
Mode
Walking using a variety of devices including a treadmill
and hands-free walker; ascending and descending stairs.
Intensity Functional Training in Work (Job/
Walking at a speed that allows for smooth coordinated School/Play), Community, and Leisure
control of LE Integration or Reintegration, Including
Duration Instrumental Activities of Daily Living,
20 minutes Work Hardening, and Work Conditioning
Frequency Description of the Intervention
1 to 2 times per week Jill would practice getting in and out of a vehicle. She
Description of the Intervention would start with a variety of cars but then progress in diffi-
Walking on a treadmill without AFOs to facilitate cen- culty to vans, SUVs, and trucks. Jill would develop strategies
tral pattern generators and allow ankle and foot motion. for managing her wheelchair. She would then practice fold-
Allow 2 hands on lateral rails, then progress to holding on to ing and putting her wheelchair into the back seat and trunk
horizontal poles with the PT facilitating arm swing. Walking of a variety of vehicles.
using a hands-free walker without AFOs, focusing on equal Jill would develop and implement a fitness program at her
stride, and landing on heel while weight shifting through community health club. She would communicate with her
pelvis. May use horizontal poles to facilitate arm swing. school PT about her progress and any questions regarding
Face forward on stairs using one handrail. Practice lifting updating her program.
and placing foot on step, keeping knee straight ahead while
74 Chapter 2
Jill would develop and practice an evacuation plan for Anthropometric Characteristics
school and home.
Body Fat Percentage
Prescription, Application, and Fabrication
of Devices and Equipment (Assistive, Body fat handheld analyzer 25.2%
Adaptive, Orthotic, Protective, Skinfold measurement 24.5%
Supportive, or Prosthetic)
Description of the Intervention Height/weight formula (kg/m2) 20.88%
Jill would explore alternative walking devices, including
walking sticks, forearm crutches, and canes for walking, as Body Measurements/Circumference
well as how to use them in conjunction with her wheelchair.
AREA MEASURED MEASUREMENT (INCHES)
*All measurements are circumfer-
REEXAMINATION ence except height and weight
LEFT RIGHT
Subjective Height 61
After 4 weeks of strength training, Jill stated she enjoyed Weight 112 pounds
the class and ate lunch with a few of the students from the Shoulders 343/4
class. She stated she felt it was easier to walk in the classroom:
“I don’t need to hold onto my friends or use the desks when Chest (under arms) 33
I am walking in the room.” She also reported she was walk- Bicep (flexed) 103/8 103/4
ing down the stairs at home but would still scoot if she were
Forearm (wrist 91/2 101/8
in a hurry as it was still faster. She felt it was easier to get in
flexed)
and out of her family car, but she still had trouble with her
friend’s truck. Waist 27
At the end of the first semester of strength training, Jill Hips 351/8
stated she was excited about being able to continue the class
next semester. She said she was walking a lot more at school, Thigh (midpoint) 181/2 183/4
and, “I even walked down the hall to my next class when the Thigh (widest point) 20 201/4
halls weren’t very crowded and made it without falling!” She
said it takes her less time to get dressed after strength train-
flexed)
ing class and, “I can even sit on the bench and put my jeans
on.”
Note increased length in gastrocnemius muscle on both
legs as muscle belly no longer restricted by AFO.
Objective Range of Motion
Jill participated in class every day during the first semes-
ter, missing 1 day in December for a medical appointment. JOINT MOTION LEFT RIGHT
She initially complained of being tired and having sore legs, (DEGREES) (DEGREES)
but this stopped after the second week. Jill participated in all
Hip flexion 0 to 130 0 to 139
activities and demonstrated a good work ethic in the weight
room. She appeared to enjoy the aerobic and agility activities Hip extension -11 -7
and pushed herself to complete an activity even when it was
Hip external rotation 0 to 30 0 to 37
difficult and she was tired.
Hip internal rotation 0 to 60 0 to 50
Aerobic Capacity/Endurance
Hip abduction 0 to 30 0 to 40
EEI in Heartbeats/Meter
Hip adduction 0 to 40 0 to 30
Walking independently at regular pace 1.04 Knee flexion 10 to 155 7 to 152
Walking independently at fast pace 1.17 Knee extension -10 -7
Ankle dorsiflexion 0 to 28 0 to 29
Ankle plantarflexion 0 to 30 0 to 37
Hamstring length̶ 25 short of 18 short of
popliteal angle full extension full extension
Muscle Performance Orthotic, Protective, and Supportive
Devices
MUSCLE LEFT RIGHT
Jill no longer needs to wear her AFOs. Her physician dis-
GROUP (POUNDS) (POUNDS) continued use at Jill’s December medical appointment.
Hip flexion 36 47 Self-Care and Home Management
Knee extension 44 46 Jill reported taking less time in the morning to get ready
Knee flexion 8.0 6.7 for school. Completed her dressing while sitting on a bench
or standing for physical education. Independent in pulling
Hip abduction 24.1 17.9 pants up after toileting.
Work, Community, and Leisure Integration
• Ankle plantarflexion: Single leg toe raises with knee
straight; L: 5; R: 8. Transferred into cars and some vans independently.
Needed assistance with transfers for trucks.
• Ankle dorsiflexion: Lifted toes in standing but could
not hold feet up to walk on heels. Active dorsiflexion Environmental, Home, and Work Barriers
against gravity, but unable to take any resistance. Evacuated from second floor using stairs to go down fol-
• Abdominal strength: Completed 5 sit-ups with arms lowing other students.
crossed over chest. Completed 4 forced exhalations
(transverse abdominals). Completed 2 rotational sit-ups Assessment
(elbow to opposite knee) with arms behind head.
Jill made progress on her all of her goals. She met or
• Functional strength: Walked up stairs with pelvis, legs, exceeded the 20% increase for strengthening and aerobic
and feet forward using one handrail. Walked down endurance while walking at a fast pace. Body circumference
stairs in slow, controlled manner. Kept pelvis, legs, and increased by 0.25 to 1 inch, with the largest increases in her
feet forward. Lowered self into chair in slow, controlled legs. Jill demonstrated an increase in muscle strength, endur-
manner. ance, flexibility, and agility. Functional skills also improved,
Posture especially her ability to walk up and down stairs in a con-
trolled manner. Jill’s strength training program appeared to
Jill was able to correct posture when sitting in wheelchair. be effective in increasing her fitness and functional abilities.
Stood with heels on floor and knees and hips in a slight crouch.
Gait, Locomotion, and Balance Plan
• Gait: Walked in classroom with limited use of friends or Jill would benefit from another semester of strength-
support surfaces to balance. Began to walk in hallways training class. Jill needs to practice walking in more variable
without students in them between classes that were environments to gain confidence to walk in community
close, less than 100 yards away. settings.
• Locomotion: Jill reported she was walking most of the
time at home.
• Balance: Standing balance REEXAMINATION
CONDITION BOTH LEFT RIGHT Subjective
FEET (MIN/SEC) (MIN/SEC)
(MIN/SEC) At the end of 8 weeks of strength training in the second
semester of school, Jill reported she was going to her com-
Eyes open 05.00.00 00.04.68 00.05.53 munity health club and “working out on the machines” on
Eyes closed 05.00.00 00.02.45 00.03.36 the weekends. She was excited that she knew which machines
to use and how to use them; she “even taught my mom how
to use them!”
Motor Function At the end of the semester, Jill reported she went with her
Increased control to stop, start, and change directions friends to the mall and “we shopped all day and I was able to
while walking. Movement improves with practice. keep up with them and walk through the stores without wor-
Assistive and Adaptive Devices rying that I would fall if I got bumped.” She did report she
took frequent breaks and a friend would sit and talk with her
Tried various canes, crutches, and walkers and deter- while others shopped.
mined that forearm crutches were the most adaptable for use
with a manual wheelchair.
76 Chapter 2
Objective JOINT MOTION LEFT RIGHT
(DEGREES) (DEGREES)
Aerobic Capacity
Hip adduction 0 to 40 0 to 30
EEI in Heartbeats/Meter
Knee flexion 5 to 154 5 to 155
Walking independently at regular pace 0.71 Knee extension -5 -5
Walking independently at fast pace 0.94 Ankle dorsiflexion 0 to 24 0 to 25
Ankle plantarflexion 0 to 34 0 to 37
Anthropometric Hamstring length̶ 30 short of 22 short of
Body Fat Percentage popliteal angle full extension full extension
Body fat handheld analyzer 23.4%

Muscle Performance
Skinfold measurement 22.8%
Height/weight formula (kg/m2) 21.74% MUSCLE LEFT RIGHT
GROUP (POUNDS) (POUNDS)
Body Measurements/Circumference Hip flexion 70 79
Knee extension 58 62
AREA MEASURED MEASUREMENT (INCHES)
Knee flexion 25 28
*All measurements are circumfer-
ence except height and weight Hip abduction 28 29
LEFT RIGHT
• Ankle plantarflexion: Single leg toe raises with knee
Height 61
straight; L: 15; R: 18.
Weight 115 pounds • Ankle dorsiflexion: Walked on heels with feet in dorsi-
Shoulders 351/2 flexion for 10 feet.
Chest (under arms) 331/2 • Abdominal strength: Completed 15 sit-ups with arms
crossed over chest. Completed 10 forced exhalations
Bicep (flexed) 113/4 121/4 (transverse abdominals). Completed 10 rotational sit-ups
Forearm (wrist 101/2 107/8 (elbow to opposite knee) with arms behind head.
flexed) • Functional strength: Walked up and down stairs using
Waist 27 a reciprocal pattern without a handrail if alone and with
a handrail if others on stairs.
Hips 36
Thigh (midpoint) 181/8 183/4 Posture
Appropriate alignment when sitting in wheelchair. Stands
Thigh (widest point) 191/2 197/8
with hips and knees in slight flexion, slight lumbar lordosis.
flexed)
Gait, Locomotion, and Balance
• Gait: Walked between classes if on the same side of the
building. Decreased lateral trunk motions when walk-
Range of Motion ing. Used wheelchair for safety in crowded hallways.
• Locomotion: Jill reported she walked all the time at
JOINT MOTION LEFT RIGHT home but was cautious when outside on the grass.
(DEGREES) (DEGREES) • Balance: Standing balance
Hip flexion 0 to 137 0 to 143
CONDITION BOTH LEFT RIGHT
Hip extension -8 -5 FEET (MIN/SEC) (MIN/SEC)
Hip external rotation 0 to 35 0 to 43 (MIN/SEC)
Hip internal rotation 0 to 60 0 to 50 Eyes open 05.00.00 00.10.15 00.15.07
Hip abduction 0 to 35 0 to 40 Eyes closed 05.00.00 00.05.27 00.09.13
Used ankle strategies when standing instead of hip; stood next year if she chose to continue them. Jill would be dis-
still for periods of time instead of swaying. charged from her school-based physical therapy service when
she no longer demonstrated educational needs that required
Motor Function
the expertise of the PT. This would be determined by her IEP
Jill walked in the halls with some students present but team at her yearly meeting each school year.
could not manage large crowds.
Able to anticipate and set her body for throwing activities
in standing but had difficulty keeping body set for catching
the ball.
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14. Novacheck TF, Stout JL, Gage JR, Schwartz MH. Distal femoral
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1200. 43. Rhea MR, Alderman BL. A meta-analysis of periodized versus
20. Wiart L, Darrah J. Test-retest reliability of the energy expenditure nonperiodized strength and power training programs. Res Q Exerc
index in adolescents with cerebral palsy. Dev Med Child Neurol. Sport. 2004;75(4):413-422.
1999;41:716-718. 44. Willardson JM. The application of training to failure in periodized
21. Kendall FP, McCreary DK, Provance PG. Muscles Testing and multiple-set resistance exercise programs. J Strength Cond Res.
Function With Posture and Pain. 4th ed. Baltimore, MD: Williams 2007;21(2):628-631.
& Wilkins; 1993. 45. Philbin J. High-Intensity Training. Champaign, IL: Human Kinetics;
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23. Hislop HJ, Montgomery J. Daniels and Worthingham’s Muscle
Testing. 7th ed. Philadelphia, PA: WB Saunders Company; 2002.
24. Jones MA, Stratton G. Muscle function assessment in children. Acta
Paediatr. 2000;89:753-761.
CASE 2-2
25. Palisano R, Rosenbaum P, Bartlett D, Livingston MH. Content
validity of the expanded and revised Gross Motor Function
Kathleen Coultes, PT, PCS
Classification System. Dev Med Child Neurol. 2008;50(10):744-750.
26. Palisano R, Rosenbaum P, Bartlett D, Livingston MH. Gross Motor
Function Classification System Expanded and Revised. Hamilton,
Ontario: CanChild Centre for Childhood Disability Research,
EXAMINATION
McMaster University; 2007. http://motorgrowth.canchild.ca/en/
GMFCS/resources/GMFCS-ER.pdf. Accessed June 1, 2011. History
27. American Academy of Pediatrics. Strength training by children and
adolescents. Pediatrics. 2001;107(6):1470-1472. Current Condition/Chief Complaint
28. National Center on Health, Physical Activity, and Disability. High-
intensity weight training for people with disabilities. NCHPAD. Jack was an obese 11-year-old White male who was
http://www.ncpad.org/24/162/High-Intensity~Weight~Training~fo referred to outpatient physical therapy. Three weeks prior, he
r~People~with~Disabilities. Accessed June 1, 2011. had undergone a left tibia and fibula osteotomy with external
29. Damiano DL. Activity, activity, activity: rethinking our physical
fixation. Jack returned to school 1 week prior.
therapy approach to cerebral palsy. Phys Ther. 2006;86:1534-1540.
30. Fowler EG, Kolobe TH, Damiano DL, et al. Promotion of physical History of Current Complaint
fitness and prevention of secondary conditions for children with
cerebral palsy: section on Pediatrics Research Summit Proceedings. Jack received a diagnosis of Blount disease 3 months
Phys Ther. 2007;87:1495-1510. prior to his surgery. The monitoring of his status during
31. Damiano DL. Should we be testing and training muscle strength in the 3-month interval documented worsening of the varus
cerebral palsy? Dev Med Child Neurol. 2002;44:68-72. deformity (bowing) in his left tibia. It was also noted that he
32. Eagleton M, Iams A, McDowell J, Morrison R, Evans CL. The
effects of strength training on gait in adolescents with cerebral
developed a leg length discrepancy of approximately 1.5 cm
palsy. Pediatr Phys Ther. 2004;16:22-30. as a result of the bowing, the left LE shorter than the right.
33. O’Connell DG, Barnhart R. Improvement in wheelchair propulsion He had increasing complaints of pain and stiffness. Pain
in pediatric wheelchair users through resistance training: a pilot would begin after walking more than 5 minutes, sitting still
study. Arch Phys Med Rehabil. 1995;76:368-372. for more than 20 minutes, or any attempt with running.
34. Unger M, Faure M, Frieg A. Strength training in adolescent learn-
ers with cerebral palsy: a randomized controlled trial. Clin Rehabil. Jack underwent a left tibia/fibula osteotomy with external
2006;20:469-477. fixation and was released from the hospital after a 2-week
35. Kang LJ, Palisano RJ, Orlin MN, Chiarello LA, King GA, Polansky stay. He was to ambulate with bilateral bariatric axillary
M. Determinants of social participation—with friends and others crutches with the precaution of toe-touch weightbearing of
who are not family members—for youths with cerebral palsy. Phys
less than 10 pounds. In addition to the referral to physical
Ther. 2010;90:1743-1757.
36. Scianni A, Butler JM, Ada L, Teixeira-Salmela LF. Muscle strength- therapy at the time of his hospital discharge, a referral was
ening is not effective in children and adolescents with cerebral made for a pulmonary consult to follow up on his snoring
palsy: a systematic review. Aust J Physiother. 2009;55:81-87. noted while he was in the hospital. Also, at the time of dis-
37. Taylor NF. Is progressive resistance exercise ineffective in increas- charge, a bariatric wheelchair and commode were requested.
ing muscle strength in young people with cerebral palsy? Aust J
Physiother. 2009;55:222; author reply 223.
38. Graham HK, Thomason P. Is there sufficient evidence? Aust J
Physiother. 2009;55:223; author reply 223.
Clinician Comment Blount disease is a skel-
39. Lancaster A, Mudge A, Wu J, Lewis J, Bau K. Should we change etal disorder affecting the medial side of the proximal tib-
practice? Aust J Physiother. 2009;55:291; author reply 292. ial epiphysis.1 Blount initially reported the acquired varus
40. Verschuren O, Ada L, Maltais DB, Gorter JW, Scianni A, Ketelaar deformity of the proximal tibia in adolescents. Further
M. Muscle strengthening in children and adolescents with spastic classification by Thompson et al led to the description of
cerebral palsy: considerations for future resistance training proto-
2 types of the deformity: juvenile onset of varus deformity
cols. Phys Ther. 2011;91:1130-1139.
occurring in children between ages 4 through 10 years, and epidemic.3 Eighteen percent of children and adolescents
the true adolescent onset, late onset tibia vara, occurring in are reported to be at or above the 95th percentile in weight.
children 11+ years of age.2 There is a prevalence of impaired fasting blood glucose
Generally, there is a history of normal knee alignment prior levels recorded in youth at a 7% or higher level. From that
to the development of the genu varum deformity.2 The statistic, it is not surprising, therefore, that there is an
presence of obesity in a growing adolescent can lead to an increasing incidence of Type 2 diabetes reported in 12 to
unequal loading of the tibial plateau, placing undue stress 19 year olds.3 Hyperlipidemia, hypertension, metabolic
on the medial aspect.1 This increased pressure on the medi- syndrome, obstructive sleep apnea, asthma. and orthopedic
al physis leads to a posteromedial growth suppression—the complications, such as a slipped capital femoral epiphysis
Hueter-Volkmann principle.1 The growth suppression first and Blount disease, are all rising in the pediatric patient
produces a varus deformity but then causes a progressive populations.3
procurvatum of the proximal part of the tibia. Marked Jack was fortunate to return to an accessible school, and his
tibial varum and tibial torsion can result. teachers had developed a plan to help Jack with classroom
In-toeing during gait worsens as the deformity progresses. changes. His mother was also available to help him at school
This occurs first as a functional accommodation to allow if needed. She reported that one aspect of the teachers’ plan
the foot to be placed as close to the line of progression as had a positive social benefit for Jack: his classmates begged
possible. However, the in-toeing subsequently worsens with him to be chosen to accompany him so that they, too, could
progressive tibial torsion.2 leave class early.
Social History/Environment Medical/Surgical History

Jack lived at home with his family, including his mother, Past medical history was reported to be insignificant upon
father, and 2 siblings. His father was disabled and did not initial evaluation. It was reported that Jack has a drug allergy
work. Jack’s mother was employed as a teacher’s aide at the to penicillin. The only surgery reported was the left tibia/
school he attended. fibula osteotomy and placement of the external fixator.
Jack was in the sixth grade at an accessible school. His
mother reported that Jack’s teachers had arranged for Jack Clinician Comment The osteotomy consisted
to select a classmate to leave class with Jack a few minutes of removing a wedge-shaped piece of bone from the medial
before each classroom period. The classmate would then side of his femur and inserting it into the tibia to replace the
accompany and assist Jack as he changed classrooms during posteromedial growth suppression. Pins and screws were
his school day. utilized to hold the bone wedge in place, with the external
Social/Health Habits fixator further securing the bone from the outside with
pins. Use of the external fixator offered the opportunity
Jack admitted he was not physically active, even prior
for further gradual correction of the varus deformity over
to the onset of his leg pain. He reported enjoying video
3 weeks by distraction osteogenesis. Typically, the frame
games, television, and movies. As his leg pain increased, he
would be removed about 12 weeks postoperatively when
reported he avoided walking any more than his daily activi-
the bone had consolidated.4 For Jack, the projection for the
ties required.
external fixator’s removal would coincide with approxi-
Jack appeared to be tall for an 11-year-old male. His moth-
mately 2 months into physical therapy.
er reported that Jack’s entire family was tall. Jack appeared to
be overweight, even for his large frame.
Reported Functional Status

Clinician Comment Even before his leg began
to hurt and limit his weightbearing activities, Jack pursued Jack reported, and his mother concurred, that he needed a
sedentary leisure activities. Given his sedentary activities little assistance from family members with all of his self-care
and limited weightbearing in the months prior to surgery, activities, including dressing, grooming, and toileting tasks.
as well as the surgery and 2-week hospital stay, Jack was A family member would assist with management of his left
probably deconditioned. Further, obesity has been identi- LE during position changes to ensure safety. When asked
fied as a precursor to the development of Blount disease. about household mobility, his mother reported that Jack’s
Jack appeared to be overweight. His height and weight dad and siblings were doing a lot for him, rather than making
needed to be measured to determine his BMI and category him maneuver around the house independently using either
for weight. the crutches or wheelchair.
The probable obesity and deconditioning were not the only Jack’s family members were trained in pin site care prior
health risks he might face. Youth obesity is a public health to his discharge from the hospital. Both Jack and his mom
expressed concern that the pin sites could become infected.
80 Chapter 2
Jack reported that he tended to use the wheelchair at
deformity calculations in describing the rotational compo-
school rather than walk with the crutches. He reported that
nent of tibia varum.5
walking with the crutches and trying to limit weightbear-
ing on his left LE to 10 pounds was difficult. He said he was Doppler ultrasound was used to rule out a DVT because of
afraid he might fall at school if he used the crutches. the presence of swelling in the left calf, with associated red-
Jack stated that his goal for physical therapy was to be able ness. Because Jack’s level of activity had been significantly
to walk without the crutches. decreased postoperatively, DVT needed to be ruled out
given his presenting symptoms. An increase in the occur-
rence of DVT has been reported in adolescents who are
Clinician Comment Jack had a supportive obese. Medical intervention to prevent DVT and pulmo-
family who was concerned about his safety, comfort, and nary embolism has been recommended in obese adolescents
pin site status during his convalescence. He had supportive undergoing orthopedic surgeries.6
teachers who created a plan to help with his mobility that
Next, in the examination portion of the evaluation, was
also offered him a bit of social cache. Some of this help,
the systems review. The limited examination of the systems
however, may have been interfering with his transition to
review aided in the identification of indicated tests and
improved independence with ADL. It was certainly having
measures as the examination moved forward, as well as
an impact on his already-reduced activity level.
establishing that there were no contraindications for Jack
Jack was not physically active prior to his surgery. He was to be seen in physical therapy.
in the hospital for 2 weeks. He was probably deconditioned.
He tended to use the wheelchair at school. The assistance
by a classmate gave him an alternative to self-propelling the
wheelchair that would have provided him with some physi- Systems Review
cal activity. Even though using his crutches might have been
more difficult than using the wheelchair, the challenge of Cardiovascular/Pulmonary
crutch walking would have, at least, improved his activity HR: 90 bpm
tolerance over time. BP: 145/85
Walking with the crutches was perceived as challeng- Respiratory rate: 15
ing—not only physically, but also emotionally—as he did The recommended outpatient pulmonary evaluation that
have a fear of falling. As an 11 year old, peer interactions was recommended at his hospital discharge had not yet
are a strong motivating factor for Jack. He did not want to occurred.
suffer the embarrassment of falling. He was, therefore, not
motivated to use the crutches in school, which was where he
was spending the majority of his day. Gaining experience
Clinician Comment Jack’s slightly elevated
vital signs could be attributed to being apprehensive about
and confidence with crutch walking at home was thwarted
his first outpatient physical therapy session. He had no his-
by understandable concern for his comfort by his family.
tory of hypertension but did admit to being a little fearful
Further, the secondary gain of increased attention needed
of what was going to happen in the evaluation. Monitoring
to be considered in attempting to motivate Jack to progress
of Jack’s BP in future visits was indicated to rule out any
with his independence.
clinically relevant findings.
One of the comorbidities associated with obesity is sleep
Medications apnea. A high prevalence of sleep apnea in morbidly obese
patients with late-onset Blount disease has also been
Jack took Tylenol as needed for pain.
reported.6 Therefore, a high index of suspicion for sleep
Other Clinical Tests apnea in snoring adolescents needs to be considered and
Radiograph taken preoperatively showed abnormal bone ruled out. If the sleep apnea is confirmed, then it can be
growth patterns in the posteromedial aspect of the left tibia. addressed pre- and postoperatively to avoid complications
Prior to his hospital discharge, Jack had experienced swelling after surgery.6
in his left calf and associated redness. A Doppler ultrasound In Jack’s case, the snoring was not observed until after his
of his left LE ruled out a deep vein thrombosis (DVT) prior surgery and while he was still in the hospital. The presence
to discharge. of sleep disturbance could have had an impact on Jack’s
success with rehabilitation. Sleep apnea is known to lead
to behavioral and mental problems for children, as well
Clinician Comment No data were available as cardiovascular issues. Excessive sleepiness through the
from the radiology report on the left leg pre- and postopera- day, decreased academic performance and learning ability,
tive mechanical medial proximal tibial angles (mMPTA) in growth disturbances, high BP, and abnormal heart func-
the records brought to the initial physical therapy appoint- tion can all be symptoms related to sleep apnea.7 Again,
ment. An mMPTA angle is used as a basis for degree of
for fear of moving or effecting the position of the external
monitoring Jack’s BP would be indicated. With any endur-
fixator. The weight in combination with the bulk of the fix-
ance complaints in treatment or with physical activity, Jack
ator also contributed to Jack’s apprehension to move the left
could be asked if he was feeling sleepy or if his muscles were
leg. Jack preferred to reposition his left leg passively by using
tired to distinguish between the effects of sleep apnea and
his arms.
deconditioning.
Height: 5 feet, 8 inches
Weight: 190 pounds
Integumentary Neuromuscular
The 2 medial and 2 lateral tibial pin sites from the external Balance
fixator were observed to be clean and without sign of infec- Impaired balance was noted both in static standing and
tion. The sites were moist and clean. The pins were in good dynamic weight-shifting movements in standing. His bal-
condition where they attached to the external fixator. His ance was poor +, as tested in supported standing both using
mother reported that she was following the pin site cleaning crutches and then holding the edge of the plinth. Because
protocol she had been taught. The patient denied specific of weightbearing restrictions and a reluctance to attempt
pain at the pin sites except during knee flexion. active LE movements, his fear of falling limited his balance
He exhibited intact sensation to light touch throughout significantly.
his left LE.
Locomotion
As noted in the interview, Jack reported that he struggled
Clinician Comment In a retrospective review to maintain the weightbearing restriction and still manage
of complications associated with tibial osteotomy and exter- his crutches for ambulation. He had a strong preference to
nal fixation in adolescents with Blount disease, Wilson et use the wheelchair and, in addition, to have his friends push
al found that wound complications were the most common him.
complication for 53% of surgeries reviewed.5 Of the 28
complications reported, 20 were at pin sites and 8 were deep
infections. This rate of wound complication was increased Clinician Comment It was already clear that
over previous reports. One difference, however, was that Jack’s gait with the crutches was impaired and needed to be
98% of the patients included in this study were morbidly assessed more fully as a test and measure than the limited
obese. This suggests pin site infections are yet another pos- systems review. The anxiety-producing gait task would be
sible postoperative complication in obese teens.5 Consistent tabled until the tests and measures portion of the examina-
monitoring of Jack’s pin sites would need to be a component tion and placed toward the end.
of his physical therapy treatment.
Transfers/Transitions
Musculoskeletal Jack required minimal assistance to position his left LE
during position changes and bed mobility tasks during the
Gross Symmetry/Posture systems review. His ability to move from sitting to standing
Jack held his left LE in extreme external rotation at the hip in transfers, however, required close supervision to ensure
in the supine, sitting, and standing positions. An increased maintenance of his balance as well as limit his weightbearing
thoracic kyphosis was evident with associated rounded on the left LE. His mother reported Jack still needed assis-
shoulders and forward head position when he was standing tance when showering because of his decreased balance. She
and when sitting. Jack was able to correct his posture easily, reported he was independent with dressing and grooming
however, when given verbal cues. He could maintain the once he was assisted for set-up only.
corrected posture with verbal cuing but would return to the
“relaxed” poor posture position when not reminded. Communication, Affect, Cognition,
Language, and Learning Style
Gross Range of Motion/Strength
Both UEs and right LE were without impairments in Jack was a pleasant young man. He was alert and oriented
gross mobility and strength as measured using goniometric but seemed anxious about progressing with his rehabilita-
measurements and MMT. Trunk strength was within normal tion. He was quiet throughout most of the evaluation and
limits for age using a sit-up test, with decreased overall tone tended to defer to his mother. She asked appropriate ques-
secondary to excessive soft tissue mass. tions and helped answer questions when the patient was
unable to remember. He did not seem to have any barriers
The left LE ROM and strength were difficult to assess
to learning. He thought he might learn best from verbal and
secondary to Jack’s apprehension to actively move the leg and
written instructions as well as pictures when available.
the presence of the external fixator. There was a significant
reluctance to actively contract the muscles of the lower leg
82 Chapter 2
Clinician Comment In working with adoles- Clinician Comment Jack’s obesity was now
cents, it is important to determine the style of learning that confirmed, and the impact of his obesity on his physi-
suits them best. It is even more important to validate and cal therapy prognosis needed to be considered. Further,
empower them as the primary person responsible for the it was important to educate Jack and his parents on the
rehabilitation process. In directing all questions and con- negative impact obesity may have on his future health and
cerns directly to the patient (provided he or she is at an age wellness. This educational component of physical therapy
to answer), it suggests to him or her that the parent is there practice was consistent with the Vision 2020 statement
for support, but it is the patient him- or herself who will be by the American Physical Therapy Association. In it, PTs
in control of the session. Empowering the young patient in are identified as practitioners with the knowledge and
this manner can make future requirements easier for him skills to promote direct, frank, and honest conversations
or her to take, such as performance of self-stretching or with patients on issues of weight to maximize health and
completion of home exercise program. It will also validate wellness.
to him or her that he or she is being heard, which will build Jack and his mom reported that they had been told by
trust between the PT and the child in the rehabilitative Jack’s doctor that Jack may have future weight issues if he
process. continued to gain weight at a rapid pace. It appeared from
Nothing occurred in the systems review that indicated Jack Jack’s BMI that he had weight issues already. The stigma
would not be a candidate for physical therapy. Selection of of conversing with youth regarding weight issues can lead
the tests and measures for the examination was indicated to the issue not being addressed. The Vision 2020 state-
next and would be based on the findings thus far. Because ment is clear that the PT needs to consider obesity as an
Jack’s obesity appeared to be a factor in many aspects of opportunity for education of the patient. The Centers for
his care and future fitness considerations, his height and Disease Control website has resources both for the health
weight measures needed to be assessed, as well as the care professional and the family/patient.
other anthropometric measures of leg length and limb The most accurate measures of leg length occur with the
circumference. use of radiographs. Radiograph measures were not avail-
His pain needed to be documented as well as any addi- able at the time of the PT’s evaluation. Because a leg length
tional environmental, home, school, and play barriers he discrepancy is a hallmark of Blount disease, the attempt to
faced. Measures of ROM and strength were indicated from track this measure—even with tape measure estimates—
the deficits noted in the systems review. The overall con- was appropriate to address at the initiation of treatment.
cern for his deconditioning suggested tests and measures While girth measurements of the left LE were difficult
of his aerobic capacity needed to be included, especially because of the external fixator, subjective documentation
regarding the effort required for him to walk with crutches was recorded. Subjective observations of the skin color and
and gait. temperature were noted also.
Tests and Measures Pain

A pain assessment using a numeric rating scale revealed
Anthropometric Measures Jack reported his lowest pain at a 0/10 intensity and 3/10 for
Based on Jack’s height and weight at the time of evalua- the worst pain intensity. The pain was described as “an ache”
tion, his BMI was 28.9, placing his BMI-for-age at the 98th with occasional “shooting pains” around the pin sites. Jack
percentile for boys aged 11 years.8 In addition, Jack was reported the pain was random but did seem to intensify with
within the “obese” category for his age.8 walking and weightbearing.
Leg length measurements, using a tape measure, were
taken from the anterior superior iliac spine to the medial
malleolus on each leg. The process was more challenging on Clinician Comment Pain assessment used
the left because of the presence of the external fixator. The included a numeric rating scale using whole numbers from
left LE measured approximately 1.25 cm shorter than the 0 to 10 to rate the intensity of the discomfort at a given time.
right. Zero would indicate no pain and 10 would be “take me to
the hospital” pain. It is worth noting here that there has
Only slight swelling was noted in the left LE compared
been documentation of health care providers’ observational
to the right. Girth measurements were not taken to confirm
ratings being lower than self-ratings by the children.9
this on the first visit because of time and the difficulty posed
by the presence of the external fixator on the left. Skin color In this case, it may have been beneficial to have utilized
and temperature throughout the left leg were equal to those a pediatric pain rating scale such as the Faces Pain Scale-
on the right. Revised10 or the Coloured Analogue Scale.11 The self-rating
by Jack varied greatly throughout the examination, calling MUSCLE RIGHT LEFT
into question the validity of using the numeric rating scale FLEXIBILITY
with him. He often gave a number that exceeded his previ-
Quadriceps 0 to 135 degrees Nor tested sec-
ous report of his worst pain. Further, it also appeared as if
ondary to pain
Jack’s fear of the pain that might occur with active move-
ments was the bigger issue. Hamstrings -20 degrees -40 degrees
Whether it was a lack of understanding of the number (90 to 90)
rating scale or an inability to accurately assess pain, the Heel cord 0 to 10 degrees -10 degrees
reliability of Jack’s use of the numeric rating scale became
Hip flexors -5 degrees -10 degrees
irrelevant. The scale was used to help Jack feel as though he
(Thomas test
was in control of any movement or activity that might cause
position)
pain. Throughout the examination, 6/10 became the pain
intensity threshold for Jack, above which he had difficulty
tolerating. Not exceeding this pain intensity level would
become one of the guidelines to be used to define exercise
Clinician Comment ROM measurements
confirmed impairment within the hip and ankle as well as
intensity limits in his program.
the knee that will need to be addressed. Knee extension and
ankle motion would be focal points in the treatment strate-
gies. Identifying and then using a consistent procedure for
Environmental, Home, and Work (School/ the ROM measurements now and in reassessments later
Play) Barrier would allow for comparable measures.
Follow-up questions were employed to amplify the infor-
mation already gained from Jack and his mother in the
interview about barriers to his mobility. No additional infor- Muscle Performance (Including Strength,
mation was gained except to learn that he climbed stairs at Power, and Endurance)
home by sitting on the stairs. He would raise himself up to
The only adjustment to standard MMT positions was that
sit on the adjacent superior stair to move up the stairs. He
all left leg testing was performed with the patient supine on
repeated the process in reverse to descend the stairs. He
the table.
reported, and his mother concurred, that he did this inde-
pendently and without pain.
MUSCLE GROUP RIGHT LEFT
Range of Motion (Including Muscle
UEs 5/5 5/5
Length)
Hip flexion 5/5 3+/5
For the AROM, Jack moved his left leg independently and
was not allowed to assist with his hands. Because of Jack’s Hip extension 4+/5 3-/5
apprehension of having his left leg moved as well as the larger Hip abduction 4+/5 3-/5
girth of the leg, the primary PT needed assistance from a col-
league to ensure accurate passive measures (PROM). Hip adduction 4/5 3-/5
Measurements for the joint ROM in the left leg were Knee flexion 5/5 2/5
obtained with the patient lying supine on the plinth.
Knee extension 5/5 2+/5
Ankle dorsiflexion 5/5 3-/5
JOINT RIGHT LEFT
MOTION Ankle plantarflexion 5/5 3-/5
AROM AROM PROM Ankle inversion 4+/5 3-/5
Knee flexion 0 to 135 -12 to 109 -10 to 111 Ankle eversion 4+/5 3-/5
degrees degrees* degrees*
Knee 0 degrees -12 -10 Clinician Comment MMT was utilized for
extension degrees* degrees* measuring muscle strength and performance. There are
Ankle 0 to 20 -10 -5 degrees limitations of MMT in the pediatric population because
dorsiflexion degrees degrees accurate measures require consistent maximal efforts by
the subject as well as the subject’s understanding of how
Plantarflexion 0 to 40 -10 to 30 -5 to 35
to reproduce the exact motion being tested. With Jack,
degrees degrees degrees
he seemed to understand what was being asked but was
*Limited by pain. unwilling to offer maximal effort in testing the left LE.
84 Chapter 2
While he denied pain with testing, he admitted to being Clinician Comment The gait of children who
afraid of tearing the skin around the pin sites. In reassess- are obese is typically altered even without the presence of
ments, the continued presence (or eventual absence) of the Blount disease.12 Children of normal weight tend to place
external fixator needs to be noted with MMT measures the advancing foot close to the midline of foot progres-
as the fixator may be a significant variable in comparable sion. This foot placement minimizes weight transfer and
muscle performance. decreases energy expenditure in gait.
In working with an adolescent population, it is important For children who are obese, body mass at the thigh limits
to remember the youth’s desire to appear strong and inde- the ability to adduct the hip. This interferes with the abil-
pendent to a new adult, particularly when the patient is ity to place the foot close to the midline of foot progression,
male and the therapist female. A submaximal effort may be thereby increasing energy expenditure necessary for gait.
the youth’s attempt to avoid a painful level of contraction. This wider-than-usual foot placement also results in a
Adolescent patients may need extra encouragement to give varus moment at the knee that increases the pressure on the
100% effort and may be reassured that any pain will dimin- medial aspect of the proximal tibial physis. This increase
ish as therapy progresses. in medial pressure inhibits growth in accordance with the
Hueter-Volkmann law. As described earlier in this report,
this bone growth inhibition leads to the development of
Gait, Locomotion, and Balance Blount disease.2,13 With the probability that Jack had
an altered gait pattern even prior to surgery, it was dif-
Gait ficult to assess how his postoperative gait pattern differed.
Jack demonstrated his ability to walk using bilateral axil- Consideration of preexisting range and strength deficits in
lary crutches while attempting to maintain the weightbear- the involved extremity associated with an altered gait pat-
ing restriction on the left. He required close supervision tern, because of his obesity, needed to be considered in the
for safety. He tended to hold his left leg in approximately development of his treatment program.
25 degrees of external hip rotation. He used a left hip hike
For the testing of gait, visual observation was utilized only
and circumduction to advance his left LE during the swing
since it was not safe at the time of the examination to con-
phase of gait. Further, he showed decreased dorsiflexion of
sider standardized tests with Jack, such as the Timed Up
the left ankle during swing. During the stance phase of gait,
and Go test14 or Berg Balance test15 given his difficulty with
Jack showed decreased hip extension bilaterally. He used a
ambulation.
step-to, 3-point gait pattern but required maximal verbal
cueing to maintain weight restriction on the left LE. He The tests and measures confirmed that Jack had altered
required close supervision and occasional contact guard to anthropometric measures, pain intensity, and environ-
maintain safety in walking. mental barriers to movement. ROM, muscle length, and
A scale was utilized to help him see how much actual strength testing further documented his existing impair-
weight he was putting through his left leg. Initially, he placed ments. Though not tested directly, his shortness of breath
15 and 25 pounds of weight on his left LE. Jack required with ambulation suggested decreased aerobic capacity.
significant practice while standing in the parallel bars and This along with the comorbidity of obesity and generalized
using the scale before he could consistently avoid exceed- decreased fitness level would affect his gait and balance. He
ing the 10-pound restriction. To help with the carryover of was using bariatric crutches that were larger and heavier
awareness gained in the practice session, he was instructed than those typically used by patients his same age. The
to just place his toe on the ground when ambulating to limit effort of attempting to maintain the weightbearing restric-
his weightbearing to an acceptable level. tion on his left leg led to a faster increase in his perceived
His bariatric crutches were heavier than standard crutch- level of exertion for walking.
es. With manipulating the heavier crutches as well as the
effort of ambulating, he began to exhibit shortness of breath
after completing a distance of 50 feet. EVALUATION
Balance
Jack’s balance score improved from that noted in the sys- Diagnosis
tem review to a Fair minus. His overall balance continued
to be limited because of his difficulty with manipulating the Jack was 3 weeks postoperative from a left tibia/fibula
crutches within the weightbearing restriction. When stand- osteotomy to correct altered tibial plateau alignment associ-
ing still, Jack held the left LE in flexion and external rotation ated with Blount disease. He had significant limitations in
at the hip, knee slightly flexed, and ankle plantarflexed. mobility and function because of weightbearing restrictions
and the presence of an external fixator. He showed decreased
ROM, muscle lengths, and strengths. His mobility was fur-
ther affected by his obesity and deconditioning.
Practice Pattern progressed through weightbearing as tolerated and finally to
ambulating independently without an assistive device.
Based on the history, systems review, and tests and mea-
An endurance reconditioning program would be
sures, this patient was classified into 2 Preferred Practice
addressed with a daily ambulation schedule.
Patterns:
The patient would be instructed in a home exercise pro-
1. Musculoskeletal Practice Pattern 4I: Impaired Joint
gram. A paper copy of the exercises with written instructions
Mobility, Motor Function, Muscle Performance, and
and drawings would be provided. Frequency for Jack’s home
Range of Motion Associated With Bony or Soft Tissue
exercise program would be recommended as twice daily.
Surgery
2. Cardiovascular/Pulmonary Practice Pattern 6B: Proposed Frequency and Duration of
Impaired Aerobic Capacity/Endurance Associated With Physical Therapy Visits
Deconditioning Over the course of 12 weeks, Jack will be seen 2 times per
International Classification of Functioning, week at school for a total of 24 visits.
Disability and Health Model of Disability Anticipated Goals
See ICF Model on page 86. 1. Jack will move from sitting in his wheelchair to standing
in his crutches independently (1 week).
Prognosis
2. Jack will actively flex his left knee to greater than
Jack had a good physical therapy prognosis. He could be 110 degrees (2 weeks).
expected to make a complete recovery of ROM and strength
in his left LE over the course of his treatment. His gait and 3. He will be able to tolerate active assistive ROM left knee
endurance should return to his prior level. He should be able extension to at least -10 degrees (2 weeks).
to return to all previous functional activities consistent with 4. Family and patient will demonstrate continued indepen-
an 11-year-old male with comorbidity of obesity. dence with pin care and skin check to avoid infection
(2 weeks).
Clinician Comment It is important to note 5. He will show active knee extension to at least –10 degrees
in the prognosis for Jack that he will be somewhat limited (3 weeks).
in his outcomes by his comorbidity of obesity. As Wilson 6. Jack will have 3+/5 strength throughout left LE (4 weeks).
et al illustrate in the review of complications from tibial 7. He will show active knee flexion in his left knee greater
osteotomies, there exists a higher prevalence of complica- than 120 degrees (4 weeks).
tions postsurgery in those patients with the presence of 8. He will ambulate community distances with bilaterally
obesity.5 In order to maximize Jack’s functional prognosis, axillary crutches and following appropriate weightbear-
it would be indicated to address his obesity and decreased ing restrictions independently (4 weeks).
activity levels as well as how both may affect his course of
treatment. 9. Jack will show independent performance of a home exer-
cise program with 100% accuracy for all stretching and
strengthening procedures (4 weeks).
10. Jack will rate his pain no more than 2 out of 10 with all
Plan of Care ADL and perform independently (6 weeks).
Intervention 11. He will show active knee ROM to 5 to 130 degrees with
no report of pain-limiting motion (8 weeks).
Jack and his family would benefit from continued educa-
12. Family and patient will demonstrate knowledge of risk
tion regarding Blount disease and his status, plan of care, and
factors of complications due to obesity with Blount dis-
discharge plan. A periodic review of pin care techniques was
ease (8 weeks).
indicated to prevent infection.
Active assisted and AROM exercises for his left LE, 13. Jack will participate in 30 minutes of cardiovascular
including hip flexors, extensors, abductors, and adductors; endurance activities including biking or elliptical train-
knee flexors and extensors; and ankle dorsiflexors, plantar ing with 0/10 pain rating (10 weeks).
flexors, invertors, and evertors, were indicated. His program 14. Jack will demonstrate 4+/5 LE strength throughout left
would be progressed to closed-chain strengthening exercises LE with MMT (11 weeks).
when weightbearing restrictions were reduced. Progressive
resistance exercises would be added as tolerated with the
Expected Outcomes (12 Weeks)
external fixator. 1. Jack will be independent in all ADL as well as school and
Gait training with bilateral axillary crutches would begin community ambulation with or without an ambulation
on level surfaces and stairs while also maintaining his device.
weightbearing restriction. When allowed, Jack would be 2. Jack will be independent with an appropriate fitness
activity to ensure continued lifelong weight control.
86 Chapter 2
ICF Model of Disablement for Jack

Health Status
• Blount disease, left knee
• S/p left tibia/fibula osteotomy with external fixation
• Possible sleep apnea

Function
• Contact guard needed for • Uses wheelchair and
• Obesity ADL assistance to change
• Altered standing posture • Inability to transfer classrooms
due to nonweightbearing independently • Unable to complete a full
status in left lower extremity • Gait deviations present school day
• Pain with lower extremity • Walking limited by dyspnea • Inability to participate in
movement recreational activity typical
• Decreased strength in left for age
lower extremity
• Decreased static and
dynamic balance
• Decreased aerobic capacity

• Age = 11 years • Elevator at school
• Tall for age • Doting parents and siblings
• Sedentary leisure activities
• Limited experience with exercise
• Afraid of falling at school with crutch use
• Prefers to use wheelchair
• Enjoyed the attention of selecting a helper for
classroom changes
Discharge Plan Intensity
Rate of perceived exertion (RPE) < 8/20, pain intensity
It was anticipated that Jack would achieve the anticipated
< 6/10
goals and expected outcomes at the end of the plan of care. It
was expected that he would be discharged to a home program UBE: 60 rpm
of exercises as well as an identified fitness activity. Jack and Duration
his mother understood, and agreed with, the plan of care. Walking: 5 minute walks around the house; UBE: 3 min-
utes forward, 3 minutes backward
Frequency
INTERVENTION Walking: 3 times per day during school days, 6 on week-
ends; UBE: at physical therapy 2 times per week
Coordination, Communication, and Description of the Intervention
Jack was instructed first in a walking program to help
Documentation increase his endurance for physical activity. Since he had
Coordinated dialogue with the medical team, educational difficulty with ambulation, this activity was supplemented
team, and family regarding progression of care and treat- at the school-based physical therapy clinic with the use of
ment plan was essential to motivate Jack to maximize his a UBE. The UBE was used in the clinic to increase Jack’s
functional independence and remove any secondary gains of HR and cardiovascular conditioning because he began with
remaining dependent for mobility. Ongoing communication limited ability for repetitive fitness movements with his LEs.
with the patient, family, and school staff regarding progres-
sion toward goals and any changes in his weightbearing Clinician Comment RPE was used to define
status would be integral. Documentation would include all a low level of exertion for Jack rather than a target for him
aspects of care, including initial evaluation, progress reports, to reach in each session. This patient was not active prior
reexaminations, and discharge summary. to surgery and admitted to not liking physical activity,
preferring more sedentary activities such as watching TV
Patient-/Client-Related Instruction and computer games. While the speed or distance of the
walk was not specified, the repetition of the ambulation in
The patient and his family were given extensive education 5-minute blocks would serve to increase his overall activity
regarding the plan of care, frequency of visits, and discharge level. For Jack, it was important that he feel the beneficial
plan as mentioned previously. They also received a review of effect in his exercise tolerance that could occur with even a
pin and skin care around the external fixator, following the modest increase in his activity level. Further, his confidence
original instructions given at the hospital prior to Jack’s dis- with walking at home would increase and then could be
charge. A written home exercise program was created, along carried over to ambulating in school at a later time.
with information on how to begin an endurance recondition-
ing program using his UEs as well as LEs until weightbearing
precautions were lifted. Comorbidities of sleep disturbances
and obesity were also discussed. The family was encour- Flexibility Exercises
aged to pursue the pulmonology consult recommended by Mode
the hospital discharge team. Jack received an explanation of Assisted and active self-stretching flexibility exercises
what progress he could expect to gain from physical therapy Intensity
sessions in terms of movement, strength, pain reduction, and Slow movements through the entire ROM as able with a
progressive weightbearing. Jack reported he understood why hold at end range with no pain sensation, only a stretch
physical therapy was necessary and why his follow-through Duration
with his home exercise program was critical to his successful 5 to 10 minutes of flexibility activities daily
return to his previous functional level. Frequency
3 repetitions 2 times per day
Procedural Interventions Description of the Intervention
A program of flexibility exercises was developed based
Therapeutic Exercise Prescription on the ROM deficits identified in the initial evaluation. The
Aerobic Capacity/Endurance exercises for his school-based physical therapy sessions as
Conditioning or Reconditioning well as part of his home exercise program consisted of the fol-
lowing specific stretching and ROM activities for the left LE:
Mode
• Dorsiflexion stretch with use of a towel: In long sitting,
Walking program and use of an upper body ergometer
wrap towel around bottom of left foot and pull back into
(UBE)
dorsiflexion for a 30-second hold.
88 Chapter 2
• Knee flexion stretch: Lying in prone, use a jump rope
another adult’s assistance to reinforce the focus on Jack’s
looped around the left foot and use arms to assist in flex-
gain of functional independence. The less Jack needed to
ing the knee to tolerance for a 30-second hold.
rely on adults, the more responsibility Jack would take to
• Hamstring stretch: Sitting on edge of bed, drop right ensure his own progress. This approach eliminated the
leg off edge and leave left leg on bed, toes pointed to oft heard excuse with a pediatric client when confronted
ceiling while reaching with both hands out to the toes. with poor home program compliance that a parent was not
Emphasize keeping left knee completely straight and available to help.
bending forward at the hip. Early in the exercise program, it was explained to Jack that
Strength and Endurance Training the discomfort associated with exercise should never be
Training for trunk and leg muscles and home exercise above a 6/10 rating on a 0 to 10 numeric rating scale. If his
program pain reached a 6/10 during his school-based program, he
Mode was to inform the primary PT, who would modify the activ-
ity to decrease the pain intensity felt. This again reinforced
Active and against gravity isometric and progressive iso-
to the Jack that, while the PT might direct the course of the
tonic exercises
session, Jack had active control. It was also explained to
Intensity
Jack that if all of the exercises seem easy or no stretch was
Slow movements through the entire ROM felt, the intensity of the exercise needed to be increased for
Duration the exercises to be beneficial.
20 minutes for entire routine
Frequency
2 sets of 10 repetitions each exercise at least 1 time per day Gait and Locomotion Training
Description of the intervention Mode
A comprehensive strength and conditioning program Walking with appropriate assistive device and obeying
was developed that initially consisted of active exercises per- weightbearing precautions
formed in sitting, prone, and supine positions. When lifting Intensity
restrictions are lifted, then the exercises would be progressed
Walking at a pace that is age appropriate
to standing activities as well as closed kinetic chain activities.
Duration
The exercises included the following:
10 minutes progressing, up to 30 minutes
• Gluteal sets in supine with 10-second hold
Frequency
• Quad sets in supine with 5-second hold of the contrac- Daily practice at least 10 minutes
tion. Because of his difficulty in recruiting the quadri- Description of the Intervention
ceps for this exercise in the clinic, an inflated BP cuff
With Jack standing in the parallel bars and his left LE on
was positioned under Jack’s left leg. To increase the pro-
a scale, he will practice loading his left LE to the weightbear-
prioceptive input of a correct quad contraction, he held
ing restricted amount. Jack will progress to walking with
the dial and monitored the effectiveness of his contrac-
the bilateral axillary crutches with appropriate weightbear-
tion by watching to see if the needle position changed.
ing through the left leg. As the weightbearing restriction
Pushing his posterior distal thigh into a towel roll was
changes, Jack will be progressed to weightbearing as toler-
recommended for his home program.
ated, and eventually to full weightbearing as indicated by the
• Ankle pumps were performed through the entire ROM physician. Emphasis will be placed on increasing step length
to assist in dissipating the minimal swelling present in and improving safety awareness of obstacles in his path. Stair
the left knee. training will be performed when appropriate.
• Assisted heel slides were performed using a rope around
the ankle to allow Jack to bring his knee to full available Clinician Comment Experience suggests that
range without assistance from an adult. the more learning techniques that can be employed to teach
• Seated march performed over edge of bed a motor pattern, the more successful a pediatric client
might be in achieving the goal. Jack understood that he was
• Closed kinetic-chain activities would be added when
not to exceed 10 pounds of weightbearing through his left
cleared by doctor.
leg, but he had difficulty identifying what that felt like. By
spending time using a visual cue of the scale, he was able to
Clinician Comment As previously stated, perceive what the 10 pounds of pressure felt like and became
Jack’s activity level prior to his surgery was decreased as better able to adjust his weightbearing when given a verbal
compared to same-aged peers. It was therefore recom- reminder. Another motor learning strategy was used when
mended that he perform these exercises at home on both teaching Jack how to recruit his quadriceps in performance
LEs. Care was taken to avoid exercises that would require of the “quad set” exercise. By handing him the dial of the
sphygmomanometer and placing the inflated cuff behind REEXAMINATION

his knee, he was given the visual aid of the needle moving,
indicating the correct muscular contraction. With a pedi- Jack’s progress was monitored at each treatment; however,
atric client, using a visual cue will often lead to decreased formal reexaminations occurred at 6 weeks, 4 months, and
frustration and improved outcomes. 6 months from the initiation of physical therapy sessions.
These reports were generated prior to Jack’s return visits to
the referring physician.
Balance, Coordination, and Agility Training
Mode Reexamination at 6 weeks
Age-appropriate tests of balance, coordination, and agil-
ity, such as timed shuttle runs, jump tests, and obstacle Subjective
courses “I’m more comfortable walking.”
Intensity Objective
Moderate to high intensity when cleared by physician
Duration Pain
Up to 5 minutes in duration As noted previously, Jack reported he was able to walk
Frequency with his crutches with less pain. The pin site symptoms were
2 to 3 times per week when cleared to participate reported a 4/10 on the numeric rating scale, especially when
bending the left knee during swing phase of gait.
When cleared by the physician for the increased weight- Environmental, Home, and
bearing that would be required, balance, coordination, and School/Play Barriers
agility training will be initiated with use of timed shuttle Jack returned to full days of school. He no longer required
runs, completion of obstacle courses, and upper-level balance assistance with transfers, gait, or trips to the bathroom
training as appropriate for an 11-year-old male. while at school. He ambulated independently with crutches
Functional Training between classrooms but was still given additional time.
Training in home and work (job/school/play), commu- He continued to be mostly sedentary when at home. His
nity, and leisure integration or reintegration, including ADL, family still offered him assistance with his needs rather than
instrumental ADL, work hardening, and work conditioning having him perform them independently.
Description of the Intervention Range of Motion (Including Muscle Lengths)
• ADL, instrumental ADL, and functional training. Symptoms limited his left knee flexion to 110 degrees. Left
Training to include the following: knee extension was –6 degrees. Left ankle dorsiflexion (knee
◦ Bed mobility and transfer training bent) was –2 degrees and plantarflexion 35 degrees. His left
hip ROM was within functional limits.
◦ Developmental activities appropriate for an 11 year Specific muscle length testing showed improved but still
old limited lengths. His left hamstring length, measured from a
◦ Simulated school environment, including crowded vertical 90-degree standard, was –38 degrees. Ankle dorsi-
hallways and school cafeteria flexion measured with the knee straight to assess gastrocne-
◦ Household chores mius length showed –10 degrees. Hip flexor length measured
in the Thomas test position showed –8 degrees.
◦ Recreational activities, including simulated physical
education tasks Muscle Performance (Including
Strength, Power, and Endurance)
• Injury prevention or reduction
◦ Injury prevention education during self-care and MUSCLE GROUP MUSCLE GRADE
home management
Hip flexion 3+/5
◦ Injury prevention or reduction with use of devices
and equipment including strict adherence to weight- Hip extension 3-/5
bearing restrictions Hip abduction 4/5
◦ Safety awareness training during self-care, home, and Hip adduction 4/5
school management
Knee flexion 4-/5
• Functional training
Knee extension 2+/5
◦ Energy conservation techniques
Ankle dorsiflexion 4/5
Ankle plantarflexion 3/5
90 Chapter 2
Gait, Locomotion, and Balance Reexamination at 16 Weeks (4 Months)
Jack walked independently with his crutches at school.
He was allowed to increase the weightbearing on his left LE Subjective
to 20 pounds. Though the pin sites remained healthy and “It is so much easier to do this [physical therapy] without
without signs of infection, he continued to report decreased the fixator.”
ability to comfortably bend his left knee when advancing his
left LE forward in gait. Objective
Assessment Weightbearing Status
Jack was able to show an increase in his overall ambu- Jack remained at 20 pounds weightbearing until the fix-
lation ability in the first 6 weeks of physical therapy. He ator was removed 12 weeks after therapy started. He was then
progressed to 20 pounds of weightbearing on his left LE. required to go back to a 10-pound weightbearing restriction
Jack did not show significant changes in muscle lengths on his left LE for 5 weeks—a restriction still in place at the
because of continued related symptoms at the pin sites. He time of this reexamination.
did show increased strength in left knee flexors and overall Pain
hip strength. Jack reported his pain level was 0/10. He was also more
Of the goals anticipated to be met by 6 weeks, he met motivated during rehab sessions.
numbers 1, 3, 4, 5, and 8. Though he made gains with each
visit, he did not gain knee flexion greater than 110 degrees Environmental, Home, and
(#2) or 120 degrees (#7), or the strength goals for hip and Work (School/Play) Barrier
knee extension (#6). He knew his home program, but he had Jack was not in school because of the summer break. He
decreased compliance (#9). Goals for pain intensity (#10) and spent most of his time at home. His endurance for walking
left knee AROM (#11) were thwarted by continued pin site appeared to decrease slightly since he was no longer walking
reactivity. between classes at school. He was able to perform all ADL at
home without supervision.
Clinician Comment Jack made gains, but not Range of Motion (Including Muscle Length)
as anticipated. The rate of allowed weightbearing was not
increased as anticipated because follow-up radiographs did LEFT LE 4 MONTHS AROM
not show the expected bone healing at the rate projected. Knee flexion 122 degrees
Increased in weightbearing might have assisted in a more
normal gait pattern for his left LE and, thus, left hip and Knee extension -3 degrees
knee strength. The pin site reactivity continued to limit his Ankle dorsiflexion 5 degrees
movement. He was scheduled to attend physical therapy
Ankle plantarflexion 40 degrees
3 times per week, but with transportation complications, he
attended only 1 to 2 times per week. FLEXIBILITY
Hamstrings (90 to 90) -34 degrees
Plan Gastrocnemius -10 degrees

The described physical therapy intervention plan would Hip flexors -5 degrees
be continued. The following time changes would be made for
his yet-to-be met goals and outcomes. Muscle Performance (Including
Anticipated Goals Strength, Power, and Endurance)
• #2: Jack will actively flex his left knee to greater than
110 degrees (8 weeks). MUSCLE GROUP 4 MONTHS (16 WEEKS)
• #6: Jack will have 3+/5 strength throughout left LE Hip flexion 4/5
6 weeks after the removal of the fixator or weightbearing
Hip extension 3+/5
as tolerated was allowed.
• #9: Jack will show independent performance of a home Hip abduction 4/5
exercise program with 100% accuracy for all stretching Hip adduction 4/5
and strengthening procedures (8 weeks).
Knee flexion 4/5
• #10: Jack will rate his pain no more than 2/10 3 weeks
Knee extension 3+/5
after the fixator is removed.
• #11: He will show active knee ROM to 5 to 130 degrees Ankle dorsiflexion 4+/5
with no report of pain-limiting motion (12 weeks). Ankle plantarflexion 3/5
Gait, Locomotion, and Balance Objective
Jack was able to demonstrate gait with his crutches and
Weightbearing Status
maintenance of the 10-pound weightbearing restriction
without difficulty. Weightbearing status was increased to 50% 8 weeks prior,
with increase to full weightbearing over 4 weeks.
Clinician Comment Pain was no longer an Pain
issue for Jack. He was completing his ADL independently at Jack continued to report 0/10 pain.
home but walking less overall with summer break. He was Environmental, Home, and
meeting the goals for his knee motion. His muscle lengths Work (School/Play) Barrier
were not as improved as anticipated with the removal of the
Jack returned to school in the fall and ambulated through-
fixator, but he was still limited in his gait pattern because of
out the full school day with no restrictions except for physical
the weightbearing restriction. His overall improvement in
education. He returned to performing chores at home and
ROM, muscle lengths, and strength gave him a good base
was performing his home exercise program and his fitness
from which to make further gains.
regime at least 3 times per week.
Range of Motion (Including Muscle Length)
Assessment
Jack met the original anticipated goals numbers 1 through LEFT LE AROM 24 WEEKS
8 as well as numbers 10 and 12. He met expected outcome Knee flexion 135 degrees
number 1 using an ambulation device. He was more moti-
vated to be consistent with his home program. Knee extension 0 degrees
Plan Ankle dorsiflexion 15 degrees
The projected time interval for achievement of the remain- Ankle plantarflexion 40 degrees
ing anticipated goals and expected outcomes were amended. FLEXIBILITY AROM 24 WEEKS
The first expected outcome was changed to “without an
ambulation device.” Hamstrings (90 to 90) -25 degrees
Anticipated Goals Heel cord 5 degrees

• #1: Jack will show independent performance of a home Hip flexors 0 degrees
exercise program with 100% accuracy for all stretching
and strengthening procedures (24 weeks).
Muscle Performance (Including
• #11: He will show active knee ROM to 5 to 130 degrees
with no report of pain-limiting motion (20 weeks).
Strength, Power, and Endurance)
• #13: Jack will participate in 30 minutes of cardiovascular
endurance activities, including biking or elliptical train- MUSCLE GROUP 24 WEEKS
ing, with 1/10 pain rating (24 weeks). Hip flexion 4+/5
• #14: Jack will demonstrate 4+/5 LE strength throughout Hip extension 4/5
left LE with MMT (24 weeks).
Hip abduction 4+/5
Expected Outcomes (24 Weeks)
Hip adduction 4+/5
1. Jack will be independent in all ADL as well as school and
community ambulation without an ambulation device. Knee flexion 5/5
2. Jack will be independent with an appropriate fitness Knee extension 4+/5
activity to ensure continued life-long weight control.
Ankle dorsiflexion 5/5
Ankle plantarflexion 4-/5
Reexamination at 24 Weeks
Subjective Gait, Locomotion, and Balance
“I can do everything I used to do [before surgery] and Jack had a slightly asymmetrical gait with a slight drop in
better now, but I get tired more easily.” “I think I’m walking his center of gravity during stance phase on the left LE when
funny.” walking without an ambulation aid. He walked better with it.
92 Chapter 2
Assessment
Clinician Comment This case report ties
Jack performed his home exercise program and fitness together multiple factors that need to be considered beyond
program at home 3 times per week (#9 and #13). Jack had a patient’s initial medical diagnosis. Jack was a young
achieved the ROM and muscle length goals (#11). All left LE man referred to physical therapy for an orthopedic issue
muscle strength grades were greater than or equal to 4+/5, but benefitted from a comprehensive treatment approach
with the exception of left hip extension and ankle plantar that included cardiovascular, integumentary, and wellness
flexion (#14). Pain was absent. His increased ROM and goals. Pediatric patients have many special circumstances
strength allowed him to move with less perceived exertion at to consider, but adolescent patients in particular can be
home and at school. a challenge to motivate and empower to be an active par-
At the time of this reexamination, Jack had just been ticipant in the process. Through the course of Jack’s care,
cleared to run. He would benefit from a few additional physi- communication between Jack, his family, and his school
cal therapy sessions to practice pre-running and running had to be clear and thorough to ensure follow-through and
tasks, as well as higher level balance and coordination drills. compliance. Issues that may not be typically addressed by
Plan a PT—obesity, explanation of BMI for age, risk factors
related to obesity in youth, sleep apnea, and promoting
The frequency of treatment sessions would be reduced functional independence—needed to be addressed for this
to once per week. Pre-running and running tasks would be patient. Although all goals were not met completely, he was
introduced. High-level balance and agility drills would be able to resume his previous activities and became educated
practiced. Continued education on the importance of fitness on how following an active lifestyle would be important for
and a wellness lifestyle would be included. maintenance of good health, now and in the future.
OUTCOMES REFERENCES
Discharge 1. Wills M. Orthopedic complications of childhood obesity. Pediatr
Phys Ther. 2004;16:230-235.
While it was recommended Jack continue with physical 2. Thompson GH, Carter, JR. Late-onset tibial vara (Blount’s disease):
therapy for 1 additional month, Jack’s family chose not to current concepts. Clin Orthop Relat Res. 1990;(255):24-35.
continue the sessions when their insurance coverage would 3. Shulman ST. A sweet solution? And a major philatelic error. Pediatr
Ann. 2010;39(3):115-116.
not authorize additional visits. This patient did undergo an 4. A patient’s guide to Blount’s disease in children and adolescents.
extensive course of therapy that lasted over 6 months with eOrthopod www.eorthopod.com/content/blounts-disease-in-chil-
sessions occurring 1 or 2 times per week and an extensive dren-and-adolescents. Accessed February 28, 2010.
home exercise program. Patient and family education were 5. Wilson NA, Scherl SA, Cramer KE. Complications of high tibial
critical components in this case to help control the risk of osteotomy with external fixation in adolescent Blount’s disease.
Orthopedics. 2007;30(10):848-852.
recurrence or complication. 6. Sabharwal S. Blount disease. J Bone Joint Surg Am. 2009;91:1758-
At the time of discharge, Jack had achieved all anticipated 1776.
outcomes except a return to running. He had a mildly asym- 7. Section on Pediatric Pulmonology, Subcommittee on Obstructive
metrical gait: his left LE strength did not yet equal the right. Sleep Apnea Syndrome. American Academy of Pediatrics. Clinical
Practice guideline: diagnosis and management of childhood
He was not yet fully participating in physical education.
obstructive sleep apnea syndrome. Pediatrics. 2002;109:704-712.
Near his 12th birthday, Jack was measured at 5 feet, 8. Centers for Disease Control and Prevention. Growth charts. http://
9 inches tall and 188 pounds. His BMI was calculated to be www.cdc.gov/growthcharts. Updated September 9, 2010. Accessed
27.8, which was in the 97th percentile in BMI for age for a February 28, 2010.
12-year-old boy. The reduction in his BMI and his BMI-for- 9. deTovar C, von Baeyer CL, Wood C, Alibeu JP, Houfani M, Arvieux
C. Post-operative self-report of pain in children: interscale agree-
age was an outstanding accomplishment for Jack as development, response to analgesic, and preference for a faces scale and a
ing life-long weight control habits was a secondary goal of visual analogue scale. Pain Res Manag. 2010;15:163-168. Accessed
his program. via Pub Med July 21, 2010.
At the time of discharge, there had been no follow-up 10. Hick CL, von Baeyer CL, Spafford PA, van Korlaar I, Goodenough
B. The Faces Pain Scale-Revised: toward a common metric in pedi-
with pulmonary regarding possible sleep apnea despite
atric pain measurement. Pain. 2001;93(2):173-183.
multiple attempts to encourage Jack’s mother to schedule an 11. McGrath PA, Seifert CE, Speechley KN, Booth JC, Stitt L, Gibson
appointment. MC. A new analogue scale for assessing children’s pain: an initial
validation study. Pain. 1996;64(3):435-443.
12. McMillan AG, Auman NL, Collier DN, Blaise Williams DS. 14. Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic
Frontal plane lower extremity biomechanics during walking in functional mobility for frail elderly persons. J Am Geriatr Soc.
boys who are overweight versus healthy weight. Pediatr Phys Ther. 1991;39(2):142-148.
2009;21:187-193. 15. Berg KD, Wood-Dauphinee SL, Williams JI, Maki B. Measuring
13. Goshue DL, Houck J, Lerner AL. Effects of childhood obesity balance in the elderly: validation of an instrument. Can J of Public
on three-dimensional knee joint biomechanics during walking. Health. 1992;83 Suppl 2:s7-s11.
J Pediatr Orthop. 2005;25(6):763-768.
System Changes in the Aging Adult
3
• Discuss how the age-related changes to the 3 compo-

CHAPTER OBJECTIVES nents of motor control affect the function (including fall
risk) and the quality of life in aging adults.
• Identify the physiologic changes with aging that occur
in ventilation, gas exchange, oxygen (O2) delivery, and
cellular O2 uptake that impact the aerobic capacity of
older adults. CHAPTER OUTLINE
• Name the exercise prescription parameters for aerobic
• Age-Related Changes in Aerobic Capacity
capacity training with older adults that have led to effec-
tive gains in maximum O2 consumption (VO2max). ◦ Ventilation
• List the cardioprotective effects seen as a result of exer- ▪ Changes in Ventilatory Muscles
cise for aging adults. ▪ Changes in the Lung
• Describe the age-related changes in the cardiovascular ▪ Changes in the Chest Wall
system and the impact they have on an older adult’s
▪ Physiologic Measures of Lung Function
hemodynamic response to exercise.
◦ Gas Exchange
• Describe the relationship between O2 consumption for
activities of daily living (ADL), peak VO2, and func- ▪ Ventilation-Perfusion Matching
tional capacity. ▪ Diffusion
• Name the changes in the aging musculoskeletal system ◦ Oxygen Delivery
that affect muscle strength and power.
▪ Changes in the Heart
• Discuss what research study results suggest about mus-
▪ Changes in the Blood Vessels
cle endurance in aging adults.
▪ Physiologic Measures at Rest
• Describe the relationship between muscle performance
(strength, power, and endurance) and functional perfor- ▪ Physiologic Measures With Exercise
mance of the older adult. ▪ Cellular Oxygen Uptake
• Using the concept of physical reserve, summarize the ◦ Benefits of Aerobic Training
impact of function in aging adults with regard to aerobic
◦ Summary
capacity and muscle performance.
• Age-Related Changes in Muscle Performance
• Summarize what research studies have shown about
muscle performance training in aging adults and the ◦ Age-Related Changes in Skeletal Muscle
impact on physical function. ▪ Muscle Mass
• Contrast the postural stability control strategies used by ▪ Muscle Fiber Type and Size
aging adults compared to younger adults.
▪ Motor Units

- 95 - © 2015 SLACK Incorporated.
96 Chapter 3
◦ Effect on Muscle Performance the results of research on aging. The use of cross-sectional
▪ Muscle Strength designs to test subjects of different ages at a given point in
time is relatively common because it is less expensive and
▪ Muscle Power requires less subject commitment over a long period com-
▪ Muscle Endurance pared to longitudinal studies. Such studies, however, are
◦ Effect on Function subject to a cohort or generational effect. That is, individuals
born at any particular time are exposed to a specific set of
◦ Benefits of Strength Training factors (eg, nutritional deficiencies, infections, environmen-
◦ Summary tal exposures) that may influence the physiological variables
• Age-Related Changes in Motor Control under investigation. If these confounding variables are
unknown, the differences between age groups may be erro-
◦ Sensory Integrity neously attributed to the effect of aging rather than the effect
▪ Vision of the confounding variable.
▪ Somatosensation In addition, cross-sectional study designs increase the risk
of selective mortality. When older age groups are studied,
▪ Vestibular Function the only subjects left to participate are those from the birth
◦ Central Processing cohort who did not have significant risk factors for disease
▪ Sensory Organization that caused morbidity or mortality at a younger age. Selective
mortality may therefore underestimate the rate of change of
▪ Motor Organization aging.2
◦ Effector System The cross-sectional study design is not the only type
◦ Effect on Function of research with issues when it comes to accurately docu-
menting the changes of aging. While longitudinal studies
◦ Benefits of Training
may avoid some of the previously described problems, this
◦ Summary experimental design has limitations as well. For example,
• Summary repeated exposure to a measurement can cause subjects to
change their performance because they have learned about
• References
the measure, not because of a true change in their abilities
or perceptions. There also may be significant changes in the
Physical therapists (PTs) interpret examination data and lifestyle or environment of the subjects over the course of the
identify abnormal test results to formulate accurate diag- study that must be accounted for. Finally, attrition of partici-
noses and effective treatment plans for their patients and pants and changes in technology and instrumentation over
clients. The ability to recognize abnormal findings requires time can have a significant impact.1,2
a clear understanding of the expected or normal results of Despite the difficulties involved in the investigation of
tests and measures. “Normal” often changes as a result of the aging process, significant evidence exists that docu-
the aging process. Data that might be considered abnormal ments age-related changes in anatomy and physiology. This
in a young adult are often considered usual and acceptable chapter presents the changes in aerobic capacity, muscle
in an older individual because of age-associated changes in performance, and motor control that inevitably occur with
anatomy and physiology. An appreciation of the expected advancing age.
age-related changes in the body’s systems is therefore critical
to accurate interpretation of test results and determination of
a realistic prognosis and plan of care. As the demographics
of the United States population continue to change and the
AGE-RELATED CHANGES IN
proportion of seniors steadily increases, PTs will be more AEROBIC CAPACITY
and more likely to interact with an aging clientele. Thus,
knowledge of the physiology of aging will become increas- Aerobic capacity is the ability to perform work or par-
ingly pertinent. ticipate in activities over time using the body’s O2 uptake,
Many challenges exist in studying the effects of aging on delivery, and energy-release mechanisms.3 This requires the
the body. Primarily, it is difficult to establish age as the sole integrated work of the cardiovascular and pulmonary sys-
independent variable in any sample. Rigorous screening is tems to ensure adequate O2 delivery to the tissues.
required to exclude subjects with occult disease, significant Ventilation is the movement of gas into and out of the
lifestyle differences, or influential environmental exposures. lungs. On inspiration, the diaphragm and external inter-
In addition, research about age-related changes is frequently costals contract to expand the thorax, decreasing intratho-
flawed by lack of the oldest adults (ie, > 80 years old) in the racic pressure and causing atmospheric gas to flow into the
sample. lungs. The difference in the partial pressure of O2 between
Masoro1 describes many of the major confounders in the alveoli and the blood in the pulmonary capillaries
study designs that need to be considered when interpreting allows O2 to passively diffuse into capillary blood and be
System Changes in the Aging Adult 97
TABLE 3-1. AGE-RELATED CHANGES IN THE TABLE 3-2. REFERENCE VALUES WITH
PULMONARY SYSTEM LOWER LIMITS OF NORMAL FOR
ANATOMICAL PHYSIOLOGICAL MAXIMAL INSPIRATORY PRESSURE AND
Increased Increased MAXIMAL EXPIRATORY PRESSURE
● Collagen cross- ● O2 cost of ventilatory AGE (YEAR) MIP (CM H2O) MEP (CM H2O)
linking4 muscles7
(LLN) (LLN)
● Diameter of alve- Ventilation/perfusion
●
20 to 54 Male: 124 (80) Male: 233 (149)
oli and enlarged (V/Q) mismatch
airspaces4 Female: 87 (55) Female: 152 (98)
Decreased:
● Alveolar surface ● Elastic recoil of the lung4 55 to 59 Male: 103 (71) Male: 218 (144)
area5 Female: 77 (51) Female: 145 (105)
● Chest wall compliance2
● Functional resid- 60 to 64 Male: 103 (71) Male: 209 (135)
● Ventilatory muscle
ual capacity4 Female: 73 (47) Female: 140 (100)
strength7,8
● Residual vol- 65 to 85 Male: 83 (65) Male: 174 (140)
● Forced expiratory vol-
ume4 ume in 1 second (FEV1) Female: 57 (45) Female: 116 (90)
Stiffening of the and forced vital capacity LLN: lower limits of normal.
chest wall4 (FVC)2 Reprinted with permission from Mason RJ, Broaddus VC, Martin
Possible changes ● Diffusion9 T, et al, Murray and Nadel s Textbook of Respiratory Medicine,
in alveolar-capillary 5th ed, Hegewald MJ, Crapo RO. Pulmonary function testing,
membrane6 Ventilatory fatigue at a lower Copyright Elsevier 2010.
workload8
review of the literature provides evidence of an age-related

transported through the pulmonary vasculature to the left decline in MIP, averaging 15% to 20% between 20 and
side of the heart. The left ventricle pumps the oxygenated 70 years. Hautmann et al7 studied 504 healthy subjects aged
blood through the arterial system to the body’s tissues where 18 to 82 years and found age to be an independent predictor
peripheral gas exchange occurs. Metabolically active tissues of MIP. Enright and colleagues10 also found age to be a nega-
extract O2 from the blood for use in aerobic metabolism, a tive predictor of maximal respiratory pressures in their study
process that creates carbon dioxide (CO2) as a byproduct. of a large sample of ambulatory older adults (n = 4443 for
CO2 is diffused out of the cell into the venous blood for MIP and n = 790 for MEP). Using the data from a healthy
transport to the right side of the heart. The right ventricle subgroup of their sample, the authors derived reference equa-
is then responsible for pumping venous blood into the lungs tions to identify normal ranges of MIP and MEP values that
for CO2 to be diffused back into the alveoli and exhaled. The are based on age and weight. The investigators note that there
movement of gas out of the lung occurs passively, relying on is large between-subject variability; therefore, the normal
the recoil of the chest wall and lungs. Efficient functioning of range of MIP and MEP values is wide (Table 3-2).
each of these component processes is integral to achieving a Tolep and Kelson8 identified multiple limitations asso-
functional exercise capacity. ciated with MIP and MEP measurements, including the
Anatomical and physiological changes occur with aging influence of subject motivation and the inability to isolate
that affect the ventilation, gas exchange, O2 delivery, cellular individual ventilatory muscles. In addition, the value may
O2 uptake and, therefore, aerobic capacity of older adults. reflect elastic recoil properties of the lung and chest wall
instead of ventilatory muscle strength when measurements
Ventilation are taken at lung volumes other than functional residual
capacity (FRC).8 For these reasons, they examined the
Significant anatomic and physiologic age-related changes strength of the diaphragm in older subjects compared to
occur in the pulmonary system that affect the ventilation of young adults by measuring maximum static transdiaphrag-
older adults. The most important changes are decreased ven- matic pressure. They concluded that diaphragmatic strength
tilatory muscle strength, decreased elastic recoil of the lung, is reduced by approximately 20% to 25% in older subjects
and decreased chest wall compliance (Table 3-1). compared to young adults (Figure 3-1). From examination of
Changes in Ventilatory Muscles animal models, the authors suggest that preferential atrophy
of type II (fast twitch, oxidative) muscle fibers, changes in
Clinical measurement of maximal inspiratory pressure
myosin heavy-chain content, and decreased capillary density
(MIP) and maximal expiratory pressure (MEP) can quantify
may be responsible for the age-related decline in ventilatory
the strength of the ventilatory muscles. Tolep and Kelson’s8
muscle strength. Janssens et al4 additionally cite impairment
98 Chapter 3
Figure 3-1. Maximum transdiaphragmatic pressures in young and elderly

subjects. (Reprinted with permission from Clin Chest Med, 14(3), Tolep
K, Kelsen SG, Effect of aging on respiratory skeletal muscles, p 372.
Copyright Elsevier 1993.)
Figure 3-2. Static elastic recoil as a function of age. Static elastic
recoil was measured at 60% of total lung capacity. Shaded area shows
of the sarcoplasmic reticulum Ca2+ pump and a decline in ± 1 standard deviation of plotted means. (Reprinted with permission from
mitochondrial respiratory chain function as possible expla- Turner J, Mead J, Wohl M. Elasticity of human lungs in relation to age.
J Appl Physiol. 1968;25:664-671.)
nations for impaired ventilatory muscle performance in older
adults.
Tolep and Kelsen suggest that, although there are few decade, there was a decrease of approximately 30%. This air-
rigorous studies, preliminary evidence supports preserved space enlargement is similar to the morphologic changes that
ventilatory muscle endurance in healthy older people.8 They occur in emphysema. Unlike emphysema, however, age-relat-
suggest that older adults are more prone to ventilatory fatigue ed changes in the airways and alveoli occur rather homoge-
(this occurs when the average pressure during each breath neously throughout the lung, and they are not accompanied
divided by the maximum pressure exceeds 50% to 60%) by alveolar wall destruction.
than young adults because of the close relationship of muscle Because of the loss of elastic support around the airways,
strength and endurance. At any given workload, older people there is also a tendency of the small airways to collapse.
are functioning at a higher percentage of their maximum Premature collapse may occur during tidal breathing in
capacity due to the age-related decline in maximum strength. advanced age.4,12 The combination of lost elastic recoil and
Thus, they are less likely to be able to continue contracting early airway collapse results in air trapping and contributes
for a prolonged period of time. to the age-related increase in residual volume (the amount of
Clinical evidence has shown an age-related decline in air in the lungs at the end of maximum expiration).13
ventilatory muscle strength, which consequently increases
the risk of earlier onset ventilatory muscle fatigue at any Changes in the Chest Wall
given workload. In addition, the ventilatory muscles of With age, there is stiffening of the chest wall, which is
older adults consume more O2 at any given workload. These thought to arise from the narrowing of intervertebral disc
changes decrease ventilatory reserve and the ability to meet spaces and calcifications in the rib cage and its articulations,
the increased O2 demands of higher levels of activity or the including the costal cartilage and rib-vertebral articula-
physiologic stress associated with disease.11 tions.4 This decreases the compliance of the thorax. The
Changes in the Lung change in the compliance of the thorax (which determines
the elastic work of breathing during inspiration) is greater
There is an age-related decline in the elastic recoil of the than the change in the compliance of the lung (which deter-
lung (Figure 3-2) that results in increased lung compliance mines force and rate of expiration). Thus, the net result is a
(ie, change in volume for a given change in pressure).4 The decrease in the total compliance of the ventilatory system
total amount of collagen and elastin in the lung parenchyma with advancing age.2
does not change with aging, but the collagen becomes
more stable because of the increased number of cross-links. Physiologic Measures of Lung Function
Changes in the orientation and cross-linking of the elastic Age-related changes in the ventilatory pump produce
fibers may explain the decrease in elastic recoil. alterations in certain lung volumes (Figure 3-3). Total lung
Elastic fibers around the respiratory bronchioles and capacity remains essentially constant throughout adulthood,
alveoli degenerate, contributing to an increase in the diam- but the changes in lung and thorax compliance contribute to
eter of alveolar ducts and enlargement of the airspaces.4 an increased FRC (the amount of air in the lungs at the end of
Gillooly and Lamb5 examined the lung tissue of nonsmokers a quiet expiration). This causes elderly individuals to breathe
ages 21 to 93 years and found a decrease in the surface area at higher lung volumes than their younger counterparts.
of airspace wall per unit volume of lung tissue beginning in Both cross-sectional and longitudinal studies have demon-
the third decade and continuing throughout life. By the 10th strated that there is also an increase in residual volume (the
Figure 3-3. Evolution of lung volumes with aging. (Reproduced with

permission of the European Respiratory Society. Eur Respir J. January 1,
1999 13:197-205.) Figure 3-4. Evolution of FEV1 (solid line) and FVC (dotted line) as a func-
tion of age. Average of data from 746 subjects free of cardiorespiratory
symptoms and who had never smoked. M: males; F: females. (Reproduced
with permission of the European Respiratory Society. Eur Respir J. January
amount of air left in the lungs after maximum expiration) 1, 1999 13:197-205.)
due to air trapping associated with the lung’s decreased
elastic recoil and increased compliance. An increase in
residual lung volume prevents the diaphragm from reaching near optimal perfusion, an increasing mismatch in the venti-
its longest resting length at end expiration, which flattens lation/perfusion (V/Q) ratio develops. V/Q mismatch causes
and shortens the diaphragm, decreasing its biomechanical a decline in PaO2 and the progressive increase in AaDO2
advantage and force-generating capability. with advancing age.4,13 Several age-based equations are
Flow rates are also affected by age (Figure 3-4). Forced widely used to predict PaO2 and AaDO2 values. In her review
expiratory volume in 1 second (FEV1) and forced vital capac- of the original data that generated these equations, Zeleznik
ity (FVC) decrease beginning in the mid-30s and demonstrate highlights several shortcomings and cautions against using
an accelerated rate of decline with age.2 Studies that have these equations as precise estimates of age-adjusted values.2
been conducted to develop regression equations that predict Nonetheless, the majority of evidence supports the presence
spirometric values based on age have not included sufficient of an age-related decline in gas exchange that is primarily
numbers of older subjects to validly identify true age-related attributable to a decrement in optimal V/Q matching and
ranges. It appears that the extrapolations from younger results in a lower normal PaO2.
adults’ values have overestimated predicted values for FEV1,
FVC, and FEV1/FVC in older individuals. Consequently, Diffusion
the usual practice of classifying those who achieve below The rate of diffusion of gases between the alveoli and the
80% predicted as abnormal likely results in overdiagnosis of capillaries is proportional to the membrane surface area and
obstructive disease in older adults. Zeleznik 2 reports that the the difference in gas partial pressure between the 2 sides. It
data from the Cardiovascular Health Study suggest a value is inversely proportional to the thickness of the membrane.14
of 56% to 64% of predicted FEV1/FVC as the lower limit of Decreases in V/Q matching, alveolar surface area, density of
normal for those aged 65 to 85 years old instead. lung capillaries, and capillary blood volume may all contrib-
ute to a decline in diffusion in older age.12 Stam et al9 found
Gas Exchange that the diffusion of carbon monoxide (which is commonly
used to study the diffusion properties of the human alveolar-
The age-related decrease in the lung surface area that capillary membrane) was decreased in older subjects. The
is available for diffusion of gases causes an increase in the results were normalized for alveolar ventilation to isolate
difference between the partial pressure of O2 in the alveolar the effect of alterations in the alveolar-capillary membrane
spaces and the arterial blood (the alveolar-arterial pressure on diffusion. The decline observed appears specifically due
difference for O2, or AaDO2). The result is a decline in the to age-related changes in the structure of the membrane
partial pressure of arterial O2 (PaO2) of older adults. rather than changes in membrane surface area or ventila-
Ventilation-Perfusion Matching tion patterns. The results need to be interpreted with cau-
tion, however, because of the small number of older subjects
Change in the quality of elastin in older adults results in (n = 6) represented in the sample. It is important to note that
decreased support of the distal airways, which causes col- an age-related decline in diffusion does not occur with CO2
lapse and closure of the alveoli at higher lung volumes or and, therefore, an abnormal partial pressure of CO2 level is
earlier in expiration when compared to younger individuals. always abnormal, regardless of age.2
Because these portions of collapsed lung continue to receive
100 Chapter 3
TABLE 3-3. AGE-RELATED CHANGES IN THE CARDIOVASCULAR SYSTEM

ANATOMICAL PHYSIOLOGICAL
Increased Increased
● Left ventricular wall thickness15-17 ● Risk of isolated systolic hypertension32,33
● Cardiac mass15-17 ● Reliance on Frank-Starling21,35,37
● Myocyte size18 Decreased
● Compliance of arteries20,24
● Amount and cross-linking of myocardial colagen19
● Cardiovagal baroreflex sensitivity26
● Myocardial lipofuscin and amyloid20
● Possible change in resting heart rate27,28
● Circumference of heart valves17,19,21
● Heart rate variability27-31
● Arterial diameter and wall thickness20,22,23
Decreased ● Rate of ventricular filling during diastole21
● Number of sinoatrial pacemaker cells24,25 ● VO2max34
● Elastin and ↑ collagen in arteries20,21 ● Maximum heart rate (HRmax)35-41
● Maximum stroke volume (SVmax)36,38,39
Oxygen Delivery of a higher afterload may be what stimulates left ventricular

hypertrophy.20,21,23
Once O2 enters the bloodstream, it is delivered to the When an increase in heart mass does occur, it appears that
body’s tissues for utilization in aerobic metabolism. The it may be due to an increase in myocyte size.18 Additionally,
transport process relies both on the pumping mechanism of as is seen in the lung parenchyma, there is an alteration in
the heart and the O2-carrying capacity of the blood, while the collagen of the myocardium with age. An increase in the
the delivery system relies on the dense network of blood amount of collagen and greater cross-linking may contribute
vessels. Morphologic and physiologic changes in the cardio- to increased left ventricular wall thickness and greater mass
vascular and autonomic nervous systems affect the ability of of the heart.19 There are also greater amounts of myocar-
the older adult to meet the body’s O2 delivery demands. The dial lipofuscin and amyloid in the older heart, though the
most significant changes affecting O2 transport and delivery functional significance of these changes is unknown.20 As
include decreased compliance of the arterial system, a loss with ventricular wall thickness, this age-related alteration in
of myocytes and atrial pacemaker cells in the myocardium, cardiac structure is distinct from pathological change. For
decreased responsiveness to β-adrenergic stimuli, an increase example, the pathological amyloid accumulation associated
in the contribution of atrial contraction to end-diastolic with primary cardiac amyloidosis has different character-
volume, and an increased reliance on the Frank-Starling istics than the changes that occur in healthy older adults.20
mechanism to maintain cardiac output (CO) at rest and with Fibrosis and calcification of the fibrous skeleton of the
exercise (Table 3-3). heart (annular rings and fibrous trigones) also occur.22
Changes in the Heart Combined with the age-related alterations in myocardial col-
lagen, this may decrease left ventricular compliance in older
Several studies have utilized echocardiography to demon- adults.22,23 However, this parameter, which requires simul-
strate a small increase in left ventricular wall thickness and taneous measurement of pressure and volume, has not been
cardiac mass with age.15-17 Lewis and Maron21 note that the specifically measured in healthy older individuals.
increase in wall thickness is mild and usually within gener-
The valves and electrical conduction system of the heart
ally accepted normal limits in absolute terms (ie, < 11 mm).
undergo changes with aging as well. All of the heart valves
They concluded that even with some age-related increase
(aortic, pulmonic, bicuspid, and mitral valves) show a pro-
in left ventricular wall thickness, it would be unusual for a
gressive increase in circumference throughout life.17,19,21
healthy older adult to have a wall thickness > 13 mm, which
The aortic valve demonstrates the greatest enlargement with
consequently allows for distinction between the aging heart
age, such that it almost equals the mitral valve in size by the
and one affected by pathological change.
tenth decade of life. The aortic and mitral valves also exhibit
One factor that may contribute to left ventricular wall thickening and calcification of the leaflets, but none of these
hypertrophy is the age-related decline in distensibility of the changes appear to cause any significant valvular dysfunction
aorta, as that may increase systolic blood pressure (SBP) and, in the healthy older adult.21
therefore, increase the workload on the heart. The increased
Changes in the conduction system of the heart may pre-
work that the heart must perform to overcome the resistance
dispose older adults to arrhythmias.32 A large decline in
the number of sinoatrial pacemaker cells occurs with age so alterations in arterial BP and transmit afferent input about
that by age 50, there is a loss of 50% to 75%, of cells and by these changes to the central nervous system. Such informa-
age 75, fewer than 10% of the cells remain.14,17 Additionally, tion triggers rapid compensatory adjustments in heart rate
there is fibrosis and fatty infiltration in the sinoatrial node.32 (HR) and CO to modify an undesirable BP.
Moderate age-associated cellular loss and fibrosis also occur This protective mechanism is known to decline with age.
in the bundle of His. In contrast, the number of atrioventric- However, Seals et al26 have demonstrated that the decline
ular nodal cells is relatively well preserved in the older adult. can both be delayed to older ages and decreased to about
Changes in the Blood Vessels half with moderate to strenuous exercise, perhaps because
of the maintenance of improved arterial compliance that
Age-related changes in the blood vessels of older adults occurs with regular exercise. Results from their laboratory
also affect the ability of the cardiovascular system to trans- indicate that the differences in arterial compliance associated
port O2-rich blood to the tissues. With increasing age, the with exercise are positively correlated to the differences in
compliance of the large-sized arteries in the cardiothoracic cardiovagal baroreflex sensitivity. The authors suggest that
region declines.24,33 While this decline in central arterial maintenance of cardiovagal baroreflex sensitivity could have
compliance appears to be an unavoidable effect of aging, the significant clinical implications, including improved electri-
magnitude of the decline can be attenuated by participation cal stability in the aging heart, increased ability to withdraw
in regular, vigorous endurance exercise.24 The internal radi- vagal tone to generate tachycardia in response to acute stress,
us of the aorta during systole has also been shown to increase and decreased arterial BP variability with age.
on average 9% per decade in subjects aged 19 to 62 years.26
Finally, there is also an age-related increase in the wall thick- Physiologic Measures at Rest
ness of the large arteries.24,33 Studies investigating age-associated changes in resting
Alterations in the size and distensibility of blood vessels HR are not entirely in agreement. Some studies have dem-
occurs in the peripheral arteries as well.20 These changes in onstrated that the resting HR of older adults is comparable
the vasculature of the older adult are thought to be due to a to the resting HR of younger individuals.29,42 These stud-
diffuse process in the vessel walls that occurs independently ies, however, did not examine substantial numbers of older
from the process of atherosclerosis. Alterations in elastin patients. This affects the generalizability of the conclusions
and collagen are implicated in the age-related changes in to individuals in their eighth decade and beyond, the fastest
blood vessels. Evidence suggests there is elastin degradation, growing subset of our population.
calcification, and disappearance, as well as an increase in the Umetani et al27 used 24-hour ambulatory Holter echocar-
amount of collagen in the arteries of older individuals.20,21 diography monitoring to study age and gender effects on HR
According to Lakatta,20 one implication of the enlarge- in 260 healthy subjects, including 62 subjects 60 to 99 years
ment and decreased distensibility of the aorta is a decline in old. They concluded that HR declines gradually in females
its volume elasticity and its ability to manage the fluctuations but not in male subjects (Figure 3-5). Women < 50 years old
in blood volume that occur during the cardiac cycle. The had significantly higher HR than their male counterparts,
thoracic aorta stores approximately one-half of the left ven- but HR was equal in older men and women because of the
tricular stroke volume (SV) during systole, and then, because decline in the female subjects’ resting HR with increasing
of the elastic forces of the aortic wall, propels it to the periph- age.
ery during diastole. Up to the age of 60 years, the age-related Tasaki et al28 conducted the first longitudinal study to
increases in the diameter and volume of the aorta allow it to investigate the change in HR with aging. In contrast to the
accommodate larger volumes of blood during systole, despite previously mentioned studies, they found resting HR to
an increase in wall stiffness (and consequent decreased abil- increase with advanced age. They obtained two 24-hour
ity to change its radius in response to fluctuations in blood Holter monitor recordings for 15 subjects with an interval of
volume). However, beyond the age of 60, volume elasticity 15 years between the 2 recordings. The subjects were 64 to
decreases significantly. With increasing stiffness, there is 80 years old at the initial recording, free of any abnormalities
a decrease in diastolic aortic elastic recoil and a declining on medical testing, and not taking any medications during
ability to propel blood forward in the arterial system. This either testing session. These researchers suggest that age-
change affects not only peripheral blood flow, but it has been related changes in HR may be unique to the very old.
shown to also affect coronary blood flow, blood pressure Less conflicting information is present in the investiga-
(BP), and left ventricular afterload. tion of HR variability in older adults. There is general agree-
Another ramification of decreased central arterial comment that this physiologic function, proposed as a marker
pliance is that it has been identified as an independent risk of pathology and increased risk of mortality, declines with
factor for future cardiovascular disease.24 In addition, Seals age.27-31 This is noted to occur during monitoring of spon-
et al26 hypothesize that decreased central arterial compliance taneous variations in HR over a 24-hour period, as well as in
contributes to the decline in cardiovagal baroreflex sensitiv- response to positional change. The decrease in HR response
ity that occurs with aging. Cardiovagal baroreflex sensitiv- to position change may be attributable to the age-related
ity is the ability of the arterial baroreceptors located in the decline in baroreceptor reflex function and may predispose
large elastic arteries (carotid sinus and aortic arch) to sense older individuals to orthostatic hypotension.32
102 Chapter 3
A B
Figure 3-5. Relations between age and HR for (A) all subjects and for (B) male and female subjects. (A) Linear regression line and upper and lower 95%
confidence limits are depicted by solid lines. (B) Linear regression line and upper and lower 95% confidence limits are depicted by solid lines for male
subjects and dashed lines for female subjects. HR for the cohort as a whole declines gradually with aging (A), but this principally reflects a decline in
female HR. Male HR does not decline significantly with age (B). (Reprinted from J Am Coll Cardiol, 31, Umetani K, Singer DH, McCraty R, Atkinson M,
Twenty-four hour time domain heart rate variability and heart rate: relations to age and gender over nine decades, p 599, Copyright 1998, with permis-
sion from Elsevier.)
Systolic function is largely unaffected by aging.21,22,32 VO2max declines with age and has been reported to decline
Both SV, the amount of blood ejected from the ventricle with an average of 9% per decade.34 This information is largely
each contraction, and CO (CO = HR × SV) are preserved at based on the data from cross-sectional studies. Fleg et al43
rest. In contrast, there are age-related changes in diastolic conducted a longitudinal study of VO2max and found that
function. The older person demonstrates a prolonged ven- longitudinal rates of decline in VO2max in older age decades
tricular relaxation phase and a decreased rate of ventricular (n = 810, including 24 subjects ≥ 80 years old) were significant-
filling during diastole. Consequently, a greater proportion ly greater than the rates derived from cross-sectional analyses
of blood enters the ventricle late in diastole.21 There is also in the same subjects. This suggests that previously reported
a greater reliance on the contribution of atrial contraction to rates of decline underestimate the decrease in VO2max in
late diastolic filling and left ventricular end-diastolic volume. older age. Fleg et al43 also demonstrated that the age-related
Thus, there is no detrimental change in CO with aging, but decline in VO2max is not linear. The rate of decline signifi-
there are age-related alterations in the patterns of blood flow. cantly accelerated with successive age decades. For example,
Unlike resting SV and CO, SBP is affected by age-related men ≥ 70 years of age showed a 17.6% decline in VO2max
changes. SBP is equal to the product of CO and the total (when indexed for fat-free mass) over the 10-year follow-up
peripheral resistance (TPR; SBP = CO × TPR). Because of the period, while 40-year-old men lost only an average of 5.1%.
decline in arterial compliance with age, there is an increase Multiple age-related changes contribute to the reduction
in TPR and, therefore, a tendency for isolated systolic hyperin the maximal work capacity of the older adult. One of the
tension in older individuals.32,33 most significant age-related changes in the cardiovascular
In summary, the cardiac function of the older adult is rela- system is the progressive decline in HR max.35-39 It has been
tively well preserved at rest. HR, SV, and CO are maintained, suggested that the HR max can be estimated by the equa-
though there are alterations in diastolic filling patterns and a tion HR max = 220 – age, but several studies have shown that
tendency for increased SBP. this prediction may underestimate the HR max that an older
individual can actually achieve.40 For this reason, Tanaka
Physiologic Measures With Exercise et al have proposed a new equation to predict HR max.41
Though cardiac function at rest is generally unaltered They conducted a meta-analysis of 351 studies and then
in the older adult, changes in the cardiovascular system cross-validated their newly developed equation in a sample
do cause limitations in maximal exercise capacity. One of of 514 healthy subjects that included sedentary as well as
the best measures of cardiovascular fitness and the abil- trained individuals. Data from both of these methods sup-
ity to meet increased O2 demands is VO2max. VO2max is a port the use of a new equation to predict HR max in healthy
measure of the O2 consumed at maximal levels of exercise adults: HR max = 208 – (0.7 × age).
and is equal to the product of maximal CO and maximal The reason for the decline in HR max with age is not
arteriovenous O2 content difference (a-vO2diff ), a com- entirely clear. It may be related to decreased levels of circulat-
parison between the O2 in the arterial and the venous blood, ing catecholamines during exercise at any given workload, or
which quantifies the muscle’s ability to extract O2 from the to diminished sensitivity and responsiveness to the catechol-
blood. Thus, VO2max can be represented by the equation amines’ effect. Catecholamines normally stimulate a chrono-
VO2max = (HR max × SVmax) × (a-vO2diff )max. tropic cardiac response, so either of these mechanisms would
result in a lessening of the expected rise in HR.40
Though there is not uniform agreement, most investiga- largely to effects of declining levels of activity associated with
tors suggest that ejection fraction (EF), the percentage of advancing age rather than the aging process itself.
end-diastolic blood volume pumped from the left ventricle To better study this hypothesis, Proctor and Joyner45
during systole, and SV during maximal levels of exercise also examined the relationship between appendicular muscle
decrease with age.36,38,39 In combination, these decreases mass, estimated by dual energy X-ray absorptiometry, and
cause an age-related decline in COmax and therefore contrib- treadmill VO2max in chronically endurance-trained subjects.
ute to the progressive decrease in VO2max. This design eliminated the possibility that differences in
In addition, there are age-related changes in the mecha- cellular O2 uptake could reflect decreased activity levels or
nisms used to increase VO2 with increases in activity level. the body composition changes that frequently accompany
Older adults rely more heavily on an increase in SV and less older age. Their data support a decline in aerobic capacity
on an increase in HR to enhance CO (recall CO = HR × SV) per unit of active muscle in highly trained older men and
in the setting of increased O2 demand.35,37 To improve SV women. This can be attributed to either reduced O2 extrac-
with higher workloads, older adults increasingly use the tion by the muscles or reduced O2 transport to the muscles.
Frank-Starling mechanism. That is, they rely more on an The authors suggest that, because muscle enzyme activity
increase in end-diastolic volume in the left ventricle in order and capillarization is known to be similar in young and old
to increase SV than on an increase in EF. This is supported by endurance-trained subjects, this difference between their
the fact that older adults have been shown to have increased groups should be ascribed to an age-related reduction in O2
end-systolic volumes in addition to end-diastolic volumes. delivery. Wiebe et al39 concur. Based on their examination
In contrast, young adults generally maintain end-diastolic of older endurance-trained women, they suggest that reduc-
volumes during exercise that are similar to resting values but tions in VO2max are due to changes in maximal HR, SV, and
demonstrate reduced end-systolic volumes as they improve CO, but not maximal a-vO2diff. There are small numbers of
their EF in response to increasing workloads.38 subjects in these studies, however, so they should be repli-
Fleg et al37 demonstrated gender differences in the car- cated with a larger sample before drawing firm conclusions
diovascular response to exercise. As the workload increased, about the relative contribution of peripheral changes to the
older men demonstrated greater augmentation of EF and age-related decline in VO2max.
higher cardiac volumes (indicating greater use of the Frank- It appears that central changes (ie, HR, SV, and CO)
Starling mechanism) than the women did. That is, they significantly affect an older adult’s level of cardiovascular
relied more on increasing SV to improve CO in the setting of fitness, while the contributions of age-related changes in the
increased O2 demand when compared to women. In contrast, skeletal muscle remain inconclusive. It is important to note
the female subjects showed a more rapid increase in HR with that decreasing levels of activity, as is often encountered in
exercise (though this HR increase was still significantly less the older population, contribute to changes in the muscle (eg,
than the younger subjects). decreased capillary density and mitochondrial content) that
Despite limitations in maximum work capacity due to negatively affect O2 extraction and work capacity, further
aging, older adults demonstrate relatively well-preserved car- reducing the VO2max of sedentary older adults.
diovascular function when exercising at submaximal work-
loads. The data of Stratton et al38 showed a greater increase Benefits of Aerobic Training
in BP and a lesser increase in HR in the older subjects at any
given workload. There were, however, no age-related differ- Fortunately, research demonstrates that much of the age-
ences in EF or end-diastolic volume, end-systolic volume, or related decline in cardiovascular and pulmonary physiologic
SV indices during submaximal exercise. Proctor et al44 have function can be attenuated or reversed with regular physi-
also shown the ability of older, endurance-trained adults cal exercise. This finding supports the inclusion of aerobic
to demonstrate responses to exercise that are comparable capacity training in a comprehensive physical therapy plan
to younger subjects. Their data support the ability of older of care directed toward improving the health and wellness
people to utilize increases in CO and SV in response to sub- of older clients.
maximal exercise that are equal to the responses of younger Yerg et al46 have demonstrated that older athletes sustain
individuals. better ventilatory efficiency than age-matched sedentary
controls. Sedentary older subjects had a significantly higher
Cellular Oxygen Uptake ventilatory response to submaximal exercise (Ve/VO2) than
In addition to central cardiac changes affecting O2 trans- elite endurance-trained athletes of similar age. Prolonged
port to the tissues, there are peripheral changes that may endurance training was able to improve the ventilatory effi-
contribute to the decline in VO2max of older adults. Older, ciency of sedentary subjects to the level of the athletes, sug-
sedentary adults are less able to extract O2 from the blood gesting that the decline in older adults may be more related to
than their younger counterparts, likely because of a lower decreased activity than age. It is beneficial for the older adult
mitochondrial content and capillary density in their mus- to preserve the ability to function with maximum ventila-
cles.35 These characteristics of muscle, however, are signifi- tory efficiency so they can perform ADL without pulmonary
cantly affected by fitness level, and the difference identified limitation and have a large ventilatory reserve for exercise
between old and young subjects may, in actuality, be due and the stress of illness.
104 Chapter 3
Summary
The older adult demonstrates decreased ventilatory mus-
cle strength, lung elastic recoil, and chest wall compliance
that combine to create less efficient ventilation and increased
O2 cost of breathing. Gas-exchange capacity also declines
with age, primarily because of increased V/Q mismatching
associated with lessening of the elastic support of alveolar
structures. Fortunately, these changes do not significantly
affect the physiologic functional ability of the older adult
at rest or during daily activities. However, reductions in
ventilatory efficiency and gas exchange decrease the reserve
capacity of older adults and increase the risk that they will
be unable to effectively meet the demands of more intense
physical activity or the stresses of pathology when they are
superimposed on the changes of advancing age.
The cardiovascular system of the older adult is also
Figure 3-6. Linear regression of peak O2 consumption (VO2peak) mea-
surements and Continuous-Scale Physical Functional Performance test
affected by age-related changes. Arteries become larger, less
(CS-PFP) scores. Points A and B represent different physical reserves. compliant, and less able to sense and respond to fluctuations
If point B loses 8 mL.kg-1.min-1 of aerobic capacity, the loss in physical in BP, which predisposes older adults to arrhythmias, ortho-
function is a CS-PFP score of approximately 3 units (8 × 0.32). If point A static hypotension, and systolic hypertension. There is less
loses 8 mL.kg-1.min-1 of aerobic capacity, the expected drop in function
would be a CS-PFP score of approximately 21 units (8 × 2.67). The solid
HR variability and delayed diastolic filling in advanced age.
line designates the 95% confidence interval for the VO2peak measure- Adaptations such as increased reliance on atrial contraction
ments. (Reprinted from Phys Ther. 2003;83(1):37-48, with permission of and the Frank-Starling mechanism work together to pre-
the American Physical Therapy Association. Copyright © 2003 American serve CO at rest, but COmax declines because of decreases in
Physical Therapy Association. APTA is not responsible for the accuracy of
the translation from English.)
HR max and SVmax. This results in a decline in the maximal
exercise capacity of the older adult and causes performance
of all ADL to utilize a greater percentage of their VO2max.
Exercise also has many beneficial effects on the aging If an older adult decreases his or her activity level during
cardiovascular system. These are well outlined in a recent a period of illness, deconditioning may cause a reduction in
position stand published by the American College of Sports VO2max. Because older adults already have a declining level
Medicine (ACSM).34 The authors performed an extensive of cardiovascular fitness, this additional reduction may, in
review of the literature and concluded that there is strong evi- fact, cause the individual to have a VO2max that results in
dence from high-quality studies that “aerobic capacity train- disability. Some ADL may require a level of O2 consumption
ing of sufficient intensity (≥ 60% of pretraining VO2max), that is a high enough percentage of the patient’s maximal
frequency, and length (≥ 3 days/week for ≥ 16 weeks) can level to cause significant discomfort, dyspnea, or fatigue. As a
significantly increase VO2max in healthy middle-aged and result, older adults may need to slow the speed of movements
older adults”34(p 1517) that is on average 16.3%. They note that or take frequent rests to decrease the VO2max required for
larger improvements are observed with longer training peri- the activity level to still accomplish the task. Some tasks may
ods and that adults ≥ 75 years old may demonstrate smaller simply be beyond their capacity to perform.
improvements in VO2max than younger seniors. The increase Cress and Meyer47 investigated the concept of physical
in VO2max is attributed to central and peripheral adaptations reserve (maximal aerobic capacity in excess of that needed
in men, but only to improved a-vO2diff in women. In addition to perform daily functions). Their data on the peak VO2
to gains in VO2max, there has been shown to be a reduction of 192 older subjects (69 to 97 years, mean age = 76 years)
in resting HR and HR at any submaximal workload. Exercise demonstrated an ability to define a peak VO2 threshold or
also provides numerous cardioprotective effects including “breakpoint” below which individuals experienced functional
improved lipid profile, arterial compliance, HR variability, limitations as measured with the Continuous-Scale Physical
body composition, BP, and plasma insulin levels.34 Functional Performance test (Figure 3-6). The threshold
Experts from the ACSM and the American Heart identified by their work is a VO2peak of 20.1 mL∙kg-1∙min-1.
Association developed and published recommendations for VO2peak levels below this critical level were associated with a
the type and amount of physical activity required for older significant decline in physical function.
adults to maintain or improve health. They suggest moderate As shown in Figure 3-6, individuals with a VO2peak well
intensity aerobic activity for at least 30 minutes 5 days of the above the aerobic capacity threshold have good physical
week or vigorous exercise for at least 20 minutes 3 days of the reserve. That is, a modest decline in their aerobic capacity
week. They define moderate-intensity aerobic activity as a would not result in a decline in function. In contrast, an older
5 or 6 on a 0 to 10 scale, where sitting is 0 and all-out effort is adult with a lower initial VO2peak and less physical reserve
10. Vigorous-intensity activity is defined as a 7 or 8. would experience the onset of functional limitations with a
similar reduction aerobic capacity. Cress and Meyer suggest
that this aerobic capacity threshold can therefore be used to TABLE 3-4. AGE-RELATED
help predict the level of support that is needed by older adults CHANGES IN SKELETAL MUSCLE
given their personal fitness level or to determine the level of
fitness that should be achieved and maintained to ensure an ANATOMICAL PHYSIOLOGICAL
adequate physical reserve. Increased Decreased
The evidence supports that exercise can attenuate declines ● Intramuscular fat and ● Muscle strength,
in cardiovascular fitness and also that older adults can make connective tissue50,51 concentric > eccen-
substantial gains with training. Even in the absence of sig- tric, leg > arm34,55-58
nificant improvements in cardiovascular fitness, older adults
● Expression of hybrid
can enhance their health status with increased levels of activ- fibers54 ● Muscle quality56,59,60
ity, which warrants the inclusion of aerobic training in the ● Size of each motor ● Muscle power61
plan of care for the older client. unit50 ● Protein metabo-
Decreased lism59
● Muscle mass48-52
AGE-RELATED CHANGES IN ● Number of type I and
● Motor unit firing
rate65
MUSCLE PERFORMANCE II muscle fibers48,50,53 Preserved muscle
● Size of type II endurance62-64
Muscle performance is the capacity of a muscle or group fibers48,50,53
of muscles to generate forces to perform ADL.3 Age-related
changes in skeletal muscle, including declines in muscle
● Number of motor
mass, protein metabolism, and number of motor units, result units50
in a loss of muscle strength and power, negatively affecting
the ability of the older adult to function (Table 3-4). As with
aerobic capacity, the decline in the maximal capability of the II fibers.48,50,53 The size of type I fibers appears preserved
musculoskeletal system often causes older adults to perform until very old age.48
ADL at a high level of exertion and decreases the functional In addition to the changes in the number and size of
reserve they have to respond to the stress of exercise or illness. muscle fibers, there is an age-related alteration in the expres-
sion of myosin heavy-chain isoforms, which are the various
structures of the contractile proteins (myosin) found in the
Age-Related Changes in Skeletal Muscle sarcomeres of muscle fibers. The isoform affects the function
and properties of a muscle fiber. Older adults increasingly
Muscle Mass
express more than one myosin heavy-chain isoform in the
Loss of muscle mass with advancing age is well document- same muscle fiber. Recent investigations of single muscle
ed.34,48-52 By age 65 years, muscle mass is approximately 25% fibers using gel electrophoresis technique indicate the pres-
to 30% less than the peak values measured at 25 to 30 years ence of “hybrid” fiber types that contain 2 or more myosin
of age.48,49 Computed tomography of thigh muscles shows an heavy-chain isoforms (eg, I/IIa and IIa/IIx, which compose
age-related decrease both in cross-sectional area of the thigh 50% of older adults’ muscle fibers) in addition to “pure”
and muscle density beginning at age 30 years.55 The decline fiber types.54 Aging muscle contains a significantly larger
in muscle mass is accompanied by increased amounts of proportion of hybrid muscle fibers and fewer pure myosin
intramuscular fat and connective tissue.50,51 Lower extrem- heavy-chain isoforms compared to young adults.54 Pure type
ity muscles appear to be more affected by this process than IIx fibers (originally identified as the myosin heavy-chain
upper extremity muscles.34,50 IIb isoform) become rare in seniors. The age-related decrease
Regular muscle protein turnover maintains the size and in the expression of pure fiber types and the substantial
quality of skeletal muscles by replacing damaged proteins increase in the proportion of hybrid fibers has shown to be
with newly synthesized proteins.59 There is an age-related reversible with strength training.69
decline in this regenerative process that contributes to
decreased muscle mass and strength in older adults.59 In
Motor Units
contrast, the rate of muscle degradation has not been shown The motor unit consists of a single motor neuron and the
to change with age.66 Altered muscle-building hormone lev- collection of muscle cells that it innervates. The process of
els and chronic low-level inflammation are also considered motor unit remodeling is ongoing; denervation at the neu-
causes of the age-related decrease in muscle mass.67,68 romuscular junction, followed by axonal sprouting and rein-
nervation, results in continual turnover of synapses. During
Muscle Fiber Type and Size young adulthood, this process does not cause any change in
The age-related decrease in muscle mass is thought to be motor unit size, total number of motor units, or fiber distri-
due to a decrease both in the total number of type I (slow- bution. However, motor unit estimation has demonstrated a
twitch) and type II (fast-twitch) fibers and in the size of type
106 Chapter 3
significant age-related decline both in concentric and eccen-
tric peak torque in a large sample of older individuals, but
the impact of age on eccentric strength was less than its effect
on concentric strength.56,58 Lindle et al58 found that the
loss of eccentric strength began at least a decade later than
the loss of concentric strength. Lynch et al56 comment that,
although their results do not fully support previous reports
of preserved eccentric strength in older age, the variance in
eccentric strength in their subjects that was explained by
age was less than for concentric strength. Thus, the evidence
demonstrates that eccentric strength is less affected by age
than concentric strength.
The age-related loss of strength has been shown gener-
ally to be greater and to occur earlier in the leg than in the
arm.56,70 Because no physiological mechanisms have been
identified to explain this, it has been hypothesized that it
is due to greater disuse in the leg muscles in older age. The
Figure 3-7. Effect of age on maximal strength throughout the human decline in strength has been found both in proximal and
lifespan. (Reprinted from Vandervoort AA. Aging of the human neuro- distal appendicular muscles.50
muscular system. Muscle Nerve. 2002;5:17-25, with permission of John
Wiley and Sons.)
Decreased muscle mass can explain the majority of the
age-related decline in strength. It has been shown, however,
that the loss of strength in later decades often exceeds the loss
decline in the number of excitable motor units beginning in of muscle size. This indicates that the specific force of muscle
the seventh decade of life.50 Research has also demonstrated or muscle quality (ie, strength per unit of muscle mass) also
an increase in the size of the motor unit and a decline in the lessens with age. Lynch et al examined age-related changes in
motor unit firing rate.65 muscle quality in 502 older subjects using dual-energy X-ray
Researchers hypothesize that the reduction in the total absorptiometry to estimate muscle mass and an isokinetic
number of motor units with age is due to healthy motor dynamometer to measure concentric and eccentric peak
neurons capturing muscle fibers of failing motor neurons torque of the elbow and knee flexors and extensors.56 Their
nearby. That is, during the process of motor unit remodel- results demonstrate the presence of an age-related decline
ing, strong axonal sprouting and reinnervation result in in muscle quality both in men and women. Only the muscle
expansion of some motor neurons’ territories; there is the quality of the arm in women during eccentric contractions
simultaneous degeneration and elimination of motor neu- was preserved across the lifespan.
rons that have presumably reached the end of their lifespan. Results of studies investigating muscle quality as deter-
Thus, older adults have fewer and larger motor units than mined by normalization of muscle strength for muscle size
their younger counterparts. It has been suggested that inner- are not conclusive. Lynch et al attribute the inconsistency
vation of a muscle fiber by a new motor neuron may alter its in results to differences in the techniques used to measure
physiological and biochemical properties, supported by the muscle mass and strength for the determination of muscle
presence of increased numbers of hybrid muscle fibers in quality.56 Rather than use whole muscle mass, some inves-
older adults.48,50 tigators have studied isolated single muscle fibers to deter-
mine specific force, eliminating the question concerning the
Effect on Muscle Performance validity of muscle mass estimations. These studies support a
decline in muscle quality with aging.59,60 As noted previous-
Muscle Strength ly, reduction in gene transcription or protein synthesis may
affect the basic properties of the myosin molecule, thereby
Muscle strength, the force exerted by a single muscle or a lessening the force-generating capacity of muscle fibers in
group of muscles to overcome resistance under a specific set older age.48,60
of circumstances,3 decreases with age. Muscle strength peaks
at about age 30 years and begins to decline by approximately Muscle Power
12% to 15% per decade after age 50 years.55,56 The rate of Muscle power is a measure of the work done (force × dis-
decline becomes even greater later in life and is estimated to tance) per unit of time. While it is dependent on muscle
be up to 30% per decade in those age 70 years and older.55 strength and the ability to generate forces, it is also affected
Investigators have demonstrated a greater age-associated by nervous system control and the timing and speed of
loss of concentric strength than eccentric strength, with responses. Research has demonstrated that muscle power
some research finding no difference at all between the eccen- begins to decline both in men and women by about age
tric strength of young and old adults (Figure 3-7).50,57 Data 40 years, and that this age-related loss in power is greater
from the Baltimore Longitudinal Study on Aging did show a than the strength loss that occurs with advancing age.61
Muscle Endurance
Unlike muscle strength and power, muscle endurance,
the ability to sustain forces repeatedly or to generate forces
over a period of time, is not clearly impaired in older adult-
hood.3 In fact, many studies indicate that muscle endurance
is unaffected by advancing age. For example, Lindström et
al62 examined the effects of increasing age on knee exten-
sor fatigue and endurance. Twenty-two young subjects and
16 healthy older adults performed 100 repeated maximum
dynamic knee extensions on an isokinetic dynamometer
(Cybex II, Lumex, Inc). Maximal voluntary contraction was
significantly lower in the older adults compared to the young
subjects, but the relative muscle force reduction and fatigue
rate between the groups was not significantly different.
Bäckman et al63 also conclude that muscle endurance Figure 3-8. Time to decline of force output to < 50% maximum voluntary
is preserved in old age. These authors examined the time contraction for 2 consecutive contractions during muscle endurance
to exhaustion in the shoulder abductors and hip flexors of testing. Time to fatigue was significantly less in older women fallers than
in both young women and older women non-fallers. (Reprinted from
57 women and 62 men aged 17 to 70 years by having the Schwendner KI, Mikesky AE, Holt WS Jr, Peacock M, Burr DB. Differences
subjects hold their limbs in a static position (90 degrees of in muscle endurance and recovery between fallers and nonfallers,
shoulder abduction in sitting and 30 degrees of hip flexion and between young and older women. J Gerontol A Biol Sci Med Sci.
in supine) as long as possible. Muscular endurance was 1997;52(3):M157, by permission of Oxford University Press.)
extremely variable between individuals but did not decline
significantly with age. It is important to note that the sample
size was small; there were only 10 subjects over the age of Effect on Function
60 years enrolled in the study.
Research has demonstrated that strength affects many
The results of Schwendner et al64 agree with the stud- different functional activities. Lower extremity strength has
ies described previously. The time to fatigue (performing been shown to correlate significantly with the time to com-
maximal concentric knee extensions until the force output plete a sit-to-stand transfer in older adults.71-74 Hernandez
fell below 50% of maximal voluntary contraction) was no et al75 found that trunk and knee extensor and ankle dorsi-
different between young and old women. Older persons with flexor and plantar flexor strength contribute to older adults’
a history of falls did demonstrate significantly decreased ability to stoop, crouch, and kneel. The results of studies
muscular endurance when compared to older non-fallers examining the connection between strength and balance in
and to young women, though they did not have significantly older adults are less conclusive. For example, Ringsberg et
decreased maximum voluntary contraction when compared al76 did not find a significant relationship between maximum
to older non-fallers (Figure 3-8). isometric leg strength (knee and ankle flexors and extensors)
The evidence suggests that there is no significant differ- and tests of balance (single-leg stance and stance on a static
ence in the fatigability or endurance of older adults when and moving platform, each performed with both eyes open
compared to young adults. It is important to note once again and eyes closed). In contrast to these results, Wolfson et al77
that sample sizes are small and generally include few adults concluded that a strong relationship between strength and
over 75 years of age. Thus, generalization of the results to the balance exists. In their study, strength had an independent
very old population should be made with caution. The limita- effect on the odds ratio for frequency of loss of balance
tions of cross-sectional studies should be remembered as well during a sensory organization test on a balance platform in
when considering the results of these studies. healthy, community-dwelling older adults (average age of
Though muscle endurance may be preserved with age, 80 years). The investigators measured isokinetic peak torque
older adults are not fully protected from fatigue with daily for flexion and extension of the hip, knee, and ankle and for
activities. Because of the age-related loss of strength, move- hip abduction and adduction. They calculated the sum of the
ments required during certain functional or mobility activi- lower extremity strength measurements and divided by body
ties may require near maximal levels of strength for an mass. For each Nm/kg increase in strength, there was a 20%
older adult. Repetition of these challenging movements to decrease in the odds ratio for a loss of balance on a sensory
complete the activity will be difficult. Thus, older adults may organization test.
experience significant fatigue with tasks such as unloading It is likely that the choice of variables (eg, which muscles
heavy items from grocery bags or climbing stairs. Greater are tested and which balance tests are chosen) affects the
strength capacity allows a person to complete ADL at a strength of the relationships identified, an idea that is sup-
lower percentage of maximum and, therefore, to perform the ported by the work of Daubney and Culham.78 These inves-
movement repeatedly without undo fatigue. tigators measured the force generated by 12 lower extremity
muscle groups with a handheld dynamometer and balance
108 Chapter 3
they are beyond the linear portion of the relationship where
these variables improve in concert.
As is the case with balance, the contribution of strength
to gait speed may be activity dependent. Lamoureux et al84
found that knee extensor strength (measured one repetition
maximum [1-RM]) explained 14.2% to 30.8% of the variance
in gait speed when older adults walked along a timed obstacle
course designed to represent commonly encountered envi-
ronmental challenges (stepping over an obstacle, negotiat-
ing a raised surface, stepping across an obstacle, and foot
targeting). When the investigators progressively increased
Figure 3-9. Hypothesized relationship between leg strength and usual
gait speed. Area A corresponds to the range where strength is sufficient
the challenge of each task, the amount of variance explained
for normal walking and where changes in strength affect physiological by strength also got larger, particularly for stepping over an
reserve but not gait speed. Area B corresponds to the range of marginal obstacle and for rising onto a raised surface. The authors
or inadequate strength. In Area B, changes in strength cause changes in suggest that strength is a critical factor in older adults’ ability
gait speed, and there exists a curve that quantifies the relationship. In
Area C, strength is below the minimum needed to walk at all. (Reprinted
to negotiate community environments, and that it becomes
from Buchner DM, Larson EB, Wagner EH, Koepsell TD, de Lateur BJ. increasingly important as the ambulatory challenges become
Evidence for a non-linear relationship between leg strength and gait greater.
speed. Age Ageing. 1996;25:386-391, by permission of Oxford University More recently, the contribution of muscle power to func-
Press.)
tional performance has been appreciated.82,85-87 Puthoff
and Nielsen82 demonstrated that while both strength and
using a variety of tests, including the Berg Balance scale power were related to functional limitations and indirectly
(BBS), the Timed Up and Go test, and the Functional Reach to disability (the Short Physical Performance Battery, the
in adults between the ages of 65 and 91 years. Only ankle 6-Minute Walk Test [6MWT], and the Late Life Function
muscle force was predictive of the results of the balance tests. and Disability Instrument), power consistently explained
Dorsiflexor and evertor force accounted for 58% of the score more of the variance in the outcomes than strength did. The
on the BBS, plantar flexor and invertor force accounted for investigators also examined the effect of the relative inten-
48.4% of the Timed Up and Go score, and plantar flexor sity level of power and suggest that different tasks require
force accounted for 13% of the Functional Reach score. power at different relative intensities. For example, while
Because each balance scale incorporates different motions, peak power (defined as the highest power output regard-
the contribution of each muscle varies depending on the less of the external load at which it was achieved) explained
test performed. Thus, strength appears to contribute to bal- more of the variance in most outcome measures, power at a
ance scores. However, the relative contribution of each lower high relative intensity (90% of 1-RM) explained more of the
extremity muscle group to balance differs depending on variance in sit-to-stand transfers than either peak power or
the balance measurement that is chosen and the task that is power at a low relative intensity (40% of 1-RM). Puthoff and
performed. Nielsen82 therefore recommend clinicians consider training
As just described, Ringsberg et al did not find a significant older adults’ power at different intensities to maximize per-
relationship between muscle strength and balance, but the formance of all functional skills and to decrease disability.
authors did demonstrate a link between muscle strength and Puthoff and Nielsen82 noted that there is a good deal of
gait performance, a finding that is more consistently sup- the variance in the performance of these skills that remains
ported in the literature.76,77,79-83 Lower extremity strength unexplained. Other factors must be considered as possible
has been shown to correlate with gait speed, but the exact contributors to the ability to successfully complete functional
relationship between the variables is not clear. Some have movements. Lord et al73 examined the effect of multiple
suggested a linear relationship.81,82 If the relationship is sensorimotor and psychological factors on sit-to-stand per-
linear, then every increase in strength is associated with a formance. They found that visual contrast sensitivity, lower
faster gait speed. Other investigators have shown a plateau limb proprioception, peripheral tactile sensitivity, reac-
in the correlation, or a curvilinear relationship.80,83 That is, tion time, sway with eyes open on a foam rubber mat, and
there comes a point when higher levels of strength are not body weight were independent and significant predictors
associated with further increases in gait speed (Figure 3-9). of sit-to-stand performance. Quadriceps strength was the
For example, Kwon et al80 found that levels of knee extensor most important variable in explaining sit-to-stand time, but
strength above 130 Nm as measured with a dynamometer at other measures accounted for half of the explained variance,
30 degrees/second were not associated with ongoing increas- highlighting the need for a comprehensive examination to
es in comfortable gait speed. If the relationship is curvilinear identify all factors contributing to an older adult’s function.
as Kwon et al suggest, an improvement in strength in a frail, Puthoff et al87 recognized that walking ability may be
weak patient would be associated with a significant increase different in a research lab from what it is in the community.
in gait speed. In contrast, a healthy senior would show little Because actual ambulation in daily life is critical to older
to no gain in gait speed with increases in strength because adults’ function, quality of life, and wellness, they sought to
understand the contributions of lower extremity strength a total of 12 weeks. This strength-training regimen resulted
and power to everyday walking behaviors. Using a pneumatic in a significant increase both in thigh total muscle cross-
leg press, they measured the lower extremity strength and sectional area (11.4% as estimated from computed tomog-
power of 30 older adults with mild to moderate functional raphy) and strength (107.4% for knee extensor and 226.7%
limitations based on the Medical Outcome Survey (SF-36) for knee flexors as measured by 1-RM). In addition, vastus
physical function subscale. The subjects wore accelerometers lateralis muscle biopsies showed significant increases in the
that measured total steps, walking distance, and walking size of both type I and type II fibers of ~30%. Subsequently,
speed over a 6-day period. Strength and power (peak, at 40% Fiatarone et al90 studied strength training in frail, institu-
1-RM and at 90% 1-RM) were significantly related to walking tionalized individuals in their 80s and 90s. Their results
distance and speed; peak power was related to total number provided additional evidence that even the oldest individuals
of steps. Again, power demonstrated a stronger relationship can safely participate in high-intensity resistance exercise
to function than strength did. The results of this study pro- training and enjoy significant strength gain as a result.
vide important evidence about the contribution of muscle These early studies highlighted that the plasticity of the
performance to actual daily walking and suggest that exer- muscular system is retained in old age. Since then, the results
cise designed to improve lower extremity strength and power of numerous studies have confirmed the ability of older
may translate into gains in everyday walking behaviors. adults to improve strength with regular exercise, with gains
The concept of physical reserve that was described ear- ranging from less than 25% to more than 100%.34 In their
lier in relation to aerobic capacity also applies to muscle analysis of data pooled from 41 studies of strength training
performance. Because of age-related declines in maximum (n = 1955 subjects), Latham et al91 noted a moderate to large
strength and power, older adults have less reserve to draw beneficial effect of progressive resistance strength training
on during situations of high physiologic stress, such as ill- on quadriceps strength. They do note, however, significant
ness or exercise. As they did with aerobic capacity, Cress and variability in the size of the strength gains seen in these
Meyer47 defined a strength threshold below which individu- studies. This is likely related to differences in factors such as
als demonstrated significant decline in physical function as intensity of training, amount of supervision provided, and
measured with the Continuous-Scale Physical Functional duration of training, all of which may affect outcome.
Performance Test. The authors measured maximal voluntary Studies that have examined muscle cross-sectional area
torque of the knee extensors using an isokinetic dynamom- have shown moderate increases in muscle size resulting from
eter in 192 elderly subjects. Those with less than 2.5 N.m/ strength training, but these changes are not nearly as sub-
(kg.m-1) of knee extensor strength demonstrated significant stantial as the gains in muscle strength.50 This finding has led
declines in physical function. Cress and Meyer suggest that many investigators to believe that the improvements in mus-
this strength threshold can estimate an older adult’s physical cle strength that occur with training are due both to muscle
reserve and predict functional limitation and level of assis- fiber hypertrophy as well as neuromuscular adaptations in
tance required. motor control pathways (eg, increased motor unit firing
Because most of the studies described are cross-sectional, frequency and motor unit recruitment rates, and decreased
we cannot conclude that decreased muscle performance coactivation of agonist and antagonist muscles). For example,
causes a decline in function. In reality, the causal relation- Tracy et al92 studied the effects of 9 weeks of strength train-
ship is often bidirectional for older adults. An age-related ing in 23 healthy older men and women. The subjects showed
decline in muscle performance, along with other factors, an increase in muscle strength of approximately 30% dur-
contributes to decreased mobility; consequently, the decline ing 1-RM quadriceps contraction measurements and a 12%
in physical activity further weakens the individual through increase in muscle volume measured by magnetic resonance
deconditioning. While it may be hard to tease out the exact imaging. Thus, muscle quality (ie, strength/muscle volume)
nature of this relationship, it is clear that muscle performance improved in these subjects, supporting the assertion both
is related to functional performance in older adults and, that hypertrophy and neuromuscular adaptations contribute
therefore, exercise prescribed to maximize muscle strength, to older adults’ strength gains after training. Muscle quality
power, and endurance should prove beneficial to maintain increases in older adults are similar to those demonstrated
optimal physical performance with advancing age. by young adults.34
There is some evidence that older adults can also improve
Benefits of Strength Training their muscle endurance with resisted exercise training, but
there is far less research in this area.34 In contrast, there are
Early studies of strength training in the elderly examined multiple investigations that demonstrate that older adults
the efficacy of exercise programs that were fairly conserva- also have the ability to improve their muscle power with
tive in terms of the prescription intensity.88 In the mid-1980s, resistance exercise training. Ferri et al93 studied 16 older
Frontera et al89 demonstrated the ability of older healthy men (aged 65 to 81 years) who participated in a 16-week low-
men to benefit from high-intensity lower extremity strength volume, high-intensity (1 set of 10 repetitions at 80% 1-RM)
training without adverse effects. Twelve men aged 60 to strength-training program for the plantar flexors and knee
72 years completed 3 sets of 8 repetitions of knee flexion and extensors. At the conclusion of training, significant increases
extension exercises at 80% of their 1-RM 3 days per week for were found in 1-RM, maximum isometric torque, maximum
110 Chapter 3
muscle power, and muscle cross-sectional area. Gains in participated in a combined aerobic capacity and strength-
power resulted from high-intensity strength training at a training program 3 times per week for 6 months. Compared
relatively slow speed. Even greater gains in power can be seen to the control group, the exercise group showed significant
when exercises are performed at high-velocity. Bottaro et al94 increases in VO2max, muscle strength, and the CS-PFP test.
compared 2 groups of older men (aged 60 to 76 years) who The authors suggest that perhaps the CS-PFP test is better
exercised twice each week for 10 weeks. Both groups per- able to capture changes in function than the other famil-
formed 3 sets of 8 to 10 repetitions of exercises at 60% 1-RM. iar measures used (eg, Sickness Impact Profile, SF-36, and
The power training group (PTG) performed the movements 6MWT). They do note that the change in dynamic strength
as quickly as possible, while the traditional strength training accounted for < 15% of the variance in the change in function
(TST) group performed contractions over 2 to 3 seconds. The as measured by the CS-PFP test. Thus, their results also sup-
groups demonstrated equal gains in strength, but improve- port the assertion that, while gains in strength may contrib-
ments in muscular power were significantly greater in the ute to improved function, there are many additional variables
PTG compared to the TST group (increase in bench press that affect the physical abilities of older adults.
37% vs 13% and leg press 31% vs 8%, respectively), which is Similar to strength training, power training has not dem-
not surprising given the principle of specificity of training. onstrated the ability to improve standing static balance, but
Older adults clearly have the ability to increase muscle it has resulted in gains in dynamic balance, walking capac-
performance, but a more meaningful question is whether ity, and functional performance.96-98 Holviala et al96 showed
those gains translate into improved function. In their sys- that a program of strength and power training did not
tematic review of the literature, Latham et al examined the change timed measures of static balance (standard stance,
effects of progressive resistance training on impairment and feet together, and semi-tandem, each with both eyes opened
functional limitation measures in older adults.91 No clear and eyes closed). Subjects did demonstrate significant gains
strength-training effect was identified for measures of stand- in dynamic balance, however, and these were correlated with
ing balance, including timed position holding and balance increases in power. Significant gains in dynamic balance
during more complex activities, such as those on the BBS. were observed before there were changes in muscle power.
Progressive resistance training did have a significant effect Consequently, the authors note that increased power was
on the 6MWT (weighted mean difference 53.7 meters), a only part of the reason for the large improvement in dynamic
moderate to large effect on sit-to-stand time (standardized balance; other factors must also contribute to the changes in
mean difference –0.67), and a modest beneficial effect on gait this outcome.
speed (weighted mean difference 0.07 meters per second). Miszko et al98 found that power training improved func-
Though the results are statistically significant, they need to tion when measured by the CS-PFP test. In fact, their results
be interpreted considering how much improvement is needed proved power training to be superior to strength training for
to affect meaningful change in functional mobility for an improving physical function. The study by Bottaro et al that
individual. For example, it must be determined if a gait speed was described earlier confirmed these results.94 The subjects
improvement of this size will affect an older client’s daily in their PTG demonstrated greater improvements on the
mobility and ability to negotiate the environment. Senior Fitness Test compared to those in the TST group. This
Unfortunately, when analyzing the results of 14 studies measure, developed by Rikli and Jones,99 is a battery of tests
that reported on disability outcomes, Latham et al found that examines upper and lower extremity strength and flex-
no evidence that progressive resistance training had a posi- ibility, balance, and aerobic capacity.
tive effect on either health-related quality of life or ADL The evidence clearly demonstrates the benefits of strength
measures.91 Successful performance of higher-level func- and power training for older adults. The optimal exercise
tional tasks relies on multiple contributing factors, including program is less clear than the need to exercise, however.
physical, psychosocial, and cognitive aspects of function. It is The exact parameters of intensity, frequency, sets, and rep-
possible that strength training alone is not enough to affect etitions are not yet conclusively established in the literature.
physical disability, but that it is a critical element of a com- Nonetheless, there is evidence that can guide exercise pre-
prehensive approach to maximizing older adults’ well-being. scription to improve the muscle performance of older adults.
Cress et al95 present another explanation for the lack The ACSM has published specific recommendations that
of significant results when examining the effectiveness of outline exercise parameters based on the evidence to date.28
strength training on physical function in healthy older adults. To improve strength and hypertrophy muscle, they suggest
They suggest that commonly used measurement tools may slow to moderate lifting velocity for 1 to 3 sets per exercise
not be able to detect changes in the higher ranges of func- with 60% to 80% of 1-RM for 8 to 12 repetitions with 1- to
tional ability that occur as a result of exercise. They sought 3-minute rests in between sets for 2 to 3 days per week.
to determine if the Continuous Scale-Physical Functional The authors of the ACSM position stand note the benefits
Performance (CS-PFP) test, a measure that includes a broad of power training and advocate inclusion of this in older
range of activities, would be able to capture changes that adults’ exercise programs, using 30% to 60% of 1-RM for
occur after a period of exercise intervention. They randomly 6 to 10 repetitions with high-repetition velocity. Muscle
assigned 49 healthy older adults to a control group or to endurance training has not been studied as thoroughly,
an exercise group. The subjects in the experimental group but it appears that exercising with lower loads and higher
TABLE 3-5. AGE-RELATED CHANGES IN SYSTEMS CONTRIBUTING TO MOTOR CONTROL

SENSORY INTEGRITY CENTRAL PROCESSING EFFECTOR SYSTEM
Increased Increased Decreased
● Glare sensitivity102 ● Reaction time117,120-122 ● Muscle strength34,56,130
Decreased ● Execution time120,122,123 ● Muscle power61
● Visual acuity102 ● Muscle co-contraction124 ● Range of motion127,128
● Contrast sensitivity102 ● Use of hip strategy117 ● Postural alignment129
● Peripheral vision102 Preserved muscle endurance62-64
● Reliance on stepping125,126
● Dark adaptation102 Decreased
● Proprioception103-109 ● Sensory organization117,118
● Tactile sensitivity110-112 ● Sensory reweighting119
● Vibratory sense6 ● Dual-task ability120
● Vestibulo-ocular reflex function113,114
● Otolith function114-116
repetitions can lead to gains in this area of muscle perfor- power training. This type of intervention can result in gains
mance and should be considered for inclusion in an exercise in function and physical capacity that may improve an older
program as well. adult’s quality of life.
Not all older adults are willing or able to participate in high-
intensity strength training. Even if individuals are not candi-
dates for such an exercise regimen, they should be counseled AGE-RELATED CHANGES IN
about the benefits of physical activity. Brach et al100 found that
older adults who lived physically active lives were less likely MOTOR CONTROL
to have functional limitations compared with individuals
who were sedentary. Exercise, however, provided the added Motor control is the ability to initiate, execute, and termi-
benefit of greater physical capacity and functional reserve. nate movements to complete purposeful tasks. Performance
The authors suggest that any type of physical activity is better of smooth and coordinated movements during dynamic
than no activity to protect against functional limitation, but tasks requires adequate sensory input to determine the
emphasize the ability of exercise (ie, “planned, structured, and body’s position and path in space, processing of information
repetitive bodily movement for the purpose of improving or to plan effective postural adjustments and limb trajectories,
maintaining one or more components of physical fitness”(p and execution of movements through the body’s effector
502)) to enhance functional reserve in older adults. system (eg, strength, endurance, range of motion [ROM]).101
Aging affects each of these areas, and these age-related
Summary declines may combine to cause deterioration in coordination,
balance, and gait in older adulthood (Table 3-5).
The older adult experiences an age-related decline in
muscle strength and muscle power due to decreases in Sensory Integrity
muscle mass and muscle quality, preferential atrophy of
type II muscle fibers, and decreased number and function Vision
of motor units. In contrast, muscle endurance appears rela-
tively well-preserved into the later decades, though there is Vision contributes to motor control by providing environ-
still susceptibility to fatigue with ADL due to age-related mental cues to use as references for an individual to deter-
decline in maximum strength. Losses in muscle perfor- mine his or her position in space. Body parts’ relationships
mance contribute to worsening balance, slower performance to each other and to the external world can be ascertained
of sit-to-stand transfers, decreased gait speed, and a decline through observation. These data are used to understand
in function. However, a significant proportion of the vari- alignment and location of the body, as well as to identify
ance in the performance of these activities remains to be environmental challenges that may be encountered.
explained by additional physical, psychological, and cogni- Jackson and Owsley102 provide a comprehensive review
tive variables. Older adults maintain the ability to improve of visual system changes that are part of the normal course
muscle performance with a progressive resistance exercise of aging. By far, the most common age-related deficit in
program and can safely perform high-intensity strength and the visual system is presbyopia, the inability of the lens to
112 Chapter 3
accommodate to allow a viewer to focus on objects at near input from calf intrafusal receptors that contributes to better
distances. This impairment is typically first noticed in the 40s preserved proprioception with weightbearing compared to
and is easily managed with corrective lenses. Visual acuity nonweightbearing.
(ie, the smallest spatial detail that can be resolved), declines An additional finding of Thelen et al’s105 work is that the
with increasing age as well, even with corrective lenses. older women were more successful sensing ankle displace-
Investigators disagree on the rate of decline and timing of ments that occurred at faster angular speeds (highest speed
onset of this impairment. Spatial contrast sensitivity (ie, how was 2.5 degrees/second) compared to slower angular speeds
much contrast a person requires to detect a pattern of a given (slowest speed was 0.5 degrees/second). Older women had
size) also decreases with age, particularly at higher spatial the most difficulty sensing speeds that were representative of
frequencies and lower levels of light. Excessive and intensive ankle rotational velocities observed during postural sway. In
illumination, on the other hand, can also be problematic for fact, the negative effect of proprioceptive decline on postural
older adults. Because of age-related increases in the opacity sway has been documented. McChesney and Woollacott109
of the lens and degenerative changes in the cornea, seniors found that older adults with very poor knee or ankle proprio-
have more problems with glare sensitivity than their young ception (as measured by the amount of movement required
adult counterparts. Visual sensitivity in peripheral visual to detect passive motion when the joint was moved at a slow
fields and sensitivity for moving targets both decline. Dark speed of 0.4 degrees/second) had significantly greater center
adaptation diminishes after the age of 60 years, as does the of pressure variance, a measure of static postural control,
“useful field of view.” Jackson and Owsley102 define this term compared to older adults with good proprioception. Impaired
as the spatial area of the visual field, over which rapid visual proprioception did not, however, affect the subjects’ ability to
discrimination and identification can take place. respond to abrupt, unexpected perturbations (movement of
The causes of these problems vary. Some have been the platform 3.80 cm at a speed of 20 cm/second).
attributed to optical changes in the aged eye (eg, increased Thus, it appears that lower extremity proprioception
opacity of the lens, decreased size and responsiveness of the declines with advancing age, particularly in nonweightbear-
pupil), while others are thought to be due to degeneration of ing positions, and that this reduction may affect postural
the neural visual pathway.85 Regardless of their origin, these control. Recent research suggests a relationship with quiet
problems result in an older adult having less accurate avail- standing, but not with successful response to unexpected
able sensory input to optimize motor control, which contrib- perturbations. Further investigation is warranted to fully
utes to impaired balance and increases the risk of falls.131 examine the relationship between impaired proprioception
Somatosensation and motor control.
In addition to a decline in proprioception with advanc-
Proprioception, which includes the awareness of joint ing age, the sensitivity to tactile and vibratory stimuli also
position and the awareness of movement at a joint, also declines.6,110-112 It is not clear whether these age-related
declines with advanced age. Multiple investigators have declines in sensory integrity are due to alterations in aging
examined age-related changes in proprioception in the lower skin, a decrease in density and change in receptor mor-
extremity in a nonweightbearing position. Skinner et al103 phology, an alteration in number and structure of afferent
examined the joint position sense of 29 volunteers, aged 20 to nerve fibers, or a combination of these factors. The clini-
82 years, and found a significant correlation between age and cal significance of these changes is not firmly established
both the ability to reproduce the position of the knee and either. Studies consistently demonstrate a loss of these sen-
the ability to detect motion at the knee in nonweightbear- sory modalities; the difference between young and old is not
ing position. Pai et al104 confirmed a moderate correlation always large and has, in absence of other impairments, not
between age and the threshold for detection of joint displace- consistently been linked to functional limitations. It has also
ment at the knee. Age-related declines in proprioception have been observed that there is great variability in the sensation
also been identified at the ankle when in a nonweightbearing of older adults, with many older subjects demonstrating
position.105,106 In contrast, it appears that proprioception at levels of tactile and vibratory sensitivity that equal or exceed
the hip joint may be preserved.107 their younger counterparts.
Research suggests that weightbearing may affect the size
of the age-related loss of proprioception at the knee and Vestibular Function
ankle.105,108 Thelen et al105 demonstrated that older women The vestibular system gathers and synthesizes data about
have more difficulty than younger women detecting both head position and motion (velocity and acceleration) to
the presence and direction of movement of the ankle while ensure appropriate eye movements for gaze stability and pos-
standing. They report that the decrease in proprioception tural responses for balance. In addition, the vestibular system
that they found in the weightbearing ankle was less than that acts as a mediator, resolving conflicting information from
previously measured with subjects in a nonweightbearing the visual and somatosensory systems to facilitate appropri-
position. The authors suggest that smaller declines in pro- ate postural responses.
prioception with weightbearing may be due to the use of sen- The vestibular system includes a peripheral sensory appa-
sory input from plantar pressor receptors. Because the calf is ratus, a central processor, and ocular and spinal motor out-
in an elongated position, there may also be increased sensory put mechanisms. The peripheral system consists of otoliths
Figure 3-10. Normative hair cell
data for crista of the lateral semi-
circular canal. (Adapted from
Velázquez-Villaseñor L, Merchant SN,
Tsuji K, Glynn RJ, Wall C 3rd, Rauch
SD. Temporal bone studies of the
human peripheral vestibular system.
Normative Scarpa’s ganglion cell
data. Ann Otol Rhinol Laryngol Suppl.
2000;181:14-19.)
(saccule and utricle) and semicircular canals (anterior, pos- annually for 5 years. The integrity of the horizontal semicir-
terior, and horizontal) that provide sensory input to the cular canal and the superior vestibular nerve was tested by
vestibular nuclei located in the pons and medulla and to the measuring the VOR during rotational testing. The investi-
cerebellum, where it is integrated to produce motor outputs gators also tested visual-vestibular interaction by providing
through the vestibulo-ocular, vestibulocervical, and vestibu- additional visual input during the rotary chair testing. The
lospinal reflexes. ability to appropriately combine vestibular and visual input
There is a significant, progressive age-related decline in requires an intact brainstem and cerebellum. Thus, visual-
the hair cells (the motion sensors of the periphery) in the vestibular interaction testing is useful in identifying central
peripheral vestibular apparatus (Figure 3-10). In a study nervous system involvement. A significant decrease in gain
by Lopez et al,132 there was a decrease of 11.6% of hair cell and increase in phase lead of the VOR was found. There
number in the horizontal semicircular canal of adults in was also a decline in gain of visual-vestibular responses at
their 80s and 25% of adults in their 90s compared to a group low-frequency sinusoidal stimulation over the 5 examina-
of younger adults (42 to 67 years of age). There may also be tions. The researchers therefore suggest that the age-related
a loss of hair cells in the otoliths, but this research is not as declines in vestibular function are likely due to a combina-
conclusive. In addition to hair cell loss, there is a decrease in tion of both peripheral and central vestibular structures.114
the number of neurons in the vestibular ganglion (Scarpa’s Research has demonstrated an age-related decline in tests
ganglion). Park et al133 found that the average number of of the function of the otoliths. Both cross-sectional and lon-
nerve cells declined gradually between 30 and 60 years of age gitudinal studies have documented a decline in the ampli-
and then leveled off. tude of vestibular-evoked myogenic potentials, a measure
The exact effect of these anatomical changes on measures of saccular function, and/or the corresponding inferior ves-
of vestibular function is still being determined. The vestib- tibular nerve.114 Serrador et al115 report a decline in utricular
ulo-ocular reflex (VOR) stabilizes images on the retina dur- function as evidenced by a reduction of ocular counter roll
ing head movement by generating an eye movement in the (ie, a reflexive ocular torsion in response to head tilt in the
direction opposite to the head movement. Multiple studies roll plane). An additional important finding in their study is
have documented an age-related decline in the VOR.113,134 a correlation between ocular counter roll and medial-lateral
Peterka et al113 examined the VOR by testing the responses to sway as examined during posturography. Since medial-later-
caloric and sinusoidal rotational stimuli in 216 subjects aged al sway has been associated with falls, this raises the possibil-
7 to 81 years. Caloric test parameters did not change with ity that otolith function is also related to fall risk. Decreases
age, but there was a slight progressive change throughout the in vestibular function as demonstrated in all of the studies
lifespan in rotation test gain (the magnitude of the eye move- described is important to appreciate as vestibular problems
ment response) and phase (the timing of the eye movement can affect an individual’s balance and risk of falls.116
response) with age. The investigators note that only 10% to
15% of the variance in gain data could be explained by age, Central Processing
so factors other than age are contributing significantly to
measures of VOR gain. They also report that the magnitude Sensory input from the visual, somatosensory, and vestib-
of the changes with age were not large compared to the vari- ular systems is redundant and, at times, in conflict, requiring
ability within the population. the brain to compare the information from these systems to
In a longitudinal study of the effects of aging on ves- determine the relation of body parts to one another and to
tibular function, Enrietto et al114 tested the vestibulo-ocular the external environment. Afferent input to the brain is inte-
function of 57 normal older adults (mean age of 82 years) grated, and then an appropriate motor response is planned
114 Chapter 3
and executed with consideration of task demands, the envi- condition 4 (normal vision but inaccurate proprioceptive
ronment, the limitations of the effector system, and previous information). Because the old old adults were unable to use
experiences. Research indicates that there are changes that vision to compensate for the loss of accurate proprioceptive
occur with aging that affect the ability of the central ner- information, the researchers suggest there is an age-related
vous system to manage either reduced or conflicting sensory increase in reliance on proprioceptive input for balance.
input and to select and execute effective and efficient motor Benjuya et al’s135 research demonstrated decreased reli-
responses. ance on visual information for balance with advancing age.
Sensory Organization They measured body sway of young and old subjects under
4 conditions: wide base of support with eyes open and eyes
The ability to effectively process and utilize sensory input closed, and narrow base of support with eyes open and eyes
in advanced age can be challenging to study. The Sensory closed. Their data revealed that the reduction in visual input
Organization test has been used frequently to identify older had a greater effect on the postural sway of the younger sub-
adults’ difficulty maintaining quiet stance during conditions jects when compared to the older subjects. The investigators
of changing sensory input.117 During this test, postural con- suggest that this is because the older individuals are not rely-
trol is examined under 6 conditions: ing on the visual system’s input for balance as much as the
1. Normal vision and stable, static platform surface younger adults, so the loss of this information affects their
2. Eyes closed and stable surface (decreased visual input balance to a lesser degree.
and normal proprioceptive input) Thus, the evidence supports that, in old age, individuals
3. Visual surround sway-referenced and stable surface are less able to maintain quiet stance without postural sway
(inaccurate visual input and normal proprioceptive in conditions of reduced sensory input on posturography
input) testing. It has been suggested that this can be attributed to
a decrease in central processing of sensory information.124
4. Eyes open and platform sway-referenced (normal visual
The possibility exists that, though these subjects were free of
input and inaccurate proprioceptive input)
known disease and impairment, there were mild age-related
5. Eyes closed and platform sway-referenced (decreased declines in the integrity of the peripheral sensory modalities
visual input and inaccurate proprioceptive input) that were not captured on physical exam, and these deficits
6. Both visual surround and platform sway-referenced contributed to age-related changes in Sensory Organization
(inaccurate visual and proprioceptive inputs) test responses. There is heterogeneity in the aging process,
Results from this research indicate that older adults have including the aging of the sensory systems. The strength of
a slight increase in postural sway under normal conditions the visual, somatosensory, and vestibular inputs available for
(ie, eyes open and a firm, static surface) when compared to postural control varies from adult to adult. An older adult’s
young adults, though the magnitude of the change is not stability in different situations is dependent on the strength
large enough to threaten postural stability.117,118 of the sensory systems of that particular older adult.
Older people do, however, demonstrate increased sway The sensory input available to an individual is also
and a decreased ability to maintain their balance when sen- dependent on environmental conditions and the informa-
sory input is reduced. This is particularly true in conditions tion available in different situations. In daily life, the sensory
5 and 6 of the Sensory Organization test when accurate sen- input available to a person changes frequently (eg, walking
sory input is reduced from more than one system and seniors outside into the bright light from a dark movie theater or
are challenged to rely primarily on vestibular input.117,118 walking from a boardwalk onto a sandy beach). Individuals
When challenged to stand with abnormal proprioceptive change the relative contribution of each of the senses to pos-
input and either absent or abnormal visual input, 30% to 50% tural control as conditions change, a process termed sensory
of older adults subjects took a step to regain their balance reweighting.119 This process is important to maintain bal-
on the first test trial compared to none of the young adults, ance. Research suggests that older adults are less able to adapt
suggesting seniors require more sensory input than their their use of sensory inputs in response to changes in situation
younger counterparts to maintain balance.117,118 compared with young adults.119
The work of Camicioli et al124 suggests that balance prob- The integrity of the sensory systems, patterns of sensory
lems in situations of decreased sensory input are progressive reliance, and sensory reweighting abilities need to be deter-
and become even more pronounced in very advanced age. mined during a physical therapy examination. Does an older
The investigators compared the Sensory Organization test adult have accurate visual, somatosensory, and vestibular
results of “old old” individuals (88 ± 5 years) with those of input available? Does he or she effectively use all of the
“young old” subjects (72 ± 3 years). Both groups had difficulty available sensory input, or is there excessive reliance on one
in conditions 5 and 6, when sensory information from 2 sys- system? Is the individual able to change the input relied on in
tems was reduced. The old old adults also demonstrated dif- response to changing environmental conditions? Answers to
ficulty in a situation with inaccurate sensory input from only these questions help a PT design the most effective balance
one of the systems. Specifically, they had significantly greater training program for an older adult.
sway and more frequent falls than younger counterparts in
Motor Organization unexpected translation of a force platform, a situation that is
similar to the experience of a slip while walking.117,138 They
After integrating incoming sensory input, the central
also more frequently contract muscles in a proximal to distal
nervous system must organize and execute a motor response
fashion rather than the usual distal to proximal order when
that is both coordinated and timely. Research indicates that,
compared to young adults.
with age, both the pattern and timing of movements change.
Individuals rely on ankle, hip, or stepping movements
Postural muscles contract to stabilize the body in prepara-
(or a combination) to respond to unexpected challenges to
tion for a voluntary movement. Early research demonstrated
their postural control. Older adults use hip movements more
that older adults had difficulty quickly generating these
often than young adults, who tend to maintain postural sta-
anticipatory postural adjustments when performing volun-
bility in response to small perturbations using ankle muscle
tary movements.136 In contrast, Rogers et al137 found that
activation.117 Older adults also use a stepping strategy more
older adults triggered anticipatory postural events as quickly
often and in response to smaller perturbations than the
as younger subjects when asked to generate a voluntary step
young.125,126 For example, Hall et al125 examined younger
in response to a visual cue. The time to unload the limb and
and older adults’ responses to forward and backward trans-
step was significantly longer in older adults compared with
lations of a force platform at varying amplitudes and veloci-
young adults, but there was no difference in the onset of pre-
ties. Older adults generated ankle muscle torques that were
paratory postural muscle activation.
similar to the younger subjects’ torque in amplitude, rate
St. George et al120 also examined the timing of older of development, and scaling to the size and velocity of the
adults’ voluntary stepping movements in response to a visual perturbation. Despite having the same ankle motor function,
stimulus. In their study, subjects were required to step on older subjects used a stepping strategy to maintain upright
1 of 4 foot plates as quickly as possible once it became illumi- more often than the younger adults. It is possible that older
nated. Older adults took longer to initiate a movement, which adults stepped more frequently because of proximal leg or
the authors suggest indicates an age-related decline in central trunk motor function deficits and an associated inability to
processing of information. In addition, the older adults took rely on a hip strategy, but this remains unknown as those
longer to reach the foot plate once leg movement had begun. forces were not measured in this study.
This suggests there is also a decline in the speed of motor
Mille et al126 also studied the effect of external perturba-
execution with age.
tions of various velocities and displacements on the threshold
An additional and important component of this study was for inducing a stepping response in young (25.3 ± 4.2 years)
an investigation of the impact of cognitive and motor sec- and old (71.0 ± 7.0 years) subjects. Their work supports the
ondary tasks on stepping ability. The results demonstrated conclusion that seniors step more frequently than young
a decline in performance that was dependent on the type adults in response to both low- and high-velocity displace-
of secondary task added. Specifically, subjects performed ments. The authors also examined the relationship between
a visuospatial working memory task immediately prior to multiple sensorimotor factors (vibration sense, touch-pres-
illumination of the foot plate. Subjects were also required sure sensation, proprioception, visual acuity, ankle plantar-
to step over a low obstacle to reach the foot plate. Initiation flexion strength, and foot voluntary reaction time) and the
and execution times were measured with each of these stepping response. Decreased sensorimotor performance was
tasks performed alone as well as when the tasks were per- significantly associated with more frequent stepping. Once
formed together. The addition of the memory task increased age was removed as a factor, however, these associations were
response times by more than 40% in the older adult group, no longer present, which suggests that the sensorimotor vari-
but by only 7% in the young adult group. Increases in move- ables were not directly responsible for the change in stepping
ment execution time were smaller and equal in size in young behavior seen with advancing age.
and old adults. The additional challenge of the obstacle
The effect of age on upper extremity motor control has
increased movement time by ~40% in all subjects, but it only
also been examined. Fozard et al121 analyzed both cross-
minimally affected response time. Older adults consistently
sectional and longitudinal data from 1265 volunteers aged
had more errors in stepping, poorer performance on the
17 to 96 years and identified an increase in upper extremity
memory task, and more contact with the obstacle compared
reaction time with advancing age. That is, older adults took
with young adults. The investigators concluded there is an
significantly longer to press a handheld button in response
age-related decline in the ability to initiate and execute quick,
to an auditory stimulus compared with younger adults. The
accurate voluntary steps. The decline is most notable when
difference in reaction time was more pronounced when
attention is divided between 2 tasks.
the complexity of the task was increased. Beginning at age
There are additional age-related delays in the onset of 20 years, simple reaction time increased at a rate of approxi-
muscle activation in reactive balance situations, such as mately 0.5 ms/year, and the more difficult disjunctive reac-
when a force platform is unexpectedly moved.117 Changes tion time (ie, subjects had to decide if they were going to
in the patterns of muscle activation have also been noted in press the button depending on the pitch of the auditory cue)
response to this challenge. Older adults have been shown increased at a rate of 1.6 ms/year. Additionally, the variability
to have greater cocontraction of lower extremity muscula- of responses and number of errors was greater in old age.
ture compared with young adults when they respond to an
116 Chapter 3
Houx and Jolles122 found age-related slowing mainly in the way an older adult is able to move. ROM decreases with
the execution of reaction time tasks, though a slowing in the age.127,128 There is significant variability in how individuals’
initiation of a motor response was identified when the task posture develops with advancing age, but older adults tend to
was more complex. In addition to increases in the time to have a greater kyphosis, more posterior hip position, and for-
execute upper extremity tasks, research has demonstrated ward lean at the hips (Figure 3-11). All of these factors must
age-related changes in the patterns of movement.123 Older be considered when examining an older adult’s performance
individuals rapidly reaching for a target spend more time in of functional tasks.
the deceleration phase, the period of sensory processing that
ensures accuracy of movement, than their younger counter- Effect on Function
parts. There is less evidence to suggest that older adults spend
proportionally more time accelerating toward a target. Pohl Cross-sectional and longitudinal data have indicated
et al123 examined the ability of old and young subjects to that changes in upper extremity performance may affect
perform reciprocal tapping with the hand under conditions the older adult’s ability to perform ADL. Potvin et al140 and
of differing complexity: tapping a stylus on an 8-cm–wide Desrosiers et al141 examined multiple tests of sensorimo-
target, alternating between 8-cm–wide targets placed 37 cm tor performance, including gross and fine motor control,
apart, and alternating between 2-cm–wide targets placed strength, coordination, sensory integrity, and reaction time.
37 cm apart. Older adults demonstrated longer movement Age-related declines were documented on almost all tests.
times and more than 5 times the number of adjustments In addition, measures of ADL performance were found to
in trajectory compared with those in the young group. decline in older age. It is important to note that the measures
The older subjects also spent more time reversing direc- chosen by these investigators were timed tests. As older
tion between targets than the young subjects. Thus, older adults took more time to complete a task similar to an ADL,
adults may take longer to reach because of slowing to ensure the score they received declined. Thus, it is not known how
adequate determination of position in space and added time well the subjects were able to complete the functional tests,
spent adjusting the path of movement to reach their target. only that they required more time to do so.
The investigators found that age-related differences became There are significant age-related changes in gait perfor-
more pronounced in the more difficult conditions. mance that affect the safety and functional abilities of older
Wishart et al139 also found that the performance of older adults. Seniors demonstrate slower gait speed, shorter steps,
adults on upper extremity coordination tasks was dependent decreased single limb support time, slight hip flexion, ante-
on the speed and complexity of the task. Subjects were asked rior pelvic tilt, toeing out of the feet, and decreased ankle
to complete an upper extremity task in which the mirror plantarflexion power at push-off when compared to younger
image actions of the upper extremities were performed (ie, adults.142 Himann et al143 found that the decline in gait
shoulders both internally or externally rotated at neutral speed accelerated after age 62 years. Prior to age 62 years, the
flexion to slide pegs back and forth on steel rods) at 5 dif- normal walking speed decline was demonstrated to be 1% to
ferent movement speeds. This task was believed to represent 2% per decade. After age 62 years, the more rapid decline of
an automatic process. The subjects also performed this task 12.4% per decade for females and 16.1% per decade for males
with the upper extremities out of phase (ie, moving like was seen. It also has been shown that older adults are less
windshield wipers), which was believed to be automatic at able than younger adults to increase their gait speed from
slow speeds, but a conscious and effortful process at fast a preferred gait speed to a fast pace of walking.144 These
speeds. Compared with younger subjects, the older adults declines in gait speed may limit an older adult’s ability to
demonstrated decreased accuracy and stability of movement be functional in the community because certain mobility
at high speeds when performing the more complex task. The tasks, such as crossing a street, require an older adult to walk
researchers suggested that older individuals often perform quickly. In fact, Hoxie and Rubenstein145 found that 27% of
as well as younger subjects with automatic tasks, but that 592 pedestrians observed crossing the street were unable to
age-related differences in motor performance become more make it to the opposite curb before the light changed, all of
pronounced when conscious, effortful processing is required. them being older adults.
A significant safety concern for older individuals is the
Effector System increased risk of falling that comes with advanced age.146
Older adults have delayed, slower, and smaller muscle acti-
Automatic and voluntary adjustments of the body for sta- vation after slips and trips, which may contribute to the
bility or mobility occur within the constraints of the effector inability to recover from these events.138,147 They also have
system. That is, factors such as muscle performance, aerobic a decreased ability to terminate gait rapidly compared to
capacity, ROM, and posture all affect how motions may be younger adults.148 Priest et al149 note that variability in stride
carried out. The age-related changes in aerobic capacity and velocity is a characteristic of unstable gait and predicts falls
muscle performance discussed earlier may affect an older in older adults. In their study, community-dwelling older
adult’s ability to perform desired movements once motor women (mean age of 80 years) had significantly more vari-
plans are created by the central processing system. In addi- ability in stride velocity compared to young adults. In addi-
tion, age-related changes in ROM and posture may also affect tion, they found that this variability increased and gait speed
Figure 3-11. Typical young and old subjects. (Modified from Aging Clin Exp Res, 4(3), 1992, pp 219-225, Changes in pos-
ture and balance with age, Woodhull-McNeal AP, with kind permission from Springer Science+Business Media B.V.)
decreased in dual-task walking (ie, walking while counting of the PT’s evaluation and plan of care for the older adult
backwards in increments of 3, 4, or 6). Because the addition of at risk for falls is to identify and remediate all correctable
a cognitive task has a destabilizing effect on gait, the authors impairments and to help the individual compensate for those
emphasize the need to incorporate such dual-task situations that cannot be changed.
into a rehabilitation intervention. This may be through edu-
cation about the need to avoid cognitive tasks while walking Benefits of Training
or through training under dual-task conditions.
Several impairments described previously have been posi- Older adults retain the ability to improve many aspects
tively associated with falls in community-dwelling older of motor control with physical activity, exercise, and train-
adults, including visual acuity, depth perception, contrast ing. Buatois et al152 found that older adults who were physi-
sensitivity, proprioception, vibratory sense, lower extrem- cally active had improved postural control and better ability
ity strength, reaction time, and postural sway during static to manage situations with sensory conflict on the Sensory
stance with eyes open.131,146,150 Perhaps even more threat- Organization test compared to sedentary peers. Current phys-
ening to fall risk than the presence of a single impairment ical activity was the major determinant for measures of pos-
is the effect of multiple impairments. Several authors have tural stability compared to age, gender, body mass index, and
noted that a single impairment may explain only a small por- past physical activity. Thus, physical activity can minimize
tion of the fall risk of an older adult or may not significantly age-related declines in sensory organization. It is important to
increase a senior’s risk of being a recurrent faller. Instead, the note that it was not just older adults who had been physically
accumulation of several impairments appears to escalate fall active for their entire lives who performed well. Older adults
risk more dramatically.146,151 Thus, an essential component who became active later in life (ie, after retirement) performed
118 Chapter 3
significantly better than those who were not currently active. authors note that these interventions do result in other gains
This highlights that a simple change in lifestyle, even made that are important to older adults’ health, such as improved
later in life, is valuable for older adults. fitness and lower BP. Impaired balance may be a greater risk
Physically active older adults have also demonstrated factor for falls, but declines in strength and aerobic capacity
better reaction times compared with those who described do have important implications for function as discussed
a sedentary lifestyle. Spirduso et al153 found this difference earlier in the chapter and need to be considered for inclusion
both with a simple lower extremity response test (pressing in a comprehensive exercise program for an older adult.
a foot switch in response to a visual cue) and a discrimina- In addition to remediating impairments and improving
tion reaction time test (pressing a foot switch only when function through training, PTs can help older adults adapt
the proper color visual cue was presented). An encouraging to irreversible problems to improve safety. For example, a
research finding is that older adults can improve their reac- clinician can make recommendations for environmental
tion time with training. Falduto and Baron154 had 8 older modifications to decrease or minimize the extrinsic risk fac-
and 8 younger women practice sorting cards for 5 training tors for falls or provide equipment to facilitate performance
sessions. At the end of the training, older women demon- of ADL (eg, a reacher to obtain objects from high shelves,
strated significantly better sorting ability both in simple and eliminating the need to climb a step stool). Finally, recogni-
complex conditions. tion of risk factors for falls that can effectively be managed by
Lord and Castell155 implemented a comprehensive 10-week other health care providers should trigger referrals to these
group exercise program for 44 older men and women (mean clinicians, such as an ophthalmologist for optimal eyewear
age = 62.4 years), consisting of walking, lower extremity prescription or a primary care physician for medication
strength training (using gravity as resistance and targeting modification.
ankle dorsiflexors, knee extensors, hip abductors, and the The age-related decline in motor control cannot be avoid-
quadratus lumborum), bicycle riding, flexibility, balance ed, but with training and exercise, older people can lessen the
exercises, and education regarding safe exercise techniques magnitude of the changes that they experience in reaction
and proper posture. At the end of this period, the group that time, postural sway, gait speed and pattern, and fall risk.
exercised demonstrated significant improvements in quad-
riceps strength, simple lower extremity reaction time, and Summary
postural sway (on a firm surface with eyes open and on foam
with both eyes open and eyes closed) compared to a control The ability to initiate, execute, and terminate coordi-
group, demonstrating the reversibility of many impairments nated and timely movements depends on sensory input from
found in old age. There were no measures of function or dis- the visual, vestibular, and somatosensory systems; central
ability in this study, so it is not known how these affected the processing to integrate this afferent information and plan
subjects’ functional performance. In a subsequent random- an appropriate motor response; and an expression of that
ized controlled trial, however, Lord and his colleagues156 response within the constraints of the body’s effector system.
were able to demonstrate that a 22-week exercise program, Age-related changes occur in each of these components of
similar to the one described previously, had a positive impact motor control. Older adults often develop impairments in
on the gait pattern of seniors. Older adults had significantly visual acuity, contrast sensitivity, glare sensitivity, peripheral
increased gait speed, cadence, stride length, and shorter field vision, and dark adaptation. Proprioception, tactile sen-
stride times at the end of the training period, while none of sitivity, and vibratory sense also frequently decline in older
the gait parameters of the control subjects changed. adulthood. Age-related decreases in vestibular function have
Of paramount concern to older adults and PTs is the abil- been found and are thought to be due to changes both in the
ity to reduce the risk of falling associated with advancing peripheral and central vestibular structures.
age. Evidence suggests that community-dwelling older adults Older people sway more than young adults during quiet
are able to reduce their risk of falling with training, though stance and demonstrate decreased ability to maintain their
the optimal frequency, intensity, duration, and combination balance in the setting of reduced sensory input during
of interventions is not completely clear.146,157,158 In their posturography testing. Reaction times are greater, espe-
meta-analysis of 44 randomized controlled trials involv- cially as conditions become more complex. The patterns of
ing 9603 subjects, Sherrington et al130 found that exercise movement of older adults also change, including increased
reduced fall rates in older adults by 17%. Additionally, they cocontraction of lower extremity musculature and more
identified 3 characteristics of programs that were associ- frequent reliance on hip or stepping strategies in response to
ated with better outcomes: inclusion of challenging balance a perturbation.
exercises, higher doses of exercise (a minimum of twice per These changes in the sensory and central processing sys-
week for 25 weeks), and absence of a walking program. The tems combine with the muscle performance impairments
authors suggest that these findings should be considered described earlier to slow the performance of older adults dur-
when designing an exercise program to reduce the fall risk ing gait and ADL and put them at risk for falls. Though train-
of an older client. Though the inclusion of moderate- or ing cannot alleviate these problems, the current evidence
high-intensity strength training or a walking program did demonstrates that multifactorial interventions can improve
not provide added benefit to the reduction of fall risk, the the coordination, gait, and fall risk profile of older adults.
7. Hautmann H, Hefele S, Schotten K, Huber RM. Maximal inspira-
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crista ampullaris. J Neurosci Res. 2005;82:421-431. The effect of exercise on gait patterns in older women: a random-
133. Park JJ, Tang Y, Lopez I, Ishiyama A. Age-related change in the ized controlled trial. J Gerontol A Biol Sci Med Sci. 1996;51(2):M64-
number of neurons in the human vestibular ganglion. J Comp M70.
Neurol. 2001;431:437-443. 157. Gillespie LD, Gillespie WJ, Robertson MC, Lam SE, Cumming
134. Ishiyama G. Imbalance and vertigo: the aging human vestibular RG, Rowe BH. Interventions for preventing falls in elderly people.
periphery. Semin Neurol. 2009;29:491-499. Cochrane Database Syst Rev. 2003;(4):CD000340.
135. Benjuya N, Melzer I, Kaplanski J. Aging-induced shifts from a reli- 158. Shumway-Cook A, Gruber W, Baldwin M, Liao S. The effect of
ance on sensory input to muscle cocontraction during balanced multidimensional exercises on balance, mobility, and fall risk in
standing. J Gerontol A Biol Sci Med Sci. 2004;59(2):166-171. community-dwelling older adults. Phys Ther. 1997;77:46-57.
136. Shumway-Cook A, Woollacott MH. Motor Control: Translating
Research Into Clinical Practice. 3rd ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006.
137. Rogers MW, Hedman LD, Johnson ME, Martinez KM, Mille ML.
Triggering of protective stepping for the control of human bal-
CASE STUDY 3-1
ance: age and contextual dependence. Brain Res Cogn Brain Res.
2003;16:192-198.
138. Tang PF, Woollacott MH. Inefficient postural responses to unex-
pected slips during walking in older adults. J Gerontol A Biol Sci
Med Sci. 1998;53(6):M471-M480.
139. Wishart LR, Lee TD, Murdoch JE, Hodges NJ. Effects of aging
EXAMINATION
on automatic and effortful processes in bimanual coordination.
J Gerontol B Psychol Sci Soc Sci. 2000;55(2):P85-P94.
140. Potvin AR, Syndulko K, Tourtellotte WW, Lemmon JA, Potvin JH.
History
Human neurologic function and the aging process. J Am Geriatr
Soc. 1980;28:1-9. Current Condition/Chief Complaint
141. Desrosiers J, Hébert R, Bravo G, Rochette A. Age-related changes
Ms. Arbor was an 82-year-old White female referred
in upper extremity performance of elderly people: a longitudinal
study. Exp Gerontol. 1999;34:393-405. to physical therapy by her primary care physician (PCP)
142. Judge JO, Ounpuu S, Davis RB. Effects of age on the biomechanics because of increasing difficulty completing her instrumental
and physiology of gait. Clin Geriatr Med. 1996;12:659-678. activities of daily living (IADL).
143. Himann JE, Cunningham DA, Rechnitzer PA, Paterson DH. Ms. Arbor stated she had been going out less frequently
Age-related changes in speed of walking. Med Sci Sports Exerc.
1988;20:161-166.
over the past 6 months because she was afraid she was going
144. Shkuratova N, Morris ME, Huxham F. Effects of age on balance to fall (though she had not fallen yet) and because she became
control during walking. Arch Phys Med Rehabil. 2004;85:582-588. “winded” with community-level activities. Her main goal
145. Hoxie RE, Rubenstein LZ. Are older pedestrians allowed enough was to be confident and independent walking in the com-
time to cross intersections safely? J Am Geriatr Soc. 1994;42:241- munity and completing all of her IADL.
244.
Social History/Environment family is present, the dynamics of the relationship can
Ms. Arbor lived alone in senior housing and was a widow be observed, which can be another influential factor in a
without children. She had a college education and worked as patient’s care. Knowledge of a patient’s life roles, functional
a secretary until age 65. Ms. Arbor moved into senior housing requirements, and environment will facilitate development
after her husband died because she did not want to manage a of goals and a plan of care that will best meet the patient’s
home by herself. She spent her time during the day watching needs. It is also important to understand the impact of a
TV, reading, and doing puzzles. She also enjoyed the build- patient’s social support system on his or her lifestyle. Lack
ing’s activities, including weekly bingo and bridge games. of social support has been identified as a factor contribut-
Ms. Arbor had friends in the building, but their ability to ing to nursing home placement1 and a major risk factor
help her was limited because of their own health problems. for increased morbidity.2 In the absence of an adequate
Ms. Arbor lived in an apartment in an urban location. social network, Ms. Arbor may have been forced to make
Her home was on the 6th floor with elevator access. There independent risky trips into the community, raising the
were no stairs to enter the building, but the building was on likelihood of her falling. Alternatively, she may have chosen
a slight hill. There was a curb to negotiate for vehicle access to stay home, limiting her ability to access supplies such as
and a flight of stairs to get to the train stop outside her home. groceries and medication.
Social/Health Habits The patient’s report can help a provider accurately direct
the physical examination and choose the most appropri-
Ms. Arbor had a glass of wine with dinner several times ate tests and measures. A directed examination can be
per week. She had never smoked. Though she had never less invasive and more efficient for the patient, saving both
exercised regularly, she was very willing to begin an exercise time and cost.3 When questioned, Ms. Arbor identifies
program. 2 problems that need to be investigated: fear of falling and
Medical/Surgical History shortness of breath.
She reports mild osteoarthritis in both knees. Ms. Arbor Falling is a significant problem for older adults. It can
uses glasses for reading. have a tremendous effect on function and quality of life
and, unfortunately, is an increasingly common problem
Reported Functional Status in advancing age. One-third of individuals over the age of
Ms. Arbor ambulated without an assistive device in her 65 years fall each year, a statistic that worsens with age to
building and was independent with basic ADL without the point where 50% of those 85 years and older fall each
undue effort or fatigue. She was having more difficulty year. More than 30% of those who fall sustain moderate
with community-level ambulation and IADL, however. She or severe injuries.4 After a fall, many older adults restrict
reported uncertainty when ambulating outdoors or in a their activity because of fear.5 The resultant deconditioning
crowded environment and found it increasingly difficult to can further increase a person’s risk of falling. The ability to
carry grocery bags. She had begun buying frozen dinners identify an older adult at risk of falling and intervene early
and canned goods so that she would need to go to the store presents a wonderful opportunity to preserve function and
less frequently. Ms. Arbor stated that she was able to walk decrease disability in the individual’s later years. Thus, it
about one block and then felt too winded to continue without was very fortunate that Ms. Arbor’s PCP referred her to
a rest. She had started taking a cab because she was afraid she physical therapy before she had fallen.
would not get a seat on the train and would lose her balance Many factors can increase fall risk, including impaired
when it moved. vision; decreased lower extremity strength, power, and
Medications endurance; poor balance and gait; and cognitive deficits.6,7
Given Ms. Arbor’s reported fear of falling, further testing in
Ms. Arbor reported taking acetaminophen approximately
these areas was warranted. Ms. Arbor provided important
twice per week for knee pain. She takes no other prescription
information about balance and gait in her chief complaint.
or over-the-counter medications.
She reported difficulty when outdoors, in crowds, and while
carrying bags. Because of these comments, I chose, among
Clinician Comment During the interview, a other testing, to examine her balance and gait in situations
great deal of information can be gathered that will help the that provide reduced or inaccurate sensory input and/or
clinician determine an accurate diagnosis, realistic progno- require her to dual-task.
sis, and optimal plan of care for a patient. The interview Ms. Arbor’s complaint of shortness of breath with higher
is a time to establish a rapport with the patient, which can level functional activities also needed further evaluation.
influence the patient’s experience and engagement in his An examination of her pulmonary system (ie, respiratory
or her treatment. Through careful questioning and active rate [RR], breathing pattern, breath sounds, O2 saturation)
listening, the PT can gain insight into the patient’s values, was indicated. In addition, her aerobic capacity needed to
culture, perception of the problem, and goals, all of which be measured to identify a possible impairment that may
need to be considered when developing a plan of care. If have limited her function.
124 Chapter 3
Systems Review Clinician Comment The systems review is a
brief, standard examination of all body systems to screen
Cardiovascular/Pulmonary for movement system abnormalities and identify areas that
HR: 78 beats per minute (bpm) need more specific testing. This information, combined
RR: 12 seated at rest with data collected during the interview, directs the clini-
BP: 136/86 cian’s choice of tests and measures.8
Edema: no edema present Ms. Arbor’s systems review revealed several areas of abnor-
Integumentary mality. Her BP was in the “prehypertension” range accord-
ing to the American Heart Association (SBP = 120 to 139 or
No skin disruption, normal skin color and pliability diastolic BP = 80 to 89), which significantly increases her
Musculoskeletal risk of cardiovascular disease.9 It was important that her
BP was discussed, including the risks associated with the
Gross Symmetry elevated value, the benefits of exercise to help lower it, and
Thoracic kyphosis in sitting and standing the need to work with her PCP to address it. In addition,
Gross Range of Motion close monitoring of her BP with exercise was needed.
Decreased shoulder elevation and ankle dorsiflexion Because osteoporosis becomes more common in older
age, Ms. Arbor’s thoracic kyphosis was concerning. It was
Gross Strength reasonable to wonder if her loss of vertebral height might
Deferred gross testing since more thorough and care- be due to compression fractures. Because of this and the
ful testing of strength was indicated as well as for postural impact of impaired posture on balance, further examina-
stability tion of her alignment was indicated. The other finding on
Height/Weight her musculoskeletal screen that indicated the need for more
Height: 62 inches (5 feet, 2 inches) testing was her limited shoulder and ankle ROM.
Weight: 124 pounds (body mass index = 22.7) Ms. Arbor stopped walking when she engaged in conversa-
tion, which indicated a decreased ability to dual-task and
Neuromuscular suggested she was at an increased risk of falling.10 This
Gait finding provided further evidence of the need to test her
Ms. Arbor was cautious with trunk/hip flexion. When balance in dual-task conditions.
asked questions as she walked from the waiting room to the Ms. Arbor noted that she had some memory deficits.
examination room, she significantly slowed her gait speed or Because she did not have any family or friends with her,
stopped to respond. the reliability of the information she provided could not be
Locomotion determined as well as whether she accurately assessed that
it did not affect her safety. Therefore, testing her cognition
Independently transferred supine ↔ sit ↔ stand
was indicated. A cognitive impairment would affect her
Balance ability to remember instructions and recommendations for
No loss of balance during basic mobility skills observed as her physical training, but, more important, it could prevent
she walked in the clinic and transferred into and out of chairs her from living safely and independently in the community.
and onto and off of the examination table
Motor Function
Decreased ability to control descent into a chair Tests and Measures
Communication, Affect, Cognition, Arousal, Attention, and Cognition
Learning Style Saint Louis University Mental Status Examination
Ms. Arbor was oriented to person, place, and time. She (SLUMS) = 27/3011
engaged easily in conversation and followed all directions
well. She was interested in the examination process and
asked appropriate questions about the rationale and mean-
Clinician Comment The Mini-Mental State
Examination (MMSE) is probably the most widely used
ing of the tests performed. She reported some difficulty with
instrument to screen for dementia. While it is able to iden-
memory that she attributed to “old age.” She stated that it
tify individuals with dementia, it has been shown to have
had never affected her function or safety (eg, forgetting to
limited ability to detect mild levels of cognitive impairment,
turn off the stove, missing appointments, not paying bills
which was necessary in this case.12 Tariq et al11 developed
on time). She believed, however, that she would need writ-
the SLUMS to address this limitation. It is a 30-point scale
ten instructions to remember her exercise prescription and
that tests orientation, memory, attention, and executive
educational information.
function. In a comparison of the 2 scales, the MMSE and
the SLUMS were found to have similar ability to detect Ms. Arbor reported that, though she was working at
dementia. Tariq et al11 conclude that the SLUMS is possibly approximately 70% of her HRmax,19 she was not limited by
better at detecting mild neurocognitive disorder, however. fatigue or dyspnea. Instead, she felt that her balance prob-
The investigators propose that Ms. Arbor’s score indicates lems prevented her from walking faster. Thus, based on her
she had normal cognitive function, which was a reassuring subjective report, it appears that Ms. Arbor’s fear of falling
finding. was the limiting factor in this test.
Aerobic Capacity and Endurance Gait, Locomotion, and Balance

The6MWT13 = 285 meters or 935 feet without rest. Ms. • Activities-Specific Balance Confidence (ABC) scale20-22
Arbor complained of mild knee aching with ambulation. = 68% (out of 100%)
When asked what kept her from walking farther during the • Modified Clinical Test of Sensory Interaction and
6 minutes, Ms. Arbor said that she was afraid she would fall Balance (modified CTSIB)23
if she walked any faster. Her vital signs during the test were
as follows: ◦ Condition 1 (firm surface, eyes open) = 30 seconds
◦ Condition 2 (firm surface, eyes closed) = 18 seconds
ACTIVITY BP HR RR BORG ◦ Condition 3 (standing on foam, eyes open) = 16 seconds
DYSPNEA ◦ Condition 4 (standing on foam, eyes closed) = imme-
SCALE14 diate loss of balance; required assist to stay upright
Baseline 136/86 78 12 0 • BBS24,25 = 46/56, difficulty in situations that required a
End of test 164/90 106 18 3 (Moderate) decreased base of support
Recovery: 132/84 94 Not 0 ◦ 6-meter comfortable gait speed = 0.84 m/s
2 minutes taken ◦ 6-meter fast gait speed = 1.0 m/s
Recovery: 120/84 80 12 0 ◦ 6-meter gait speed with cognitive task = 0.72 m/s
5 minutes Ms. Arbor demonstrated decreased step length bilaterally
and increasingly flexed posture as she continued walking.
She was able to walk and carry a glass of water or a stack of
Clinician Comment The 6MWT was cho- sheets without increased gait deviation, but at a slowed speed.
sen to help identify the limitations to Ms. Arbor’s com- She had repeated lateral deviations in her gait path when
munity ambulation and to obtain a baseline measure of walking with horizontal head turns. With light perturba-
functional exercise capacity. Ms. Arbor’s 6MWT perfor- tions at her sternum or waist, she utilized a hip strategy to
mance was below normal for her age. In his meta-analysis, maintain her balance.
Bohannon15 determined the normal 6MWT distance for
an apparently healthy woman between the ages of 80 and
89 years to be 382 meters (95% confidence interval 316 to
Clinician Comment Ms. Arbor had a signifi-
cant fear of falling, so the ABC Scale was chosen to quantify
449). Ms. Arbor’s subjective and objective responses to the
her perception of her postural control and functional abil-
test helped to identify those factors that might explain her
ity. Her score demonstrated a substantial fear of falling and
abnormal 6MWT result.
predicted only a moderate level of functioning.22 Fear of
Analysis of Ms. Arbor’s hemodynamic response to activity falling and the perceived negative consequences of falling
suggested she was deconditioned. She demonstrated exces- (ie, loss of functional independence and damage to identity)
sive HR and BP increases to the workload she performed. are correlated with the avoidance of activity.26 If Ms. Arbor
She walked at a speed of 1.8 miles per hour, which approxi- further decreased her activity level, she would have expe-
mates a 2.4 metabolic equivalent (MET) activity and an rienced declines in aerobic capacity, muscle performance,
increase in workload of around 1.4 METs compared to her and motor control and would have been at an even greater
resting state (if we estimate that to be 1 MET, recogniz- risk of falling. It was hoped that, with a comprehensive
ing there is variability in individuals’ resting metabolic physical therapy program, Ms. Arbor would feel more con-
rates).16,17 A normal response to exercise is a 10 ± 2 bpm fident with her function and that would be reflected by an
rise in HR and a 10 ± 2 mm Hg rise in SBP per MET.18 increase in this measure, which has been shown to change
Thus, we can estimate a normal response to this 6MWT to with rehabilitation intervention.22
be achievement of an HR of ~92 and an SBP of ~150. Ms.
The modified CTSIB helped identify what sensory informa-
Arbor exceeded these values, suggesting she was in a decon-
tion Ms. Arbor used to maintain her balance while standing
ditioned state, which is not surprising given she reported a
still. Ms. Arbor had difficulty in all of the situations that
sedentary lifestyle.
126 Chapter 3
had reduced sensory input. These test results helped iden- Clinician Comment Ms. Arbor demonstrated
tify what activities might be challenging for her and also impairments in muscle performance that certainly may
allowed more specific tailoring of her balance training. For have affected her functional abilities. Her lower extremity
example, Ms. Arbor was unable to safely stand still with her strength may have contributed to her decreased balance
eyes closed, so she was questioned about her ability to stand and gait speed. While she did not complain of any problems
and wash her hair in the shower. Because this ADL was with activities that required upper extremity strength, it
risky for her, a shower chair was recommended so she could was important to include her arms in her resisted exercise
bathe in a more stable position. Ms. Arbor also demonstrat- program to improve the strength and physical reserve she
ed difficulty with dynamic balance in situations that had had for ADL.
reduced sensory input, such as walking with head turns.
Walking outside her home required Ms. Arbor to negoti-
ate uneven pavement and crowds, situations that decrease
Posture
the amount of accurate sensory information available.
Therefore, training in situations of reduced sensory input Ms. Arbor had a fixed thoracic kyphosis. Her protracted
was incorporated to address her deficits in these situations. scapulae and forward head were partially reversible.
A cutoff of 45/56 on the BBS has frequently been used to
identify if a person is at high risk of falling, but the use Clinician Comment Ms. Arbor was able to
of this scale in a dichotomous manner is not appropriate. achieve a more upright posture with cues, indicating a
Muir et al27 performed the first prospective study to deter- habitual change in posture that could be improved with
mine the predictive validity of the BBS and found that this physical therapy. However, she also had structural changes
cut-off to identify individuals who were going to fall had in her thoracic spine, and there was concern that her abnor-
poor sensitivity. There was some risk associated with all mal posture might indicate thoracic compression fractures
scores on the BBS. Shumway-Cook et al28 also identified associated with osteoporosis. According to the National
a gradient of risk in their study of the BBS. Based on the Osteoporosis Foundation, 55% of the people 50 years of age
model these investigators developed, Ms. Arbor’s score of and older have osteoporosis.35 It was suggested she follow
46, together with the fact that she had never fallen, sug- up with her PCP about the possibility of having a bone
gested that she had a 26% chance of falling. density test and taking medication if appropriate. Back
Though Ms. Arbor’s gait speed was normal for her age,29 it extensor strengthening exercises would improve her posture
did impair her ability to cross the street easily. The stop light and decrease her risk of compression fractures.36 A review
was not red long enough for her to reach the other side of the of proper body mechanics and suggestions about how to
road before it changed back to green. Her speed slowed with perform ADL without forward bending would be useful for
the addition of a cognitive or manual task, indicating dif- Ms. Arbor since spinal flexion has been shown to increase
ficulty walking with confidence and stability in dual-task the risk of compression fractures.37
conditions. These examination results identified additional
areas that needed to be addressed during physical therapy.
Ms. Arbor’s posture became more flexed with ongoing Range of Motion
ambulation, suggesting a muscle endurance impairment Normal ROM, 38-40 except right shoulder flexion
in her trunk and lower extremity extensors. This was = 112 degrees, left shoulder flexion = 118 degrees, bilateral
an important impairment to identify because decreased dorsiflexion = 0 degrees, hip extension = 0 degrees, all with
muscle endurance is not an age-related change,30,31 and is firm end feels. Ms. Arbor demonstrated decreased cervical
associated with falls in the elderly.6,32,33 and thoracic rotation bilaterally.
Muscle Performance (Strength With Clinician Comment Mecagni et al41 found

Manual Muscle Test)34 correlations between total active-assisted ROM of the ankle
and the Tinetti gait subscore. Beissner and colleagues42
• Right shoulder flexion and abduction 4/5, elbow flexion found lower extremity ROM was able to predict function as
and extension 4/5 measured by the Physical Performance Test in older adults
• Left shoulder flexion and abduction 4/5, elbow flexion living in assisted living or skilled nursing facilities. Thus,
and extension 4/5 there is support that Ms. Arbor’s loss of lower extremity
ROM might have contributed to her functional decline.
• Right hip flexion 4/5, hip extension 4/5, hip abduction
3+/5, knee extension 4/5, knee flexion 4/5, dorsiflexion Ms. Arbor’s decreased spinal and upper extremity ROM was
4/5, plantarflexion 3/5 also affecting her function and postural control. Because of
her loss of shoulder flexion and thoracic ROM, Ms. Arbor
• Left hip flexion 4/5, hip extension 3+/5, hip abduction
changed the way she reached for objects overhead. She
3+/5, knee extension 4/5, knee flexion 4/5, dorsiflexion
demonstrated increased reliance on lumbar extension,
4/5, plantarflexion 3/5
which increased her risk of losing her balance posteriorly. level that resulted in slight shortness of breath. Ms. Arbor
In addition, because she did not have the shoulder flexion had a decline in her VO2max due to her age as well as her
to reach high shelves, she sometimes climbed on a chair to sedentary lifestyle. As a result, the intensity of her walking
retrieve objects. This was a risky activity that might have may have caused her to work at a high enough percentage
caused her to fall. of her VO2max that it caused her to experience dyspnea.
Sensory Integrity
Ms. Arbor shows intact sensation to light touch through-
EVALUATION
out and impaired joint position sense at the 4th toe, but intact
at the ankle. Diagnosis
Clinician Comment Ms. Arbor’s propriocep- Practice Pattern
tion was assessed by her ability to sense displacements of Ms. Arbor’s subjective complaints and objective findings
her 4th toe.43 Grasping the digit on its sides, it was moved suggested 2 practice patterns:
up and down and randomly stopped in one of these direc- 1. Primary Prevention/Risk Reduction for Loss of
tions (ie, toe flexion or extension), then Ms. Arbor was Balance and Falling: Ms. Arbor’s major complaint was a
asked which position her toe was in. Though it is widely fear of falling. Her examination confirmed that she was
used in clinical practice, no studies were located that have at risk of falling and identified multiple impairments
examined the reliability or validity of this test. that contributed to her postural instability, including
This test was performed to identify an impairment that balance, muscle performance, posture, ROM, and sensa-
might be contributing to Ms. Arbor’s postural instability. tion. Of primary importance was establishing a compre-
Knowing that she had decreased proprioceptive input led hensive program to minimize her risk of falling.
to consideration of situations that might be challenging for 2. Impaired Aerobic Capacity/Endurance Associated
her. It was hypothesized that Ms. Arbor would be more reli- With Deconditioning: As identified on her 6MWT,
ant on her visual and vestibular senses for postural stability Ms. Arbor also had an aerobic capacity impairment that
because of this loss. Consequently, she might be more likely needed to be addressed. While this was not as urgent a
to lose her balance in situations where information from safety issue as her fall risk, it was affecting Ms. Arbor’s
these systems was reduced, such as walking in the dark. function and was important to address with an indepen-
Because this impairment would not improve with physical dent aerobic conditioning program.
therapy intervention, Ms. Arbor would have to compensate
for it. Consideration was given to having her use a cane International Classification of Functioning,
to provide sensory input through her upper extremity and Disability and Health Model of Disability
stability in the most challenging situations, such as walking See ICF Model on page 128.
on uneven sidewalks with many pedestrians. Ms. Arbor
understood the recommendation, but she feared it would
make her look old and decided not to use a cane at that
Prognosis
point. Research has shown exercise, balance, and gait training
to be effective interventions to reduce the risk of falling.44-46
This evidence, combined with the fact that Ms. Arbor had
Ventilation and Respiration/Gas Exchange few comorbidities and excellent motivation, led me to believe
Ms. Arbor’s breathing pattern showed no accessory mus- that she would reduce her risk of falls and improve her con-
cle use at rest or with activity. fidence with community activities with a comprehensive
Her breath sounds included few inspiratory crackles physical therapy program. Though Ms. Arbor had several
(basal segments of bilateral lower lobes) that did not change impairments that could not be changed (eg, fixed kyphosis,
with ambulation. proprioceptive loss), she also had the potential to improve
Blood O2 saturation (SpO2) = 92% to 93% at rest and with others with exercise (eg, strength, ROM). In addition to
ambulation exercise and balance training to address her physical per-
formance, I chose to explore community resources with Ms.
Arbor. Because of the environmental challenges in her com-
Clinician’s Comments Given the age-related munity, such as hills and busy urban streets, I felt Ms. Arbor
changes in the pulmonary system, these results are normal.
might need to modify her methods for completing IADL. For
There was no evidence of pulmonary pathology contribut-
this reason, I believed it was important to provide her infor-
ing to Ms. Arbor’s dyspnea on exertion. Rather, it seemed
mation on programs and services in her area that could help
that the speed at which Ms. Arbor walked on the 6MWT
her remain independent.
and in the community required energy expenditure at a
128 Chapter 3
ICF Model of Disablement for Ms. Arbor

Health Status
• Ms. Arbor reports mild memory deficits
• Borderline hypertension

Function
• Able to ambulate in her • Inability to easily and
• Decreased aerobic capacity building without difficulty confidently access the
• Decreased muscle • Fatigue and SOB with IADL community for IADLs such
performance as grocery shopping and
• Slow gait speed with dual
banking
• Impaired posture tasking
• Decreased sensory integrity • Poor control of transition
• Decreased balance from sit to stand
• Decreased ROM • Difficulty carrying grocery
bags
• Difficulty standing and
walking in situations of
decreased sensory input
(uneven terrain, head turns,
darkness)

• Age = 82 years • Lives alone in senior housing
• Fear of falling • Social activities are planned in her building
• Enjoys largely sedentary activities • Elevator access to her living unit
• Willing to exercise • Building is located on a slight hill
• Pursues sedentary social and recreational • Needs to navigate curb for vehicle access
activities • Flight of stairs to reach the train stop near her
home
Plan of Care INTERVENTION
Intervention
Therapeutic exercise to address muscle performance,
Coordination, Communication, and
aerobic capacity, flexibility, balance and gait training, and Documentation
patient education, all as detailed below.
The initial examination findings and plan of care were
Proposed Frequency and Duration of sent to Ms. Arbor’s PCP. In particular, her prehypertensive
Physical Therapy Visits BP and thoracic kyphosis were noted so that the doctor was
Twelve visits over the course of 6 weeks: 3 times per week aware of the abnormal findings that might require further
for 2 weeks, 2 times per week for 2 weeks, and then 1 time medical testing and pharmacological treatment.
per week for 2 weeks with a final check-in over the phone
1 month after that. Patient-/Client-Related Instruction
Anticipated Goals • Benefits of seeing an eye doctor yearly to ensure an up-
• Patient will be independent with a comprehensive home to-date eyewear prescription
exercise program with written instructions designed to • Available community resources to assist with IADL:
improve her aerobic capacity, balance, muscle perfor- community car service for older adults, grocery delivery,
mance, and flexibility so that she may perform her IADL Elder Services, homemaker agencies
with greater ease and safety (1 week to learn her initial
• Home modification to improve safety: increase lighting,
program and ongoing as her exercise prescription was
pick up throw rugs, minimize clutter, obtain night lights,
progressed.)
install grab bars in the bathroom
• Patient will demonstrate understanding of community
• Strategies to consider to improve safety: allow time for
resources available to her to allow her to remain liv-
visual accommodation when transitioning from areas
ing independently in the community (eg, community
with different brightness/lighting, wear sturdy, wide-
transportation options for older adults, grocery delivery,
soled shoes with good tread,47 do not get up if the train
Elder Services) (2 weeks).
is still moving, have cordless phone with her in the house
• Patient will demonstrate improved functional mobility to avoid rushing to answer the phone
and aerobic capacity on her 6MWT to allow her to per-
• Body mechanics focused on decreasing spinal flexion
form IADL with greater ease and less shortness of breath.
• Benefits of exercise and instruction in an exercise pro-
• Patient will have improved balance to increase safety
gram to continue indefinitely
with ADL as evidenced by a BBS score ≥ 51/56 (6 weeks).
• Patient will have a fast gait speed of 1.3 m/s to allow
her to cross the street safely before the light changes
Procedural Interventions
(4 weeks).
Therapeutic Exercise
• Patient will ambulate at ≥ 0.85 m/s while performing a
cognitive task to demonstrate improved ability to func- Strength and Power Training
tion in dual-task situations (4 weeks). Mode
• Patient will have decreased fear of falling as evidenced Strength and power training with body weight, elastic
by an ABC Scale score of 80% (4 weeks). bands, and hand weights for resistance
Intensity
Expected Outcomes (10 Weeks) One set of each of the exercises at the following intensities:
• Patient will be able to complete 2 trips per outing into • Week 1: ~40% to 60% 1-RM to ensure Ms. Arbor learned
the community (eg, bank and post office) to complete proper technique before increasing to the intensity
IADL without complaints of fear of falling or shortness needed for maximum strength gains. Ms. Arbor did not
of breath. perform 1-RM testing to prescribe the intensity of her
• Patient will be able to use the public car service for older exercise program. Instead, her intensity was estimated
adults to go to the grocery store and will walk in the by having her perform higher numbers of repetitions to
crowded environment while carrying groceries without fatigue. For example, Ms. Arbor performed wall slides
fear of falling. to a depth that caused her to have muscle fatigue and an
inability to continue after ~15 to 20 reps, which equates
Discharge Plan to < 60% 1-RM.18
Ms. Arbor will be discharged from physical therapy with a • Week 2: continue at 40% to 60% 1-RM.
home exercise program to continue on her own indefinitely.
130 Chapter 3
• Week 3: increase to 60% to 80% 1-RM. Her intensity was the resistance of the band and the duration that she
progressed by having her bend her knees further and held the position, and then by performing the exercise
hold the contraction longer. She performed the exercise in a standing position. This change provided greater
in a manner that allowed her to complete ~8 to 12 reps challenge to her balance and recruited more back and
before fatigue, which equates to 60% to 80% 1-RM, lower extremity muscles to stabilize her in standing. She
the intensity of the exercise desired to maximize her was instructed to ensure full retraction so that she also
strength gains safely.18,48 stretched her anterior chest wall with the exercise.
• Week 4: maintain 60% to 80 % 1-RM for strength train- • Elbow flexion and shoulder flexion exercises with hand-
ing. Add power training at 30% to 60% 1-RM. held weights
• Weeks 5 and 6: as described previously, adjusting the Flexibility Exercises
difficulty of the exercises as needed to maintain the Mode
desired training intensity.
Body position and light weight
Duration Intensity
Three seconds both for concentric and eccentric con- Slow progressive stretch to tolerance using either body or
tractions for strength training. One second for concentric lightweight resistance
contraction and 3-second eccentric contraction for power Duration
training.
3 repetitions with 60-second hold
Frequency
Frequency
Twice per week
Twice per week
• Wall slides: This exercise worked on Ms. Arbor’s lower
• Gastroc-soleus and hip flexor stretch while leaning for-
extremity extensor muscle strength, which was impor-
ward against the wall with her spine in neutral. Because
tant for functional activities such as sit-to-stand trans-
a 60-second stretch has been shown to be more effective
fers and negotiation of curbs. Wall slides allowed her
than a 30-second stretch to gain muscle length in older
to work on closed-chain, eccentric contractions as used
adults,49 Ms. Arbor was instructed to hold the stretch
during stand-to-sit transfers, a skill that was difficult for
initially for as long as tolerated, with the goal of increas-
Ms. Arbor to perform with control.
ing this time to 1 minute.
• Standing toe/heel raises: I chose this exercise because
• Supine shoulder flexion stretch: In supine, Ms. Arbor
ankle muscle strength contributes to balance and gait.
raised her arms above her head and slowly stretched
Ms. Arbor was instructed to hold very lightly onto a
them back toward the bed. After she was comfortable
counter or the back of a chair for support as she per-
with holding this position, she held a can of soup to pro-
formed the exercise. By minimizing the amount of upper
vide a slightly stronger stretch.
extremity support she used, this exercise also provided
some challenge to her balance. Initially, she was not able Aerobic Capacity Training
to lift her foot off of the floor during the toe raise portion Mode
of this exercise because of her decreased dorsiflexion Interval walking
ROM. The exercise was therefore performed with an Intensity
isometric contraction of her dorsiflexors. 5 to 6 on a 0-to-10 scale, where 0 is equivalent to sitting
• Bridging: To improve hip extensor and trunk strength, and 10 is all-out effort50
Ms. Arbor performed bridging. When she was able to Duration
perform 12 repetitions with good form and controlled, A total of 30 minutes per day, in bouts of at least 10 min-
smooth contractions, she progressed to doing single-leg utes each
bridges. Frequency
• Side lunges: In the clinic, Ms. Arbor performed side At least 5 times per week
stepping with an elastic band around her ankles. As she Description of the Intervention
had difficulty getting a band around her ankles indepen- She initially walked for 10 minutes, 3 times per day. She
dently, she modified this exercise when doing it at home. progressed to walking for 15 minutes at a time twice per day
She performed hip abduction in sitting with an elastic and eventually to one continuous 30-minute walk.
band around her thighs.
• Seated rowing with resistance from an elastic band: Clinician Comment While Ms. Arbor’s
This exercise focused on the recruitment and strength 6MWT distance ultimately may have been limited by her
of Ms. Arbor’s thoracic extensors. While seated, Ms. fear of falling with fast-paced walking, she did achieve
Arbor pulled back on an elastic band and held a posi- a HR that was 70% of her age-predicted HRmax, which
tion of scapular retraction. She progressed by increasing was an adequate intensity for aerobic capacity training.
• Walking while carrying an object and naming categories
Since she had never exercised before, it was safest for her
of objects (eg, words that begin with the letter “z”)
to begin at a moderate intensity. We had determined that
she could safely manage this workload during her exercise • All activities performed in a complex environment (eg,
test. The ACSM has defined moderate intensity as 5 to 6 on with people walking by)
a 0-to-10 scale that they recommend for use with older • Stair climbing with and without the railing
adults.50 Ms. Arbor used this as a guideline.
Clinician Comment Ms. Arbor’s balance pro-

Balance and Gait Training gram was designed to challenge her with tasks and situa-
tions that were difficult for her during her examination,
Mode
such as balancing on a narrow base of support, walking
Static and dynamic balance activities and gait training in dual-task situations, managing situations of reduced
with progressively harder challenges sensory input, and walking at a fast speed. Consideration
Intensity was also given to reported difficulties like negotiation of
Complexity and difficulty of activities progressed based uneven outdoor surfaces and management of crowded
on performance to continue to provide significant challenge environments. The program initially incorporated more
to her balance static activities performed without a secondary task and
Duration in simple environments. It was progressed by including
Twenty minutes performed during her first 10 physical more dynamic activities, adding cognitive and motor tasks
therapy sessions to perform during the balance activities, and eventually
Frequency increasing the complexity of the environment. Activities
3 times per week for 2 weeks, then 2 times per week for were included that required Ms. Arbor to perform more
2 weeks than one task at once, as it has been shown that dual-task
Description of the Intervention ability does not improve with single-task training.51
The balance and gait program initially included the
following:
• Static stance with a narrow base of support, performed
with eyes open and eyes closed REEXAMINATION
• Static stance on foam with eyes open and eyes closed
• Semi-tandem stance with head still and with horizontal
Subjective
and vertical head turns Ms. Arbor reported that she was able to walk with less
• Walking with a narrow base of support fear in the grocery store when she was carrying food and
managing crowded aisles. She had applied for the senior
• Stance while withstanding external nudges provided at
transportation service and was waiting for approval. She was
the sternum and hips from all directions
very excited with her progress.
Program progression included activities such as the
following:
Objective
• Standing and reaching for objects at all heights (includ-
ing from the floor) and in all directions Aerobic Capacity
• Standing while throwing and catching a ball 6MWT = 307 meters with a hemodynamic response and
• Walking and counting backwards by 3s dyspnea level similar to that seen on her initial examination.
• Walking while carrying a glass of water She felt that she could not cover more ground during the
6 minutes because of dyspnea on exertion.
• Walking with changing speed
• Walking in dim light and from bright to dark and dark
to bright spaces • ABC = 80%
• Walking with horizontal and vertical head turns • BBS = 52/56 m, which suggests a fall risk of 7.3%
Final progression of activities included the following: • Comfortable gait speed = 1.02 m/s
• Walking around and over obstacles without a secondary • Fast gait speed = 1.15 m/s
task, while carrying an object, and while performing • Gait speed with cognitive task = 0.90 m/s
basic arithmetic
• Carrying objects while walking on uneven surfaces and Range of Motion
while carrying weights • Right shoulder flexion = 138 degrees; left shoulder flex-
• Walking quickly with head turns ion = 136 degrees
132 Chapter 3
• Right ankle dorsiflexion = 10 degrees; left dorsiflexion
= 12 degrees OUTCOMES
• Hip extension = 10 degrees bilaterally
Discharge
Clinician Comment Ms. Arbor made good At the end of 10 weeks, Ms. Arbor had made clinically
progress with physical therapy intervention, demonstrating significant gains and had met all of the established program
gains in all areas. Her gains exceeded the minimal detect- goals. She increased her community mobility and overall
able change (the minimum amount of change that is not level of activity. In addition, she had identified community
due to measurement error) for those tests with established resources she could rely on to help her with her IADL, allow-
values (ie, 6MWT, BBS, and gait speed).51,52 This allowed ing her to avoid difficult and potentially risky trips into the
confidence that the improvement in her scores was a true community that might cause her to fall. Another important
change from her physical therapy intervention and not due outcome was that Ms. Arbor had become a regular exerciser
to error. and planned to continue her home exercise program for the
rest of her life with the goal of maximizing her function and
quality of life as she aged.
Assessment
Ms. Arbor’s balance, gait, and fear of falling had improved
significantly and she was accessing the community more
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SECTION II
PATHOPHYSIOLOGY OF
DECONDITIONING AND
PHYSIOLOGY OF TRAINING
Fatigue and Deconditioning
4
LeeAnne Carrothers, PT, PhD
- Growth Hormone Levels

CHAPTER OBJECTIVES - Sleep Cycles
• Compare and contrast the contribution(s) of anxiety and ▫ Assessing Depression
depression to fatigue. - History and Interview
• Discuss the effects of lifestyle and habits on sleep and - Screening Tools
fatigue.
- Common Presenting Signs
• List changes in the cardiovascular, respiratory, and mus-
▪ Anxiety Disorders
culoskeletal systems associated with bed rest and how
those changes affect response to upright positioning and ▫ Biological Events With Anxiety Disorders
exercise after cessation of bed rest. ▫ Common Presenting Symptoms
• Describe the effects of systemic illness on the perception ▪ Substance Abuse
of fatigue and tolerance to activity.
▪ Lifestyle Issues Associated with Fatigue
• Discuss the energy costs associated with living with a
▫ Sleep Habits/Hygiene
disability and how living long term with a disability
increases risk for fatigue. ▪ Summary of Fatigue
• Identify objective indicators of deconditioning during ◦ Fatigue Associated With Deconditioning
examination of patients at rest and in response to activ- ▪ Bed Rest, Zero Gravity, and Head-Down Bed Rest
ity. Research
• Distinguish between a normal response to exercise and ▫ Cardiovascular Changes
one that indicates that the patient is deconditioned, and
- Fluid Balance
make appropriate modifications to the exercise prescrip-
tion. - Loss of Red Blood Cell Mass
- Cardiovascular Pump Changes
- Alterations in Oxygen Uptake
CHAPTER OUTLINES ▫ Musculoskeletal Changes
• Fatigue ◦ Other Physiological Causes of Fatigue
◦ Psychological Causes ▪ Endocrine System
▪ Depressive Disorders ▫ Hypoglycemia
▫ System Changes With Depression That Lead ▫ Infection and Inflammation

to Fatigue ▫ Stress
- Cortisol ▫ Thyroid Disorders
- Thyroid Function ▪ Anemia
- 137 - Prescription for Movement-Related Disorders (pp 137-163).
© 2015 SLACK Incorporated.
138 Chapter 4
▪ Malnutrition causes and the mechanisms by which each contributes to
▪ Cancer fatigue.
▪ Respiratory Distress
Psychological Causes
▪ Renal Failure
▪ Chronic Obstructive Pulmonary Disease Depressive Disorders
▪ Aging With a Disability A 2008 study reported on the prevalence of depression
in the United States during the year 2006 based on answers
• Examination of Patients With Symptomatic Fatigue and
given by nearly 200,000 respondents to the Behavioral Risk
Signs of Deconditioning
Factor Surveillance Survey.11 The weighted prevalence of
◦ History lifetime experience of depressive disorder was nearly 16%
◦ Systems Review among respondents aged 18 years or older. Female prevalence
was 20.6%, which was approximately twice as high as the
◦ Tests and Measures
prevalence found among males (11%). Based on the results
◦ Diagnosis of this study, the authors hypothesized that from the year
▪ Deconditioning 2005 to 2050, the total number of US adults with depres-
sive disorder will increase from 33.9 million to 45.8 million,
◦ Prognosis
representing a 35% increase. The increase is projected to be
• References greater in the elderly population aged 65 years than in the
young population aged < 65 years.12
Approximately 80% of individuals with depression suf-
FATIGUE fer from sleep abnormalities, ranging from insomnia (most
common, with late insomnia or early-morning awakenings
Fatigue is a commonly presenting subjective complaint being most prevalent) to the less common hypersomnia.13
in primary care and community settings, with early studies Fatigue may be both a symptom of depression and a prognos-
reporting an adult prevalence of fatigue ranging from 6.7% tic indicator. Addington and colleagues, in a 13-year study
to 33%, depending on whether the survey was conducted in of community-dwelling adults, found that individuals who
primary care or community settings.1-5 It may account for reported unexplained fatigue at baseline and follow-up were
as many as 7 million visits to primary care providers per at significantly increased risk for the development of major
year in the United States.6 A 2007 telephone study of nearly depression when compared with those who had no such com-
29,000 US adults reported a fatigue prevalence of 37.9% in the plaints of fatigue.14
2 weeks preceding the study, accounting for a $136.4 billion Although the exact etiology of depression is still large-
loss of productive time.7 Further, the researchers reported ly unknown, abnormalities in effective use of the neu-
higher rates of fatigue for workers who were female, younger rotransmitters norepinephrine, dopamine, and serotonin in
than 50 years old, White (vs Black) and in well-paid jobs with depression are well documented. Decreased levels of these
decision-making responsibilities.7 stimulatory neurotransmitters or inability to effectively use
Defining fatigue can be difficult because of the variety of available adrenergic neurotransmitters are likely, or at least
nonspecific symptoms experienced by those who struggle partially, responsible for the fatigue symptoms associated
with it. Components of fatigue may include difficulty initiat- with depression. Theories about the role of biogenic amines
ing or maintaining previously tolerated activities, feelings of in depression have been generated, in part, from the obser-
exhaustion associated with usual activities, and/or mental vation that patients who took monoamine-oxidase inhibi-
fatigue that manifests itself as difficulty with concentration tors and tricyclic antidepressants demonstrated increased
and memory.8,9 Evans and Lambert, in their 2007 review of norepinephrine and serotonin at central adrenergic receptor
the physiological basis of fatigue, used the definition: “physi- sites in the limbic system and hypothalamus. Further, since
cal and/or mental weariness resulting from exertion, that is, depression-provoking drugs (such as Reserpine) deplete
an inability to continue exercise at the same intensity with biogenic amines at these sites, it was proposed that naturally
a resultant deterioration in performance.”10 Other compo- occurring depressions might be associated with a deficiency
nents of fatigue may include weakness, dyspnea, lethargy, of these substances.15 According to Nutt,16 dopamine in
and somnolence, though these may simply be symptoms particular may be important in the formation of learned
associated with fatigue. pleasurable outcomes. When presented with “normal social
Discerning the causes of fatigue can be daunting, as many interactions,” individuals with depression do not experience
conditions share fatigue as a principal symptom. To better the typical sense of reward from social interactions, as evi-
understand the patient’s complaints of fatigue, the clinician denced by dopamine deficiency in the nucleus accumbens.17
needs to consider the potential psychologic, lifestyle, and Further, the relative deficiency of dopamine may be due to
physical contributors. What follows is a description of these chronic stress, which “burns out” dopamine terminals in the
prefrontal cortex.16
Fatigue and Deconditioning 139
23
subjects had lower serum cortisol levels. These findings
System Changes With Depression
That Lead to Fatigue both support (cortisol) and contradict (growth hormone)
Cortisol previous studies on the neuroendocrine systems involved in
depression.
Cortisol, commonly referred to as the stress hormone,
may play an important role in the clinical manifestations of Sleep Cycles
depression. Transient exposure to increased levels of corti- The Diagnostic and Statistical Manual of Mental
sol/glucocorticoids plays an important role in the “fight or Conditions, Fourth Edition (Text Revision) (DSM-IV-TR)
flight” response and is responsible for such cognitive and defines circadian rhythm disorder as “a persistent or recur-
emotional functions as regulating energy levels, attention, rent pattern of sleep disruption leading to excessive sleepi-
and cognition. Chronic overexposure to cortisol (whether ness or insomnia that is due to a mismatch between the
due to endogenous or exogenous exposure), however, causes sleep-wake schedule required by a person’s environment and
many undesired responses, including detrimental effects on his or her circadian sleep-wake pattern.”24(p 629) Behavioral
arousal, attention, and memory.18 and lifestyle causes are the most likely causes for these
According to Thompson and Craighead, altered cortisol mismatches, including jet lag, work shift disturbances, and
secretion can be found in up to 80% of individuals with phase-delay disturbances (going to bed late and arising late).
depression.19 Individuals with elevated cortisol levels experi- Other causes for circadian rhythm disturbances may occur
ence depressive symptomatology and dysphoria (a state of because of changes in exposure to ambient light.
feeling “bad or unhappy”), and a tendency to form sad inter- Assessing Depression
pretations of events when compared to their nondepressed History and Interview
peers.18 Individuals with depression further experience alter- No medical or laboratory tests are currently in use that
ations in the hypothalamic-pituitary-adrenal (HPA) axis, definitively diagnose depression. However, laboratory tests
which leads to stimulation of adrenocorticotropic hormone are available that validate the neuroendocrine changes asso-
and thus abnormally increased cortisol release. Cortisol has ciated with depression (eg, Dexamethasone Suppression Test,
profound effects on many systems and has been demon- Corticotropin-Releasing Hormone Test, Serum Thyroxine
strated to alter mood, learning, and memory in the central Concentrations, Thyrotropin-Releasing Hormone Test).13
nervous system (CNS).18 Other cortisol-related findings in Diagnosis is made on the basis of history and interview.
depression include pituitary and adrenal gland hypertrophy Screening Tools
and elevated cerebrospinal fluid corticotropin-releasing fac- Several well-validated screening instruments are avail-
tor concentrations,20 possibly indicating abnormal function able, including the Beck Depression Inventory (a 21-item
of cortisol receptors in the hippocampus.15 self-report assessment of current depression)25,26 and the
Thyroid Function Geriatric Depression Scale (GDS).27 The GDS excludes
Impairments in the hypothalamic-pituitary thyroid sys- somatic complaints from the items for which it screens and is
tem have been documented in association with depression. able to distinguish symptoms caused by physical symptoms
Findings include elevated cerebrospinal fluid levels of thy- from depressive symptoms in older adults.15 The GDS has
roid-stimulating hormone (TSH), alterations in the thyroid- also been demonstrated to effectively screen for depression
stimulating response to thyrotropin-releasing hormone, and in individuals with Parkinson’s disease.28 Interestingly, indi-
abnormally high rates of anti-thyroid antibodies.20 Although viduals with fatigue that is psychogenic in nature demon-
abnormalities in thyroid function are well documented in strate no weakness. Tests of muscle strength and power are
individuals with depression, many of the symptoms of hypo- normal, as is muscle bulk and tendon reflex activity.29
thyroidism itself (eg, fatigue, weight gain, difficulty concen- Common Presenting Signs
trating, and memory disturbances)21 may mimic those of The DSM-IV-TR24 defines major depression as the pres-
depression, so screening for levels of thyroid hormones is an ence of 5 or more of the following symptoms during the
important step in the differential diagnosis of depression. same 2-week period that represents a significant change in
Growth Hormone Levels functioning. In addition, the symptoms are severe enough
People with depression have been demonstrated to to cause the patient distress and interfere with social, occu-
have a blunted release of growth hormone during sleep.15 pation, or other important functioning. Symptoms are as
Additionally, Birmaher et al demonstrated that children follows:
and adolescents at risk for major depressive disorder secrete • Depressed mood most of the day
significantly less (p = 0.007) growth hormone in response to
growth hormone-releasing hormone than their age-matched • Diminished interest or pleasure in activities (anhedonia)
low-risk peers. These abnormal levels of growth hormone may • Significant weight loss or weight gain (+ 5% total body
account for some of the fatigue experienced by individuals weight)
with depression and has been identified as a trait marker for • Change in sleep patterns (insomnia or hypersomnia)
depression.22 Interestingly, increased growth hormone levels
were associated with higher fatigue in individuals at least • Psychomotor retardation/agitation
1 year after traumatic brain injury, although brain-injured • Fatigue or loss of energy nearly every day
140 Chapter 4
• Feelings of worthless or excessive/inappropriate guilt 3. Difficulty concentrating
• Diminished ability to think or concentrate, or indeci- 4. Irritability
siveness 5. Muscle tension
• Recurrent thoughts of death or suicidal ideation 6. Sleep disturbance (difficulty falling or staying asleep, or
These symptoms in conjunction with the endocrine restless unsatisfying sleep)
abnormalities combine to produce a chronic feeling of Regardless of the cause, the sleep disturbances associated
exhaustion and lack of initiative to participate in physical with anxiety in combination with the inability to exercise at
activity. Individuals suffering from depression describe a levels that would both improve fitness and reduce anxiety
sometimes-paralyzing inertia, with even simple activities symptoms makes fatigue a difficult symptom to overcome.
requiring monumental energy. This sense of inertia, along
with the changes in sleep observed in depression, combine
Substance Abuse
to contribute to the fatigue associated with this disorder. Alcohol is often used as a form of self-medication to treat a
An additional factor, which may paradoxically contribute to variety of disorders, including insomnia, anxiety, or stress.32
fatigue associated with depression, is the use of antidepres- Abuse of alcohol may cause or result from sleep distur-
sant drugs.30 bances.33 It contributes to difficulties associated with sleep,
including decreased sleep duration and daytime sleepiness.34
Anxiety Disorders Alcohol is sometimes used as a means of getting to sleep
There are a number of anxiety disorders that share com- without realizing that it disrupts the normal sleep cycle.35
mon symptoms with the depressive disorders, as well as the Loss of sleep during a single night or multiple nights has been
pathophysiology related to excessive/abnormal sympathetic associated with fatigue. Alcohol dependence is frequently
activation. Theories regarding the development of anxiety associated with chronic insomnia, despite alcohol consump-
come from 2 opposite schools of thought. Strict biologi- tion at bedtime.32 Sleep induced by alcohol is typically
cal theorists believe that behavioral changes are a result of shorter and more fragmented than usual, especially toward
measurable biological events, while strict behaviorists argue the end of the night.32,35 Despite shortened overall duration,
that the measurable biological changes are the results of psy- rapid-eye movement (REM) sleep is increased in the second
chological events. While this presents a set-up for a “chicken half of the night.32,35 Frequent awakenings and vivid dreams
or egg” discussion, a discussion of the biological events may are common.32,35
provide the best explanation for the fatigue associated with Sleep disruptive symptoms may persist for many months,
anxiety disorders. even after the individual has stopped drinking.32 Acute with-
Biological Events With Anxiety Disorders drawal of alcohol or other sedatives can cause delayed onset
Increased sympathetic tone has been implicated as a cause of sleep and REM rebound with intermittent awakening
for symptoms in individuals with anxiety. According to during the night.32 Interestingly, drinking-related behaviors,
Retford, CNS anxiety precedes the peripheral manifestations heavy smoking (> 1 pack per day), and excess caffeine intake
of anxiety, including tachycardia, tachypnea, headache, and are also related to sleep disorders, specifically difficulty fall-
diarrhea.15 These manifestations of anxiety have been tied to ing asleep.32 Use of other stimulant (ie, sympathomimetic)
an overall increase in sympathetic tone. Neurotransmitters drugs is also associated with decreased total sleep time and a
associated with anxiety include norepinephrine, serotonin, reduction of non-REM sleep.32 The fact that disordered sleep
and gamma-aminobutyric acid. At a cellular level, individu- is associated both with depressant and stimulant substances
als with chronic anxiety have increased levels of lactic acid is a demonstration of the fragility of the sleep cycle, and that
both at rest and with exercise. The increased levels associated use of such substances should be considered in moderation,
with anxiety make the exercise that is necessary to maintain/ especially for the individual who is experiencing difficulty
improve fitness levels and ameliorate fatigue impossible.31 falling or staying asleep.
Common Presenting Symptoms Lifestyle Issues Associated With Fatigue

Fatigue is a central feature of most anxiety disorders, Sleep Habits/Hygiene
presumably due to the extreme amounts of energy spent in Fatigue may be due to causes as simple to deal with as
apprehension and worry. The DSM-IV-TR24 describes the behavioral habits related to sleep. Sleep changes are normal
symptoms of generalized anxiety disorder as follows: with aging (decreased stages 3 and 4 sleep with increased
• Excessive anxiety and worry periods of wakefulness),36 but in younger adults, fatigue
• Difficulty controlling the worry due to sleeplessness can often be mitigated with relatively
The anxiety/worry are associated with 3 or more of the simple behavioral changes. Suggestions for increasing the
following 6 symptoms (with at least some symptoms present likelihood of restful sleep adapted from the National Sleep
for more days than not for at least 6 months): Foundation37 include the following:
1. Restlessness/feeling “keyed up” or on edge • Avoid stimulating substances (caffeine, nicotine, or
other stimulants) in the evenings, or altogether if pos-
2. Being easily fatigued
sible.
• Save the use of one’s bed for sleep or sex; avoid watching 38
an obvious deterioration.” Some of the first research stud-
TV, reading, or listening to the radio. ies into the harmful effects of bed rest were conducted in the
• Avoid large meals right before bedtime; if spicy foods are first half of the 20th century, as researchers noted bone loss
irritating, avoid those altogether. in individuals confined to bed rest as a treatment for acute
poliomyelitis. Dietrick et al confined 30 healthy medical
• Avoid napping during the day. students to bed rest and documented that simple bed rest, in
• Attempt to maintain regular exposure to natural day- the absence of pathology, was linked to loss of bone density
light—it helps to maintain normal sleep-wake cycles. and increased calcium excretion.39 World War II physicians
• Regular exercise is important, although vigorous exer- noted that soldiers who returned to activity sooner after
cise in the evenings (especially before bedtime) should surgery or injury recovered faster than those who remained
be avoided. in bed to recover,40 thus hastening a return to community
activity and life roles.
• A relaxing pre-bedtime routine should be established Eventually, with the initiation of manned spaceflight in
(by performing activities such as deep breathing or 1961 and previously undocumented effects of micrograv-
yoga), but stressful conversations should be avoided ity on astronauts, another application evolved for bed rest
around bedtime. research. While the use of bed rest as a therapeutic interven-
Summary of Fatigue tion waned in the late 20th century, bed rest studies were
continued as a means of documenting the effects of zero-
Given the prevalence and costs associated with the con-
gravity conditions experienced in spaceflight on human
ditions listed previously, significant numbers of Americans
anatomy and physiology. Further, these studies had clinical
are affected by these disorders at a huge cost to productivity
application to the effects of prolonged bed rest as a result
and health. The impairments associated with these disorders
of illness or injury. Cosmonauts returning from prolonged
either prevent individuals from being able to participate in
space missions in the early 1970s complained of difficulty
exercise or render them incapable of overcoming the inertia
sleeping in a horizontal position because of the perception of
that limits their ability to participate in many life activi-
sliding off of the foot of the bed. They attempted to correct
ties, including exercise. As a result, they are additionally at
this sensation by raising the foot of the bed a little at a time
significant risk for the deconditioning related to a sedentary
until staying in the horizontal position for sleep felt “nor-
lifestyle and its related comorbidities.
mal” again. The Russian researchers observed the behaviors
of the cosmonauts and hypothesized that lying with their
Fatigue Associated With heads down more accurately replicated what it “felt like to be
Deconditioning in space.”40 This led to the question of whether head-down
bed rest (HDBR) more accurately replicated the zero-gravity
Individuals who are deconditioned have greater fuel needs environment experienced in space. Several studies were con-
for all activities when compared with those who are better ducted to answer this question, and HDBR with the head of
trained. In other words, people who are deconditioned will the bed down 6 degrees was subsequently validated as the
burn more oxygen (O2) per metabolic equivalent of activity best simulation of microgravity.40,41 Because of the similar-
than their more highly trained/conditioned counterparts. ity of these 2 scenarios (HDBR and the microgravity expe-
One consequence of the increased fuel requirements for rienced in spaceflight), evidence from both types of studies
daily activities is the perception of activity being more dif- will be included in this review. A summary of the changes
ficult than usual. Additionally, individuals who are decon- experienced after bed rest and spaceflight can be seen in
ditioned will report a higher rate of fatigue after completing Figure 4-1.
relatively low-level activities because of the higher energy One criticism of the research conducted on the effects of
requirements for completing these tasks. This section will bed rest and/or spaceflight on human physiology is that the
explore the various physiologic mechanisms responsible for studies have small numbers of subjects, and that there are
the increase in fuel expenditure, and thus fatigue, associated only a few studies that demonstrate the effects of long-term
with deconditioning. bed rest or spaceflight. Nicogossian et al, in a summary of
Bed Rest, Zero Gravity, and Head-Down overall physiologic changes observed after spaceflight, stated
that by 1993, only 283 individuals had traveled into space
Bed Rest Research (see Figure 4-1).42 Ethical considerations limited both the
Bed rest has evolved from being perceived as a healing numbers of subjects and the duration of studies because
intervention to the cause and risk for myriad pathologies, from the early days of the studies, it was known that bed rest
ranging from systemic to cellular. With bed rest, decon- and spaceflight caused deleterious changes in the subjects.
ditioning happens. These detrimental effects of bed rest are These studies were difficult logistically as well because of the
well documented, although the most prolific research into constraints of spaceflight and mandatory bed rest. In sup-
the topic has occurred in the last 50 years. Even Hippocrates port of this body of research, however, the results reported
commented on the subject: “Should a long period of inactiv- have been eminently repeatable, as proven by more than
ity be followed by a sudden return to exercise, there will be 40 years of studies reporting similar results. Studies that have
142 Chapter 4
Figure 4-1. Physiologic changes associated with
weightlessness. (Reprinted with permission from
Nicogossian A, Sawn C, Huntoon C. Overall physi-
ologic response to spaceflight. In: Nicogossian
A, Huntoon C, Pool S, eds. Space Physiology and
Medicine. 3rd ed. Philadelphia, PA: Lea & Febiger;
1994.)
investigated the impact of HDBR have provided significant Early bedrest results in rapid diuresis with marked loss of
insight not only into the effects of space travel on human sodium and potassium.53 With prolonged bed rest (up to
physiology, but also extended and refined essential studies 80 days), overall plasma volume has been demonstrated to
into the harmful effects of immobility and thus bed rest on decrease as much as 21%.49 Women have been demonstrated
the cardiovascular, pulmonary, and musculoskeletal systems. to experience greater losses in plasma volume after short-
Cardiovascular Changes term spaceflights (5- to 16-day missions) than their male
counterparts (19.5 vs 7% [p = 0.001]),54 a factor that likely
The main physiologic effect of bed rest on the cardiovas-
contributes to the increased orthostatic intolerance observed
cular system is orthostatic intolerance,43,44 or the inability to
in women vs men. When diuresis occurs, a new hemody-
maintain adequate blood pressure (BP)/perfusion during the
namic steady state occurs, with a “resetting of aortic and
shift to or maintenance of the upright position after being
carotid baroreceptors”55,56 that causes further decreases in
horizontal. Orthostatic intolerance after bed rest occurs from
SV and cardiac output (CO) in response to diuresis-induced
changes in fluid balance, loss of red blood cell (RBC) mass,
hypovolemia. Perhonen et al demonstrated decreases in SV
and changes in the cardiac structure itself.
and CO after as little as 2 weeks of bed rest from 110 ± 20 to
Fluid Balance 83 ± 11 mL/min (p = 0.02) and 7.1 ± 0.7 to 5.9 ± 0.2 L/min
Immediate changes resulting from assumption of the bed (p = 0.0009), respectively.44 Further significant changes were
rest position or subsequent to spaceflight include a fluid shift not measured with up to an additional 10 weeks (for a total
from the lower extremities (LEs) to the thorax, with a change of 12 weeks) of bed rest.
in thoracic fluid volume of ~1 liter, with acute increases in Loss of Red Blood Cell Mass
right and left ventricular filling pressures.45,46 This occurs
In a 1981 summary of changes experienced as a result of
as the shift of fluid into the central vasculature from the LEs
96-day and 140-day spaceflights, Cogoli documented losses
outpaces the ability of the upper extremity capillaries to filter
of RBC up to 21% and hemoglobin (Hgb) decreases of up to
the fluid, redistributing the blood into the central circula-
33%.57 Losses of RBC mass have been shown within 2 weeks
tion.47-49 The initial fluid shift results in a transient increase
of bed rest,47,50,58 and continue on a linear basis (% change
in preload from increased plasma volume.48 As a result of the
RBC mass = 0.89 + 0.24 × bed rest days)59 for up to 60 days
increase in preload, there is a transient increase in stroke vol-
and beyond.50 Losses of 10% to 15% are seen consistently
ume (SV) with an accompanying decrease in heart rate (HR)
after spaceflight and/or bed rest; recovery to preflight levels
and total peripheral resistance due to Starling mechanisms
of RBC takes up to 4 to 6 weeks.60
and stimulation of carotid and aortic baroreceptors, respec-
The etiology of RBC loss is not completely understood,
tively.50,51 SV increases in this immediate period have been
though loss of RBC mass via inhibition of RBC formation
measured as high as 9.2% after only 6.5 hours.52
seems to be the most likely explanation.50,60 Several studies
After this initial response, the increase in preload results in
have proposed possible explanations for the decrease in RBC,
increased cardiac filling and a transient rise in central venous
including a drop in erythropoietin (EPO) levels,61 changes
pressure, which stimulates neural and hormonal responses
in bone marrow response to EPO,60 inadequate nutritional
supporting a significant diuresis, with increased urine out-
intake and decreases in lean body mass,62 and decondition-
put and sodium and potassium excretion (Table 4-1).40
ing and decreased O2 demand.63
TABLE 4-1. PHYSIOLOGIC CHANGES ASSOCIATED WITH SPACEFLIGHT AND HEAD-DOWN BED REST
SPACE HEAD-DOWN BED REST
Height ↑ ± 1.0 cm ↑ ± 1.0 cm
Body mass/weight ↓ 3% to 4% ↓ 3% to 4%
Maximum O2 consumption (VO2max) Not measured ↓ 25%
Plasma volume ↓ 10% to 15% ↓ 10% to 15%
Urinary calcium Increases Increases
Bone density ↓ 1.6%/month ↓ 0.5% to 1.0%/month
Absorption of calcium from the gut Decreases Decreases
Risk for renal stones Increases Increases
Muscle mass Decreases Decreases
Muscle strength Decreases Decreases
Insulin resistance Increases Increases
Adapted from Fortney S, Schneider V, Greenleaf J. The physiology of bedrest. In: Handbook of Physiology. New York: Oxford University
Press; 1996:899-939.
Drops in EPO levels are linked to the hemoconcentra- Changes in cardiac size have also been observed in bed
tion (increased hematocrit) that occurs with diuresis/plasma rest and spaceflight studies. During the first 24 hours of bed
volume losses associated with bed rest,50 while other stud- rest, the shift to the head down position increases the left-
ies posit that RBC loss is the result of changes in the bone ventricular end-diastolic volume (LVEDV; ie, the volume of
marrow response to EPO that is caused by bone deminer- the LV at its fullest).66,67 The increase in LVEDV is an indi-
alization and negative calcium balance.60 Others suggest cation of increased overall chamber volumes and reflects the
that inadequate caloric or protein intake during bed rest/ increased preload experienced with the shift to horizontal
spaceflight may be the primary cause for suppression of position. Interestingly, increases in preload reach their high-
erythropoesis.62 Finally, decreases in O2 demand that occur est levels with the assumption of a horizontal position—no
with deconditioning are thought to be responsible for loss of further increases in preload are observed after a shift to
RBC with bed rest—this was confirmed by Greenleaf et al 6 degrees of HDBR.64
in 1992, who established that, with the addition of aerobic After prolonged bed rest and short-term spaceflight,
(vs isokinetic) exercise, RBC mass was maintained despite cardiac size decreases have been demonstrated in animal
30 days of 6-degree HDBR.63 Regardless of cause, EPO lev- and human models. Studies of rodents have demonstrated a
els return to normal levels within 2 weeks after cessation of decrease in cardiac myocyte size, which is indicative of cardi-
spaceflight/bed rest.61 ac atrophy after as little as 14 days of bed rest.43,44 Total myo-
Cardiovascular Pump Changes cardial protein losses of 9% and 18% have been documented
Changes in cardiac function associated with bed rest after rat immobilization durations of 30 and 100 days.68
occur in 3 distinct phases.64 In the first 24 hours after Decreases in size and number of rat cardiac mitochondria
assumption of the supine/HDBR position or initiation of have also been observed during prolonged bed rest,69 while
spaceflight, the change in pressure that results from the losses of 23% of total cardiac mass have been observed in as
shift to a horizontal position causes transient increases little as 20 days of immobilization.64,68
in cardiac filling pressures (venous return) and SV due to Human studies have revealed similar changes. In a study
Starling mechanisms.51,65 Over the next 24 to 48 hours, comparing the effects of spaceflight and bed rest, Perhonen
increased pressures on carotid and aortic baroreceptors and et al70 noted that LV mass decreased by 8.0 ± 2.2% (p = 0.005)
an increase in plasma rennin activity52 stimulates diuresis40; after 6 weeks of bed rest. No significant differences in LV
the resultant hypovolemia effects a decrease in SV and CO.50 mass existed in controls over the same time period. Control
As bed rest persists, a third stage emerges in which there is subjects were “freely ambulatory” and performed their usual
a continued drop in CO and SV that results from overall occupational and recreational activities. After 10 days of
decreased O2 demand and decrements in active lean muscle spaceflight, LV mass decreased by 12.0 ± 6.9% (p = 0.07).44
mass; decreases in circulating blood volume and shifts in cir- Cardiac atrophy and impaired compliance lead to a reduction
culation as an accommodation to the headward shift in blood in SV and orthostatic intolerance.43,70 These changes occur
volume contribute to the decreases in CO and SV as well.50 as a result of ventricular remodeling and not as a result of
hypovolemia alone.70 Further, no significant differences exist
144 Chapter 4
between men and women with regard to cardiac atrophy Musculoskeletal Changes
experienced after bed rest,71 but women tend to suffer from Several bed rest studies conducted by Americans and
more severe orthostatic intolerance after bed rest. Possible Russians demonstrate a dose-response relationship between
explanations for this gender difference include a desen- the duration of bed rest and the resulting loss of muscle
sitization of beta-adrenergic receptors with bed rest,72,73 strength.84,85 Zhang et al described the process of atrophy
decreased cardiac filling,74 decreases in SV,74 low vascular that occurs because of bed rest, denervation, hindlimb
resistance,54 and gender-specific differences in ventricular unloading, immobilization, or microgravity as a “high-
size and distensibility.74 ly ordered and regulated process, which is characterized
Perhonen et al70 set out to determine if observed reduc- by decreased fiber cross-sectional area (CSA) and protein
tions in SV were due to changes stimulated by bed rest or content, reduced force, increased fatigability, and insulin
due to the influence of hypovolemia alone. To that end, LV resistance.”86(p 310) Further, unlike in illness states, disuse
volume and Starling curves were analyzed after 2 weeks of atrophy begins with a “decrease in muscle contractile activity
HDBR and administration of intravenous furosemide. Both and muscle tension rather than by inflammatory cytokines”
interventions led to similar reductions in plasma volume, but and results in a conversion from slow- to fast-twitch muscle
SV was reduced more and Starling curves were steeper dur- fiber types, which predominantly affect anti-gravity muscles
ing orthostatic stress after HDBR. Further, a 20% decrease in when studied in animal models.86 Dietrick et al, in a study
LVEDV was observed in the HDBR group, as compared with of bed rest with added LE immobilization in waist-to-toe
a 7% decrease with hypovolemia alone, leading the authors to casts, documented an increase in urinary nitrogen excretion
conclude that HDBR leads to ventricular remodeling that is (reflecting protein degradation/muscle loss) that peaked at
not seen after hypovolemia alone.70 2 weeks of bed rest at 20% to 43% above baseline.39 Other
Alterations in Oxygen Uptake studies have replicated the observation of losses in lean body
Decreases in exercise tolerance after bed rest/spaceflight mass in as few as 14 days.87-89 Tissue losses in these studies
have been observed in a number of studies75-79 that identify were associated with decreases in overall protein synthe-
there is a greater sensation of fatigue, or subjects having to sis88,89 and decreases of peak torque of up to 18% to 20%.90
work harder to get less work done. The degree of reduction Tests of disuse include unilateral limb suspension. Hather
in maximum O2 consumption (VO2max) is directly related el al reported losses of 7% and 14% of muscle CSA at mid-
to the duration of bed rest and pre-bed rest level of aerobic thigh vs no change reported in the contralateral (control)
conditioning, but it seems to be independent of age or gen- limb after 4 and 6 weeks, respectively.91 Losses of muscle
der.75,76,80 Convertino initially proposed that there is a linear mass were greater in the anti-gravity muscles (ie, gastrocne-
decrease in VO2max with bed rest75 and projected that loss to mius and soleus and vastus medialis, oblique, and lateralis)
be ~1%/day. Such a loss would result in a VO2max of 0 after than in their corresponding antagonists (tibialis anterior
100 days of bed rest, which does not occur. Capelli and col- and hamstrings, respectively).91 This preferential atrophy
leagues demonstrated that in a 90-day period of bed rest, of extensor muscles has been extensively documented else-
most of the decline in VO2max occurs in the first 14 days of where.92-94 Hides et al demonstrated a significant loss of
bed rest and then decreases at a progressive but slower rate CSA in the multifidus muscle after 8 weeks of bed rest, with
toward the 90th day.81 Feretti et al demonstrated that bed significant losses noted as early as 2 weeks into the period
rest-associated decreases in VO2max result from concurrent of bed rest. At the same time, anterior abdominal muscles
actions of 2 factors: a decrease in cardiovascular O2 transport increased in CSA, demonstrating a possible overuse of the
and a decrease in muscle oxidative capacity that accompanies trunk flexors during bed rest.87 In studies of individuals
bed rest-related decreases in muscle mass.77 Decreases in with low-back pain, the evidence points to a selective atrophy
VO2max cause the individual to experience fatigue and/or of the multifidus muscle when compared to the psoas and
breathlessness when performing skills that were well toler- erector spinae muscles.95 The similar pattern of atrophy pro-
ated before the decline in conditioning. The symptoms expe- duced by bed rest may produce conditions in which bed rest
rienced are a reflection of the increased fuel cost of activities. makes the individual confined to bed rest more susceptible
Further analysis of bed rest studies of up to 128 days led to the development of low-back pain.
Capelli and colleagues to hypothesize that the time required Other studies demonstrate that the predominant and
for bed rest-related VO2max changes consists of at least most significant losses of skeletal muscle associated with
2 components: fast changes related to losses in cardiovas- bed rest/immobilization occur in the LE vs upper extremi-
cular transport and slower changes related to the decreases ties.96 A study of Mir crew members on 4- to 6-month mis-
in peripheral muscle oxidative potential.81 Changes in CO sions showed decreases of ~15% in LE and back muscles.
were reported in as early as 1968 by Saltin et al.82 Subsequent Greatest losses of muscle mass were observed in the lower
studies have demonstrated that HDBR impairs carotid baro- leg muscles.93
reflexes,55 decreases resting blood catecholamine concen- Older individuals are particularly susceptible to the
trations,83 and reduces blood Hgb concentration despite changes caused by bed rest/immobilization, a reflection of
reduced plasma volume.47 These collective changes may in the lowered physiologic reserve associated with aging. In
fact explain the reduced CO at any given exercise intensity a 2007 study of 10 days’ bed rest in 12 healthy older adults
after as little as 15 days of bed rest. (> 65 years old), Kortebein et al demonstrated significant
decreases in protein synthesis, lean body mass both overall Hypoglycemia
and in the LEs, and loss of isokinetic LE strength.90 The older Hypoglycemia most frequently results from taking hypo-
adults showed a 6.3% loss in LE lean body mass (p = 0.001) glycemic medications or other drugs, including alcohol. It is
after only 10 days of bed rest,90 which was a greater loss than also associated with a number of other disorders, including
that experienced by younger adults in a 2004 study after sepsis, end-stage organ failure, endocrine disorders, and
28 days of bed rest.97 The sometimes deadly results associ- inherited metabolic disorders. Sometimes hypoglycemia is
ated with bed rest and deconditioning for this at-risk age defined as plasma glucose level < 2.5 to 2.8 mmol/L (< 45 to
group is reflected in the 2006 report of mortality associated 50 mg/dL), but laboratory thresholds for hypoglycemia vary
with hip fracture in 606 elderly Brazilian women. The risk for considerably depending on the setting. The presence of
mortality was 21% in the first year.98 Whipple’s triad, therefore, provides an important reference
Vernikos-Danelli et al documented increases in plasma point for diagnosis. Whipple’s triad includes the following
glucose levels for the first 30 days of a 56-day bed rest study characteristics: “symptoms compatible with hypoglycemia, a
of 5 healthy young men, while glucose levels remained low plasma or blood glucose concentration, and resolution of
unchanged.99 Stuart et al demonstrated that only 6 to 7 days those symptoms after the glucose concentration is raised to
of bed rest were enough to impair muscle ability to use normal.”107(p 1904) Symptoms can be split into 2 categories:
glucose and that this insulin resistance occurs primarily in those that result from CNS neuronal glucose deprivation
skeletal muscle.100 This finding was further corroborated by and those that are autonomic responses. CNS deprivation
Blanc et al, who reported increased insulin-to-glucose levels of glucose results in symptoms of confusion, fatigue, behav-
after only 6 days of HDBR.101 ioral changes, seizures, loss of consciousness, and, ultimately,
Decreases in bone density associated with bed rest/immo- death. Autonomic symptoms include palpitations, tremor,
bility occur because of several factors, including loss of usual and anxiety (which are triggered by adrenergic activation)
weightbearing forces, decreases in longitudinal compression, as well as cholinergic symptoms (eg, hunger, perspiration,
and loss/decrease of muscle contractions, particularly con- and paresthesia). HR and systolic BP (SBP) are typically
tractions of postural muscles used in normal gravity. Losses elevated in hypoglycemia, but these findings may not be
of bone density are dose-dependent (ie, longer periods of prominent.107
spaceflight/bed rest result in greater losses of bone density).42
Infection and Inflammation
Bone density is spared in the upper extremities during bed
rest or immobilization,102,103 with 97% of bone loss originat- Inflammatory and infectious disorders have potent effects
ing in the LEs and pelvis.93 Specific losses of bone density on metabolism and create potential for fatigue. A wide spec-
are most significant in long bones, lumbar vertebrae, and the trum of microorganisms, when present in the bloodstream,
calcaneus with bed rest. induces the synthesis and release of pyrogenic (fever-caus-
ing) cytokines. Cytokines regulate immune, inflammatory,
Objective indicators of bone loss, such as urinary calcium
and hematopoietic processes. The increase in white blood
and other bone resorption markers, are increased in as little
cell count seen in infections with an associated increase in
as 4 to 7 days after the initiation of bed rest.104-106 Further,
the proportion of neutrophils, for example, is the result of the
a 2007 review of skeletal responses to spaceflight indicates
cytokines interleukin (IL) 1 and IL-6. The pyrogenic cyto-
that the evidence thus far suggests that complete recovery of
kines include IL-1, IL-6, tumor necrosis factor, ciliary neuro-
bone mineral density may require between 1 to 3 years after
trophic factor, and interferon. Each cytokine is encoded by a
bed rest or spaceflight.96 Bone density changes with bed rest
separate gene, and each pyrogenic cytokine has been shown
are not fully reversed after 6 months of a return to normal
to cause fever in laboratory animals and in humans.108
weightbearing activity.94 In a study investigating potential
Levels of proinflammatory cytokines have been associated
mitigating factors, LeBlanc et al demonstrated that daily
with several disorders with fatigue as an important symp-
doses of alendronate during 17 weeks of bed rest minimized
tom, including depression, chronic fatigue syndrome, and
most of the bone loss changes typically produced by bed
fibromyalgia.109-111 This may also account, in part, for the
rest.102
presence of fatigue as a symptom in a variety of autoimmune
The musculoskeletal alterations described previously pro-
disorders, including rheumatoid arthritis, multiple sclerosis,
duce an individual with decreased muscle strength, fuel
and systemic lupus erythematosus.112
utilization, and endurance following even a short period of
Fever, however, can be a manifestation of disease in the
bed rest.
absence of microbial infection. Inflammatory processes,
trauma, tissue necrosis, or antigen-antibody complexes can
Other Physiological Causes of Fatigue induce the production of cytokines, which—individually
or in combination—trigger the hypothalamus to raise body
Endocrine System temperature to febrile levels.108 Regardless of whether fever
Endocrine system pathologies result in a wide variety of is caused by systemic inflammation or infection caused by
symptoms, as the impact of dysfunction in hormone balance a pyrogenic organism, each 1°C rise in body temperature
and function can be detrimental to a number of systems. increases basal metabolic rate by 14%,108,113 increasing the
energy demand for any given task.
146 Chapter 4
Figure 4-2. Physiologic changes associated with chronic
stress.
Stress has been associated with increased immune and inflam-

In 1976, Hans Selye attempted to introduce the concept of matory responses, also demonstrated to be contributors to
stress into physiology, when he defined stress simply as “the fatigue.116,117 Autonomic dysregulation in the presence of
rate of wear and tear in the body” and more rigorously as chronic stress, characterized by increases in resting and exer-
“the state manifested by a specific syndrome which consists cise HRs and/or reduced HR variability, may also account
of all the nonspecifically induced changes within a biologi- for immune system hyperactivity and resultant fatigue.112
cal system.”114 A more recent definition by Christiansen that Finally, excess stress or the inability to handle the challenges
reflects today’s understanding of the complex interplay of a stressful life has been linked to depression, anxiety, and
between an individual and his or her environment states, coronary artery disease (CAD), each of which has the ability
to contribute to the development of fatigue.
Stress is a process of interchange between an organ-
ism and its environment that involves self-generated Thyroid Disorders
or environmentally induced changes that, once they Hypothyroidism is a common endocrine dysfunction—it
are perceived by the organism as exceeding available affects more than 1% of the general population and about
resources (internal or external), disrupt homeostatic 5% of individuals aged 60 years and older. Primary symp-
processes in the organism-environment system.115 toms include weakness, cold intolerance, fatigue, constipa-
This disruption in processes has physiologic consequenc- tion, weight gain, depression, menorrhagia, and hoarseness.
es; 2 main physiologic processes occur in the face of stress: Laboratory findings associated with hypothyroidism include
autonomic hyperreactivity and immunosuppression. low levels of thyroid hormone (T4) and radioactive iodine
uptake, anemia, and elevated TSH. Other objective findings
The neuroendocrine (autonomic and HPA axis) systems,
include the presence of a goiter (enlarged thyroid), dry skin,
when activated in response to short-term stress, ensure
bradycardia, and decreased deep tendon reflexes.118
that energy substrates are available to meet the increased
metabolic demands of the individual. When an individual is An excess of thyroid hormones causes hyperthyroid-
faced with chronic stress, however, chronic activation of the ism. Common causes include a toxic diffuse goiter (Graves’
“stress response” can have a deleterious effect on a number disease), thyroiditis, iodine-induced hyperthyroidism, over-
of systems. Prolonged duration and amplified magnitude of secretion of pituitary TSH, and excess exogenous thyroid
these activities, however, may lead to erosion of lean body hormone. Presenting symptoms include tremor, palpitations,
mass and tissue injury (Figure 4-2) as well as dysregulation of weight loss, dyspnea on exertion, difficulty concentrating,
immune regulatory responses via the HPA axis.112 This dys- bowel irritation/diarrhea, and fatigue. Objective physical
regulation, characterized by a decrease in cortisol secretion, exam findings include tachycardia and elevated BP (increase
in SBP > diastolic BP [DBP]), muscle weakness, resting trem- they can occur as a result of inadequate intake or increased
or, and cardiac arrhythmias (eg, atrial fibrillation) on elec- metabolic demand. Criteria for diagnosis of malnutrition
trocardiogram (EKG). Laboratory tests for hyperthyroid includes the presence of one or more of the following criteria:
include screening for free T4 levels, thyroid antibodies, or • Unintentional loss of ~10% of usual body weight in the
thyroid-stimulating immunoglobulins.119 preceding 3 months
Both hypo- and hyperthyroid conditions have a negative
• Body weight < 90% of ideal for height
impact on skeletal muscle, known as thyroid myopathies. The
exact etiology of the effect on muscle is as of yet unknown. • Body mass index (BMI; weight [kg] divided by height
Research to date demonstrates that thyroxine interferes with [m2]) < 18.5
contraction but does not affect transmission of impulses Severity is classified according to body weight: body
in the peripheral nerve along the sarcolemma or across the weight < 90% of ideal for height represents risk for malnutri-
myoneural junction. In hyperthyroidism, the changes in tion, < 85% of ideal constitutes malnutrition, < 70% of ideal
muscle augment the speed of the contractile process and slow represents severe malnutrition, and < 60% of ideal is typically
its duration, with resultant fatigability, weakness, and dimin- incompatible with survival. Although fatigue is not specifi-
ished endurance. Conversely, in hypothyroidism, muscle cally named as a complication of malnutrition, the term fail-
contraction and relaxation are slowed.120 ure to thrive is used to describe a constellation of symptoms
including weakness, progressive functional decline, and
Anemia
weight loss. There is typically a triggering event, such as a
Defined as a reduction in circulating RBCs, anemia is loss of social support, a bout of an acute illness, or the addi-
clinically measured as reduction in RBC count, Hgb concen- tion of a new medication.131 This event may serves as a pre-
tration, or hematocrit. Hgb concentration is measured as the cursor to a major loss of function for the elderly individual,
concentration of O2-carrying pigment in whole blood, and putting the capability for independent living at risk.131,132
is expressed as grams/liter of blood or grams of Hgb per mL
of whole blood. Hematocrit is measured as the percentage Cancer
of RBCs that occupy a sample of whole blood, while RBC Improved treatments for cancer and resultant increases
count is the measure of the number of RBCs in a specified in survivability have changed the perception of cancer from
volume of whole blood (millions of RBC/μL).121 The most being a death sentence to a chronic illness with associated
common cause of anemia is iron deficiency.122 primary health management needs designed to improve/maintain
etiologic factors for iron deficiency anemia include dietary quality of life. The National Comprehensive Cancer Network
insufficiencies/poor absorption and hemorrhage (including describes the fatigue associated with cancer as “a distress-
blood loss from the gastrointestinal system, trauma, tumor, ing persistent, subjective sense of tiredness or exhaustion
and menstrual loss). related to cancer or cancer treatment that is not proportional
In chronic conditions like cancer, renal failure, or infec- to recent activity and interferes with usual functioning.”133
tion with HIV, low Hgb levels may result from inadequate Recent studies of individuals with cancer reveal fatigue rates
production of RBCs by the bone marrow and reduced pro- as high as 70% to 80%.134-137 Physical activity is often dif-
duction of EPO by the kidneys.123 Anemia associated with ficult to sustain and, in some cases, even minimal exertion
these conditions is reported to negatively affect work and causes symptoms like dyspnea.138 Oncologists report a belief
sleep, as well as physical and emotional well-being.124,125 It that pain interferes with patient function more severely than
has also been shown to be a potent predictor of survival in fatigue (61% vs 37%), but patients reported that fatigue had
individuals with heart failure, AIDS, renal failure, and vari- a more devastating affect on their daily lives than pain (61%
ous cancers, despite controlling for known prognostic factors vs 19%).139 Fatigue and cancer pain often coexist, and the
like age, gender, and other comorbidities.126-128 The anemia greater fatigue reported by individuals who complain of pain
associated with these conditions has been demonstrated to may in part be a side effect of pain medications,140 although
respond favorably (improved Hgb and health-related quality one study reported that more than 50% of cancer patients
of life) to treatment with EPO alfa.129 For individuals with report significant difficulties with sleep.141 Analgesics used
anemia, the overwhelming symptoms of fatigue that are to treat cancer pain often cause sleep disturbance, leading
associated with even low levels of activity can be daunting to greater daytime fatigue.140 Although use of analgesics for
when facing simple activities associated with activities of pain control contributes to fatigue, studies show that pain
daily living (ADL). alone is a significant predictor of fatigue in cancer patients,
regardless of analgesic use.142
Malnutrition
Other causes of fatigue in cancer result both from pro-
Malnutrition is a frequent component of acute and chron- cesses associated with the cancer itself and treatments for
ic illness and is found in ~50% of all hospitalized adults. the cancer.136 Frequent causes include anemia, cachexia, and
Increases in in-hospital morbidity and mortality among deconditioning.10 When cancer-related fatigue is caused by
medical and surgical patients are associated with malnutri- deconditioning, physicians often prescribe more rest and
tion, as is an increased frequency of hospital admissions relaxation, leading to further deconditioning and exacerba-
among the elderly.130 Weight loss and/or undernutrition tion of fatigue-related symptoms.10 Rest, sleep, or relaxation,
occur when energy expenditures exceed caloric intake, and
148 Chapter 4
however, do not return perceived sense of vigor or strength Objective signs of respiratory distress include nasal flar-
back to normal. Symptoms of fatigue may abate to a degree ing, increased ventilatory rate (VR; > 22 to 26 breaths/
with rest, but perceived stamina and strength do not return minute), increased use of accessory muscles of ventilation
to normal.138 Studies of function revealed that performance (particularly at rest), active contraction of abdominal mus-
in function-related tasks (6-Minute Walk tests [6MWT], cles on expiration, intercostal or sternal retraction, and a par-
a 50-foot walk, or forward reach) was lower in individuals adoxical breathing pattern.152 The most common laboratory
with lymphoma than age- and gender-matched controls, and test for documenting the status of gas exchange is the arterial
performance was linked with self-reports of fatigue in these blood gas, from which information can be gleaned about O2,
subjects.143 CO2, pH, and bicarbonate levels in arterial blood.153
Despite the inclination to rest when fatigued or even Renal Failure
following physician instructions to do so, exercise is an
effective intervention for preventing and/or minimizing Fatigue is the most frequently reported symptom expe-
cancer-related fatigue. Stricker and colleagues, in a 2004 rienced by individuals on hemodialysis.125,154-157 Chronic
review of the evidence on exercise as an intervention for renal failure (CRF) results in a decrease in Hgb concentra-
cancer-related fatigue, found exercise to be an effective inter- tion due to an overall decrease in RBC lifespan.158 Other
vention.144 Two separate studies145,146 demonstrated that factors implicated in CRF-related anemia include a decline
exercise in cancer survivors was inversely related to fatigue in erythropoiesis due to uremic substrates and a deficiency
and anxiety. In addition, Courneya further demonstrated of EPO.159 Administration of exogenous synthetic EPO
that exercise during treatment reduced symptoms of depres- does not result in significantly improved VO2max, as the
sion and number of days hospitalized.145 Schwartz, in a study difficulty with O2 extraction reflects a decreased ability to
of women undergoing treatment for breast cancer, found move O2 from muscle capillaries to the mitochondria.160-162
that women who exercised during treatment reported less A decrease in overall muscle mass occurs with CRF,163 char-
fatigue than their nonexercising counterparts and greater acterized by increased insulin resistance164 and a decline in
decrements in fatigue reported with each treatment cycle.147 muscle quality, known as uremic myopathy.160 The myopathy
Benefits of exercise on mitigating fatigue occur when exer- associated with CRF causes a decrease in strength that occurs
cise is performed during and after treatment for cancer,148 because of a decline in contractile tissue as opposed to an
emphasizing the point that exercise can help decrease fatigue inability to effectively use the available muscle.163
regardless of when that exercise is initiated in the course of Aerobic exercise performed both on non-dialysis and dial-
treatment. In addition, a study of 85 women149 who exercised ysis days results in improvements in VO2max and increased
while undergoing chemotherapy treatments demonstrated exercise times until exhaustion,165 although better improve-
decreased depression scores in addition to increased physical ments in exercise capacity are observed when exercise is
activity scores. Improvements in depression can help to miti- performed on non-dialysis days. Further, aerobic exercise
gate the subjective experience of fatigue in these individuals in patients undergoing hemodialysis has been reported to
and can positively contribute to quality of life. increase Hgb, augment insulin sensitivity, decrease risk fac-
tors for cardiovascular disease (BP and lipid profile), and
Respiratory Distress improve quality of life.166
Individuals in respiratory distress may suffer from hyper-
Chronic Obstructive Pulmonary Disease
capnia (increased carbon dioxide [CO2]), which is defined
as a PaCO2 > 45 mm Hg, and results from alveolar hypoven- Reduction of exercise capacity was demonstrated by
tilation.150 It may or may not be accompanied by hypox- Oga et al to be the best predictor of mortality in chronic
emia (decreased O2), depending on the cause. Distress can obstructive pulmonary disease (COPD), regardless of age
result from a number of causes, including ventilatory mus- or airflow limitation.167 Skeletal muscle changes that occur
cle fatigue, acute pulmonary infections or chronic airway in COPD include decrements in strength, muscle mass, and
obstruction that impairs gas exchange, splinting from pain mitochondrial enzyme activities, and they are coupled with
caused by thoracic or abdominal trauma or incision, reduced excessive lactate accumulation during exercise.168 Significant
ventilatory drive from drugs (recreational and therapeutic, accumulation of skeletal muscle lactate often occurs early in
analgesics being the most common), and diseases/disorders submaximal exercise and is independent of LE circulation at
of the neuromuscular system impairing the mechanics of rest and during exercise.169 Pepin and colleagues reported
breathing and the ventilatory pump.151 The patient with that the difficulties with physical functional performance
hypercapnia resulting from hypoventilation or impaired gas reported by individuals with COPD can be attributed to the
exchange may complain of symptoms of lethargy, headache, discomfort (predominantly dyspnea and LE fatigue) pro-
or confusion. Degree of symptoms is directly related to the voked by activity.170 In a 22-month study that documented
severity of hypercapnia, and at higher levels of hypercapnia, the symptoms in 74 patients with COPD, fatigue showed the
seizures or coma can result.150 In less severe cases of hyper- greatest increase over time of the symptoms tracked dur-
capnia associated with hypoventilation, the individual may ing the test period. At baseline, 19% and 50% reported mild
complain of simple fatigue or report a decreased energy level and severe fatigue, respectively. At follow-up, 30% reported
or exercise tolerance. mild fatigue and 62% reported moderate or severe fatigue
(p = 0.001).171 Interestingly, in this same study, participants
with COPD reported significant (p = 0.03) increases in feel-
ings of depression over the same time period, which could
compound sensations of fatigue in this population.171
While hypotheses exist that these changes are due to a
COPD-related systemic disease or specific myopathy, the
evidence of such a systemic myopathic process is equivocal
to date. Wagner, in his 2006 review of the evidence related to
skeletal muscle function in COPD, reports that decrements
in muscle activity and mass are due to the inactivity-induced
peripheral muscle deconditioning experienced by this popu-
lation.169,172 In the population of individuals with COPD (as
well as other chronic conditions), a vicious cycle develops—
performance of an activity leads to an undesired or unpleas-
Figure 4-3. Stimulus and avoidance.
ant experience (in this case shortness of breath or dyspnea).
The person associates the activity with the unpleasant expe-
rience and thus avoids it. Avoidance of the activity results in
was soon discovered, however, that overexertion made the
deconditioning, and an increased energy cost for the activity.
weakness and symptoms worse rather than better.173,177 Mild
It then takes less provocation for the symptoms to result;
to moderate exercise, on the other hand, has been reliably
continued avoidance results in a significant deterioration of
demonstrated to improve strength and function in those
functional status and physiological reserve (Figure 4-3).
with PPS.176,181,182 Best results for treating fatigue in this
Aging With a Disability population have been achieved with energy conservation
Individuals living long term with a physical disability strategies, including pacing, use of bracing, frequent rest
are at particular risk for the development of fatigue. First periods, and use of assistive technology.173,176
observed in individuals who had poliomyelitis in the 1940s Further research indicated that the functional losses expe-
and 1950s, new functional losses were observed in indi- rienced by those with PPS were not, in fact, unique to polio.
viduals who had lived successfully with polio for many (20+) As life expectancy has increased for individuals without
years, some of whom had years of stable function.173,174 disabilities because of improvements in medical care, so has
Average onset of symptoms occurs at reported averages of the life expectancy for individuals with disabilities (the most
20 to 35 years after initial infection.173,174 These losses were frequently studied group is composed of individuals with
characterized by losses of previously regained function with spinal cord injury).183 Like the phenomena that occurred
new onsets of pain, fatigue, weakness, and depression.174 In in people with PPS, people with physical disabilities (spinal
the mid-1980s, the phrase post-polio syndrome (PPS) was cord injury, cerebral palsy, spina bifida, etc) experience age-
coined at the Warm-Springs Georgia Rehabilitation Center related losses of function with new onsets of pain, fatigue,
to describe the constellation of functional losses experi- and weakness.184,185 The onset of these new issues can result
enced by this population.175 Fatigue and weakness were in progressive losses of functional independence as the per-
the 2 most common symptoms experienced by those aging son with a disability ages.184 As in PPS, the key to manage-
with polio.173,174,176,177 Studies have reported that 91% of ment of symptoms experienced by individuals aging with
individuals with PPS experience new or heightened fatigue, a disability lies in energy conservation. If possible, mild to
while 41% report symptoms severe enough to interfere with moderate exercise can play a role in maintenance of function,
work, and 25% reporting that fatigue interferes with perfor- but the preservation of function is key. Appropriate evalua-
mance of ADL.174,178,179 Up to 42% of individuals with PPS tion and management of new symptoms (eg, pain, depres-
report new breathing problems, and many require additional sion) and seeking strategies to conserve and thus preserve
ventilatory support. The largest percentage of those with PPS function can accomplish this.
who require ventilatory support had ventilatory compromise
as part of their initial experience with polio, but some indi-
viduals with PPS require ventilatory support despite no such EXAMINATION OF PATIENTS
previous history.174
Initial studies were based on the assumption that the WITH SYMPTOMATIC FATIGUE AND
functional losses were as a result of a pathophysiologic pro-
cess unique to having had the poliovirus. Indeed, muscle
SIGNS OF DECONDITIONING
changes were observed in those with PPS, including motor
In each of the physiologic and psychological condi-
unit enlargement and overuse failure of the nerve axon
tions described, the complicated interactions of symp-
sprouts.173,180 First treatments considered for the weakness
tomatic fatigue and its interrelationship with physiologic
associated with PPS revolved around vigorous exercise in
deconditioning have been presented. Often, it is difficult
hopes of restoring strength and thus restoring function. It
150 Chapter 4
The clinician must have a working knowledge both of the
normal response to exercise and what is expected in a patient
who is deconditioned. For the patient who is deconditioned,
the clinician will likely observe a higher than normal HR and
VR at rest and with response to activity. Typically, both HR
and VR increase proportionally to workload, but the degree
of response to activity can be greatly exaggerated when a
person who is deconditioned exercises (Figure 4-4). This is
true particularly in the early stages of the initiating exercise
after prolonged bed rest. The intensity of exercise required
to produce an abnormal exercise response will vary from
patient to patient, with the general proviso that the longer the
patient has been immobile, the less exercise will be required
to produce an abnormal response. In addition, the older the
patient is at the initiation of exercise, the more pronounced
Figure 4-4. HR and VR responses to exercise. the abnormal response will be, reflecting greater sensitiv-
ity to deconditioning and with losses of physiologic reserve
associated with aging.
to separate the precipitating factors from the consequential When monitoring HR response, the clinician should
results. It is essential, however, to separate out the fixed be mindful of the patient’s age-predicted HR max, as the
pathology from the malleable impairments and function- patient’s HR may be significantly elevated both at rest and
al limitations to accurately manage the impairments and with exercise. It is not uncommon for a patient who is
reduce the limitations. severely deconditioned to have resting HRs in the low 100s,
for example. Even minor increases in activity may therefore
History cause the patient’s HR to elevate to unsafe levels (depending
on the patient’s age). As HR increases and thus O2 demand,
Examination of these patients proceeds by taking an accu-
the clinician should also be alert for indications of myocar-
rate history that consists of a comprehensive inventory of
dial ischemia, especially onset of angina or arrhythmias (or
past and present conditions requiring medical interventions,
worsening of a previously stable cardiac rhythm).
past surgeries, family history, current/past medications,
Evaluation of the patient’s ventilatory status is critical
social/occupational history, and history of past or current
as well. A careful examination of the patient’s ventilatory
substance use/abuse (to include smoking history). This can
and respiratory status will assist the clinician in his or her
occur via a structured interview in combination with analy-
decision of whether to initiate or continue activity. Signs of
sis of data collected via the health history form.
ventilatory muscle fatigue/distress include VR > 20, use of
accessory muscles of ventilation, sternal/intercostal retrac-
Systems Review tions, forced use of abdominals on expiration, and/or a
The systems review is a brief physical examination con- paradoxical breathing pattern (in which ventilatory muscle
ducted to glean information about areas that may require fatigue produces a breathing pattern in which the patient’s
further examination or testing. This hands-on examination abdominal contents fall with inspiration and rise with expi-
consists of a brief check of the integumentary, cardiovascu- ration). Presence of any of these signs at rest can be consid-
lar, pulmonary, neurologic, and musculoskeletal systems for ered relative contraindications to the initiation of exercise.
indications that more in-depth examination is warranted. In As a general guideline for evaluation of respiratory status,
the case of individuals with complaints of fatigue or signs of pulse oximetry can provide valuable information about the
deconditioning, the systems review may reveal the follow- patient’s ability to deliver O2 to his or her RBCs (and con-
ing: a faster resting HR/VR, difficulty breathing (evidenced sequently to peripheral tissues), with normal being ≥ 96%.
by increased work of breathing), a lower BP than usual, Resting or exercise levels of O2 saturation (as measured by
evidence of muscle disuse/atrophy, limited range of motion, pulse oximetry) below 92% reflect arterial partial pressures
peripheral edema, and skeletal muscle weakness (manifested of O2 that approach levels of O2 found in venous blood; ini-
by a decreased ability to perform functional tasks/maintain tiation or continuation of exercise under these circumstances
balance). should therefore occur only given careful consideration of
Initiation of exercise for patients who are deconditioned the patient’s history and current clinical presentation.
requires careful scrutiny on the part of the clinician, espe- In the presence of any of these objective vital sign indica-
cially with regard to the cardiac and/or pulmonary system. tors of unstable cardiac or pulmonary systems, incremental
When determining whether to initiate exercise for patients initiation of carefully monitored activity may be necessary.
who are deconditioned, the clinician must evaluate the If exercise produces one or more of the previously mentioned
patient’s condition at rest and then determine whether the signs, especially in the context of poor subjective tolerance
patient has the capacity to respond to increased demands. to activity, exercise should be discontinued until the patient
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post polio sequelae. In: Halstead L, Weichers D, eds. Research and endurance and weakness.” So, was Mr. Biscotti primarily
Clinical Aspects of the Late Effects of Poliomyelitits. White Plains, a deconditioned patient or a cardiac patient whose cardiac
NY: March of Dimes; 1987:145-156. status limited his physical activity? That could not yet be
180. Grimby G, Stålberg E, Sandberg A, Sunnerhagen K. An 8-year lon- determined but pointed the way for additional information
gitudinal study of muscle strength, muscle fiber size, and dynamic
that needed to be gathered.
electromyogram in individuals with late polio. Muscle Nerve.
1998;21(11):1428-1437. Next, it might have been tempting to pursue the medical
181. Ermstoff B, Wetterqvist H, Kvist H, Grimby G. The effects of aspects of his history to determine when the MI occurred,
endurance training on individuals with post-poliomyelitis. Arch what was the extent of myocardium damage, and what
Phys Med Rehab. 1996;78(8):107-118.
182. Arge J, Rodríguez A, Franke T. Strength, endurance and work
interventions were used. Medical history, though impor-
capacity after muscle strengthening exercise in postpolio subjects. tant, is only one aspect of the information needed from the
Arch Phys Med Rehab. 1997;78:681-686. patient interview.
183. DeVivo MJ, Krause JS, Lammertse DP. Recent trends in mortality
and causes of death among persons with spinal cord injury. Arch
Phys Med Rehabil. 1999;80(11):1411-1419. Social History/Environment
184. Kemp B, Mosqueda L. Introduction. In: Kemp B, Mosqueda L,
eds. Aging with a Disability: What the Clinician Ought to Know. Mr. Biscotti had earned a high school degree and owned a
Baltimore, MD: Johns Hopkins University Press; 2004:1-5. produce shop. Until 5 months ago, he worked 50 to 60 hours
185. Kingbeil H, Baer H, Wilson P. Aging with a disability. Arch Phys per week. Work tasks included beginning his day at 4:00 am
Med Rehabil. 2004;85(3):S68-S73.
186. Rasekaba T, Lee AL, Naughton MT, Williams TJ, Holland AE. The
to select the fruits and vegetables, then lifting the crates onto
Six-Minute Walk test: a useful metric for the cardiopulmonary the truck and hauling the produce to the store. Occasionally,
patient. Intern Med J. 2009;39:495-501. he helped with setting up the store and assisting customers.
187. Bean J, Kiely D, LaRose S, Alian J, Frontera W. Is stair climb power More often, however, he supervised these 2 latter tasks in
a clinically relevant measure of leg power impairments in at-risk order to have time to complete the office tasks necessary for
older adults? Arch Phys Med Rehab. 2007;80(5):604-609.
188. Roig M, Eng J, MacIntyre DL, Road JD, Reid WD. Associations of
the business.
the Stair Climb Power Test with muscle strength and functional Mr. Biscotti lived with his wife of 45 years. He reported
performance in people with chronic obstructive pulmonary dis- she was in good health, though she had to occasionally
ease: a cross-sectional study. Phys Ther. 2010;90(12):1774-1782. modify her activities because of mild bilateral knee pain. His
189. Shumway-Cook A, Brauer S, Woolacott M. Predicting the probabil-
wife prepared all of the meals and completed all houseclean-
ity for falls in community-dwelling older adults using the Timed Up
& Go test. Phys Ther. 2000;80(9):896-903. ing tasks. Mr. Biscotti reported he had a supportive family. In
190. American Physical Therapy Association. Guide to Physical addition to his wife, he noted that he had 3 grown daughters
Therapist Practice. 2nd ed. Alexandria, VA: American Physical who all lived within a 15-mile radius of his home and were
Therapy Association; 2001. available to assist with his care when needed.
156 Chapter 4
Mr. Biscotti lived on the second and third floors of a Medical/Surgical History
2-family home. He reported he needed to ascend 30 “outside”
Mr. Biscotti reported that he had yearly physicals with his
stairs, with a hand rail on the right, to enter his home. He had
primary care physician with no significant medical history
only 13 stairs to ascend to get to his bedroom on the third
except an episode of gout. His mother died of pneumonia,
floor of the building, but there were rails on both sides.
and Mr. Biscotti’s father died of a heart attack in his mid-70s.
Five months prior, while working around his home, Mr.
Clinician Comment There are interesting Biscotti reported he began to perspire profusely and felt
regional differences to consider in patient interviews. lightheaded. When the symptoms did not decrease after sit-
Whereas one area in the country may be known for ting down to rest for 10 minutes, he was taken by ambulance
the great number of revolving doors to navigate, in Mr. to the emergency room of a small local hospital.
Biscotti’s region, it is the 2- or 3-family residential dwellings From medical reports Mr. Biscotti brought with him to
that need to be considered. the initial physical therapy appointment, it could be deter-
True 2- and 3-family residences were built in the late 1800s mined that when an EKG showed changes associated with
and early 1900s to accommodate the large families of mill an acute MI, though the changes were not specified, heparin
workers in mill towns. Typically, there are 4 to 5 steps, often and Integrilin (eptifibatide) were administered to him in the
without rails, to reach a front porch area and the front door. emergency room.
The front door will lead to an entry with additional doors. Following a transfer to a larger regional hospital, he
One door will be the entrance door to the home on the first underwent a left heart catheterization, left ventriculography,
floor. Behind a second door will be a flight of stairs to the and coronary angiography. He was diagnosed with CAD
front door of the second-floor home. Sometimes an addi- and an acute inferior wall MI, then treated with angioplasty
tional door on the second-floor landing will lead to another including stinting of the mid and distal circumflex artery
flight of stairs to a third-home unit on a third floor. More and second circumflex marginal artery.
often, however, if a third floor exists, it becomes the addi- A post-procedure echocardiogram confirmed the stunt
tional living space for the second-floor home. The latter is placement and documented an ejection fraction (EF) of
the situation for Mr. Biscotti’s home and are the stairs that 40% to 45%. In addition, he showed mild mitral and tri-
lead to the floor with his bedroom. The 30 stairs to which cuspid valve regurgitation and borderline left ventricular
he referred as “outside stairs” are outside of his living area hypertrophy.
but inside the building. His troponin level on admission (128 ng/mL) had
This contrasts with another residential situation found in decreased to 72.9 ng/mL at discharge 2 days later. During
the same region. Patients may have a living area in a large the hospitalization, he was diagnosed with diabetes mellitus
house that has been divided into smaller units. Secondary (DM) and hypertension. He was discharged with the follow-
exits to units on upper floors may be metal fire escape-type ing medications: Lipitor (atorvastatin), Toprol (metoprolol
staircases placed on the outside of the building. succinate), Zestril (lisinopril), Plavix (clopidogrel bisulfate),
aspirin, Glucophage (metformin Hcl), and nitroglycerine; the
latter as needed.
After his hospital discharge, Mr. Biscotti met with a
Social/Health Habits dietician for instruction in diabetes management strategies,
Mr. Biscotti reported that he did not smoke and had never including monitoring blood sugar levels, making appropriate
smoked. He reported he would occasionally have an alcoholic food choices, and beginning regular exercise.
beverage when he would eat out for dinner.
Mr. Biscotti did not have a regular exercise program nor
had he ever followed a regular program. He reported that he
Clinician Comment Mr. Biscotti seemed
unaware that he had a number of risk factors for CAD
was active enough with his work tasks and with watching his
or heart attack as identified by the American Heart
grandchildren when they would visit.
Association.2 As a male over 65 years of age, with a fam-
ily history of heart disease, he had all the risk factors that
Clinician Comment From the interview thus could not have been changed. Based on his perception
far, it was learned that Mr. Biscotti needed to be able to (prior to his MI) that his medical status was unremark-
climb stairs easily to get into his home as well as navigate able and that he was active enough, he might have judged
within his home. He did not have experience with a regular that he had none of the risk factors that could have been
exercise program, which has been shown to affect follow- modified; namely, use of tobacco, high cholesterol, high BP,
through with a recommended regular exercise program in physical inactivity, obesity, and DM. After his MI, the need
other patient groups.1 Something happened 5 months prior to assess the modifiable risk factors was indicated.
that changed Mr. Biscotti’s activity level. Chest pain is a well-known symptom indicator of a possible
MI.3 The World Health Organization cites chest pain as a
Mostly, he supervised the store’s workers and operation
diagnostic criteria for an acute MI.4 In a cohort of patients
and completed the business office tasks for the store. He
diagnosed with an acute MI, however, 33% of the patients
found he needed to rest during his work day. He lived close
did not present with chest pain before admission to the
enough to be able to go home to rest. However, to avoid the
hospital. When compared to the cohort, these patients were
exertion required to climb the stairs to get into his home, he
older, more likely to be female, or had a higher prevalence
tended to rest in a recliner in the office at work.
for DM.5
He did not want to stop working but recognized that he
Mr. Biscotti arrived at the emergency room in distress but might need to accept working reduced hours.
without chest pain. He was not elderly or female and did
not have a diagnosis of DM at that time, so he did not even Other Relevant Information
fit the characteristics noted in the study above. Fortunately, Mr. Biscotti reported that he attended a cardiac rehabili-
an EKG was administered and the diagnosis of an acute MI tation program for 3 months. He noted he was inconsistent
was made quickly. This allowed the timely administration with keeping the 3 times per week schedule. He stopped
of a prophylactic regimen of medications to diminish addi- when his insurance coverage ended for the program.
tional ischemia6 while he was being transported to another
medical center.
The normal rate for an EF, the percentage of blood that is
Clinician Comment Patients who understand
the role of exercise after an MI were more likely to partici-
pumped out of the ventricle with each heartbeat, is 55% to
pate in a cardiac rehabilitation program.11 Mr. Biscotti was
70%.7 At 40% to 45%, Mr. Biscotti’s EF is lower than nor-
inconsistent in attendance at his cardiac rehabilitation pro-
mal, but not so low as to increase his 30-day mortality rate
gram. He believed he was active enough with ADL, instru-
or readmission into the hospital for failure.8
mental ADL (IADL), and work tasks. It did not appear,
Mr. Biscotti’s experience with altered glucose metabolism however, that he met the recommended standard of moder-
associated with an acute MI is not unusual. In a prospec- ate activity for 30 minutes per day for 5 or more days per
tive study with more than 10,000 patients, 57% of patients week to bring health benefits to his cardiovascular system,
admitted to the hospital for an acute MI with no prior or 60 minutes 5 days per week for weight management.12
history of DM had abnormal glucose metabolism at dis- Further, he did not appear to understand the beneficial
charge.9 In a similar cohort, 45% of patients discharged effects of exercise not just for his cardiovascular system
after an acute MI had impaired glucose metabolism. Less and, thus, his survival,13 but for improved management of
than 35% of these patients returned to normal glucose levels his diabetes as well.14
3 months after discharge.10
As central as exercise appeared to be to manage Mr.
Biscotti’s health and improve his function, a systems review
needed to be completed to determine whether he was a
Reported Functional Status candidate for physical therapy and then to guide the selec-
Mr. Biscotti reported that he needed to sit to dress but tion of tests and measures if the examination was to move
dressed independently. Bathing required the use of a bench forward.
in the tub for showering. He reported he was reluctant to try
standing to shower. Prior to his hospitalization, he took baths
but doubted that he’d be able to rise from the bathtub.
The only transfer for which he reported any difficulties in Systems Review
ADL was rising from, or sitting down onto, his home toilet.
He was unable to do either without grabbing onto or leaning
Cardiovascular/Pulmonary
into an adjacent vanity for support. Seated resting values: HR, 57 beats per minute (bpm); BP,
Mr. Biscotti reported he could walk without the use of 122/68 mm Hg; resting rate, 15 breaths per minute.
his straight cane but found he needed it when climbing or No edema was observed in bilateral LE. He had shown
ascending stairs, or when he got fatigued. He was unable to mild difficulty in carrying on a conversation when walking
climb the 30 stairs to his second-floor home without resting from the waiting area to the treatment room. By counting the
several times. He reported he became short of breath (SOB) number of syllables the patient uttered between breaths while
and hunched over by the time he reached the second-floor walking, a dyspnea index of 2 to 3 was estimated. No dyspnea
landing and the entrance to his home. was noted in the patient’s conversation during the interview.
He had reduced his work hours to 20 to 30 hours a week, Integumentary
leaving more of the customer service aspects of the business
to his daughter and son-in-law, who worked for him. He still No discoloration or breaks in the integument were seen.
rose at 4:00 am every morning to select the fruits and vegeta- Continuity of skin color appeared normal and general pli-
bles for the store but was no longer involved with transferring ability was normal.
the produce to the store.
158 Chapter 4
Musculoskeletal information from the interview assisted the selection of
Height: 5 feet, 9 inches; Weight: 197 pounds (BMI 29.1) tests and measures to consider.
His extremity and trunk range of motion were symmetri- Mr. Biscotti’s BMI places him in the overweight category15
cal and appeared unimpaired to gross active movements. as well as at moderate risk for heart disease2 or, in his case,
He did show increased effort needed at end ranges of lifting continued heart disease. An exercise program at the level
each arm overhead as well as full extension of each knee, so required to begin to assist with weight control as well as
strength appeared impaired. Mr. Biscotti’s sitting and stand- blood sugar levels required that his aerobic capacity and
ing posture showed an increased forward lean of his trunk. endurance be determined.13
Neuromuscular He reported, and was observed, having difficulty mov-
ing between sitting and standing. Given that he also used
Locomotion increased effort with end-range extremity movements and
Impaired—Mr. Biscotti remained stooped forward after reported difficulty on stairs, his muscle performance need-
rising from the chair in the waiting area and walked to the ed to be tested more thoroughly.
treatment room using a slow cadence, shuffling gait. He car-
It was not clear whether he continued to sit to shower
ried his cane.
because of impaired balance or because sitting to bathe
Transfers/Transitions matched closer with his previous habit of tub bathing.
Impaired—Mr. Biscotti already reported that he had dif- Because of this question about his balance, as well as the
ficulty moving between sitting and standing with his toilet observed wide-based stance, his balance needed to be
at home. Mr. Biscotti was observed requiring the assist of the assessed further.
arms of the chair in the waiting area to rise to standing and It was also not clear whether he was able to use his cane
did not lower himself smoothly into the chair in the treat- effectively, nor was it known whether his forward posture
ment room. could be corrected with verbal prompting or was due to a
Balance muscle performance impairment in postural muscle or a
Impaired—Mr. Biscotti did not lose his balance or misstep balance strategy.
when walking to the treatment room from the waiting area. Mr. Biscotti needed tests and measures to determine his
His shuffling gait and wide-based stance in standing sug- aerobic capacity and endurance, muscle performance, bal-
gested his balance was impaired. ance, posture, and gait. The 6MWT was selected along with
extremity manual muscle testing (MMT), Berg Balance
Motor Function
Scale, posture screen, and gait observation. It was decided
No impairment noted. to start with the posture screen followed by the MMT to
Communication, Affect, Cognition, serve as an activity warm-up to the more vigorous 6MWT.
Language, and Learning Style Though he might be fatigued after the 6MWT, waiting to
test his balance under fatigued circumstances may show a
Mr. Biscotti is oriented to person, place, and time. No more realistic picture of his balance with functional tasks.
communication problems were detected. His emotional and
behavioral responses were appropriate. No learning barriers Mr. Biscotti was instructed in the Borg Rate of Perceived
were identified. He preferred to have pictures and demon- Exertion (RPE) scale before any testing was initiated. Using
stration of exercises. the RPE during the tests and measures would provide
another method, in addition to vital signs, to monitor his
He would benefit from education regarding use of his
response to the activities, and it also allowed him to gain
assistive device, the role physical therapy can play with
experience using the scale before the 6MWT. The Borg scale
regard to his goals as well as cardiac and blood sugar health,
was designed to have the RPE number chosen by the patient
and an exercise program. In addition, he would benefit from
to reflect the actual working HR (RPE × 100 = HR).16 Mr.
instruction in monitoring his response with exercise.
Biscotti’s Toprol medication could be expected to diminish
his adaptive HR rise with exercise, but the RPE has still
Clinician Comment As shown previously, been a useful tool with cardiac patients.17 The 6MWT has
gathering information about a patient can begin with been found to be an effective tool to evaluate functional
the introduction in the waiting area. Observations of the capacity even in patients with an EF < 40%.18
patient’s movements, along with information gained in the
interview, is combined with the brief examination of the
systems review to guide the clinician’s choice of tests and
measures once the clinician has confirmed that the patient Tests and Measures
is an appropriate candidate for physical therapy.
Posture
The system review did not uncover any findings that would
exclude Mr. Biscotti as a candidate for physical therapy. In Tests were performed to determine whether Mr. Biscotti’s
fact, the findings from the systems review combined with trunk forward lean in sitting and standing was due to
structural changes and could not be corrected, or due to
habit. In sitting and standing, Mr. Biscotti was shown and Clinician Comment Mr. Biscotti showed an
asked to practice a “slump and then sit tall” movement. The adaptation in HR and BP with increased activity from his
same was repeated in standing. In both instances, he was able resting values, but walked only a distance of 350 feet. Even
to correct his posture, with minimal verbal cues, to one with considering the evidence that patients with an EF ≤ 40%
balanced spinal curves and aligned shoulder girdle and head/ cover less distance and, of those patients, the patients who
neck position. He reported an RPE of 10/20. also had DM covered even less distance, 350 feet is low.20
He began the test walking at a slow speed and took frequent
Muscle Performance (Including Strength, standing rests as if he wasn’t certain that he could complete
Power, and Endurance) the test. When told he had 1 minute remaining, he increased
To ensure Mr. Biscotti did not hold his breath during his speed and did not take any breaks. Had he been more
MMT, he was instructed to count to 3 with the therapist dur- familiar with his ability to walk continuously for 6 minutes,
ing the resisted portion of each test. With Mr. Biscotti posi- he may have performed differently on the test. Nonetheless,
tioned in supine, side-lying, prone, and then standing, the 350 feet on the 6MWT became the baseline measure.
following muscle strength grades were identified with MMT:
RIGHT LEFT Gait, Locomotion, and Balance

Iliopsoas 4‒/5 4‒/5 Gait
Gluteus maximus 3+/5 3/5 During the 6MWT, Mr. Biscotti walked with a slow
cadence and short step length. There was little evidence of
Gluteus medius 4‒/5 4‒/5
initial contact, loading response or propulsion during the
Hip adductors 4‒/5 4‒/5 stance phase of gait, bilaterally. This resulted in a shuffling
Quadriceps 4‒/5 4‒/5 gait. As he continued to walk, his corrected and erect posture
began to show more and more of a forward lean.
Hamstrings 4‒/5 4‒/5
Locomotion
Gastrocnemius 3+/5 3+/5 Mr. Biscotti had been observed earlier having difficulty
rising and moving between standing and sitting.
In hook lying, he was unable to perform a short-range sit-
Balance
up or bridge. He reported an RPE of 12.
In a single-leg stance (SLS) test, Mr. Biscotti was able to
maintain SLS on the right for 12 seconds, and on the left for
Clinician Comment Mr. Biscotti was able to less than 5 seconds. He scored 44/56 on the Berg Balance
correct his posture with minimal verbal cuing in sitting and Scale (BBS). He was reluctant to perform the tasks of plac-
standing. Therefore, his altered posture was not structural. ing alternate feet on a step, maintaining a tandem stance
Having Mr. Biscotti avoid breath-holding with MMT mini- position, or standing on one foot. He needed supervision to
mized any CO and BP changes with isometric exercise.19 attempt standing with eyes closed and with feet together.
MMT showed strength deficits throughout bilateral LEs,
with the greatest deficit in left gluteus maximus (3/5), fol-
lowed by the left gluteus maximus and bilateral gastrocne-
Clinician Comment Muscle weakness at the
hips and LEs was a risk factor for falls.21 A score on the BBS
mius (3+/5). The decrease in hip and ankle strength needed
below 45/56 suggested an increased risk for Mr. Biscotti for
to be considered when testing his balance performance.
multiple falls, but it is not as significant as a score below
Mr. Biscotti was able to use the Borg scale effectively. As 40/56.22 Mr. Biscotti did have weakness in hip extensors
anticipated, his RPE of 12 did not match the formula to pre- and in his LEs, but he did not report a history of imbalance
dict HR. His predicted rate would have been 120 bpm based or falls. The latter, along with an improved performance on
on an RPE of 12, but it was actually measured at 62 bpm. the BBS, would place him at a lower risk for falls.23
Again, the RPE has been found to be an effective measure
of exertion in cardiac patients.17
EVALUATION
Aerobic Capacity and Endurance
6MWT: After instruction, Mr. Biscotti walked 350 feet in Diagnosis
6 minutes with an RPE of 14. Immediately after stopping, he
showed a HR of 99 bpm and BP of 132/64 mm Hg. Practice Pattern
Based on the information from the patient interview
and findings from the systems review, tests, and measures,
160 Chapter 4
Mr. Biscotti was classified into Cardiovascular/Pulmonary Discharge Plan
Pattern 6B: Impaired Aerobic Capacity/Endurance Associated
It was anticipated that Mr. Biscotti would achieve the
with Deconditioning.
anticipated goals and expected outcomes at the end of the
International Classification of Functioning, plan of care and would be discharged to a home program of
Disability, and Health Model of Disability exercises and regular walking.
See ICF Model on page 161.
Prognosis INTERVENTION
Mr. Biscotti had a good prognosis to improve his func-
tional walking status, including stairs, as well as increase his
ease with position changes. He could expect improved confi- Documentation
dence with weightbearing tasks that challenged his balance.
The initial evaluation including plan of care was sent to
Mr. Biscotti’s referring primary care physician with plans for
Plan of Care regular updates on Mr. Biscotti’s progress toward the stated
goals. All aspects of his physical therapy care were docu-
Intervention
mented in Mr. Biscotti’s outpatient physical therapy record.
Mr. Biscotti would benefit from instruction in the impor-
tance of regular exercise to address his deconditioning, car-
diovascular risk management of weight control, and blood
Patient-/Client-Related Instruction
sugar management. Instruction would continue on self-mon- Mr. Biscotti received instruction in, and practiced, self-
itoring techniques to assess his response to exercise. Exercise monitoring techniques to be used during exercise sessions.
sessions would include aerobic reconditioning, therapeutic He was instructed in energy conservation strategies, includ-
exercises for core and extremity musculature strengthening, ing slower pace on stairs, marking time, and the correct
and gait and balance activities. use of his cane. Review of the printed materials and rein-
forcement of self-management techniques from his session
Proposed Frequency and Duration of
with the dietician were integrated into his physical therapy
Physical Therapy Visits sessions.
Mr. Biscotti was to be seen 2 times per week for 6 weeks.
Treatment session would begin with a 30-minute length until Procedural Interventions
he was gradually able to tolerate a 60-minute session.
Anticipated Goals Therapeutic Exercise
1. Mr. Biscotti would be able to self-correct his posture Aerobic Capacity/Endurance
during treatment sessions (1 week). Conditioning or Reconditioning
2. Mr. Biscotti would tolerate an initial strengthening, bal- Mode
ance, and endurance program (2 weeks). Recumbent bike, upper body ergometer (UBE)
3. He would tolerate continuous aerobic activity for 20 min- Intensity
utes without rest (2 weeks). RPE for warm-up = 7 to 8/20; for interval work = 9 to
4. He could maintain a standing position with simulated 12/20
upper extremity movements as for showering (3 weeks). Duration
5. He would show an increased ease with transfers on/off 2- to 3-minute warm-up, 5 to 10 minutes for interval work
a chair the same height as his toilet at home (3 weeks). Frequency
6. Mr. Biscotti would ambulate at least 600 feet on a level 2 times per week
surface, without an ambulation device, in 6 minutes. Description of the Intervention
7. He would be able to climb a full set of stairs without rest Easy pedaling for LEs or upper extremities during warm-
or SOB, using rails (5 weeks). up. Increased speed in pedaling for LEs in timed intervals,
alternating with slower speed pedaling later in treatment
Expected Outcomes (6 Weeks) session.
1. Patient would report full independence with ADL and Strength, Power, and Endurance Training
IADL. Training for head, neck, limb, pelvic floor, trunk, and
2. Mr. Biscotti would report the ability to climb the ventilatory muscles
30 stairs to his home without rest with an RPE ≤ 12/20. Mode
Active movements
ICF Model of Disablement for Mr. Biscotti

Health Status
• S/p Inferior wall MI, 5 months prior
• Coronary artery disease
• Hypertension
• Diabetes mellitus
• Episodes of gout in the past

Function
• Difficulty with position • Unable to complete work
• Cardiac ejection fraction of changes, especially sit to tasks of lift and carry
40% to 45% stand • Had to decrease work hours
• Inability to maintain • Shuffling gait, uses cane and tasks due to fatigue
posture when fatigued • Decreased ability to climb • His difficulty with stairs
• Strength deficits bilateral stairs meant he avoided going
lower extremities • Decreased and home midday to rest
• Decreased endurance asymmetrical ability to • Avoided multiple trips out
• Decreased balance single leg stance of his home in a day to
• Unable to stand to shower prevent the need to climb
or dress entrance stairs on his return
• Difficulty managing ADL,
IADL, and work tasks
without frequent rests

• Age = 68 years • Flight of stairs to reach entrance to home
• Inactive and no prior experience with an exercise • Another flight of stair within his home to reach
program his bedroom
• Owns his business, can flex hours and tasks • Moving produce and stocking his store required
• Supportive family lifting and carrying tasks
• Male, over 65 years old with a family history of
heart disease
162 Chapter 4
Intensity Subjective
Low repetitions (3 sets of 5 repetitions) initially, then
increasing repetitions (2 sets of 10 repetitions) He reported, “I don’t think I need to come to physical
Duration therapy anymore.”
10 to 12 minutes
Frequency Objective
2 times per week He reported that he was able to transfer on and off the
Description of the Intervention toilet without using the bathroom vanity for leverage. He no
Standing exercises using a bar for support to complete longer used the shower chair and stood for showers without
active hip movements, short range squats, step-ups, and difficulty. He had not attempted a bath but noted that he was
step-overs. Theraband exercises for upper extremities. Leg able to step over obstacles that were as high as the tub sides
curls using a multigym. Mat exercises for core strengthening, without difficulty. Though it was not an initial goal, he noted
including bridging and abdominal muscle setting with LE that he was able to get up from the exercise mat without help.
exercise is supine and side-lying. He reported that the squats and step-downs in his physical
Gait and Locomotion Training therapy sessions still were his most demanding tasks and
Mode judged his effort during these tasks as RPE = 14/20.
Forward and backward walking, and sideways stepping He thought he was able to walk as much as he did before
Intensity his MI. He no longer used the cane on level surfaces or stairs.
Mr. Biscotti reported that if he took 2 short standing rests on
Lengths of a 50-foot hallway, RPE < 12/20
the stair landings when ascending stairs at home, he could
Duration
control his breathing. If he rushed or avoided the rests, he
10 to 15 minutes combined with balance activities noted SOB. He had started regular walking at the local mall
Frequency for 20 to 30 minutes and had already done so 5 times since
2 times per week beginning physical therapy. He reported sitting down or
Description of the Intervention standing to rest, which might also occur when stopping to
Forward and backward walking, and sideways stepping talk with someone he knew. He continued to work modified
with bilateral handheld support, decreasing to single-hand hours at 20 hours per week.
then no-hand support in a 50-foot hallway, with seated rests
after each length.
Aerobic Capacity and Endurance
His resting vital signs were HR = 56 bpm; BP = 132/66;
Balance, Coordination, and Agility Training
RPE = 10/20
Mode He completed the 6MWT without SOB and covered
Walking on an obstacle-strewn path, static weightbearing 800 feet. He reported his RPE while walking as 12/20. His
positions post test vitals were HR = 79 bpm; BP = 140/62.
Intensity
Just enough difficulty to gently challenge his balance but Strength
not cause frequent balance losses MMT was delayed because of time until the 1 month
Duration reevaluation.
10 to 15 minutes combined with walking activities Gait, Locomotion, and Balance
Frequency
2 times per week Gait
Description of the Intervention He no longer shuffled his feet when walking and had a
Walking a 50-foot obstacle course with walking around or near normal gait cadence. He still showed a decreased load-
stepping over obstacles with bilateral hand support initially, ing response and propulsion with a more whole foot-loaded
then decreasing to single-hand then no-hand support. Also gait pattern, but he modestly improved from the initial
practiced SLS on balance cushions. observations. He was able to maintain erect posture through-
out the 6MWT.
Locomotion
REEXAMINATION As Mr. Biscotti noted himself, he was no longer observed
having difficulty moving from sitting to standing or during
Mr. Biscotti was reassessed 2 weeks after his initial more extensive position changes during treatment.
evaluation.
Balance 5. Canto JG, Shlipak MG, Rogers WJ, Malmgren JA. Prevalence, clini-
cal characteristics, and mortality among patients with myocardial
Mr. Biscotti’s SLS on the right was 22 seconds, and left infarction presenting without chest pain. JAMA. 2000;283:3223-
16 seconds. A repeat BBS had him earning a 54/56 score. 3229.
6. Zafari AM. Myocardial infarction. Medscape. http://emedicine.
medscape.com/article/155919-overview. Updated May 27, 2014.
Assessment Accessed June 29, 2014.
7. Grogan M. Ejection fraction: what does it measure? Mayo Clinic.
Mr. Biscotti reports marked improvement in his func- Sept. 19, 2008. http://www.mayoclinic.org/ejection-fraction/expert-
tional status. He accomplished all of the anticipated goals for answers/faq-20058286. Updated February 20, 2013. Accessed
the 2-week time period except tolerating continuous aerobic February 13, 2010.
activity for 20 minutes without rest (#3). In fact, he had met 8. Bhatia SR, Tu JV, Lee DS, Austin, PC. Outcome of heart failure with
all of the remaining anticipated goals except climbing a full preserved ejection fraction in a population-based study. N Engl J
Med. 2006;355:260-269.
set of stairs without rest or SOB (#7), projected to be met by 9. Conaway DG, O’Keefe JH, Reid KJ, Spertus J. Frequency of undiag-
5 weeks. nosed diabetes mellitus in patients with acute coronary syndrome.
The expected outcome goal for full independence with Am J Cardiol. 2005;96:363-365.
ADL and IADL was met, but not the stair-climbing goal for 10. Norhammar A, Enerz A, Nilsson G, Hamsten A. Glucose metabo-
lism in patients with acute myocardial infarction and no previ-
home.
ous diagnosis of diabetes mellitus: a prospective study. Lancet.
2002;359:2140-2144.
Plan 11. Cooper AF, Weinman J, Hankins M, Jackson G, Horne R. Assessing
patients’ beliefs about cardiac rehabilitation as a basis for prediction
To begin the transition to independent exercise, Mr. attendance after acute myocardial infarction. Heart. 2007;93:53-58.
Biscotti’s plan of care was amended to decrease physical 12. Haskell WL, Lee IM, Pate RR, et al. Physical activity and public
health: update recommendation for adults from the American
therapy sessions to once per week for 3 weeks, with the stated
College of Sports Medicine and the American Heart Association.
expectation that he would continue his mall-walking pro- Circulation. 2007;116:1081-1093.
gram 3 times per week. 13. Balady GJ, Williams MA, Ades PA, et al. Core components of car-
diac rehabilitation/secondary prevention programs: 2007 update a
scientific statement from the American Heart Association Exercise,
OUTCOMES Cardiac Rehabilitation, and Prevention Committee, the Council

on Clinical Cardiology; the Councils on Cardiovascular Nursing,
Epidemiology and Prevention, and Nutrition, Physical Activity, and
Mr. Biscotti returned for one visit and did not sched- Metabolism; and the American Association of Cardiovascular and
Pulmonary Rehabilitation. Circulation. 2007;115:2675-2682.
ule additional visits. Calls to his home were not returned.
14. American Diabetes Association. Physical activity/exercise and dia-
Therefore, no final reevaluation was performed. betes. Diabetes Care. 2004; 27(Suppl 1): S58-S62.
When Mr. Biscotti did not return for the remainder of his 15. National Heart, Lung, and Blood Institute. Calculate your body
plan of care, the referring physician was sent a report based mass index. http://www.nhlbi.nih.gov/guidelines/obesity/BMI/
on the reevaluation status at 2 weeks, and Mr. Biscotti was bmicalc.htm. Accessed April 17, 2010.
16. Borg GA. Perceived exertion: a note on “history” and methods. Med
discontinued from physical therapy. Sci Sports. 1973;5:90-93.
17. Scherer S, Cassady S. Rating of perceived exertion: development
and clinical applications for physical therapy exercise testing and
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Demers C, McKelvie RS, Negassa A, Yusuf S. Reliability, validity
and responsiveness of the six minute walk test in patients with heart
1. Iverson MD, Fossel AH, Ayers K, Palmsten A, Wang HW, Daltroy failure. Am Heart J. 2001;142:698-703.
LH. Predictors of exercise behavior in patients with rheumatoid 19. O’Connor P, Sforzo CA, Frye P. Effect of breathing instruction
arthritis 6 months following a visit with their rheumatologist. Phys on blood pressure responses during isometric exercise. Phys Ther.
Ther. 2004:84:706-716. 1989;69:757-761.
2. American Heart Association. Understand your risk of heart attack. 20. Tibb AS, Ennezat PV, Chen JH, et al. Diabetes lowers aerobic capac-
http://www.heart.org/HEARTORG/Conditions/HeartAttack/ ity in heart failure. J Am Coll Cardiol. 2005;46:930-931.
UnderstandYourRiskof HeartAttack/Understand-Your-Risk-of- 21. Kenny RA, Rubenstein LZ, Martin FC, Tinetti ME. Guideline for
Heart-Attack_UCM_002040_Article.jsp. Updated June 19, 2014. the Prevention of Palls in Older Persons. New York, NY: American
Accessed June 29, 2014. Geriatrics Society Panel on Falls in Older Persons; April 15, 2001.
3. American Heart Association. Warning signs of heart attack, 22. Muir SW, Berg K, Chesworth B, Speechley M. Use of the Berg
stroke, and cardiac arrest. http://www.heart.org/HEARTORG/ Balance Scale for predicting multiple falls in the community-
C o n d i t i o n s / 9 1 1-Wa r n i n g s - S i g n s - o f - a - H e a r t - A t t a c k _ dwelling elderly: a prospective study. Phys Ther. 2008;88:449-459.
UCM_305346_SubHomePage.jsp. Accessed June 29, 2014. 23. Shumway-Cook A, Baldwin M, Polissar NL, Gruber W. Predicting
4. Gillum RF, Fortmann SP, Prineas RJ, Kottke TE. International the probability for falls in community-dwelling older adults. Phys
diagnostic criteria for acute myocardial infarction and acute stroke. Ther. 1997;77:812-819.
Am Heart J. 1984;108:150-158.
Principles of Training and
5
Exercise Prescription
Skye Donovan, PT, PhD, OCS and LeeAnne Carrothers, PT, PhD
▪ Nonoxidative Training
CHAPTER OBJECTIVES ◦ Clinical Relevance
• List the general exercise benefits that are possible for an • Principles of Training
adult who follows the exercise recommendation from the ◦ Overload
joint Centers for Disease Control and Prevention (CDC)
◦ Specificity
and American College of Sports Medicine (ACSM)
expert panel. ◦ Reversibility
• Compare and contrast the oxidative and nonoxidative • System Changes With Exercise
pathways for adenosine triphosphate (ATP) production. ◦ Cardiovascular and Pulmonary Systems
• Identify the event duration benefits of the 3 major sub- ▪ Specific Adaptations to Exercise
strates for fuel.
▫ Blood Volume
• Name and describe the 3 principles of training.
▫ Cardiac Muscle
• Summarize the physiologic changes that occur in the
▫ Blood Pressure
cardiovascular/pulmonary system to acute versus chron-
ic exercise interventions. ▪ Pulmonary System
• List the chronic adaptations in response to exercise that ▪ Considerations for Patient Care
occur in the musculoskeletal system. ◦ Musculoskeletal System
• Discuss what is known about the relationship between ▪ Specific Adaptations to Exercise
exercise and the immune system and exercise and
▫ Motor Recruitment
depression.
▫ Muscle Hypertrophy
• Identify and define the components of exercise prescrip-
tion. ▫ Muscle Fatigability
• Give 2 examples of exercise prescription modification ▫ Bone Growth
for a varied pathology. ▪ Considerations for Patient Care
◦ Immune System
▪ Changes With Exercise
CHAPTER OUTLINE
▪ Considerations for Patient Care
• Metabolic Fuel ◦ Psychological Factors, Specifically Depression
◦ Chronic Adaptations to Exercise ▪ Changes With Exercise
▪ Oxidative Training ▪ Considerations for Patient Care
166 Chapter 5
• Exercise Prescription
Energy production
◦ General Considerations • Proteins
◦ Mode
◦ Intensity
• Carbohydrates
• Fats }
Oxidation
◦ Duration
ADP + Pi ATP
◦ Frequency
◦ Exercise Prescription and Movement-Related Energy utilization
Disorders • Active ion transport
• Muscle contraction
• Summary • Synthesis of molecules
• References • Cell division and growth
Figure 5-1. ATP as the central link between energy-producing and

In recent years, there has been a growing interest in health energy-utilizing systems of the body. ADP, adenosine diphosphate; Pi,
and wellness, specifically the impact exercise and physical inorganic phosphate. (Adapted from Hall JE, Guyton AC. Guyton and Hall
activity have on the prevention of chronic diseases. After a Textbook of Medical Physiology. 12th ed. St. Louis, MO: Saunders Company;
review of the evidence related to clinical, physiological, and 2011.)
epidemiologic factors associated with exercise, an expert
panel from the CDC and ACSM made the following recom-
mendation: “Every US adult should accumulate 30 minutes aspects of endurance and strength training, and how the
or more of moderate-intensity physical activity on most, body responds according to the type of training employed. It
preferably all, days of the week.”1(p 407) Moderate-intensity is important to note that there are significant effects on the
activity (defined as requiring 3 to 6 metabolic equivalents various systems by other training types (known as exercise
[METs]) was chosen for its ability to produce lasting health modes), such as flexibility and balance, that will not be dis-
benefits, even if there are not observable changes in maxi- cussed in this chapter.
mum oxygen consumption (VO2max).2 Exercise serves as an Finally, this chapter highlights the importance of thought-
important source both of primary and secondary preven- ful and accurate exercise prescription. Physical therapists
tion3 for diseases such as cancer, coronary artery disease (PTs) are experts in formulating exercise programs to meet
(CAD), obesity, diabetes, and hypertension (HTN), in addi- the needs of their clients and patients. This chapter will
tion to affecting multiple other diseases.4,5 This prevention discuss guidelines for screening for exercise readiness and
occurs through risk factor reduction in the form of reduced recommendations for creating a thorough exercise prescrip-
blood pressure (BP), decreased insulin needs/increased glu- tion for various patient/client populations. Benefits of an
cose tolerance, maintenance of normal blood lipids, and appropriate exercise prescription include improving func-
reduced total body fat.2,6 tion and encouraging optimal health both in healthy indi-
Exercise should be considered as medicine with ben- viduals and those individuals with disease and dysfunctions.
efits including (but not limited to) longevity, quality of life, Although understanding principles of exercise physiology is
socialization, weight control, disease prevention, and disease straightforward, the application of those principles to patient
management. A major benefit of regular exercise is reduced populations is less so. This chapter explores exercise from the
morbidity and mortality associated with cardiovascular dis- clinician’s point of view, paying particular attention to the
ease (CVD) and cancers. Lee and Skerrett7 demonstrated that integration of physiologic principles into exercise prescrip-
1000 kcal per week of exercise decreased mortality rates by tion and treatment plans.
30%, with a further 20% decrease with more than 2000 kcal/
week. There is also strong evidence to support that exercise
leads to improved cardiorespiratory and muscular fitness, METABOLIC FUEL
prevention of falls, reduced depression, and better cognitive
function.8 Finally, several studies report an improved sense The body uses 3 major substrates for fuel: fats, car-
of well-being, better work and sport performance, and reduc- bohydrates, and proteins. These substrates are broken
tions in anxiety and depression. down through various metabolic pathways into ATP to
This chapter provides an overview of the relevance of power the body for different levels of activity (Figure 5-1).
physiologic principles of training as they relate to exercise Conventionally, the term calorie is used to denote units of
prescription. While the previous chapter presented system energy. One calorie is the amount of energy required to use
changes with deconditioning, this chapter will explore the 1 g of water 1°C. Fat provides 9.4 kcal while carbohydrates
“reversibility” of deconditioning through the use of exercise. and proteins provide only 4.1 kcals. At any level of activity,
Using a systems basis, the impact of exercise on the car- a combination of the 3 substrates is being used to provide
diorespiratory, musculoskeletal, and metabolic function is energy; however, various conditions dictate their relative
explored in this chapter. A section of the chapter will present contributions.
Principles of Training and Exercise Prescription 167
Figure 5-2. Overall schema of energy transfer from foods
to the adenylic acid system and then to the functional
elements of the cells. (Adapted from Hall JE, Guyton AC.
Guyton and Hall Textbook of Medical Physiology. 12th ed. St.
Louis, MO: Saunders Company; 2011.)
Figure 5-3. Interorgan energy transfers. (Adapted from Levy MN,

Stanton BA, Koeppen BM. Berne & Levy Principles of Physiology. 4th ed.
St. Louis, MO: Mosby; 2006.)
At rest, the majority of energy needs are derived from a the mitochondria) to generate high amounts of ATP. These
combination of carbohydrates and fats. Each type and level critical differences in timing and energy yield account for the
of exercise requires different substrates and is dictated by contributions each pathway plays in exercise. It is important
substrate availability and metabolic efficiency. The metabolic to note that the 2 systems do not work in isolation; rather, all
systems that generate ATP can be divided into oxidative and of the metabolic pathways are working together during any
nonoxidative pathways (Figure 5-2). Glycogenolysis, glycoly- activity.
sis, and conversion of creatine phosphate (PCr) to ATP make Whole-body proportion of fat and fat-free mass also
up the nonoxidative pathways. These pathways are rapid contributes to metabolic drive (Figure 5-3). Skeletal muscle
and are able to generate only small amounts of ATP, but has much higher metabolic activity than adipose tissue.
can do so in the absence of or under low concentrations of Skeletal muscle is a key player in insulin-regulated glucose
oxygen (O2). Conversely, the oxidative pathway is slower to uptake, accounting for as much as 80% of whole-body glu-
turn on but is capable of a much greater energy yield. After cose uptake.9 Preservation of skeletal muscle mass has been
initial oxidation, carbohydrates, fats, and proteins enter into associated with increased insulin sensitivity.10 Likewise, it
the Krebs cycle and electron transport chain (located in has been shown that many metabolic diseases are linked to
168 Chapter 5
TABLE 5-1. SKELETAL MUSCLE FIBER TYPE AND METABOLIC PREFERENCE PROFILE
FIBER TYPE TYPE I TYPE IIA TYPE IIB
Metabolic nomenclature Slow oxidative Fast oxidative glycolytic Fast glycolytic
Diameter Small Intermediate Large
Glycolytic enzyme activity Low Intermediate High
Oxidative enzyme activity High Intermediate Low
Intensity/timing of exercise Low; unlimited 35% VO2max; intermediate 65% VO2max; short
term
Resistance to fatigue High Intermediate Low
Adapted from Thompson WR, Gordon NF, Pescatello LS, eds. ACSM s Guidelines for Exercise Testing and Prescription. 8th ed. Philadelphia,
PA: Wolters Kluwer, Lippincott Williams & Wilkins; 2010.
abnormally functioning mitochondria. Kelley et al11 describe are necessary to complete high-intensity exercise. Longer,
that mitochondria-deficient skeletal muscle is present in type less intense exercise utilizes oxidation of carbohydrates and
2 diabetics and obese insulin-resistant individuals as com- fat for sustained energy production. Oxidative metabolism is
pared with controls. responsible for activities lasting greater than 2 to 5 minutes
Sedentary lifestyle and aging both contribute to decreased (Figure 5-4).
insulin sensitivity. Studies examining obesity demonstrate Carbohydrates are a useful fuel to provide ATP via glucose
impaired glucose oxidation, decreased insulin sensitivity, oxidation; however, they have limits to their storage capacity.
and mitochondrial dysfunction concurrent with excess adi- Circulating glucose is taken up into muscle and liver cells
pose tissue.12 It has been shown that weight loss through diet to be stored as glycogen, which can then rapidly be broken
in the absence of physical activity improves insulin sensitiv- down to provide ATP. A limiting factor of glycogen use is its
ity and whole body metabolism.13 The addition of exercise, limited storage capacity, measuring less than one-tenth of fat
however, has a unique and important impact on whole-body storage capacity.14 Maximized glycogen stores can typically
metabolism. This section explores the role aerobic (endur- sustain activities of moderate intensity lasting up to 2 hours;
ance) and anaerobic (strength/interval training) training has activities longer than that require glucose supplementation.15
on altering metabolism. For events of longer duration, fats are primarily oxidized.
Skeletal muscle largely dictates whole-body metabolism. Fats produce a high-energy yield but at a greater O2 cost. The
The individual fibers that make up larger muscles are clas- body has an unlimited storage capacity for fat, but the break-
sified by their metabolic profile. Type I fibers are oxidative down process requires many steps and more O2 than car-
(slow), and Type II fibers are glycolytic (fast). There are bohydrate oxidation. Fat is less readily available. It is stored
also the intermediate Type IIa fibers, which are glycolytic- as triglycerides and must be broken down to free fatty acids
oxidative. The Type I fibers utilize aerobic metabolism and before it can be metabolized. The increased time and O2
therefore can remain activated for slower, sustained exercise. need associated with fat oxidation comes at a price, namely
They are also resistant to fatigue. Type II fibers generate exercise intensity. When fats are used as a primary fuel, the
energy from the nonoxidative, glycolytic pathway. These intensity of exercise may need to drop to accommodate the
fibers fatigue quickly and are used mainly for rapid bursts of increased O2 needed to metabolize the fats; however, the
activity. There are no muscles in the body that are made of length of exercise is virtually unlimited.
one type of fiber; all muscles are mixed-fiber type. The per- The role of proteins is not to provide substantial energy
centage of fiber type determines whether the muscle is used for cellular activity but to act as the building blocks for
for high-force, short-term activity or low-load, long-term the body’s tissues. Although protein is not a major fuel, its
activity (Table 5-1). metabolic contribution is affected by training. With exercise,
Given equal access to substrates and activity of metabolic more proteins participate in gluconeogenesis to provide glu-
enzymes, the intensity and duration of exercise determines cose to the cells.16 In general, the most important changes in
which metabolic pathway is activated. During intense, short- protein metabolism are the rates of muscle protein synthesis
duration muscular effort, the body relies mostly on carbohy- and protein breakdown. Evidence has shown that exercise
drates to generate ATP through nonoxidative metabolism. can improve whole-body protein levels. This anabolic result
The nonoxidative ATP-PCr system is used during short, is due to the effect exercise has on insulin levels and protein
intense bursts of exercise less than 30 seconds in duration, synthesis rates. Insulin has been shown to inhibit muscle
and glycolysis kicks in for bouts lasting 30 seconds to 2 min- protein breakdown.17 Also important in stimulating protein
utes.14 They are usually stored as glycogen in muscle and liver anabolism is the availability of appropriate substrates such as
and are the primary energy source for muscle. Carbohydrates amino acids and carbohydrates.17
Figure 5-4. Energy sources during exer-
cise. (Reprinted with permission from
Berne & Levy Principles of Physiology, 4th
ed, Levy MN, Stanton BA, Koeppen BM.
Copyright Mosby 2006.)
Chronic Adaptations to Exercise response to exercise.27-29 This increase in GLUT4 promotes

cellular glucose uptake, the first step in carbohydrate metab-
Oxidative Training olism and glycogen synthesis. Overall, endurance training
increases liver and muscle glycogen reserves, and decreases
Endurance (aerobic) training is usually defined as low- glycogen depletion—both of which help stave off fatigue.16
intensity, long-duration training. This type of training pri-
marily affects the cardiovascular/pulmonary system. From a Nonoxidative Training
strict metabolic standpoint, endurance-type exercise increas- Nonoxidative training can be defined as short, high-
es mitochondrial function, thereby increasing oxidative intensity interval training. It is important to note that
capacity.18 It is well documented that exercise increases mito- strength training falls into this category. In general, exercise
chondrial protein synthesis.19-21 With aerobic training, mito- most enhances oxidative metabolism as opposed to glyco-
chondria exhibit increases in their size, number, and enzyme lytic metabolism. In order to improve glycolytic capacity,
activity. These mitochondrial changes enhance the Krebs training needs to specifically match the event. Activities
cycle, oxidative phosphorylation, and the electron transport relying on anaerobic metabolism would benefit by engaging
chain, which ultimately supplies ATP. This increase in mito- in high-intensity, brief-duration training. The anaerobic sys-
chondrial function is supported by a concurrent increase tem relies on ATP-PCr and lactic acid to provide energy. A
in genes that encode mitochondrial proteins.22 Hawley and training program that stresses these systems will produce the
Holloszy12 provide evidence that a single bout of exercise desired results, namely enhanced speed and performance.
generates a signal to elevate mitochondrial biogenesis. Sprint training has been shown to target glycolytic enzyme
All substrate utilization is improved with training, but it activity. With increased glycolytic enzymes (lactate dehydro-
has its greatest effect on the capacity to oxidize fats. Exercise genase, phosphofructokinase, and glycogen phosphorylase),
increases mobilization of free fatty acids, resulting in elevat- utilization of glucose and glycogen is more efficient.30
ed circulating free fatty acids, which in turn increases the Glycogenolysis rates are increased with interval training,
use for metabolic fuel.23 Exercise has been shown to increase allowing substrate to be released faster in trained than in
fatty acid transport in the mitochondria, sarcolemma, and untrained muscle.30 Interval training has also been shown to
at the plasma membrane in human skeletal muscle.24 These increase ATP-PCr turnover.31 Short bouts of sprint training
results suggest that exercise-induced increases in skeletal have been shown to increase both myokinase and creatine
muscle fatty acid oxidation are supported in part by fatty acid phosphokinase, resulting in more rapid breakdown of PCr.32
transport.25 Enhanced fatty acid oxidation allows glucose In addition, trained muscle maintains higher storage of ATP
substrates to be relatively preserved. This so-called glycogen- and PCr as compared with untrained muscle.12,33 A study
sparing effect enables the body to maintain its glucose/glyco- investigating strength training demonstrated trained muscle
gen stores, which plays a role in delaying muscle fatigue.26 exhibited increased PCr and glycogen storage and subse-
Endurance exercise also improves carbohydrate metabo- quent increased ability to generate ATP.34 An unavoidable
lism. Insulin sensitivity is improved with exercise, as evi- consequence with anaerobic training is the build-up of lactic
denced by increased expression of the insulin-sensitive acid. Despite the improvements in ATP generation, there also
glucose transporter, GLUT4. Both the number and concen- need to be lactate-handling changes that occur in muscle
tration of GLUT4 transporters increases in skeletal muscle in for enhanced performance in anaerobic activities. Both the
170 Chapter 5
muscle’s capacity for lactate and speed of lactate clearance are higher than what it is normally exposed to. In other words,
improved with exercise. It has been shown that with train- the body and its systems must undergo relative stress to
ing, less lactate accumulates in muscle for a given workload; promote changes. It is also important to stress the difference
whether it is decreased production or increased clearance is between intensity needed to promote health benefits vs high-
yet to be elucidated.35 performance training. For many patients, exercise prescribed
Recent studies demonstrate that sprint interval training by the PT is at a volume and workload commensurate with
promotes similar metabolic adaptations to endurance train- health promotion and risk factor reduction.
ing. Both types of training increase lipid oxidation through Initial exposure to overload commonly results in fatigue
increased mitochondrial enzyme activity, which secondarily and altered physiologic function. The body has immedi-
promotes glycogen and PCr sparing during exercise. This ate reactions to increased load, including localized skel-
evidence suggests that high-intensity training may be suf- etal muscle damage with strength training, disproportionate
ficient and a more time-efficient method to promote similar increases in heart rate (HR) and shortness of breath (SOB)
changes than endurance training.36 The key to short, intense with aerobic activity, and rapid metabolic substrate depletion.
bouts of training mimicking changes seen with endurance Once exercise is terminated, the body undergoes an array
training is the subject’s need to endure a significant meta- of changes in an effort to recover from the imposed stress.
bolic stress.37 These changes include (but are not limited to) increasing the
number of red blood cells (RBCs) and mitochondria, repair of
Clinical Relevance skeletal muscles, and activation of antioxidant enzymes. This
recovery is more of an adaptation that will allow the body to
Not to overshadow training specificity, it is important sustain greater levels of similar type of stress. In effect, the
realize that all metabolic pathways are used to some extent body is attempting to acclimate to the imposed demands and
during different activities, albeit their percentage of con- to better prepare the body for the next bout of exercise.
tribution may be minimal. There is merit in stressing each This beneficial remodeling is dependent on appropriate
of the metabolic pathways by incorporating various types selection of exercise specific to the patient/client. Exercise
of training for meeting goals. For example, it is important below the adequate intensity threshold will not elicit the
for the sprinter to engage in aerobic training to establish adaptation response and will not promote beneficial changes.
an appropriate aerobic base. This will allow the athlete to Overload is commonly described as high-force contractions
withstand the more intense anaerobic training needed for or metabolic stress demands placed on the body. Metabolic
his or her event.23 Likewise, the older adult whose goal is stress, namely substrate availability and rate of depletion, is
to ambulate community distances would benefit from some greatest in endurance activities, where high force contrac-
anaerobic training to assist with more taxing tasks such as tions are usually used in short bursts of activity or in strength
climbing stairs. training.39 The overload principle also states that intensity
must increase over time to continue to promote and sustain
change. It is important to note that intensity does not have to
PRINCIPLES OF TRAINING be on a steady unending climb; rather, incorporating periods
of relative rest and changing mode of exercise may be a better
Exercise is a perceived stress to the body that triggers an way to get desired results.
adaptive response resulting in physiologic benefits. With The ACSM recommends training intensities of 60% to
repeated exposure to exercise, the body is able to adjust to the 70%1 repetition maximum (RM) for strengthening and
challenge (eg, by improved strength, O2 capacity, and flex- 60% to 80% of VO2max for cardiovascular fitness in healthy
ibility). The manner in which the body responds to exercise is adults.2 PTs should view these recommendations as guide-
dependent on how and to what degree exercise is performed. lines and modify as needed for varying patient populations.
Three principles—overload, specificity, and reversibility— Appropriate monitoring before, during, and after exercise
govern response to exercise and are the foundation for effec- is necessary to determine the appropriate training load for
tive exercise prescriptions. A recent publication reviewed the patients. Conventional methods of monitoring include HR,
use of exercise prescription for breast cancer survivors and BP, resting rate (RR), and rate of perceived exertion (RPE).
found that, of the 29 papers reviewed, none of them applied This illustrates the importance both of establishing base-
all of the principles of training (specificity was applied by line and incorporating progression into PT exercise pre-
64%, progression by 41%, overload by 31%).38 PTs must have scriptions. Clinicians must adequately stress the system to
a thorough understanding of these principles in addition produce change, but also do so in a safe manner in order to
to the role they play across the wellness spectrum for their protect the patients. Initially, the demand placed on the body
patients and clients. systems should be greater than at rest but not so difficult that
the patient will decompensate and not be able to complete
Overload the exercise bout. PTs must prudently alter rehabilitation
programs to either increase resistance, sets, repetitions, or
The overload principle states that, in order for the body total time of exercise. As the patient improves, the intensity
to change in response to exercise, it must receive a load of the exercise should increase to meet the anticipated goals
leading to the expected outcomes established by the PT and enjoys and to incorporate those into the prescription. The
the patient. PT is well trained to creatively design exercises that will best
benefit the patient while recognizing the implications of the
Specificity training on overall function.
Different types of exercise exert different physiologic ben-

efits, which is the underlying principle of specificity. It stands
Reversibility
to reason that adaptations occur in only systems that are Reversibility refers to the temporary nature of the benefits
actively stressed. The type and robustness of the adaptations of exercise; the benefits of exercise are not maintained if exer-
are also specific to the training stimulus. The explicit gains cise is discontinued. The loss of physiologic adaptations with
from exercise are restricted to the location and/or system the termination of or a gross reduction in training is defined
receiving the imposed demand. For instance, resistive upper as detraining. A decrease in either the intensity or the fre-
extremity (UE) exercises do not improve lower extremity quency in training may result in physiologic decline. In order
(LE) strength, nor does strength training improve aerobic to sustain the beneficial changes associated with exercise, a
capacity. maintenance plan of persistent and regular exercise must be
Specificity is addressed within the framework of exercise carried out.
prescription by the mode of exercise selected by the PT. In Termination of endurance training induces negative
choosing the right mode of exercise, the PT can alter sys- changes in the cardiovascular system, including decreased
tems of the body that will ultimately produce the best func- blood plasma volume, cardiac contractility, left ventricular
tional improvements. For example, individuals who require (LV) mass, and VO2max. A rapid decline in aerobic capacity
improvements in range of motion (ROM) will benefit most is seen with detraining, including a 10% to 17% decrease in
from flexibility training as opposed to endurance or strength stroke volume (SV) seen in just 12 to 21 days,42-44 and a 3.6%
training. It is extremely important to select activities that to 14% reduction in VO2max in 2 to 4 weeks.42,43,45-53 There
will match desired outcomes. From a broader perspective, are also accompanying metabolic changes such as a decrease
it is important to realize that functional tasks incorporate in mitochondrial number and enzyme activity resulting in
many individual skills. For example, gaining community a diminished oxidative capacity.54 Insulin sensitivity and
ambulation function may require exercise modes to improve glycogen storage capacity is also reduced, negatively affect-
strength, aerobic endurance, balance, and flexibility. ing carbohydrate metabolism.48,55-60 Cessation of strength
There is little transfer of skill from one training program training results in loss of power, force, and speed. Fiber
to another, which encourages the use of task-specific train- cross-sectional area also declines, primarily in Type II fibers
ing. From a rehabilitation perspective, it is imperative to with disuse over several weeks.48,61 Importantly, all of these
prescribe exercises that will promote carryover to functional changes can be avoided by engagement in proper mainte-
activities. For example, for a person with chronic obstruc- nance programs.
tive pulmonary disease (COPD), light resistance training In order to prevent detraining, an exercise program must
will help strengthen accessory breathing muscles, while either sustain the intensity or frequency of the prior level of
endurance training will help with ambulating community exercise. Despite a one-third to two-thirds decrease in train-
distances. As noted in a study by Ries et al,40 balance training ing duration, healthy adults are able to maintain aerobic
significantly improved balance performance and decreased capacity while keeping the intensity of their work elevated.54
risk of falls in patients with Alzheimer’s disease.40 This The same is true for strength training; exercising only 1 to
is especially interesting because it implies that cognition 2 times per week but using an intense workload will main-
regarding the exercises does not need to play a role in pro- tain strength for up to 20 weeks.54 Maintenance programs
moting adaptations. Other studies demonstrate the restricted can be designed to prevent atrophy and loss of strength or to
transfer of skill to other systems outside of those specifically preserve aerobic capacity, flexibility, and function. The PT
trained. Young describes that, although strength training must consider this fact not only while treating the patient,
improves body mass and muscle hypertrophy, it has little but, more important, on discharge. It is crucial to educate the
impact on sports performance.41 This review article also patient on the reversibility of exercise benefits. PTs should
states that sports-specific exercise prescription is necessary encourage patients to engage in exercise of an appropriate
to achieve maximal performance. Another example is noted intensity that will sustain health and to find an enjoyable
in a paper by Potdevin et al38 describing plyometric train- exercise routine that will help with long-term compliance.
ing that was employed in swimmers. It was shown that only
the dive and turns (plyometric activities during swimming)
improved with this type of training, and there was no effect SYSTEM CHANGES WITH EXERCISE
on kick propulsion or stroke refinement.38
Prescribing the type of exercise includes many variables
such as deciding what metabolic system to stress, type of Cardiovascular and Pulmonary Systems
contraction utilized, and patient position for exercise. It is The cardiorespiratory system has many roles in the
also important to consider what types of exercise the patient body. It serves as an O2 and nutrient delivery system, aids
172 Chapter 5
Specific Adaptations to Exercise
TABLE 5-2. CHRONIC ADAPTATIONS
IN THE CARDIOVASCULAR SYSTEM IN Blood Volume
Blood is made of up several elements that aid in O2 deliv-
RESPONSE TO EXERCISE ery (RBCs and hemoglobin), immunity (white blood cells),
● Increased venous return coagulation (platelets), temperature regulation, and pH bal-
ance. Regular exercise improves the O2 transport system by
● Increased contractility
increasing total blood volume, the number of RBCs, and
● Decreased resting HR hemoglobin.67 While plasma volume increases immediately
● Increased SV and cardiac output in response to exercise, RBC and hemoglobin volume take
days to weeks to increase.67 This increase in O2 delivery
● Increased coronary perfusion capacity allows the body to respond to the increased demand
● Increased blood volume of exercise.
● Increased blood flow Cardiac Muscle
Chronic exercise also allows the heart to maintain a
● Decreased resting SBP
lower HR for a given workload than that of an untrained
● Increased O2 extraction individual. With training, the heart undergoes long-term
changes in contractility and decreased overall myocardial
VO2, reducing demand, accounting for lower HR. After 10 to
in thermoregulation and immune function, and helps rid 20 weeks of habitual training, resting HR has been shown to
the body of unwanted materials. During exercise, incredible decrease by 5 beats per minute (bpm) with the potential to
demands are placed on the body, many of which are met decrease 1 to 2 bpm every 1 to 2 weeks in sedentary individu-
by the cardiorespiratory system. Fortunately, this system als.14 This change is beneficial because a lower resting HR
responds readily to exercise and is able to adapt according to increases physiologic reserve, which will be available to the
the needs of the body. body in times of stress. This decreased resting HR does not,
PTs recommend exercise to a wide variety of patient however, compromise the overall blood supply to the body.
populations because of the beneficial effects on the cardio- A slower HR allows for increased filling of the LV. Increased
respiratory system (Table 5-2). Engaging in cardiovascular filling beneficially places the wall of the LV on a slight
(aerobic) training promotes an increase both in health and stretch, allowing the LV to more effectively eject, through the
fitness. In addition, exercise may be used as an intervention Frank-Starling effect.68 This improved contractility results
for a variety of cardiovascular disorders and also as a preven- in an increased SV, defined as the amount of blood ejected
tive measure against chronic disease. from the left ventricle with each contraction. Improved SV
Regular exercise improves venous return and heart con- is often noted as a hallmark of cardiovascular endurance.
tractility, while beneficially lowering systolic BP (SBP).62 With chronic exercise, elevated SV is present even at rest; a
Both the intensity and the duration of exercise are important sedentary individual has an average SV of 65 mL, whereas a
factors in dictating changes in the cardiorespiratory system. trained individual can average 110 mL.23 Regular training
Moderate to vigorous activity is beneficial in the prevention allows for increased cardiac output (CO) at rest, largely due
of CVD.63,64 Currently, the ACSM recommends healthy to increased SV and not HR, as training decreases resting
adults engage in cardiovascular exercise at a “moderate to HR. Increased SV also depends on the volume of blood that
vigorous activity for a minimum of 30 minutes at least 5 days returns to the heart, the capacity of the LV, and the resistance
per week.”2(p 8) Vigorous exercise has the greatest impact on (afterload) the heart needs to work against.
the cardiorespiratory system but moderate exercise can ben- The size of the myocardium, especially the LV, has the
efit those who are not medically stable enough to undergo capacity to enlarge with regular aerobic training. Usually
vigorous intensity exercise.65 A study by Zheng et al sub- only noted in endurance-trained athletes, both the wall
stantiates that walking at an intensity of 8 METs 30 minutes thickness and the internal chamber diameter increase in
per day/5 times per week reduces the risk of congestive heart response to stresses endured by the LV. The thickened wall
disease by 19%.66 Most adaptations occur in this system in has more muscular mass and therefore is more powerful and
response to aerobic exercise. While there are some changes augments LV contractility. The increased chamber diameter
noted with anaerobic and resistance training, those effects is caused by the increase in ventricular filling secondary to
are negligible compared to aerobic activity. There are impor- increased plasma volume and diastolic filling. These adapta-
tant acute and long-term changes resulting from exercise tions are particularly beneficial to deliver O2 to exercising
therapy. This section will primarily focus on the chronic tissue.
adaptations (see Figure 5-1). Myocardial contractility improves with interval training
even with severe CVD.69 Cardiac rehabilitation programs
have been shown to significantly decrease cardiac mortality
BP
CO TPR
HR SV Vascular structure Blood viscosity
Contractility Blood volume
Figure 5-5. BP regulation.
up to 25% as compared with usual care.70,71 Evidence indi- what is seen in the heart and circulatory system. The pulmo-
cates that with adherence to a cardiac rehabilitation program, nary system has been described as being “overbuilt,” in that
changes in fitness, risk, and quality of life can continue to be a large respiratory reserve already exists to allow the body to
seen for up to 5 years after the initial event.72 withstand and meet the demands of heavy exercise.23 Despite
Blood Pressure this reserve, there are modest improvements seen with long-
term training. Improved respiratory strength and endurance
Habitual exercise benefits the hemodynamic system
have been reported to take 6 to 10 weeks to occur and are
in many ways, of which the most profound is overall
seen across all age groups with land- and water-based exer-
BP-lowering capability (Figure 5-5). A meta-analysis con-
cise.23 In those with diminished lung capacities, long-term
ducted in 2002 demonstrated that all frequencies, intensities,
exercise is especially beneficial, promoting changes in an
and types of aerobic exercise lowered BP both in normoten-
accelerated time frame.
sive and hypertensive subjects of varying ethnic groups and
Clinicians use exercise in patients with respiratory dis-
body weight.73 Exercise influences various factors that play
orders with the goal of improving aerobic capacity and
a role in determining BP, including decreasing amounts of
submaximal exercise tolerance. Resistance training of ven-
circulating norepinephrine, increasing vasodilatory sub-
tilatory pump muscles using intensity of 30% maximum
stances, reducing insulin resistance, and directly affecting
inspiratory pressure has been shown to improve respiratory
the kidney.74-78 The exact mechanism of how regular exercise
muscle strength.97 This intensity has been cited to be the
lowers BP is unknown. The first of 2 hypotheses states that
minimal resistance needed to promote functional improve-
exercise training reduces HR and CO at rest and that contrib-
ments. Additionally, UE resistance exercises, which stress
utes to lower BP. An alternative theory supports the concept
accessory breathing muscles, have been noted to positively
that immediate hypotension that follows individual exercise
affect quality of life while decreasing fatigue in those suf-
sessions can have an additive response by repeating bouts on
fering from COPD.98 A recent study by Kortianou et al98
successive days, resulting in ultimately lower BP.79-81
suggests that interval training is also a good method to train
It is well established that exercise is a highly successful
the pulmonary system. Integrating periods of rest allowed
strategy to prevent and treat HTN.81,82 Sedentary indi-
patients to exercise at a higher intensity than they were able
viduals have a 35% to 70% greater risk of developing HTN
to when completing a continuous exercise session, which
as compared with age-matched subjects who were physically
then equated to the same total work. In patients with COPD,
active.83-85 Chronic HTN is the primary risk factor for the
exercise has been shown to improve surfactant levels, which
development of coronary vascular disease.83-85 Sedentary
helps to reduce surface tension in the alveoli, making it easier
lifestyle has been shown to be an independent risk factor
to breathe.99 Additionally, it has been shown that exercise
relating to cardiovascular mortality.86-90 Increased activity
may help with desensitization toward dyspnea and increasing
is the best way to decrease risk of CAD.90-92
overall exercise capacity.97
Aerobic exercise in hypertensive subjects lowers BP in all
ages and genders.80,82,93 Multiple studies report that regular Considerations for Patient Care
physical activity lowers both SBP and DBP by 8 to 10 mm Hg Ultimately, the goal of training the cardiorespiratory
in patients with HTN.86,94-96 Over a period of 16 weeks, system is to enable patients to return to activities of daily
patients with severe HTN who engaged in regular exercise living within the limits imposed by their disease. In order
exhibited a decrease in SBP and diastolic BP (DBP), LV to maximize cardiorespiratory endurance, the exercise pro-
mass, and the need for HTN-lowering drugs.78 The clearest gram must sustain a considerable increase in O2 consump-
benefits are achieved by exercise set at an intensity of 40% to tion and should use a large amount of muscle mass. Examples
60% VO2max.1,90,91 of exercise modes that accomplish this are cycling, brisk
Pulmonary System walking, jogging, and swimming. The ideal frequency of
this endurance-promoting exercise is 20 to 60 minutes per
Exercise training over time does not favor notable benefits day, 3 to 5 times per week. Intensity should be above the
to the respiratory system in healthy subjects as opposed to
174 Chapter 5
TABLE 5-3. ATHEROSCLEROTIC CARDIOVASCULAR DISEASE RISK FACTOR THRESHOLDS

POSITIVE RISK FACTORS DEFINING CRITERIA
Age Men ≥ 45 years; women ≥ 55 years
Family history Myocardial infarction, coronary revascularization, or sudden death before 55 years of
age in father or other male first-degree relative, or before 65 years of age in mother or
other female first-degree relative
Cigarette smoking Current cigarette smoker or those who quit within the previous 6 months or exposure
to environmental tobacco smoke
Sedentary lifestyle Not participating in at least 30 minutes of moderate intensity (40% to 60% O2 uptake
reserve) physical activity on at least 3 days of the week for at least 3 months
Obesitya Body mass index ≥ 30 kg/m2 or waist girth > 102 cm (40 inches) for men and > 88 cm
(35 inches) for women
HTN SBP ≥ 140 mm Hg and/or DBP ≥ 90 mm Hg, confirmed by measurements on at least
2 separate occasions, or on antihypertensive medication
Dyslipidemia Low-density lipoprotein cholesterol (LDL-C) 130 mg/dL-1 (3.37 mmol/L-1) or high-density
lipoprotein cholesterol (HDL-C) 40 mg/dL-1 (1.04 mmol/L-1) or on lipid-lowering medica-
tion. If total serum cholesterol is all that is available, use 200 mg/dL-1 (5.18 mmol/L-1)
Prediabetes Impaired fasting glucose fasting plasma glucose 100 mg/dL-1 (5.50 mmol/L-1) but
126 mg/dL-1 (6.93 mmol/L-1) or impaired glucose tolerance 2-hour values in oral glucose
tolerance test 140 mg/dL-1 (7.70 mmol/L-1) but 200 mg/dL-1 (11.00 mmol/L-1) confirmed
by measurements on at least 2 separate occasions
NEGATIVE RISK FACTOR-DEFINING CRITERIA
High-serum HDL-C ≥ 60 mg/dL-1 (1.55 mmol/L-1)
It is common to sum risk factors in making clinical judgments. If HDL is high, subtract 1 risk factor from the sum of positive risk factors,
because high HDL decreases CVD risk.
aProfessional opinions vary regarding the most appropriate markers and thresholds for obesity; therefore, allied health professionals
should use clinical judgment when evaluating this risk factor.
Reprinted with permission from Thompson WR, Gordon NF, Pescatello LS, eds. ACSM s Guidelines for Exercise Testing and Prescription.
8th ed. Philadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins; 2010.
training threshold but below that which induces abnormal contraindications to exercise (Table 5-5). Field tests are easy
clinical signs and symptoms. This intensity typically falls to administer, are inexpensive, and require little equipment,
between 50% to 80% VO2max for a healthy adult.2 Note that making them suitable for use in various clinical settings.
the PT may need to adjust accordingly to baseline fitness Field tests enable the PT to estimate the patient’s workload
level; someone of low fitness may start (and see gains) at 40% (VO2) based on simple measurement techniques including
to 50% VO2max and may exercise only for a much shorter HR and distance traveled. While VO2 is important to deter-
time frame (eg, 5 to 7 minutes). To see continued gains, the mine, it is technically difficult, expensive, and burdensome
program should be progressed at the rate of a 10% increase to patients, again highlighting the role of field testing in the
in volume per week. clinic. Selection of the appropriate cardiorespiratory endur-
Baseline exercise testing and monitoring throughout ance field test is dependent on the patient presentation and
training are of paramount importance. The ACSM recom- reliability/validity data for those tests in the given popula-
mends that individuals with 2 or more risk factors undergo tion. Some of the most common field tests used to determine
a graded exercise test before starting an exercise regimen cardiorespiratory fitness include the Rockport 1-Mile Walk
of vigorous intensity, while those who have known CVD Test, the 6-Minute Walk Test (6MWT), and the YMCA Step
require an exercise test both for moderate and vigorous activ- Test. Detailed instructions for these tests, including stratifi-
ities (see Tables 5-1, 5-3, and 5-4). Additionally, the ACSM cation tables, can be found in ACSM publications.2 Proper
recommends males over the age of 40 years and females over monitoring is an important part of field testing before, dur-
the age of 50 years also receive a graded exercise test before ing, and after the test. HR, RPE, BP, and workload are often
engaging in vigorous activity.2 All other patients are appro- used as methods of monitoring for field tests.
priate for a submaximal field test, given there are no absolute
TABLE 5-4. ACSM MAJOR SIGNS OR SYMPTOMS SUGGESTIVE OF

CARDIOVASCULAR, PULMONARY, OR METABOLIC DISEASE
SIGN OR SYMPTOM CLARIFICATION/SIGNIFICANCE
Pain, discomfort (or other One of the cardinal manifestations of cardiac disease, in particular CAD
anginal equivalent) in the Key features favoring an ischemic origin include the following:
chest, neck, jaw, arms,
or other areas that may ● Character: Constricting, squeezing, burning, heaviness or heavy feeling
result from ischemia ● Location: Substernal, across mid-thorax, anteriorly; in one or both arms, shoul-
ders; in neck, cheeks, teeth; in forearms, fingers in interscapular region
● Provoking factors: Exercise or exertion, excitement, other forms of stress, cold
weather, occurrence after meals
Key features against an ischemic origin include the following:
● Character: Dull ache, knife-like, sharp, stabbing, jabs aggravated by respiration
● Location: In left submammary area; in left hemithorax
● Provoking factors: After completion of exercise, provoked by a specific body
motion
SOB at rest or with mild Dyspnea (defined as an abnormally uncomfortable awareness of breathing) is one
exertion of the principal symptoms of cardiac and pulmonary disease. It commonly occurs
during strenuous exertion in healthy, well-trained persons and during moderate
exertion in healthy, untrained persons. However, it should be regarded as abnor-
mal when it occurs at a level of exertion that is not expected to evoke this symp-
tom in a given individual. Abnormal exertional dyspnea suggests the presence of
cardiopulmonary disorders, in particular LV dysfunction or COPD.
Dizziness or syncope Syncope (defined as a loss of consciousness) is most commonly caused by a
reduced perfusion of the brain. Dizziness and, in particular, syncope during exer-
cise may result from cardiac disorders that prevent the normal rise (or an actual
fall) in CO. Such cardiac disorders are potentially life threatening and include
severe CAD, hypertrophic cardiomyopathy, aortic stenosis, and malignant ventricu-
lar dysrhythmias. Although dizziness or syncope shortly after cessation of exercise
should not be ignored, these symptoms may occur even in healthy persons as a
result of a reduction in venous return to the heart.
Orthopnea or paroxysmal Orthopnea refers to dyspnea occurring at rest in the recumbent position that is
nocturnal dyspnea relieved promptly by sitting upright or standing. Paroxysmal nocturnal dyspnea
refers to dyspnea, beginning usually 2 to 5 hours after the onset of sleep, which
may be relieved by sitting on the side of the bed or getting out of bed. Both are
symptoms of LV dysfunction. Although nocturnal dyspnea may occur in persons
with COPD, it differs in that it is usually relieved after the person relieves him- or
herself of secretions rather than specifically by sitting up.
Ankle edema Bilateral ankle edema that is most evident at night is a characteristic sign of heart
failure or bilateral chronic venous insufficiency. Unilateral edema of a limb often
results from venous thrombosis or lymphatic blockage in the limb. Generalized
edema (known as anasarca) occurs in persons with nephrotic syndrome, severe
heart failure, or hepatic cirrhosis.
Palpitations or tachycardia Palpitations (defined as an unpleasant awareness of the forceful or rapid beat-
ing of the heart) may be induced by various disorders of cardiac rhythm. These
include tachycardia, bradycardia of sudden onset, ectopic beats, compensatory
pauses, and accentuated SV resulting from valvular regurgitation. Palpitations also
often result from anxiety states and high CO (or hyperkinetic) states, such as ane-
mia, fever, thyrotoxicosis, arteriovenous fistula, and the so-called idiopathic hyper-
kinetic heart syndrome.
(continued)
176 Chapter 5
TABLE 5-4 (CONTINUED). ACSM MAJOR SIGNS OR SYMPTOMS SUGGESTIVE OF

CARDIOVASCULAR, PULMONARY, OR METABOLIC DISEASE
SIGN OR SYMPTOM CLARIFICATION/SIGNIFICANCE
Intermittent claudication Intermittent claudication refers to the pain that occurs in a muscle with an inad-
equate blood supply (usually as a result of atherosclerosis) that is stressed by exer-
cise. The pain does not occur with standing or sitting, is reproducible from day to
day, is more severe when walking upstairs or up a hill, and is often described as a
cramp, which disappears within 1 to 2 minutes after stopping exercise. CAD is more
prevalent in persons with intermittent claudication. Patients with diabetes are at
increased risk for this condition.
Known heart murmur Although some may be innocent, heart murmurs may indicate valvular or other
CVD. From an exercise safety standpoint, it is especially important to exclude
hypertrophic cardiomyopathy and aortic stenosis as underlying causes because
these are among the more common causes of exertion-related sudden cardiac
death. Although there may be benign origins for these symptoms, unusual fatigue
or SOB also may signal the onset of or change in the status of usual activities of
cardiovascular, pulmonary, or metabolic disease. These signs or symptoms must be
interpreted within the clinical context in which they appear because they are not
all specific for cardiovascular, pulmonary, or metabolic disease.
Adapted from Gordon S, Mitchell BS. Health appraisal in the non-medical setting. In: Durstine JL, King AC, Painter PL, eds. ACSM s
Resource Manual for Guidelines for Exercise Testing and Prescription. 2nd ed. Philadelphia, PA: Lea & Febiger; 1993:219-228.
PTs often use HR to determine appropriate exercise Bone mass is influenced by multiple factors, including
intensity. Calculating a patient’s maximum HR (HR max) genetics, hormonal and nutritional status, and activity sta-
is clinically relevant as it is a direct correlate to percentage tus. Bones have the ability to adapt to mechanical stimuli
workload. A common equation used to estimate an individ- (eg, increased load) and maintain the potential to remodel
ual’s maximal HR is HR max = 220 – age (in years); however, throughout life, which is described as Wolff’s law.103 The
this equation yields as much as a 10 mm Hg error.100,101 In major force that is responsible for bone remodeling is ground
addition, this estimate cannot be used for children younger reaction force (eg, landing from a jump). High-intensity
than age 16 years.102 Many clinicians instead choose to loading is common in jumping and gymnastics activities
use the Karvonen formula to determine HR reserve (HRR) exhibiting ground reaction forces up to 7.5 times greater than
calculated as HRR = HR max – HR rest.23 Exercise intensity low-intensity activities such as walking.104 The intensity,
is then prescribed at a range of HR max or HRR. The ACSM duration, and frequency of loading in the form of ground
recommends exercising at 45% to 75% of HRR or 65% to 90% reaction forces contribute to the magnitude of bone remod-
HR max for optimal cardiorespiratory benefits. eling. Animal studies have demonstrated that only a modest
number of high-intensity loading activities (5 repetitions of
Musculoskeletal System jumping from a height) per day led to increased bone mass.105
These studies also note that there are no added benefits when
The musculoskeletal system is one of the areas of the body the number of repetitions was increased to 10.105,106 The
with the most robust adaptations to exercise. It has been well animal studies described employed supraphysiologic strain,
documented that exercise increases bone density, skeletal which might not be able to be replicated in humans; it does,
muscle size, motor recruitment, and metabolism. In line however, highlight important concepts that warrant further
with the fundamental exercise principles of specificity and research. It has been shown that muscular contraction also
overload, in order for the musculoskeletal system to change, contributes positively to bone growth; however, its magni-
the exercise must be specifically targeted to the muscle group tude is difficult to determine.107 Resistance training has been
and its supporting structures and must impose an appre- shown to increase bone mass but only at an intensity that also
ciable load. Physiologic changes will occur in response both promotes muscular hypertrophy.107
to strengthening and endurance training, and each training
type will have its own unique effect. Depending on the mode Specific Adaptations to Exercise
of exercise, variable changes will occur in skeletal muscle Motor Recruitment
(Table 5-6). Endurance training improves fatigue resistance, The motor unit, composed of the motor neuron and the
while strength training increases force-generating capabil- fiber(s) it innervates, is the fundamental unit of the muscu-
ity. Additional adaptations induced by training include loskeletal system. Firing of the motor unit requires integra-
increased recruitment, bone density, and muscle size. tion of motor and sensory information from the central and
TABLE 5-5. CONTRAINDICATIONS TO EXERCISE TESTING

ABSOLUTE
● A recent significant change in the resting electrocardiogram suggesting significant ischemia, recent myo-
cardial infarction (within 2 days), or other acute cardiac event
● Unstable angina
● Uncontrolled cardiac dysrhythmias causing symptoms or hemodynamic compromise
● Symptomatic severe aortic stenosis
● Uncontrolled symptomatic heart failure
● Acute myocarditis or pericarditis
● Suspected or known dissecting aneurysm
● Acute systemic infection, accompanied by fever, body aches, or swollen lymph glands.
RELATIVEA
● Left main coronary stenosis
● Moderate stenotic valvular heart disease
● Electrolyte abnormalities (eg, hypokalemia, hypomagnesemia)
● Severe arterial HTN (ie, SBP of > 200 mm Hg and/or a DBP of > 110 mm Hg) at rest
● Tachydysrhythmia or bradydysrhythmia
● Hypertrophic cardiomyopathy and other forms of outflow tract obstruction
● Neuromuscular, musculoskeletal, or rheumatoid disorders that are exacerbated by exercise
● High-degree atrioventricular block
● Ventricular aneurysm
● Uncontrolled metabolic disease (eg, diabetes, thyrotoxicosis, or myxedema)
● Chronic infectious disease (eg, mononucleosis, hepatitis, AIDS)
● Mental or physical impairment leading to inability to exercise adequately
aRelative contraindications can be superseded if benefits outweigh risks of exercise. In some instances, these individuals can be exer-
cised with caution and/or using low-level end points, especially if they are asymptomatic at rest.
Reprinted with permission from Thompson WR, Gordon NF, Pescatello LS, eds. ACSM s Guidelines for Exercise Testing and Prescription.
8th ed. Philadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins; 2010.
peripheral nervous system to promote the desired motor

response. The motor neuron activates the appropriate num- TABLE 5-6. CHRONIC ADAPTATIONS IN THE
ber of motor units to provide the necessary force required
by the movement. Motor unit activation is of critical impor-
MUSCULOSKELETAL SYSTEM IN
tance in performance of activities, with higher levels of RESPONSE TO EXERCISE
activity requiring increased recruitment of motor units. The ● Increased skeletal muscle strength
majority of recruitment occurs according to motor unit size,
● Increased motor control and motor learning
with small Type I having a lower recruitment threshold than
the larger Type IIa and IIb motor units. There is evidence to ● Enhanced mapping of the primary motor cortex
support high threshold activity may occur in the absence of ● Increased motor recruitment
low threshold activity in limited situations such as in elite
● Increased firing frequency
athletes requiring enhanced muscle action.101
Training can improve motor unit recruitment and is ● Decreased coactivation of agonist and
thought to be the initial adaptation seen in muscle in response antagonists
to exercise. Enhanced muscular performance in the absence ● Increased muscle cross-sectional area
of increased strength is proposed to be of neurogenic origin. ● Increased collagen synthesis
Improvements occur within the first 2 weeks of training and,
although the evidence is not confirmed, these benefits can ● Increased collagen stiffness
be from learning, enhanced mapping of the primary motor ● Increased motor recruitment
cortex, increased motor recruitment, morphologic changes
178 Chapter 5
at the neuromuscular junction, increased firing frequency, and the cross-sectional area of the whole muscle also increas-
and decreased coactivation of agonist and antagonists.108,109 es. The increase in contractile tissue leads to enhanced cross-
There are central mechanisms at play for all skilled move- bridge formation, enabling muscle to develop greater levels of
ments. Practicing these movements or components of these tension. Both Type I and Type II fibers are capable of hyper-
movements increases performance through neural adapta- trophy. It is has been shown, however, that resistance training
tions. Task-specific learning allows for appropriate balance, favors hypertrophy of Type II fibers largely because of their
biomechanics, and postural support to complete exercises enhanced plasticity.123 Type II fibers have been shown to
that can in turn enhance skill. Practice also improves ability hypertrophy in just 6 weeks, whereas Type I fibers take lon-
to contract muscles in desired patterns and allows for carry- ger than 10 weeks.118,123 Now larger in size and in number,
over from one limb to another.110,111 Further supporting the the fibers need to be packed more tightly within the muscle.
idea of central control of movement is that mental imagery In order to accomplish this, fibers may alter their angle of
and mental (imagined) practice enhance muscle contraction pennation. Several studies show evidence of hypertrophy
and performance of skilled movements.112 coincident with increased angle of pennation with resistance
Muscle Hypertrophy training.124-126 Both the increased fiber diameter and the
increased angle contribute to increased production of force,
Skeletal muscle mass continues to increase until early
which equates to strength gains.
adulthood (ages 18 to 25 years), which is associated with nor-
Noted hypertrophy has been documented with 8 to
mal growth and maturation processes, but steadily declines
12 weeks of resistance training127 but can vary slightly by
with advancing age.14 This progressive loss of skeletal muscle
gender, age, and muscle group. Both genders demonstrate
mass, known as sarcopenia, is seen in aging and disease. The
marked increases in strength with resistance training; how-
relative decrease in muscle mass has deleterious effects on
ever, males exhibit greater absolute strength and muscle
whole-body metabolism, strength, and heat production. In
cross-sectional area than women. This difference in muscle
order to prevent sarcopenia, skeletal muscle protein synthesis
size is relatively confined to the UE. Many studies document
must outpace skeletal muscle protein breakdown. Increased
that women have a capacity similar to men for strength and
muscle mass is achieved largely through hypertrophy. Skeletal
muscle size gains in the LEs with strength training.128-134
muscle is not capable of initiating cell division and prolif-
The UE dominance exhibited in males is largely due to the
eration to repair and replace damaged muscle fibers. Skeletal
higher circulating levels of testosterone and muscle androgen
muscle, although mitotically silent, remains plastic and able
receptors located in the UEs.135,136
to respond to a wide variety of stimuli. Exercise is one of the
most powerful stimuli inducing muscular protein synthesis. Muscle Fatigability
Transient hypertrophy is seen with an acute exercise Endurance training is of long duration and lower intensity
bout (one session) because interstitial edema and muscles and is geared toward increasing resistance to fatigue. This
will return to their original size after several hours. Chronic type of exercise preferentially targets slow oxidative (Type I)
hypertrophy is a longer-standing morphologic change in and fast oxidative glycolytic fibers (Type IIa), with no appre-
the muscle that is supported by increased protein synthesis. ciable hypertrophy noted. Benefits of endurance training in
This growth is induced by longer-term strength training the musculoskeletal system include an increase in number
and also from the influence of anabolic hormones, namely of mitochondria, mitochondrial enzymes, and substrate
testosterone.113-115 Overall, the mechanism of chronic hyper- availability—all of which affect muscle metabolism, which is
trophy leads to an increased number of contractile myofibril discussed in detail in the Metabolism section found earlier
proteins (actin and myosin) that enable greater cross-bridge in this chapter.
formation and force development. The increased growth of Bone Growth
muscle fibers occurs at the level of the myofibrils, which
The crest of bone accumulation occurs at puberty, illus-
exhibit the addition of contractile materials at their periph-
trating the importance of high-intensity137 exercise in this
ery.116 It has been postulated that the addition of these
age range. It is important to note, however, that in cases of
proteins is dependent on the activation of mitotically active
hormonal imbalance such as is seen in athletic female triads
satellite cells.117 Another potential mechanism of increas-
or in menopause, high-intensity loading exercise cannot
ing muscle area is the process of hyperplasia. Evidence of
attenuate the bone loss associated with estrogen deficiency.
hyperplasia exists from experimental studies using animals
Bone loss starts as early as in a person’s mid-30s when con-
and describes myofibril “splitting” after training, leading to
sidering trabecular bone and in their mid-50s in cortical
frank division of the myofibril and subsequent increase in
bone and can occur at a rate as fast as 0.5% per year.138-140
myofibril number.118,119 Despite its description in animals,
Participation in activities promoting high ground reaction
hyperplasia in humans occurs at a very slow rate and contrib-
forces (eg, jumping sports) leads to higher bone density and
utes only minimally to increased muscle size and therefore is
increased propensity to lay down new bone.141-143 In the
not matched to strength gains.120-122
absence of these forces, bone integrity suffers as demon-
The extent to which each muscle group is loaded will
strated by studies surrounding antigravity flight, complete
determine the amount and location of hypertrophy. An
bed rest, and neurological injuries that compromise weight-
increase in cross-sectional area of individual fibers occurs
bearing status.144
Considerations for Patient Care strength training. A compensatory body position or altered
biomechanics may activate different muscles during per-
Strength can be determined both statically (isometrics)
formance of the exercises. Strength training also affects the
or dynamically through functional ROM. PTs have various
supporting elements of the musculoskeletal system, namely
methods to determine strength both from the perspective of
tendons. Training has been shown to increase tendon stiff-
a single maximal contraction and muscular endurance. One
ness and also to promote tendon hypertrophy, which may
RM is defined as the greatest load through full ROM and
have implications in tendon response to rapid force.152-154
often relates to the gross strength of a single muscle group.
Beyond increased muscle mass, resistance training is an
Many tests exist to estimate 1-RM from several contractions.
excellent method of accruing bone strength. Moderate resis-
For example, the clinician selects a weight of appropriate
tance training ≤ 60% 1-RM at least 2 to 3 times per week
intensity for the patient to perform between 4 and 12 con-
is necessary to optimize bone density. Additionally, the
tractions. The number of completed contractions and the
ACSM recommends high-impact activities (eg, gymnastics,
weight are then entered into an equation, resulting in an
plyometrics, sports that involve running and jumping)
approximate 1-RM. One such method is the Brzycki equa-
for 30 to 60 minutes at least 3 days per week for increased
tion (1-RM = weight lifted (pounds)/[1.0278 – (repetitions to
bone strength. It is important to encourage patients who
fatigue × 0.0278)], which allows the patient to perform mul-
are at risk for osteoporosis to engage in a strength train-
tiple contractions and still evaluate 1-RM.145 This and other
ing program early on in their fitness pursuits to maximize
1-RM estimations are considerably less reliable and valid if
benefits. Resistance training is also an excellent intervention
the patient is able to complete more than 8 repetitions.
for maintaining or increasing bone density with a diagnosis
The clinical relevance of determining 1-RM is limited of osteoporosis; it is often safer than plyometric or dynamic
since functional activities require repeated contractions of exercises as there is a low risk for fractures.
multiple muscle groups acting together. PTs usually prescribe
resistance exercises of 8 to 12 repetitions, which equates to the
ACSM recommendation of an intensity of 50% to 75% 1-RM. Immune System
Resistance training is beneficial for all age groups when the The relationship between exercise and the immune sys-
proper techniques and guidelines are followed. For children, tem still remains unclear. The immune system is driven
the ACSM recommends 1 to 3 sets of 6 to 16 repetitions for by complex interactions of cells, hormones, and chemical
major muscle groups at a moderate intensity 2 to 3 noncon- messengers both innately derived from the body and those
secutive days of the week.146 The practitioner should realize that invade the body from an outside source. Additionally,
that significant muscle hypertrophy will not occur before the the neuroendocrine system greatly influences the immune
onset of puberty, and that the benefits of resistance training system, further complicating the organization and com-
are to improve coordination, motor response, increased bone munication of these pathways (Figure 5-6). Despite the
density, and the promotion of health through exposure to intricate cross-talk of the 3 systems, the overall function of
various modes of exercise. Adults of all ages have the capac- the immune system is clear: to initiate tissue repair when
ity to improve strength and muscle cross-sectional area. The it is damaged. This damage can be in many forms such as
ACSM recommends adults engage in 8 to 10 various muscle- direct tissue injury, infection with a pathogen, or exposure to
strengthening exercises 2 to 3 times per week. Each muscle stress. The immune system responds to injury by removing
group needs to be targeted with 2 to 3 different exercises damaged tissue and promoting movement and proliferation
at an intensity that brings muscle to fatigue (8 to 12 repeti- of special cells to the area to support tissue healing. These
tions).2 In the older adult, the literature is conflicted. There cells have specific roles in the immune response such as inac-
is evidence that at an advanced age the potential for muscle tivating pathogens, destroying infected cells, and activating
hypertrophy is decreased.147-149 Other studies cite that age inflammation.
has no effect on hypertrophy.131,150 Despite the impact aging
has on amount of hypertrophy, the ACSM recommends that Changes With Exercise
the older adult engages in muscle strengthening consisting of Exercise is considered to be a stress to the immuno-
8 to 10 exercises at moderate intensity (10 to 15 repetitions) logic system; the body responds over time by increasing the
2 to 3 times per week.2 number and activity of lymphocytes. It has been noted that
Resistance training most often benefits activities requir- lymphocytes are increased from 6 to 24 hours after an acute
ing strength and/or power. Endurance is also increased bout of exercise.155 Evidence suggests that regular exercise
because of an improved economy of performance.151 Strength promotes resistance to illness, inflammation, and tumor
increases have been documented early on in resistance train- progression.156,157 Regular exercise elevates the number
ing programs, even before physiologic hypertrophy has and activity of cytokines and natural killer (NK), B, and
occurred. This increased improvement is primarily due to T cells.23 The increase in NK cells is of particular interest
neurological recruitment. because of their protective effects against viral infections and
It is important to also focus on technique when perform- cancer.158,159 Moderate exercise has been shown to prevent
ing strength training. Correct and accurate body position upper respiratory tract infections23 and is associated with
is required to target the desired muscles for hypertrophy in delayed progression of HIV.160 In a review by Haaland et
180 Chapter 5
Figure 5-6. Integrated responses to stress mediated by the sympathetic nervous system and the hypothalamic-pituitary-adrenocortical
axis. (Adapted from Levy MN, Stanton BA, Koeppen BM. Berne & Levy Principles of Physiology. 4th ed. St. Louis, MO: Mosby; 2006.)
al, long-term endurance programs decreased inflammation Considerations for Patient Care
in patients with heart failure and type 2 diabetes.156 It has
The amount of damage the body incurs with exercise is
been estimated that regular exercise improves immunity by
dependent on the intensity, duration, and frequency of the
15% to 25%. It is debatable, however, how this affects disease
exercise. A fine line exists between enhancement and sup-
susceptibility.157
pression of immune system based on training parameters. In
Acute bouts of exercise result in an increase in circulating
a position statement published by the Exercise Immunology
white blood cells, known as leukocytosis.23 Neutrophils and
Review, “The general consensus on managing training to
monocytes (macrophages) have also been noted to increase
maintain immune health is to start with a programme of
after exercise proportional to the duration and intensity
low to moderate volume and intensity; employ a gradual and
exercise. A clinically relevant difference is seen in T, B, and
periodized increase in training volumes and loads.”163(p 64)
NK cells, which are suppressed after exercise, and typically
The position statement also warns against excessive train-
return to normal levels within 24 hours.157 It is thought that
ing loads that could result in injury or exhaustion while also
the release of catecholamines during exercise contributes to
ensuring adequate rest and recovery. The clinician should
this drop in B and T cell activity.160
also realize that time to exhaustion, internal stress, and
A fine line exists between enhancement and suppression of immunocompetence are all individual factors that will vary
the immune system based on training parameters. Following from one patient to the next. Factors that may negatively
strenuous exercise the immune system is suppressed for affect immunocompetence include presence of disease, psy-
several hours or days, increasing the risk for infection.23 A chological or physiologic stress, and various medications
study focused on marathon runners and endurance athletes (eg, chemotherapy). There are no definitive exercise pre-
demonstrates a self-reported increase in incidence of upper scriptions for optimizing immune function in patients with
respiratory tract infections.161,162 A proposed mechanism for chronic diseases. The clinician should be prudent by pre-
this increased predisposition to infection is the acute decline scribing appropriate intensity and duration of exercise that
of NK, B, and T cells following strenuous exercise.157 would enhance immune function while not exacerbating the
patient’s confounding medical diagnoses. Lastly, importance
should be stressed on adequate recovery time in order to are created to improve overall health, reduce risk for the
avoid exhaustion and overtraining that could negatively development or progression of disease, and promote physical
affect the immune system. fitness in a manner that ensures safety for the participant.
Each person will have his or her own definition of fitness; it
Psychological Factors, Specifically will be specific to his or her personal view of optimal health
and well-being whether that involves disease prevention or
Depression minimizing disability. A well-designed exercise program can
provide a means for increasing independence and overall
Both aerobic and strength training improve symptoms
function.
in those diagnosed with depression.164,165 It is important
to note, however, that regular activity does not prevent the The program needs to consider the patient’s baseline
onset of depression. Individuals with depression have been health status, abilities, and desired goals. The PT should also
found to have a hyperactive hypothalamic-pituitary-adrenal consider the patient’s familiarity with the mode of exercise,
and with accompanying elevated levels of cortisol (see Figure access to equipment, and time constraints. Each exercise
5-6). Depression has also been associated with decreased prescription should be unique to the individual for whom it
hippocampal expression of various neurotrophic factors (eg, is prescribed, taking into account the specific health needs,
brain-derived neurotrophic factor).166 interests, and clinical status of that person.2 Customized
exercise programs that are patient- and function-focused will
Changes With Exercise help improve compliance and prevent injury. Despite the vast
Acute exercise is viewed as a stressor and causes rise in variability in the factors and resultant exercise prescriptions
norepinephrine and cortisol through direct activation of the described earlier, all programs should have one common
hypothalamic-pituitary-adrenal axis.23 Those who engage predominant feature: they are specifically individualized to
in regular exercise, however, exhibit decreased levels of cor- the needs, desires, and stated goals of the person who plans
tisol in response to acute bouts of exercise or stress.167-169 to follow the program.
It is thought that exercise positively affects hippocampal The broad categories of exercise include cardiovascu-
neurotrophic gene expression and subsequently improves lar training, strength, flexibility, speed, agility, and bal-
the symptoms of depression. An additional benefit of exer- ance.2 Ideally, the exercise prescription is determined from
cise is the resultant increase in monoamines, tryptophans data obtained in an objective assessment of the individual
and B-endorphin levels, which also attenuate symptoms of response to exercise, be it by standard exercise testing proto-
depression. col or by a previously presented functional or field test. Both
Exercise has been used successfully to ameliorate categories of testing can be used to help diagnose, assign risk
symptoms of depression in health subjects across all age stratification, and set appropriate guidelines and goals for
groups.170-173 Patients who exercised regularly reported patients and clients. Many options exist to stratify patients
symptom reductions similar to those receiving cognitive in various states of fitness and disease or dysfunction. Using
behavioral therapy.174,175 Likewise, exercise has been shown tests with high validity and reliability will produce more
to decrease depression accompanying various chronic dis- meaningful interpretation. However, ease of use, cost, time of
eases, including cancer,176 neuromuscular disorders,177 car- administration, and appropriateness for the patient are also
diac conditions,178 and COPD.179 critical factors to consider.
Fitness tests range from medically monitored clinical
Considerations for Patient Care exercise tests to field tests conducted in a variety of settings.
Despite strong evidence for the links between exercise Commonly used tests include the use of treadmills, cycle
and reduction of clinical depression, its use is still under ergometers, upper body ergometers, and steps. Certainly the
investigation. More studies on the clinical effects and dos- test chosen must be justified by past medical history and
age response to exercise are needed to determine optimal screening and/or physical examination. The practitioner
prescription parameters. It is known that overtraining mim- should have a general familiarity with many fitness tests
ics depressive symptoms, so treatment plans should employ in order to select the most appropriate one based on mode
appropriate rest, recovery, and variety of activity. Currently, of exercise, end point of test, and safety considerations.
exercise should be used as an adjunct to psychological and Additionally, the clinician should be aware of tests for vari-
pharmacologic interventions, and patient response should be ous ages and levels of ability, as those criteria often require
monitored closely. modifications of standard fitness tests. The clinician should
also monitor the patient throughout the test and have proper
equipment and personnel to accomplish this effectively.
EXERCISE PRESCRIPTION Various monitoring techniques include HR, BP, electrocar-
diogram (ECG), VO2, RR, and RPE. Each fitness test should
also allow for a warm-up or practice period before the test
General Considerations and cool down period after the test to maximize results and
The benefits of exercise both for fitness and general health for the safety of the patient. Testing should be terminated if
and well-being are well documented.2,180 Exercise programs
182 Chapter 5
muscle groups over prolonged periods in activities that are
TABLE 5-7. WHEN TO STOP AN EXERCISE rhythmic and aerobic in nature (walking, running, hiking,
TEST (ACSM RECOMMENDATIONS) cycling, stair climbing, etc).”2(p 163) The mode of exercise
selected to attain these qualities should reflect the indi-
● SOB/wheezing vidual’s goals and specific functional deficits, as well as skill
● Intermittent claudication level and enjoyment of the activity. Careful attention to these
● Angina factors is likely to improve compliance and thus chances for
success.181,182
● Chronotropic incompetence
● HR fails to increase with increased exercise inten- Intensity
sity and subject wants to stop
● SBP > 250 mm Hg or DBP > 115 mm Hg The ACSM recommends a broad range of training intensi-
ties depending on the activity. For cardiorespiratory training,
● Cyanosis, lightheadedness, nausea, pallor they range from a level corresponding to 55% to 90% of HRmax,
● Severe fatigue 40% to 85% of O2 uptake reserve (VO2R = VO2max – VO2rest), or
● Subject requests to stop or testing equipment 50% to 85% of HRR (HRR = HRmax – HRrest).2 Higher intensi-
fails ties of exercise are appropriate and safe to improve cardiore-
spiratory fitness in healthy/fit individuals, while intensities
Reprinted with permission from Committee Members; Gibbons as low as 40% to 49% HRR have been demonstrated to bring
RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for
exercise testing: summary article. Circulation. 2002;106(14):1883- about changes in sedentary or deconditioned individuals.
1892.
Duration
any of the identified criteria for cessation of an exercise test Early ACSM recommendations for exercise duration pro-
are met, as listed in the ACSM resource guide (Table 5-7). moted continuous exercise for durations of 30 to 60 minutes,
The information gained from the fitness test will allow for which proved to be somewhat daunting for many individu-
a thorough, adequate, and specific exercise prescription. The als, especially those who were sedentary or just beginning an
essential components to exercise prescription are described exercise program. The most recent ACSM/CDC guidelines183
by the FITT principle: frequency, intensity, type (mode), and reflected a consensus desire to include the most number of
time. An important addition to the FITT principle is progres- Americans and to reflect a continuum of activity recom-
sion of the prescribed activity, which fosters continued gains mendations. Their recommendation stated that adults should
and achievement of patient goals. It is important to note the “accumulate”146 minutes of moderate intensity exercise per
rate of progression is highly variable among individuals and week vs performing continuous activity. As an individual
is dependent on functional status. gains endurance and exercise tolerance, exercise duration
can be increased with the goal of increasing exercise time.
When designing a specific exercise program, the ACSM
For individuals who have been sedentary or deconditioned,
recommends that clinicians consider the specific health
an important goal is to attain durations of 30 to 40 min-
needs of the individual when creating or modifying a
utes of continuous ambulation, which provides the indi-
program for that person. Specifically, variability of percep-
vidual with the endurance necessary to achieve community
tual and physiologic responses to exercise necessitates careful
ambulation.184-186
titration of duration and intensity of exercise as well as the
need to ensure patient safety. Additionally, each exercise ses-
sion should include a warm-up, focused exercise, cool down, Frequency
and stretching.2 Time should also be devoted to educating Fitness goals may be attained for those who are decondi-
the patient in goal-setting, self-monitoring techniques, and tioned or sedentary with only twice-weekly exercise, though
independent progression of exercises. In doing so, the patient optimal benefits can be attained with 3 to 5 sessions per
will be empowered to continuously exercise for the benefits week. An analysis of the potential benefits of increasing
of improved health and function. Finally, the best exercise exercise frequency beyond 5 days per week demonstrates that
program will be the one that is the most successful in bring- there is a greater likelihood of injury and only minimal ben-
ing about long-term health changes associated with exercise, efits to be attained. When determining appropriate exercise
which requires a balance of behavioral change techniques frequency for a patient, intensity of exercise should also be
and solid exercise science to support attainment of the indi- considered. For individuals exercising at higher intensities
vidual goals.2 (60% to 80% HRR), fewer bouts of exercise (twice weekly)
are adequate to attain desired changes. Individuals who are
Mode sedentary or deconditioned when beginning an exercise
program and exercising at lower intensities may not only
The greatest benefit (measured as changes in VO2max)
require more frequent weekly exercise sessions, but they also
attained from exercise occurs when exercise “uses large
may need to perform multiple short bouts of exercise each
day to meet their training goals. Frequency and duration
of exercise can be adjusted to attain a goal of 45 minutes of SUMMARY
continuous activity. Once the individual is able to tolerate
45 minutes of continuous activity, only then should intensity Exercise is an important intervention to promote benefi-
be increased.186 cial morphologic, physiologic, and metabolic change in the
body. These changes are highly specific and can be modi-
fied depending on intensity, mode, and duration of exercise.
Exercise Prescription and Movement- Exercise adaptations are readily reversible and are affected by
Related Disorders cessation of training, increased age, and presence of disease.
Individual differences based on heredity, prior training expe-
Exercise is vital to the maintenance of health and wellness. rience, and health status affect the amount of physiologic
It is also a valuable intervention to slow the rate of change change induced by exercise.
brought about by disease as well as to aid the recovery of As the chapter content in the next section will show,
health, function, and well-being lost by patients because of the PT is able to prescribe an appropriate and individual-
injury or illness. Initiating and progressing exercise pro- ized exercise intervention based on knowledge of disorder
grams for individuals who are ill or recovering, however, pathophysiology, thorough patient examination, and careful
requires careful consideration. Exercise prescriptions need consideration of individual patient needs. Well-considered
to factor in not just individual desires and goals, but the exercise prescriptions for patients can enhance fitness, pro-
pathophysiological effect system disorders have on exercise mote health, and ensure safety as well as encourage long-
tolerance. For individuals with acute or chronic movement- term compliance.
related disorders that limit exercise tolerance, a parameter
based on an age-related HR max or percentage of VO2max
may not be appropriate. For these individuals, the onset of
disorder-specific signs or symptoms determine the intensity,
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188 Chapter 5
He was able to play board games with his grandchildren, but
CASE STUDY 5-1 not able to play ball, go for walks, or play any active games.
Mr. Cedar reported difficulty with locomotion and move-
Lola Sicard Rosenbaum, PT, DPT, MHS ment. His knee symptoms and fatigue increased with walk-
ing greater than 50 feet on level ground, or uneven terrain, as
well as with using stairs or ramps.
EXAMINATION He stated he was not able to participate in any exercise
beyond daily activities because of SOB and fatigue.
History
Clinician Comment A significant cardiac
Current Condition/Chief Complaint history along with a patient report of fatigue beyond expec-
tations for an activity would be a red flag for careful moni-
Mr. Cedar, an obese 51-year-old White male, was referred
toring when examining a patient for consideration of an
to physical therapy by his primary care physician (PCP) for
exercise program.1 In addition, Mr. Cedar had significant
an aquatic exercise program to improve his activity tolerance
comorbidities of HTN, arthritis, and obesity. These needed
without aggravating his arthritic knee pain. He reported that
to be considered when determining whether he would be an
he wanted to be able to take walks with his grandchildren or
appropriate aquatics physical therapy candidate. Further,
play with them without getting so tired.
it was possible that Mr. Cedar’s dyspnea and fatigue with
Social History/Environment activity were due to underlying heart failure. Heart failure,
He was previously employed as a police officer, but accept- along with his HTN, would be an important consideration
ed a medical retirement 3 years ago because of deteriorating with aquatic treatment as the presence of either might des-
cardiac health. ignate the level of water immersion he would tolerate.
Several months prior to the physical therapy appointment, A 100-cm column of water exerts a pressure of 76 mm Hg
he was awarded custody of his 2 preschool-aged grandchil- on a person’s body surface. This pressure compresses super-
dren. He was designated as the primary caregiver since his ficial veins, resulting in a blood volume shift to the heart
wife worked outside their home. and thorax. This blood volume shift is not significant on
He lived in a private home with 4 outside stairs with immersion to the iliac crest but can increase significantly on
no railing, and one flight of inside stairs with railings. His immersion up to the neck.2 Immersion past the xiphoid pro-
grandchildren’s bedrooms were on the second floor and Mr. cess can produce hemodynamic problems in a patient with
Cedar complained of difficulty climbing up and down stairs. moderate MI or heart failure. Unfortunately, the patient is
Mr. Cedar smoked cigarettes in the past but quit 4 years not aware of the hemodynamic deterioration taking place
prior. He reported alcohol use of 2 to 3 beers 2 days per week. in deeper water, and a patient can maintain a false sense of
well-being. Immersion to the xiphoid process does not affect
Family History mean pulmonary artery pressure or pulmonary capillary
Mr. Cedar’s father was still living and diagnosed with pressure. Immersion to the neck or in a supine position
CAD, HTN, diabetes mellitus (DM), and hyperlipidemia. increases both pulmonary artery and capillary pressure,
Mr. Cedar reported CAD “runs in my family.” His mother resulting in LV overload and increased SV, both of which
and both sets of grandparents died from CAD complications, are dangerous in moderate MI and heart failure patients.2
either stroke or cardiac pathology. Aquatic therapeutic exercise for patients with moderate
Medical/Surgical History to severe MI or heart failure can be allowed provided the
patient remains in an upright position immersed no deeper
Mr. Cedar had 2 previous cardiac catheterizations and than the xiphoid process. Water-based therapy with the
was diagnosed with severe CAD. He had a myocardial appropriate modifications, therefore, can be as safe as land-
infarction (MI) and coronary artery bypass graft prior to his based physical therapy in the treatment of middle-aged
catheterizations. He was also diagnosed with hyperlipidemia, males with cardiovascular impairments.2
HTN, morbid obesity, dyspnea, and recurrent angina.
Heart failure is a difficult disease to define. The American
Mr. Cedar wanted to improve his cardiac health but was
Heart Association lists 4 stages of heart failure3:
not able to continue in a standard cardiac rehabilitation pro-
gram because of bilateral knee pain, left greater than right. 1. Stage A: At risk to develop heart failure without evi-
He underwent a left knee arthroscopy and was diagnosed dence of heart dysfunction.
with osteoarthritis (OA). 2. Stage B: Evidence of heart dysfunction without symp-
Reported Functional Status toms.
He reported difficulty with self-care and home manage- 3. Stage C: Evidence of heart dysfunction with symptoms.
ment. He reported SOB with dressing, getting breakfast, 4. Stage D: Symptoms of heart failure despite maximal
doing housework, or caring for his 2 young grandchildren. therapy.
Though easier to recognize in the moderate to severe stages, • Xanax, a benzodiazepine: used for the management of
heart failure is often missed in the early stages when a anxiety disorders or for the short-term relief of symp-
patient may complain of dyspnea but not have evidence toms of anxiety or anxiety associated with depressive
of LV systolic dysfunction.4 Dyspnea, fatigue, and ankle symptoms
edema are physical signs of heart failure that are sensi- • Diovan, an ace inhibitor: used alone or in combination
tive but nonspecific and of low predictive value since they with other classes of antihypertensive agents (eg, thia-
occur in many other diseases. Orthopnea and paroxysmal zide diuretics) in the management of HTN
nocturnal dyspnea are specific signs of heart failure but Reviewing Mr. Cedar’s medications helped to identify
have low sensitivity because heart failure has to be quite medical conditions he had not mentioned when originally
advanced before they occur. asked, such as hypothyroidism, anxiety, depression, and
Mr. Cedar’s body mass index (BMI) of 53.75% indicates gastroesophageal reflux disease. It was important to stress
extreme obesity and more than doubles his risk of heart that the 2 medications to manage his HTN needed to be
failure.5 Other clinical clues from Mr. Cedar’s history were taken consistently.
the presence of a previous MI, HTN, dyspnea, and fatigue.
The possibility of early heart failure needed to be considered
as the interview continued.
An addendum to Mr. Cedar’s referral to physical therapy
Medications indicated that he had undergone a recent treadmill stress test,
during which he maintained a normal ECG with no evidence
Mr. Cedar’s current medications were Synthroid (levo-
of exercise-induced ischemia. His report of varying treadmill
thyroxine sodium), Lasix (furosemide), Plavix (clopidogrel
speeds and inclines, as well as the assessment of ischemia (in
bisulfate), Prevacid (lansoprazole), acetylsalicylic acid (ASA),
his case, absent) suggests he underwent a symptom-limited
Zetia (ezetimibe), Lopressor (metoprolol tartrate), Xanax
maximal exercise stress test. The normal ECG result along
(alprazolam), Diovan (valsartan), and Aleve (naproxen).
with BP, O2 saturation (SpO2), and HR monitoring reason-
ably rules out left- or right-sided heart failure and unman-
Clinician Comment Mr. Cedar was taking aged HTN.10
many prescription medications, taking a few over-the-
counter medications, and occasionally used alcohol. Mr.
Cedar has a veritable cocktail of prescription medications Clinician Comment Mr. Cedar was a medi-
to which he occasionally adds an alcoholic drink or over- cally retired, obese, middle-aged male with a cardiac his-
the-counter medication, such as Advil. Using 2 different tory and an arthritic left knee. His goal was to improve his
online drug interaction checkers,6,7 more than 10 possible ability to care for his dependent grandchildren. Because of
interactions between his medications and social drinking his arthritic knees, aquatic physical therapy might be an
were identified, which, in turn, may affect his status for ideal treatment to improve his activity tolerance. The stress
physical therapy treatment. test findings suggested that his dyspnea was not due to heart
Since Mr. Cedar was at risk for a drug interaction,8 he failure or a gas-exchange disorder. Further confirmation of
needed to be advised to tell his physicians and pharmacists this could be achieved in a full systems review. It could be
about all of his medications. Filling all of his medications anticipated that auscultation would confirm the absence
at the same pharmacy that has a conscientious drug-drug of an S3 heart sound associated with heart failure.11 Clear
interaction monitoring program was advised.9 lung sounds and normal SpO2 would eliminate restrictive
lung disease or a gas-exchange disorder as the cause of his
His prescription medications and their indications are as dyspnea.10 A full systems review would determine whether
follows: Mr. Cedar would be an appropriate candidate for physical
• Synthroid: used as replacement or supplemental therapy therapy.
in congenital or acquired hypothyroidism of any etiology
• Lasix: used in the management of edema.
• Plavix: used to reduce the risk of MI in patients with Systems Review
atherosclerosis documented by recent ischemic stroke,
recent MI, or established peripheral arterial disease Cardiovascular/Pulmonary System
• Prevacid: used for short-term treatment and symptom- Resting: HR: 70; BP: 134/84; RR: 22; SpO2 96%; S1S2
atic relief of gastroesophageal reflux disease sounds only: no S3 heard, breath sounds clear
• Zetia: used as a cholesterol absorption inhibitor Edema: impaired. Mild edema noted bilateral ankles,
• Lopressor, a beta adrenergic blocking agent: used alone which was not pitting edema.
or in combination with other classes of antihyperten-
sive agents in the management of HTN
190 Chapter 5
Clinician Comment Mr. Cedar had pre- Mr. Cedar’s obesity is an issue. In this instance, his BMI
sented himself for his physical therapy initial evaluation was determined. Other clinical tests conducted by PTs dur-
approximately 20 minutes early so he would have time to ing an examination that would indicate obesity include
recover from his walk from the parking lot to the waiting waist to height, waist circumference, hip circumference,
room. After walking with him the 150 feet from the wait- waist:hip ratio, and abdominal height in supine (as mea-
ing room to the treatment room, his SOB was noted. His sured from the table).17 Patients may also undergo more
SOB abated after a short rest while sitting in a chair with elaborate testing to determine the extent of their obesity,
back support. including dual-energy X-ray absorptiometry, bioimped-
ance, skinfold thickness, and plethysmography. Despite the
Mr. Cedar sat, rested, and answered patient interview
fact that PTs may not actually conduct these tests, they
questions for approximately 10 minutes before vital signs
should be aware of how to interpret their findings and use
were taken. This met the guideline recommendation for
the results to enhance patient treatment.
taking resting BP measures of at least 5 minutes rest prior.12
An aneroid device was used and a large-size cuff positioned
on his right arm and lined up with the lines drawn on the
cuff to indicate proper circumference. He was positioned Neuromuscular System
with his back and arm supported. Gait: He ambulated independently, without an assistive
Clear breath sounds and the absence of S3 heart sound were device. An antalgic gait pattern was noted with decreased left
confirmed at rest but remained to be assessed with activity. stance time. Walking speed appeared slower than normal.
Locomotion: He transferred independently but slowly
using bilateral UEs to assist sit to stand and vice versa.
Integumentary System Balance: Normal bilateral stance, impaired single-leg
stance, bilaterally
Presence of scar formation 24 cm long in midsternal area
Motor function: No gross deficits noted.
was noted.
Continuity and pliability of skin was within normal limits Communication, Affect, Cognition,
(WNL). Learning Style
Musculoskeletal System No deficits were noted in communication, affect, and
Gross symmetry: WNL cognition. He was able to make his needs known, was ori-
ented ×3, and demonstrated a normal emotional response.
Gross ROM: WNL, slight decrease in left knee flexion
He reported he learned best by demonstration with written
Gross strength: 3/5, no break testing done
instructions. No learning barriers were noted.
Height: 69 inches (1.75 m); weight: 364 pounds (165 kg);
BMI: 53.75, very obese Education Needs
He would benefit from education regarding his disease
Clinician Comment Mr. Cedar’s multiple- processes as well as the role exercise would play to manage
year history of arthritis in his left knee, lack of exercise, and control disease progression. Instruction in self-moni-
and decreased function suggested that he had muscle toring of HR, RPE, and respiratory rate during exercise was
weaknesses in one or both of his LEs. Manual muscle test- indicated.
ing (MMT) is used by PTs to test strength. Sustained and
repetitive isometric exercise can cause an increase in CO Clinician Comment Mr. Cedar walked inde-
and a disproportionate rise in SBP, DBP, and mean BP.13 pendently without the use of an assistive device. During the
The sustained hold for 1 to 3 seconds against resistance interview, he reported function limiting left knee pain; how-
required by the patient to determine MMT grades above ever, his observed ability to walk was hampered more by
3/5 is a precaution in certain patient populations, but does SOB and the need for frequent rests. Mr. Cedar’s knee pain
not need to be avoided.14 Clear instructions to avoid breath was a contributing factor to his functional limitations, but
holding during the resisted effort can minimize the CO and his impaired aerobic capacity and endurance were probably
BP changes noted earlier.15 a greater limiter of his function. The results of the systems
Mr. Cedar’s strength was assessed by asking him to move review indicated that further testing of Mr. Cedar’s aerobic
his extremities through a full ROM against gravity, but capacity and endurance was needed, in addition to explo-
his strength at end range was not break tested. Without ration of his LE joint mobility, ROM, and performance
the applied resistance, the optimal MMT grade that could in gait. Since he showed an impaired ability to perform a
be assigned was 3/5, which corresponded to the ability to single-leg stance on either LE, further testing of his balance
contract the tested muscle through a full ROM against was indicated to determine if he was at risk for falls.
gravity.16
Tests and Measures therapy interventions are having an effect on ankle edema.
Figure-of-eight ankle measurements have been shown to
Aerobic Capacity and Endurance be reliable, valid, and an efficient measurement of ankle
Two-minute walk test (2MWT): Distance walked 125 m edema as compared to the gold standard of water displace-
(410 feet); BP: 144/80; HR: 88; RR: 32; SpO2: 96%; S1 and S2 ment volumetry.20
heart sounds only; complained of SOB and sweating. Borg
Rating of Perceived Exertion was 15/20. Mr. Cedar com-
plained of left anterior knee pain afterwards. Gait, Locomotion, and Balance
Gait: Mr. Cedar ambulated on level surfaces without an
Clinician Comment A clinical decision need- assistive device but with a slow pace, wide base of support,
ed to be made on whether to use the 2MWT or the 6MWT and slight decrease in left stance time. While ambulating,
with Mr. Cedar. The 6MWT has been shown to be the test Mr. Cedar reported 3 to 4/10 pain intensity in his left knee.
of choice when using a functional walk test for clinical During the 2MWT, Mr. Cedar exhibited SOB after walking
purposes.18 2 minutes with a respiratory rate of 32 respirations per min-
The 6MWT can be conducted at the patient’s rate. If the ute. His walking speed of 1.0 m/s (39.3 in/s) is slightly below
6MWT had been the selected tool, Mr. Cedar could have the normal walking speed for a 50-year-old male of 1.4 m/s
stopped to rest by leaning against the wall. With rests, he (55.1 in/s).21
may have completed the test. If he had not, then the time Locomotion: No further testing was conducted.
and distance could have been noted in his chart. Being able Balance: Berg Balance Score 45/56, low fall risk
to complete the entire test could have then become one of Single-leg stance time: right LE 5 sec; left LE 3 sec; eyes
his goals for therapy. opened
The 2MWT has not been studied as extensively as the
6MWT. The 2MWT, however, showed moderate correla- Clinician Comment The tests and measures
tion with measures of physical function in patients before confirm that Mr. Cedar is more limited by his aerobic
and after coronary bypass surgery and may prove to be the capacity than by his knee pain. He was able to complete
recommended test for cardiac patients, or for patients whose the 2MWT with relatively low pain but with notable SOB.
comorbidities make the completion of the 6MWT difficult.19 After 2 minutes of slower-than-normal walking for his age,
Mr. Cedar experienced dyspnea with the short walk from Mr. Cedar rated his perceived exertion as 15/20, which is
the waiting area to the treatment room. This observation, defined as “hard” or “heavy” work. His reported knee pain
along with his comorbidities of CVD, LE OA, and obesity, rating was 2 to 3/10 at rest with increases to 3 to 4/10 when
led to the selection of the 2MWT. ambulating. His painful left knee ROM was 15 degrees less
than his right knee. A Timed Up and Go Test was not per-
During the 2MWT, Mr. Cedar’s HR and BP were adaptive
formed but would have been an effective measure of loco-
as expected to the increased activity. He rated the effort as
motion. Mr. Cedar’s Berg Balance Scale score and single-leg
“hard,” which corresponds to 15/20 on the Borg RPE scale.
stance times confirm he is at a low risk for falls. Limitations
He became dyspneic, but his normal range of SpO2 was
in balance may be a result of knee pain.
maintained. After walking, an S3 heart sound remained
absent and breath sounds clear. Therefore, it was reason-
able to conclude that, for this level of exercise, he showed
no gas-exchange or cardiac pathology. The SOB and effort
were probably due to deconditioning of the exercising mus-
EVALUATION
cles in the LEs and possibly those of the ventilatory pump.
Diagnosis
Based on the history, systems review, and tests and mea-
Joint Integrity and Mobility sures mentioned previously, Mr. Cedar was classified into
Goniometric ROM: right knee 0 to 115 degrees (obesity 2 practice patterns. His major pattern is Cardiopulmonary
limited); left knee 0 to 100 degrees Pattern 6B: Impaired Aerobic Capacity/Endurance
Patellar mobility: Decreased on left as compared to right, Associated With Deconditioning. His secondary pattern
crepitus noted left. is Musculoskeletal Pattern 4E: Impaired Joint Mobility,
Joint mobility: Unable to assess secondary to obesity. Motor Function, Muscle Performance, and Range of Motion
Edema: Bilateral ankle edema. Used a tape measure with Associated With Localized Inflammation.
figure-of-eight wrap: right 56.5 cm; left 57.5 cm. International Classification of Functioning,
Disability, and Health Model of Disability
Clinician Comment Use of the figure-of-eight See ICF Model on page 192.
ankle measurements is a tool for determining if physical
192 Chapter 5
ICF Model of Disablement for Mr. Cedar

Health Status
• Severe CAD
• S/p MI, coronary artery bypass graft
• Hyperlipidemia
• Hypertension
• Morbid obesity
• Dyspnea
• Recurrent angina
• Hypothyroidism
• Gastroesophageal reflux disease

Function
• Unable to maintain single • Community ambulation
• Obese leg stance limited due to pain, fatigue
• Left knee OA • Unable to complete IADL • Does not exercise due to
• Mild edema, both ankles due to pain and fatigue dyspnea and fatigue
• Decreased left knee flexion • Difficulty ascending and • Unable to play active games
descending stairs or walk with grandchildren
• Pain in left knee with
walking • Difficulty getting into and
out of a car
and endurance
• Decreased balance
• Cleared for exercise by
recent stress test

• Age = 51 years • 4 entrance steps to home without a railing
• Motivated to walk and play with grandchildren • Bedrooms—his and grandchildren—are on the
• Is the primary caretaker for 2 young second floor
grandchildren
• Anxious and depressed
• Medical retirement from police force, 3 years
prior
• Smoking history, but not last 4 years
Clinician Comment Before moving forward was as simple as prescribing a monitored aquatics exercise
in the evaluative process to establish the prognosis, plan program instead of a land-based program. Would water-
of care, and intervention, a consultation with Mr. Cedar’s based physical therapy be as effective as land-based physi-
physician was indicated. Though Mr. Cedar was referred cal therapy for Mr. Cedar?
with a musculoskeletal diagnosis, his systems review and Both issues of cardiovascular impairments and OA were
tests and measures identified that his major limitation was addressed in a study by Foley et al.24 A total of 105 subjects
deconditioning. over 50 years old with LE arthritis were randomized into
Further, the indoor pool available for Mr. Cedar’s program 1 of 3 groups: hydrotherapy (n = 35), gym (n = 35), or control
had a water depth of 1.07 m to 1.37 m (3.5 to 4.5 feet). Mr. (n = 35). Both exercising groups had 3 exercise sessions per
Cedar was 1.75 m (5.75 feet) tall. With water walking and week for 6 weeks. At the beginning and end of the exercise
exercises performed in standing, Mr. Cedar would not be program, a single, trained, blinded-to-group PT performed
submerged past his xiphoid process. Nonetheless, his pri- all outcome assessments. Outcomes included the 6MWT,
mary physician was consulted to ensure she was aware of muscle strength dynamometry, the Western Ontario and
the caution with regard to an aquatic program. McMaster Universities Osteoarthritis Index (WOMAC),
total drugs, the SF-12 quality of life, the Adelaide Activities
Mr. Cedar’s physician was not surprised with the report of
Profile, and the Arthritis Self-Efficacy Scale. The par-
findings that defined Mr. Cedar’s deconditioned status. She
ticipants in the groups had a mean age that was older than
reaffirmed his clearance for monitored exercise from the
Mr. Cedar, but more than one-third of each group had
recent stress test. Though she stated that she was not aware
comorbid conditions of cardiac conditions and/or obesity.
of the hemodynamic implications of immersion past the
The water-based group demonstrated a significant gain in
xiphoid process for some patients, she concurred with the
muscle strength compared with the control group, but less
conclusion that he would not be at risk, even with HTN,
than the land-based group. The water-based group, how-
given his height and the pool depth.
ever, showed a significant increase in physical function over
both the land-based and control groups.
Since progressive overloading of the muscles and loading
Prognosis through the eccentric phase of muscle contraction is not
Mr. Cedar gained 60 pounds in 3 years and was decondi- possible in water, the researchers attempted to balance
tioned from lack of exercise. His left knee pain hindered his the intensity of exercise. Higher and faster repetitions
ability to walk for exercise. A monitored exercise program were used in the water, and the water group was subject
was indicated, as well as intervention for his knee pain. His to the continuing effects of water movement while moving
obesity and knee pain impeded his progress in a cardiac through their exercise program. The land-based group exer-
rehabilitation program. Mr. Cedar would improve his aerobic cising on gym equipment had pauses and rests that may
capacity and endurance as well as strengthen his supporting have accounted for decreased aerobic benefit as compared
knee musculature in a monitored aquatic exercise program. with the aquatics group. The aerobic effect as a result of
Over the course of 12 weeks, it could be expected that Mr. aquatic exercise was supported by Meyer and Bucking.2
Cedar would demonstrate improved aerobic capacity/endur- Mr. Cedar was deconditioned but was unable to tolerate a
ance and joint mobility, motor function, and ROM to achieve land-based program because of his knee pain. It could be
a higher level of functioning in home, community, and lei- anticipated that water-based physical therapy would be as
sure environments. effective as land-based physical therapy to address his OA
knee pain, balance,25 and deconditioning.
Clinician Comment Patients with cardiac

disease and symptomatic arthritis of the knee can improve
levels of functional capacity that are comparable to changes Plan of Care
observed in patients with cardiac disease only.22 Cardiac
rehabilitation results in significant improvement in the car- Intervention
diovascular risk profile at all levels of BMI, independently Patient-/client-related instruction regarding decondition-
of weight loss, and can achieve significant improvements ing, heart failure, and arthritis. Instruction will also include
in exercise capacity and metabolic profile, even without normal HR, BP, and respiratory response to exercise, as well
weight loss.23 When comorbidities are recognized and the as self-monitoring techniques, including use of RPE scale.
exercise interventions appropriately modified, the pres- Aquatics physical therapy program to include cardiac and
ence of activity limitation may be associated with a greater respiratory conditioning, balance training, ROM, therapeu-
potential for improved prognosis and outcomes from physi- tic exercise, and strength and endurance training for ventila-
cal therapy. tory muscles.
Mr. Cedar had comorbidities of HTN, arthritis, cardiac Instruction in home exercise or fitness center program.
disease, and obesity. Modifying his exercise interventions
194 Chapter 5
Proposed Frequency and Duration of as a cardiac population with anginal symptoms. The spe-
Physical Therapy Visits cific instruments allow responsiveness and sensitivity to be
Aquatic exercise program 2 to 3 times per week for 8 to maximized and detect small changes that the patient and
12 weeks. PT consider important.26
Outcome measures to quantify the effects of physical ther-
Anticipated Goals
apy interventions include joint-specific and disease-specific
1. Patient will be able to use the RPE scale to report his rating instruments. The disease-specific instruments report
exercise effort (1 week). a more global picture of outcomes from the patient’s per-
2. Patient will demonstrate knowledge of appropriate BP, spective. An example of a joint-specific instrument would
HR, and respiratory response to exercise (2 weeks). be the Lysholm Knee Rating Scale,27 and an example of a
3. Patient will be able to participate in 30 minutes of aquat- disease-specific instrument would be the WOMAC.28
ics physical therapy at an RPE level from 9/20 to 12/20 The WOMAC is a disease-specific, self-administered, wide-
(3 weeks). ly used instrument that measures symptoms and physical
4. Patient will be able to complete a 2MWT without SOB disability. It was originally developed for people with OA
(4 weeks). of the hip or knee to measure changes in health status after
some kind of treatment intervention.
5. Patient will show increased left knee flexion by 10 to
15 degrees (6 weeks). The WOMAC has been shown to be effective instruments
for measuring outcomes in populations with arthritis of
6. Patient will show reduced LE edema by 1 to 2 cm on
the knee.29 The WOMAC would have been an appropriate
figure-eight measure (6 weeks).
measure to use with Mr. Cedar. Mr. Cedar did not complete
7. Patient will increase his single LE stance by 6 to 8 sec- a subjective, impairment-specific outcome instrument for
onds (8 weeks). either his dyspnea and fatigue or his OA knee status.
8. Patient will report his left knee pain intensity has
decreased by 2 levels (8 weeks).
9. Patient will be able to participate in 60 minutes of exer- Discharge Plan
cise (land- and water-based) with 20 minutes at the RPE It was anticipated that Mr. Cedar would achieve the antic-
level from 12/20 to 14/20 (12 weeks). ipated goals and expected outcomes at the end of the plan of
10. Patient will be able to complete a 6MWT without SOB or care and would be discharged to a home exercise program.
fatigue (12 weeks).
Expected Outcomes (Upon Discharge)
1. Patient will be independent in a home- or fitness center-
INTERVENTION
based exercise program.
2. Patient will resume cooking and cleaning tasks without Coordination, Communication, and
significant fatigue. Documentation
3. Patient will report he can walk 20 minutes with his
2 dependent grandchildren without significant fatigue. The findings of Mr. Cedar’s examination were discussed
with him. All elements of his management were documented.
4. Patient will report no loss of balance or falls with stair Through his PCP, he was referred to a dietitian for instruc-
climbing or walking on uneven ground. tion in weight control guidelines and appropriate nutrition
5. Patient reports he can flex left knee to get in and out and food choices to aid his effort in weight loss and risk fac-
of automobile without difficulty and stoop to pick up tor reduction.
grandchildren’s toys on the floor.
Clinician Comment Increased survival and
optimal quality of life are 2 major objectives of health care. Education regarding his current condition, impairments,
Quality of life can be defined as the patient’s ability to enjoy and functional limitations were discussed with Mr. Cedar.
normal life activities. Mr. Cedar’s functional status as a The importance of following the designed home exercise pro-
result of his cardiac and arthritis problems significantly gram, including progressive walking or biking, was stressed
affected his quality of life. Health-related quality of life with Mr. Cedar, as well as the need to continue exercising
instruments measure the patient’s perception of the func- after his course of physical therapy ended in order to main-
tional effect of an illness and the results of the therapeutic tain gained aerobic conditioning. Mr. Cedar was informed
intervention. of the danger of drinking alcohol while taking prescription
medications.
A health-related quality of life instrument would focus
on a population with a specific condition or disease, such
Procedural Interventions Strength, Power, and Endurance
Training for Limb, Pelvic-Floor,
Therapeutic Exercise Trunk, and Ventilatory Muscles
Mode
Active resistive isotonic exercises
Conditioning or Reconditioning
Intensity
Mode
Using buoyant devices and increasing velocity over time
Water walking
Duration
Intensity
10 to 15 repetitions
RPE between 9/20 and 12/20
Frequency
Duration
2 to 3 times per week
10 to 15 minutes
Frequency
Using the resistance of the water and buoyant devices such
as dumbbells for UE and noodles for LE, move the extrem-
Description of the Intervention ity through the water at increasing speeds for each muscle
Walk forward, backward, and sideways in the water, group, concentrating on breathing deeply and regularly
varying step length and step height. Increased speed, ankle while exercising. Progress to using water weights on LEs and
weights, and/or resistance board or dumbbells held in UEs water resistance gloves on UEs. All exercises will be per-
may be added to increase RPE as conditioning improves. formed with submersion no deeper than chest level.
Walking will be performed in a 25-meter pool with submer-
sion no deeper than chest level. Gait and Locomotion Training
Mode
Flexibility Exercises
Water walking
Mode
Intensity
Muscle lengthening and stretching
Self-paced
Intensity
Duration
To a position of mild discomfort
10 minutes
Duration
Frequency
30 to 60 seconds for 2 to 3 repetitions
Frequency
Walk in water chest deep holding dumbbells or noodle in
Description of the Intervention UE with heel-toe gait pattern, concentrating on taking equal
Hamstring, hip flexor, gastrocnemius, and soleus stretch- step lengths and swing-through motions. UEs are stationary,
ing. For all stretches, he will isolate the muscle to be stretched, initially progressing to no-hand holds with proper arm swing
then stretch the muscle to a position of mild discomfort and with each step.
hold for 30 to 60 seconds, concentrating on breathing deeply
and regularly while stretching. The water level for all stretch- Balance, Coordination, and Agility Training
es should be approximately waist high. Mode
• Hamstring stretch: Standing on the right LE with his Posture awareness training and standardized exercise
back to the wall of the pool, perform a straight leg raise approaches to task-specific performance training
with the left LE until the left LE is on stretch. Place a Intensity
buoyant noodle around the ankle of the left LE and Challenge beyond usual positions/length of time
keep the left knee straight and the left ankle dorsiflexed. Duration
Allow the buoyancy of the water acting on the noodle 10 to 15 minutes
to stretch the left hamstrings. Repeat with the right LE. Frequency
• Hip flexor stretch: Standing on the right LE facing the 2 to 3 times per week
wall of the pool, bend the left knee toward the buttocks. Description of the Intervention
Place a buoyant noodle around the left ankle. Keep the Single-leg stance activities, tandem walking, crossover
knees together and the hips extended and allow the walking. While standing at rail in water at chest level, lift
buoyancy of the water acting on the noodle to stretch the one leg off the floor in a stork stance. Maintain this posi-
left hip flexors. Repeat with the right LE. tion without hand hold for 20 to 30 seconds. Move both UEs
• Gastrocnemius and soleus stretch: Perform this stretch through various motions and activities (ie, throwing and
in the water as would be done on land. catching a ball) while maintaining single-leg stance. Repeat
for the opposite LE. Walk forward and backward on straight
line in pool, placing one foot directly in front of or behind
196 Chapter 5
the other. Walk sideways in pool, crossing leading LE in front discharged to a water exercise and land walking program at a
of the stance extremity, then on the next step, cross-behind local fitness center with written instructions.
stance extremity.
Informed Consent REFERENCES

Mr. Cedar helped formulate, and agreed with, the pro- 1. Goodman CC, Boissonnault WG, Fuller KS. Pathology: Implications
posed plan of care. for the Physical Therapist. 2nd ed. Philadelphia, PA: Saunders; 2003.
2. Meyer K, Buking J. Exercise in heart failure: should aqua therapy and
swimming be allowed? Med Science Sports Exerc. 2004;36(12):2017-
2023.
OUTCOMES 3. Bonow RO, Bennett S, Casey DE Jr, et al. ACC/AHA Clinical
Performance Measures for Adults With Heart Failure: a report of the
American College of Cardiology/American Heart Association Task
Reexamination Force on Performance Measures (Writing Committee to Develop
Heart Failure Clinical Performance Measures): endorsed by the
Reexamination took place at monthly intervals until Heart Failure Society of America. Circulation. 2005;112(12):1853-
discharge. After 4 weeks of twice weekly aquatics physical 1887.
therapy, Mr. Cedar was able to use the RPE scale to report his 4. Struthers AD. The diagnosis of heart failure. Heart. 2000;84:334-
338.
exercise effort and understood what his appropriate BP, HR,
5. Kenchaiah S, Evans JC, Levy D, et al. Obesity and the risk of heart
and respiratory response should be to exercise. He was able failure. N Engl J Med. 2002;347:305-313.
to participate in 30 minutes of aquatics physical therapy at an 6. Medscape. Drug interaction checker. http://reference.medscape.
RPE level from 9/20 to 12/20. He walked 135 meters but was com/drug-interactionchecker. Accessed March 20, 2010.
not yet able to complete the 2MWT without SOB. 7. Drug Digest. Check interactions. http://www.drugdigest.org/wps/
portal/ddigest. Accessed March 20, 2010.
His 8-week reassessment showed that he was able to com- 8. Juurlink D, Mamdani M, Kopp A, et al. Drug-drug interactions
plete 160 meters in the 2MWT test without SOB, his left knee among elderly patients hospitalized for drug toxicity. JAMA.
pain intensity was decreased by 2 levels, and his left knee 2003;289:1652-1658.
flexion was increased by 10 degrees from 100 to 110. His LE 9. Sandson N. Drug-drug interactions: the silent epidemic. Psych
edema was reduced by 1.5 cm and he could balance on a sin- Services. 2005;56(1):22-24.
10. DeTurk WE, Cahalin LP. Evaluation of patient intolerance to
gle LE for 10 to 15 seconds. Mr. Cedar reported that he was exercise. In: DeTurk WE, Cahalin LP, eds. Cardiovascular and
able to walk to his mailbox, an approximately 4- to 5-minute Pulmonary Physical Therapy: An Evidence-Based Approach. New
walk, without SOB or fatigue. He was progressing toward his York, NY: McGraw-Hill; 2004:361-378.
physical therapy discharge goals as planned. 11. Cahalin LP. Chapter 10. Cardiovascular evaluation. In: DeTurk
WE, Cahalin LP, eds. Cardiovascular and Pulmonary Physical
Therapy: An Evidence-Based Approach. New York, NY: McGraw-
Discharge Hill; 2004:297.
12. Pickering TG, Hall JE, Appel LJ, et al. Recommendation for blood
Mr. Cedar was discharged from physical therapy at pressure measurement in humans and experimental animals:
10 weeks, which was earlier than intended secondary to Part 1: blood pressure measurement in humans: a statement for
insurance and monetary issues. At that time, he had not professionals from the Subcommittee of Professional and Public
achieved his 12-week goals of being able to participate in Education of the American Heart Association Council on High
Blood Pressure Research. Hypertension. 2005;45(1):142-161.
60 minutes of exercise (land- and water-based) with 20 min- 13. Vincent KR, Vincent HK. Resistance training for individuals with
utes of the exercise performed at the RPE level from 12 to cardiovascular disease. J Cardiopulm Rehabil. 2006;26:207-216.
14/20. 14. Clarkson HM. Musculoskeletal Assessment: Joint Range of Motion
He did not meet the goal of completing a 6MWT without and Manual Muscle Strength. 2nd ed. Baltimore, MD: Lippincott
SOB. He was able to walk continuously for 6 minutes, but
15. O’Connor P, Sforzo CA, Frye P. Effect of breathing instruction
with mild SOB. He attributed the SOB during the test to his on blood pressure responses during isometric exercise. Phys Ther.
attempt to walk faster than his normal walking pace. He was 1989;69:757-761.
instructed to continue to work toward achieving these goals 16. Kendall FP, McCreary EK, Provance PG, et al. Muscles: Testing and
by continuing to participate and progress his home exercise Function with Posture and Pain. 5th ed. Baltimore, MD: Lippincott
program.
17. Heyward VH. Advanced Fitness Assessment & Exercise Prescription.
Mr. Cedar did achieve the expected outcomes of indepen- 6th ed. Champaign, IL: Human Kinetics; 2010.
dence in a home- or fitness center-based exercise program, 18. Solway S, Brooks D, Lacasse Y, Thomas S. A qualitative systematic
resumption of cooking and cleaning tasks without significant overview of the measurement properties of functional walk tests
fatigue, no loss of balance or falls while traversing stairs and used in the cardiorespiratory domain. Chest. 2001;119:256-270.
19. Brooks D, Parsons J, Tran D, et al. The two-minute walk test as a
uneven ground, and adequate flexion in his left knee to get in measure of functional capacity in cardiac surgery patients. Arch
and out of automobile without difficulty and stoop to pick up Phys Med Rehabil. 2004;85(9);1525-1530.
his grandchildren’s toys on the floor. His expected outcome 20. Rohner-Spengler M, Mannion AF, Babst R. Reliability and minimal
of being able to walk 20 minutes with his 2 dependent grand- detectable change for the figure-of-eight-20 method of measurement
children without significant fatigue was not achieved. He was of ankle edema. J Orthop Sports Phys Ther. 2007;37(4):199-205.
21. Fitz S, Lusardi M. White paper: “walking speed: the sixth vital
sign”. J Geriatr Phys Ther. 2009;32(2):46-49. could also assess that any impairments might be addressed
22. Woodard CM, Berry MJ, Rejeski WJ, Ribisl PM, Miller HS. Exercise within the scope of a monitored fitness program.
training in patients with cardiovascular disease and coexistent knee
Based on Ms. Caster’s age (over 55 years) and her single
arthritis. J Cardiopulm Rehabil. 1994;14:255-261.
23. Shubair MM, Kodis J, McKelvie RS, Arthur HM, Sharma AM. risk factor known thus far (sedentary lifestyle), she would be
Metabolic profile and exercise capacity outcomes: their relationship placed into the moderate risk stratification category accord-
to overweight and obesity in a Canadian cardiac rehabilitation set- ing to the ACSM for participation in an exercise program
ting. J Cardiopulm Rehabil. 2004;24(6):405-413. (Figure 5-7). Generally, her age and single risk factor alone
24. Foley A, Halbert J, Hewitt T, Crotty M. Does hydrotherapy improve
would not require a stress test, though she would need a
strength and physical function in patients with osteoarthritis—
a randomized controlled trial comparing a gym based and a physician’s clearance for vigorous exercise according to the
hydrotherapy based strengthening programme. Ann Rheum Dis. ACSM guidelines. To answer the question, “What prompted
2003;62:1162-1167. the stress test?” the interview needed to continue. As well,
25. Douris P, Southard V, Varga C, Schauss W, Gennaro W, Reiss A. results from a participation screening questionnaire could
The effect of land and aquatic exercise on balance scores in older
have been administered and reviewed. Even though she was
adults. J Geriatr Phys Ther. 2003;26(1):3-6.
26. Oldridge NB. Outcome assessment in cardiac rehabilitation: health- cleared by her physician for exercise, it would be useful to
related quality of life and economic evaluation. J Cardiopulm identify how Ms. Caster described the nature of her fatigue.
Rehabil. 1997;17(3):179-194.
27. Kocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ.
Reliability, validity, and responsiveness of the Lysholm Knee Scale
for various chondral disorders of the knee. J Bone Joint Surg Am. Social History/Environment
2004;86;1139-1145. Ms. Caster had earned a college degree in finance and
28. Tegner Y, Lysholm J. Rating systems in the evaluation of knee liga-
had worked in the banking field for more than 30 years. In
ment injuries. Clin Orthop. 1985;190:43-49.
29. Angst F, Aeschlimann A, Michel BA, Stucki G. Minimal clinically her current position as a manager of a commercial bank, she
important rehabilitation effects in patients with osteoarthritis of worked 40 to 60 hours per week. She reported that the major-
the lower extremities. J Rheumatol. 2002;29(1):131-138. ity of her work tasks were completed while sitting at her desk,
using her computer or phone. She engaged in little physical
movement during the work day since she rarely left her desk,
CASE STUDY 5-2 even to take a lunch break.
Ms. Caster lived with her husband of more than 30 years.
Mary Jane Myslinski, PT, EdD They had 2 grown children and 3 grandchildren. Each of her
children lived out of state and she lamented that she no lon-
ger had her children as a support system. Her husband was
EXAMINATION an investment banker and worked more than 80 hours per
week, including weekends. She was the sole caretaker of the
house and performed all household duties such as food shop-
History ping, laundry, and cleaning. Ms. Caster had a large home,
3600 square feet, with 2 stories and a finished basement. The
Current Condition/Chief Complaint bedrooms were on the second floor and the laundry room
Ms. Caster, a 56-year-old female, was referred to a well- was on the main level. Her home office was located in the
ness center by her PCP to begin a fitness program. Ms. finished basement.
Caster stated she worked long hours, felt fatigued when she The grounds of her home had a built-in swimming pool
came home, and then was unable to perform many of her with a cabana, a multi-level deck with Jacuzzi and gas grill,
household tasks. She reported she was “out of shape” and was and extensive gardens. Ms. Caster reported she gardened as
largely sedentary. “therapy” but hired a pool company to maintain the pool.
The patient had completed an exercise stress test 1 week She reported that her weekends were very busy with the nor-
prior and brought the report with her. She was “cleared for mal upkeep of the house. She often felt overwhelmed with the
vigorous exercise” according to the script from her PCP. impossibility of what she needed to accomplish at home. She
also noted she had little time to herself.
Clinician Comment Ms. Caster was referred Clinician Comment Based on this informa-
to a hospital-based fitness and wellness center by her PCP.
tion, it appeared that Ms. Caster had a large house to main-
New fitness clients at this center were evaluated by a PT.
tain with little help. Her children lived out of state and her
With the findings from the initial examination, the PT
husband worked even more hours at his job than she did at
determined if the client required physical therapy to address
her own demanding job. Making time for a fitness program
impairments prior to beginning a fitness program. If so, then
may pose a challenge for her.
the patient was scheduled for outpatient physical therapy
until ready to begin a fitness program. The evaluating PT
198 Chapter 5
Figure 5-7. Risk stratification for exercise
testing. (Adapted from Pescatello LS, Arena R,
Riebe D, Thompson PD, eds. ACSM’s Guidelines
for Exercise Testing and Prescription. 9th ed.
Philadelphia, PA: Wolters Kluwer, Lippincott
Social/Health Habits current home, she was living a much healthier lifestyle. It
Ms. Caster reported she did not smoke nor had she ever also sounded as if her children had been her support system
smoked. She reported drinking an occasional alcoholic bev- to help her cope with her husband’s extensive work hours.
erage, generally a glass of red wine, when her husband was It also appeared that the lack of exercise and her eating
home and not working. She reported that she and her hus- choices in the past years have led to a significant amount
band seldom took vacations because of their work schedules. of weight gain. The health risks of abdominal weight gain,
In fact, her last vacation was 9 years ago. She stated she didn’t especially after menopause (if appropriate for Ms. Caster),
cook on work nights but would stop for takeout. needed to be kept in mind.1 Also, her body fat and BMI
Ms. Caster reported she did not have a regular exercise were not known at this point. Once these are known, more
program because of her busy work schedule and home main- information about the type of fat distribution, thus the
tenance schedule. She was an avid exerciser prior to the pur- health risks, could be identified.
chase of her current home 8 years ago. Before then, she would She did not have a smoking history. She drank only red
exercise 4 to 5 times per week with aerobic and anaerobic wine, which might have imparted some health benefit. One
program components. Ms. Caster reported she had gained glass of red wine for females may protect against coronary
about 30 pounds over the course of 5 years, mostly in her heart disease and will increase antioxidants.2,3 Her rapid
abdomen. She also noticed a decrease in her overall muscle recent weight gain of 15 pounds was a concern.
mass. She reported that she had gone up 4 clothing sizes. She
had a more recent weight gain of another 15 pounds over the
past 2 months. Medical/Surgical History
Ms. Caster reported that she had physicals with her
Clinician Comment Based on the interview PCP nearly every 4 years. She had yearly physicals with her
so far, we have learned a lot about Ms. Caster and her gynecologist. She had a hysterectomy at age 36 and was in
lifestyle choices. It appears that prior to the purchase of her menopause.
Four months prior, Ms. Caster noted the onset of chest
might benefit from a thiazide-type diuretic, possibly in
palpitations and increased fatigue after another significant
combination with another medication.8
weight gain of 15 additional pounds. She defined the fatigue
as being tired after work, which did not allow her to accom- More was also known about Ms. Caster’s definition of
plish all of the home maintenance tasks she needed to do. fatigue. Fatigue is physical and/or mental exhaustion
She reported that she ate quickly with her husband, when he that can be triggered by stress, medication, overwork, or
was home, and then she worked to get her “chores” done. She symptom of a disease.9 Since the latter was ruled out by the
reported feeling exhausted around 10:00 at night and would physician examination and stress testing, it was anticipated
need to go to sleep. To make up for not getting enough done that an exercise program would assist in alleviating some of
the evening prior, she would be up at 4:00 am every day to get the fatigue Ms. Caster reported.5,10
more done at home before leaving for work.
She mentioned the onset of chest palpitations and fatigue
at her gynecologist’s appointment. Her doctor also noted an Reported Functional Status
elevation in Ms. Caster’s BP from previous visits. Ms. Caster She complained again about her daily fatigue and her
reported her BP was 150/90 at that visit. Her gynecologist concern that she should be able to accomplish more things
referred her to a cardiologist to evaluate the heart palpita- in her day. She reported annoying aches and pains in her
tions and to manage the HTN. knees, especially when she took repeated trips up and down
Ms. Caster reported she saw the cardiologist and had a the stairs or was on her knees while cleaning.
cardiac work up of ECG, Holter monitor, nuclear stress test, She stated she had no other issues related to function. She
and blood work. When these reports were forwarded to her was able to perform all of the individual activities related
PCP with the cardiologist’s appraisal, Ms. Caster’s PCP sub- to daily living without difficulty. She felt restricted only
sequently referred her to the fitness and wellness center. because of the noted fatigue. If needed, she could push past
Family Medical History the fatigue and accomplish more if she wished.
Ms. Caster’s mother was still living but had a history Medications
of CAD, triple coronary artery bypass graft surgery, MI, Ms. Caster reported that she took Diovan HCT
and peripheral arterial disease of both LEs. Her father was 160 mg/12.5 mg daily for the last year to manage her HTN.
deceased but also had an extensive cardiac history of a qua- With the recent rise in her BP, one option for improved con-
druple coronary artery bypass graft, pacemaker, and defi- trol was an increase in her medication. She did not wish to
brillator insertion. He also developed type 2 DM along with increase her medications, however, until she had tried exer-
many in his family. cise and weight loss to improve control of her BP. She took
over-the-counter supplements of calcium and vitamin D3.
Clinician Comment More was known about She did not take hormone replacements.
the medical factors that led to the stress test. More risk
factors for CAD, as identified by the American Heart Clinician Comment Diovan HCT (valsartan
Association4 and the ACSM Risk Stratification for CAD, and hydrochlorothiazide) is a combination of valsartan, an
had emerged. Ms. Caster had HTN, a strong family history orally active, specific angiotensin II receptor blocker acting
of heart disease, and episodes of heart palpitations. This on the AT1 receptor subtype, and hydrochlorothiazide, a
put her into the high-risk category according to the ACSM diurectic.11
risk stratification. Based on the ACSM preparticipation The overall frequency of adverse reactions is neither dose-
screening algorithm, medical examination and exercise related nor related to age, gender, or race. In clinical trials,
testing prior to the start of moderate or vigorous exercise the most common reason for discontinuation of Diovan
was recommended.5 Moderate exercise is defined as activi- HCT was because of complaints of headache and dizziness.
ties of 3 to 6 METs and vigorous above 6 METs.5
Diovan HCT was the type of drug that the JNC8 recom-
Ms. Caster was in menopause. Therefore, some of the weight mended for Stage I HTN. There were no known adverse exer-
gain could be explained, but she was at increased risk for cise/drug interactions, making exercise safe with this drug.5
heart disease and osteoporosis because of the decrease in
estrogen.6,7 It was not yet known if she was on hormone
replacement therapy or if she had a bone mineral density Other Clinical Tests
test to determine the presence of osteoporosis or osteopenia.
Ms. Caster reported she had undergone a bone mineral
According to the Eighth Report of the Joint National
density test, as ordered by her gynecologist, with a normal
Committee on Prevention, Detection, Evaluation, and
result. Radiographic studies of both knees showed possible
Treatment of High Blood Pressure (JNC8), Ms. Caster had
early-stage arthritis. The results of the blood chemistry, ECG,
BP that fits under recommendation 2 and 3 in JNC8. She
Holter monitor, and nuclear stress test results are shown as
follows:
200 Chapter 5
Blood ● Hemoglobin: 15 mL/dL Her stress test was normal with normal exercises responses.
chemistry ● Fasting blood glucose: The HR and SBP increased as expected, and the DBP
90 mg/dL remained the same.10 She achieved 100% of her age-predict-
ed HRmax during the stress test. No sign of ischemia, in the
● Triglyceride: 200 mg/dL form of ST depression, was noted. The stress test was valid
● Cholesterol: 260 mg/dL since she requested to stop after she had already achieved
her age-predicted HRmax.5 Her predicted VO2max was
● LDL: 150 mg/dL between 20 and 24.7 mL/kg/min based on the MET level
● HDL: 47 mg/dL she achieved on the Bruce Protocol.5 Based on her VO2max,
she falls into the 15th percentile for her age and gender.
ECG (obtained Short run of supraventricular
According to research, a VO2 below the 20th percentile for
from physician) tachycardia (SVT)
age and gender is indicative of a sedentary lifestyle and is
Holter monitor Short run of SVT associated with an increased risk of death from all causes.13
(obtained from Based on the norms for the strength tests,5 she was in the
physician) 15th percentile for upper body (poor) and in the 15th per-
Nuclear stress 1. No ST depression centile for the lower body (well below average). Her muscu-
test results lar endurance test put her into the fair category.
2. MET level: 7 METS (VO2max
(obtained from ‒ 20 to 24.7 mL/kg/min)
physician)
3. Completed stage 2 of the Other Relevant Information
Bruce protocol
Ms. Caster stated that she’d been thinking about starting
Nuclear stress 4. Patient s complaints: fatigue, an exercise program even before she was referred by her PCP.
test results patient requested to stop She said she really wanted to “get back in shape,” lose weight,
(obtained from and make her muscles “less flabby.” She believed she could fit
5. Resting HR: 90 bpm
physician) exercise back into her busy schedule since the wellness center
6. Resting BP: 150/90 mm Hg was across the street from where she worked.
7. Peak HR: 160 bpm
8. Peak BP: 180/90 mm Hg Clinician Comment Based on this interview,
the client had more fitness goals than functional goals.
Strength test ● Upper body using 1-RM bench
Physical fitness is defined as a set of attributes such as
press: 70 pounds
cardiorespiratory endurance, skeletal muscular endurance,
● Lower body using 1-RM leg strength, power, speed, flexibility, agility, balance, reaction
press: 150 pounds time, and body composition.14 She had expressed a desire to
● Muscular Endurance test lose weight, change her body composition, and increase her
aerobic endurance as well as her muscular endurance and
● Push-up test: 3 completed strength. These parameters will need to be measured and
then incorporated in the fitness prescription for this client.
It is also important to determine a client’s readiness for
Clinician Comment Based on the bone min- change. This can be accomplished by understanding and
eral density test, osteoporosis was not a precaution in her using the Transtheoretical Model to promote physical
exercise prescription. Considerations for the early arthritis activity.15 Based on the information Ms. Caster gave, she
in her knees should be factored into the exercise choices for appeared to be in the second stage of the model: contempla-
her program. tion. This meant that she was thinking about increasing
When reviewing the Holter monitor and the ECG results, her physical activity but had not taken any steps toward
it was noted that Ms. Caster had short runs of SVT. SVT this goal. To assist the client with this goal, the clinician
is a type of supraventricular arrhythmia that is fairly com- can encourage the client to get started in a variety of ways.
mon, often repetitive, occasionally persistent, and rarely Encouragement can take the form of suggesting enrollment
life-threatening.12 Patients who experience SVT are often in an appropriate exercise class or simply to identify the
asymptomatic and have symptoms only during the burst barriers to getting started and discuss how to overcome
of SVT. Symptoms can include palpitations, fatigue, light- them. In this case, Ms. Caster walked over to the fitness
headedness, chest discomfort, dyspnea, presyncope, or more and wellness center, located near her work site, during her
rarely, syncope.12 This arrhythmia is generally brought on lunch time.
by caffeine, anxiety, alcohol, nicotine, recreational drugs, The purpose of the information gathered in the system
or hyperthyroidism. It is rarely caused by exercise.12 review is to further ensure that Ms. Caster is a candidate
for physical therapy or the fitness program to which she has In planning the tests and measures portion of the examina-
been referred. tion, it was determined to confirm the stress test findings
with a measure of her aerobic capacity that could be used
to compare outcomes, but the stress test was not repeated.
Systems Review Because Ms. Caster had a stress test prior to the fitness
program and it was negative, insurance would not pay for
Cardiovascular/Pulmonary/Fitness another full stress test simply to be used later to determine
outcomes. Additional anthropometric measures would be
Resting vital signs: HR = 90 bpm; BP = 150/90 mm Hg; gathered. The extent of muscle length deficits as well as test
respiratory rate = 14 breaths per min muscle strengths would be measured. A pain profile for her
Integumentary knees would be useful and would be completed.
No abnormalities of the skin were noted; no abnormal
moles, no skin discoloration, no open cuts or wounds. Skin
was intact. Tests and Measures
Musculoskeletal Aerobic Capacity and Endurance
Height = 5 feet, 4 inches
The YMCA Submaximal Bike test was administered with
Weight = 180 pounds VO2max extrapolation to be used as an outcome measure. Her
BMI = 30.9 HRsubmax was 139 bpm, Peak BP was 170/90, RPE was 8, and
Gross UE and LE and trunk active ROM was WNL. extrapolated VO2max was 22 mL/kg/min. She had no adverse
Strength was generally 4/5 throughout. Posture exam responses.
revealed the presence of a forward head posture with round-
ed shoulders. Muscle length tests found tight hamstrings, Clinician Comment The YMCA Submaximal
bilaterally, as well as tight pectoralis minor muscles. All Bike test is one of the most popular assessment techniques
joints were intact, including the knees. to estimate VO2max.5 This test was used because it is a more
Neuromuscular fitness-based test and not a functional measure of how far
Cleared, no impairments were noted. a client can walk. The ACSM has extensive research and
instructions on this test, including its validity and reli-
Communication, Affect, Cognition, ability.5 Ms. Caster’s response to the Submaximal test was
Language, and Learning Style normal, but it confirmed her low fitness level in the area
Ms. Caster was an educated, intelligent, and pleasant of cardiopulmonary endurance. She did achieve the 85%
woman. No impairments were noted. She was motivated to of age-predicted HRmax, which is the stopping point for a
start her exercise program and requested individualized ses- Submaximal test. As has been discussed in the Chapter 4
sions until she was comfortable with the program. cases, her RPE did not reflect her actual HR but is still a
valid measure of exertion.16
Clinician Comment Based on the resting vital

signs, Ms. Caster was classified as being in Stage I HTN. Anthropometric Measurements
Her resting HR was slightly elevated, but still considered to Body fat: 38% (caliper method)
be WNL. Generally, a normal resting HR is between 60 and Somatotype: endomorphic
100 bpm, with a more conservative number range between
Regional fat distribution: android-type obesity
60 and 90 bpm. Her measured normal respiratory rate was
Waist circumference measure: 89 cm
normal, as would have been expected for someone without
a history of pulmonary disease or cardiac disease.
Her BMI was greater than would be expected for good Clinician Comment The client’s BMI placed
health. She showed muscle length and strength deficits. Her her into obesity class I, and her waist circumference mea-
posture was not optimum. The neuromuscular and integu- surement placed her into the very high disease risk clas-
ment reviews were clear. sification.5 The BMI, or Quetelet index, assesses weight
relative to height and is calculated by BMI = body mass
There were no findings that contraindicated participation
(kg)/stature (m2).10 It is important to note that BMI fails to
in physical therapy. The tests and measures would assist
distinguish between body fat, muscle mass, or bone; there-
with the evaluation on whether existing impairments could
fore, other methods of body composition should be used to
be addressed within the scope of a fitness program rather
calculate body fat. Based on the caliper method for measure
than formal physical therapy treatment.
of body composition, her body fat was 38%, which put her
into the obese category for older women.10
202 Chapter 5
on the distance of the shoulder from the table and from the
Based on the BMI and body composition measure, this cli-
amount of resistance offered by the muscles to downward
ent is obese and faces many risks for disease. A study by
pressure on the shoulder.
Field et al17 showed that the risk of developing diabetes,
gallstones, HTN, heart disease, and stroke increased with
severity of overweight among both sexes. They also found Clinician Comment Muscle length testing is
that the risk of developing chronic diseases was evident important to determine what fitness exercises the client
among adults in the upper half of the healthy weight ranges may or may not perform until the muscle lengths are WNL.
of BMI 22.0 to 24.9. They concluded that a BMI between To not consider muscle length with regard to exercises cho-
18.5 and 21.9 was required to minimize the risk of disease. sen may increase a muscle imbalance. Further, shortened
That BMI range might be very difficult for Ms. Caster to muscles can contribute to other injuries such as low back
achieve, but a decrease in weight by 10% does confer a pain with shortened hamstrings or arm pain with decreased
health benefit and decreases the risk of disease. length in pectoralis minor muscles.
She also has an increased risk of disease, given her regional Normal length for the hamstrings is 80 degrees on a straight
fat distribution. The android-type obesity or central-type leg raise test. The pectoralis minor is considered normal
obesity marks an increase in the fat deposits in the inter- when the full shoulder girdle and shoulder rests on the mat
nal viscera.10 Central fat deposition reflects an altered when the client is lying in supine.19 When a length deficit
metabolic profile that increases the risk for hyperinsu- is present, the short muscles need to be stretched. Later, the
linemia, glucose intolerance, type 2 DM, endometrial can- lengths need to be reexamined and judged to be restored to
cer, hypertriglyceridemia, hypercholesterolemia, HTN, and normal length before exercises that can further shorten the
atherosclerosis. Looking at her blood chemistry, she already muscles can be started by the client. The muscle length tests
presented with an increased triglyceride, cholesterol, and for Ms. Caster were conducted in a manner to spot substitu-
LDL and a lower HDL. Given these issues, she was at risk tions or other length imbalances.19
for developing metabolic syndrome.18
Metabolic syndrome is defined as “a constellation of inter-
related risk factors of metabolic origin—metabolic risk Muscle Performance (Including Strength,
factors—that appear to directly promote the development Power, and Endurance)
of atherosclerotic cardiovascular disease.”18(p 2735) The risk
Ms. Caster presented with weakness in both her UEs and
factors for developing this syndrome include abdominal
LEs in the systems review. To ensure a full and accurate sur-
obesity, insulin resistance, physical inactivity, and hormon-
vey of extremity musculature, MMT was performed while
al imbalance. She presented with normal glucose, but if she
she was positioned supine, side lying, prone, and then stand-
did not correct her behavior, she was at risk of developing
ing. The following muscle strength grades were identified:
insulin resistance given her current health status as well
as her family history. Therefore, Ms. Caster might benefit
from a referral to a registered dietician. RIGHT LEFT
Shoulder flexion 3+/5 3+/5
Posture Shoulder extension 3+/5 3+/5
Ms. Caster presented with marked forward head posture, Shoulder abduction 3+/5 3+/5
rounded shoulders, and slightly protracted scapulas. Abdominals 3/5 3/5
Hip flexion 4/5 4/5
Clinician Comment Her posture reflected Hip extension 4/5 4/5
what clinicians sometimes call “computer posture” because
it is a posture that is seen in someone who works on the Knee extension 4/5 4/5
computer all day and does not take breaks. This posture Knee flexion 3+/5 3+/5
exam was conducted using a visual assessment, which was
more subjective than measures taken from a plumb line.19 Plantarflexion 4/5 4/5
Clinician Comment MMT showed strength

Muscle Length Tests deficits throughout bilateral LEs and UEs as suggested by
Ms. Caster had shortness in her hamstrings and pectoralis the strength deficits noted in the systems review. Although
minor muscles. A straight leg raise test documented ham- these strength deficits are less than those noted in the sys-
string length at 60 degrees, bilaterally. The tightness in the tem review fitness exam, her decreased strength still needed
pectoralis minor muscles was classified as moderate based to be addressed in the exercise program both to maintain
bone stock and improve function.
It is worth noting that strength testing can give false mea- Prognosis
surements if not performed correctly.10 For example, use of
Ms. Caster had an excellent prognosis to increase her
only 1 or 2 1-RM attempts underestimates the “true” 1-RM
aerobic capacity, improve her posture, and increase her mus-
by as much as 11% because of learning improvement.
cular strength and endurance with a fitness program. She
could also anticipate that she would improve her fitness pro-
file, including improve her lipid panel, decrease her weight,
Pain improve her BP, improve her posture, and change her body
Using the numeric rating scale, Ms. Caster rated her knee composition, thus decreasing the risk factors for cardiovas-
pain as 2/10 when she went up and down stairs and 3/10 when cular, metabolic, and systemic diseases.
she knelt down on her knees.
Plan of Care
Clinician Comment Ms. Caster’s low pain Intervention
intensity could be expected because of the mild arthritis
in her knees as noted in the radiology report. Pain will be Ms. Caster would benefit from a progressive fitness pro-
another vital sign monitored during her exercise session to gram to address her poor fitness level. The program would
avoid having exercises exacerbate her knee arthritis. The include aerobic and anaerobic exercise (anaerobic exercise
numeric rating scale uses a 0 to 10 intensity scale, where in the form of resistive training), a flexibility program, and
0 indicates no pain and 10 is the worst pain ever. The cli- postural education. She would also benefit from a cardiovas-
ent is asked to rate pain using this scale during exercise as cular risk management program of weight control, BP, and
another indicator of exercise intensity. lipid management, as well as stress management. Education
in prevention of osteoporosis and metabolic syndrome would
be included. She may benefit from referrals to a registered
dietician and stress management counselor.
EVALUATION Proposed Frequency and Duration of
Physical Therapy Visits
Diagnosis Ms. Caster would arrange to work out at the fitness and
wellness center 3 to 5 times per week for 30 to 60 minutes to
Practice Pattern start. She would start with one-on-one training and progress
Based on the information from the client interview, sys- to independent sessions after 1 month.
tems review, and indicated tests and measures, Ms. Caster
was classified into 2 cardiovascular/pulmonary practice Clinician Comment Her insurance covered
patterns: 6A—Primary Prevention/Risk Factor Reduction $300.00 per year for a fitness center. This will be used to
for Cardiopulmonary Disorders, and 6B—Impaired Aerobic offset the cost of the entire program.
Capacity/Endurance Associated With Deconditioning.
International Classification of Functioning,
Anticipated Goals
1. Ms. Caster will be able to monitor her HR accurately and
See ICF Model on page 204. independently (1 week).
2. Ms. Caster will show 100% compliance with a 3 times
Clinician Comment It was concluded that per week fitness program (2 weeks).
Ms. Caster had no findings on the tests and measures that 3. Ms. Caster would demonstrate correct posture when
required physical therapy treatment prior to beginning walking on the treadmill (2 weeks).
a fitness program. Her impairments should be able to be
4. Ms. Caster would tolerate aerobic activity for 30 minutes
addressed with a well-designed and monitored fitness pro-
(2 weeks).
gram at the fitness and wellness center.
5. Ms. Caster will tolerate the addition of resistance train-
Further, Ms. Caster’s own goals also matched those of
ing, 2 sets of 10 repetitions at 50% of her maximum
a fitness program, namely improved cardiorespiratory
(3 weeks).
endurance, skeletal muscular endurance, strength, power,
speed, flexibility, agility, balance, reaction time, and body 6. Ms. Caster would demonstrate an understanding of
composition.14 risk factor reduction for cardiac and metabolic diseases
(4 weeks).
204 Chapter 5
ICF Model of Disablement for Ms. Caster

Health Status
• Stage I hypertension
• Stage II obesity
• Hypercholesterolemia
• Cardiac dysrhythmias

Function
• Difficulty completing IADL • No regular fitness program
• Decreased aerobic capacity after work
• Poor posture • Pain with ascending and
• Decreased muscle lengths descending stairs
• Decreased muscle strengths
• Decreased muscle
endurance

• Worked 40 to 60 hours a week • Home office in finished basement
• Often overwhelmed with home responsibilities • Sole caretaker of large home and grounds (has a
on weekends and evenings service for the pool)
• Recent additional weight gain
• No vacation in last 9 years
• Previous positive experience with exercise
• Family history of cardiovascular disease
7. Ms. Caster would be independent in her exercise pro- report to her PCP was a request to have Ms. Caster referred
gram, demonstrating proper technique and understand- to a registered dietitian and a stress management counselor.
ing of progression (4 weeks). HRs and RPE along with the exercises completed would
8. Ms. Caster would have 0/10 pain with steps and kneeling be documented in the fitness chart by Ms. Caster. At the end
(6 weeks). of each exercise session, Ms. Caster and the fitness program
monitor would review the session and adjust Ms. Caster’s
Expected Outcomes: 3-Month Mark program as indicated for the next session.
1. Ms. Caster would show a decrease in her resting HR and
resting BP to normal values.
Clinician Comment Some insurance compa-
2. Ms. Caster would achieve a 20% increase in her aerobic nies will pay for fitness benefits. Also, some plans consider
capacity. obesity a disease and will cover the services of a dietician. If
3. Ms. Caster would demonstrate an increase in muscle Ms. Caster was referred to, and evaluated by, a dietician, it
strength and endurance by 40%. could be anticipated that the dietician would send a report
4. Ms. Caster would be able to perform all exercises and documenting weight loss, body composition, and blood
daily activities with no complaints of fatigue. profile goals to the PCP and cardiologist. Along with prog-
ress notes, the dietician would also send requests for repeat
5. Ms. Caster would achieve optimal results on her lipid
blood profiles to the physicians.
panel.
6. Ms. Caster would achieve a 24-pound weight loss.
7. Ms. Caster would demonstrate a significant change in
body composition with a 7% decrease in her body fat. Patient-/Client-Related Instruction
8. Ms. Caster would demonstrate continued compliance in Ms. Caster would receive instruction in HR and RPE
her fitness program. monitoring. She would be shown, and would practice, the use
of the equipment with correct proper body form. Additional
educational sessions were planned for use of a proper warm-
Clinician Comment The opportunity to up and cool-down and the importance of maintaining the
improve her impairments with a fitness program at the fit- defined target heart range. Exercise responses to monitor
ness and wellness center also allowed Ms. Caster a longer for her safety would be identified for her as well as how to
time interval to make the needed gains with monitoring minimize the effects of delayed onset muscle soreness. As her
than might have been approved by her insurance carrier program progressed, the educational topics on osteoporosis
for physical therapy treatment. Initial fitness goals can be and metabolic syndrome would be presented.
achieved in 3 months.10 It can take up to 1 year or more to
achieve optimal goals based on the person’s needs and the
initial fitness level. For example, weight loss should only Procedural Interventions
occur at a 2-pound per week loss to maintain lean tissue.
Lipid panels can show changes but can take 3 to 6 months
Therapeutic Exercise Prescription
to show significant changes. Aerobic Capacity/Endurance
Mode
Discharge Plan Dual-action bike, elliptical, treadmill—any aerobic equip-
It was anticipated that Ms. Caster would achieve the antic- ment the client favors except a single-action bike
ipated goals and expected outcomes at the end of the fitness Intensity
program plan of care. She would need to continue regular HR = 132 bpm; RPE < 11/20
exercise sessions at the fitness and wellness center to achieve Duration
optimal outcomes and then to maintain her new fitness level. 20 to 30 minutes of aerobic exercise to start and progress
accordingly
Frequency
INTERVENTION 3 to 5 times per week; start with 3 days per week and
progress
Coordination, Communication, and Ms. Caster was instructed to exercise on the dual-action
Documentation bike using the following stages:
• Warm-up for 5 to 10 minutes on the bike at a lower
The initial examination findings and evaluation, includ-
intensity
ing the fitness program plan of care, was sent to Ms. Caster’s
referring PCP and to her cardiologist. Accompanying the
206 Chapter 5
• Training zone for 20 to 60 minutes at identified HR Duration
intensity 1 to 3 sets, 8 to 12 repetitions to start
• Cool-down for 5 to 10 minutes by slow biking or walk- Frequency
ing, followed by gentle stretching as outlined in her flex- 2 to 3 times per week
ibility program Description of the Intervention
When able, the exercises will begin with light eccentric
work and progress to concentric. Large muscle group exer-
Clinician Comment A dual-action bike was cises will precede those for small muscle groups. Multiple-
selected for Ms. Caster because she had HTN. Single-action
joint exercises will occur before single joint. There will be
bikes can increase the BP response because of increased
a rotation of exercises in a session of upper and lower body
vascular constriction from nonworking muscles.
exercises. Ms. Caster will be shown and reminded to main-
Ms. Caster’s HRmax (160 bpm) was identified from the tain correct body position.
stress test. This allowed a more accurate calculation for her
target HR range for exercising than using the age-predicted
formula for the HRmax of 220 – age. Tanka et al20 did for- Clinician Comment There are many methods
mulate another way to determine HRmax that is more exact in strength training. The description noted previously relies
but unnecessary for Ms. Caster since hers was identified in on the recommendations for resistive exercises by Kraemer
the stress test. et al.22
The Karvonen formula was used to calculate her tar-
get HR for exercising at 60% of her HRmax: target
HR = [(HRmax – resting HR) × 60%] + resting HR; target HR
= [(160 – 90) × 0.6] + 90 = 132 bpm REEXAMINATION
RPE was used as a measure of her perceived work and
monitored along with her HR.21 Ms. Caster was assessed 1 month after starting her fitness
program.
Flexibility Exercises Subjective

Mode
Muscle lengthening and stretching “I am amazed at my progress.”
Intensity
To a position of mild discomfort Objective
Duration Client reported a weight loss of 10 pounds and one drop
30 seconds for 2 repetitions in dress size. She was less fatigued and able to complete tasks
Frequency when she returned to home. Knee pain was gone with stairs.
Twice a day Ms. Caster was keeping regular appointments with a dieti-
Description of Intervention cian and a stress management counselor. Ms. Caster thought
• Hamstring and pectoralis minor stretches: She will iso- both practitioners had been helpful. She was very compliant
late the muscle to be stretched and work up to holding with her fitness program. She was tolerating slow but consis-
the stretch for 30 seconds. tent progression in her program.
• Hamstring stretch: Patient will sit on one of the benches Aerobic Capacity and Endurance
located against the gym wall, where she is able to sit with Resting vital signs were: HR = 87 bpm; BP = 140/82
her back maintained straight against the wall, then she Submaximal Bike test would be repeated at 3 months from
will slowly extend her knee as much as possible without program initiation.
changing her buttocks and back position.19
Muscle Length
Strength, Power, and Endurance
Pectoralis minor and hamstring length were normal,
Training for Head, Neck, Limb, Pelvic- bilaterally.
Floor, Trunk, and Ventilatory Muscles
Mode Strength
Weight machines initially then progressing to free weights Strength increased to 5/5 throughout and the 1-RM
Intensity increased by 30% for UEs and LEs. Muscular endurance also
60% to 70% of 1-RM. Rest intervals will be 2 to 3 minutes improved by increasing her to the 30th percentile.
for core exercises and 1 to 2 minutes for multi-joint using
heavy loads. Velocity was to be slow to moderate.
Anthropometric Measurements 4. American Heart Association. Coronary artery disease - coronary
heart disease. http://www.heart.org/HEARTORG/Conditions/
BMI: 29.2 More/MyHeartandStrokeNews/Coronar y-Arter y-Disease---
Weight: 170 lbs Coronary-Heart-Disease_UCM_436416_Article.jsp. Accessed July
2, 2010.
Body fat: 34% 5. Pescatello LS, Arena R, Riebe D, Thompson PD, eds. ACSM’s
Waist circumference measure: 79 cm Guidelines for Exercise Testing and Prescription. 9th ed. Philadelphia,
PA: Wolters Kluwer, Lippincott Williams & Wilkins; 2014.
6. WebMD. Menopause. http://www.webmd.com/menopause/default.
Assessment htm. Accessed July 3, 2010.
7. National Osteoporosis Foundation. NOF’s clinician’s guide to the
Client showed excellent progress the first month.
prevention and treatment of osteoporosis. Bone Source. http://nof.
Significant changes were noted in her resting vital signs. An org/hcp/resources/913. Accessed July 3, 2010.
increase in strength and muscular endurance were noted. 8. James PA, Aparil S, Carter BL, et al. 2014 evidence-based guideline
Significant changes were also noted in the anthropometric for the management of high blood pressure in adults report from
measurements. Muscle lengths were normal and the postural the panel members appointed to the eighth joint national commit-
tee (JNC8). JAMA. epub Dec 18, 2013. doi:10.1001/jama.2013.28447.
dysfunction was corrected. Ms. Caster reported she no longer
9. Fatigue. Answers. http://www.answers.com/topic/fatigue. Accessed
had knee pain during functional activities. Ms. Caster still July 8, 2010.
had Stage I HTN but she had reduced her BMI to the over- 10. McArdle WD, Katch FI, Katch VL. Exercise Physiology Energy,
weight category. Her risk for disease dropped from the very Nutrition, and Human Performance. 7th ed. Philadelphia, PA:
high risk category to the increased risk category. Her body fat Lippincott Williams & Wilkins; 2010.
11. Gladson B. Pharmacology for Physical Therapists. Philadelphia, PA:
measures kept her in the obese category.
Elsevier; 2008.
12. Blomström-Lundqvist C, Scheinman MM, Aliot EM, et al. ACC/
Plan AHA/ESC guidelines for the management of patients with supra-
ventricular arrhythmias—executive summary. A report of the
Ms. Caster was kept on her basic fitness program. Her American College of Cardiology/American Heart Association
program would be reviewed with her monthly and pro- Task Force on Practice Guidelines and the European Society of
Cardiology Committee for Practice Guidelines (Writing Committee
gressed accordingly. She would exercise at the fitness and to Develop Guidelines for the Management of Patients With
wellness center independently. The education sessions were Supraventricular Arrhythmias) developed in collaboration with
to continue until completed as planned. The expected out- NASPE-Heart Rhythm Society. J Am Coll Cardiol. 2003;42(8)1493-
comes remained as those established in the initial fitness 1531.
program plan of care. 13. Blair SN, Kohl HW 3rd, Barlow CE, Paffenbarger RS Jr, Gibbons
LW, Macera CA. Changes in physical fitness and all-cause mortal-
ity: a prospective study of healthy men and unhealthy men. JAMA.
1995;273:1093-1098.
OUTCOMES 14. Pollock M, Chairperson. ACSM position stand: the recommended
quantity and quality of exercise for developing and maintaining
cardiorespiratory and muscular fitness and flexibility in healthy
At 3 months, a review of Ms. Caster’s fitness record adults. Med Sci Sport Exerc. 1998;30:6-28.
showed that she continued to exercise regularly at the fitness 15. Pekmezi D, Barbera B, Marcus B. Using the transtheoretical model
and wellness center with a steady progression of her pro- to promote physical activity. ACSM’s Health & Fitness Journal.
gram. Based on the reports filed in her fitness record, all the 2010;14:8-13.
16. Borg GA. Perceived exertion: a note on history and methods. Med
expected outcomes established in the initial fitness program Sci Sports. 1973;5:90-93.
plan of care had been achieved. 17. Field AE, Coakley EH, Must A, et al. Impact of overweight on
the risk of developing common chronic diseases during a 10-year
period. Arch Intern Med. 2001;161:1581-1586.
REFERENCES 18. Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and manage-
ment of the metabolic syndrome: an American Heart Association/
National Heart, Lung, and Blood Institute scientific statement.
1. Mayo Clinic. Belly fat in women: taking—and keeping—it off. Circulation. 2005;112:2735-2752.
http://www.mayoclinic.org/healthy-living/womens-health/in- 19. Kendall FP, McCreary EF, Provance PG. Muscles Testing and
depth/belly-fat/art-20045809. Accessed July 2, 2010. Function. 4th ed. Baltimore, MD: Williams & Wilkins; 1993.
2. Klatsky A, Armstrong MA, Friedman GD. Red wine, white wine, 20. Tanka H, Monahan K, Seals R. Age-predicted maximal heart rate
liquor, beer and risk for coronary artery disease hospitalization. Am revisited. J Am Coll Cardiol. 2001;37:2001-2005.
J Cardiol. 1997;80:416-420. 21. Eston RG, Thompson M. Use of rating of perceived exertion for
3. Pignatelli P, Ghiselli A, Buchetti B, et al. Polyphenols synergisti- predicting maximal work rate and prescribing exercise intensity in
cally inhibit oxidative stress in subjects given red and white wine. patients taking atenolol. Br J Sports Med. 1997;31:114-119.
Atherosclerosis. 2006;188:77-83. 22. Kraemer WJ, Adams K, Cafarelli E, et al. Progression models in
resistance training for healthy adults. Med Sci Sports. 2002;34:203-
208.
SECTION III
PATHOPHYSIOLOGICAL
CONSIDERATIONS AND
CLINICAL PRACTICE
Individuals With Cardiovascular
6
Pump Dysfunction
Daniel Malone, PT, PhD, CCS and Scot Irwin, PT, DPT, CCS
CHAPTER OBJECTIVES CHAPTER OUTLINE

• Review the statistics and physiologic processes that • Epidemiology
make it likely that a physical therapist (PT) will encoun- • Pathology/Pathophysiology
ter a patient with primary or secondary cardiovascular
pump dysfunction. • Coronary Artery Disease
• List the survival prognostic factors identified in the ◦ Atherosclerosis

study by Proudfit et at.1 ◦ Mechanisms of Atherogenesis: Relationship to Risk
• Answer the question, “What is known about the effect Factors
risk factors have on vessel tissues that lead to the devel- ◦ Hemodynamics of Coronary Artery Flow in Normal
opment of coronary artery disease (CAD)?” and Diseased States
• Outline the sequence of events that can occur in an • Cardiac Pump Ischemia
artery that can lead to an eventual occlusion or throm- ◦ Pathophysiology of Ischemia
bosis.
◦ Acute Myocardial Infarction
• Describe the mechanical and metabolic factors, as well
as the neural influences, that determine coronary artery ◦ Reversal and Retardation of Progression of
blood flow. Atherosclerosis
• Outline the sequence of events during exercise that may • Heart Failure
lead to cardiac ischemia in a patient with an obstructive ◦ Congestive Heart Failure
lesion. ◦ Differences Between Left- and Right-Sided Heart
• Discuss the sequence of events that lead to an acute myo- Failure
cardial infarction (MI) and the findings that confirm ◦ Distinguishing Between Left- and Right-Sided
that an infarction has occurred. Failure
• Identify the evidence that suggests risk factor reduction ◦ Summary of Cardiac Pump Disorder
may favorably alter arterial lesions. Pathophysiology
• Compare and contrast the sequence of events, signs, and • Patient Examination: History, Systems Review, Tests,
symptoms for right vs left congestive heart failure. and Measures
◦ History and Interview
◦ Systems Review
◦ Test and Measures

212 Chapter 6
◦ Heart Rate Response
▪ Normal
BOX 6-1. PHYSIOLOGICAL
▫ Heart Rate Responses to Exercise
PROCESSES THAT MAY RESULT IN
▪ Abnormal CARDIOVASCULAR PUMP DYSFUNCTION
▫ Mechanisms ● Alcohol abuse ● Contusions
▫ Summary of Clinical Significance ● Autonomic nervous ● Dysrhythmias
system dysfunction
◦ Blood Pressure Response ● Heart failure
▪ Normal
● Cancer ● Inflammation of
▪ Abnormal ● Chronic diabetes myocardial and peri-
(Type I or Type II) cardial structures
▫ Systolic Abnormality
● Chronic hyperten- ● Ischemia
- Mechanisms
sion ● MIs
- Summary of Clinical Significance
● Conduction distur- ● Surgery
▫ Diastolic Abnormalities bances
- Mechanisms ● Valvular disorders
● Congenital malfor-
- Summary of Clinical Significance mations
◦ Angina This list is not exclusive; it is only a selection.
▪ Angina Threshold
▪ Mechanisms Although mortality has decreased, the incidence of car-
diovascular pump dysfunction and failure is growing steadi-
▪ Summary of Clinical Significance
ly in the United States.2 Over the last decade, the number
• Summary of individuals surviving heart surgeries, transplants, CAD,
• References MI and heart failure has increased, but the burden of these
disease processes remains high. The cost of heart failure
care alone in the United States exceeds $20 billion per year.
This chapter will provide a brief description of the most
Heart failure is the most common discharge diagnosis for
common pathologies associated with cardiovascular pump
hospitalized Medicare patients and the fourth most com-
dysfunction, CAD, and heart failure. This will include a
mon discharge diagnosis for all patients hospitalized in the
review of the pathophysiological consequences of these
United States.3-5 Greater than 5 million patients have been
diseases and their impact on patients’ aerobic capacity and
diagnosed with heart failure and 670,000 new cases are diag-
subsequent functional abilities. An overview of examination
nosed annually. Given these statistics, therapists working
considerations and intervention strategies will be presented.
in any environment are likely to encounter patients with a
The chapter will conclude with the critical thinking required
primary or secondary diagnosis that may include cardiovas-
to examine, evaluate, and treat a patient with a cardiac pump
cular pump dysfunction.
disorder.
EPIDEMIOLOGY PATHOLOGY/PATHOPHYSIOLOGY
The most common cardiac diagnoses are a result of CAD
Cardiovascular pump dysfunction may result from myr-
and heart failure. CAD may be treated conservatively (medi-
iad pathophysiological processes (Box 6-1). Regardless of
cally) or surgically (eg, coronary artery bypass grafting,
the medical diagnosis and the etiology of the cardiac pump
angioplasty, stenting, or atherectomy).
dysfunction, the practitioner must be able to appropri-
ately identify the limitations and alterations in the oxygen Heart failure is usually treated through the use of medica-
(O2) transport system to determine the most efficacious tions, but diagnosis of either heart failure or CAD requires
long-term follow up. As heart failure progresses, activities of
intervention(s) for the patient.
daily living (ADL) and quality of life will become impaired,
The impairments resulting from cardiovascular pump
life expectancy will be limited, and the patient may become a
dysfunction have a direct effect on an individual’s maximum
candidate for heart transplantation or mechanical assistance
O2 consumption, an individual’s aerobic capacity, and ulti-
(eg, left ventricular [LV] assist device). Although CAD and
mately, on O2 transport. Any pathology that reduces or limits
heart failure are primarily diseases of adulthood, the pedi-
cardiac output (CO) will impair aerobic capacity. Cardiac
atric specialist should also be aware that congenital cardiac
dysfunction can progress to the point that it may limit even
anomalies can also have detrimental effects on cardiac pump
the least demanding of daily activities.
function.
Individuals With Cardiovascular Pump Dysfunction 213
BOX 6-2. DATA POINTS COMMONLY USED BOX 6-3. RISK FACTORS
TO FORM A TREATMENT PROGRAM FOR ASSOCIATED WITH THE DEVELOPMENT AND
CORONARY ARTERY DISEASE PROGRESSION OF ATHEROSCLEROSIS
● Clinical monitoring ● Physiology
● Exercise testing ● Age
● Results from special studies ● Male sex
● Echocardiography ● Lifestyle
● Angiography/ventriculography ● Cigarette smoking
● MRI ● Sedentary lifestyle
● Patient history ● Medical indicators
● Physical examination ● Increased serum levels of low-density lipoprotein
cholesterol (LDL-C) and triglycerides
● Decreased serum levels of high-density lipopro-
In addition to the direct effect of the numerous cardio- tein cholesterol (HDL-C)
vascular pathologies on the heart’s contractile function, the
clinician must also be concerned with the effects of electrical ● Elevated homocysteine and fibrinogen levels
abnormalities on cardiac pump function. A heart that is free ● Hypertension
of any apparent pathology can develop an electrical abnor-
mality resulting in blood clot formation, leading to stroke
● Diabetes
(atrial fibrillation), acute orthostasis/shortness of breath
(SOB; ventricular tachycardia or supraventricular tachycar-
dia), or sudden death (ventricular fibrillation or third-degree Though the natural history of the disease is difficult to
heart block). The interventions by the PT will vary depend- document because of intervening variables (eg, medical and
ing upon their examination findings, the goals of the patient, surgical therapy, risk factor changes, aging, the presence or
and the progression of the pathology. absence of other coexisting illnesses), mortality and morbid-
ity rates are primarily dependent upon 2 factors:
1. Ventricular function (ejection fraction)
CORONARY ARTERY DISEASE 2. Total atherosclerotic load (number of vessels occluded)
Those aside, it is important to have some indication of
whether certain factors relative to the severity of the disease
Atherosclerosis at the time of initial evaluation predict the likelihood of
An understanding of the natural history of CAD is impor- future coronary events (eg, progression of symptoms, recur-
tant to the clinician for risk stratification and understanding rent MI, or cardiac death). For example, women have been
the patient’s prognosis. Ideally, awareness of diagnostic sub- shown to have significantly higher mortality rates than men
sets of patients with CAD, along with the data accumulated after their first MI.8
from various examinations or tests (Box 6-2) will provide the As noted in Chapter 1, there are 2 major epicardial, or sur-
basis for an individualized treatment program. face, coronary arteries: the right coronary artery and the left
Atherosclerosis affects the large- and medium-size arter- main coronary artery. The left coronary system is the major
ies throughout the body; its nomenclature depends on the source of blood supply to the LV, perfusing up to 60% to 70%
location of the plaques: of the LV muscle mass. The precise perfusion distribution
• In the extremities, aorta, or iliac arteries (a common patterns of the coronary arteries vary among patients.
manifestation of systemic atherosclerosis): peripheral Most of the literature describing the progression of
arterial disease or peripheral arterial occlusive disease cardiovascular disease postdiagnosis is limited by short
follow-up study periods; an exception to this trend is the
• In the vessels of the heart: CAD work of Proudfit et al.1 The Proudfit study involved a 10-year
The exact etiology of atherosclerosis is not fully under- follow-up period of 601 nonsurgical patients. The number
stood; however, there are certain factors that have been of coronary arteries involved, especially the left anterior
shown to increase the likelihood of the disease process descending (LAD) artery, was an important prognostic fac-
occurring in a given person (Box 6-3). tor, with 10-year survival rates for patient with single-vessel,
CAD is generally considered to be a progressive disease double-vessel, and triple-vessel disease being 63%, 45%,
that can develop and manifest as early as the second decade and 23%, respectively.1 The presence of a 50% or greater
of life,6,7 but the disease process begins in early childhood. lesion in the left main coronary artery, also associated with
214 Chapter 6
index (score derived from total number of risk factors) and
TABLE 6-1. LAYERS OF AN ARTERY the presence or absence of coronary disease found at the time
LAYER PHYSIOLOGY of angiography. The study highlighted the significant rela-
tionship between the risk factors and the presence of CAD.
Intima (inner Lined with endothelial cells
The study also demonstrated that patients with multi-vessel
layer) Supported by connective tissue disease had significantly higher risk factor indexes than
Media (middle Consists mainly of smooth muscle patients with single-vessel disease. The exact relationship
layer) cells between the risk factors and atherogenesis is still not specifi-
cally determined, but current evidence points to a long-term,
Adventitia Consists of collagenous elastic progressive cycle of inflammation, lipid accumulation, scar-
(outer layer) fibers and small blood vessels ring, smooth muscle cell proliferation, and endothelial cell
(vasa vasorum) dysfunction as the basis of athersclerosis.13
As noted in Chapter 1 (see Figure 1-16), arteries consist of
3 distinct layers (tunicae; Table 6-1). Veins, like arteries, have
multi-vessel disease, was another important prognostic fac- 3 layers, but the amount of smooth muscle tissue and elastic
tor limiting survival.9 Ventricular function, quantified as the tissue is considerably less, most likely because veins function
ejection fraction, is also associated with prognosis. Patients in a low-pressure system.
with poor LV function and low ejection fractions (less than
There is evidence that the major component of the athero-
35%) had lower survival rates than those with small areas
sclerotic plaque is LDL-C. Despite overwhelming evidence
of damage and normal ventricular function. Patients with
that LDL is an atherogenic lipoprotein, the precise mecha-
a ventricular aneurysm or with ejection fractions less than
nisms of atherosclerosis remain unknown. Current concepts
40% have 10-year survival rates of 10% to 18%.10 Other fac-
hypothesize that LDL-C filters and accumulates into the
tors, independent of the number of coronary vessels diseased
intima (insudate) when the permeability of the vascular
and ventricular function, associated with poor prognosis
endothelium increases due to injury (Table 6-2). When LDL
include the following:
begins to accumulate, endothelial cells increase production
• Severity of functional impairment imposed by angina of adhesion molecules and inflammatory proteins, which in
pectoris turn augments the adhesion and subsequent egress of macro-
• Electrocardiogram (ECG) evidence of LV hypertrophy phages into the subendothelium.14 The artery responds with
or conduction defects smooth muscle cell proliferation, increased collagen forma-
• Persistence of risk factors such as cigarette smoking, tion, and inflammatory reactions that lead to the develop-
diabetes, and hypertension1 ment of obstructive atherosclerotic lesions.15
This damage to the arterial endothelial layer allows insu-
Functional performance during a 6-minute walk test
dation and adherence of several macromolecules such as LDL
(6MWT) has also been shown to be an important predictor
and fibrinogen, both of which are believed to be key factors
of survival in patients with heart failure.11
in the atherogenic process. It is well documented that hypox-
ia and elevated levels of serum carbon monoxide alter arterial
Mechanisms of Atherogenesis: permeability,16 which suggests one way cigarette smoking
Relationship to Risk Factors plays a direct role in atherogenesis. Hypertension (probably
as a result of direct trauma) and angiotensin II also have
Atherosclerosis is a disease process that potentially can been shown to damage the endothelial cells and therefore
affect the majority of the medium and large arteries through- alter permeability of the endothelial layer. Catecholamines
out the body, including the vertebral, basilar, carotid, cor- (epinephrine, norepinephrine, serotonin, bradykinin), which
onary, femoral, and popliteal arteries, and the thoracic can be elevated by stress or cigarette smoking, also cause
and abdominal aortas. Its effects are varied; atheroscle- endothelial damage.17
rotic changes in the aorta include thinning of the media with Once the endothelium has been damaged, one potential
weakening of the vessel wall, and aneurysm formation (with cascade of events follows the course depicted in Figure 6-1.17
possible rupture), whereas the major change in the coronary This may eventually predispose the individual to plaque
artery is a stenotic, occlusive lesion. The following informa- rupture or thrombosis. In short, the endothelium is dam-
tion will focus on the particular atherosclerotic process that aged by various factors as listed in Table 6-1. Once damaged,
leads to the type of occlusive lesions that form in the coro- an injury response occurs with inflammation, cell necrosis,
nary arteries. phagocytic activity, and scarring. LDLs are not completely
It is clear that there are certain factors that increase the digested by the phagocytes and large pools of lipids become
likelihood of developing CAD or vein graft atherosclerosis deposited in the smooth muscle. These lipids are acti-
after bypass surgery. However, a cause-and-effect relation- vated when oxidized and further facilitate an inflammatory
ship between the risk factors and atherosclerosis cannot be response. The arterial reaction to this accumulation is to sur-
assumed on the basis of the epidemiological studies alone. round the pools of LDL with collagen (fibrous caps).18 These
Salel et al12 investigated the relationship between a risk factor caps are thin-walled and exposed to the shear forces of blood
TABLE 6-2. SUMMARY OF VARIOUS FACTORS THAT HAVE BEEN SHOWN TO

ALTER ENDOTHELIAL PERMEABILITY TO LIPOPROTEINS AND MACROPHAGES
SUBSTANCE OR PHYSICAL MECHANISM INVOLVED CLINICAL CONDITION
CONDITION
Hemodynamic forces; tension, Separation or damage to endothe- Hypertension
stretching, shearing, eddy currents lial cells, increased permeability,
platelet sticking, stimulation of
smooth muscle cell proliferation
Angiotensin II Trap-door effect Hypertension
Carbon monoxide or decreased O2 Destruction of endothelial cells Cigarette smoking
saturation
Catecholamines (epinephrine, nor- Hypercontraction, swelling, and Stress, cigarette smoking
epinephrine, serotonin, bradykinin) loss of endothelial cell and platelet
agglutination
Metabolic products Endothelial cell damage Homocystinemia, uremia
Endotoxins and other similar bacte- Endothelial cell destruction, plate- Acute bacterial infections
rial products let sticking
Ag-Ab complexes, immunological Platelet agglutination Serum sickness, transplant rejec-
defects tion, immune complex diseases,
lupus erythematosus
Virus diseases Endothelial cell infection and Viremias
necrosis
Mechanical trauma to endothelium Platelet sticking, increased local Catheter injury
permeability
Hyperlipidemia with increase in Platelet agglutination in areas of Chronic nutritional imbalance
circulating lipoproteins (cholesterol, usually hemodynamic damage, (high-fat and high-cholesterol
triglycerides, phospholipids) and over fatty streaks diets), familial hypercholesterol-
free fatty acids emia, diabetes, nephrosis, hypothy-
roidism
Reprinted with permission from Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine. Philadelphia, PA: WB Saunders;
1984.
Figure 6-1. Sequence of events leading

After normal process to adverse outcomes in CAD if cardio-
↓ vascular risk factors persist. FMD, flow-
Damaged endothelium (injury) mediated dilation; IVUS, intravascular
ultrasound sonography; QIMT, quantita-
↓ tive intima media thickening. (Adapted
Endothelial dysfunction (generalized) with permission from Barth JD. Which
↓ tools are in your cardiac workshop?
Carotid ultrasound, endothelial function,
Endothelial dysfunction (regional/local modification) and magnetic resonance imaging. Am J
↓ Cardiol. 2001;87(4A):8A-14A.)
Raised lesion in vessel wall/atherosclerotic plaque
↓
Plaque vulnerability to rupture
↓
Plaque ruptures
← Local factors →
Clinical event Silent progression of
← Time → plaque growth/obstruction
Death, MI, unstable angina
← Magnitude →
216 Chapter 6
Figure 6-2. (A) Diagram of area of endothelial damage
or injury; the major initial phase of atherogenesis. (B) A B
Secondary phase of atherogenesis involving platelet aggre-
gation; a phase that probably precedes smooth muscle
cell proliferation. (C) Diagram of smooth muscle cell pro-
liferation and migration from the media to the intima. (D)
Insudation of LDL-C within the inner layers of the arterial
wall. (Adapted from Ross R, Glosmet JA. The pathogenesis
of atherosclerosis. N Engl J Med. 1976;295(7):369-377.)
C D
flow. When the caps break, the oxidized lipids are exposed muscle cells of the intima. Epidemiological studies have con-
to thrombogenic factors in the blood stream, platelets, and sistently shown low levels of serum HDL to be a strong risk
fibrinogen. This can lead to thrombosis or embolic obstruc- factor for CAD.
tion of the narrowed lumen. There is growing scientific evidence relating the major risk
There is also evidence that certain blood components, factors directly to the pathogenesis of atherosclerosis. These
such as platelets and monocytes, play a role in the pathogen- data underscore the importance of therapeutic modalities
esis of atherosclerosis.19 Part of the normal activity of plate- aimed at risk factor reduction that are used in both primary
lets is to adhere to damaged, irregular, or injured arterial and secondary prevention programs.22
intimal surfaces, and when they aggregate, the preliminary
step in forming a clot has started. In fact, hyperlipidemia, Hemodynamics of Coronary Artery
cigarette smoking, and glucose intolerance have been shown
to increase the tendency for platelet aggregation.20 Repeated Flow in Normal and Diseased States
aggregation is believed to contribute to the progression of
It is important to understand the normal determinants of
the atherosclerotic process. Plaque fissures may be sites
myocardial O2 (MO2) supply and demand to fully appreciate
where this aggregation takes place. The work of Ross and
the consequences of hemodynamically significant athero-
Glosmet18,21 has confirmed that platelet aggregation and
sclerotic occlusions in the coronary arteries. CAD manifests
degeneration occurs at the site of intimal injury and that
itself in 3 ways: angina, infarction, and sudden death. The risk
a platelet-derived growth factor is released at these sites.
for developing one or more of these manifestations is corre-
Platelet-derived growth factor has been shown to stimulate
lated with the extent (number of coronary vessels occluded)
increased cholesterol synthesis and LDL-C binding to the
and severity (percentage narrowing) of the occlusions.
smooth muscle cells, as well as stimulating proliferation of
The average resting coronary blood flow in humans is
smooth muscle cells contributing to the pathogenesis of ath-
75 mL of blood/min per 100 g of myocardium; this can
erosclerosis (Figure 6-2).18
increase to as high as 350 mL of blood/min per 100 g at
The actions of HDLs should be considered when one is
maximal exercise.23 Coronary blood flow or supply depends
examining risk factors in the pathogenesis of atherosclerosis.
on the driving pressure through the coronary artery and
There is evidence that HDL-C protects against the formation
the resistance to flow along the coronary vascular bed.
of atherosclerotic plaques by removing cholesterol and cho-
During ventricular contraction (the systolic phase of the car-
lesterol esters from smooth muscle cells in the arterial wall
diac cycle), the extravascular pressure from the LV increase,
and blocking the atherogenic action of LDL on the smooth
which subsequently increases subendocardium pressures
compressing the coronary arteries, increasing vascular resis-
tance (see Chapter 1, Blood Flow section on p 15) and result-
ing in severely restricted blood flow to the subendocardial
zones and minimal flow to the subepicardial regions of the
LV. Therefore, the driving pressure for filling the coronary
arteries is primarily determined by the pressure during ven-
tricular relaxation or the diastolic phase of the cardiac cycle.
The systemic blood pressure (BP) provides a driving force
that promotes retrograde blood flow into the coronary arter-
ies, and this coronary blood flow is impeded by ventricular
pressure and coronary vascular resistance. The forces that
impede coronary blood flow are least during ventricular
diastole, resulting in phasic coronary blood flow to the LV.
In the normal person, the LV end-diastolic pressure is low
(5 to 10 mm Hg) and has little or no adverse effect on the net
driving pressure (systemic diastolic BP [DBP] minus LV end-
diastolic pressure; Figure 6-3).23 Because the right ventricle
develops less pressure, the changes in coronary vascular
resistance are also less and coronary blood flow is more con-
stant throughout the cardiac cycle.
The vascular resistance to flow depends on the tone of the Figure 6-3. Scheme of epicardial, subepicardial, and subendocardial
smooth muscle of the arteries, resulting in coronary vasodi- branches. (Adapted from Ellestad MH. Physiology of cardiac ischemia. In:
Stress Testing. 3rd ed. Philadelphia, PA: FA Davis; 1986.)
lation or constriction and the length of the arteries. A third
factor in determining coronary flow is duration of diastolic
filling time. Since the coronary arteries fill during diastole
The coronary blood flow (O2 supply to the heart) is deter-
and diastole comprises two-thirds of the cardiac cycle at rest,
mined by mechanical factors such as the driving pressure,
filling time does not impede coronary artery filling at rest.
extravascular pressure, and diastolic filling time; metabolic
However, during exercise, as the heart rate (HR) increases,
factors such as hypoxia; and, to a lesser degree, neural influ-
the time span of systole remains fairly constant, while dia-
ences resulting from innervation of both alpha and beta
stolic filling time can decrease as much as 35% to 40%.24 The
adrenergic fibers. The O2 demand is a function of HR, mean
reduced filling time in the normal person even during maxi- arterial BP (afterload), ventricular wall tension, and con-
mal exercise is not a limit to coronary blood flow. tractility. When atherosclerosis is present, coronary artery
Normally, the myocardium extracts 75% of the O2 (an BP is decreased beyond the site of the atherosclerotic lesion
O2diff, or arterial and central venous O2 difference) from (Figure 6-4).23
the coronary blood supply both at rest and with exercise. The greater the number and/or length of lesions, the
Therefore, any increase in MO2 demand must be matched by lower the downstream pressure and blood flow. The resul-
an increase in coronary blood supply.1 The factors that deter- tant problem is that fixed coronary atherosclerotic lesions
mine MO2 demand are HR, systemic systolic BP (SBP), myo- may decrease coronary flow ability to below cardiac muscle
cardial wall tension, and rate pressure generation in the LV. demand levels. What degree of stenosis is hemodynamically
At rest, the average MO2 demand is 10 mL of O2/min/100 g significant? Logan27 demonstrated that, at low flow rates
of myocardium, and with exercise the MO2 can exceed 50 mL (10 to 30 mL/min), resistance to flow was minimal; how-
of O2/min/100 g. Coronary blood flow is auto regulated by ever, at flow rates of 30 to 100 mL/min, resistance increased
both neural and metabolic influences. A potent metabolic 2- to 3-fold. More importantly, he demonstrated that lesions
coronary vasodilator is hypoxia, which leads to the release involving less than 70% to 80% stenosis had fairly constant
of vasodilator substances from the smooth muscle cells of curves of flow vs percent stenosis, but with lesions greater
the coronary arteries (eg, adenosine, bradykinin, carbon than a range of 70% to 80% stenosis, minimal increases in
dioxide).25 It is assumed that the vasodilatory influence of luminal narrowing resulted in pronounced increases in resis-
hypoxia overrides the vasoconstricting influence of the alpha tance to flow and decrease in flow beyond the stenosis. Due
adrenergic fibers that innervate the coronary vessels during to the physiology of laminar blood flow, the longer an ath-
exercise.26 The coronary arteries are also innervated by beta1 erosclerotic lesion, the greater the resistance and the worse
and beta2 adrenergic fibers, which vasodilate the vessels but the overall hemodynamic effect. As shown in Figure 6-5,
play a relatively minor role in the regulation of coronary a diffuse, lengthy, 50% lesion could impair coronary flow
blood flow. The endothelial cells of the coronary tree secrete as much as or more than a discrete 70% lesion. Sequential
a hormone (adenosine) that acts as a potent vasodilator. lesions can also have more of a bearing on flow and coronary
Endothelial secretory function may become dysfunctional in driving pressure than a single discrete lesion, depending on
the presence of inflammation and plaque formation.14 the percent stenosis.
218 Chapter 6
ISCHEMIC CASCADE
Resting coronary blood flow adequate

Normal end-diastolic pressure (gradient normal)
Endocardial ischemia begins as oxygen demand
exceeds supply
Increased myocardial oxygen demand (HR × SBP)
Fixed coronary flow (obstructive disease)
Increase Ca2+ retention in the endocardial myocytes
(↓ relaxation)
↑ Preload due to ↑ venous return from exercise
↑ End-diastolic pressure (worsens pressure gradient)
Worsens ischemia
Figure 6-5. Ischemic cascade created by obstruction of the coronary

arteries and increasing MO2 demand.
CARDIAC PUMP ISCHEMIA

Figure 6-4. Fall in diastolic coronary artery driving pressure beyond the
area of obstruction. Note the fall in pressure as the blood flows toward
the endocardium. (Adapted from Ellestad MH. Physiology of cardiac isch- Pathophysiology of Ischemia
emia. In: Stress Testing. 3rd ed. Philadelphia, PA: FA Davis; 1986.)
Why is the heart so much more susceptible to isch-
emia and infarction than other areas of the human body?
The idea that all atherosclerotic lesions are fixed and There are over 600,000 MIs in the United States each year.
rigid is somewhat misleading. In fact, there is evidence that The heart has 3 distinct disadvantages contributing to the
coronary lesions are dynamic and variable, depending on increased susceptibility to ischemia and infarction. First, the
the degree of vasomotor tone at the lesion site. Coronary heart has only a small capability to function anaerobically. It
plaque fissures create opportunities for intermittent episodes is primarily an aerobic muscle that has constant, high rates
of platelet aggregation, which may result in ischemia and of O2 and nutritional demand. Secondly, the heart receives its
thrombus formation. Sharp increases in vasomotor tone blood supply primarily in diastole, not during systole like the
leading to a localized or diffuse spasm of a coronary artery rest of the body. This means that the DBP is the driving force
(with or without a fixed lesion) have been shown to reduce for circulatory distribution, not the systolic pressure. Finally,
coronary flow significantly, resulting in one of several clini- the heart receives blood from the external surface—epicar-
cal manifestations including resting angina, MI, or sudden dial arteries—which then must pass through an extensive
death. Evidence suggests that coronary spasm often occurs in network of capillaries to the internal or endocardial areas.
persons with atherosclerotic lesions, and the degree of spasm The reader is encouraged to study Figure 6-4 carefully.
is more severe at the site of the atherosclerotic lesion than it The relationship between coronary artery blood flow and
is at adjacent uninvolved areas of the same artery in the same normal blood flow is uniquely depicted by this figure. Note
person.28 An interrelationship exists between the vasomotor there is a diastolic pressure reading inside the LV of 5 mm Hg.
tone of an artery and the integrity of the endothelium, the The normal end-diastolic pressure is 4 to 12 mm Hg. This is
presence of vasoactive substances, and certain components the pressure being exerted by the volume of blood in the LV
in the blood, including catecholamines thromboxane A2 just prior to systole. This blood volume does not provide O2,
(a substance derived from phospholipids of agglutinated glucose, or waste removal to the heart muscle.
platelets), serotonin, and histamine.29 Persons with periodic This requires the circulating DBP to exceed the end-
coronary spasm that results in myocardial ischemia often diastolic pressure in the ventricle in order to assure perfusion
exhibit certain characteristic signs or symptoms that include, of the endocardial myocytes. Regardless, the perfusion of
but are not limited to, a variant angina pattern often involv- the endocardial tissues has to overcome the pressure gradi-
ing discomfort at rest and a variable threshold for exertional ent between the DBP and the LV end-diastolic pressure as
discomfort, cyclic symptom patterns such as recurrent noc- it decreases from the epicardium to the endocardium. This
turnal or early morning discomfort, and ST segment eleva- pressure gradient relationship is insignificant to a normal
tion with or without symptoms. nonoccluded coronary vascular tree, but with even small
occlusions of the epicardial arteries, the pressure gradient
can diminish significantly (see Figure 6-4).
Prior to exercise, a patient may have sufficient coronary
artery blood flow to meet MO2 demand. With the onset of
exercise, there is an increase in MO2 demand, HR, and BP.
This increased demand may not be met due to the resis-
tance in coronary artery blood flow and the reduction in
net driving pressure beyond the obstructions. This usually
results in an endocardial, regional ischemia and contractile
dysfunction. This reduction in contractility in turn leads
to an increase in end-systolic volumes and ultimately end-
diastolic volumes, which may cause increases in end-diastolic
pressure. The rise in end-diastolic pressure further reduces
the net coronary artery driving pressure and worsens the
ischemia. As the myocardium becomes ischemic, it does not
relax completely, a condition that leads to a prolonged period
of systole and thus shorter diastolic filling time, decreased
compliance of the LV, and increased LV end-diastolic pres-
sure that further decreases the net coronary driving pressure,
all of which leads to more severe ischemia. Ischemia is often Figure 6-6. Illustration of subendocardial and transmural infarctions in a
accompanied by dysrhythmias, and dysrhythmias are a com- single-plane view.
mon cause of sudden death.30
The hemodynamic consequences of a coronary lesion
depend on the degree of luminal narrowing, the severity and as catecholamine release rates, activity of the autonomic
frequency of plaque fissures ulcerations, the degree of calci- nervous system, the SBP, and the LV end-diastolic volume
fication or soft plaque formation, the length of the stenosis, and pressure. There are generally 2 types of MIs: transmural
the coronary blood flow rate, and the degree of vasomotor infarction, also called a Q wave infarction, which extends
tone of the affected artery. In a person with a hemodynami- through the subendocardial tissue to the epicardial layer of
cally significant obstructive lesion, exercise with the associ- the myocardium, and subendocardial infarction, also called
ated increases in the HR and SBP (MO2 demand) results in a non-Q wave infarction, which involves only the innermost
increased extravascular pressure, insufficient coronary flow, layer of the myocardium and, in some cases, portions of the
and increased LV filling pressures, resulting in decreased middle layer of tissue, but does not extend to include the epi-
coronary perfusion pressures, myocardial ischemia, and cardial region of the myocardium (Figure 6-6).
potentially, dysrhythmias. This series of events is depicted in The diagnosis of acute MI is made from the combination
Figure 6-5.23 of several findings, including clinical history of signs and
symptoms, elevation of specific serum markers in the blood,
Acute Myocardial Infarction presence of an acute injury pattern on the 12 lead ECG, and
positive findings of special radioisotope studies. It is impor-
Myocardial cell death (infarction) may result from pro- tant to recognize that all of the previously mentioned find-
longed ischemia, which is the result of complete occlusion of ings are not necessarily evident in every acute MI and that,
a coronary artery vessel, vasospasm, or plaque rupture and in most cases, the changes in serum markers and the 12 lead
embolism. There are numerous possible mechanisms that ECG are relied on most heavily.
lead to coronary artery occlusion, including the following: The classic symptoms of an acute MI involve severe
• Progression of the atherosclerotic lesion to complete central chest or retrosternal discomfort (unstable, resting
occlusion angina). The nature of the discomfort varies but most com-
• Near total obstruction coupled with a thrombosis, monly is described as either pain, pressure, or heaviness
resulting in total obstruction of the vessel that the patient states is “like a heavy weight on my chest.”
The discomfort often will radiate to several areas, includ-
• Near total obstruction coupled with coronary spasm ing the neck or jaw, one or both upper extremities, and the
• Near total obstruction coupled with prolonged, relatively midscapular region. Infarction symptoms usually persist for
high MO2 demands prolonged periods of time (hours) but may wax and wane
• Plaque rupture with thrombosis or embolism and are not relieved by nitroglycerin. Associated signs and
symptoms commonly include dyspnea, diaphoresis, light-
Myocardial cell necrosis is followed by an inflammatory headedness, nausea, apprehension, weakness, vomiting, and
response, cell absorption, and eventually scar formation. hypotension. The clinician must be aware, however, that
The exact site and extent of necrosis depend on the the so-called classic symptoms described do not always
anatomic distribution of the artery, the adequacy of col- accompany an infarction and that the nature, location, and
lateral circulation, presence and extent of previous infarc- intensity of discomfort, along with the associated signs and
tion, and factors that influence the MO2 demand, such symptoms, can vary widely among patients. Finally, MIs can
220 Chapter 6
Figure 6-7. Serum markers indicative of MI. The relative rate of rise, peak
values, and duration of cardiac marker elevations above the upper limit
of normal for multiple serum markers following acute MI. (Reprinted with
permission from Porth CM, Hennessey CL. Alterations in cardiac function.
In: Porth CM, ed. Pathophysiology. 6th ed. Philadelphia, PA: Lippincott
Figure 6-8. Illustration of a classic acute infarction pattern seen in a

occur without symptoms; in fact, based on postmortem and single-lead ECG tracing.
epidemiological studies, 20% to 25% of all infarctions are
“silent” or asymptomatic.
The use of serum markers to diagnose an acute MI is The acute changes in the 12 lead ECG that occur as a
based on several assumptions that are still somewhat contro- result of an MI depend on the type of infarction (transmural
versial. First, it is assumed that elevation of a specific marker vs subendocardial) and the area of infarction. By definition,
occurs only with cell death and not in instances of prolonged subendocardial infarctions result in new T wave inversion,
ischemia. Second, the rise in the marker is not attributable ST segment depression, or both that persist for 48 hours with
to damage in other major organs. Finally, there is a direct no new Q wave changes or R wave losses. Transmural infarc-
relationship between the amount of rise in the marker and tions usually result in ST segment elevation associated with
the size of the infarction. T wave inversion in leads specific to the area of infarction.32
The 3 serum markers that are characteristically elevated In addition, evolutionary changes in the ECG pattern of
when an acute MI has occurred are myoglobin; creatine a patient with a transmural infarction induce a significant
kinase (CK), formerly called creatinine phosphokinase (CK- Q-wave (greater than 0.04 seconds in duration and greater
MB), a cardiac specific isoenzyme of CK; and troponin I. than 25% of the amplitude of the R wave) and, in some cases,
The serum levels of all of these markers will increase within decreased R wave voltage (Figure 6-8). Reciprocal ST seg-
the first 36 hours of an infarction (Figure 6-7).31 The myo- ment depression often occurs in undamaged areas opposite
globin levels are the first to rise and they peak during the the area of infarction. Studies indicate that ECG changes
first 4 to 8 hours after the infarct. CK also rises early after establish the correct diagnosis 85% of the time in men.
infarction but may remain elevated for several days after the Postmortem studies indicate that the sensitivity of acute
infarct. CK-MB rises more gradually and follows a pattern ECG changes in infarction patients is 60% and the false posi-
resembling CK by dissipating within 3 days. Troponin I rises tive rate is 42%. The most common causes of “false positive”
with CK but may remain elevated for several days after the 12 lead ECG changes include cardiomyopathies, cerebrovas-
infarct. False positive rises in the CK and CK-MB can occur cular accidents, pulmonary emboli, hyperkalemia, idiopathic
in patients with myositis, muscular dystrophies, and pericar- hypertrophic subaortic stenosis, and 12 lead conduction
ditis. The clinical significance of these changes for the thera- abnormalities such as left bundle branch block and Wolff-
pist working in an acute care setting is as follows: Prior to Parkinson-White syndrome. It is often 24 or more hours
increasing activity levels with a patient, it is prudent to check before the acute ECG changes described previously appear.
the latest serum levels. If the serum markers are spiked, the
patient may have extended their infarction or had another Reversal and Retardation of
infarction that has gone undocumented. Although this is a
rare phenomenon, it is better to know their current serum Progression of Atherosclerosis
marker status than to just assume that the other medical The concept that the normal progression of atherosclero-
staff will tell you to hold rehabilitation. The other clinically sis can be altered and, in some cases, reversed is no longer
significant information that can be obtained from the mark- theoretical. There is evidence that risk factor reduction has
ers is that, in general, the higher the level of CK and CK-MB, a major impact on the disease process both for those with
the larger the area of infarction. The patient’s prognosis is known coronary disease and for those at high risk of develop-
directly related to the extent of tissue damage and the degree ing hemodynamically significant coronary atherosclerosis.
of additional coronary artery obstruction.
TABLE 6-3A. FUNCTIONAL AND THERAPEUTIC CLASSIFICATIONS OF

HEART DISEASE FROM THE NEW YORK HEART ASSOCIATION
FUNCTIONAL CAPACITY CLASSIFICATION THERAPEUTIC CLASSIFICATION
Class I: No limitation of physical activity. Ordinary physical Class A: Physical activity need not be restricted
activity does not cause undue fatigue, palpitation, dys-
pnea, or anginal pain
Class II: Slight limitation of physical activity. Comfortable Class B: Ordinary physical activity need not be
at rest, but ordinary physical activity results in fatigue, pal- restricted, but unusually severe or competitive
pitation, dyspnea, or anginal pain efforts should be avoided
Class III: Marked limitation of physical activity. Comfortable Class C: Ordinary physical activity should be mod-
at rest, but less than ordinary activity causes fatigue, pal- erately restricted, and more strenuous efforts
pitation, dyspnea, or anginal pain should be discontinued
Class IV: Unable to carry on any physical activity without Class D: Ordinary physical activity should be mark-
discomfort. Symptoms of cardiac insufficiency or of the edly restricted
anginal syndrome may be present even at rest; any physi-
Class E: Patient should be at complete rest and
cal activity increases discomfort
confined to bed or chair
(continued)
Evidence shows that arterial lesions can be favorably altered

by a reduction in hypertension, hypercholesterolemia, and HEART FAILURE
hyperglycemia.33-35
Multiple studies have provided impressive clinical evi- Heart failure may be defined as the inability of the heart
dence, indicating that lipid lowering is an effective preven- to pump sufficient amounts of blood to meet the physiologic
tion intervention.36-38 Additionally, diet modification has demands of the body.46 Heart failure is a common coexist-
been shown to reduce coronary lesion size accompanied ing condition in patients with strokes, diabetes, chronic
by decreased arterial lipid content in primates.39,40 There obstructive pulmonary disease (COPD) and the multitude of
have also been several human studies involving coronary potential combinations of these diseases and other chronic
angiography that have demonstrated that lipid lowering disease states. The advancements in cardiac care have created
through diet or medical therapy results in a decreased an ever-growing population of individuals living with heart
incidence of coronary lesion progression and an improved failure.47 In fact, heart failure is the final common pathway
clinical course.41,42 Additionally, Blankenhorn et al43,44 have for virtually all forms of heart disease, including CAD/isch-
demonstrated that aggressive lipid lowering and elevation emic heart disease, HTN, cardiomyopathies, valve disorders,
of HDL led to a decreased incidence of lesion progression, arrhythmogenic diseases, and congenital heart disease.15
but a treated group of post-coronary artery bypass grafting This requires that the rehabilitation professional recognize
patients also demonstrated a significantly higher incidence and quickly assess the presence of worsening failure or the
of lesion regression. onset of acute heart failure. Heart failure may be classified
based on the severity of the patient’s symptoms and func-
The angiographic evidence of the beneficial effects of
tional limitations by the New York Heart Association. The
aerobic exercise on coronary progression is by no means as
New York Heart Association classification system is a well
extensive. However, Kramsch et al45 have published evidence
accepted scale for heart disease and heart failure and should
that moderate exercise carried out over a period of 3 or more
be familiar to all health care providers who may see patients
years and associated with improvements in HDL, LDL, and
with heart diseases (Table 6-3).
triglyceride levels resulted in decreased degree of athero-
sclerosis, decreased lesion size and collagen accumulation, Heart failure is a medical condition that can be slow in
and increased heart size and vessel lumen. These authors development and progressive in nature, but it may also be
concluded that regular aerobic exercise may prevent or retard characterized by acute exacerbations. Clinically, heart failure
the development of coronary atherosclerosis, especially if it is may be categorized by several terms, including high output/
initiated before an atherogenic diet. low output or right-sided/left-sided, but the most frequent
description is systolic heart failure (failure of the ventricular
The evidence is now clear that aggressive management of
pump) or diastolic heart failure (limited ability to fill prop-
dyslipidemia, hypertension, glucose intolerance, and regular
erly). Regardless of etiology, the common manifestations of
moderate levels of aerobic exercise can significantly moder-
the disease result from an inadequate CO. The most common
ate the course and outcome of the pathophysiology of athero-
causes of heart failure in the adult population in the United
sclerosis and its subsequent manifestations.
States are ischemic heart disease and chronic hypertension.
222 Chapter 6
TABLE 6-3B. GUIDELINES FOR RISK STRATIFICATION FROM THE

AMERICAN HEART ASSOCIATION WHEN CONSIDERING AN EXERCISE PROGRAM
AHA NYHA EXERCISE ANGINA/ISCHEMIA AND ECG MONITORING
CLASSIFICATION CLASS CAPACITY CLINICAL CHARACTERISTICS
A: Apparently healthy Less than 40 years of age; No supervision or monitoring
without symptoms, no major required
risk factors, and normal GXT
B: Known stable CHD, I or II 5 to 6 METs Free of ischemia or angina at Monitored and supervised
low risk for vigorous rest or on the GXT; EF = 40% to only during prescribed ses-
exercise 60% sions (6 to 12 sessions); light
resistance training may be
included in comprehensive
rehabilitation programs
C: Stable CHD with I or II 5 to 6 METs Same disease states and clini- Medical supervision and ECG
low risk for vigorous cal characteristics as class B monitoring during prescribed
exercise, but unable to but without the ability to self- sessions; nonmedical supervi-
self-regulate activity monitor exercise sion of other exercise sessions
D: Moderate-to-high ≥ III < 6 METs Ischemia (≥ 4.0 mm ST depres- Continuous ECG monitoring
risk for cardiac com- sion) or angina during exercise; during rehabilitation until safe-
plications during 2 or more previous MIs; EF ty established; medical super-
exercise < 30% vision during all exercise ses-
sions until safety established
E: Unstable disease ≥ III < 6 METs Unstable angina; uncompen- No activity recommended
with activity restric- sated heart failure; uncontrol- for conditioning purposes;
tion lable arrhythmias attention directed to restoring
patient to class D or higher
CHD, coronary heart disease; EF, ejection fraction; GXT, graded exercise test; NYHA, New York Heart Association.
Adapted from American College of Sports Medicine. Guidelines for Exercise Testing and Prescription. 6th ed. Baltimore, MD: Williams &
Wilkins; 2000.
Chronic ischemic disease will result in ischemic cardiomyop- Figure 6-9). In this way, the LV causes the right ventricle to
athy with ventricular dilatation and volume overload, while fail.
patients with chronic hypertension will exhibit hypertrophy
due to elevated afterload, termed pressure overload, and Congestive Heart Failure
concentric hypertrophy. As the heart’s contractile function
deteriorates, multiple compensatory mechanism attempt to Congestive heart failure, as the name suggests, is failure of
increase blood volume and raise cardiac filling pressure to the heart causing congestion in the chest, often resulting in
maintain the CO and raise BP (Figure 6-9). the patient complaining of an inability to take a deep breath
As CO falls, LV pressure rise. This pressure is transmitted or dyspnea on exertion. Some of the most common signs and
from the LV into the left atrium and then to the pulmonary symptoms of left-sided failure or congestive heart failure are
venous vasculature. As noted in Chapter 1, the pulmonary shown in Table 6-4.
venous system is normally a low-pressure system. As pul- Pulmonary edema occurs at the base of lungs first in the
monary venous hydrostatic pressures increase, fluid may be upright position, and the associated crackles are best heard
pushed out of the venous capillaries into the interstitial space in the posterior bases early in an acute exacerbation of heart
and eventually into the lung itself, resulting in pulmonary failure. As the failure worsens, the edema will ascend (from
edema. This rise in pressure is eventually reflected in a rise bases toward apices) and eventually (end stage), the patient
in pulmonary artery pressure. The right heart, which is sig- may develop frothy pink-tinged sputum and bubbly respira-
nificantly smaller in cross-sectional area and not designed to tion known as the death rattle. A dry nonproductive cough
pump against elevated pressures, will also begin to fail. The is common. Cough in the middle of the night if the patient
right ventricular end-diastolic pressure begins to rise and has been lying horizontal for a prolonged period is described
the result is elevations in right atrial pressures and increases as night cough or paroxysmal nocturnal dyspnea. When a
in peripheral venous pressures and peripheral edema (see patient assumes the horizontal position, venous return is
Figure 6-9. Illustration of normal and
abnormal pressure changes that occur
as a result of left heart failure. (LVEDP, LV
end-diastolic pressure; RVEDP, right ven-
tricular end-diastolic pressure.)
enhanced. If the heart is unable to increase CO in the pres-

ence of this increasing volume, then decompensation and TABLE 6-4. MOST COMMON SIGNS AND
pulmonary edema develop, leading to cough and the sensa- SYMPTOMS OF LEFT-SIDED FAILURE OR
tion of dyspnea and the patient is awakened.
Another sign of heart failure or decompensation is a third CONGESTIVE HEART FAILURE
heart sound (S3). This sound is thought to be the result of ● Pulmonary edema ● Exertional hypotension
an increase in ventricular wall stiffness (a decreased ven- ● Dry cough ● Sudden weight gain
tricular compliance). The rapid inflow of blood during early
diastole is met by a noncompliant ventricular wall, creating ● Nocturnal dyspnea ● Cardiac enlargement
a soft extra sound. An S3 may be a normal sound in children ● S3 by chest x-ray and
and athletes but is usually pathological in adults over age hypertrophy on a
40 years.46,48 ● Orthopnea 12 lead ECG
Orthopnea, SOB when lying flat, is also a common symp- ● Exertional dyspnea ● High resting HRs > 100
tom due to heart failure and may be further described by the at low levels of
● SOB at rest
number of pillows required to alleviate the symptom (eg, 1-, exercise (2 to
2-, or 3-pillow orthopnea). Exercise intolerance is due to mul- 4 METs)
tiple factors. Exercise requires an increase in CO to augment
O2 delivery to the exercising muscle. A failing heart may have
224 Chapter 6
An elevation in the pulmonary artery pressure will have a
similar effect on the right ventricle that elevations in sys-
temic pressures (hypertension) has on the LV, an increase in
ventricular afterload. The greatest difference being, as seen
in Figures 6-1 through 6-9, is that the right ventricle has
significantly less cross-sectional area (muscle mass) than the
left and cannot as easily tolerate even increases in ventricular
afterload. The signs and symptoms of right-sided failure are
peripheral edema and poor exercise tolerance. The edema
usually manifests itself in the lower extremities initially and
then can progress up into the abdomen (ascites), and liver.
Whenever a patient has bilateral lower-extremity edema,
the clinician should always rule out the possibility of right-
sided failure before initiating any anti-edema interventions.
Attempting to reduce the edema by using pressure garments,
pressure pumps, or gravity may increase the right heart
pressures, cardiac wall tension, and MO2 demand. This can
worsen the patient’s failure and put undo stress on the failing
ventricles.
There are many additional causes of right-sided failure
besides left-sided failure; these include but are not limited
to chronic or acute pulmonary hypertension, cor pulmo-
nale, right ventricular infarct(s) and valvular dysfunctions
Figure 6-10. Illustration of pressure changes that occur as a result of (tricuspid and pulmonary semi-lunar valves regurgitation
advanced COPD that leads to cor pulmonale (right heart failure). and stenosis). Cor pulmonale is right-sided heart failure
resulting from pulmonary disease. This may be commonly
encountered as a secondary diagnosis in patients with
a normal CO at rest but is not capable of increasing CO to any COPD. The primary cause of the right-sided heart failure is
substantial degree with increasing demand. Additionally, the chronic elevations in pulmonary artery pressures as a result
peripheral resistance of the vasculature is increased com- of chronic hypoxia and pulmonary hypoxic vasoconstriction
pared to normal, further limiting O2 delivery.49 Heart failure and resultant vascular remodeling (Figure 6-10).
is also associated with altered skeletal muscle. Specifically,
there is atrophy, muscle fiber transitions from type I to type
II-like muscle fibers, and reduced mitochondria and capil-
Distinguishing Between Left- and
lary density.50,51 Patients with heart failure will also demon- Right-Sided Failure
strate altered pulmonary responses to exercise with limited
The signs and symptoms of selective right-sided failure
pulmonary reserve.52-54 The combination of these alterations
are similar to left-sided failure, namely peripheral edema
in exercise responses limit the activity and exercise perfor-
and limited exercise tolerance. Right-sided failure is not
mance of patients with heart failure.
congestive heart failure because pulmonary edema does
Sudden weight gain (ie, 6 to 10 pounds or more in 1 to
not develop. However, similar to left-sided failure, there is
2 days) results from the body’s attempt to increase CO by
failure to sustain CO resulting in inadequate tissue/organ
retaining sodium and subsequent fluid retention and blood
perfusion and exercise intolerance. The signs and symptoms
volume expansion (see Chapter 1, Frank-Starling Reflex sec-
of right-sided failure with exercise include hypotension, due
tion on p 13). Finally, pathological findings on the ECG (LV
to reduced LV filling, no pulmonary edema (no crackles),
hypertrophy), chest x-ray findings (pulmonary engorgement
and usually no audible S3. Thus, the clinician that monitors
and cardiomegaly), and echocardiography (ejection fraction)
the patient’s responses to exercise may be able to differenti-
are used to confirm the diagnosis of congestive heart failure.
ate a patient suffering exclusively from right-sided failure
from one suffering from left-sided failure because of the
Differences Between Left- and Right- difference in signs and symptoms. It is also imperative that
the clinician who is treating a patient with the diagnosis of
Sided Heart Failure COPD and cor pulmonale monitor the patient’s BP and pulse
How does left-sided heart failure differ from right-sided oximetry responses to exercise. This will assist in identifying
heart failure? As previously noted, right-sided heart fail- a patient with SOB because of heart failure (cor pulmonale)
ure commonly occurs as a result of left-sided failure. The from a patient who is SOB strictly from pulmonary disease
pressure changes on the left are transmitted via the closed (eg, COPD).
vascular network of the lung to the pulmonary arteries.
Summary of Cardiac Pump Disorder History and Interview
Pathophysiology The patient’s history should include but is not limited to
age; gender; race; and past medical history with particular
The adequacy of coronary blood flow to the myocar- emphasis on previous MIs, cardiac surgeries, and hospital
dium depends on the balance between supply and demand. admissions for angina, heart failure, or syncope. A careful
Atherosclerotic changes in the coronary arteries can sig- review of the patient’s risk factors should also be completed
nificantly decrease coronary supply because of luminal nar- at this time. Those individuals with the greatest number of
rowing. Supply can be further compromised by increased risk factors for CAD have an increased risk for progression of
vasomotor tone in the coronary arteries, leading to acute the disease. The clinician should probe carefully about fam-
spasm of the artery. The possible consequences of an imbal- ily history and smoking history. A simple question like, “Do
ance between supply and demand include myocardial isch- you have a family history of heart disease?” is often answered
emia with or without symptoms, MI, or sudden death. The with a quick no, whereas a few additional questions like,
diagnosis of an acute MI is based on a combination of find- “Has anyone in your family ever had a heart attack or high
ings. Clinical symptoms, serum markers of cardiac damage, BP?” will bring a more elucidating response. Another often
and changes in the 12 lead ECG are all used to determine the missed risk factor is cigarette smoking. Patients will say they
diagnosis of MI. are not smokers when they are or when they just quit. Again,
CAD is a progressive process. The prognosis of a patient a more probing request is to ask, “Have you every smoked?”
with coronary disease depends primarily on the number of Establishment of the patient’s risk factors will assist in direct-
vessels diseased and the degree of LV dysfunction as a result ing the patient’s and families’ education programming.
of infarction or ischemia. Angiographic evidence exists, A thorough review of the patient’s current medications
demonstrating that risk factor reduction, including improve- can be very revealing. The most common medications used
ment of lipid levels and regular aerobic exercise, does alter when someone has CAD are beta blockers, nitrates, ACE
the progression of coronary atherosclerosis and, in some inhibitors, and calcium channel blockers. Patients with heart
cases, leads to regression of the disease process. Further failure will often be prescribed cardiac glycosides (Digitalis),
study is needed to uncover the various ways in which risk ACE inhibitors, low doses of beta blockers, and diuretics
factor reduction alters the normally progressive course of (Lasix). An understanding of the mechanism of action of the
atherosclerosis. medications and their potential side effects can help explain
Due to the significant advances in the treatment of all examination findings.
heart conditions, we are seeing an ever-growing population A review of the patient’s social and work history may
of individuals living with heart failure. Recognizing the provide information regarding activity/exercise tolerance.
signs and symptoms of heart failure are important to the During this portion of the examination, the therapist should
rehabilitation professional who may be working with patients ask the patient about his or her goals and determine his or
with secondary morbidities (stroke, hypertension, diabetes). her chief complaint. The therapist should understand that
An ability to use the findings from an examination of the patients may often experience denial, especially if they have
patient with cardiac and pulmonary diseases to differenti- just recently had an MI or episode of angina.
ate left- and right-sided heart failure is useful in determin-
Identification of the patient’s family will help with dis-
ing the most appropriate selection of interventions for each
charge and educational interventions. Heart disease pre-
individual.
vention should include the children of patients with heart
disease. The data on the incidence of heart disease in families
are clear, and if the risk factors are present in childhood, then
PATIENT EXAMINATION: they will progress into adulthood.55,56 The patient’s support
HISTORY, SYSTEMS REVIEW, system and work requirements will often direct the goals of
therapy. For example, a patient who works using primarily
TESTS, AND MEASURES his or her upper extremities needs to be trained using upper
extremity equipment and monitoring. One of the more com-
The history, systems review, and tests and measures are mon effects of CAD is depression, which may lead to a poor
key components to the clinician’s evaluation. For those prognosis.57 It is important to recognize other confounding
patients with cardiovascular pump dysfunction, these com- factors that would promote psychological dysfunction, such
ponents revolve around any medical diagnoses or comorbidi- as being a widow or living alone.
ties that may create increases in O2 consumption demands
or interfere with O2 transport within the body. Common Systems Review
comorbidities are COPD, type II diabetes, chronic hyper-
A brief gross inspection of the neuromusculoskeletal
tension, age, renal disease, and any neuromusculoskeletal
systems can be completed on most patients with a primary
impairments that require an increased demand on the car-
physical therapy diagnosis of cardiovascular pump dysfunc-
diovascular system for even normal daily activities.
tion by doing a gross manual muscle test. The integumentary
226 Chapter 6
Prior to the exercise test, the therapist should have
reviewed any other tests that may be available on the patient.
This includes echocardiography, angiography, chest x-ray,
24-hour ECG monitoring, and laboratory values, (cardiac
enzymes, 12 lead ECG, blood gases, glucose, hemoglobin,
cholesterol, and any renal function studies). The signifi-
cance of each of these variables will be clarified as a part of
the patient case presented at the end of this chapter. Instant
interpretation requires the therapist to understand both the
normal and abnormal responses to exercise.
To understand the abnormal responses often observed in
clinical environments, one must have a sound understanding
of normal human responses. To the purist, the term abnormal
is a misnomer, because a clear-cut definition of “normal” has
Figure 6-11. HR response to Bruce Protocol Treadmill test in Patient A, not been established. Normal values may range from those
a 45-year-old man, before surgery. Patient completed 6 minutes and less than average to those above average. This makes it dif-
6 seconds of the Bruce Protocol. He was limited by angina. Resting HR ficult to distinguish normal variations from true aberrations.
was 54 bpm, and maximum HR was 118 bpm. Resting BP was 164/98,
and maximum BP was 244/126. He demonstrated moderate systolic and
There are several established normal physiological
severe progressive diastolic hypertension with exercise. No ST-segment responses to exercise. For example, HR and SBP rise as the
changes were found in any of the 6 leads: V1, V5, V6, X, CM4, and Y. No dys- workload is increases. Normally, CO is the primary limita-
rhythmias occurred. His medications were nitroglycerine as needed and tion to maximum O2 consumption and determines the maxi-
Dyazide (triamterene and hydrochlorothiazide). An S4 was auscultated.
mal physical work capacity. Furthermore, numerous articles
describe the angina threshold (the point at which a patient
first perceives angina) as a fixed phenomenon based on MO2
system can be examined by inspection and is rarely contribu-
demand, which is strongly correlated to the product of HR
tory to the PT diagnosis unless the patient has undergone a
and SBP, the rate pressure product.58 Various pathological
surgical procedure. In patients with severe burns, the car-
conditions and treatments (including medications) can cre-
diovascular system demands may be so great that the func-
ate demonstrable changes in normal HR, BP, and anginal
tional limitations are a result of cardiovascular limits and not
responses during exercise.
integumentary embarrassment. The cardiopulmonary sys-
tem can also be grossly examined by obtaining resting and
activity associated HR, respiratory rate, BP, lung sounds, O2 Heart Rate Response
saturation, symptoms, perceived exertion, and heart sounds.
A more detailed explanation of the importance of these mea- Normal
sures is included in the test and measures section to follow. At normal and submaximal levels of exercise, CO and HR
responses increase linearly as the workload and O2 consump-
Test and Measures tion demands increase. At near maximum and maximum
levels of exertion, however, the HR response becomes less
The definitive test for the rehabilitation professional in linear and increases disproportionately to the workload
examination and evaluation of the patient with any pathol- imposed (Figure 6-11). If the workload is applied using arm
ogy that affects cardiovascular system is the exercise test—a work exclusively, the HR and BP responses are significantly
measure of aerobic capacity/endurance. The format for this higher for any given workload. The maximum workload
test can range from the maximum symptom-limited tread- achievable with arm work is significantly lower than with leg
mill exercise test with thallium scanning or echocardiog- work. These 2 concepts are important to keep in mind when
raphy to a simple self-care evaluation involving minimal treating debilitated patients with primary or secondary car-
demands on cardiovascular reserves. diopulmonary dysfunction. Although arm work appears to
The primary ingredients in any exercise test though are be significantly easier, the work on the heart may be higher
as follows: with relatively arm work versus even moderate levels of leg
1. A known measurable workload or O2 consumption work (Figure 6-12).
requirement (ie, speed, grade, kilogram-meters, METS) Normal resting HR ranges from 60 to 100 bpm. Below
2. Repeated measurement during the test of HR, BP, ECG, 60 bpm is called bradycardia. Above 100 bpm is called
and symptoms tachycardia. Although a resting HR of less than 60 bpm is
3. Heart sounds assessment before and after testing described as bradycardia, significant hemodynamic con-
sequences do not become apparent until the resting HR
4. Instant interpretation of the data being obtained from approaches 40 bpm. As noted in Chapter 1, CO is defined
numbers 1 and 2 as HR multiplied by stroke volume (SV) (CO= HR x SV). In
order to maintain a CO of 4 to 6 L/min (normal range for
Figure 6-13. Maximum HR decreases with increase in age.

Figure 6-12. Relationship between the HR response to arm work relative
to leg work.
hemoglobin, anxiety, fever, hormonal imbalance, or myriad

resting CO) at an HR of 40 bpm, the client’s SV would have other negative possibilities.
to be 100 to 150 mL per beat. The majority of patients with Heart Rate Responses to Exercise
clinically significant heart disease do not have the contractile An adult’s maximum attainable HR decreases with age. A
strength required to achieve this level of SV. Their CO falls useful but limited formula for predicting a maximum HR is
below the levels required to provide adequate O2 delivery to to subtract the patient’s age from 220 (Figure 6-13).
the tissues (heart failure). Many patients with CAD are pre- The accuracy of this formula is limited because of the
scribed beta-blocking medications, which reduce resting and effects of medications, abnormal HR responses, and the wide
exercise HRs. Even when these medications are present, a range of individual variations in maximum HR response
resting HR near or below 40 bpm should be considered a red (±10% to 15%).60 This variability is especially prevalent in
flag and the appropriate actions immediately implemented to women. Clinical experience has demonstrated that women,
prevent further untoward events. especially those over age 50 years have significantly higher
In addition to the effects that a low resting HR has on CO, maximum HRs than is predicted by the formula. The
it may indicate another problem such as heart block. Second- 220 – age formula should not be used to assess HR responses
and third-degree heart blocks are potentially life threatening of patients on medications (beta-blockers or sympathomi-
and are closely associated with low but regular HRs at rest. metics) or post-cardiac transplant. Beta-blockers blunt the
These blocks indicate that there is a conduction abnormality resting and exercise HR, and sympathomimetics (bron-
impacting the signal transmission from the SA node through chodilators) have nearly the opposite effect. Many patients
the AV node to the ventricles. The clinician is encouraged post-heart transplant have denervated hearts (no autonomic
to routinely assess the client’s resting HR and rhythm even nervous system input). Thus, their resting and exercise HR
when the primary diagnosis for referral or clinic visit is not responses are markedly abnormal compared to a normally
because of a cardiac or pulmonary origin. The adult resting innervated heart. On the other hand (for clinical guidance),
HR is, under normal conditions, a very stable variable and for individuals not on cardiac medications, the formula pro-
does not vary as a function of age.59 vides a gross indication of the intensity of work being per-
Clearly, pathophysiological considerations will cause formed. It is preferable to obtain a patient’s true maximum
changes, but that is all the more reason to routinely assess HR by performing a maximum symptom-limited exercise
each patient’s resting HR. Drastic changes in the resting HR, test.
up or down, may be the result of any number of associated
pathological conditions (heart failure, autonomic nervous Abnormal
system dysfunction, anemia, conduction system blocks, In the clinical setting, a small subset of patients with CAD
supraventricular and ventricular dysrhythmias, hormone demonstrates a clearly abnormal HR response to exercise.
imbalances, MIs, systemic infections, and a wide variety of This phenomenon has been described by Ellestad,61 Miller
medications). For example, your patient is referred for home et al,62 and others.46,63 Although each describes slightly dif-
health rehabilitation for a total knee replacement. His resting ferent criteria for the response, and thus a slightly different
HR on the first visit is a regular 78 bpm. On a subsequent population of patients, they agree that this response is a sign
visit 1 week later, the patient’s HR is 54 to 60 bpm. This may of an advanced pathological condition. Generally, the follow-
have been the result of a change in medications (beta-blocking criteria are observed:
er). If so, there is a significant reason for the addition of this • Low resting HR (50 to 70 bpm)
drug. On the other hand, what if his resting HR was greater
• Poor physical condition (untrained)
than 100 bpm? The patient may be experiencing a drop in
228 Chapter 6
Figure 6-14. HR response to Bruce Protocol Treadmill test in Patient A,

8 weeks after bypass surgery. Patient completed 6 minutes and 7 seconds Figure 6-15. Abnormal rate response. Life-table display of incidence of
of the Bruce Protocol. He was limited by leg pain. Resting HR was 62 bpm MI. Notice the higher incidence of infarction in those with poor chrono-
and maximum HR was 160 bpm. Resting BP was 176/110, and maximum tropic response to exercise. (Adapted from Ellestad MH. Physiology of car-
BP was 292/120. He demonstrated severe SBP and DBP response through- diac ischemia. In: Stress Testing. 3rd ed. Philadelphia, PA: FA Davis; 1986.)
out the test. He had no angina or ST-segment changes. One PVC occurred
during exercise. He was not using medications. An S4 was auscultated.
• Right coronary artery 75% stenotic at the ostium and
midpoint
• Advanced CAD
• Hemodynamically, the right ventricle and atrium had
• Maximum symptom-limited HR achieved during exer- greatly elevated end-diastolic and systolic pressures
cise testing is well below the person’s predicted maximal
HR, obtained by subtracting the individual’s age from • LV end-diastolic pressure was greatly elevated
220 • Ejection faction was normal
• Men between the ages of 40 and 60 years • The LV contractile pattern was normal
• Not using chronotropic inhibiting/exciting medications An abnormal HR response to exercise testing using the
(chronotropic means influencing the rate of the heart criteria listed may be the only abnormality found on the
beat) exercise test. This finding often signifies advanced CAD
and a poor prognosis. In an otherwise normal individual, a
• Poor, slow HR increase in response to incremental
slow gradual increase in HR with large increases in workload
increases in exercise workload
would signify someone with extremely good levels of physical
• Poor exercise tolerance fitness. This is clearly not the case with this subset of cardiac
An example of this phenomenon in a patient tested before patients.
and after bypass surgery (see Figures 6-11 and 6-14). A sum- Mechanisms
mary interpretation of each of these tests follows the graph.
There appears to be a close relationship between the
Each exercise test was performed using a standardized exer-
patient’s HR response and ischemia. (Note that there were
cise testing protocol.
no ST-segment changes on either test.) The first test, which
It is extraordinary that this patient’s exercise tolerance vividly demonstrates chronotropic incompetence, illustrates
was unchanged despite a 42 bpm increase in his maximum the need to watch all factors involved in exercise testing, not
HR between the first test before surgery and the second just the ST segments.
test 8 weeks after surgery. In effect, this patient had a 36%
Ellestad,61 confirmed by Brener and others,46,63 found
increase in his HR reserve but essentially no change in his
that this decreased response is an ominous sign of advanced
physical work capacity.
CAD associated with accelerated rates of mortality and mor-
The following findings were recorded on his bidity (Figures 6-15 and 6-16), especially when compared
catheterization: with patients with normal HR responses.
• 25% narrowing of the left main coronary artery If ischemia is the cause of this decreased HR response,
• Less than 50% narrowing at the junction of the proximal the body’s defense mechanism is appropriate because a
and middle thirds of the LAD artery, plus a somewhat reduced HR facilitates improved coronary blood flow and
narrowed appearance throughout its length decreases MO2 demand. A lower HR lengthens the dia-
• About 75% stenosis at the origin of the second postero- stolic filling time, enhancing LV perfusion. Alternatively,
lateral branch of the circumflex and mildly irregular an increased diastolic filling time may cause large increases
throughout in end-diastolic volume, especially during exercise. Volume
increases are well tolerated by a normal, well perfused
Figure 6-16. Combined events bradycardia. Those with bradycardia Figure 6-17. Comparison of SBP responses between men and women.
(pulse fell below 95% confidence limits for age and sex) and normal ST
segments have a high incidence of combined events (similar to those
with ST-segment depression). (Adapted from Ellestad MH. Physiology
of cardiac ischemia. In: Stress Testing. 3rd ed. Philadelphia, PA: FA Davis;
5. A decrease in HR with an increase in O2 demand (exer-
1986.) cise workload) is associated with potentially serious
dysrhythmias and conduction defects and is a contrain-
dication to continued exercise.
myocardium, but in the ischemic myocardium, volume
changes are associated with increased pressures and thus
decreased subendocardial perfusion (see Figure 6-4) As the
Blood Pressure Response
reader may note from the patient example, his end-diastolic Normal
pressure was greatly elevated—20 mm Hg—at rest (normal
is 0 to 12 mm Hg). One could speculate that the rising end- In normal adult men, BP responses to increasing levels
diastolic pressure that undoubtedly occurred with increased of exertion is not nearly so clearly described as their HR
venous return during exercise may have somehow been the response. Systolic pressure rises with increasing levels of
impetus to a reflex inhibition in HR.61 The pathological workload, and diastolic pressure either rises slightly (less than
chronotropic incompetence exhibited during a progressive 10 mm Hg), remains the same, or drops slightly (less than
increase in workload should not be taken lightly by clini- 10 mm Hg). In healthy individuals who can achieve or exceed
cians, but instead interpreted as a highly abnormal, patho- their predicted maximum HRs, the systolic pressure may rise
logical response to exercise.46 steadily during the submaximal workloads and then plateau
There are no normal conditions wherein an individual’s or even fall at peak exercise. This is not an abnormal finding.
HR decreases with an increase in workload. Clinical con- Generally, the SBP response to exercise in adult women is less
ditions that may alter the normal HR response include pronounced than that found in men (Figure 6-17).
second- or third-degree heart block, bigeminal rhythms The primary reason that BP responses are difficult to
(premature ventricular contraction [PVC] every other beat) interpret is that the auscultatory method of obtaining BP
and sick sinus syndrome. A decrease in HR with increasing during exercise can be unreliable. It requires good clinical
levels of exercise is always a red flag for the clinician. The skill to obtain any BP readings when someone is exercising
client should discontinue his or her exercise program, and on a treadmill or free walking, but reliable readings are dif-
the cause of the decreased HR should be determined and the ficult to obtain because of the excessive extraneous noise and
physician notified. No further exercise training should be the arm movement that occurs during an exercise session. At
carried out until the patient is cleared to resume exercise by low levels of exercise, it is possible to get fairly reliable and
his or her cardiologist. reproducible data, but accurate readings are increasingly dif-
ficult at high levels of exercise.64 An arterial indwelling pres-
Summary of Clinical Significance sure sensor would be the most accurate means of obtaining
1. Failure to perform symptom-limited, maximum exercise BPs, but this is highly impractical to the PT.
tests may mask the patient with abnormal HR responses. SBP rises during exercise because the increase in CO is
2. A slow HR at rest and a slow HR response to exercise greater than the decrease in peripheral vascular resistance
does not always signify a good state of fitness. (Figure 6-18). The normal physiological response to exercise
3. Abnormal HR response to exercise may be an ominous is a dramatic redistribution of blood flow away from the
sign, predictive of severe CAD. nonworking muscles and organs to the working muscles.
With lower extremity exercise in normal adults, this will
4. Patients who exhibit an abnormal HR response to
cause a decrease in overall peripheral vascular resistance.
exercise should be monitored carefully and medically
As noted in Chapter 1, the mean arterial pressure (MAP) is
supervised closely if they are enrolled in a cardiac reha-
the average pressure over a cardiac cycle and is considered
bilitation program.
230 Chapter 6
Figure 6-18. Relationship between CO, peripheral vascular resistance,

and SBP with increasing levels of exercise.
to be the perfusion pressure of the organs of the body. MAP

is directly proportional to the product of CO and periph-
eral vascular resistance (MAP = CO × TPR) and, clinically,
MAP is estimated by adding the DBP to the pulse pressure
(PP = SBP – DBP) in the equations: MAP ~ DBP + 1/3 (PP).
MAP includes the relationship between SBP and DBP, and
the clinician should keep this relationship in mind when C
interpreting BP responses to exercise. In well-conditioned
athletes and in younger persons, the DBP may fall precipi-
tously during exercise, creating a wide pulse pressure. This
phenomenon is rarely seen with patients or persons over
40 years of age. Additionally, there is no evidence that a drop Figure 6-19. (A) Abnormal SBP response to exertion. Flat response. (B)
in DBP with exercise has any relationship to adverse patho- Poor response with an abnormal fall at peak exercise. (C) Abnormal SBP
response to exertion. Striking fall in SBP with exercise despite a normal
logical conditions. response at submaximal levels of exertion.
Abnormal
Significant abnormalities in BP responses to increasing
Bruce et al65 and Ben-Ari et al66 have found that this
levels of exertion occur both in SBP and DBP. Both abnor-
response is highly indicative of serious pathological condi-
malities often represent the existence of significant patho-
tions. They found that patients not on medications, with
logical conditions and should be recognized, interpreted, and
poor SBP responses and peak systolic pressures less than
incorporated into each patient’s examination and evaluation.
140 mm Hg, had a much higher incidence of sudden death. In
Systolic Abnormality addition, they found that this response was most commonly
There are 3 abnormal SBP responses that occur during found in 3 patient groups: those with severe obstructive
increasing levels of exertion. The first is the flat response, in CAD, which caused pronounced ischemia with exertion but
which the pressure may rise slightly but fails to continue to with normal ventricular function; those with cardiomegaly
rise and remains generally below 140 mm Hg (Figure 6-19A). or gross myocardial damage and poor ventricular function;
The second is a response in which the systolic pressure is low and those with a combination of these 2 conditions.67
to start (less than 110 mm Hg), rises slightly, and then begins The abnormal SBP response should not remove a patient
to fall despite increases in HR and workload (Figure 6-19B). for consideration in a cardiac rehabilitation program, but the
The third and clinically most common response, especially exercise prescription must be adjusted to accommodate this
in patients following an infarction, is a normal submaximal abnormality. Patients with these responses must be moni-
response with a precipitous fall in SBP at higher workloads tored closely.
(Figure 6-19C). This response is often associated with pro- Mechanisms
nounced ST-segment depression, cardiomyopathies, and When we look at the normal SBP response, it is common
large infarctions with poor ejection fractions. In order for to see a person’s BP flatten or fall at peak exercise. As noted
a fall in SBP with increasing HR to be significant, it must in Chapter 1, BP = CO × TPR. Theoretically, as HR exceeds
be at least a 20-mm Hg drop. Lesser drops may be clinically 190 bpm, the filling time for the ventricle decreases to a
significant, but they need to be related to other clinical signs point at which SV actually falls. As SV falls, CO declines
and symptoms (SOB and the development of an S3). (CO = HR × SV), but peripheral vascular resistance continues
to fall so that a decrease in systolic pressure results. This
normal response provides context to explain the mechanism
of abnormal BP responses.
An ischemic ventricle, a ventricle with a large scar, or a fail-
ing ventricle will quickly achieve a maximum SV. Normally,
during progressive incremental increases in exercise work-
loads, venous return rises, causing elevation in the end-dia-
stolic volume. In the normal heart, this elevation in volume is
met by increased contractility (see Chapter 1, Frank-Starling
Reflex section on p 13) with a resultant increase in ejection
fraction. On the other hand, patients with severe pathologi-
cal conditions (ischemia, large infarcts, heart failure) are not
able to increase contractility. SV does not increase and in fact
may fall. A decreasing SV limits increases in CO. Because
systolic pressure is a result of the relationship between CO
and peripheral vascular resistance, an abnormal CO response
with a normal fall in peripheral vascular resistance during
exercise may cause a fall in SBP.65,67,68
A fall in systolic pressure is often associated with addi- Figure 6-20. Normal flattening of SBP due to prolonged exercise at the
same workload.
tional signs and symptoms of inadequate CO, including SOB,
deep ST-segment depression or elevation, angina, and pallor.
After exercise, patients may exhibit an S3. Care should be
exercise workloads. The normal DBP response to exercise
taken not to overinterpret a flat or falling systolic response
in middle-aged women or a patient on antihypertensive or is to have DBP fall slightly (10 to 20 mm Hg) in younger
beta-blocking medications. These patients may exhibit this persons or to rise slightly, fall slightly, or remain the same in
response, but unless there are additional signs or symptoms, older persons.69,70
it may not be significant. A common sequel to a progressive rise in diastolic pres-
The clinician should be sure that the BP fall occurs with sure with exercise is for the diastolic pressure to remain
an increase in workload. It is normal for SBP to flatten and elevated several minutes after exercise. There is no literature
fall with prolonged (30 to 45 minutes) bouts of exercise at the that describes the significance of this finding, but in the
same workload (Figure 6-20). This should not be considered author’s clinical experience it is an abnormal finding. An
an abnormal response. The decline in SBP is explained by abnormal DBP response occurs when the diastolic pressure
the decline in peripheral resistance as a result of an increase rises 15 to 20 mm Hg or more above 90 mm Hg with increas-
in body temperature. Blood flow has been redistributed to ing levels of exercise. A patient’s actual abnormal response
the skin to assist in maintaining or lowering the core tem- and the generally accepted normal response are depicted
in Figure 6-21. Patients who exhibit this response may have
perature, and this has caused a further decline in peripheral
vascular resistance with little or no increase in CO. CAD even in the absence of ST-segment changes.71
Summary of Clinical Significance Mechanisms
1. Abnormal SBP responses are exhibited by patients with The cause or causes for progressive DBP responses to
exercise are open to speculation, and humoral, neurological,
severe ischemia, poor ventricular function, or a combi-
or hemodynamic factors could be the cause. It is of interest,
nation of these pathological conditions.
though, to speculate that patients exhibiting the progressive
2. This abnormality is commonly associated with other diastolic response to exercise may have a reflex mechanism
significant signs and symptoms including angina, SOB, that senses a need for increased coronary blood flow. This as
pallor, and S3s. yet unidentified mechanism may exert an influence on the
3. Patients who demonstrate falling SBP have higher annu- peripheral vascular tree to increase diastolic pressures and
al morbidity and mortality rates than those with normal thereby cause an increase in coronary artery driving pres-
BP responses. sure. The cause or causes may also be simple coincidence.
4. An abnormal SBP response with accompanying signs Patients with severe coronary disease generally have some
and symptoms is a clinical indication to discontinue additional peripheral vascular disease, which can dramati-
exercise and contact the referring physician. cally affect systolic and diastolic pressures.
5. These patients can still undergo exercise conditioning, Again, a rise in progressive diastolic pressure with exer-
but must be closely monitored for signs of ventricular cise is a clinical sign that adds to each patient’s data base
dysfunction and the advent of serious dysrhythmias. and should be recognized and incorporated into exercise
test interpretations and individualized exercise training pro-
Diastolic Abnormalities grams. If the diastolic pressure rises more than 20 mm Hg
The second, less commonly cited, abnormal BP response above 90 during increasing levels of exercise, the exercise
is a persistent rise in diastolic pressure with increases in should be terminated and the patient’s physician notified.
232 Chapter 6
it.” Most patients do not use the word pain when describing
their angina. They may use it when describing the discom-
fort associated with an MI, but they rarely use the word pain
when describing the discomfort associated with activity.
Although this symptom is most often associated with the
chest in male patients, in female patients, the anatomical site
for the discomfort can vary widely. Typical distribution pat-
terns for the discomfort are depicted in Figure 6-22.
Any clinician working with patients with known heart
disease should attempt to determine if they have or have had
angina. Once this has been determined, the clinician should
only refer to that patient’s angina using the word(s) he or she
used to describe his or her symptom. The patient will not
respond or understand your requests to tell him or her about
any anginal symptoms if you use words that do not describe
Figure 6-21. Abnormal DBP response to the Bruce Protocol maximum
symptom-limited exercise test. Patient E was a 47-year-old man who
his or her angina. This can be critical when exercise training
completed 7 minutes and was limited by leg fatigue and SOB. Resting patients or when initially getting patients up early after their
BP standing was 176/104 mm Hg, and maximum BP was 246/126 mm Hg. MIs or bypass surgery.
He exhibited 2 mm of ST-segment depression in 4 leads and mild angina It is also important to help the patient differentiate non-
4 minutes after exercise. He had frequent multifocal PVCs throughout the
test and an S4 after exercise. anginal pains from angina of cardiac origin. Chest, jaw,
and shoulder discomforts occur for a multitude of reasons.
Potential causes of noncardiac chest pain include but are not
Summary of Clinical Significance limited to costochondritis, pleurisy, gall bladder dysfunc-
1. A progressive rise in DBP with exercise may indicate tion, cervical impingements, and dental diseases. These
severe CAD. noncardiac causes of chest pain are not reproducible with
2. The rise should be at least 20 mm Hg or more above exercise, eating, or emotional distress and are not relieved
90 mm Hg and persist after exercise testing or training. by nitroglycerin. Many patients who are early postinfarction,
angioplasty, or bypass surgery may not clearly understand
their angina, but a clear explanation of differences between
Angina angina and other chest wall pains will assist the patient in
Angina is classically described as a chest discomfort better defining and living with their symptoms. From this
caused by an impaired blood supply (ischemia) to cardiac point on, anyone working with the patient should use the
muscle. This impairment results in an imbalance between term aching when asking about the patient having any symp-
MO2 supply and demand. It is a well documented finding toms, especially with increasing levels of exercise.
that a patient’s threshold for angina is roughly equivalent Although angina is a common symptom of people with
to a fixed, clinically measurable product of his or her HR heart disease, it is not always so easy to determine if your
multiplied by his or her SBP, the rate pressure product, and patient is having this symptom. Careful review of the
is linearly correlated with MO2 demand.23,58,72 Angina that patient’s prior history with close attention to the description
recurs at a fixed rate-pressure product is referred to as chron- of his or her symptoms is helpful. Remember that angina
ic stable angina. There are 2 other types of angina: unstable does not always present itself as a discomfort in the chest and
and variant. Variant angina, also called Prinzmetal’s angina, most patients do not describe it as a pain (see Figure 6-22).
is caused from vasospasm of a coronary artery. Variant Angina Threshold
angina can occur any time and may lead to infarction, but
it is not common and is usually treated with vasodilating Many current practitioners have found that patients with
medications. Unstable angina is angina that occurs at rest chronic stable angina can improve their exercise tolerance
or wakes a patient during the night. This form of angina is and maximum pre-angina working capacity, but patients
also referred to as preinfarction angina and is an ominous with angina are unable to exceed their angina threshold or
symptom of impending myocardial damage. Chronic stable rate-pressure product.
angina that begins to occur at lower and lower rate-pressure One of the more rewarding clinical improvements is
products may also be considered unstable angina. when a patient exceeds his or her angina threshold. Through
Chronic stable angina may be defined as any discom- careful screening and monitored exercise training, some
fort that occurs above the waist that is reproduced by eat- patients can raise their angina threshold and rate-pressure
ing, emotional distress, or exercise and relieved by rest or product before experiencing angina. There is even a small
nitroglycerin. Patient descriptions of chronic stable angina percentage of patients who actually eliminate their angina
is variable. Descriptions include but are not limited to tight- completely. Those who are capable of increasing or eliminat-
ness, burning, pressure, aching, hurting, soreness, difficulty ing their angina threshold commonly have the following
taking a deep breath, squeezing, and “I can’t really describe characteristics:
Figure 6-22. Typical and atypical anginal patterns.
• Inoperable CAD or patients who refuse surgery Mechanisms

• Highly motivated and compliant with their exercise pro- As with the other abnormal findings, it is difficult to
gram, diet, and risk factor modification explain how a person’s angina threshold can be increased or
• Chronic, stable angina eliminated. These patients still exhibit ST-segment depres-
sion at the same rate-pressure product as they did before their
• Capable of walking through their angina within the first
exercise training program, and the depth of the depression is
3 months of their training program
unchanged. This indicates that ischemia may still be present,
Walk-through angina is angina that occurs during a train- but the discomfort that previously accompanied it is gone.
ing session at a specific workload but gradually diminishes Although unproven, there are numerous potential expla-
and finally goes away despite the fact that the workload is the nations for the occurrence of this phenomenon, including
same or even slightly higher. This is not recommended unless the following:
there is approval by the physicians and the patients have a
• Increased oxidative enzymes in the heart muscle
clear understanding of their angina symptom. It is common
for patients with chronic stable angina to experience angina • Improved coronary blood flow through the development
when they begin their exercise training program. With care- of collateral arteries73,74
ful instruction and monitoring, they should learn to train at • Accommodation of the pain stimulus created by the
a level that is just below their angina threshold. The time to ischemia via the central nervous system
onset of angina can be lengthened by having the patient pro-
• Decreased atherosclerotic load and improved stability of
long their warm-up time. As the training program progresses
coronary artery smooth muscle73
and the patient’s exercise intensity and tolerance improves,
they may begin to experience walk-through angina. Regardless of the cause for increasing or eliminating
Increasing or eliminating angina thresholds in patients angina thresholds, the therapist conducting a cardiac reha-
with CAD is not a quick process. It often takes 12 to bilitation program for patients with reproducible angina
24 months of training and must be combined with risk fac- thresholds should consider this threshold as a symptom that
tor modification, including but not limited to lowering BP, can be successfully treated and, in some cases, eliminated
decreasing cholesterol levels, and eliminating smoking. completely with proper exercise conditioning and risk factor
modification.
234 Chapter 6
Summary of Clinical Significance 10. Haim M, Hod H, Reisin L, et al. Comparison of short- and long-
term prognosis in patients with anterior wall versus inferior or
1. Angina symptoms are best described by the patient. lateral wall non-Q-wave acute myocardial infarction. Secondary
Prevention Reinfarction Israeli Nifedipine Trial (SPRINT) Study
2. The therapist should carefully determine the patients
Group. Am J Cardiol. 1997;79(6):717-721.
with angina and use their terminology when asking 11. Cahalin LP, Mathier MA, Semigran MJ, Dec GW, DiSalvo TG. The
them about their symptoms. six-minute walk test predicts peak oxygen uptake and survival in
3. Descriptions of angina are as varied as individuals and patients with advanced heart failure. Chest. 1996;110(2):325-332.
12. Salel AF, Fong A, Zelis BS, Miller RR, Borhani NO, Mason DT.
may not follow the classic descriptions depicted in the Accuracy of numerical coronary profile. Correlation of risk factors
media. with arteriographically documented severity of atherosclerosis.
4. Angina may be successfully treated by exercise training. N Engl J Med. 1977;296(25):1447-1450.
13. Libby P. Coronary artery injury and the biology of atherosclero-
5. Angina threshold measured by multiplication of the HR sis: inflammation, thrombosis, and stabilization. Am J Cardiol.
and SBP is not a fixed value. 2000;86(8B):3J-8J; discussion 8J-9J.
14. Smith JK. Exercise and atherogenesis. Exerc Sport Sci Rev.
6. Further research into the mechanisms of elimination of
2001;29(2):49-53.
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sary. 5th ed. Philadelphia, PA: WB Saunders Company; 1997.
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20. Sullivan JM, Heinle RA, Gorlin R. Studies of platelet adhesiveness,
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236 Chapter 6
CASE STUDY 6-1 Clinician Comment What is known about

Ms. Damask and her medical status thus far? Ms. Damask
Scot Irwin, PT, DPT, CCS is female and women have lower mortality rates following
admission with heart failure than men.1 Her CAD involved
multiple vessels and especially her LAD coronary artery,
which provides blood to the anterior and septal portions of
EXAMINATION the LV. In the CCU, she initially had prolonged episodes of
both angina and heart failure, which defined her cardiac
History condition as “complicated.” Because of the area and size
of the infarction, she was at a high risk for failure and life-
Current Condition/Chief Complaint threatening ventricular dysrhythmia.
Ms. Damask was a 68-year-old Black female referred to A review of the patient’s medical record and the thera-
physical therapy for a functional assessment shortly after pist’s interview provided the following additional historical
transferring from the coronary care unit (CCU) to the CCU information.
step-down unit. She had been admitted to the CCU via the
emergency room with the diagnosis of an acute anteroseptal
MI 5 days prior to the referral to physical therapy. It was Social History/Environment
anticipated that she would be discharged from the hospital Ms. Damask reported that she lived alone in her 2-story
in 2 days. home. Her bedroom was on the second floor. She had been
History of Current Complaint widowed 6 years prior; her husband died from a heart attack
when he was in his late 50s. Ms. Damask had been a full-time
On the day of her admission, Ms. Damask reported she
homemaker for her entire adult life. She had 2 cats and 1 dog.
was performing her normal housework when she felt a dull
Ms. Damask was active in her church and had several female
“pressure-like” discomfort in her jaw and neck. She noted
friends in her neighborhood.
that the discomfort did not abate when she rested. Over the
Her 2 adult daughters lived nearby. Both daughters were
next 10 to 30 minutes, the discomfort worsened and she
married, had children, and worked outside the home. Her
noticed that she was getting sweaty and nauseated. She called
4 grandchildren were of various ages. She helped her daugh-
the local hospital and an emergency team was sent to her
ters by providing day care for the 2 youngest grandchildren
home. The patient did not remember anything else until she
as well as afternoon care for the older children.
woke up in the CCU at the local general hospital.
The emergency medical technician’s notes indicated that Social/Health Habits
the patient was found unconscious but breathing with a Ms. Damask reported that she had been in great health all
very fast irregular pulse of 116 bpm. Her SBP could not be of her life and her 2 daughters confirmed this. The patient
measured by auscultation but was 66 mm Hg by palpation. had never smoked, but her husband smoked 2 packs per day
She was attached to a portable ECG monitor and appropriate for their entire married life of 38 years. She reported that she
emergency procedures were implemented. She was trans- had never followed a regular exercise program. Ms. Damask
ported to the hospital emergency room. appeared to be overweight.
Upon arrival at the emergency room, she was in atrial
fibrillation with a pulse of 108 bpm. She had multifocal Medical/Surgical History
premature ventricular dysrhythmias with occasional runs of Until this admission, her medical history was unremark-
ventricular tachycardia. She had signs of LV failure, includ- able except for 2 normal pregnancies, a hysterectomy in her
ing crackles in her lung bases, and S3 and mild SOB at rest. early 50s, and hypertension. She was diagnosed with hyper-
She had positive troponin levels that indicated a large infarc- tension on a routine physical when she was 40 years old and
tion. Ms. Damask was diagnosed with an acute anteroseptal had been treated with a variety of medications over the last
MI. Thrombolytic therapy was considered but the attending 18 years. These medications included diuretics, beta-block-
physician thought that she was outside the time frame for ers, and, most recently, an ACE inhibitor. Her BP had been
optimal results. She was admitted to the CCU. well controlled over the prior year with the ACE inhibitor.
On her second day postinfarction, the patient underwent Ms. Damask reported that her mother and father died
cardiac catheterization with the following findings: exten- from heart failure.
sive CAD involving the proximal right coronary artery (70%
occluded), LAD (100% occluded just distal to the first septal
perforator and some minor plaque formation distally), and
Clinician Comment Though she reported great
health, Ms. Damask had several risk factors for CAD. She
the circumflex artery (50% occluded).
had a 38-year history of secondhand smoke, an 18-year his-
Ms. Damask’s ejection fraction was 32%. Her LV end-dia- tory of hypertension, and a family history of heart disease.
stolic pressure was 18 mm Hg. Her initial chest x-ray showed She did not exercise regularly and appeared overweight.
mild cardiomegaly with some signs of pulmonary edema.
Reported Functional Status levels had returned to a normal level. Her glucose levels were
mildly elevated at 136 mg/dL. Her hematocrit and hemo-
Ms. Damask reported she was fearful of attempting any
globin were within normal ranges. Elevated cholesterol and
activity. She reported she had not been out of bed since she
triglycerides were recorded with no apparent treatment for
was admitted to the hospital. While in the hospital, she had
the high cholesterol.
been using a bedpan for toileting. The nursing staff had been
She still had occasional ventricular ectopy at rest with
performing most of her daily hygiene.
some couplets, but no runs of ventricular tachycardia. She
Prior to her admission, she was independent with all ADL
had no overt signs of heart failure, but the cardiologist’s
and IADL. Her daughters confirmed that she was managing
examination continued to detect an S3 with a mild systolic
well on her own. All were hopeful that she could return to her
murmur (I/VI) in the midclavicular line. No reports of angi-
prior level of function. Ms. Damask reported that she enjoyed
na had been recorded for the 24 hours prior to the physical
caring for her grandchildren, though she was concerned that
therapy referral.
she would not be able to do so anymore.
She would like to be discharged to her home. If discharged
to home, she would need to be able to climb the stairs to her Clinician Comment Since her hemoglobin
bedroom. Each daughter expressed willingness to have her and hematocrit were within normal limits, Ms. Damask
convalesce at one of their homes, but it was not clear if either could be expected to have adequate O2 carrying capacity for
had a ground floor bedroom to offer her. activity. What was not yet known was whether she would
be able to show adequate SV for activity without a compen-
satory rapid rise in her HR or develop dysrhythmia.
Clinician Comment Ms. Damask expressed Cardiomegaly by chest X-ray is an ominous finding.
fear of activity and concern that she might not be able to
Cardiomegaly is defined as the patient’s cardiac silhou-
continue to care for her grandchildren. Fear is a very typical
ette being greater than half the width of her chest cavity.
early postinfarction response, especially when the patient
Usually, the heart’s dimension is less than half the width of
has experienced a near-death experience. A primary ben-
the chest, and this degree of change in heart size is strongly
efit of early safe mobilization for Ms. Damask, along with
associated with long-standing hypertension as one poten-
education for her and her family, would be to prevent her
tial cause of Ms. Damask’s heart failure.
from becoming psychologically crippled by her fear of her
disease. The system review was next and would help determine
if Ms. Damask was a candidate for physical therapy. She
To return to her previous normal daily activities, she would
had multi-vessel CAD. Though she had not had angina
need to acquire an exercise tolerance of about 4 to 5 METs,
for the 24 hours prior to the physical therapy referral, her
including at least one trip up and down a flight of stairs in
specific descriptors for her angina symptoms needed to be
a day.
identified. As well, she needed to be guided to report the
reappearance of the symptoms if any occurred during the
therapy session.
Medications She had a moderate to poor ejection fraction. The ejection
In the CCU step-down unit, Ms. Damask’s medications fraction is a strong predictor of mortality and morbidity.
were a beta-blocker, digitalis, diuretic, ACE inhibitor, and It is inversely related with the incidence of systolic heart
aspirin. The patient’s ventricular dysrhythmia and atrial failure—the lower the ejection fraction, the higher the risk
fibrillation had not returned since cardioversion and the of failure. This meant that the therapist should be closely
administration of the beta-blocker. monitoring Ms. Damask’s breath sounds and SBP during
any exercise activities. Before activity could be considered,
Clinician Comment Ms. Damask was taking however, Ms. Damask’s breath sounds needed to be evalu-
medications that relieved her signs and symptoms of acute ated and found absent of pulmonary edema signs (crackles).
congestive failure, namely the digitalis and the diuretic.
She was taking a low-dose beta-blocker, which has been
found to reduce the risk of life-threatening dysrhythmias for Systems Review
patients in heart failure.2 Beta-blockers are also prescribed
to most patients following an MI because they reduce mor- Cardiovascular/Pulmonary
tality and morbidity.3
HR: 60 bpm
She had a loud S3 gallop
Other Clinical Tests Resting BP: 116/76 mm Hg
The review of the medical record revealed that the latest Her lungs were clear but her breath sounds were distant.
chest radiograph showed the pulmonary edema had resolved Edema: No evidence of peripheral edema
but the cardiomegaly remained. Her initially raised troponin
238 Chapter 6
Integumentary transplant, heart valve surgery, and cardiomyopathy. The
Her skin was clear and intact. primary objective—examination of the patient’s cardiac
responses to increasing levels of activity—remains, regard-
Musculoskeletal
less of the medical diagnosis. The clinical measurements
Gross symmetry/posture: She was able to sit at the side of do not change, with the exception of adding breath sounds
her bed with symmetrical and nearly erect posture and O2 saturation measurements with pulmonary patients.
Gross range of motion: Extremities and trunk showed full Ms. Damask would remain connected to the ECG moni-
and symmetrical movements with no report of pain. tor during the activities providing immediate data on HR
Gross strength: Normal, in bilateral upper and lower and heart rhythm. The evaluating therapist would take
extremities and trunk, and without apparent impairment and record BP and heart sounds as well as monitor Ms.
Height: Her medical record indicated she was 5’4” Damask’s verbal and nonverbal reaction to the activities.
Weight: 170 pounds, also from the medical record It was anticipated that her HR would rise with the increase
Neuromuscular in activity. As stated previously, the rate at which her
HR increased would reflect her heart’s ability to adapt to
Balance: No difficulty with sitting balance
increased activity with increased SV. Although she was on
Locomotion: Not attempted in systems review
2 antihypertensive medications (ACE inhibitor and beta-
Transfers: Not attempted in systems review blocker), her SBP could be expected to rise in relation to any
Transitions: No impairment or difficulty with bed mobility elevation in her HR with exercise. If the systolic pressure fell
Communication, Affect, Cognition, with an increasing HR, however, and she developed SOB,
Language, and Learning Style there was a strong probability that the exertion exceeded
her heart’s ability to maintain CO. These would be signs
Ms. Damask was alert, cooperative, and oriented. She was that she was going into overt heart failure, as would the
able to report most of her medical history with modest sup- development of postexercise crackles, indicating pulmonary
plementation by her daughters. She reported no chest pain or edema.
the previously noted presenting symptoms of pressure in her
neck and jaw. The decision whether to include short-distance ambulation
would be based on Ms. Damask’s tolerance with the initial
Ms. Damask was initially fearful about sitting up at the
activities.
side of the bed. She was pleasant and polite, even when
expressing her initial misgivings with the suggested activity.
She again expressed that she wanted to go home, to her own
home. She was concerned, none-the-less, that she might not Tests and Measures
be able to return to her previous activities.
Aerobic Capacity
Clinician Comment Her resting HR and BP Ms. Damask’s vital signs were recorded while she was sit-
were in acceptable ranges. The S3 is consistent with her ting inclined in bed, sitting at the side of the bed, and stand-
history of heart failure. Auscultation of the chest reveals ing and during ADL activities of dressing, teeth brushing,
that the pulmonary edema and subsequent crackles have and walking. The results were as follows:
resolved and the distant breath sounds may be due to her
obesity or pulmonary changes associated with her long HR BP ECG SX HS
exposure history to secondhand smoke. Rest 66 116/76 NSR none S3
Even though Ms. Damask was cooperative with the bed Sitting 66 104/70 NSR none S3
mobility and sitting activity, her concerns about her status
with activity meant she would require reassurance when Standing 72 96/66 NSR dizzy S3
the examination required higher-intensity activity. ADL activity 72 to 102/70 rare none S3
The examining therapist decided to use a low-level activity Dressing 78 PVC
assessment with self-care items to measure Ms. Damask’s
Teeth
aerobic capacity. Items assessed can include, but are not
brushing
limited to, dressing, hygiene, grooming, and the transfers
or short-distance walking required to complete each. A Ambulation 78 to 102/68 6 to 8 SOB S3
low-level activity assessment is a patient’s first exercise test. 150 feet 84 PVCs
A low-level activity assessment can be appropriately per- in 1 min
formed on patients with a multitude of medical diagno- HS, heart sounds; NSR, normal sinus rhythm; Sx, symptoms
ses, including angioplasty, bypass surgery, stenting, heart
Clinician Comment Ms. Damask had a fairly EVALUATION

flat BP response with increasing levels of activity. Her HR
increase was a little high considering she was on a beta-
blocker. Many patients on beta-blockers during the early
Diagnosis
postinfarction period may have little or no HR change with Practice Pattern
activity. The development of SOB with a very slow walk-
ing speed was also a concern. This finding, along with the Based on the patient history, systems review, and measured
blunted BP response, suggested marked impairment of her aerobic capacity, Ms. Damask was classified into Preferred
cardiac function. The therapist stopped the ambulation Practice Pattern: Cardiovascular/Pulmonary Practice Pattern
because of the increasing dysrhythmia frequency and SOB 6D: Impaired Aerobic Capacity/Endurance Associated With
combined with the patient’s recent cardiac event. Cardiovascular Pump Dysfunction or Failure.
There were 3 possible causes of her SOB: International Classification of Functioning,
1. The exercise exceeded her LV performance ability. The Disability and Health Model of Disability
venous return and end-diastolic volume exceeded the Please refer to the ICF Model on p 240.
pumping ability of the LV and blood started to back up
in her lungs (ie, heart failure). Prognosis
2. The SOB was an angina equivalent, and the ventricle,
which was experiencing further ischemia in the pres- It was anticipated that Ms. Damask would be able to
ence of depressed contractility, resulting in heart fail- meet goals to prepare her to continue a progressive activ-
ure. ity and walking program at home within safe and defined
parameters.
3. Her responses were a result of the combination of both
of the explanations above, along with the dampening
effects of her medications. Plan of Care
The antihypertensive may be limiting the rise in BP and her
HR is accelerating to augment CO and subsequently the BP.
Intervention
The clinical finding was that Ms. Damask’s cardiac impair- Ms. Damask would benefit from an inpatient physical
ment was significant enough to limit her walking velocity. therapy program of monitored ambulation including warm-
Note that the aerobic capacity chart includes not just the up movements, ambulation, and cool down. Ms. Damask
distance walked, but also the time it took to cover that would be shown, and would practice, self-monitoring skills.
distance. Noting the time and distance allows the walking A home program of activity would also be identified for her
velocity to be calculated. Walking velocity is a functional to follow when she is discharged. Ms. Damask and her family
measure. If Ms. Damask was able to walk 150 feet but it would benefit from participation in a series of educational
took her 5 minutes to do so, then her walking would not sessions.
have been functional. She would have been walking at less
than 1 mile per hour. She could not cross a street within the PATIENT AND FAMILY EDUCATION TOPICS
usual duration of a walk signal or make it to a bathroom Structure and function of the heart
in an adequate amount of time to avoid an accident. In Heart disease and risk factors
addition, the walking velocity becomes a defined workload
against which to measure a patient’s response and note Cardiac medications (individual)
changes. Effects of exercise training
What was the significance of the dysrhythmias with walk- Self-monitoring: HR, angina, SOB (perceived exertion)
ing for Ms. Damask? An increased frequency of PVCs at Dietary considerations (cholesterol, fats, sugar)
any time is a finding that requires documentation and (Individualized)
close monitoring. Any time this occurs, it is worthy of writ- Lifestyle adjustments (psychosocial impact of heart
ten and verbal communication with the patient’s nursing disease)
and medical staff. If coupling or tripling of PVCs were to
occur, then any activity should be immediately terminated Emergency procedures (CPR course for family mem-
and followed up with immediate verbal, and then written, bers)
notification of the medical team.
Ms. Damask would be seen twice per day until she is dis-
charged from the hospital, anticipated to be in 2 days.
240 Chapter 6
ICF Model of Disablement for Ms. Damask

Health Status
• MI 5 days ago
• Multiple vessel CAD
• Hypertension

Function
• Walking limited by dyspnea • Ability to resume childcare
• Obesity and PVCs duties unknown
• Ejection fraction = 32% • Completing basic self-care • Ability to continue
• Left ventricular end- • Tolerance of usual IADL not participation in her church
diastolic pressure = known activities unknown
18 mm Hg

• Fearful of resuming activities • Second floor bedroom
• Supportive family
• Has friends in her neighborhood
• Was active at her church
Anticipated Goals communication with the members of Ms. Damask’s medical
team and her family regarding the program and progres-
1. Ms. Damask would be able to identify, and complete,
sion toward goals will be carried out. Documentation in her
components of a low-intensity exercise program includ-
medical record would include all aspects of care including
ing warm up (easy extremity and trunk movements in
initial evaluation, session progress notes, reexaminations,
sitting), monitored progressive ambulation, and cool
and discharge summary.
down (first follow-up session).
2. She would be able to set an ambulation pace without dys-
pnea or exceeding 72 to 78 bpm (second session).
3. Ms. Damask would be able to accurately, and inde- Ms. Damask and her family members would be encour-
pendently, count her pulse to identify her HR during a aged to attend any of the educational series sessions during
therapy session (third session). Ms. Damask’s hospitalization. Continuing cardiac rehabilita-
tion once she is discharged would also be recommended.
4. Ms. Damask would be able to pace herself to climb up
and down a flight of stairs using a standing rest every Additional individual instruction would be centered on
2 to 4 steps (fourth session). recognizing the signs and symptoms of heart failure. Ankle
swelling, nocturnal cough, increased SOB at lower levels of
5. Ms. Damask would be making progress toward activity activity, or angina with activity should be noted and reported
tolerance to walk 500 feet in 2 minutes without dyspnea to Ms. Damask’s physician.
and with an HR up to 72 to 78 bpm.
One or 2 of her family members would be encouraged to
Expected Outcomes (4 Sessions Over accompany her during at least one ambulation session while
2 Days) she is an inpatient to learn the pacing and self-monitoring
techniques Ms. Damask will need to follow on her home pro-
1. Ms. Damask would be independent in a self-monitoring gram. In addition, Ms. Damask would be instructed to have
activity program for home. someone with her during walking sessions once she is home
Discharge Plan for the first 6 weeks.
It was anticipated that Ms. Damask would be able to meet
the anticipated goals and expected outcome before her dis- Clinician Comment As noted in the inter-
charge from the hospital in 2 days. Further, it was anticipated vention table on p 239, several of the general educational
that she would be referred to an outpatient cardiac rehabilita- topics require individualization. A group discussion of
tion program to begin 2 weeks after discharge. medications is difficult and not fruitful if a patient is not
on the medications discussed. In general, the patient’s fam-
ily will retain far more information than the patient will.
Clinician Comment The plan of care is con- It is important to supplement any educational information
sistent with phase I cardiac rehabilitation. The general goal with booklets, handouts, websites, and video material. All
of phase I rehabilitation is to enable the patient to tolerate of this information is available from the American Heart
ADL, including self-care activities, stair climbing, toileting, Association.
and walking functional distances (typically 1 to 5 METs of
activity), with minimal to no cardiovascular symptoms and
appropriate vital sign responses Since hospital lengths of
stay are short, education is of paramount importance, and Procedural Interventions
this is a time to introduce risk factor and behavior modi-
fication in addition to a home exercise program. It is well
Therapeutic Exercise
established that risk factor modification and living a more Aerobic Capacity/Endurance
“heart healthy” lifestyle can reduce secondary complica- Conditioning or Reconditioning
tions and future coronary events.
Mode
Monitored progressive walking, inpatient
Intensity
INTERVENTION HR should exceed 72 to 78 bpm
Duration
~30-minute physical therapy session
Coordination, Communication, and Frequency
Documentation 2 sessions per day
The PT evaluating and then treating Ms. Damask would Ms. Damask’s vital signs would be monitored while she
coordinate the planned treatment session with Ms. Damask’s completed a routine of warm-up exercises consisting of
hospital schedule and other medical providers. Clear easy active extremity and trunk movements while seated.
242 Chapter 6
Ambulation in a hallway with marked distances would fol-
should be progressively increased from 2 minutes until the
low. She would be instructed to walk at a comfortable pace
patient can ambulate continuously without symptoms, at
within her tolerance with rests as needed. Vital sign monitor-
an HR of 72 to 78 bpm or less for 20 minutes. Work toward
ing would continue throughout the session at regular inter-
increasing duration before any changes in intensity.6,8,9
vals, including 5 minutes and 10 minutes after the activity
has ended. Ms. Damask will be shown, and will then practice,
self-monitoring of HR, symptoms, and walking pace.
Aerobic Capacity/Endurance HOSPITAL DISCHARGE
The results from the low-level activity assessment were
Mode
documented in Ms. Damask’s medical record and brought to
Self-monitored walking—home program
the attention of the nursing and medical staff. The medical
Intensity staff decided to alter the dosage of her beta-blocker and ACE
HR only to 72 to 78 bpm, and gradually increase to the inhibitor medications due to the excessive HR increase and
pace of 500 feet in 2 minutes flat BP response. Ms. Damask was discharged to the home of
Duration one of her daughters that afternoon. A referral was made for
Short interval of walking, 3 to 5 minutes, after warm-up outpatient cardiac rehabilitation to be initiated 2 weeks after
exercises her hospital discharge.
Frequency
2 to 3 times per day, 3 to 5 days per week4-6
Description of the Intervention Clinician Comment The evaluating therapist
Ms. Damask would be instructed to continue with the had no opportunity to provide further intervention for
identified active movements while seated for a warm-up Ms. Damask. Fortunately, Ms. Damask was referred to an
activity prior to walking. The short interval walking may outpatient program. Women, especially elderly women, are
take place in her home or outside. Once she is able to walk less likely to be referred for cardiac rehabilitation than their
500 feet in 2 minutes, then she would continue to maintain male counterparts.4
that velocity for gradually increasing distances.
Clinician Comment Ms. Damask and her REEXAMINATION AND

family should understand that more is not necessarily bet-
ter with her exercise program. Exercising several days in a EVALUATION (OUTPATIENT)
row may cause secondary joint, back, or leg trauma that
will preclude her from exercising on subsequent days. The
goals for this part of her rehabilitation would be to learn
Subjective
how to exercise, make exercise a part of her life, and moni- “I’m still anxious about how I’m doing; I don’t know how
tor her own signs and symptoms with activity. much I can do for myself at home.”
Patient instruction in an unmonitored home exercise
program requires that the patient is accurate and reliable Objective
in monitoring pulse and symptoms. Preferably, a patient
should exercise with someone at all times during the heal- Four weeks after Ms. Damask’s discharge from the hospi-
ing phase, defined as discharge to 6 weeks after an infarc- tal, she was examined for home physical therapy. The inpa-
tion. If the patient and family do not appear to be reliable, tient physical therapy evaluation was available for review by
then a supervised program recommendation is necessary. the examining PT. The following updates were noted:
Transtelephonic monitoring in the home has been shown to • Ms. Damask reported she had had no episodes of angina
be safe with elderly cardiac patients.7 or acute SOB.
Patients should avoid walking up inclines or in poor weath- • She had been walking a couple of times per day in her
er conditions during the healing phase. Either can challenge living room for about 5 minutes each session without
exercise tolerance. A solution may be to walk indoors at a incident.
mall, gym, or home. • Her HR had remained below 78 bpm every time she
HR, on a self-monitored home program, should not exceed walked and whenever she checked it during other activi-
the baseline established with the low-level activity assessment ties.
for any activities. If the patient notices that he or she is get- • She was taking the same medications as when she was
ting short of breath with any activity, that activity should be discharged from the hospital.
curtailed or the intensity should be decreased to a level where
he or she is not short of breath. The duration of ambulation • Her physician had referred her to a cardiac surgeon for
an evaluation for bypass surgery. She did not want to
proceed with a surgical intervention yet due to fear of the higher and she experienced the most symptoms during that
surgery and concerns about the expense. minute. During the assessment of the patient’s pulse, the
• She was uncertain of how to safely increase her activities therapist noted some occasional “skips.” These skips were not
for herself and her home. frequent and did not cause any symptoms.
• She wanted to safely return to her previous activity level,

including caring for her grandchildren. She also wanted INITIAL 6-MINUTE WALK TEST RESULTS
to resume attending church socials without SOB. Minute HR BP EKG Symptoms
The PT confirmed that Ms. Damask’s status for the sys- 1 66 130/88 N/A None
tems review matched the findings identified when she was
an inpatient. A 2-pound weight gain was noted; Ms. Damask 2 78 146/82 N/A None
weighed 172 pounds. The PT decided that an updated mea- 3 90 138/80 N/A Leg fatigue; SOB; patient
sure of Ms. Damask’s exercise tolerance was needed. The requested rest break
therapist determined that the most appropriate testing pro-
tocol for Ms. Damask was the 6MWT. 4 (rest) 78 136/78 N/A Ready to walk again
5 84 142/84 N/A None
Clinician Comment It was important to 6 84 136/78 N/A None
monitor Ms. Damask’s weight. Remember she was at high
risk for developing heart failure at rest due to the extent of
her infarction and coronary involvement. A rapid weight The calculated velocity of the walk was calculated from
gain of 6 to 10 pounds in less than 48 hours is a sign of 1150 feet walked in 6 minutes. At a steady pace, this would
heart failure. For accurate weight comparisons, as many convert to 11,500 feet in an hour, or 2.17 mph.
of the variables that affect weight need to be controlled (eg,
the weight of clothing, time of day, and time interval since Assessment
the last meal).
Ms. Damask was 4 weeks post-large MI with signifi-
Why a 6MWT? This test has been used extensively to cant inpatient complications of angina, heart failure, and
examine patients with cardiac dysfunction and failure.10-12 decreased exercise tolerance. Her ejection fraction and CAD
In one study, the distance walked during this test was pre- indicated moderate to severe cardiac dysfunction. Her exer-
dictive of peak O2 consumption and survival of patients cise tolerance at discharge was poor.
with congestive heart failure.10 This test is performed by Her reassessed exercise tolerance was limited by SOB
asking the patient to walk as far as he or she can in 6 min- and leg fatigue. Her HR and BP responses were normal.
utes. Walking needs to occur on a measured, level surface The slight fall in her systolic pressure with the increase in
and with close monitoring of the patient’s HR, BP, ECG HR during the third minute of her 6MWT might have been
(if available), symptoms, and heart sounds. If the patient significant, especially in light of her SOB. Her pulse findings
needs to stop and rest, that is allowed, but the 6-minute were only significant to the extent that she continued to have
clock continues to run. ventricular ectopy with exercise. Even as an averaged veloc-
If a patient is unable to walk due to musculoskeletal or neu- ity, 2.17 mph was barely a functional velocity for someone
rological involvement, then other forms of aerobic exercise attempting to cross an urban street at a signaled cross walk.
may be used such as biking or swimming. Another mode The practice pattern and ICF Model of Disability remained
of exercise may be used if that is the patient’s preference. largely as that defined during her inpatient evaluation. Her
If, however, an alternative mode of exercise is indicated or prognosis to meet an updated plan of care was good.
preferred, then the exercise test should be conducted using
that mode of exercise. Conversion of a 6MWT to an exer-
cise prescription for a biking or swimming exercise program Clinician Comment There are many methods
is not appropriate. This is especially true for those patients to assess exercise tolerance of patients with heart failure.
with heart failure because their symptoms may vary greatly A diversity of opinion exists about the most accurate and
depending on the mode of exercise used for testing.12,13 meaningful methods. The controversy revolves around the
best method of identifying those patients who should be
considered for transplantation by using measures of O2 con-
Aerobic Capacity sumption. For the PT, the important factor is that a patient’s
exercise tolerance in heart failure is not merely a matter of
As the following table shows, Ms. Damask completed the the peak O2 consumption, especially in women.1 Chronic
test and walked a total of 1150 feet without any assistance or heart failure patients are often limited by breathlessness,
assistive devices. The therapist pushed a wheelchair as Ms. and leg fatigue before they achieve their maximum O2 con-
Damask walked. Ms. Damask sat in the wheelchair to rest sumption. Chronic heart failure causes secondary changes in
during the fourth minute. Ms. Damask walked faster during exercise tolerance because of the long-term effects on arterial
the third minute of the test with the result that her HR was
244 Chapter 6
2. Ms. Damask would have clear written guidelines for a
blood flow and the loss of oxidative enzymes in muscle.14 In
home walking program with the new exercise prescrip-
addition, there are secondary changes that occur in the lung
tion (2 weeks).
that cause the patients to experience dyspnea at low levels of
exercise when CO is not the limiting factor. 3. Duration of her walking session would gradually
increase until she was able to walk continuously for
Ms. Damask’s prognosis was good to excellent to return
30 minutes (4 weeks).
to her previous level of function. She might never achieve
the intensity, frequency, and duration of exercise required 4. Ms. Damask would be able to tolerate increases in her
to modify her major CAD risk factors. She may, however, exercise prescription (4, 8, and 12 weeks).
improve her level of exercise tolerance beyond her prein- Expected Outcomes (16 weeks)
farction level.
Ms. Damask would report she had returned to at least her
There is some evidence that supports the use of home-based
preinfarction level of function.
exercise programs15 in patients post-bypass surgery and
with heart failure.16 There is some controversy about the
application of home-based programs for those patients with Clinician Comment Compliance with her
congestive heart failure,17 but since the goal is to achieve a medical and rehabilitation programs will lead to numerous
lifetime program of exercise, home-based programming will positive outcomes for Ms. Damask. The application of a
eventually be necessary. program of aerobic training for a patient with cardiac dys-
function should result in an increase in aerobic and func-
tional ability,19 decrease in elevated homocysteine levels,20
Plan of Care improvement in New York Heart Association Classification
with reduction in symptoms,16,21 improvement in quality
Intervention of life,21 reduction in body mass index,22 increases in HDL
levels, reduction in triglycerides, improvement in glucose
The education program started in the hospital will con-
tolerance and resting glucose levels, reduction in anxiety,
tinue with Ms. Damask and her family. The information
and less depression. Perhaps most interesting in this health
covered will be individualized for Ms. Damask during her
care market is the dramatic reduction in cost of care.23
physical therapy sessions but still includes topics from the
Exercise training for patients with chronic heart failure
hospital education series. See the intervention table on p 231.
reduced hospital admissions and increased life expectancy
Ms. Damask would continue with progressive walking but
by almost 2 years over a 15-year period.23
a new exercise prescription would be identified.
Clinician Comment The patient and family Procedural Intervention

will only retain a small percentage of the information unless
it is repeated several times over the course of her rehabili- Therapeutic Exercise
tation. The educational materials, (booklets, videotapes,
CDs, and advanced reading material) are all available from Aerobic Capacity/Endurance
the American Heart Association or their website.18 Conditioning or Reconditioning
The mode of aerobic exercise training for Ms. Damask Mode
initially was walking. Walking was specifically applicable Walking
to her normal activities and was easily accommodated into Intensity
her routine. Prior to accepting this mode of exercise, she HR not to exceed 84 bpm
should obtain a comfortable, durable pair of walking shoes.
Clinician Comment The intensity of the exer-

Proposed Frequency and Duration of cise was determined from the results of her 6MWT. Ms.
Damask was symptomatic and had a slight fall in her BP
Physical Therapy Visits when her HR reached 90 bpm.
Her first 2 exercise sessions following the establishment Since Ms. Damask’s exercise tolerance was so limited, the
of a new exercise prescription would be supervised and use of a target HR to determine intensity was somewhat
monitored. If the prescription allowed her to exercise without irrelevant. It was more important for the therapist to review
complaint during these supervised sessions, then she would the results of Ms. Damask’s exercise test and identify the HR
begin self-monitored sessions. The supervised sessions would at which Ms. Damask became symptomatic. Ms. Damask
continue 2 times per week for 6 weeks. and her family would be instructed that 84 bpm would be
Anticipated Goals the HR Ms. Damask should not exceed. Ms. Damask and
her family would be instructed to note any activity that
1. Ms. Damask would be able to tolerate a new exercise
caused her to become short of breath and identify her HR.
prescription without complaints (1 week).
the fifth minute of exercise. She had no angina or significant
Linking HR to activity intensity can become important
ST-segment changes during the test.
feedback to the patient and the therapist about whether the
patient’s condition is worsening or remaining the same. It is
also a wonderful way for the patient to experience positive Assessment
reinforcement about the effects of his or her exercise pro- The results of the exercise test allowed the exercise pre-
gram on symptoms and function. The patient can identify scription for her home walking program to be progressed.
those activities that he or she was unable to perform prior to The frequency of her supervised home health physical ther-
the exercise program that he or she will be able to perform apy appointments could be reduced. Referral to outpatient
asymptomatically as he or she improves. cardiac rehabilitation was considered at this time.
Duration Plan
5 minutes
Frequency
3 times per day, 4 days per week Aerobic Capacity
Mode
Walking
Clinician Comment The frequency and dura- Intensity
tion for the new exercise prescription was determined with
Walking pace of 2.8 mph, but HR was not to exceed
another walking session. Ms. Damask ambulated on a
96 bpm
level surface with standby assistance at a pace of less than
2 mph and an HR of less than 84 bpm. She was not symp- Duration
tomatic nor were there any palpable “skipped beats” until 30 minutes of continuous walking
she had been walking for 5 minutes, and then she reported Frequency
leg fatigue and asked to rest. The therapist had a wheel- 4 to 5 days per week; supervised sessions were decreased
chair available while Ms. Damask walked so sitting rest to once per week for 4 weeks, then to once per month
breaks were available. She rested for 2 minutes before her
HR was back to 66 bpm and she was ready to resume. Ms.
Damask repeated walking for 2 more intervals for a total of
Clinician Comment Should Ms. Damask have
had a resistance-training program as a component of her
3 walks of 5 minutes each. Each time, the reason for stop-
interventions? The literature supports supplementation of
ping was her leg fatigue. The total duration of exercise was
aerobic exercise with resistance exercise in patients with heart
15 minutes and the distance walked was less than 0.5 mile.
failure.16,17 However, most of this literature has been complet-
Therefore, Ms. Damask’s new exercise prescription had
ed on men, and longitudinal studies are yet to be completed. If
frequency and duration assigned as 3 times per day for
added, resistance training should be limited until the patient
5 minutes, 4 times per week.
has been completely cleared by her physician. A program of
resistance training would need to be accepted as a lifetime
goal of the patient. If a resistance-training program was initi-
REEXAMINATION ated and then stopped, the beneficial effects would be lost.
There is evidence that indicates that combining aerobic and
resistance exercise is more beneficial to ventricular function
Objective (increased ejection fraction, decreased LV end-diastolic vol-
ume) than aerobic training alone.24 The therapist and patient
Aerobic Capacity should be mindful that compliance with a resistance-training
Ms. Damask had been exercising in her home for 5 weeks. program is more difficult because of the need for standardized
She had achieved an exercise tolerance of 30 minutes of con- equipment. If the patient is motivated and has demonstrated
tinuous walking at a velocity of 2.25 mph. With the report good compliance, a resistance-training program can be insti-
of improved exercise tolerance to her physician, he had her tuted. As with any exercise prescription, and especially with
undergo a low-level exercise test. patients with heart failure, careful monitoring of the respons-
During the exercise test, she was able to complete 6 mines to initial resistance training should be obtained prior to
utes of treadmill walking at a velocity of 1.7 mph with a 5% continuing any program. Arm work, especially above the level
grade. The test was terminated with her complaints of leg of the heart, can cause acute increases in BP and HR that may
fatigue and SOB, which occurred at an HR of 96 bpm. She well exceed those levels obtained during aerobic activities.
had some ventricular ectopy but no couplets or ventricular For Ms. Damask, resistance training was not an option. She
tachycardia. Her BP response was again very flat with a had no means of follow-up other than at the hospital, which
maximum BP of 146/78 mm Hg during the fourth minute was too far from her home.
of exercise and another peak of BP at 138/78 mm Hg after
246 Chapter 6
4. Lavie CJ, Milani RV. Effects of cardiac rehabilitation and exer-
OUTCOMES cise training on exercise capacity, coronary risk factors, behav-
ioral characteristics, and quality of life in women. Am J Cardiol.
Discharge 1995;75(5):340-343.
5. Meyer K, Stengele E, Westbrook S, et al. Influence of different exer-
After 16 weeks of supervised and self-monitored progres- cise protocols on functional capacity and symptoms in patients with
sive ambulation, Ms. Damask achieved her goal of returning chronic heart failure. Med Sci Sports Exerc. 1996;28(9):1081-1086.
to her previous level of function. She was able to return to her 6. Meyer K. Exercise training in heart failure: recommendations based
on current research. Med Sci Sports Exerc. 2001;33(4):525-531.
independent living status and resume babysitting. She main- 7. Sparks KE, Shaw DK, Jennings HS III, Quinn LM. Cardiovascular
tained her routine aerobic exercise program at a local YWCA. complications of outpatient cardiac rehabilitation programs utiliz-
Her physician had her undergo a hospital-based follow-up ing transtelephonic exercise monitoring. Cardiopulm Phys Ther.
6MWT with telemetry rather than symptom-limited maxi- 1998;18(5):363.
8. Certo C. Guidelines for exercise prescription in congestive heart
mum treadmill test. The latter would have been preferred if
failure. Cardiopulm Phys Ther. 2001;12:39.
she had required a diagnostic and prognostic work-up. The 9. Smith KL. Exercise training in patients with impaired left ventricu-
6MWT was sufficient, however, to document her progress. lar function. Med Sci Sports Exerc. 1991;23(6):654-660.
As the following table shows, she walked 1600 feet in 10. Cahalin LP, Mathier MA, Semigran MJ, Dec GW, DiSalvo TG. The
6 minutes. She attained an average speed of just over 3 mph. six-minute walk test predicts peak oxygen uptake and survival in
patients with advanced heart failure. Chest. 1996;110(2):325-332.
Her only complaint was that she was mildly short of breath. 11. Delahaye N, Cohen-Solal A, Faraggi M. Comparison of left ventricu-
She continued to have some ventricular ectopy, but even that lar responses to the six-minute walk test, stair climbing, and maximal
was at a lower frequency than on her initial test. upright bicycle exercise in patients with congestive heart failure due
to idiopathic dilated cardiomyopathy. Am J Cardiol. 1997;80(1):65-70.
DISCHARGE 6-MINUTE WALK TEST RESULTS 12. Gualeni A, D’Aloia A, Gentilini A, et al. Effects of maximally toler-
ated oral therapy on the six-minute walking test in patients with
Minute HR BP EKG Symptoms chronic congestive heart failure secondary to either ischemic or idio-
pathic dilated cardiomyopathy. Am J Cardiol. 1998;81(11):1370-1372.
Rest 60 118/78 NSR None 13. Meyer K, Foster C, Georgakopoulos N, et al. Comparison of left
ventricular function during interval versus steady-state exercise
1 66 122/80 NSR None
training in patients with chronic congestive heart failure. Am J
2 78 144/86 NSR None Cardiol. 1998;82(11):1382-1387.
14. Okita K, Yonezawa K, Nishijima H, et al. Muscle high-energy
3 90 146/82 NSR None metabolites and metabolic capacity in patients with heart failure.
Med Sci Sports Exerc. 2001;33(3):442-448.
4 96 146/78 Rare unifocal PVC Mild SOB 15. Arthur HM, Smith KM, Kodis J, McKelvie R. A controlled trial of
5 96 140/80 Rare unifocal PVC Mild SOB hospital versus home-based exercise in cardiac patients. Med Sci
Sports Exerc. 2002;34(10):1544-1550.
6 96 140/78 Rare unifocal PVC Mild SOB 16. Oka RK, De Marco T, Haskell WL, et al. Impact of a home-based
walking program and resistance training program on quality of
life in patients with heart failure. Am J Cardiol. 2000;85(3):365-369.
17. Caldwell MA, Dracup K. Team management of heart failure: the
Clinician Comment Was this marked level of emerging role of exercise, and implications for cardiac rehabilita-
improvement in exercise tolerance realistic? The reality is that tion centers. J Cardiolpulm Rehab. 2001;21(5):273-279.
the worse the patient’s initial level of exercise tolerance, gen- 18. American Heart Association. 2001 Heart and Stroke Statistical
erally, the greater percentage improvement can be expected Update. Dallas, TX: American Heart Association; 2002.
and achieved. Part of the improvement in the test results was 19. Delagardelle C, Feiereisen P, Krecké R, et al. Objective effects of 6
months endurance and strength training program in outpatients with
attributable to Ms. Damask becoming familiar with the test.
congestive heart failure. Med Sci Sports Exerc. 1999;31(8):1102-1107.
The 6MWT’s reliability improves with repeated testing, as 20. Ali A, Mehra MR, Lavie CJ, et al. Modulatory impact of cardiac
does the patient’s performance. Patient familiarity with the rehabilitation hyperhomo-cystinemia patients with coronary artery
test needs to be considered when interpreting improvements. disease and “normal” lipid levels. Am J Cardiol. 1998;82:1543-1545.
21. McConnell TR, Mandak JS, Sykes JS, Fesniak H, Dasgupta H.
Exercise training for heart failure patients improves respiratory
muscle endurance, exercise tolerance, breathlessness and quality of
REFERENCES 22.
life. J Cardiopulm Rehab. 2003;23(1):10-16.
Yu CM, Li LS, Ho HH, Lau CP. Long-term changes in exercise
capacity, quality of life, body anthropometry, and lipid profiles after
1. Philbin EF, DiSalvo TG. Influence of race and gender on care pro-
a cardiac rehabilitation program in obese patients with coronary
cess, resource use, and hospital-based outcomes in congestive heart
heart disease. Am J Cardiol. 2003;91(3):321-325.
failure. Am J Cardiol. 1998;82(1):76-81.
23. Georgiou D, Chen Y, Appadoo S, et al. Cost effectiveness analysis of
2. Goldstein S. Clinical studies on beta blockers and heart failure
long-term moderate exercise training in chronic heart failure. Am J
preceding the MERIT-HF Trial. Metoprolol CR/XL Randomized
Cardiol. 2001;87(8):984-988; A4.
Intervention Trial in Heart Failure. Am J Cardiol. 1997;80:50J-53J.
24. Delagardelle C, Feiereisen P, Autier P, Shita R, Krecke R, Beissel J.
3. Packer M, Bristow MR, Cohn JN, et al. The effect of carvedilol
Strength/endurance training versus endurance training in conges-
on morbidity and mortality in patients with chronic heart failure.
tive heart failure. Med Sci Sports Exerc. 2002;34(12):1868-1872.
N Eng J Med. 1996;334(21):1349-1355.
Scot Irwin, now deceased, was the original author for this chapter and case. Both were adapted from selected chapters in Irwin & Tecklin: Cardiopulmonary
Physical Therapy: A Guide to Practice, 4th Edition, St. Louis, MO: Mosby; 2005. We are grateful to Elsevier for permission to include Scot’s work in this
book and especially to Kathy Falk for her assistance.
Individuals With
7
Peripheral Vascular Disorders
Cheryl L. Brunelle, PT, MS, CCS, CLT
◦ Epidemiology
CHAPTER OBJECTIVES ◦ Pathophysiology
• Discuss the distinction between claudication in limbs ▪ Race and Genetics
with peripheral arterial disease (PAD) and limb isch- ▪ Age
emia conditions.
▪ Gender
• Identify correlating factors with the diagnosis of PAD.
▪ Smoking
• Summarize the physiologic progression of PAD.
▪ Diabetes
• Discuss the relationship between deep venous thrombo-
▪ Hypertension
sis (DVT) and post-thrombotic syndrome.
▪ Dyslipidemia
• Compare and contrast the progression of chronic venous
disease (CVD) with that of PAD. ▪ Impaired Renal Function
• Discuss the relationship between PVD, depression, ▪ Physical Activity
revascularization, and quality of life measures. ▪ Other Risk Factors
• Identify the difference in symptom presentation with ▪ Nonatherosclerotic Causes of Peripheral Arterial
elevation, dependent limb position, and walking in PAD Disease
versus CVD.
◦ Prognosis
• Outline the sequence for measuring ankle brachial
• Chronic Venous Disease
index (ABI) and identify what can be learned from this
measure. ◦ Clinical Definitions and Classification
• Name the tests included in a vascular lab work-up for ◦ Epidemiology
PAD versus CVD. ◦ Pathophysiology
• Outline how risk factor management for PAD is similar ◦ Prognosis
to that for cardiovascular disease.
• Physical Therapy Examination and Diagnosis
• Identify the effective exercise intervention differences in
◦ The Subjective Exam
a patient with PAD and a patient with CVD.
◦ The Objective Exam
▪ Systems Review
CHAPTER OUTLINE ▫ Cardiovascular and Pulmonary
▫ Integumentary Integrity
• Peripheral Arterial Disease
▫ Musculoskeletal
◦ Clinical Definitions and Classification
248 Chapter 7
▫ Neuromuscular Although PVD encompasses pathologic conditions of
▪ Tests and Measures blood vessels supplying the extremities and the vital abdomi-
nal organs,5 this chapter will be limited to discussion of PAD
▫ Aerobic Capacity and Endurance and CVD of the lower extremities (LEs), as both can lead to
▫ Circulation significant functional disability, morbidity, and impaired
▫ Pain quality of life.
The goals of this chapter include increasing the PT’s
◦ Summary: the Clinical Examination and Peripheral understanding of the pathophysiology of PAD and CVD and
Arterial Disease helping the PT examine, diagnose, and choose evidence-
◦ Medical Diagnosis based interventions for patients with PAD and CVD.
▪ Peripheral Arterial Disease
▪ Chronic Venous Disease
• Treatment
PERIPHERAL ARTERIAL DISEASE
◦ Peripheral Arterial Disease
Clinical Definitions and Classification
▪ Cardiovascular Risk Reduction
PAD represents stenotic, occlusive, and aneurysmal dis-
▪ Exercise
eases of the aorta and its branch arteries.2 A resting ABI of
▪ Skin And Wound Care 0.90 or less is most often used as a hemodynamic definition
▪ Pharmacotherapy of LE PAD.3
▫ Pharmacotherapy for Claudication The Trans-Atlantic Inter-Society Consensus (TASC)
anatomic classification of aortoiliac (inflow) and femoral-
▫ Pharmacotherapy for Critical Limb Ischemia popliteal (outflow) lesions allow vascular surgeons to clas-
▪ Revascularization sify lesions based on location and morphology. Lesions are
▪ Other Treatments classified by location, size, and number from Lesion Type
A to Type D, and indicate the treatment of choice for best
◦ Chronic Venous Disease outcome. For example, Type A aortoiliac lesions indicate
▪ Skin and Wound Care unilateral or bilateral stenoses of the common iliac artery, or
▪ Compression unilateral or bilateral short (< 3 cm) stenoses of the external
iliac artery, and are preferentially treated endovascularly,
▪ Elevation and Exercise which yields excellent results in these kinds of lesions.3
▪ Pharmacology Some patients with PAD experience claudication, which is
▪ Surgery LE pain produced by exercise and relieved within 10 minutes
of rest,3 defined as intermittent claudication (IC) or “claudi-
• Summary cation.” PAD may lead to critical limb ischemia (CLI), which
• References is characterized by LE ischemic rest pain, ulceration, or gan-
grene. Left untreated, CLI would lead to major limb amputa-
In recent years, collaboration of various global vascular tion.2 Acute limb ischemia (ALI) is a form of CLI that arises
societies has provided several clinical practice guidelines when a sudden decrease in limb perfusion threatens tissue
and consensus documents1-5 that have significantly shaped viability.2 Patients with ALI may present with the “5 Ps”:
the practice of health care professionals treating those with pain, pulselessness, pallor, paresthesia, and paralysis. ALI is
peripheral vascular disease (PVD), thereby greatly affecting treated as a medical emergency.2
the care of these patients. Literature supporting examina- The Fontaine stages and Rutherford categories are used to
tion and interventions that are utilized by physical therapists classify the symptoms of PAD (Table 7-1).
(PTs) in these populations has been evolving, more so in
the population with PAD than in that with CVD. There is Epidemiology
sufficient evidence to guide the physical therapy examina-
tion of patients with PAD and CVD and to support various The prevalence of PAD and its most common disabling
interventions in these populations. As will be further dis- symptom, IC, varies in the literature, and there is a paucity
cussed, the prevalence of these diseases is high, they present of recent data. A study published in 20046 found that the
significant risks of morbidity and serious cardiovascular estimated prevalence of PAD among 2174 adults 40 years
events, and many of these patients are asymptomatic. It is and older was 4.3%, which corresponded to approximately
imperative, therefore, that the PT is able to appropriately 5 million individuals in the United States. In those older than
examine for, diagnose, and provide intervention for patients age 70 years, the prevalence rose to 14.5%. The prevalence of
with these diseases. PAD increased dramatically with age and disproportionately
affected Black people.6 This study did not discuss the pres-
ence or absence of IC among these individuals; however,
Individuals With Peripheral Vascular Disorders 249
TABLE 7-1. STAGING OF ARTERIAL DISEASE: FONTAINE STAGES VS RUTHERFORD CATEGORIES

FONTAINE STAGES OF PAD RUTHERFORD CATEGORIES OF PAD
Stage Clinical Grade Category Clinical
I Asymptomatic 0 0 Asymptomatic
IIa Mild claudication I 1 Mild claudication
IIb Moderate to severe claudication I 2 Moderate claudication
III Ischemic rest pain I 3 Severe claudication
IV Ulceration or gangrene II 4 Ischemic rest pain
III 5 Minor tissue loss
III 6 Major tissue loss
Reprinted with permission from J Vasc Surg, 45(1 Suppl S), Norgren L, Hiatt W, Dormandy J, Nehler M, Harris K, Fowkes FG, Inter-society
consensus for the management of peripheral arterial disease (TASC II), pp S5-S67, Copyright Elsevier 2007.
in previous studies, approximately 25% to 33% of patients Race and Genetics

with PAD had IC.7 The clinician should not assume that
The National Health and Nutrition Examination Survey
patients with PAD not experiencing claudication have nor-
found that Blacks were 2.8 times as likely as Whites to have
mal LE function.2 People with IC may experience significant
PAD.6 It is possible, therefore, that genetic factors play a role
functional disability; loss of quality of life because of clau-
in the development of PAD. The San Diego population study
dication; or severe impairment, morbidity, and/or mortal-
included 2404 multicultural males and females 29 to 91 years
ity because of CLI.8,9 Hiatt et al8,10 reported that patients
of age. Family history of PAD (defined as any first-degree
with IC had maximal oxygen (O2) consumption equal to
relative with PAD) was associated with a 1.83-fold higher
50% of age-matched controls, indicating a level of impair-
risk of PAD, and a 2.42-fold higher risk of severe PAD (ABI
ment similar to patients with New York Heart Association
< 0.70), and the authors concluded that family history of
class III heart failure. Patients with PAD are more likely to
PAD is independently associated both with prevalence and
have advanced systemic atherosclerosis,11,12 and they are at
severity of PAD.14 It is possible that a combination of genetic
increased short-term risk for cardiovascular events and death
and environmental factors led to the development of PAD;
in comparison to age-matched cohorts.2 Despite significant
however, the authors did not find any statistically significant
functional impairment, increased risk, and available effective
interaction of sex, race or ethnicity, body mass index (BMI),
treatments, between 10% and 50% of patients with IC have
pack-years of smoking or ever smoking, or diabetes with
never consulted a doctor about their symptoms.3
family history of PAD. There was limited power in these cal-
culations, so they should be viewed with caution.14 Another
Pathophysiology study examining a multi-ethnic Asian population supports
PAD is primarily caused by atherosclerosis,2 in which the role of genetics and found that subjects with PAD were
plaque progressively obstructs the lumen.13 Narrowing of more likely to be of Malay or Indian ethnicity than those
the arteries reduces blood flow to the limbs, which leads to without PAD. In a large population-based study of twins in
O2 deprivation to the working muscles, resulting in IC,5 and Sweden, including 1464 twins with PAD, traditional cardiac
symptoms usually occur distal to the narrowed arteries. In risk factors (diabetes, hypertension, hyperlipidemia, and pre-
severe cases, the blood flow is inadequate at rest, resulting vious or current smoking) were significantly more prevalent
in leg pain, termed resting claudication.12 Symptoms of PAD in twins with PAD than in those without PAD.15
may include pain, aching, cramping, weakness, or fatigue.5 Age
There are patients who do not experience symptoms of
Incidence and prevalence of PAD increases dramatically
claudication despite significant atherosclerotic blockage,
with increasing age.3,16
although the same long-term progression and complications
result as when patients are symptomatic.5 Over time, occlu- Gender
sion of vessels may lead to skin changes, including ulcers and The effect of gender on the prevalence of PAD is con-
necrosis. troversial. Some studies have found the prevalence great-
Risk factors for atherosclerosis, and therefore PAD, are er in males,17 whereas other studies have found a more
discussed next. Some risk factors in the development of PAD equal distribution between genders or greater prevalence in
are also traditional risk factors for coronary artery disease females.3,16,18,19
(CAD). Risk factors other than atherosclerosis account for
some cases of PAD and are discussed.
250 Chapter 7
Smoking in patients with PAD is related to higher levels of certain
inflammatory markers (C-reactive protein, interleukin-6,
Smoking is highly correlated with PAD,6,20
and smokers
and soluble vascular cell adhesion molecule-1).23,24 Several
are diagnosed with PAD approximately 10 years earlier than
studies have found hyperhomocysteinemia to be a strong,
nonsmokers. The risk of PAD is affected by whether a person
independent risk factor for PAD and CAD.3 Hypercoagulable
is a current smoker, a former smoker, or has never smoked.
states, specifically increased plasma fibrinogen and high
The National Health and Nutrition Examination Survey
hematocrit levels, have been reported in patients with PAD,
found that current smoking is highly associated with PAD.6
and both seem to lead to a poor prognosis.3
The number of cigarettes smoked, or the cumulative pack-
years, increases the severity of PAD.3,16 This modifiable risk Nonatherosclerotic Causes of Peripheral
factor deserves much attention, as the prevalence of smoking Arterial Disease
in the United States remains high, with 19% of adults aged
There are several causes of PAD other than atherosclero-
18 years and older reporting that they are current smokers,
sis, and these should be considered as appropriate, allowing
and 21% reporting that they are former smokers.21
for accurate diagnosis and therefore best management. These
Diabetes may include thromboembolic, inflammatory, or aneurysmal
Diabetes is highly associated with PAD,6,19 and patients disorders; trauma; cysts; entrapment syndromes; or congeni-
with diabetes are approximately twice as likely to have IC tal abnormalities.2
than those without diabetes.3 PAD in these patients is more
aggressive in terms of large vessel involvement and peripheral Prognosis
sensory neuropathy, and these patients are 5 to 10 times more
Physiologic progression of PAD is identical whether a
likely to require amputation than those without diabetes.3
patient is symptomatic or not.3 In the majority of patients
Hypertension with PAD who initially present with claudication, symptoms
As with any CVD, hypertension is positively associated stabilize. Approximately 25% will significantly deteriorate
with PAD.3,6,16,19 clinically and only 1% to 3.3% will need major amputation
over a 5-year period.3 The prognosis for the limb is poor
Dyslipidemia without immediate revascularization in patients who ini-
High total cholesterol levels are positively associated tially present with CLI.13 In patients who are not surgical
with PAD,3,6 and effective treatment reduces the progres- candidates, or whose revascularization has failed, approxi-
sion of PAD and incidence of IC.3 Elevated total choles- mately 40% will require amputation within 6 months, and
terol, low-density lipoprotein cholesterol, triglycerides, and 20% will die.3 In patients who undergo below-knee amputa-
lipoprotein(a) have been identified as independent risk fac- tions, approximately 60% heal by primary intention, 15%
tors for PAD.3,16,17 after secondary procedures, 15% need to be converted to
above-knee amputations, and 10% of patients die in the post-
Impaired Renal Function
operative period.3 Over a 5-year period, patients with PAD
The results of the National Health and Nutrition are at increased risk for myocardial infarction, stroke, and
Examination Survey found that patients with impaired vascular death in comparison to age-matched norms.2 In a
kidney function are twice as likely to have PAD (odds ratio literature review, Hooi et al found that IC, an ABI ≤ 0.90, or
2.17, 95% confidence interval 1.10 to 4.30).6 In a multi-ethnic other abnormal noninvasive test results were independent
Asian population, patients with PAD were more likely to prognostic factors for cardiovascular death in patients with
have renal impairment than those without PAD.19 noncritical ischemia secondary to PAD.25 Overall 5-year
Physical Activity mortality for patients with PAD is 15% to 30%, with the
majority of deaths secondary to cardiovascular causes.2
In a group of 1381 subjects, those reporting no lifetime
history of regular recreational physical activity had a signifi-
cantly lower ABI than those who reported a history of regu-
lar recreational physical activity.16 In another study, lack of CHRONIC VENOUS DISEASE
recreational physical activity within the year prior to exami-
nation was significantly correlated with lower ABI in patients Clinical Definitions and Classification
with IC. It was unclear whether the lack of activity was due
to patients’ inability to participate, or the sedentary nature of CVD includes medical conditions of long duration involv-
the patients.22 A sedentary lifestyle was found to be a predic- ing a range of abnormalities of the venous system manifested
tor of PAD in elderly patients in another recent study.17 by symptoms and/or signs requiring investigation and care.1
The Clinical-Etiology-Anatomy-Physiology (CEAP) classifi-
Other Risk Factors cation system for CVD was developed to facilitate commu-
Elevated levels of C-reactive protein, a marker of inflam- nication between practitioners and to assist in standardizing
mation, have been found to be associated with PAD.3,6 Several language for research and treatment purposes (Table 7-2).
recent studies have shown that impaired walking ability
TABLE 7-2. CLASSIFICATION OF CHRONIC VENOUS DISEASE

CLASSIFICATION NOTATION DESCRIPTION
Clinical C0 No visible or palpable signs of venous disease
C1 Telangiectasias or reticular veins
C2 Varicose veins
C3 Edema
C4a Pigmentation and/or eczema
C4b Lipodermatosclerosis and/or atrophie blanche
C5 Healed venous ulcer
C6 Active venous ulcer
CS Symptoms including ache, pain, tightness, skin irritation, heaviness, muscle
cramps, as well as other complaints attributable to venous dysfunction
CA Asymptomatic
Etiological Ec Congenital
Ep Primary
Es Secondary (post-thrombotic)
En No venous etiology identified
Anatomical As Superficial veins
Ap Perforator veins
Ad Deep veins
An No venous location identified
Pathophysiological Pr Reflux
Po Obstruction
Pr,o Reflux and obstruction
Pn No venous pathophysiology identifiable
Reprinted with permission from J Vasc Surg, 40(6), Eklöf B, Rutherford RB, Bergan JJ, Revision of the CEAP classification for chronic venous
disorders: consensus statement, pp 1248-1252, Copyright Elsevier 2004.
Chronic venous insufficiency (CVI) describes advanced Edinburgh Vein Study, 9.2% and 6.6% of male and female
CVD, in which subcutaneous and skin changes lead to subjects, respectively, were classified as having CVI. This
chronic changes such as edema, pigmentation, lipodermato- value increased with age, and in the 55-to-64 age group,
sclerosis, or ulcerations.1 25.25% and 12.27% of men and women, respectively, were
classified as having CVI.28
Epidemiology
CVD is the most common vascular disorder, although
Pathophysiology
estimates of prevalence vary in the literature.26 In a cross- The signs and symptoms of CVD occur secondary to
sectional study of a multi-ethnic sample of 2211 adults in prolonged venous hypertension in the LEs. Venous pressure
San Diego, California, 81.1% and 27% of the study popula- in the leg is determined by the weight of the column of blood
tion was found to have visible or functional venous disease, from the foot to the right atrium and the pressures generated
respectively. It is not clear whether prevalence of CVD is by the LE skeletal muscle pump. Venous pressures in the
higher in males or females, but it does increase with age.26 leg may reach 80 to 90 mm Hg during static standing when
A study completed in Bulgaria found that among 26,785 there is no muscle contraction; therefore, the pressure in the
subjects aged 18 years and older attending their general prac- leg is determined by the weight of the column of blood from
titioner’s office for routine consultation, 44% were found to the foot to the right atrium. Skeletal muscle contraction of
have CVD. Prevalence increased with age and BMI.27 In the the leg (eg, during activity) transiently increases the venous
252 Chapter 7
pressures of the deep venous system in the leg. When venous found that frequency of valve incompetence correlated with
valves are functioning normally, venous blood flows toward worsening of symptoms when signs of disease were present.
the heart because of the muscle pump, and the deep and Therefore, when early signs of venous disease (eg, spider
superficial venous systems are emptied, thereby decreasing veins) are noticed on examination, patients could be referred
the pressure in the venous system to less than 30 mm Hg.29 to care earlier, allowing for initiation of treatment prior to
When venous valves or the muscle pump are malfunc- progression of the disease. CVI leads to venous ulcers in a
tioning, blood flow is abnormally redirected from the deep to substantial number of cases, with up to 80% of LE ulcers
the superficial venous system, resulting in increased super- being venous in origin.41 Venous ulcers are highly prone
ficial venous pressures.29,30 This increases capillary perme- to recurrence, with recurrence rates of up to 72% reported
ability near the skin and may lead to accumulation of fluid, in the literature42 and delayed healing.43 Cost associated
leukocytes, and extravasated red blood cells in the intersti- with the treatment of venous stasis ulcers is high. Olin et
tial space.31 These elevated pressures, when prolonged, can al43 found that of 78 patients presenting with venous sta-
trigger inflammation and structural changes in the venous sis ulcers, 14 patients accounted for 18 hospitalizations for
valves and walls, leading to valvular incompetence, eventual ulcer care, and mean cost per patient in the study was $9685
valvular destruction and weakness, and reduced elasticity of over a 1-year period. In another study,44 the mean annual
the venous walls.29 Local tissue inflammation and damage, cost to treat patients with delayed venous ulcer healing was
lipodermatosclerosis (pigmentation, induration, and fibrosis between $20,041 (with Graftskin, a living human skin graft)
or scarring of the skin at or above the level of the malleoli), and $27,493 (with an Unna Boot, a commonly prescribed
edema, and ulcers may occur.28,29,31,32 Ulceration is there- nonelastic compression system). As these studies were com-
fore the end of a continuum of physiologic changes resulting pleted in 1999 and 2000, these costs would be much higher
from prolonged venous hypertension, and the patient with in current monetary value. These values did not account for
CVD remains at high risk for recurrent wounds, delayed indirect costs, such as loss of work, early retirement, loss of
wound healing, cellulitis, and lymphedema.31 independence, and emotional suffering associated with these
There are several risk factors for CVD, including ulcers.43
age,27,28,33 family history of venous insufficiency,27,33,34 obe-
sity,27,33,35,36 smoking,34,37 decreased activity (eg, frequent
or regular standing for prolonged periods or low reported PHYSICAL THERAPY
levels of physical activity),34 LE trauma, thrombosis, and
pregnancy.27,33 EXAMINATION AND DIAGNOSIS
Excess abdominal mass associated with obesity increases
abdominal pressure, which results in reduced blood flow Given the often insidious presentation of PAD and CVD,
in the pelvic veins.35 LE trauma may directly damage the association with known risk factors, and associated morbid-
venous system and/or cause LE impairments resulting in ity of both, it is prudent that the PT is able to identify those
immobility of the limb and, therefore, an inadequate muscle patients who are at high risk and may need further testing
pump. Sequelae of DVT include recurrence and post-throm- for the purposes of diagnosis and treatment. Through a
botic syndrome, which presents as peripheral venous disease, comprehensive screening examination, indication for further
secondary to venous hypertension associated with dimin- tests and measures may be identified, and patients whom the
ished blood flow distal to the clot (Box 7-1) Incidence is high examiner suspects of having PAD or CVD can be referred
after DVT; a recent study found that 23% to 60% of patients for important early intervention and serial monitoring, and/
develop post-thrombotic syndrome within 2 years of an or patients with PAD or CVD can be treated appropriately.
acute DVT of the LE.38 Post-thrombotic syndrome includes Examination of patients for PVD can be daunting for the
a continuum of signs and symptoms of CVD.39 PT; however, knowledge of the etiology, pathophysiology,
and clinical presentations of PAD and CVD should guide the
clinician through the examination process. The most appro-
Prognosis priate practice pattern in the Guide to Physical Therapist
Causative factors contributing to time course, sever- Practice45 for patients with PVD may be impaired aerobic
ity of disease, and formation of ulceration in CVD remain capacity/endurance associated with cardiovascular pump
somewhat elusive. Labropoulos et al40 tracked 116 limbs dysfunction or failure. An outline of examination in this
in 90 patients with CVD for up to 43 months with duplex population, including patient/client history, systems review,
ultrasound and clinical examination. Changes in reflux on and tests and measures is further discussed in the Guide.45
ultrasound (new or extension of previously documented
sites) were found in 31 limbs, whereas changes in symptoms The Subjective Exam
or progression of CEAP staging was noted in only 13 limbs. It
was noted that progression of CVD may not be identified by Every physical therapy examination should begin with
physical examination, and repeat duplex ultrasound should a comprehensive subjective history (provided the patient is
be performed and used for surveillance in order to document able to provide it), which can guide the examiner to appro-
progression and to make treatment decisions. Chiesa et al33 priate tests and measures based on the patient’s presentation.
BOX 7-1. DEEP VEIN THROMBOSIS: CLINICAL SUMMARY AND MANAGEMENT

DVT of the LE is classified as either distal (confined to the calf veins) or proximal (involving the popliteal, femo-
ral, or iliac veins) thrombosis. This section is limited to the discussion of proximal DVT of the LE, as this presents
increased risk to the patient and is well established in the literature. Patients with acute proximal DVT are at
significant risk for developing post-thrombotic syndrome, which presents as CVI, as a result of residual venous
impairment and damaged venous valves.1
Risk factors for DVT may include but are not limited to immobility, recent surgery, LE trauma, prior venous throm-
boembolism, obesity, malignancy, use of oral contraceptives or hormone replacement therapy, pregnancy or
postpartum status, and stroke.2
Signs and symptoms of DVT may include swelling, pain, and erythema of the involved extremity, although the
location of symptoms may not indicate the site of thrombosis.2 A recent meta-analysis, however, revealed that
individual clinical findings are not predictive of DVT.3 If DVT is suspected, further diagnostic testing is required
to confirm a diagnosis. This usually consists of compression ultrasonography, which has very high sensitivity,
reported in the literature at approximately 95%.4
Once a diagnosis of acute proximal LE DVT is made, in absence of any contraindications, the patient is antico-
agulated. Options include low molecular weight heparin, unfractionated heparin, and warfarin. Low molecular
weight heparin is dosed based on body weight alone, and laboratory studies are not routinely required to con-
firm therapeutic anticoagulation.5 Therapeutic anticoagulation status of unfractionated heparin is monitored
with partial thromboplastin time, and that of warfarin with international normalized ratio. Therapeutic antico-
agulation should be confirmed by the PT before treatment.
Management of the patient with symptomatic acute proximal DVT who is therapeutically anticoagulated should
include early ambulation and compression (calf or thigh length, 30 to 40 mm Hg at the ankle). Together, these
treatments reduce pain and edema significantly faster than bed rest or no compression, limit thrombus progres-
sion, and do not increase the risk of pulmonary embolism.1,6-9 Compression established with early ambulation
and continued for 2 years is well established in the literature to significantly reduce the risk of post-thrombotic
syndrome. In a recent study, 46% of patients not treated with compression stockings developed post-thrombotic
syndrome, compared to 26% of patients treated with compression stockings, indicating a high risk of developing
the syndrome after acute proximal DVT, and a 54% relative risk reduction with compression.10
REFERENCES
1. Blättler W, Partsch H. Leg compression and ambulation is better than bed rest for the treatment of acute deep venous thrombosis.
Int Angiol. 2003;22(4):393-400.
2. Landaw SA, Bauer KA. Approach to the diagnosis and therapy of lower extremity deep vein thrombosis. http://www.uptodate.com/
contents/approach-to-the-diagnosis-and-therapy-of-lower-extremity-deep-vein-thrombosis. Updated January 9, 2014. Accessed
September 21, 2012.
3. Goodacre S, Sutton A, Sampson F. Meta-analysis: the value of clinical assessment in the diagnosis of deep venous thrombosis. Ann
Intern Med. 2005;143(2):129-139.
4. Hamper UM, DeJong MR, Scoutt LM. Ultrasound evaluation of the lower extremity veins. Radiol Clin North Am. 2007;45:525-547.
5. Rydberg EJ, Westfall JM, Nicholas RA. Low molecular weight heparin in preventing and treating DVT. Am Fam Physician. 1999;59(6):1607-
1612.
6. Partsch H. Immediate ambulation and leg compression in the treatment of deep vein thrombosis. Dis Mon. 2005;51:135-140.
7. McCollum C. Avoiding the consequences of deep vein thrombosis. BMJ. 1998;317:696-697.
8. Jünger M, Diehm C, Störiko H, et al. Mobilization versus immobilization in the treatment of acute proximal deep venous thrombosis: a
prospective, randomized, open, multicentre trial. Curr Med Res Opin. 2006;22(3):593-602.
9. Partsch H, Blättler W. Compression and walking versus bed rest in the treatment of proximal deep venous thrombosis with low
molecular weight heparin. J Vasc Surg. 2000;32(5):861-869.
10. Musani MH, Matta F, Yaekoub AY, Liang J, Hull RD, Stein PD. Venous compression for prevention of postthrombotic syndrome: a meta-
analysis. Am J Med. 2010;123:735-740.
There has been increasing discussion in recent years Depression Scale and on the Self-Reported Life Satisfaction
regarding the effect of PVD on quality of life. The litera- score than age-matched controls. Cherr et al47 found that
ture supports significant relationships between depression 36.1% of patients undergoing intervention for PAD were diag-
and impaired quality of life and PAD. Remes et al46 found nosed with depression when screened prior to surgery. Those
that patients with PAD who had undergone percutaneous patients with depression at the time of revascularization were
transluminal angioplasty and/or one or more surgical revas- more likely to have failure of the revascularization and were
cularization had significantly lower scores on the Geriatric at significantly higher risk of recurrent symptomatic PAD.
254 Chapter 7
at rest, drainage of venous wounds) are affecting ADL and
TABLE 7-3. GRADING OF PITTING EDEMA IADL, recreational activities and interests, and quality of
GRADE DESCRIPTION TIME TO RETURN life. When asked how the current symptoms are affecting
OF EDEMA TO BASELINE activities and quality of life, the therapist can often perceive
what the patient’s goals may be. Clarification of the patient’s
0 None symptoms and course, functional limitations, discussion of
1+ Trace < 10 seconds (rapid) how these are affecting the patient’s life, and establishment of
the patient’s own goals should be the aims of the discussion.
2+ Mild 10 to 15 seconds
On interview, the patient with PAD may complain of pain
3+ Moderate 1 to 2 minutes that interferes with sleep, worsens with LE elevation, and
4+ Severe 2 to 5 minutes improves with LE dependency. In patients with claudication,
pain may increase with walking after certain distances and
Reprinted with permission from Critical Care Nursing: Diagnosis
and Management, 6th ed, Urden LD, Stacy KM, Lough ME, then is relieved quickly with rest.53 In contrast, patients with
Copyright Mosby Elsevier 2010. CVD may complain of worsening pain with dependency,
which is relieved with elevation of the leg, walking, and
compression.52 Patients should be asked about any symp-
As in PAD, there is substantial evidence that CVD affects toms of CVD, including tingling, aching, burning, pain,
health-related quality of life, and investigators are increas- muscle cramps, swelling, throbbing, heaviness, itching skin,
ingly including quality of life measures as outcomes of treat- and restless or tired legs.1,54 These symptoms may worsen
ment for CVD.48 A multinational study looking at quality throughout the course of the day, especially if patients are
of life in varicose veins49 found that the SF-36 physical and required to stand for long periods of time (eg, during work
SF-36 mental scores were significantly lower in patients with hours),54 and improve at night with sleeping. Risk factors for
varicose veins than in the general population, and that qual- PAD and/or CVD should be reviewed, as appropriate, to elicit
ity of life worsens with clinical severity of the disease. This whether the patient may be at risk.
finding was consistent with the finding of another study, The decision of whether to conduct a peripheral vascular
in which SF-36 Physical Component Summary Scores and examination should be made based on identification of risk
VEINES-QOL and VEINES-Sym scores decreased signifi- factors, the patient’s subjective history of symptoms and
cantly with increasing CEAP class.50 Palfreyman51 found limitations, and/or after screening integumentary integrity
that patients with a current or healed venous ulcer have a during the physical therapy examination.
significantly reduced self-reported quality of life as com-
pared to the general population, and 65% reported signs The Objective Exam
and symptoms of depression. Many patients with CVI fear
amputation or death due to their vascular disease and are Systems Review
unaware that these are not generally outcomes of isolated
venous insufficiency.52 Cardiovascular and Pulmonary
During the subjective history, patients should be ques- Resting blood pressure (BP), heart rate (HR), and respira-
tioned very specifically about baseline mobility in terms of tory rate should be measured. Any signs of edema should
activities of daily living (ADL) and instrumental activities be noted. Patients with CVD often present with edema that
of daily living (IADL), employment, regular exercise, and may be pitting in early stages but may become nonpitting as
distance walked, as well as about their living environment, the skin becomes more fibrotic as the disease progresses. If
recreational interests, and activities. Discussion and clarifi- edema is present, the examiner should note its location and
cation of symptoms is imperative, and limitations to baseline move on to tests and measures of anthropometric character-
mobility should be noted (eg, spinal stenosis may limit walk- istics, specifically, palpation, grading, and measurement of
ing at baseline, although this is unrelated to the limitations edema, as indicated. Edema should be palpated for pitting,
caused by the discomfort of dependency in patients with which is graded as shown in Table 7-3.
CVD). This baseline should be compared to the patient’s If edema is present and objective change over time needs
report of current abilities and limiting factors. If the patient to be monitored and/or intervention for edema is considered,
reports a decline in function, reasons for this decline should girth measures should be obtained. At minimum, landmark-
be clarified. For example, if the patient states that he or she ing using a reproducible bony landmark, with measurement
no longer drives, the examiner should question the patient at equal intervals proximal or distal to that landmark, should
as to when and why he or she stopped driving. These types be used to allow for reproducibility. For example, circumfer-
of questions can elicit information that can help guide the ential measurement every 10 cm proximal to the center of
examination. For example, if a patient stopped driving as the lateral malleolus is reproducible even in most patients
he or she is having difficulty feeling the foot pedals, the with moderate to severe edema. Girth measurements using
examiner would be sure to incorporate LE sensation testing limb circumference are often used to calculate limb volumes
into the exam. The patient should specifically be questioned in patients with edema, to make treatment decisions, and
about how current symptoms (eg, leg pain with walking or to document change over time. Typically, calculating limb
Figure 7-1. Summary of the presentation of venous (left)
and arterial (center and right) ulcers. (Reprinted with permis-
sion from Bates B. A Guide to Physical Examination and History
Taking. 4th ed. Philadelphia, PA: J.B. Lippincott Company;
Thickened 1987.)
Ulcer skin
Pitting
Ulcer
Ulcer
Shiny,
atrophicskin
Pigment Gangrenous
toe
A B
Figure 7-2. (A) Typical arterial ulcer. Location is pretibial (a potential pressure point), without signs of CVD, with a defined edge, pale, and
dry. (Reprinted with permission from Diseases of the Skin, 2nd ed, White G, Cox N, Copyright Elsevier 2006.) (B) Typical arterial ulcer. Location
is over a bony prominence, very distal, with a defined edge, dry, with some periwound edema. (Reprinted with permission from Acute &
Chronic Wounds: Current Management Concepts, 3rd ed, Bryant R, Nix D, Copyright Elsevier 2007.) (continued)
volume from circumferential measures taken in equal inter- be cold; areas of infection may feel very warm to touch.
vals from a bony landmark has been studied, comparing with Any trophic changes, which are general changes indicative
the gold standard of water volumetry. Circumferential limb of vascular impairment, should be noted on the LEs. These
measures using a segment length of 10 cm from a bony land- may include dry, shiny, or hairless skin, or thickened, hyper-
mark provide volume estimates that are highly correlated trophic toenails. Color of the skin should be noted, and if
with that of water displacement volume and are sufficient for any of these findings are abnormal, further testing may be
routine limb measurement and for estimates of limb volume warranted.
changes over time.55-57 Limbs of patients with arterial insufficiency may be discol-
Integumentary Integrity ored (pale, red, blue, or dusky purple), may lack hair growth,
and the distal extremity may be cool to the touch.53,58
Inspection of the integumentary integrity of the LEs
Arterial wounds will appear commonly on or below the
should be conducted with shoes and socks off, pant legs
ankle, specifically around areas of bony prominences (Figure
rolled up above the knees at the very least, and with the
7-2B), such as the lateral malleoli, tips of the toes, metatarsal
patient in supine and standing.
heads, or in areas of bunions.53,58 These wounds generally
Venous and arterial ulcers present very differently, and
have a defined edge (are “punched out” in appearance), are
the clinician can usually denote the etiology of the ulcer from
pale, dry (without significant drainage), and painful to touch.
a careful clinical exam (Figure 7-1).
Signs of venous insufficiency such as hemosiderin staining,
Areas of pressure points should be noted, observing stasis dermatitis, or lipodermatosclerosis are absent.53,59
for areas of callous, which may indicate areas susceptible
Patients with suspected venous insufficiency should be
to wounds (Figure 7-2A). Areas of bruising should also be
examined in the standing position to allow for maximal
noted, which may indicate recent trauma, in which case
venous distention and for visualization from the front, back,
interventions regarding skin protection should be discussed
and sides.31,54 Spider veins or telangiectasia (Figure 7-2C)
in light of potential risk of wounds. Temperature of the skin,
present as fine-lined networks of red, blue, or purple veins on
including left-right symmetry and proximal-distal differ-
the LEs and indicate broken capillaries.5
ences, should be noted. Areas of decreased perfusion may
256 Chapter 7
C D
Figure 7-2 (continued).

(C) Telangiectasias (spider E F
veins). (©iStock.com/crupho-
to.) (D) Pigmentation char-
acteristic of CVD. Note the
brownish coloring second-
ary to hemosiderin stain-
ing, as well as the thinned,
shiny skin. (E) Appearance
of varicose veins. (©iStock.
com/DIGIcal). (F) Stasis der-
matitis. (Reprinted with per-
mission from Diseases of the
Skin, 2nd ed, White G, Cox
N, Copyright Elsevier 2006.)
(continued)
Thinned skin and hemosiderin staining (Figure 7-2D) may Lipodermatosclerosis (Figure 7-2G) may eventually devel-
be apparent at the ankle, lower leg, and foot. Hemosiderin op, which presents starting at the medial ankle, progressing
staining is brown discoloration in a circumferential pat- to the entire lower leg in advanced cases as heavily pig-
tern between the malleoli and calf that results from break- mented, fibrotic, and edematous. The pigmented area will be
down of red blood cells into the interstitial space from the hardened and fibrotic on palpation.
capillaries.53 Eventually, venous ulcers may develop.5 Inspection for
Irregularities or bulges on the surface of the skin suggest any openings in the skin should be meticulous. Venous ulcers
the presence of varicose veins (Figure 7-2E), which may be are typically located below the knee and above or around the
tender to palpation31 and are easily visible in the standing ankles and are irregular in shape and draining, sometimes
position.5 excessively (Figure 7-2H). This discharge will be expected to
Moderate to severe edema that may feel hardened or improve dramatically with appropriate wound care, eleva-
woody may be apparent in patients with long-term venous tion, and compression.
disease, and untreated varicosities will become thickened In any vascular examination, odor of the wounds or of the
and hard. These patients are at risk of developing stasis der- skin should be noted, which may indicate fungal or bacterial
matitis (Figure 7-2F), which presents as an erythematous, infection. If there is demarcation of painful erythema and
pruritic plaque60 that may be very itchy and worsened with rubor, with or without systemic signs of infection, this may
scratching. indicate cellulitis (Figure 7-2I). In these cases, referral to a
physician for timely diagnosis and treatment of infection
should be mobilized.
Figure 7-2 (continued). (G)
G H Lipodermatosclerosis. Note the pro-
nounced pigmentation, edema, and
fibrosis. (Reprinted with permission from
Alguire PC, Mathes BM. Chronic venous
insufficiency and venous ulceration.
J Gen Intern Med. 1997;12(6):374-383.) (H)
A typical venous ulcer. Note the medi-
al, circumferential location on the calf,
the irregular border, and moist wound
bed. (Reprinted with permission from
Alguire PC, Mathes BM. Chronic venous
insufficiency and venous ulceration. J
Gen Intern Med. 1997;12(6):374-383.) (I)
Cellulitis. Note the demarcation of the
erythema, which would be painful to the
touch. (Reprinted with permission from
Diseases of the Skin, 2nd ed, White G, Cox
N, Copyright Elsevier 2006.)
If there are any wounds found on examination in patients Tests and Measures
at risk of or with known vascular disease, examination by a
physician is warranted as soon as possible. Aerobic Capacity and Endurance
Musculoskeletal Cardiovascular signs and symptoms in response to
increased O2 demand with exercise or activity (ADL, IADL,
The systems review should include screening of gross
and/or exercise) should be monitored. These may include
range of motion, gross strength, and height and weight.
BP; HR or rhythm; or angina, claudication, and/or exertion
Ankle range of motion and calf muscle strength and endur-
scales. Given the associated cardiovascular risk in this popu-
ance are worthy of specific mention as they pertain to
lation, close monitoring of hemodynamic response to activity
patients with CVD, as will be discussed in the Therapeutic
is warranted. Activity should mimic the maximum activity
Exercise Prescription section of Procedural Interventions in
the patient needs to accomplish in his or her everyday life to
the Case Study at the end of the chapter (see p 279).
fulfill ADL and IADL, as well as recreational and vocational
Neuromuscular interests, as appropriate. This part of the examination should
Balance, gait, and functional mobility (transfers, ambula- rely on the patient’s reports of baseline and current function,
tion), as well as motor function, should be screened. Given and further highlights the importance of a comprehensive
potential impairments in several contributing factors to subjective history.
gross motor movements and motor function, including The PT may decide, based on the patient’s report and the
vision, LE sensation, range of motion, and strength, impair- results of examination thus far, to examine aerobic capac-
ments in these areas are common among patients with PVD. ity, which is often measured during walking, potentially on
258 Chapter 7
A B
C D
Figure 7-3. Palpation of pulse points. (A) Dorsalis pedis. The dorsalis pedis artery can be found on the dorsum of the foot, where the artery passes
over the navicular and cuneiform bones just lateral to the extensor hallucis longus tendon. (B) Posterior tibial posterior. The posterior tibial artery runs
posterior to the medial malleolus and the tendons of tibialis posterior and flexor digitorum longus. (C) Popliteal, which can be felt on deep palpation
in the popliteal fossa with the knee slightly flexed. (D) Femoral; with the thigh slightly flexed and laterally rotated, the femoral artery runs from the
midpoint of the pubic symphysis and the anterior superior iliac spine. (Images A, B, and C reprinted with permission from Paul Gaspar and Robert Snow.
Image D reprinted with permission from Moore K, Agur AMR. Clinically Oriented Anatomy. 2nd ed. Philadelphia, PA: Wolters Kluwer; 1992.)
TABLE 7-4. GRADING OF PERIPHERAL PULSES Circulation

GRADE DESCRIPTION Measurement of physiological responses to position
change may be warranted and may be useful in isolating
0 Absent physiologic responses to activity, as discussed previously. For
1 Diminished example, if a patient’s BP and HR are measured with him
or her sitting prior to activity and then again standing at
2 Normal
peak activity, if the BP dropped, it should not be construed
3 Bounding as an inappropriate hemodynamic response to activity.
Reprinted with permission from J Vasc Surg, 31(1), Dormandy JA, Clarification that the patient had an appropriate response
Rutherford RB, Management of peripheral arterial disease (PAD), to position change would be required prior to concluding
S1-S296, Copyright Elsevier 2000. a failure response to activity. To isolate the hemodynamic
response to activity, this would ideally include measures of
standing resting BP and HR prior to activity, then standing
level ground or on a treadmill. The American College of peak BP and HR.
Cardiology (ACC)/American Heart Association (AHA) rec- The PT will commonly examine pulses as part of the vas-
ommends that a 6-Minute Walk Test (6MWT) is reasonable cular examination of the LE. The ACC/AHA recommends
to measure functional limitation in patients who are not able that all patients at risk of lower-extremity PAD should under-
to conduct treadmill testing.2 go a comprehensive pulse examination, including femoral,
Appropriate hemodynamic monitoring should be con- popliteal, dorsalis pedis, and posterior tibial sites, in addition
ducted throughout the aerobic capacity testing. If the patient to inspection of the feet (Figure 7-3).
complains of claudication pain during the test, both pain- Pulses should be graded numerically (Table 7-4).
free and maximum distances walked and limiting factors to A handheld Doppler device, if available, can be used to
further walking should be noted, including location of pain. assess pulses if palpation proves difficult. A normal arterial
Amount of time for resolution of symptoms should be noted.
pulse assessed with a Doppler is triphasic. In the presence of
arterial disease, the arterial signal is impaired and may be
biphasic or monophasic, or in the most severe cases, it may
be absent.13
Capillary refill time (CRT) has been used as part of
the clinical assessment of peripheral arterial perfusion for
many years. As for pulses, the PT may incorporate this into
the vascular examination. To measure CRT, the examiner
presses the finger or toe pad until the skin blanches. Pressure
is removed, and the time it takes blood to refill the blanched
area is observed. Normal CRT is less than 3 seconds, and
longer times may indicate arterial insufficiency.61 Schriger
and Baraff62 found that CRT in healthy adults varies with
age and sex (being significantly longer in older adults and
women), and the cut-off times for normal capillary refill
continue to be debated in the literature. Although abnormal Figure 7-4. Measuring the ankle pressure at the posterior tibial artery
capillary refill may indicate impaired peripheral perfusion, using a Doppler probe. (Reprinted with permission from Paul Gaspar and
it should not be relied on as the sole indicator of peripheral Robert Snow.)
arterial status, but rather one component of a comprehensive
clinical exam.
The ABI is an index that compares systolic BP at the ankle Some patients may undergo an ABI with exercise if rest-
to that at the brachial artery, and it is a measure of arterial ing ABI is within normal limits and PAD is still suspected.
perfusion of the LEs. When clinicians feel a patient may be Protocols for exercise testing for evaluation of IC and PAD
at risk of PAD based on subjective history, identification of are discussed elsewhere.65,66 After exercise, BP measure-
risk factor(s), and/or clinical examination, measurement of ment at the ankle is repeated in supine within 30 seconds of
the ABI may be considered. The ABI has sensitivity ranging stopping activity. In patients with PAD, ankle systolic pres-
from 79% to 95% and specificity consistently > 95% in the sure falls with exercise, often cannot be recorded, and does
literature in detecting PAD in patients undergoing diagnos- not recover to baseline for several minutes.5 A decrease in
tic testing.2 Current guidelines recommend that the resting ankle pressure with exercise of 15% or 20 mm Hg indicates
ABI be measured in patients with exertional leg symptoms, PAD.3,63
nonhealing wounds, increasing age (65 to 70 years), 50 years Although the ABI is often measured in a vascular lab, the
or older with cardiovascular risk factors, or subjects with a PT may choose to measure it if he or she feels it is indicated
Framingham risk score between 10% and 20%.3,4 to help diagnose or rule out PAD or to help with treatment
When measured at rest, the patient should, when able, decisions such as compression management.
assume the supine position for 5 to 10 minutes prior to mea- Pain
surement.13,63 At that time, usually with a Doppler probe, BP Examination of pain is an important part of the vascular
is measured in both arms at the brachial artery and, if dif- examination. Based on the subjective history and objective
ferent values are found, the highest brachial value is used for examination, pain patterns may lead to further testing or to
both left and right ABI calculation. The ankle BP is taken on suspicion of a certain diagnosis. For example, LE pain with
both sides using the dorsalis pedis and posterior tibial artery walking that is relieved with rest, in absence of other causes,
(Figure 7-4). may be attributed to claudication. Lack of pain in an ulcer
The higher of the dorsalis pedis or posterior tibial ankle of a patient who is diabetic, along with other observations of
BP on each side is divided by the higher of the 2 brachial the wound, may indicate venous origin of the ulcer. A Visual
pressures to establish a right and a left LE ABI (Figure 7-5).3 Analog scale or the Claudication Pain Rating scale (refer to
Normal ABI values range from 1.00 to 1.40, and an the Exercise section in Intervention for PAD) may be appro-
abnormal ABI is defined as ≤ 0.90. ABI values of 0.91 to priately used for this population. The PT needs to consider
0.99 are considered “borderline” and values > 1.40 indicate causes of pain other than PVD and examine as appropriate
noncompressible arteries (as would be found with calcifica- as part of the differential diagnosis of PVD.
tion).4 Resting or exercising ABI values of < 0.90 or < 0.85,
respectively, are universally accepted to indicate a diagnosis Summary: The Clinical Examination
of PAD in adults over 55 years of age.64 An ABI of 0.7 to
0.89 is considered mild, 0.4 to 0.69 moderate, and less than and Peripheral Arterial Disease
0.4 severe PAD.13 Calcification of the arteries, as is common One should consider that the noninvasive clinical exami-
in patients with diabetes or renal insufficiency, will falsely nation (skin inspection, palpation, pulses) is somewhat
elevate and therefore invalidate ABI measurements, and they limited in its ability to accurately identify patients who
should not be used for diagnostic purposes in that case.3 have PAD. A recent systematic review of studies compared
260 Chapter 7
Figure 7-5. Calculation of the ABI. (Adapted from Salameh MJ, Ratchford EV. Update on peripheral arterial disease and clau-
dication rehabilitation. Phys Med Rehabil Clin N Am. 2009;20(4):627-656.)
clinical examination components (skin examination, pulse is associated with moderate to severe PAD, but not in those
examination, auscultation of bruits) to ABI, duplex, or angi- with diabetes.58 When individual clinical examination find-
ography in order to assess the accuracy and precision of the ings were combined, if all were normal, likelihood of PAD
clinical examination for PAD.58 The examiners concluded was lower than if one or more individual findings were
that absence of claudication did not reduce the likelihood abnormal. It has been suggested that in the absence of any
of PAD, although the presence of claudication increased the risk factors for PAD, if clinical examination findings are all
likelihood of PAD. As previously discussed, a relatively small normal, no further testing is required.67
percentage of patients with PAD have claudication; therefore,
the absence of complaints of claudication should not be used Medical Diagnosis
to rule out a diagnosis of PAD or to make a decision not to
continue with a vascular examination. A limb that is cooler Peripheral Arterial Disease
to the touch than the opposite limb, discolored skin, and
In most cases, patients with PAD can be accurately diag-
wounds or sores all increase the likelihood of PAD, but the
nosed with noninvasive diagnostic techniques. As previously
absence of these factors, with the exception of normal skin
discussed, ABI is helpful in the diagnosis of PAD, and this
color, does not lessen the likelihood of PAD. Therefore, pres-
may be measured in a vascular lab setting as part of a for-
ence of cooler temperature, skin discoloration, and wounds
mal diagnostic work-up or for surveillance. Toe pressures
or sores may help the clinician hypothesize about the likeli-
and toe-brachial index (TBI) may be useful in patients with
hood of PAD given the risk factors and the rest of the exami-
diabetes, renal failure, or other disorders resulting in arterial
nation, but again, absence of these factors should not rule
calcification, as they provide an accurate measurement of
out PAD for the clinician, especially if risk factors are pres-
pressures in vessels that do not typically become calcified.2,3
ent. Reduced or absent femoral, posterior tibial, or dorsalis
The toe pressure is normally ~30 mm Hg less than the ankle
pedis pulse increases the likelihood of PAD at least mod-
pressure, and an abnormal TBI is < 0.70.3 A specialized cuff
erately, and the absence of any pulse abnormality decreases
is required to measure TBI, usually in a noninvasive vascular
the likelihood of PAD at least moderately.58 Abnormal CRT
laboratory.3
Segmental limb pressures (SLPs) are measured through- outflow, which can isolate impairments in the calf muscle
out the LE in the same method as at the ankle. A sphyg- pump, reflux, and venous obstruction.1 In patients with
momanometer cuff and Doppler probe are used to measure more advanced CVD, computed tomography venography,
systolic pressures at different levels of the thigh and calf, and magnetic resonance venography, ascending and descending
location of lesions are isolated by pressure gradients between contrast venography, and intravascular ultrasonography may
different levels.3 Pulse volume recordings (PVRs) use a cuff be used as appropriate.1
inflated to ~60 to 65 mm Hg (to detect volume changes with-
out occluding the arteries), connected to a plethysmograph,
which detects and records changes in limb volume through- TREATMENT
out the arterial pulse cycle.3 Amplitude of the waveform
will decrease with severity of PAD within the same patient. Medical and physical therapy interventions for PAD and
Tracings should not be compared between patients, as indi- CVD are discussed together in this section. Evidence-based
vidual cardiac and peripheral vascular factors affect the physical therapy interventions for PAD may include patient
amplitude of PVR tracings. These may be used to establish education for cardiovascular risk reduction, skin and wound
diagnosis, localize occlusions and severity, and follow change care, and exercise prescription. In CVD, the PT is paramount
over time after revascularization procedures within the in the areas of education regarding skin and wound care,
same patient.2 SLPs and PVRs are often used together, which exercise prescription, and compression.
increases accuracy and ensures that patients with calcified
arteries who may have elevated SLP will be appropriately
recognized by PVRs.3 Peripheral Arterial Disease
If further anatomic localization of the lesion is necessary
Cardiovascular Risk Reduction
beyond information provided by the previously mentioned
noninvasive tests, in order to make definitive decisions As previously discussed, PAD shares several risk factors
regarding intervention, duplex ultrasonography, magnetic with cardiovascular disease, and therefore a strong empha-
resonance angiography (MRA), computed tomography angi- sis is placed on reduction of cardiovascular risk factors in
ography, or contrast angiography may be completed, depend- the treatment of PAD. These may include pharmacotherapy
ing on availability, cost, and skill. Contrast angiography, aimed at controlling lipids; hypertension; risk of thrombosis;
with visualization from the level of the renal arteries to the and interventions aimed at reducing obesity, smoking cessa-
pedal arteries, remains the gold-standard imaging technique tion, and diabetes management.
for PAD. This is an invasive evaluation with contrast, and The ACC/AHA recommends that for patients with PAD
despite the risks and its invasive nature, remains the evalu- who are hypertensive, antihypertensives should be given to
ation of choice in many cases.3 Intervention may be com- maintain systolic BP less than 140 mm Hg for those without
pleted during angiography in some cases (eg, during acute diabetes, and less than 130 mm Hg for those with diabetes or
ischemia). chronic renal disease. Patients with PAD may require mul-
tiple agents to control hypertension.2,3
Chronic Venous Disease
Antiplatelet therapy, including aspirin, and/or clopido-
On clinical examination, LE edema and pigmentation or grel, is recommended for patients with atherosclerotic LE
other skin changes support the diagnosis of CVD in absence PAD,2,3 and combination therapy may be used for patients
of systemic causes of venous hypertension. In order to plan with symptomatic atherosclerotic PAD.4
an intervention, the anatomic site of reflux needs to be iden- The aim of glucose control in patients with diabetes and
tified, and venous duplex scanning is best for this purpose.31 PAD is to maintain the hemoglobin A1C below 7%.2,3
The Society for Vascular Surgery and the American Venous Patients with PAD who smoke should be asked about
Forum (SVS/AVF) recommends duplex scanning of the deep tobacco use, counseled to stop smoking, and assisted in
and superficial veins of the LEs in all patients with chronic developing a plan to quit, which may include pharmacothera-
disease. In this examination, pulsed-wave Doppler transduc- py and/or referral to a formal smoking cessation program.2-4
ers are used to evaluate reflux in the deep and superficial A recent study found that long-term smokers with PAD who
veins with the patient standing. All deep veins of the leg were randomly assigned to an intensive formal smoking ces-
are examined from the inguinal region distally in 3 to 5 cm sation intervention were significantly more likely to be con-
intervals, followed by the superficial veins. Four components firmed abstinent at 6 months than those assigned to minimal
are included in a venous duplex study: (1) visibility, (2) com- care (verbal advice and a list of community resources).68
pressibility, (3) venous flow, including duration of reflux,
The PT’s role in cardiovascular risk reduction in this
and (4) augmentation. Operational definitions of reflux,
population is paramount. The PT may be the health care
pathologic veins, and valvular incompetence are discussed
professional with whom the patient has the most frequent
in the Clinical Practice Guidelines.1 The SVS/AVF recom-
contact and therefore has access to the patient for monitor-
mends that venous air plethysmography be used in patients
ing and frequent reassessment. The PT should incorporate
with advanced CVD (CEAP classes 3 to 6) if duplex scan-
patient education regarding the importance of medica-
ning does not elicit definitive pathophysiology. Air plethys-
tion compliance, smoking cessation, healthy nutrition, and
mography measures passive venous refill and drainage, and
262 Chapter 7
The mechanisms by which exercise may improve walking
TABLE 7-5. CLAUDICATION PAIN RATING SCALE distances and times for patients with claudication are not
PAIN DESCRIPTION fully understood at this point, but may include the following:
RATING • Improved endothelial vasodilator responses75-77
1 Definite discomfort or pain, but only at • Improved peripheral blood flow.75,78,79 Improvements
initial or models levels (established, but in blood flow, when identified, have not correlated with
minimal) improved functional parameters (eg, walking distance)
with exercise.70,76
2 Moderate discomfort or pain from which
the patient s attention can be diverted • Improved mitochondrial function and muscle charac-
(eg, by conversation) teristics (cross-sectional area and fiber type)76
3 Intense pain (short of grade 4) from which • Suppression of chronic inflammation76
the patient s attention cannot be diverted • Adaptation in pain threshold with exercise80
4 Excruciating and unbearable pain • An increase in stroke volume and decrease in peripheral
Reprinted with permission from Pescatello LS, Arena R, Riebe D,
resistance during exercise80
Thompson PD, eds. ACSM s Guidelines for Exercise Testing and Central mechanisms have been postulated given improve-
Prescription. 9th ed. Baltimore, MD: Wolters Kluwer/Lippincott ments in walking performance through an upper extremity
aerobic exercise program.80,81
Evidence suggests that patients who can safely exercise
should partake in programs that include walking for 30 to
meticulous skin care. Any barriers to cardiovascular risk
50 minutes 3 to 5 times per week. Patients should walk at
reduction in these areas should be identified and addressed
an intensity that elicits symptoms within 3 to 5 minutes,
(eg, impaired vision affecting medication management and
continue to walk at moderate intensity, and stop if symp-
skin care). Consults should be mobilized as appropriate and
toms become severe on the Claudication Pain Rating scale
may include that for smoking cessation, to a nutritionist,
(Table 7-5).66,71 Duration of a supervised program should be
or for appropriate footwear (eg, referral to a pedorthist for
at least 12 weeks in order to ensure increases in maximum
custom footwear).
and pain-free walking distance.3
A recent study of 391 patients with PAD from a Canadian
Although patients with IC often present with comorbidi-
urban academic teaching hospital examined the extent to
ties that may limit exercise tolerance, they often do not pre-
which risk factors were managed according to the AHA/ACC
clude participation in a safe and effective exercise program.
guidelines for PAD. Only 37.4% of those patients in the study
In this case, many patients would not only be appropriate
with hypertension had adequate BP control, 49% of patients
candidates for an exercise program, but in fact would sig-
with diabetes had adequate glucose control, and 38.7% of
nificantly benefit from one. The PT should prescribe an
those prescribed statins did not have adequate cholesterol
exercise program individualized to the patient and consider
control. The authors concluded that, although atherosclerotic
the patient’s goals, comorbidities, and response to exercise.
risk factors are prevalent in patients with PAD, many patients
In many cases, interval walking would be indicated with the
receive suboptimal risk reduction treatments and/or are not
goal of 30 to 50 minutes of work-rest cycles per session, as
meeting risk factor control goals with treatment.69 The goal
many patients would not tolerate constant walking for this
of these interventions is to reduce the risk of cardiovascular
duration. After completion of a supervised walking program,
events in individuals with atherosclerotic LE PAD, and effec-
strategies to enhance long-term adherence with a home
tive strategies to encourage adherence to established guide-
walking program should be incorporated.82
lines need to be developed.69
It should be noted that, in patients with arterial compro-
Exercise mise, elevation may further impede flow and symptoms may
Little is known about the effects of exercise in patients be worsened with elevation of the LEs. Therefore, elevation of
with asymptomatic PAD.70 However, in patients with IC, the extremities should be discouraged. In fact, dependency of
there is much evidence to support the benefits of supervised extremities affected by PAD may help to alleviate symptoms.
exercise programs in improving maximum and pain-free In the case of an arterial wound on the weightbearing
walking distance.71 Efficacy of unsupervised exercise pro- surface of the foot, discussion with the vascular team is
grams is less extensively studied; however, in 2 recent studies, important to determine the best approach to offloading the
one found that a supervised exercise program was superior to wound during activity. Offloading the area of a diabetic
a home-based program in terms of walking times,72 and the ulceration,83 caused by excessive pressure in combination
other study found no significant difference in terms of walk- with arterial insufficiency, usually results in healing.83 For
ing times between home-based and supervised exercise pro- many patients with PAD, impairments associated with sig-
grams.73 A Cochrane review from 2008 found a significantly nificant comorbidities may make it difficult to ambulate
greater benefit of an exercise program in terms of maximum safely in a nonweightbearing fashion, even with assistance
walking time than that seen with angioplasty at 6 months.74 and an assistive device. For some patients, bed to wheelchair
transfers and wheelchair locomotion may be the best option increases O2 consumption as compared to ambulation with-
while the wound is healing. Other options for pressure relief out an assistive device.90 If the patient undergoes an amputa-
may be considered, depending on availability and feasibility. tion, mobility will require greater energy expenditure than
Armstrong et al84 found that the total contact cast (TCC) at baseline, and the patient will have lost sufficient strength
heals more wounds more quickly than a half-shoe or a and aerobic capacity without intervention in the meantime.
removable cast walker (RCW) and is considered by many the Some patients may not return to independent ambulation
gold standard of offloading devices.85 However, a technician after LE amputation but may mobilize in a wheelchair. This
with specific training or experience should apply any TCC may be the case for many patients’ status post-bilateral trans-
because improper application can lead to further ulceration. femoral amputations given that the O2 costs of prosthetic
Assessment and care of the wound on a daily basis is not ambulation with various assistive devices is significantly
possible, and patients may find bathing and sleeping dif- greater than that of independent wheelchair propulsion or
ficult in a TCC. For these reasons, TCCs are not routinely mobility without amputation.91,92 Self-paced wheelchair
used.84,85 Other offloading devices have been used for pres- propulsion is significantly faster than self-paced prosthetic
sure relief; however, they have demonstrated limited success ambulation in this population, and for these patients, wheel-
in adequately offloading diabetic wounds. Armstrong et al86 chair propulsion may simply be more feasible and functional,
found that, although patients with diabetic wounds were making it the preference for locomotion.92
more active while wearing an RCW, only 28% of daily activ-
ity occurred while subjects wore the device. This indicates
Skin and Wound Care
that compliance with RCW wear for offloading the diabetic As previously discussed, meticulous skin hygiene and
ulcer is low. More recently, it has been shown that making monitoring is encouraged in every patient with PAD given
the RCW nonremovable (for example wrapping it with a the risk of wounds and infection and the potential for
cohesive bandage or plaster) forces adherence to pressure impairments in sensation. Any wound, no matter how small,
reduction, and both proportion and rate of wound healing should be addressed urgently.2 The PT should consistently
were significantly improved.87,88 If these pressure-relieving educate the patient in this area, determine barriers to compli-
devices are not feasible or are unavailable, the best approach ance, and monitor the skin for changes. Discussion regard-
is nonweightbearing on the sole of the foot with the ulcer, if ing appropriate wound care for arterial ulcers is beyond the
possible, to allow for wound healing. The PT needs to con- scope of this chapter and should be deferred to a wound care
sider balancing the risk of limiting mobility in a patient with specialist.
multiple comorbidities and at significant risk of decondition- Pharmacotherapy
ing, with the risk of infection, necrosis, and amputation from
a nonhealing ulcer on the sole of the foot. Pharmacotherapy for Claudication
The PT should consider that patients on bed rest because Treatments aimed at reduction of cardiovascular risk
of CLI, those undergoing limb salvage procedures, and/or factors to prevent cardiovascular events associated with
those who may undergo an amputation may have significant atherosclerosis will not significantly decrease claudication
vascular compromise throughout the body and/or several symptoms. Drugs aimed at decreasing the pain of claudica-
comorbidities that have already led to a progressive decline tion are separate from those used to decrease cardiovascular
in aerobic capacity, muscle performance, and baseline func- risk.3 The ACC/AHA and TASC II working group recom-
tion.89 The PT should intervene during efforts at limb mends cilostazol to improve symptoms and walking distance
salvage procedures in anticipation that, after a period of in patients with IC associated with PAD. Cilostazol is a
decreased mobility, with or without amputation, the patient phosphodiesterase III inhibitor with vasodilatory, metabolic,
will need to mobilize. The PT should consider an exercise and antiplatelet effects, and is the most evidence-based drug
prescription that will result in maximum aerobic capacity, and the main pharmacologic agent currently used for IC in
muscle performance, and range of motion. Close commu- patients with PAD.3,13 This medication should not be used
nication with the vascular team may be warranted, and the for patients with heart failure.2 Pentoxifylline, a methylx-
PT should ensure that O2 demand in the already ischemic anthine derivative that has antiplatelet effects and lowers
extremity is not increased and that the patient is not being fibrinogen levels, may be considered as a second-line alter-
put at risk through exercise intervention. native to cilostazol. However, its clinical effectiveness is not
A return to independent ambulation is a major challenge established.2,13
to the population postamputation. All levels of amputa- Pharmacotherapy for Critical Limb Ischemia
tion, from transmetatarsal or transfemoral, place increasing
In patients with CLI, when revascularization has failed or
demands on the proximal limb and increase energy demands
is not an option, pharmacotherapy that may produce improve-
centrally. These demands increase as the level of amputation
ments in circulation, with the goal of overcoming severely
becomes more proximal.89 O2 consumption during ambu-
reduced perfusion to the distal microcirculation, may be con-
lation at 1.24 miles per hour (2 km per hour) for patients
sidered.3 Treatment with prostanoids, such as prostaglandin
post-unilateral transtibial and transfemoral amputations is
E-1 or iloprost, may be considered to reduce ischemic pain
123% and 155%, respectively; that of the patient without a
and facilitate ulcer healing.2 These drugs prevent platelet and
LE amputation. Use of assistive devices in this population
leukocyte activation and protect the vascular endothelium.3
264 Chapter 7
Revascularization a syringe to remove emboli or thrombi) and percutaneous
mechanical thrombectomy (devices trap, dissolve, and evac-
Recall that in most cases, claudication does not progress
uate thrombi) are other endovascular procedures that may
to limb-threatening ischemia; therefore, surgery is gener-
be used in conjunction with pharmacologic thrombolysis to
ally reserved for those patients whose symptoms are lifestyle
speed up clot lysis, especially when time to revascularization
limiting, unresponsive to exercise, and/or pharmacotherapy,
is critical.2,3 Data from randomized studies in patients with
with a reasonable symptomatic and medical prognosis.2
ALI suggest that catheter-directed thrombolysis results in
On the other hand, without timely revascularization, CLI lower mortality and less complex surgical procedures and
may result in loss of limb or death.93 For example, in the may reduce risk of reperfusion injury compared with open
case of ALI, surgical revascularization may be indicated in surgery.
a threatened limb or in limbs with dramatic motor and sen-
Major amputation (above the ankle) may be required
sory deficits of short duration (hours)2,3 in order to prevent
when life-threatening infection sets in, resting pain is uncon-
worsening of limb ischemia. CLI is commonly associated
trolled, or necrosis has made the foot nonviable.3 Given the
with multilevel disease and secondary to chronic impaired
severity of these end-stage issues, incidence of major ampu-
perfusion,94 and revascularization may be considered if signs
tations is limited. For some patients with CLI (eg, those who
of CLI are present or if there is a nonhealing neuroischemic
are very high risk for surgery)3 or who have necrosis of the
ulcer despite optimum conservative management. The pri-
weightbearing portions of the foot, irreversible contracture,
mary goal of revascularization is limb salvage or amputation-
irreversible loss of function in the limb, uncontrolled isch-
free survival3 through reestablishing pulsatile flow to the
emic resting pain despite pharmacologic management, sep-
distal extremity.93 A successful revascularization would
sis, or very limited life expectancy,2 primary amputation may
result in a pain-free, functional extremity.3
be required. Secondary amputation may be required when
Several factors will determine the surgical option chosen revascularization is no longer possible or the limb continues
(ie, endovascular or open surgical procedures), including to deteriorate despite what appears to be a patent revascular-
the premorbid condition of the patient and the extremity, ization.3 Incidence of major LE amputation in ALI is up to
expected durability of the reconstruction, adequate aortoiliac 25%, and the site of amputation is often more proximal than
flow (inflow), anatomy of an occlusion, contraindications, that in CLI as the muscles of the calf are often not viable. The
and local practice.2,3 Intervention for proper aortoiliac flow primary goal of amputation is to obtain primary LE healing
(inflow) may be ensured prior to intervening on the more as distally as possible; therefore, the site of amputation is cho-
distal stenosis, and, in some cases, this is sufficient to heal sen based on the lowest level of transaction at which healing
superficial ulcers or resting claudication94 without further is expected to occur.3
intervention. Endovascular procedures for aortoiliac occlu-
sive disease have been associated with significantly lower Other Treatments
complication rates, shorter length of stay, and lower hospital Most notably, stem cell therapy for CLI is emerging in
costs95 than open procedures. The approach for an endovas- the research, with publication of first results in 2011. This
cular procedure is commonly through the common femoral therapy may be a useful adjunct to current therapies and
artery, or, if needed, through the brachial artery. In both of is an option for patients with CLI who are not appropri-
these cases, the site can be easily compressed following cath- ate for revascularization. Further research is needed with
eter removal, minimizing postprocedural complications.94 more rigorous methodology to confirm current encourag-
Open procedures include several types of bypass surgeries, ing literature in terms of safety and clinical outcomes such
with nomenclature indicating the area of the arterial tree as improved pain, decreased incidence of major amputa-
that is blocked and therefore bypassed in the procedure. tion, improvement of ABI, and transcutaneous partial pres-
For example, a femoral popliteal bypass (commonly called sure of O2.96-100 Intermittent mechanical calf compression
fem-pop) bypasses the blocked portion of the femoral artery has been recently studied as an intervention for claudica-
through open visualization of the femoral artery, and a graft tion as compared with medical therapy alone. Significantly
using blood vessels or synthetic materials is attached above increased claudication distance and postexercise ABI were
the blockage at the femoral artery and below the blockage found at 1 month and maintained or further improved at
at the popliteal artery. The majority of limb salvage surgery 3 months. Postexercise ABI remained stable 3 months after
addresses the outflow circulation or that distal to the aor- discontinuation of therapy.101 Further research is required
toiliac tree, which is the femoral popliteal circulation.94 After in this area, and one should refer to the discussion around
revascularization, limb salvage procedures may take place cautious use of compression in patients with PAD, found
that may involve wound débridement or amputation of parts in the compression section for treatment of CVD next. A
of the foot once demarcation occurs, with the goal of salvag- Cochrane review concluded that, in patients with diabetic
ing some or all of the foot. arterial ulcers, hyperbaric O2 significantly decreased the risk
Catheter-based pharmacologic endovascular thromboly- of major amputation; however, methodological shortcomings
sis is often the treatment for ALI, and balloon embolec- of the included studies were noted and further research is
tomy or angioplasty may also be considered.2,3 Percutaneous required.102
aspiration thrombectomy (uses catheters and suction with
Chronic Venous Disease ankle pressure of 20 to 30 mm Hg (Class I) for patients with
varicose veins. The SVS/AVF recommends compression as
Treatment of venous disease is aimed at ameliorating the primary treatment for venous ulcers, and evidence sug-
symptoms of the disease and/or improving the cosmetic gests that compression of 30 to 40 mm Hg is more effective
appearance of the limbs. The initial treatment of CVD is than lower levels of compression at enhancing ulcer healing
conservative and consists of skin care, elevation, exercise, and preventing ulcer recurrence.1,32,107 It has been proven
and compression. The PT can be instrumental in all of these that venous ulcers heal more quickly with compression than
areas. Pharmacologic management, surgery, and wound care without.108 Once ulcer healing is achieved, lifelong compres-
are reserved for situations where patients remain symptom- sion may be recommended to prevent recurrence.52 In a
atic despite more conservative measures. recent Cochrane Review,106 noncompliance with compres-
sion was associated with ulcer recurrence.
Skin and Wound Care
Although there is no convincing evidence that intermit-
Patients with CVD are at significant risk of wounds and tent pneumatic compression improves ulcer healing when
infections. The PT should incorporate education regarding compared to continuous compression or when added to
skin and wound care into the plan of care for every patient compression garment use,109 these devices may be helpful for
with CVD, and barriers to learning or compliance should patients for whom compression garments are not tolerated or
be identified and addressed. An important goal for these not feasible. These devices consist of an air pump to inter-
patients is to maintain skin integrity, thereby avoiding ulcer- mittently inflate/deflate single or multiple bladders in nylon
ation and infection. It is important to keep areas affected sleeves that envelope the limb, either to knee or hip height.109
by venous insufficiency clean and well moisturized daily Medicare and Medicaid will cover pneumatic compression
to maintain skin health and avoid itching, thereby avoid- for patients with CVD who have refractory venous ulcers
ing the chance of trauma to the skin caused by scratching. after 6 months of conservative treatment, including compres-
Any areas of compromise, including redness or open areas, sion, wound care, exercise, and elevation.110
no matter how small, should be addressed by a health care Prescription of compression for venous disease should be
professional as soon as possible. Treatment of infection (only performed only by health care professionals with appropriate
if present), compression, and meticulous wound care are the skills and training because several complications of inap-
mainstays of treatment for venous ulceration.1,32 Discussion propriately measured or applied garments have been report-
of appropriate wound care for venous ulceration is beyond ed.1,111 Some PTs are trained and skilled in this area and will
the scope of this chapter and should be deferred to a wound provide effective compression management, whereas others
care specialist. will mobilize a referral to a local certified lymphedema
Compression therapist or wound care clinic. Compression should not be
The use of compression is a mainstay of treatment for provided in the presence of cellulitis until symptoms of the
CVD, and its mechanism of action, although not fully under- infection, specifically pain and erythema, have subsided.112
stood, is direct compensation for ambulatory venous hyper- Every patient for whom compression is considered should be
tension.1 Buhs et al103 found that 20 to 30 mm Hg thigh-high clinically examined for signs of arterial insufficiency, and, if
compression garments help preserve venous caliber and found, consideration of further testing to rule out moderate
prevent dilation in the deep, superficial, and perforating to severe arterial insufficiency may be prudent. Compression
venous system of the LEs during daily activities. Ibegbuna et should be used only with caution and meticulous monitoring
al104 found that Class II compression garments significantly in patients with arterial disease, as the application of external
improved venous dynamics by reducing residual volume compression at high pressures will reduce blood supply to the
fraction in patients with CVD during walking. There are skin and may lead to damage.53,108 Compression should be
several kinds of ambulatory compression, including multi- combined with leg exercises and walking as activation of the
layer short stretch wraps, elastic or nonelastic compression calf muscle pump is more effective with compression during
garments, impregnated paste gauze wraps (Unna boots), and activity.104 For this reason, adherence to compression and
pneumatic compression devices. There are several options development of a compression plan of care that is comfort-
available for patients who have difficulty donning or doff- able and feasible for each patient is paramount. Any patient
ing the garment, including donning devices or custom-fitted undergoing compression management should be closely
stockings with Velcro or zippers, which, unfortunately, are monitored and educated regarding donning and doffing,
significantly more expensive than off-the-shelf garments. situations that would warrant immediate discontinuation
Despite numerous compression options available, compli- of compression and consultation with a health care profes-
ance with high-grade compression (> 30 mm Hg) is poor, and sional, care of compression garments, and when and how to
in some cases, one must consider lower levels of compression obtain new garments. Stockings should be replaced every 6 to
in order to achieve compliance105,106; it is likely that some 12 months with daily wear to avoid loss of pressure.31,53
compression is better than none. Appropriate tension of Elevation and Exercise
elastic compression is disputed in the literature; however, the The literature concerning the appropriate exercise pre-
SVS/AVF recommends graded prescription stockings with an scription for patients with CVD is much less advanced or
266 Chapter 7
definitive than that for exercise in patients with PAD. It is findings speak to the importance of patient education sur-
a common theme in the literature, however, that patients rounding the benefits of exercise and compression in CVD,
should be counseled in weight loss, exercise, and elevation and addressing the individual fear-avoidance beliefs of each
of the legs as much as possible.1,54 The PT should consider patient as appropriate.
appropriate patient education and exercise prescription for In the few studies that have examined the effects of exer-
all patients with CVD. cise in patients with CVD, calf muscle pump function and
Leg elevation, with ankles at or above the level of the heart, muscle strength and endurance have improved significantly
improves venous blood flow compared with dependency of with exercise. Kan and Delis119 conducted a study comparing
the legs, thereby directly counteracting venous hypertension an exercise program of supervised isotonic calf muscle exer-
experienced by patients with CVD in the dependent position. cise consisting of plantarflexion against a 4-kg resistance for
In one study, leg elevation 30 cm above the heart significantly 3 sets of 6 minutes daily (number of repetitions started with
increased the blood flow velocity by 41% in liposclerotic 75% of the maximal number of repetitions reached at base-
skin of patients with CVI.113 Another study114 found that line during 6 minutes at 1 repetition/second), with a 5-min-
elevation above the level of the heart at least 1 hour per day ute rest in between, for 7 consecutive days. Both the exercise
for 6 or more days per week in Class II (20 to 30 mm Hg) or and the control group received ulcer dressings and compres-
Class III (30 to 40 mm Hg) compression was significantly sion bandaging. After 7 days, patients in the exercise group
associated with a lower risk of venous ulcer recurrence. showed significantly improved ejected venous volume and
Although elevation of this level may be difficult for some ejection fraction in the calf compared with the control group.
patients given musculoskeletal comorbidities (eg, back pain Calf muscular endurance in the exercise group increased
or hip osteoarthritis), patients should be strongly advised to significantly by 135%. This was a small study (exercise group
avoid dependency whenever possible, elevating the ankles at n = 10, control group n = 11) lacking power, and the signifi-
least to slightly above the level of the hip, which would allow cance of the changes is surprising given the duration of the
gravity to assist in venous drainage centrally. Working on program; however, statistical significance was reached, and
positioning strategies for patients with discomfort with leg the results of this study are promising and certainly warrant
elevation should be routinely incorporated into the plan of more stringent research in this area.
care. For patients for whom prolonged or frequent elevation In another study,120 31 patients with CVD were ran-
is not practical given the nature of their work, short periods domized into control and exercise groups, and all sub-
of elevation throughout the day may also be beneficial. jects were treated with compression garments. The exercise
As previously discussed, an impaired calf muscle pump group received 3 months of supervised exercise, followed by
can significantly contribute to development of LE edema and 3 months of unsupervised exercise. The exercise program
other symptoms of CVD.115 The goal of exercise in CVD is was designed by a PT, individualized for each patient, and
to improve the calf muscle function and the pressures gen- included lower limb and trunk stretching and strengthen-
erated by the LE skeletal muscle pump. Studies have found ing with resisted exercises 2 days per week, progressing in
that patients with CVD have a significant impairment of calf repetitions, sets, and resistance throughout the 3 months.
muscle function when compared to healthy controls. There Inclined treadmill walking was incorporated in each session
are impairments of peak torque/body weight (strength) and of the supervised component, and subjects were encouraged
total work (endurance)116 and in ulcerated limbs secondary to continue uphill walking and were taught the principles of
to venous insufficiency, significantly poorer ejection frac- exercise progression to continue during the unsupervised
tions, and greater residual volume fractions than in limbs component of the exercise program. It should be noted that
with healed ulcers or no history of ulceration.117 comorbid conditions were frequent in this study and includ-
Patients with leg ulcers have reported low levels of physi- ed obesity, coronary heart disease, heart failure, angina,
cal activity. In one study of self-reported physical activity hypertension, dyspnea, asthma, diabetes, arthritis, and DVT.
in 150 patients with leg ulcers secondary to venous insuf- Despite these multiple comorbidities, compliance to the exer-
ficiency, only 13% of patients reported that they walked for cise regimen was good (mean 18 ± 1.6 days out of 22 sessions
30 minutes or more at least 5 days of the week. Thirty-five for the supervised phase, and 63 ± 7.3 days out of a possible
percent of patients reported that they had not walked for 90 days). It should also be noted that reported compliance
10 minutes at least once the week prior to the interview, and with compression (Class II: 30 to 40 mm Hg) was excellent
only 35% of patients reported that they performed exercises in this study, with 89% of patients wearing their compres-
for the lower legs.115 It is difficult to know whether a seden- sion garments for 6.24 days per week. This rate of compli-
tary lifestyle has led to progression of venous disease in these ance is very high as compared to other studies but was not
individuals or whether the symptoms of venous disease have further discussed by the authors. Both calf muscle function
led to avoidance of activity. In one study, 83% of subjects (residual volume fraction and ejection fraction) and strength
with a leg ulcer avoided movements or activities based on improved significantly in the exercise group as compared
fear, and patients with low reported physical activity had with the control group after exercise intervention; however,
significantly stronger fear-avoidance beliefs and more severe there were no changes observed in quality of life or disease
pain than those with high reported physical activity.118 These severity. Again, this study lacked power given its sample size,
but the findings were statistically significant and warrant Surgery
further research in this area. As would be expected, in both
Surgery for varicose veins is generally reserved for patients
of these studies, the amount of venous reflux, which reflects
who require symptomatic relief.54 For those requiring sur-
the state of the venous valves, remained unchanged after
gery, open surgical treatment of varicose veins with venous
the exercise intervention. Physiologic change is not a goal of
ligation and stripping of the great or small saphenous veins
exercise intervention in the population with CVD.
and excision of large varicose veins has been the mainstay
Back et al121 found that ankle range of motion was sig-
of treatment for more than 100 years. Other less invasive
nificantly lower in patients with CVD as compared to that
surgery for varicose veins includes phlebectomy, or removal
in age-matched controls, and ankle range of motion was
or avulsion of varicosities through small wounds. Results
significantly correlated to calf muscle ejection fraction, resid-
of open surgery have continued to improve, and open sur-
ual volume fraction, and clinical severity of CVD. Although
gery continues to be considered safe and effective. In the
there are no studies examining the effects of an intervention
last 10 years, use of minimally invasive endovenous ther-
to improve ankle range of motion in this population, given
mal ablation (EVTA) has dramatically increased, and open
these findings, any impairment in ankle range of motion in
surgery has been used less in the United States.1 EVTA
this population should likely be addressed.
includes endovenous laser ablation and radiofrequency abla-
Given the lack of strong literature in this area, lim- tion. Ablation, or occlusion, of the varicose vein is accom-
ited recommendations regarding exercise prescription in plished in both cases by causing direct thermal damage to the
the population with CVD can be made. It seems as though venous wall by applying heat directly into the vein through
a combination of exercises aimed at strength and endur- a percutaneously applied catheter. This may be performed as
ance of calf musculature would be best, including some an outpatient procedure under ultrasound guidance using
resistance training, stretching, and endurance training percutaneous catheters. Patients have less pain and can
through walking. Compression in conjunction with activ- return to regular activities faster than with an open surgical
ity should be prescribed and encouraged throughout treat- procedure.1 Patient selection for EVTA or open surgery is
ment. Recommended intensity, frequency, and duration of important, as some patients may not be appropriate for endo-
programs are not clear in this population; however, con- venous procedures (eg, those with irreversible coagulopathy,
sideration of each patient’s impairments, and the literature liver dysfunction limiting local anesthetic use, immobility,
surrounding exercise and comorbidities (eg, heart failure, pregnancy, and breastfeeding).1 In any surgical procedure
osteoarthritis) in that population would be warranted. Best for varicose veins, an external compression dressing, usually
care for exercise prescription, development of plans for effec- with an elastic wrap, is applied and will be left in place for
tive and feasible compression regimens, and determinants 48 to 72 hours, and elevation should be encouraged. Often,
for adherence to compression and exercise in the population graded compression stockings are applied after removal of
with CVD are all areas in the literature that require more the primary dressing.54 Sclerotherapy, or chemical injection
development. into a vein to achieve fibrotic obstruction, may be used to
Pharmacology treat superficial varicose veins, residual or recurring vari-
cose veins following surgery, and for thread (spider) veins.128
There are several venoactive drugs used in CVI; some
There is a chance of recurrence after any treatment for
for symptom relief, some for acceleration of healing of
varicosities, and this depends on the severity of the initial
venous ulcers. Although the precise mechanism of action is
varicosities and on the treatment used.54
unknown, the main principle of these drugs is to improve
venous tone and capillary permeability.31 The SVS/AVF1
recommends the use of venoactive drugs together with
compression for symptomatic CVD, and pentoxifylline or SUMMARY
micronized purified flavonoid fraction together with com-
pression to accelerate venous ulcer healing. There has been The prevalence of PVD is high, affecting millions of
much discussion in the literature concerning use of horse- Americans. Patients with PAD and CVD experience high
chestnut seed extract (HCSE). A recent Cochrane review122 morbidity and decreased quality of life, and those with PAD
suggests that HCSE is a safe and effective short-term treat- are at significantly greater risk of cardiovascular events and
ment for CVD; however, it recommends that stronger litera- death than age-matched norms. The cost associated with
ture is required to confirm its effectiveness. These findings treating these diseases is high, including the cost in loss of
are consistent with those of other studies on the use of HSCE work hours and emotional suffering incurred by patients.
in CVD.123-126 The consensus exists in the literature that Given the prevalence, impact, and costs associated with
larger and more rigorous clinical trials are needed to improve PVD, it is imperative that the PT be able to effectively exam-
existing recommendations surrounding the pharmacological ine for, diagnose, and provide evidence-based interventions
treatment of CVD.127 for clients presenting with these diseases.
An understanding of the risk factors for, pathophysiology
of, and clinical presentation of PAD and CVD can guide the
268 Chapter 7
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101. de Haro J, Acin F, Florez A, Bleda S, Fernandez JL. A prospec- 123. Bielanski TE, Piotrowski ZH. Horse-chestnut seed extract for
tive randomized controlled study with intermittent mechanical chronic venous insufficiency. J Fam Pract. 1999;48(3):171-172.
compression of the calf in patients with claudication. J Vasc Surg. 124. Diehm C, Trampisch HJ, Lange S, Schmidt C. Comparison of
2010;51(4):857-862. leg compression stocking and oral horse-chestnut seed extract
102. Kranke P, Bennett M, Roeckl-Wiedmann I, Debus S. Hyperbaric therapy in patients with chronic venous insufficiency. Lancet.
oxygen therapy for chronic wounds. Cochrane Database Syst Rev. 1996;347(8997):292-294.
2004;(2):CD004123. 125. Ottillinger B, Greeske K. Rational therapy of chronic venous
103. Buhs C, Bendick P, Glover J. The effect of graded compression elas- insufficiency—chances and limits of the therapeutic use of horse-
tic stockings on the lower leg venous system during daily activity. chestnut seed extract. BMC Cardiovasc Disord. 2001;1(5):5.
J Vasc Surg. 1999;30(5):830-835. 126. Pittler MH, Ernst E. Horse-chestnut seed extract for chronic venous
104. Ibegbuna V, Delis K, Nicolaides A, et al. Effect of elastic compres- insufficiency. A criteria-based systematic review. Arch Dermatol.
sion stockings on venous hemodynamics during walking. J Vasc 1998;134(11):1356-1360.
Surg. 2003;37(2):420-425. 127. Perrin M, Ramelet AA. Pharmacological treatment of primary
105. Marston W. Summary of evidence of effectiveness of primary chronic venous disease: rationale, results and unanswered ques-
chronic venous disease treatment. J Vasc Surg. 2010;52(14S):54S- tions. Eur J Vasc Endovasc Surg. 2011;41(1):117-125.
58S. 128. Tisi PV, Beverley C, Rees A. Injection sclerotherapy for varicose
106. Nelson EA, Bell-Syer SE. Compression for preventing recurrence of veins. Cochrane Database Syst Rev. 2006;(4):CD001732.
venous ulcers. Cochrane Database Syst Rev. 2012;8:CD002303
107. Partsch H, Flour M, Smith PC. Indications for compression therapy
in venous and lymphatic disease consensus based on experimental
data and scientific evidence. Under the auspices of the IUP. Int
Angiol. 2008;27(3):193-219.
CASE STUDY 7-1
108. O’Meara S, Cullum NA, Nelson EA. Compression for venous leg
ulcers. Cochrane Database Syst Rev. 2009;(1):CD000265.
Cheryl L. Brunelle, PT, MS, CCS, CLT;
109. Nelson EA, Mani R, Thomas K, Vowden K. Intermittent pneumatic Paul D. Gaspar, PT, DPT, CCS; and
compression for treating venous leg ulcers. Cochrane Database Syst
Rev. 2011;(2):CD001899.
Robert M. Snow, PT, DPT, OCS, ATC
110. Centers for Medicare & Medicaid Services. National coverage
determination (NCD) for pneumatic compression devices (280.6).
http://www.cms.gov/medicare-coverage-database/details/ncd-
details.aspx?NCDId=225&ncdver=1&DocID=280.6&bc=gAAAAA
EXAMINATION
gAAAAA&. Accessed May 15, 2014.
111. Bauer NA. The 4 rights of compression therapy for patients
with chronic venous insufficiency and venous ulceration. Home
History
Healthcare Nurse. 1998;16(7):443-448.
112. Clinical resource efficiency support team (CREST). CREST Current Condition/Chief Complaint
Guidelines on the Management of Cellulitis in Adults. June 2005. Mr. Eagle is a 67-year-old English-speaking, White male.
http://www.acutemed.co.uk/docs/Cellulitis%20guidelines,%20
He was referred to physical therapy by his cardiologist for
CREST,%2005.pdf. Accessed May 14, 2015.
113. Abu-Own A, Scurr J, Coleridge-Smith P. Effect of leg elevation on LE IC and limited ability to manage his cardiovascular risk
the skin microcirculation in chronic venous insufficiency. J Vasc factors.
Surg. 1994;20(5):705-710. Mr. Eagle stated that he had episodes of LE claudica-
114. Finlayson K, Edwards H, Courtney M. Relationships between pre- tion for more than 10 years and had never received physical
ventive activities, psychosocial factors and recurrence of venous leg
ulcers: a prospective study. J Adv Nurs. 2011;67(10):2180-2190.
therapy. He reported that claudication was limiting his com-
115. Heinen MM, van der Vleuten C, de Rooij MJ, Uden CJ, Evers AW, munity level activities and that he was experiencing progres-
van Achterberg T. Physical activity and adherence to compres- sively worsening quality of life.
sion therapy in patients with venous leg ulcers. Arch Dermatol.
2007;143(10):1283-1288.
116. Yang D, Vandongen YK, Stacey MC. Changes in calf muscle func- Clinician Comment From the consult, Mr.
tion in chronic venous disease. Cardiovasc Surg. 1999;7(4):451-456. Eagle already carried a long-standing diagnosis of PAD. He
117. Araki C, Back T, Padberg F, et al. The significance of calf muscle
reported a lack of intervention for his claudication symp-
pump function in venous ulceration. J Vasc Surg. 1994;20(6):872-
877; discussion 878-870. toms, resulting in limitations in activities and participation
118. Roaldsen KS, Elfving B, Stanghelle JK, Talme T, Mattsson E. Fear- at the community level. Lack of intervention for claudica-
avoidance beliefs and pain as predictors for low physical activity in tion is not uncommon and is consistent with the literature.1
patients with leg ulcer. Physiother Res Int. 2009;14(3):167-180. The PT should consider that Mr. Eagle may have a large
119. Kan Y, Delis KT. Hemodynamic effects of a supervised calf
knowledge gap about his disease and its management;
muscle exercise in patients with venous leg ulceration. Arch Surg.
2001;136(12):1364-1369. therefore there may be a role for significant education in
120. Padberg FT Jr, Johnston MV, Sisto SA. Structured exercise improves his plan of care. The PT should, based on the current com-
calf muscle pump function in chronic venous insufficiency: a ran- plaint and reason for consult, plan on including a compre-
domized trial. J Vasc Surg. 2004;39(1):79-87. hensive social history to elicit risk factors and baseline and
121. Back TL, Padberg FT Jr, Araki CT, Thompson PN, Hobson RW 2nd.
current functional status, and a vascular examination in
Limited range of motion is a significant factor in venous ulceration.
J Vasc Surg. 1995;22(5):519-523. the initial examination. In this case, clarifying Mr. Eagle’s
122. Pittler MH, Ernst E. Horse chestnut seed extract for chronic venous understanding of his disease and its management would
insufficiency. Cochrane Database Syst Rev. 2012;11:CD003230. be helpful.
272 Chapter 7
Social History/Environment Mr. Eagle wanted to improve his walking distance, speed,
and comfort. He wanted to get back to going to some of his
Mr. Eagle lived with his wife in a 1-story house with no
favorite restaurants with his wife that required parking and
steps to enter. He had 3 adult children living locally who
walking a distance, partake in a regular exercise program, do
could help with shopping, but all worked full time and had
the grocery shopping, and be able to walk around the block
families of their own to manage. He had 3 siblings who all
comfortably next to his grandson.
lived at least 3 hours away. Mr. Eagle had a college education,
he had spent more than 40 years in the investment business,
and, for the past few years, he and his wife had been working Clinician Comment Mr. Eagle was an educat-
part time from their home (by choice) as financial advisors ed man who was still actively working and whose work had
for small businesses. He enjoyed using the Internet, reading, fortunately not been affected by his PAD. His health habits,
spending time with his grandchildren on weekends, and including low caffeine and alcohol intake, a healthy diet,
going out for dinner with his wife. and his choice to quit smoking at his physician’s request
Social/Health Habits years earlier, all spoke of a man who would likely be com-
pliant with recommendations and exercise interventions.
Mr. Eagle had been a nonsmoker for 13 years. Previously, He clearly wished to increase his ability to be active and
he had smoked 2 packs per day for more than 35 years—a participate in community-level activities, and he was artic-
70 pack-year history. He stopped smoking at his physician’s ulating his intention to participate in a structured exercise
request prior to his first carotid endarterectomy. At the time program. Risk factors for PAD had already appeared in
of the appointment, he had not had an alcoholic beverage for Mr. Eagle’s history, including his age, prior smoking his-
1 year, and prior to that had less than 1 per day. He followed a tory, and a significant family history of cardiovascular
low-cholesterol diet and drank 2 cups of coffee per day. disorders. Recall that other risk factors for PAD include
Family History diabetes, hypertension, dyslipidemia, or renal issues, and
these would need to be discussed as part of the review of
Mr. Eagle’s father died of a cerebral vascular accident at
Mr. Eagle’s medical and surgical history. Clearly, Mr. Eagle
78 years of age. His mother died at 72 years of age during a
was already diagnosed with PAD; however, identification of
heart valve replacement surgery. His 2 sisters and 1 brother,
further risk factors would help to clarify educational needs.
ages 56, 60, and 64 years, were in excellent health.
Mr. Eagle described a progressive decline over the past
Reported Functional Status decade, which has significantly affected his ability to par-
Mr. Eagle reported that he ambulated independently ticipate in activities that bring him much joy and help him
without an assistive device for both household- and com- maintain his independence. His quality of life at that point
munity-level distances, and reported no difficulty at the had been significantly affected, which is consistent with
household level. He was able to perform ADL independently. the literature in this population. Recall that the literature
He reported that, at the time of examination, his self-paced supports significant relationships between depression and
walking was limited to less than one block because of bilat- impaired quality of life in patients with PAD and those who
eral calf claudication. If he stood or sat to rest, the pain would have undergone surgical intervention for such.2,3 The PT
resolve and he could proceed another block. He reported he may consider use of an outcome measure to measure and
had no discomfort when standing for prolonged periods. monitor the effect of Mr. Eagle’s PAD on his quality of life.
He reported that, 10 years prior, he had been able to walk Mr. Eagle had clear goals in mind that should be incorpo-
1 mile with mild claudication, and his walking tolerance rated into the physical therapy plan of care.
had declined gradually. At the time of the appointment, he
had not been exercising because of claudication pain and in
fact would walk outside his home only when necessary. He
Medications
and his wife went out for dinner only if parking was close to
the restaurant and he did not have to walk any distance. He • Aspirin
avoided intersections as his walking was too slow to make it • Lipitor (atorvastatin calcium)
across the street before the pedestrian signal ended. His wife
• Norvasc (amlodipine besylate)
and children did their grocery shopping because he could not
tolerate the distances needed to walk in the large local gro- • Avapro (irbesartan)
cery store. He continued to go over to his son’s house every • Cilostazol
weekend for Sunday dinner and to play with the children. He
Mr. Eagle reported no side effects associated with these
could no longer go around the block while his grandson rode
medications and no difficulty with medication compliance.
his bike, and missed this time with him dearly. He did not
walk for exercise or perform any other type of exercise on a
regular basis. He reported he would like to be able to exer- Clinician Comment Mr. Eagle had been pre-
cise and would be willing to participate in a regular exercise scribed aspirin as an antiplatelet therapy for cardioprotec-
program either as an outpatient or independently at home. tion, Lipitor to control hyperlipidemia, Norvasc and Avapro
for control of hypertension, and Cilostazol to control symp- cerebrovascular disease, that Mr. Eagle is at high risk of
toms of IC. Additional risk factors were identified—of note, serious cardiovascular events and may have an inappropri-
those shared by PAD and CAD, including hypertension and ate hemodynamic response to mobility. It is possible that if
hyperlipidemia. The PT should assume Mr. Eagle is at high Mr. Eagle had a cardiovascular pump dysfunction during
risk of CAD and should plan on close hemodynamic moni- activity, it would likely be asymptomatic given his reports
toring to establish Mr. Eagle’s responses to position change of an absence of cardiac-related symptoms with activity.
and to activity. Cardiac history would be further elicited in
review of his past medical/surgical history.
The following measures were reported from noninvasive
Medical/Surgical History arterial studies:
Mr. Eagle has undergone several interventions in an
attempt to revascularize his impaired peripheral circulation ABI One year prior to physical therapy
and improve symptoms. He reported he was diagnosed with examination: Right, 0.31; Left, 0.37
PAD and carotid disease 12 years prior to the examination.
At that time, he noticed difficulty walking and complained MRA Completed 1 week prior to the
of “flecks” running across his eyes. He underwent a right physical therapy examination, showed
carotid endarterectomy at that time, and a left carotid end- impaired flow in the iliac, femoral, and
arterectomy 3 years ago. He underwent an angioplasty in the popliteal arteries
right femoral artery 10 years ago, and the left 9 years ago. He Echo- Performed 2 years prior to physical
had bilateral common iliac artery and external iliac artery cardiogram therapy examination, showed that
angioplasties with stent placement 1 year ago. He had an Mr. Eagle had a left ventricular ejec-
angioplasty of the mid-portion of the left anterior descend- tion fraction of 65% with normal left
ing coronary artery 3 years ago after an adenosine stress test ventricular systolic function. No wall
indicated blockage of the left anterior descending coronary motion abnormalities were noted;
artery. He had no symptoms of angina or dyspnea prior to or however, mild mitral regurgitation
since the intervention. and left atrial dilation were noted. The
Mr. Eagle reported 5 transient ischemic attacks in the right heart was within normal limits
past, but none in the 3 years prior to the physical therapy
Electro- One week prior in the cardiologist s
appointment. He had an arterial ulcer on his left heel 18
cardiogram office that read normal sinus rhythm,
months prior that healed after 3 to 4 months with restricted
rate 72
weightbearing (crutch walking) and independent wound
care at home. He reported no history of orthopedic, pulmo-
nary, rheumatologic, or oncology-related signs, symptoms, or
medical care. His only hospitalizations were for the episodes Clinician Comment Mr. Eagle’s ABI mea-
of care related to his cardiac and PVD, mentioned previously, surements were taken after his most recent revasculariza-
with the exception of a tonsillectomy many years ago. tion and indicated bilateral, severe PAD with an ABI of
< 0.40 bilaterally. One should consider that these values are
3 years old and could be even lower at this time; however,
Clinician Comment It is clear from his they would still reflect severe PAD and would not change
numerous revascularizations that Mr. Eagle not only has the clinical decision-making process of the PT. Mr. Eagle’s
advanced PAD, but also CAD. It is unfortunate that Mr. MRA also reflects the severity of his PAD, with multiple
Eagle has not had physical therapy intervention up to this continued impairments in flow throughout the LE arterial
point; however, it is possible that he was independently circulation. His cardiac echocardiogram is helpful in that
mobile after each of these revascularizations, and the it is relatively recent. However, given the severity of his
medical team was not aware of the educational and exer- vascular issues, one may consider that there could be dete-
cise physical therapy interventions that may have helped rioration within a 3-year time period. There are some early
Mr. Eagle to manage his disease. Mr. Eagle’s significant changes on echocardiogram and, again, this test is 2 years
vascular history and history of an arterial ulcer confirms old, so it is possible there have been changes since then. This
the need for a comprehensive vascular exam, specifically is a resting echocardiogram and in no way insinuates that
looking for signs of PAD on integumentary exam, includ- Mr. Eagle’s cardiovascular pump will respond normally to
ing wounds, circulation of the extremities, and claudica- activity or that hemodynamic response to activity will be
tion pain within tests and measures. It also confirms the normal. Together with his lack of any spinal complaints in
need for examination of aerobic capacity and walking his history, his markedly abnormal ABIs and MRA indi-
tolerance with close hemodynamic monitoring. The PT cate that Mr. Eagle’s claudication was likely vascular as
should consider, given his established history of CAD and opposed to neurogenic. The severity of PAD indicated by his
274 Chapter 7
ABIs identified that compression therapy would not be an greater than that in the left upper extremity, which likely
appropriate treatment consideration if edema were present indicates some arterial stenosis in the left arm impeding
because the risk of further impairment of blood flow would flow and resulting in a lower BP reading. Any subsequent
be too high. His electrocardiogram was normal at rest; BPs should be measured in the right upper extremity for
however, this does not imply that rhythm or rate would be accuracy. Not surprisingly given the severity of Mr. Eagle’s
normal with activity. In absence of any history of arrhyth- PAD as indicated by his ABIs, trophic changes were noted
mias, the PT would monitor hemodynamic response closely in the LEs, indicating vascular insufficiency; coolness, dry-
given his history, and if any arrhythmias were noted on ness, and pallor indicated arterial insufficiency. Based on
palpation of HR, immediate referral back to his cardiologist Mr. Eagle’s chief complaint, social history, reported func-
would be warranted. tional status, and established diagnosis of severe PAD, the
PT decided that tests and measures were indicated even
before the systems review in this case. In cases in which
Systems Review the patient has not been definitively diagnosed, the PT
would complete the systems review and then decide on
Cardiovascular/Pulmonary tests and measures based on a combination of the systems
review and the patient’s history together. Mr. Eagle gave a
HR: 72 beats per minute (bpm) and regular good history of his community-level activities, and the PT
Respiration rate: 16 breaths per minute should examine him based on his reports of the IADL he
BP (brachial, seated rest): 160/86 mm Hg right, needs to perform as well as with the knowledge that his
148/84 mm Hg left walking distance is significantly impaired at baseline. This
Edema: None noted bilaterally in the LEs would allow the examiner to determine whether Mr. Eagle
Integumentary can successfully complete the IADL he needs to complete to
be independent, determine his cardiovascular response to
Integumentary integrity of the LEs was intact. Trophic these activities to ensure safety, and determine limiting fac-
changes, including loss of hair and thickening of the toenails, tors that may drive the PT’s plan of care. It is unlikely that
were noted. Mr. Eagle’s feet were symmetrically cool, dry, he will be able to mobilize community distances, and one
and pale. No signs of venous insufficiency were noted. can anticipate that his main limiting factor will be IC. In
Sensation this case, walking distance and time should be noted, and
claudication pain should be measured during ambulation
Intact to light touch and proprioception bilateral LEs.
and throughout recovery.
Musculoskeletal
• Height: 6 feet, 1 inch; Weight: 170 pounds
• Gross range of motion: Within normal limits upper and Tests and Measures
LEs
Circulation
• Gross strength: Within normal limits upper and LEs
Pulses
Neuromuscular
• Femoral: 1 bilaterally
Gait, balance, and motor function were within normal
• Popliteal: Not palpable bilaterally; Dopplerable
limits. Mr. Eagle was independent without an assistive device
for transfers and ambulation. • Dorsalis pedis: 1 bilaterally
Communication, Affect, Cognition, • Posterior tibial: Left, 1; Right, not palpable; Dopplerable
Language, and Learning Style • CRT: Impaired (> 3 seconds) bilateral great toes
Mr. Eagle was an excellent historian who was alert and
oriented times 4. He reported that he did not have a strong Clinician Comment If Mr. Eagle did not have
learning preference, but enjoyed learning and reading about a confirmed diagnosis of PAD, recall that reduced or absent
his condition on the Internet. pulses throughout the LE would increase the likelihood of
PAD.5 Given that he already has been diagnosed with PAD,
Clinician Comment Mr. Eagle’s resting BP is palpation of pulses serves as a baseline for the examiner,
high, which is consistent with his history of hypertension. who will be able to note changes over time (eg, a deteriora-
As previously discussed, ACC/AHA guidelines recommend tion in pulses from diminished to absent, or Dopplerable
a systolic BP < 140 mm Hg for patients with PAD without to non-Dopplerable). Given the severity of Mr. Eagle’s PAD
diabetes.1,4 It is possible that his hypertension is not well and his MRA findings of stenosis throughout the LE arte-
controlled, and this should be communicated to his primary rial circulation, it is not surprising that pulses are reduced
care physician (PCP). BP in the right upper extremity was or absent to palpation. Recall that CRT greater than
3 seconds is associated with moderate to severe PAD,5 so it Clinician Comment The 6MWT was chosen
was not surprising to find Mr. Eagle’s CRT was impaired. because it has established reliability in the population with
Measurements of ABI were not taken during the physical PAD and its measurements are related to the functional
therapy examination. Mr. Eagle’s ABI values from 1 year and hemodynamic severity of PAD in patients with IC.7 Mr.
prior indicated severe PAD, so remeasurement was not Eagle’s 6MWT distance of 284 feet was low compared to the
likely to add any new information to the examination and healthy elderly population. One study found that healthy
therefore would not influence intervention for this patient. subjects 50 to 85 years of age walked an average distance of
2070 feet during a 6MWT.8 Mr. Eagle’s average gait speed
was very low and, in fact, was equivalent to approximately
Joint Integrity and Mobility one-third of the average comfortable gait speed of males in
their seventh decade.9 Mr. Eagle’s energy expenditure dur-
ing walking helps to determine whether his hemodynamic
Clinician Comment The PT did not feel response to this activity was appropriate. For every 1 MET
that tests and measures were indicated to rule out neu- of activity above resting (equivalent to 1 MET), systolic BP
rogenic claudication as a cause for Mr. Eagle’s symptoms. should be expected to rise 10 mm Hg and HR 10 bpm. Since
His symptoms were reproducible with a given amount of Mr. Eagle’s energy expenditure was equivalent to 1.8 METs,
exercise and relieved with standing still, which is classic in or a 0.8-MET increase beyond resting, one would expect
a patient with vascular claudication. A patient with neu- his HR and BP to rise less than 10 bpm or mm Hg, respec-
rogenic claudication may have symptoms at rest or with tively; however, his HR rose 32 bpm, and his systolic BP rose
activity, but symptoms are usually exacerbated with exten- 34 mm Hg, indicating an exaggerated response to activity,
sion of the spine, relieved with flexion of the spine, and which would be consistent with a deconditioned response.
thought to be caused by stenosis of the spinal canal.6 Relief
of symptoms with standing still would not be characteristic The absolute value of his HR is not concerning as he is not
in a patient with neurogenic claudication; therefore, Mr. near his age-predicted maximum HR. The absolute value of
Eagle’s symptoms are not consistent with neurogenic clau- his BP at peak activity is high but expected given his decon-
dication and no further testing was warranted. ditioned response superimposed on a resting hypertension.
Such a high BP with such low level activity is concerning,
and warrants discussion with the physician. If resting BP
were better controlled, even with a deconditioned response
Aerobic Capacity and Endurance to activity, absolute peak BPs would be lower. Although Mr.
Eagle’s hemodynamic response did not indicate a cardiovas-
Six-Minute Walk Test cular pump dysfunction at this workload, he would need con-
tinued monitoring with activity, especially as symptoms are
Average gait speed 0.46 m/sec (1.03 mph) expected to improve and workload may progress. He should
not be expected to have the same hemodynamic response
Average energy expenditure 1.8 metabolic equiva- at all workloads. Given Mr. Eagle’s very low gait speed and
lents (METs) deconditioned response to low-level activity, it is clear that,
Time to claudication onset 40 seconds as he reports, his quality of life was significantly affected by
his inability to walk at a functional speed or for community
Distance to claudication 66 feet (20.1 m)
distances. Mr. Eagle’s ankle BP fell dramatically with exercise
onset
and recovered slowly, consistent with the response expected
Maximum walking time 85 seconds in a patient with PAD as previously discussed.10
Maximum walking distance 144 feet (43.9 m)
Total walking distance 284 feet (86.6 m), Work (Job/School/Play/Leisure)
including a 2-minute,
50-second rest break King s College Vascular Quality of
Resting HR standing 78 bpm Life Questionnaire (VascuQol)
Peak HR 110 bpm Total score at the evaluation 2.96/7
Resting right brachial BP 164/84 mm Hg Physical activity score 2.1/7
Peak right brachial BP 198/96 mm Hg Pain score 4/7
Postexercise ankle BP 50% lower than rest- Symptom score 4.7/7
ing value, 7 minutes
to recover to baseline Psychological well-being score 2.6/7
Social activity score 2/7
276 Chapter 7
impairment in aerobic capacity on his 6MWT, and his exag-
Clinician Comment The VascuQol is a valid, gerated hemodynamic response to low-level activity (slow
reliable, and disease-specific outcome measure of quality of walking on level ground for a short distance). His PAD was
life for patients with chronic limb ischemia or PAD.11 The directly affecting his quality of life, as evidenced by his scores
questionnaire includes 25 items with 7 possible responses on the VascuQol. Of primary importance was establishing an
listed in the order of decreasing impairment. Each item individualized, comprehensive exercise program.
is scored from 1 (most impaired) to 7 (least impaired). A
total score is calculated by dividing the total of the item Impaired Aerobic Capacity/Endurance
scores by 25. Each item is classified into 1 of 5 domains: Associated With Cardiovascular Pump
physical activity, pain, psychological well-being, symptoms, Dysfunction, Specifically Peripheral
and social activity. The domains are scored by totaling Vascular Dysfunction
the scores of all items in the domain and dividing by the
number of questions in the domain. Mr. Eagle’s total score Mr. Eagle had a long-standing diagnosis of PAD that, by
of 2.96 indicates significant impact of PAD on his quality of his ABIs and MRA results and significant need for revascu-
life. His scores are lowest in the domains of physical activ- larization over the last decade, was severe. His LE skin and
ity, psychological well-being, and social activity, which are circulatory changes, history of arterial ulcer, ankle pressures,
consistent with his subjective history. Because the measure and pain ratings during exercise that recovered with rest
has been shown to be responsive to change11 and one of Mr. were evidence of his peripheral vascular system impairment.
Eagle’s main complaints is around his quality of life, he will He also carried diagnoses of CAD and cerebrovascular
complete this questionnaire at regular intervals in order disease and was therefore at significantly higher risk for
to monitor change in quality of life with physical therapy cardiovascular events and death as compared to the healthy
intervention. adult population. He had several cardiovascular risk factors
that would be important to address, and he had received no
comprehensive education or exercise intervention to address
his disease thus far in the course of his disease. It would be
Pain important to address these issues with education regarding
The Claudication Pain Rating Scale12 was used to quantify skin care and risk factor management, as well as a compre-
Mr. Eagle’s pain during activity. He reported a pain rating hensive exercise program as mentioned previously.
of 1 (minimal discomfort) within 40 seconds of slow-paced
walking on the 6MWT. His rating increased to a pain rating
of 4 (unbearable) at 144 feet before a rest was required. Disability, and Health Model of Disability
See ICF model on page 277.
Clinician Comment Mr. Eagle independently
walked until his pain was unbearable, which often discour- Prognosis
ages these patients from walking any distance. His pain fur- Mr. Eagle’s prior surgical history, medical history, vascu-
ther supports his significant impairment in walking distance lar labs, and physical therapy evaluation all indicated severe
and time and helps the PT to provide an appropriate exer- PAD. Research has shown that exercise improves walking
cise prescription using the Claudication Pain Rating Scale. distance and time in patients with IC,13-15 and strategies to
enhance long-term adherence with a home walking program
should be incorporated.15 Mr. Eagle was motivated to begin
a structured exercise program, and it was believed that he
EVALUATION would be able to achieve his goals of increased community
ambulation and return to social activities through increas-
ing walking time and distance. He had established relation-
Diagnosis ships with his PCP and cardiologist for follow-up care for his
Mr. Eagle was referred to physical therapy with the medi- PAD and had exhibited excellent compliance with medical
cal diagnosis of PAD. His subjective complaints and objective recommendations and follow-up since his diagnosis. It was
findings suggested the following 2 practice patterns. anticipated that he would be compliant with recommenda-
tions regarding follow-up for his hypertension and appropri-
Impaired Aerobic Capacity/Endurance ate skin care to decrease his risk of wounds and associated
Associated With Deconditioning complications.
Mr. Eagle’s main complaint was claudication limiting his It was anticipated that he would be able to progress to an
community-level activities, and as a result, he was experienc- independent home walking program and maintenance skin
ing progressively worsening quality of life. His examination care program once he demonstrated knowledge of risk factor
confirmed that he was deconditioned, as evidenced by his management and independence with his exercise program.
ICF Model of Disablement for Mr. Eagle

Health Status
• Moderate to severe PAD
• Hypertension
• Had multiple surgical interventions to address PAD
• Had transient ischemic attacks
• Had left heel arterial ulcer

Function
• Walking distance limited to • Unable to shop
• Impaired blood flow to one block • Avoids social activities
extremities, especially • Difficulty with stairs due to decreased walking
during exercise tolerance
• Altered gait
• Claudication with walking

• Age = 67 years • Accessible 1-story home
• Family history of cardiovascular disorders
• 70 pack-year history
• Nonsmoker for 16.5 years
• Rewarding work
• Enjoyed using the Internet
• Followed a low-cholesterol diet
• History of poor exercise compliance
278 Chapter 7
Plan of Care 2. Patient will be able to walk around the block comfort-
ably with his grandson, with standing rests as needed.
Intervention 3. Patient will report improved health-related quality of
life.
Therapeutic exercise to address aerobic capacity and
patient education, as detailed next. 4. Patient will verbalize understanding of and confidence
with independent PAD management.
Clinician Comment Of paramount impor-
36 visits, 3 times per week over the course of 12 weeks tance is that Mr. Eagle understands and independently fol-
lows the recommended parameters of his walking program;
this will be critical for his long-term independent disease
Clinician Comment Evidence shows that management. The minimal clinically important difference
patients with IC should partake in walking programs 3 to
in the 6MWT is 86 meters,16 so Mr. Eagle would need to
5 times per week, and duration of the supervised compo-
improve his 6MWT by 100% in order to establish a signifi-
nent of the program should be at least 12 weeks in order
cant change. This may take at least 8 weeks. Although pain
to ensure increases in maximum and pain-free walking
is Mr. Eagle’s limiting factor to mobility, this is incorporated
distance.1,13 If this frequency of care is not feasible, fre-
into the goals for independent use of the Claudication Pain
quency closest to 3 times weekly over 12 weeks would be
Rating Scale, maximum walking distance, and improved
recommended.
6MWT distance, so a specific claudication pain goal is not
included. Mr. Eagle verbalized an avoidance of intersec-
tions because of his slow gait. Research has shown that the
Anticipated Goals average steady state gait velocity at a pedestrian crosswalk
is 1.36 ± 0.24 m/s regardless of intersection width.17 This
1. Patient will be independent with a self-paced walking
gait speed was incorporated into the goals so that Mr. Eagle
program at least 3 times per week using the Claudication
could function more easily in the community and return to
Pain Rating Scale in order to improve aerobic capacity
going out for dinner with his wife at various downtown res-
and progress his exercise program into the community
taurants requiring distant parking and negotiation through
(1 week).
pedestrian intersections.
2. Patient will demonstrate improved functional mobil-
ity and aerobic capacity on his 6MWT to allow him to
perform IADL and short-distance community mobility
Discharge Plan
more easily (8 weeks).
It was anticipated that Mr. Eagle would be discharged
3. Patient will improve his maximum walking distance
from physical therapy with an independent exercise program
to 500 feet in order to progress toward independent
to continue on his own for the long term.
community-level ambulation distances (8 weeks).
4. Maximum walking speed will be equal to or greater than
1.3 m/s (2.90 mph) to allow him to cross the street safely
before the light changes in the community (12 weeks).
INTERVENTION
5. Patient will demonstrate improved quality of life as
evidenced by a 20% improvement in his VascuQol total Coordination, Communication, and
score (total score to at least 4.36) (8 weeks).
Documentation
6. Patient will verbalize understanding of the benefits of
exercise in PAD, the importance of a long-term inde- The initial examination findings and physical therapy
pendent walking program, importance of meticulous plan of care were sent to Mr. Eagle’s cardiologist and PCP.
skin care to decrease risk of wounds and infection, the In particular, Mr. Eagle’s resting hypertension and hemody-
importance of continued adherence to cardiovascular namic response to low-level activity were noted so that the
risk management interventions and situations neces- doctor may consider pharmacologic titration of Mr. Eagle’s
sitating immediate medical care in order to progress his BP medications.
exercise program independently and to control his risk
of wounds and cardiovascular events (1 week). Patient-/Client-Related Instruction
Expected Outcomes (12 weeks) • Encouragement to follow-up with his cardiologist
1. Patient will be able to complete grocery shopping and regarding his hypertension as soon as possible, and
partake in a weekly outing for dinner with his wife to a regarding the importance of medication compliance
restaurant of his choice. with antihypertensives
• Information on the pathophysiology, prognosis, and
treatment of his disease process through verbal educa- Clinician Comment Mr. Eagle is new to a
tion and the provision of several reputable educational structured exercise program, so making it feasible and
websites for him to review at his convenience, given his tolerable for him is very important. Working together with
interest in using the Internet him to establish appropriate interval length based on use of
the Claudication Pain Rating Scale, and tolerable number
• Pain monitoring and exercise pacing using the
of intervals per day, would hopefully help him to ease into
Claudication Pain Rating Scale
a walking program and maximize adherence. The concern
• Strategies for skin care: daily visual inspection, skin would be if the program were too difficult or too painful,
hygiene, and moisturizing, immediate medical follow- adherence may understandably be an issue. His gait speed
up in the event of any wound, no matter how small, and beginning the program was very slow, and his time and
appropriate footwear to avoid pressure points and dur- distance walked was low, making it quite easy to become
ing every exercise session discouraged by the program. Encouragement that the evi-
• Avoidance of LE elevation or compression dence supports progression of walking time and distance
with this type of walking program should help, as well as
• Importance of continuation of nonsmoking status and
highlighting small progressions of interval time or number
avoidance of second-hand smoke
as steps in the right direction. At least 3 sessions per week
should be supervised sessions, and encouraging Mr. Eagle
Procedural Interventions to increase independence with another 2 sessions would
help to establish independence and confidence with his
Therapeutic Exercise Prescription program. Any barriers to progression to an independent
program would likely declare themselves, and they could be
Aerobic Capacity Training addressed appropriately during the episode of care.
Mode
Interval walking
Intensity
Self-paced walking speed to prolong onset of symptoms REEXAMINATION
for as long as possible, with the eventual goal of walking at a
speed that elicits symptoms within 3 to 5 minutes. Continue Subjective
to walk at moderate intensity (2 on the Claudication Pain
Rating Scale), and stop if symptoms become intense (3). Mr. Eagle reported that he was able to walk for longer
Duration distances and times without requiring rest. Just the previous
Total walking time initially 15 minutes, progressing to week, he had surprised his wife and took her to dinner at
30 minutes, as tolerated their favorite restaurant for the first time in 3 years, which
required parking in a lot across the street and negotiat-
Frequency
ing through a pedestrian intersection. He was able to walk
3 to 5 times per week, including supervised sessions
around the block with his grandson slowly with minimal to
Description of the Intervention moderate discomfort, and his grandson agreed to walk with
Mr. Eagle will need to perform interval walking initially him, rather than bike, so that Mr. Eagle could pick a com-
because his walking ability was severely limited in terms fortable pace and rest as needed. He had just gone grocery
of speed and duration. Given that his maximum walking shopping with his wife on the weekend, and was able to pace
time on initial exam was 86 seconds, his intervals will be himself through the store for 1 hour, with minimal discom-
shorter than that as we do not want him to walk to maxi- fort, resting as needed as his wife shopped. He reported that
mum intensity on the Claudication Pain Rating Scale. In the he was managing to walk twice per week on his own in addi-
first several weeks of treatment, he may need to walk at least tion to the supervised program at the clinic, and his wife had
10 to 15 intervals per day to achieve a walking duration of been walking with him, which was a great motivator for him.
15 minutes. As he progresses, length of time of each interval His total walking time per independent session was 20 min-
and number of walking intervals will increase to gradually utes, in intervals of just under 4 minutes. He felt comfortable
improve his total walking time to 30 minutes daily. using the Claudication Pain Rating Scale independently,
and carried a copy with him in his pocket as he walked. He
reported feeling improvement in his health status and feeling
that his quality of life was improving.
280 Chapter 7
Objective episode of care. His aerobic capacity significantly improved
with physical therapy intervention, as evidenced by his
Integumentary Intact to the LEs, improvement in 6MWT score and gait speed, which both
unchanged exceeded the minimal clinically important difference for
each measure.16,18 Mr. Eagle’s resting BP was lower at reex-
Circulation Pulses and capillary amination, which reflected the fact that he had followed up
refill unchanged from with his cardiologist, who had titrated his antihypertensive
initial examination regimen. His BP and HR response to this workload was still
Aerobic capacity and 6MWT exaggerated, although less so than at initial examination,
endurance and given his resting BP was lower, so was his peak BP.
Mr. Eagle’s maximal walking speed had not met his goal of
Average gait speed 0.86 m/sec (1.92 mpm)
1.3 m/sec, but it was close and he was no longer reporting
Average energy expenditure 2.5 METs difficulty negotiating the main pedestrian intersection in
Time to claudication onset 1 minute, 15 seconds his town. His quality of life improved as evidenced not only
by his subjective report, but by the VascuQol score at reex-
Distance to claudication 154 feet (46.9 m) amination, which was 157% that at initial examination.
onset
Maximum walking time 3 minutes, 15 seconds
Maximum walking distance 512 feet (148.1 m)
Assessment
Mr. Eagle’s aerobic capacity, walking times, and distances
Total walking distance 726 feet (221.3 m),
had improved and he had returned to community-level activ-
including 2 rest breaks
ities as compared to initial evaluation. He had met his own
of 56 and 47 seconds
personal goals and felt that his quality of life had improved
Resting HR standing 76 bpm significantly. He had met all of his physical therapy goals with
Peak HR 98 bpm the exception of that for maximum walking speed, although
he reported no difficulty negotiating the main pedestrian
Resting right brachial BP 128/84 mm Hg intersection in his town at the time of reexamination. He was
Peak right brachial BP 148/90 mm Hg independent with his walking program and could verbalize
how to appropriately progress it. He continued to be compli-
Postexercise ankle BP 50% lower than rest- ant with all risk factor management recommendations.
ing value; 6 minutes,
30 seconds to recover Plan
to baseline Mr. Eagle was ready for discharge from therapy, with
Maximal walking speed 1.26 m/sec (2.82 mph) continuation of an independent home exercise program and
self-management program.
Work (Job/School/Play/Leisure)
King s College Vascular Quality of
OUTCOMES
Life Questionnaire (VascuQol)
Discharge
Total score 4.65/7 Mr. Eagle met all goals established at the time of his initial
Physical activity score 4.52/7 evaluation, with the exception of maximum walking speed
of 1.3 m/sec, and had made clinically significant gains both
Pain score 5/7 in walking speed and 6MWT. He was independent with
Symptom score 5.1/7 skin care, cardiovascular risk management, and his exercise
program. He could verbalize understanding of situations
Psychological well-being score 4.3/7 that would require immediate medical follow-up. Mr. Eagle
Social activity score 4.2/7 would continue his home exercise program, walking 3 to
5 times per week, with progression to walking at an inten-
sity that elicited onset of claudication symptoms within 3 to
5 minutes, continuing to walk with moderate pain, stopping
Clinician Comment Mr. Eagle’s circulation if the pain becomes intense, for 30 to 50 minutes per session.
and integumentary integrity remained unchanged, but
He was encouraged to continue his program for the long
it was important to reexamine it to ensure there was no
term, if possible, and follow up with physical therapy or with
deterioration, and this had been monitored throughout the
his physician as indicated.
5. Gosnell AL, Nedorost ST. Stasis dermatitis as a complication of
Clinician Comment Although Mr. Eagle had amlodipine therapy. J Drugs Dermatol. 2009;8(2):135-137.
shown improvements in all areas, he still had impairments 6. Comer C, Redmond A, Bird H, Conaghan P. Assessment and man-
agement of neurogenic claudication associated with lumbar spinal
in walking speed, aerobic capacity, and quality of life, and
stenosis in a UK primary care musculoskeletal service: a survey
was still walking distances less than that required for full of current practice among physiotherapists. BMC Musculoskelet
community ambulation. Given the severity of Mr. Eagle’s Disord. 2009;10:121.
PAD, it was anticipated that all of these impairments would 7. Montgomery P, Gardner A. The clinical utility of a six-minute walk
continue to improve, although they may not be expected test in peripheral arterial occlusive disease patients. J Am Geriatr
Soc. 1998;46(6):706-711.
to return to age-matched normative values. Long-term
8. Troosters T, Gosselink M, Decramer M. Six minute walking dis-
adherence to his self-management plan would be impera- tance in healthy elderly subjects. Eur Respir J. 1999;14:270-274.
tive for lifelong disease management. Mr. Eagle had shown 9. Bohannon RW. Comfortable and maximal walking speed of adults
compliance with medical recommendations and follow-up aged 20-79 years: reference values and determinants. Age Ageing.
since his PAD diagnosis, as well as throughout his physical 1997;26(1):15-19.
10. Goodman CC, Fuller KS. Pathology: Implications for the Physical
therapy episode of care; therefore, his motivation and excel-
Therapist. 3rd ed. St. Louis, MO: Saunders Elsevier; 2009.
lent compliance were anticipated to continue. 11. Morgan M, Crayford T, Murrin B, Fraser SC. Developing the vascu-
lar quality of life questionnaire: a new disease-specific quality of life
measure for use in lower limb ischemia. J Vasc Surg. 2001;33(4):679-
687.
REFERENCES 12. van Asselt AD, Nicolaï SP, Joore MA, et al. Cost-effectiveness of
exercise therapy in patients with intermittent claudication: super-
1. Norgren L, Hiatt W, Dormandy J, Nehler M, Harris K, Fowkes FG. vised exercise therapy versus a ‘go home and walk’ advice. Eur J
Inter-society consensus for the management of peripheral arterial Vasc Endovasc Surg. 2011;41(1):97-103.
disease (TASC II). J Vasc Surg. 2007;45(1 Suppl S):S5-S67. 13. McDermott MM, Ades P, Guralnik JM, et al. Treadmill exercise and
2. Cherr G, Wang J, Zimmerman P, Dosluoglu H. Depression is asso- resistance training in patients with peripheral arterial disease with
ciated with worse patency and recurrent leg symptoms after lower and without intermittent claudication: a randomized controlled
extremity revascularization. J Vasc Surg. 2007;45:744-750. trial. JAMA. 2009;301(2):165-174.
3. Hareendran A, Bradbury A, Budd J. Measuring the impact of 14. Zwierska I, Walker RD, Choksy SA, Male JS, Pockley AG, Saxton
venous leg ulcers on quality of life. J Wound Care. 2005;14(2):53-57. JM. Upper- vs lower-limb aerobic exercise rehabilitation in patients
4. Hirsch A, Haskal Z, Hertzer N, et al. ACC/AHA 2005 guidelines for with symptomatic peripheral arterial disease: a randomized con-
the management of patients with peripheral arterial disease (lower trolled trial. J Vasc Surg. 2005;42(6):1122-1130.
extremity, renal, mesenteric, and abdominal aortic): executive 15. Armstrong DG, Lavery LA, Wu S, Boulton AJ. Evaluation of
summary a collaborative report from the American Association removable and irremovable cast walkers in the healing of dia-
for Vascular Surgery/Society for Vascular Surgery, Society for betic foot wounds: a randomized controlled trial. Diabetes Care.
Cardiovascular Angiography and Interventions, Society for 2005;28(3):551-554.
Vascular Medicine and Biology, Society of Interventional Radiology, 16. Wise R, Brown CD. Minimal clinically important differences in
and the ACC/AHA Task Force on Practice Guidelines (Writing the six-minute walk test and the incremental shuttle walking test.
Committee to Develop Guidelines for the Management of Patients COPD. 2005;2(1):125-129.
With Peripheral Arterial Disease) endorsed by the American 17. Fugger TJ, Randles B, Stein A, Whiting W, Gallagher B. Analysis
Association of Cardiovascular and Pulmonary Rehabilitation; of pedestrian gait and perception-reaction at signal-controlled
National Heart, Lung, and Blood Institute; Society for Vascular crosswalk intersections. Transportation Research Record.
Nursing; TransAtlantic Inter-Society Consensus; and Vascular 01/2000;1705(1):20-25. DOI:10.3141/1705-04.
Disease Foundation. J Am Coll Cardiol. 2006;47(6):1239-1312. 18. Puthoff ML. Outcome measures in cardiopulmonary physical
therapy: gait speed. Cardiopulm Phys Ther J. 2008;19(1):17-22.
Individuals With
8
Ventilatory Pump Disorders
CHAPTER OBJECTIVES CHAPTER OUTLINE

• Identify the components of the thoracic cage and the • Biomechanics of Ventilatory Pump Dysfunction
dimensions of movement possible. ◦ Inspiration
• Describe the sequences of muscular contractions and ◦ Expiration
chest wall movements that accompany inspiration and
expiration. ◦ Accessory Muscle Actions
• Outline the mechanisms that monitor the levels of arte- • Neuromuscular Innervation/Central Control of
rial carbon dioxide (CO2) and oxygen (O2), and the Breathing
changes in ventilation that are prompted. • Ventilatory Pump Physiology
• Contrast the effect of altered length-tension of the • Epidemiology of Ventilatory Biomechanical Pathology
diaphragmatic muscle fibers in patients with chronic ◦ Age-Related Changes and Ventilatory Pump
obstructive pulmonary disease (COPD) and patients Function
with neuromuscular weakness.
◦ Incidence and Prevalence of Pathology Affecting
• List age-related changes that occur in ventilation. Ventilatory Pump Function
• Discuss anatomical variations or injuries that can con- ▪ Chronic Obstructive Pulmonary Disease
tribute to altered chest wall compliance. Pathology Affecting Ventilatory Pump Function
• Explain the physiologic basis for interventions to ▪ Neuromuscular Conditions Affecting Ventilatory
decrease ventilatory load and those to improve ventila- Pump Function
tory muscle capacity.
▪ Musculoskeletal Disorders Affecting Ventilatory
• Discuss the factors that might indicate a life-long man- Pump Function
agement of respiratory impairment needs to occur and
identify the possible components of management to be • Pathophysiology of Ventilatory Pump Disorders
considered. ◦ Mechanical and Physiologic Limitations to
• Compare and contrast altered ventilatory pump consid- Ventilation
erations in patients with nonprogressing neuromuscular ▪ Factors Related to Ventilatory Load
disorders and those with progressing neuromuscular ▪ Factors Related to Ventilatory Capacity
disorders.

284 Chapter 8
◦ Pathophysiology and Complications in Ventilatory of motion created and thereby increase the contraction of
Pump Disorders respiratory muscles.1 CO2, a byproduct of metabolism, also
▪ Chronic Obstructive Pulmonary Disease: increases with activity and stimulates breathing through cen-
Pathophysiologic Consequences and tral and peripheral chemoreceptors.2 When there is ventilato-
Complications ry pump dysfunction, individuals may have insufficient O2 to
supply energy for movement. They may choose to move more
▪ Neuromuscular Conditions: Pathophysiologic slowly or limit activity to conserve energy. Poor ventilation can
Consequences and Complications also lead to CO2 retention and respiratory acidosis.3 In some
▫ Acute Conditions cases the ability to breathe may be so impaired that there is
- Spinal Cord Injury, Guillain-Barré inadequate ventilation to support resting energy metabolism.
Syndrome, and Myasthenia Gravis These individuals will require mechanical ventilation. Thus,
ventilation is essential for life and the ability to enhance ven-
- Stroke tilatory capacity is critical to support activity and movement.
▫ Progressive Conditions
- Duchenne Muscular Dystrophy
- Multiple Sclerosis and Parkinson’s Disease BIOMECHANICS OF VENTILATORY
- Post-Polio Syndrome PUMP DYSFUNCTION
▫ Ventilation Limitations to Exercise in Chronic
Neuromuscular Disease The biomechanics of ventilatory pump function are
dependent on the structure and function of the thoracic
▫ Summary: Pathogenesis and Consequences of musculoskeletal and nervous systems. Additionally, lung
Neuromuscular Incompetence tissue must be free of disease to ensure proper mechanics of
▪ Musculoskeletal Disorders: Pathophysiologic breathing. The thoracic musculoskeletal system has a skeletal
Consequences and Complications portion and a muscular component. The skeletal system, or
• Examination of Ventilatory Pump Disorders the thoracic cage, is composed of a rib cage, formed by the
12 pairs of ribs, the sternum (breast bone), costal cartilages,
◦ Patient/Client History and the 12 thoracic vertebrae. The ribs are articulated to a
◦ Systems Review thoracic spine posteriorly by the costovertebral and costo-
◦ Tests and Measures transverse ligaments.4,5 The sternum is composed of 3 parts:
a manubrium, a body, and the xiphoid process and is loosely
▪ Posture supported by its attachment to the clavicles and has flexible
▪ Ventilation and Respiration/Gas Exchange costal cartilage articulations with the ribs. The 12 ribs have
▫ Chest Wall Movement 3 classifications; true ribs (ribs 1 to 7), false ribs (ribs 8 to 10)
and floating ribs (ribs 11 and 12). The true ribs attach directly
▫ Respiratory and Breathing Pattern to the sternum through their own costal cartilages and the
▫ Auscultation false ribs are joined to the rib just above through interchon-
▫ Airway Clearance dral cartilaginous attachment. Floating ribs do not attach to
the sternum and simply end anteriorly.4
▪ Cranial Nerve Integrity
The thoracic cage serves to protect the underlying vital
▪ Aerobic Capacity organs while remaining flexible and compliant to allow rib
▪ Ergonomics, Environmental, Home, and Work cage motion required for inspiration and expiration. The
Barriers thorax moves in 3 dimensions: anterior-posterior, superior-
inferior, and lateral costal expansion.6,7 Posteriorly, small
• Evaluation, Diagnosis, and Prognosis
movements at the costovertebral axis of the first 7 ribs result
• Interventions in larger anterior displacement of the upper chest. The ster-
• References num moves anteriorly and superiorly, referred to as pump
handle motion. There is also lateral movement in the lower
thoracic cage as ribs 8 to 10 move up and out in a bucket
Ventilation is the movement of air in and out of the lungs.
handle motion.5 The inferior division of the thorax has no
Respiration is the actual exchange of gas at the alveolar capil-
skeletal floor and depends on diaphragm partitioning of
lary interface in the lungs. As gas is exchanged in the lungs,
internal organs and respiratory muscle mechanics to support
O2 is transported for use in the creation of energy for muscle
ventilation.8,9
contraction. It is the working muscle that determines how
much energy is required. The higher the muscular demand, The muscle component of the ventilatory pump acts on a
the greater the requirement for ventilation. When a person flexible thoracic cage to deform the chest wall during quiet
moves, afferent signals from the muscles send a message for inspiration. The muscles attached to the thoracic cage con-
the nervous system to respond in proportion to the amount tract in a coordinated way, optimizing muscle fiber length
Individuals With Ventilatory Pump Disorders 285
diaphragm has 2 halves, a right and left hemidiaphragm each
TABLE 8-1. PRIMARY AND innervated by a separate phrenic nerve.12 There are 3 parts
ACCESSORY MUSCLES OF VENTILATION to each hemidiaphragm: that costal, sternal, and lumbar
portion that merge together into a central tendon. The costal
PRIMARY MUSCLES OF VENTILATION AND portion arises from the lower 4 ribs and lower 6 costal car-
SEGMENTAL INNERVATION tilages to form the dome of each of the 2 hemidiaphragms.
Diaphragm (C3 to C5) The sternal portion originates on the posterior surface of
● Costal and sternal (C3 to C4) the xiphoid process. The lumbar portion arises from the
anterolateral aspect of the first 3 lumbar vertebrae, and is
● Crural (C4 to C5)
composed of the right and left crura. The crural portion of
Chest wall muscles the diaphragm stabilizes the central tendon while the costal
● Scalenes (C2 to C7) fibers shorten during contraction of the diaphragm.12
● Parasternal intercostal muscles (T1 to T5) During inspiration the diaphragm contracts and descends
in the thoracic cavity, increasing the volume vertically. As
● Interosseous intercostal muscles (T1 to T11)
the diaphragm continues to descend, it places increased
○ Internal intercostals pressure on the internal organs in the abdominal cavity.
○ External intercostals Intra-abdominal pressure rises as abdominal muscle tone
● Triangularis sterni supports the internal organs and opposes further descent
of the diaphragm. As intra-abdominal pressure rises sig-
Abdominal muscles (T5 to T12)
nificantly, further diaphragm contraction causes the costal
● Rectus abdominis fibers to moves the rib cage laterally and anteriorly.14,15
● External oblique Thoracic volume increases transversely as well as vertically
● Internal oblique and finally superiorly in a rhythmic and biomechanically
efficient sequence. The thoracic cage expands in a variety of
● Transverse abdominis
planes (Figure 8-1).13 As the chest wall expands the intratho-
ACCESSORY MUSCLES OF VENTILATION racic pressure is decreased relative to atmospheric pressure
● Scalenes (C2 to C7) ● Pectoralis major and air moves into the lungs.2
(C5 to T1) The chest wall muscles serve to stabilize and oppose nega-
● Sternocleidomastoid (C2
to C3) ● Serratus anterior
tive forces generated by diaphragm descent, while also acting
(C5 to C7) to lift the upper rib cage superiorly.14,15 The external intercos-
● Levator scapulae (C3 to tals attach from the rib above to the costochondral junction
C5) ● Latissimus dorsi of the rib below and continue into the anterior intercostal
Rhomboids (C5) (C6 to C8)
● membrane. The muscle fibers of the external intercostal
● Trapezius (C3 to C4)
● Levator costarum are angled and can lift the rib below upward toward the rib
(T1 to T12) above and assist in expanding the chest. These actions occur
● Erector spinae (C4 to L5)
● Quadratus lumbo- at higher levels of ventilation.12,15 The scalene muscles insert
● Pectoralis minor (C6 to C8) rum (T12, L1 to L3) on the superior surface of the first and second ribs and attach
to the transverse processes of the lower 5 cervical vertebrae
to lift and expand the rib cage. The parasternal muscles run
tension and biomechanical efficiency while expanding the between the sternum and the costal cartilages and lift the
chest in multiple dimensions. The muscles acting on the tho-
.
ribs in an anterior direction. Both scalene and parasternal
rax consist of primary muscles of ventilation and accessory muscles act to prevent retraction of the upper chest due to
muscles (Table 8-1). Three groups of muscles: diaphragm, the negative forces imposed by diaphragm descent.15 If there
chest wall muscles (scalene, parasternal, and intercostal is dyssynchronous recruitment of the 3 groups of muscles
muscles), and abdominal muscles work in an interdependent (diaphragm, chest wall muscles, or abdominal muscles),
manner as primary muscles of ventilation. Accessory muscles then ventilation becomes inefficient and abnormal breath-
are active during deep inspiration prior to coughing, when ing patterns appear.14 For example, paradoxical breathing,
metabolic demands are extreme (running or heavy repetitive the inward movement of the chest wall during inspiration,
work) or when severe respiratory disorders increase the work results from paralysis of the abdominal and intercostals mus-
of breathing.10,11 cles and dominance of diaphragmatic breathing (Figure 8-2).
Inspiration Expiration
The principal muscle of inspiration is the diaphragm, Quiet expiration is a passive event that does not depend
which is responsible for 70% change in tidal volume (TV).12 on muscle contraction. Once the respiratory muscles stop
The diaphragm rests in a dome shape in the thoracic cavity contracting, at the end of inspiration, the flexible chest wall
at the level of the fifth rib at the end of expiration.13 The relaxes and recoils along with the lung tissue. There is an
286 Chapter 8
A B
Figure 8-1. Respiratory muscle action on thoracic expansion. (A) Planes of respiration:
anterior-posterior, inferior-superior, and lateral. (B) Contraction of the costal fibers of
the diaphragm causes rib eversion and elevation. (Adapted from Frownfelter D, Dean
E, eds. Cardiovascular and Pulmonary Physical Therapy: Evidence and Practice. 4th ed. St.
Louis, MO: Mosby; 2006.)
Figure 8-2. Paradoxical breathing patterns. (A) Neck acces-

sory breathing (C2 to C4). (B) Diaphragmatic breathing
(C5 to C8). (Adapted from Frownfelter D, Dean E, eds.
A
Cardiovascular and Pulmonary Physical Therapy: Evidence and
Practice. 4th ed. St. Louis, MO: Mosby; 2006.)
increase in intrathoracic pressure and air leaves the lungs. becomes shallow and the work of breathing is increased.4,15
The elastic tendency of the lungs and chest wall ensure quiet Therefore, good inspiratory capacity (IC) and a compliant
expiration is a passive event. If the chest wall becomes stiff chest wall and lungs ensure expiratory volume is normal for
because of poor posture, abnormal muscle tone or pain asso- TV breathing. Aging, immobility, or lung disease may lead
ciated with trauma (rib fractures), arthritis or surgical pro- to a loss of elasticity in the chest wall and lung tissue with
cedures (sternotomy, thoracic cage incisions), then breathing potential decline in passive expiration.16
Forced expiration is important in healthy individuals for
coughing, shouting loudly, and to produce rapid air flow dur-
ing exercise. Lungs that lack elastic recoil (aging or disease)
may become hyperinflated such that active forced expiration
appears at rest or with minimal activity. The abdominal
muscles (rectus abdominis, external and internal obliques,
and transversus abdominis) and internal intercostals actively
contract to increase intra-abdominal and intrathoracic pres-
sure. The action of these muscles forcefully expels air rapidly
from the lungs. At the end of forceful expiration, the dia-
phragm will be extended further into the thoracic cavity.14
During periods of high ventilatory demand (severe respira-
tory disorders or exercise) this new position will improve the
length-tension of the myofibrils in the diaphragm and opti-
mize breathing.15 Forced expiration may be further assisted
by accessory muscles that compress the chest wall.10
Eccentric control of exhalation is important to produce Figure 8-3. Control of respiration. Schematic representation of the
control of the muscles of respiration. Direct corticospinal and bulbos-
speech.4 Expiration can be prolonged by gradual release of
pinal pathways to respiratory motoneurons and a putative connection
inspiratory muscle contraction until the chest wall and lungs between the motor cortex and the pontomedullary respiratory centers
are near functional residual capacity (FRC). Good eccentric are shown. The output from the motoneurons to respiratory muscles
control will allow most adults to vocalize a vowel sound for includes “pump” muscles that act on the chest wall and “valve” muscles
of the upper airway. Feedback from lung, airway, and muscle afferents
at least 15 seconds.17 Volitional eccentric control is also used
reaches the 3 levels cortex, medulla, and motoneurons through reflex
during pursed-lip breathing and singing and requires intact pathways. (Adapted from Butler JE. Drive to the human respiratory
nervous system over the glottis, the diaphragm, and other muscles. Respir Physiol Neurobiol. 2007;159(2):115-126.)
inspiratory and expiratory muscles.
control of exhalation (for speech, singing) and to build pres-

Accessory Muscle Actions sure prior to coughing and sneezing. Inspiration for sniffing
Accessory muscle actions are required when the demands is also volitional.22 Each muscle is innervated at a segmental
of breathing are elevated. Healthy individuals will recruit level (see Table 8-1) and may contract at will for volitional
neck accessory muscles (scalenes and sternocleidomastoid), breathing or for other functions (eg, arm work). Automatic
stabilize the spine, scapula and upper arm (erector spinae, pathways are distinct from volitional pathways and must be
trapezius, rhomboids, and quadratus lumborum) and use activated rhythmically and repetitively for normal ventila-
the reverse actions of the chest muscles (pectoralis major and tion.23 Input from reflex pathways from the lungs, airways,
minor and serratus anterior) to assist inspiratory effort.10,12 and muscle afferents all converge and are integrated to create
In addition, the abdominal muscles will increase in intensity a precisely timed and appropriate descending respiratory
and push the diaphragm upward to improve the biomechani- drive (Figure 8-3).
cal advantage for deep inspiration14 as well as act to stabilize The descending pathways, bulbospinal from the medulla
the trunk for postural control during activity.18,19 These (automatic) or corticospinal (volitional), are coordinated to
same muscles assist TV breathing at rest in individuals with activate chest wall muscles in a timed sequence that allows
respiratory disease or neuromuscular weakness.4 Expiration the breathing response to vary according to the needs of the
may also be assisted by the latissimus dorsi and pectoralis individual. Additionally, there is a neuromechanical match-
major when other respiratory muscles are compromised.20,21 ing of drive to individual muscles that is organized at the
spinal level to allow the most efficient breathing pattern to
emerge in the face of pathological conditions or injury to pri-
NEUROMUSCULAR INNERVATION/ mary muscles of ventilation.23 Inspiratory drive arises from
cyclical firing of neurons in the medulla and is regulated by
CENTRAL CONTROL OF BREATHING ascending reflexive nervous system input and chemical stim-
ulation of neurons. Chemoreceptors located on the ventral
Breathing is responsive to activity on an unconscious and lateral surface of the medulla sense the level of CO2 and
level. Adjustments are made after a variety of signals com- hydrogen ion (H+) in the cerebrospinal fluid. As the partial
municate with the respiratory center in the medulla. The goal pressure of CO2 rises, then there will be increased firing of
is to maintain homeostasis of the body’s pH. Unconscious the rate and depth of ventilation.2,22 Peripheral chemorecep-
control can be briefly regulated by volitional control from the tors in the carotid bodies sense the partial pressure of arte-
cerebral cortex. The volitional control is important for func- rial CO2 (PaCO2) and also the partial pressure of arterial O2
tions that require breath holding (defecation, parturition, (PaO2). Ventilation increases when there is an elevation of
and Valsalva maneuver for core stabilization) and eccentric PaCO2 or a decrease in PaO2 beyond threshold levels. When
288 Chapter 8
B Figure 8-5. Posture and diaphragmatic breathing in a person with

abdominal muscle weakness.
relationships of respiratory muscles are described using a

pressure-volume curve (Figure 8-4).11 Air pressure generated
during maximal inspiration (PImax) or expiration (PEmax)
serves as an indication of tension generated by the muscles
of inspiration and expiration. Terminology used to describe
respiratory physiology and breathing mechanics is provided
Figure 8-4. (A) Diaphragm contractile force and fiber length associated in Table 8-2 to assist the reader.
with lung capacities. The relationship between contractile force (percent- The diaphragm position at rest will engage actin and myo-
age of maximum) and resting length (% Lo) for isolated diaphragmatic sin cross bridges such that contraction results in movement
fibers. Contractile force is greatest close to the resting length (usually
higher). As lung volume is increased passively to total lung capacity (TLC), through an excursion of 12 to 13 mm as it descends during
the diaphragm shortens away from its Lo and loses force-generating quiet respiration and 28 to 30 mm during maximal inspira-
capacity. (B) Relationship between lung volumes and maximum pressure- tion.12 At the end of maximal inspiration, the diaphragm is
generating capacity. At TLC, maximum expiratory pressure (PEmax) is in its shortened position and cannot generate any more force.
highest and at residual volume (RV), peak inspiratory pressure (PImax) is
minimal. (Reprinted from Clin Chest Med, 22(4), Flaminiano LE, Celli BR, Once the individual maximally inspires, the lungs are at total
Respiratory muscle testing, pp 661-677, Copyright 2001, with permission lung capacity (TLC) and will hold about 6 L (5 L vital capac-
from W.B. Saunders.) ity [VC] and 1 L residual volume [RV]) in the young male of
average height.2 Pulmonary function testing is conducted to
evaluate ventilation. A variety of lung capacities and volumes
CO2 is chronically elevated, as occurs with COPD, then the may be examined. Maximal forced vital capacity (FVC) is the
individual becomes more dependent on peripheral chemo- volume of air that can be maximally inspired and expired.
receptor signals from drops in PaO2. This type of breathing The FVC can be measured and compared to norms for age,
control is referred to as hypoxic drive. Together both reflex- height, and gender to evaluate pulmonary status and respira-
ive and chemical signals work to adjust the descending neu- tory muscle function. If the lungs are healthy, the volume of
ral drive rate and depth of breathing. Individuals with COPD air moved may be used to infer ventilatory muscle perfor-
have elevated CO2 and also hyperinflated lungs, which signal mance. However, the diaphragm can lose the ability to gener-
an increase in central neural drive. The enhanced central ate force if the lungs are hyperinflated, as occurs with lung
drives recruits more respiratory muscle to assist in managing disease. In this case the diaphragm is flat and muscle fibers
a high mechanical load during ventilation. in a shortened state so a smaller volume of air is inspired
and less air is moved during an FVC maneuver. Likewise
if the abdominal muscles are weak or paralyzed (neuro-
VENTILATORY PUMP PHYSIOLOGY muscular disorders), the abdominal contents fall forward
and pull down on the diaphragm and compromise length-
The muscles of ventilation are influenced by length-ten- tension when the individual is sitting or standing upright
sion and force-velocity principles. The force generated by any (Figure 8-5). The result is a decrease in FVC below what is
muscle involved in breathing is a function of its initial resting expected (called “predicted FVC”).
length as well as the level of neural excitation.2,10,11 Lung vol- Since the diaphragm position is compromised in indi-
umes, air pressures, and air flow will affect respiratory muscle viduals with either severe COPD or with neuromuscular
mechanics. Measures of lung volume (length) and air pres- weakness, there is a loss of optimal length-tension that
sures (tension) and air flow (velocity) are used to infer respi- lowers the volume of air moved (decreased FVC) and pres-
ratory muscle performance.10 Graphically, the force-length sure generated (decreased PImax) during maximal effort.
TABLE 8-2. PULMONARY FUNCTION AND RESPIRATORY PERFORMANCE TERMINOLOGY

TERM AND ABBREVIATION DEFINITION/RELEVANCE
Vital capacity (VC) The maximum volume of air that can be expelled after a maximum inspiration
(ie, from TLC to RV).
Total lung capacity (TLC) The total amount of air in the lungs after a maximal inspiration.
TLC = RV + ERV + TV + IRV
Inspiratory capacity (IC) The maximal volume of air that can be inhaled (sum of TV and IRV).
Functional residual capacity The volume of air remaining in the lungs at the end of an ordinary TV expira-
(FRC) tion.
FRC = ERV + RV
Tidal volume (TV) The volume of air inhaled or exhaled during breathing (at rest or during exer-
cise).
Inspiratory reserve volume The maximum volume of air that can be inhaled to TLC over and above TV
(IRV) inspiration.
Expiratory reserve volume The maximum volume of air that can be exhaled from the end expiratory level
(ERV) or from FRC to RV.
Residual volume (RV) The volume of air remaining in the lungs after a maximal expiration.
Maximum voluntary ventila- The volume of air breathed when a person breathes as deeply and as quickly
tion (MVV) as possible for a given time (15 seconds). Usually extrapolated to what could be
breathed over 1 minute.
Forced expiratory volume in The volume of air released during the first second of a VC maneuver. This indi-
the first second (FEV1) cates the speed of air movement out of the lungs. Used to detect resistance to
lung flow or poor expiratory flow.
Peak expiratory flow rate The fastest speed of airflow in liters per second or liters per minute generated
(PEFR) during a maximal VC maneuver. This measure is used to detect any airway
restriction or loss of rapid expiratory flow due to decreased speed of expiratory
muscle contraction.
Peak cough flow rate (PCFR) A measure of speed of airflow in liters per second or liters per minute gener-
ated during rapid forced expiration such as occurs with coughing.
Normal PCFR = 6 to 20 L/sec or 300 to 700 L/min
Partial pressure of carbon The gas pressure of CO2 found in arterial blood.
dioxide (PaCO2) Normal PaCO2 = 35 to 45 mm Hg
End tidal CO2 (ETCO2) Provided the patient has a stable cardiac status, stable body temperature,
absence of lung disease, and a normal capnographic trace, ETCO2 approximates
the partial pressure of CO2 in arterial blood (PaCO2.) The measure is taken non-
invasively (without needles)
Partial pressure of oxygen The gas pressure of O2 found in arterial blood.
(PaO2) Normal PaO2 = 80 to 100 mm Hg
O2 saturation of hemoglobin The percentage of hemoglobin-carrying sites that are occupied by O2.
(SaO2) Fully saturated = 100%
Diffusion capacity (DLCO) The ability of the lungs to transfer gas (carbon monoxide) across the alveoli to
the pulmonary circulation. Used to detect lung tissue thickening or disease.
(continued)
290 Chapter 8
TABLE 8-2 (CONTINUED). PULMONARY FUNCTION AND RESPIRATORY PERFORMANCE TERMINOLOGY

TERM AND ABBREVIATION DEFINITION/RELEVANCE
Peak inspiration maximum Different terms are used to denote peak or maximal inspiratory pressure gen-
(PImax) or maximal inspiratory erated during a maximal inspiratory maneuver against occluded airflow. The
pressure (MIP) subject inhales maximally from a predetermined lung volume (RV or end tidal
volume). A negative pressure is generated and recorded in cubic centimeters or
centimeters of H2O.
Peak expiration maximum Different terms are used to denote peak or maximal expiratory pressure gen-
(PEmax) or maximal expira- erated during a maximal expiratory maneuver against occluded airflow. The
tory pressure (MEP) subject exhales maximally from a predetermined lung volume (TLC or end tidal
inspiratory volume). A positive pressure is generated and recorded in cubic cen-
timeters or centimeters of H2O.
Negative inspiratory pres- A measure of inspiratory muscle strength. The subject inhales against a device
sure/force (NIP/NIF) that occludes airflow. A negative pressure in generated and recorded in cubic
centimeters or centimeters of H2O. It may or may not be a maximal effort.
Minute ventilation (VE) The volume of air moved in 1 minute. Typically used to determine the ability of
the person to move air in and out of the lungs during exercise. VE = TV × RR
Inspiratory duty cycle; inspi- Method for detecting the increase in inspiratory muscle activation during the
ratory time/total time for respiratory cycle. Increase in Ti suggests the muscles of inspiration are working
one breath (Ti/T TOT ) harder and have the potential to fatigue. Denotes an increased work of breath-
ing.
Transdiaphragmatic pressure Difference between pressure generated at the esophageal level (pleural pres-
(Pdi) sure) and pressure generated at the gastric level (abdominal pressure). The
difference in pressure suggests the ability of the diaphragm to contract and
generate force.
Pressure at the level of the A pressure reading taken in the esophagus to detect pressure during various
esophagus (sometimes phases of the respiratory cycle and used to infer pleural pressure.
called PPl for pleural pressure
[Pes (Ppl)])
Pressure at the level of the A pressure reading taken in the stomach or gastric region to detect pressure
gastric region (sometimes during various phases of the respiratory cycle and used to infer intra-abdominal
called Pab for intra-abdomi- pressure.
nal pressure [Pgs (Pab)])
Mouth occlusion pressure Measure used to indicate central respiratory motor drive. Airway pressure
(P0.1) developed at the mouth that occurs 0.1 seconds after the onset of inspiration.
The airway is occluded at the mouth. The time parameter suggests that this
measure occurs before volitional contraction of respiratory muscles and reflects
nervous system activation.
Rapid shallow breathing Method used to determine volitional breathing ability. Breaths per minute divid-
index (RR/TV) ed by TV in liters (breaths/min/L). Normal = 50
Ventilatory muscle training Resistive training for the respiratory muscles; includes both inspiratory and expi-
(VMT) ratory muscle work.
Inspiratory muscle training Resistive training for the muscles responsible for inspiration.
(IMT)
Expiratory muscle training Resistive training for the muscles responsible for expiration.
(EMT)
Threshold loading maximum The highest resistive load that can be sustained for at least 2 minutes during
(TLmax) progressive incremental resistive loading test. Used to define the endurance
capacity of the respiratory muscles.
Poor IC leads to poor expiratory capacity since the lung and Ventilatory pump physiology changes and adapts to
chest wall recoiling forces are lower. During coughing in compensate for alterations in lung compliance (COPD,
individuals with disease or weakness, the abdominal muscles pulmonary fibrosis, and pulmonary edema), chest wall
may contract but since there is little air movement into and compliance (kyphoscoliosis, rib fracture, postsurgical pain,
out of the lungs, the flow generated may not be effective for developmental or musculoskeletal postural dysfunction) and
coughing for some individuals.24 neuromuscular conditions (Guillain-Barré syndrome [GBS],
Rapid contraction of respiratory muscles is essential for spinal cord injury [SCI], hemiplegia, cerebral palsy). A vari-
coughing to clearing mucus or other particulate matter. The ety of disorders may affect ventilatory pump physiology and
velocity of respiratory muscle contraction can be examined increase the work of breathing (Table 8-3). An individual
by measuring air flow, specifically peak expiratory flow rate with pathology may have the ability to compensate at rest
(PEFR) or peak cough flow rate (PCFR) in liters per second and during routine activity but as O2 demands are extended
(L/s) or liters per minute (L/min). Normal cough volumes are during exercise, there is usually increased RR and acces-
2.3 ± 0.5 L with a PCFR of 6 to 12 L/s or 300 to 700 L/min.24-26 sory muscle use once the TV is maximized. The next 2 sec-
An individual must have a minimum PCFR of 2.7 L/s for tions (see Epidemiology of Ventilatory Pump Disorders and
effective airway clearance.4,24 However, if there is lung dis- Pathophysiology of Ventilatory Pump Disorders sections)
ease and airway collapse restricts air flow, then the decrease will discuss the clinical presentation of common ventila-
in PEFR is not simply a reflection of respiratory muscle tory pump disorders and potential compensatory breathing
performance. Any drop in flow rate may also indicate a loss actions appearing in individuals presenting with age-related
of air flow due to restrictions in the outflow of air and may changes, primary lung disease, neuromuscular conditions,
occur with asthma, mucus or dynamic airway collapse from and chest wall limitations.
obstructive lung disease or aging.
Another test of flow rate is the forced expiratory volume
(FEV). The FEV1 is the volume of air that may be expelled EPIDEMIOLOGY OF VENTILATORY
during the first second of an FVC maneuver. About 80% of
the total FVC is usually removed from the lungs during this BIOMECHANICAL PATHOLOGY
time. Normally the FEV1/FVC relationship is between 70%
and 85% and values falling below 70% indicate obstructive
disease while values above 85% indicate restrictive disease.27
Age-Related Changes and Ventilatory
For individuals with neuromuscular conditions, when the Pump Function
FEV1/FVC falls below 60%, cough flow rates may be inade-
quate.4 All pulmonary functions (FVC, FEV1, and PEFR) and Age-related changes and pathology (COPD, neuromus-
respiratory pressure measures (PImax and PEmax) may also be cular disease, musculoskeletal disorders) may disrupt the
compared to normative standards for age, height, and gender. mechanics of normal, efficient breathing. The skeletal, pul-
These values will be 100% of expected or better if there is no monary, and neuromuscular systems undergo age-related
pathology interfering with ventilation. However, values that changes that affect the ability to ventilate (Table 8-4).30 The
fall below predicted levels are abnormal. Typically, the lower physiologic changes in the skeletal system include calcifica-
the percentage predicted, the worse the ventilatory impair- tion of the costal cartilages, arthritic changes in the joints
ment. These values may be reported as FVC% predicted, of the ribs and vertebrae along with decalcification of the
FEV1% predicted, PEFR% predicted, PImax% predicted or ribs. Many older individuals develop a barrel chest and/or
PEmax% predicted and are documented in the pulmonary thoracic kyphosis.16,31 In the pulmonary system, there is a
function test reports. reduced lung elastic recoil (alveolar compliance increases)
which contributes to early airway closure and decreased
O2 requirements for movement are met by increasing
FEV1. Air trapping leads to an elevation of the RV and FRC
ventilation, which is enhanced by increasing TV and respi-
(Figure 8-6), which results in hyperinflation and flattening
ratory rate (RR). Exercise increases the need for O2 and the
of the diaphragm, disrupting the mechanics of breathing.
body responds, driving up TV (from .5 to 2 to 3 L per breath)
The work of breathing increases as the lungs lose their elas-
and RR (16 to about 40 breaths per minute) to enhance the
ticity and the chest wall stiffens.32 The inspiratory muscles
minute ventilation (VE).1 The work of breathing increases
are less optimally aligned and contract at a higher percent-
according to the rate (RR) and depth of each breath (TV) as
age of maximum during exercise, which drives up the cost of
well as the level of contractile force and overall inspiratory
breathing.33 As a result respiratory muscle strength (PImax
time (Ti) within the total respiratory cycle (TTOT) or Ti/
and PEmax) and endurance (maximum voluntary ventilation
TTOT. VE increases as activity level is elevated. However, the
[MVV]) are reduced.30,34-37
work of breathing for any given submaximal activity requires
a higher VE if the individual is either older or deconditioned Additionally, there is a loss of pulmonary capillary bed
or has pathology.28 Therefore, physiologic monitoring of perfusion, increased physiologic dead space and ventilation
therapeutic exercise and testing aerobic capacity will also perfusion mismatch decreasing the gas transfer (diffusion:
assist in describing any ventilatory limitation and developing DLCO) and causing PaO2 to decline.38 In the nervous system,
a plan of care (POC) to address these.29 both the peripheral and central chemoreceptors lose their
292 Chapter 8
TABLE 8-3. CLINICAL CONDITIONS AND TABLE 8-4. AGE-RELATED CHANGES

VENTILATORY PUMP DYSFUNCTION AFFECTING VENTILATION
Primary Lung ● Obstructive lung disease BODY SYSTEM CHANGES
Diseases
○ Chronic bronchitis SYSTEM
○ Emphysema Skeletal Costal cartilage calcification
○ Cystic fibrosis system Narrowing of vertebral discs
○ Bronchiectasis Barrel chest due to↑ a-p diameter
○ Asthma ↑ Kyphosis due to vertebral fx/com-
pression
● Restrictive lung disease
Alter angulation of rib articulations
○ Adult respiratory distress
↑ Chest wall stiffness (↓ compliance)
syndrome
○ Bronchopulmonary Pulmonary Altered connective tissue structure
dysplasia system ↓ Elastic recoil (↑ compliance)
○ Pulmonary fibrosis ↓ Alveolar-capillary surface area
○ Sarcoidosis ↓ Small airway diameter (bronchioles)
○ Asbestosis ↓ Force expiratory flow (FEV1)
↑ RV
○ Bronchiolitis obliterans
↓ FVC
○ Pneumoconiosis
↓Ventilation-perfusion matching
● Adverse medical conditions
↓ PaO2
○ Pleural effusions
↓ DLCO
○ Empyema
↑ Pulmonary vascular resistance
○ Pulmonary edema
Neuro- ↓ PEmax (MEP)
○ Pulmonary emboli muscular ↓ PImax (MIP)
Neuromuscular SCI system
●
↓ MVV
Conditions
● Spinal muscular atrophy ↓ Central drive (P0.1)
● GBS Loss of type II fibers = ↑ work of
● Multiple sclerosis breathing
● Cerebral palsy fx: fracture.
● Myasthenia gravis
● Poliomyelitis/post-polio
● Muscular dystrophy
● Cerebral vascular accident
● Brain injury
● Amyotrophic lateral sclerosis
● Parkinson s disease
Chest Wall ● Postural dysfunction
Disorders
● Ankylosing spondylitis
● Trauma
● Rib fracture
Figure 8-6. Evolution of lung volumes with aging. ERV, expi-
● Burns ratory reserve volume; FRC, functional residual capacity; IRV,
● Postsurgical inspiratory reserve volume; RV, residual volume; TLC, total lung
capacity; VC, vital capacity. (Reproduced with permission of
● Arthritis the European Respiratory Society. Eur Respir J, January 1, 1999,
13(1):197-205.)
● Connective tissue disorders
Figure 8-7. Respiratory changes with aging. V/Q:
ventilation/perfusion. (Adapted from Hillegass EA,
Sadowsky HS, eds. Essentials of Cardiopulmonary
Physical Therapy. 2nd ed. Philadelphia, PA: W.B.
sensitivity to PaO2 and PCO2. The normal PaO2 declines 5 to Compared to younger counterparts, the older individual
10 mm Hg by age 70 or and averages 75 mm Hg.34 Because reaches higher VE than younger counter parts for a spe-
the chemoreceptors lose their sensitivity, the central drive cific submaximal activity. The older individual ventilates at a
(P0.1) at rest is depressed.39,40 These changes are accelerated higher lung volume and therefore must work against higher
after age 65 to 70.32 Age-related changes affecting ventilation pleural pressures and increased elastic load (due to chest wall
are summarized in Figure 8-7. stiffness) to sustain a deeper TV in order to achieve the same
Although we begin aging in our 20s, the aging effects submaximal work rate.34 The end-expiratory lung volume
on the pulmonary system are not observed to affect func- will be increased, trapping air and preventing full expira-
tion until age 60 or 70.16,31 Normally, the young, healthy tion (hyperinflation). Expiration in the older individual is
individual can exercise to maximal level without reaching assisted by higher levels of expiratory muscle contraction.
the limits of pulmonary function. VE is elevated during a As hyperinflation volumes are increased with progressive
progressive exercise test by increases in TV and RR. During work, the diaphragm is flattened and becomes less efficient
an exercise test to maximum, TV normally plateaus at about in generating contractile force. Eventually, as submaximal
60% of maximum O2 consumption (VO2max), after which activity increases in intensity, the frequency of breathing
the increase in VE is achieved by further increases in RR.1 (f or RR) also increases to a greater extent in the older per-
In the younger individual cardiac output limits further final son. The O2 consumption for the respiratory muscles may
maximal work rate. This is also true for the older individual require as much as 10% to 12% of the total VO2max.16,34
although lower HR max and cardiac output result in lower Despite the increase in the work of breathing, the elderly may
VO2max compared to younger individuals.41 have a diminished sensitivity to increased respiratory load
After age 70 there is evidence that VE limits may be that may or may not translate into higher levels of perceived
reached. Even those with superior fitness cannot attenu- breathlessness.43
ate age-imposed limitations to pulmonary ventilation at The impact of age-related changes to the pulmonary sys-
maximal exercise. McClaran et al32 demonstrated, in a tem on acute exercise can be improved with training.16,44
longitudinal study over 6 years, the impact of aging and For those older individuals who are sedentary or not highly
reduced ventilation on VO2max in 18 fit older individuals trained, aerobic training will lower ventilatory requirement
(67 to 73 years). During high-intensity exercise, the venti- for submaximal exercise and raise the VO2 max and VE
latory response (VE) was limited because of reduced TV at maximal exercise.45 These changes are primarily due to
component. As a result of a lower TV during exercise, RR improved O2 uptake in the peripheral muscle, lowering the
increases to compensate. There is an excessive elevation in relative ventilatory requirement.16 The physiological benefits
CO2 production (VCO2) that is due in part to an increased observed with training in the older individual translate to
respiratory muscle demand for breathing.42 Although mild greater improvements in older individuals with ventilatory
and moderate intensity exercise (< 60% of VO2max) is not pump limitations. Peripheral training effects and enhance-
affected by age-related changes in the pulmonary system for ment of VE serve as a basis for use of exercise training
the well-trained older individual, there are several reports in many individuals with ventilatory pump dysfunction.
documenting an increase in the work of breathing during Various forms of exercise training play a key role in improv-
submaximal work for those who are older and sedentary.16,34 ing functional status in older individuals who may also have
lung tissue disorders.
294 Chapter 8
TABLE 8-5. GOLD CLASSIFICATION SYSTEM FOR

SEVERITY OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
STAGE CHARACTERISTICS
0: At risk Normal spirometry
Chronic symptoms (cough, sputum production)
I: Mild COPD FEV1/FVC ‹ 70%
FEV1 greater than or equal to 80% predicted
With or without chronic symptoms (cough, sputum production)
II: Moderate COPD FEV1/FVC ‹ 70%
FEV1 greater than or equal to 30% to ‹80% predicted
IIa: FEV1 greater than or equal to 50% to ‹ 80% predicted
IIb: FEV1 greater than or equal to 30% to ‹ 50% predicted
With or without chronic symptoms (cough, sputum production, dyspnea)
III: Severe COPD FEV1/FVC ‹ 70%
FEV1 ‹ 30% predicted or FEV1 ‹ 50% predicted plus respiratory failure or clinical signs
of right heart failure
GOLD, Global Initiative for Chronic Obstructive Lung Disease; respiratory failure, arterial partial pressure of O2 ‹ 60 mm Hg with or without
arterial partial pressure of CO2 greater than or equal to 50 mm Hg while breathing air at sea level.
Reprinted with permission from Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS. Global strategy for the diagnosis, management,
and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Intiative for Chronic Obstructive Lung Disease (GOLD)
Workshop summary. Am J Respir Crit Care Med. 2001;163:125-1376.
Incidence and Prevalence of Pathology not fully reversible.”50 The degree of air flow limitation is
assessed by FEV1 and describes disease severity. Individuals
Affecting Ventilatory Pump Function are classified as having mild, moderate, severe or very severe
based on criteria listed in Table 8-5. As the disease pro-
Many individuals seen by health professionals are older
gresses, activity is limited by symptoms of dyspnea, fatigue,
and also have pathology that affects ventilation. These condi-
and lower extremity (LE) weakness.51-54 Symptoms do not
tions may alter body homeostasis and may affect function. It
become overt until the FEV1 declines substantially (FEV1
is beyond the scope of this chapter to discuss every condition
< 50% predicted) or stage II COPD.52,55 The prevalence of
that may affect ventilation. However, the chapter will next
stage II COPD or higher is approximately 10% worldwide.56
discuss the incidence and prevalence of 3 major classifica-
Incidence of COPD is increased in those who are older,
tions or health conditions that may affect ventilatory pump
male, and smoke or have hazardous environmental expo-
function: COPD, neuromuscular disease, and musculo-
sures.57 Smoking will double the rate of loss of FEV1 as the
skeletal disorders. Following a discussion of incidence and
individual ages and smoking cessation in smokers will slow
prevalence of each condition will be an explanation of the
this decline.58,59 The prevalence of COPD is increased in
pathology and physiological consequences that influence
civilized countries where levels of smoking and life expec-
ventilatory pump function.
tancy are greater.60 Countries that are unable to manage the
Chronic Obstructive Pulmonary Disease spread of tuberculosis also have an increased prevalence of
Pathology Affecting Ventilatory Pump COPD within the population. Therefore, a variety of socio-
Function economic and regional factors influence the prevalence of
COPD.60 Genetics appear to play a role in the development of
Nearly 14 million adults in the United States (US) have COPD in some individuals.61 Alpha 1 antitrypsin deficiency
COPD. It is the fourth leading cause of death, responsible is a hereditary condition that results in the loss of an enzyme
for 1 in 20 deaths.46,47 Those with advanced COPD die from that protects the lungs. This hereditary condition occurs in
respiratory failure, and these individuals comprise 40% of 60,000 to 100,000 people with lung disease and comprises
all cases of chronic respiratory failure.48,49 According to the approximately 13% of individuals with emphysema.58,62 In
Centers for Disease Control and Prevention, approximately summary, a variety of factors influence the development of
75% of the deaths are due to smoking.47 COPD is defined COPD, a disease that ends in respiratory failure.48
as a “disease state characterized by flow limitation that is
Neuromuscular Conditions Affecting or experience breathlessness that is out of proportion with
Ventilatory Pump Function activity.81 The frequency of pulmonary complications in
those with rheumatoid arthritis has been reported to be as
Approximately 1.9% of the US population or high as 45%.82 Many of these individuals need surgery, which
5,596,000 people report some form of paralysis. Distribution further impairs breathing mechanics during the postsurgical
of individuals reporting weakness is as follows: stroke 29%, recovery period.83,84
SCI 23%, traumatic brain injury 4%, cerebral palsy 7%, Surgery and traumatic injury to the thorax (rib fractures,
post-polio syndrome (PPS) 5%, and other conditions 9% flail chest, vertebral and sternal fractures) may make breath-
(amyotrophic lateral sclerosis [ALS], GBS, myasthenia gravis, ing painful. Pain can limit deep breathing for up to 2 weeks
Parkinson’s disease, etc).63 There are numerous reports of post-event and interfere with coughing for up to 6 months.31
diminished lung capacities and impaired respiratory muscle After upper abdominal surgery, the VC may temporarily
function that coincides with level of disability in the major- decrease by 55% in part because of the effects of anesthesia.85
ity of neuromuscular conditions.31,64-70 Pulmonary function Anesthesia will depress the central nervous system, decrease
testing usually reveals a restrictive pattern that is confirmed diaphragm tone, and increase the FRC.86 When there is a
when FEV1/FVC > 85% predicted and FVC falls below 80% traumatic injury to the chest wall, lung tissue may be dam-
predicted.27,31 Additionally, declines in PImax and PEmax aged by pneumothorax, pleural effusions, and later empyema
values confirm weak respiratory muscles.3 Most individuals if infection occurs. Hemothorax occurs in 70% of individuals
with neuromuscular disease who have impaired breathing having chest trauma.85 Rib fractures occur in about 10% of
mechanics do not notice limitations to activity until mea- patients who have suffered a traumatic injury and are associ-
sures of FVC and strength (PImax and PEmax) drop below ated with a 35% incidence of pulmonary complications.87
50% predicted.71 However, these individuals rapidly fall into Risk for mortality after rib fracture is about 12% overall but
respiratory failure once these values reach 25% predicted. is much higher in the older individual.88 Ribs may fracture in
Respiratory failure and pneumonia are the major compli- 2 or more places and result in a “flail chest.” In this case, the
cations leading to increased morbidity and mortality in those chest wall is no longer stable and the injured portion moves
with neuromuscular disease.72-74 Almost all individuals with paradoxically. Lung contusion is typically associated with
ALS will die from respiratory failure.71 Respiratory failure this injury.89 Pneumonia will develop within contused seg-
and infection is the cause of death in 75% of individuals who ments in 50% to 70% of individuals, while 35% will develop
have Duchenne muscular dystrophy (DMD).31 After a stroke, empyema.85,90
between 50% and 90% die once they are intubated.72 The
majority of cases resulting in acute respiratory failure from
neurological conditions occur in individuals with GBS and
myasthenia gravis.72 Greater than 50% of those with GBS
PATHOPHYSIOLOGY OF
and myasthenia gravis will contract pulmonary conditions
and 15% to 30% will requiring mechanical ventilation.75,76
VENTILATORY PUMP DISORDERS
SCI is the most common cause of chronic ventilatory insuf- Pathophysiology results when an abnormal condition
ficiency in young adults.71 Sixty-seven percent of individuals disrupts the body structure and function of a specific bio-
with SCIs (C1 to T12; Grades A, B, or C77) have respiratory logical system (ie, digestive, respiratory, cardiovascular). The
complications in the initial weeks after injury.74 Thus, for impact of pathology on body structure and function influ-
individuals with neuromuscular conditions, it is critically ences activity participation differently in each individual.91
important to monitor the pulmonary function, specifically Contextual factors, such as access to quality rehabilitation,
FVC and measures of strength (PImax and PEmax) to prevent one’s adaptability to stress, age, fitness, and existing comor-
complications and identify interventions to reduce the effects bidities, will further define the eventual level of activity
of respiratory compromise.68,76,78 participation for an individual with a ventilatory pump dis-
Musculoskeletal Disorders Affecting order. Therefore, according to the Guide to Physical Therapist
Ventilatory Pump Function Practice, pathophysiology is defined as “the interruption of
normal processes important to physical functioning and
Musculoskeletal disorders may affect ventilatory pump activity participation critical to maintaining or returning to
function by restricting the movement of the chest wall. usual self-care, home management, work, community and
Therefore, these conditions are referred to as chest wall dis- leisure roles.”92(p 29) This broad definition goes beyond con-
orders (see Table 8-3). Approximately 6% of all individuals sideration of the disease state and encompasses the concept
with chronic respiratory failure have severe kyphoscoliosis.49 of health status. Today’s health care environment requires
Kyphosis, scoliosis or kyphoscoliosis are postural deformi- practitioners look at the total well-being and overall health
ties that can result from idiopathic causes, osteoporosis or condition as well as the degree to which any disease or injury
disease (ankylosing spondylitis [AS], arthritis, or neuro- impacts on participation in expected and desired life roles.
muscular conditions). Severe deformity can limit pulmo-
The pathophysiology of ventilatory pump disorders will
nary function.79,80 Approximately 32% of individuals with
be described in this section in 2 ways: First, the mechani-
idiopathic scoliosis have pulmonary symptoms either at rest
cal and physiologic disruptions that may limit ventilation
296 Chapter 8
Figure 8-8. Balance of capacity and load for ventilation. ADL, activities of daily living; ARDS, Adult Respiratory Distress Syndrome; CWE, chest wall
excursion measurements; DS, dead space; FEV1, forced expiratory volume 1 second; MEP, maximum expiratory pressure; MIP, maximum inspiratory
pressure; PEFR, peak expiratory flow rate; PO1, pressure occlusion 1 second; RR, respiratory rate; TLC, total lung capacity; TV, tidal volume; VC, vital
capacity; VE, minute ventilation. (Adapted from Vassilakopoulos T, Zakynthinos S, Roussos CH. Respiratory muscles and weaning failure. Eur Respir J.
1996;9:2383-2400.)
will be presented. Second, an explanation of the patho- affected by a disease or condition, but the impact on ventila-
physiology and complications of specific conditions (COPD, tion is specific to examination of factors related to ventilatory
neuromuscular conditions, and musculoskeletal disorders) load and capacity.
and the factors that affect activity participation will be
Factors Related to Ventilatory Load
discussed. Understanding how pathology may affect ventila-
tion should assist the health care professional in identifying Ventilatory load is the force that must be overcome to
which examinations will be important to assist in designing allow movement of gas in and out of the lungs. The factors
a POC aimed at restoring function. The POC may then be influencing load include lung tissue and chest wall elasticity
developed to address primary impairments directly resulting (compliance), pulmonary airway resistance, and VE.93 VE
from pathology that may lead to ventilatory pump dysfunc- (VE = TV × RR) varies according to activity demands and
tion (chest wall tightness, respiratory muscle weakness), or is lowest at rest (about 6 to 10 L/min) and highest during
the POC may include interventions to assist the individual maximal exercise (over 100 L/min).1 During quiet breathing
in compensating for or managing the ventilation disorder at rest about 75% of the breath reaches the gas-exchanging
(conditioning, breathing control strategies). regions (alveolar ventilation) of the lung while 25% is dead-
space ventilation and cannot participate in gas exchange.2
As the need to enhance ventilation increases with activity,
Mechanical and Physiologic VE is elevated by raising both the TV and RR. Eventually,
Limitations to Ventilation as exercise demands are extended, TV plateaus at about 2 to
2.5 L per breath. To achieve higher levels of activity, RR con-
The goal of the ventilatory pump is to create changes in tinues to climb above 40 breaths per minute. The respiratory
intrathoracic pressure that allow air to move between the muscle O2 utilization increases from about 3 mL O2/L at rest
lungs and the atmosphere in order to exchange O2 and CO2.2 to 4.5 mL/L (2% to 4% of total VO2) at peak exercise.94,95
Good gas exchange optimizes metabolism and stabilizes The respiratory muscles in the healthy individual are strong
blood gases to maintain homeostasis. Pathologic processes and well coordinated and can easily meet the increased load
may affect ventilation in 2 ways: either the load to the venti- imposed by exercise. Individuals with ventilatory pump dis-
latory muscles is increased or the capacity of the ventilatory orders are unable to increase TV effectively.1,28 RR increases
muscle is diminished (Figure 8-8).93 In many individuals earlier at lower, submaximal workloads. This pattern of ven-
both load and capacity are affected by pathology. The actual tilation increases the work of breathing and results in exces-
medical diagnosis may help the clinician identify systems sive dead-space ventilation.
A variety of pathologies may affect ventilatory load. In Factors Related to Ventilatory Capacity
pathology the cost of breathing for those with restrictive
Ventilatory capacity is the potential of the neuromuscular
lung disease (ie, pulmonary fibrosis) may require as much
system to work efficiently in a coordinated manner to move
as 25% of the O2 consumed throughout the body.95,96 This
the chest wall against the ventilatory load.93 Inspiratory
is because of a higher RR since the rate climbs excessively to
muscles are recruited repetitively in the most biomechani-
compensate for a severely diminished TV. Additionally, chest
cally efficient manner (see earlier section: Introduction-
wall stiffness and decreased lung compliance also require
Inspiration). The VE is adjusted so adequate gas exchange
respiratory muscles to generate higher forces to open the
can support activity.28 Capacity is dependent on respiratory
lungs. More intercostal and accessory muscles are recruited,
control (drive, neuromuscular transmission), breathing coor-
adding to energy cost of breathing.14 The individual with
dination, and ventilatory mechanics (muscular strength and
pathology will have an elevated RR, increased dyspnea
endurance; see Figure 8-8).93
scores, early onset of accessory muscle use, and possibly
oxyhemoglobin desaturation, if there is a ventilation/perfu- Respiratory muscles do not rest and must repetitively
sion (V/Q) mismatch resulting from increased physiologic contract with enough force to sustain breathing against
deadspace.1 elastic and resistive loads. The ability to sustain a load with-
out fatigue is called endurance. Like all skeletal muscles,
When dead-space ventilation increases, alveolar ventila-
the ability to generate and sustain contraction depends on
tion becomes compromised, limiting gas transfer from the
adequate energy supplies (O2, glucose, fatty acids, blood-
alveoli to the pulmonary capillaries. Compared to healthy
borne substrates, etc).93,101 Respiratory muscles that are well
persons, individuals with a ventilatory pump disorder reach
conditioned with good perfusion can extract O2 and glucose
higher VE at a given submaximal workload and require
from the blood and also use stored energy (creatine phos-
even greater respiratory muscle effort during activity.1,28,97
phate, adenosine triphosphate, glycogen, etc). However, if the
Higher VE with submaximal work also occurs because cel-
muscle is weak or deconditioned, then capacity is reduced.
lular adaptations are underdeveloped, resulting in inefficient
Abnormal breathing patterns demand higher levels of energy
oxidative capacity in the peripheral muscle.28 Mild impair-
that may not be sustainable. Nutritional support is crucial for
ments in ventilatory function (early neuromuscular disease
individuals using compensatory breathing patterns.102,103
or COPD) are most apparent during exercise.28 Interventions
Respiratory muscle fatigue occurs when either the energy
that reduce chest wall restriction (chest wall mobilization) or
supplies to the muscle are not adequate to meet the energy
offset poor oxidative capacity (energy conservation or aero-
required for contraction or when neuromuscular transmis-
bic training) may reduce the ventilatory load.4
sion is impaired. Either the individual slows activity and
Finally, ventilatory load may be elevated when airway
becomes less functional or mechanical ventilation is required
resistance is increased as a result of pathology. This can
when TV breathing cannot be managed at rest.
occur when there is a mechanical torsion and compression of
A variety of pathological processes may affect ventilatory
the bronchioles and vasculature (kyphoscoliosis, AS), when
capacity. It is important to remember that pathology causes
there is dynamic airway collapse or bronchospasm (COPD,
alterations in ventilatory muscle mechanics that increase
asthma) or when the individual develops a respiratory com-
respiratory muscle demands and limit endurance. This
plication (pneumonia, pneumothorax, effusion). Infections
means the inspiratory muscles work longer in the entire
may produce a fever that can reduce the performance of
respiratory cycle (Ti/TTOT) and they work at a higher per-
respiratory muscles.98 Individuals with infections and poor
centage of maximum (PI/PImax).104 This concept is referred
cough function may have excessive mucus in the airways,
to as tension time index (TTI = Ti/T TOT × PI/PImax). As
and those with lung tumors may have mechanical restric-
TTI increases, so does the energy requirement and the risk
tions obstructing the flow of air. These events all restrict air
for fatigue. Respiratory muscles fatigue when they reach
flow and increase the work of breathing.
a critical level and work above 40% of the PImax.101,104
Interventions for airway clearance, breathing control or
Interventions designed to strengthen the respiratory muscles
to correct posture may be offered to minimize the patho-
(ventilatory muscle training [VMT], proprioceptive neuro-
physiologic consequences resulting from these conditions.31
muscular facilitation [PNF]) or to improve the biomechanics
Effective coughing requires high flows to mobilize thick
of breathing (abdominal binder, posture alignment) may
secretions. Individuals with excess mucus who also have
reduce the TTI and enhance ventilatory capacity.13,105 In
excessive compliance and collapsible airways will need to
many cases, medical intervention is necessary to eliminate
learn alternative strategies, other than vigorous coughing,
the cause of respiratory muscle failure (sepsis, drug overdose)
to clear mucus. High pressures required to generate forceful
or to assist the individual through a problem like sleep-
air flow for coughing (2.7 L/s) contribute to airway collapse
induced hypoventilation (by offering noninvasive mechani-
and trapping of mucus.99 Individuals with decreased inspira-
cal ventilation). Clinicians working with the medical team
tory volume (neurological conditions) and poor capacity for
can assist by recognizing and reporting signs and symptoms
forced expiration will need to use cough-assist techniques to
or respiratory muscle incompetence (Table 8-6). Early inter-
create effective expulsion of air to clear mucus.100
vention with some form of mechanical ventilation improves
298 Chapter 8
and contributes to CO2 retention, increasing the risk for sleep
TABLE 8-6. SIGNS AND SYMPTOMS OF apnea in those with neurological conditions.109,110 Bulbar
RESPIRATORY MUSCLE INCOMPETENCE weakness and poor expiratory muscle function lead to aspi-
ration and decreased cough, contributing to onset of pneu-
SIGNS monia in those with neuromuscular conditions.67,75,76,111,112
● RR > 30 at rest Chronic Obstructive Pulmonary Disease:
● RPD > 3/10 (Borg Scale) at rest Pathophysiologic Consequences and
● VC < 20 mL/kg IBW Complications
● PImax > ‒30 cm H2O COPD arises from an inflammatory process stimulated
● PEmax > 40 cm H2O by foreign matter that enters the lungs. Normal airways are
protected by a mucociliary blanket that captures antigens
● PaCO2 > 50 mm Hg and moves them up and out of the lower airways until they
● PaO2 < 50 mm Hg (O2 saturation < 85%) reach the upper airways, where they can be expectorated or
coughed up. Foreign particles reaching the alveoli are small
SYMPTOMS
but must be managed by the cells of immunity (neutrophils,
● ↓ Level of alertness, sleepiness macrophages, eosinophils, etc). These cells will attract medi-
ators (protease, elastase, and histamine) to the region where
● Memory loss or change in cognition
an antigen resides and will digest the antigen. Normally,
● Headache alpha 1-antitrypsin protects the lung by inhibiting the action
● Shallow breathing of the mediators. However, in COPD there are reactive O2
species (due to smoke, pollution or chemicals from immune
● Excessive neck/accessory muscle breathing
cells) that enter the lung compartment and inhibit alpha
● Inability to lift head (supine) 1-antitrypsin, leading to a destruction of lung tissue.113 Thus
● Head bobbing (sitting) both oxidative stress and inflammation are partners in a
destructive pathophysiologic process in COPD. Some indi-
● Respiratory alternans
viduals may have a hereditary condition wherein the alpha
● Paradoxical breathing 1-antitrypsin is not produced in adequate amounts. In those
● Dyssynchronous breathing presenting with deficiency, the level of alpha 1-antitrypsin in
plasma is only 15% of normal. As a result there is excessive
● Inability to use arms for functional tasks
destruction of lung tissue by neutrophil elastase. Normally
● Blue/gray appearance neutrophil elastase is an immune system mediator designed
RPD: rating of perceived dyspnea; IBW: ideal body weight. to eradicate antigens but in excess destroys lung tissue if not
Reprinted with permission from Mehta S. Neuromuscular disease controlled by alpha 1-antitrypsin.61,114
causing acute respiratory failure. Respir Care. 2006;51(9):1016-1021. When there are recurrent inflammatory periods, destruc-
tion of alveolar walls becomes significant and damages parts
of the pulmonary vasculature. Destruction of alveolar walls
long-term survival for most patients who have impending decreases the lungs elastic capacity so air will move into the
ventilatory pump failure.68,106 lungs but does not meet a recoiling pressure required for
passive expiration. The person with COPD must actively
Pathophysiology and Complications in exhale using the respiratory muscles. This raises intratho-
racic pressure excessively. Air becomes trapped when high
Ventilatory Pump Disorders intrathoracic pressure affects fragile collapsible airways,
leading to hyperinflation and the development of bullae as
Alveolar hypoventilation, atelectasis, and pneumonia are
disease progresses. Since both the vascular and alveolar walls
the primary complications leading to death for individuals
are destroyed, there is a V/Q mismatch impairing gas trans-
with ventilatory disorders.31,74-76,107 Individuals with severe
fer and increasing the potential for hypoxemia.115 Low O2
lung disease or chronic chest wall deformities have high
results in pulmonary vasoconstriction, which shunts blood
elastic and ventilatory loads that cannot be sustained by the
away from underventilated areas to patent, well-ventilated
respiratory muscles.108 Ultimately, breathing becomes shal-
airways.2,116 This event, plus the destruction of portions of
low, increasing dead-space ventilation. Because the airways
the pulmonary vasculature, increase pressure within the
are also destroyed or deformed, the lung tissue collapses
vascular system. Hypoxemia stimulates greater red blood
and foreign matter becomes trapped, setting the stage for
cell production and may elevate hematocrit (55% to 60%),
pneumonia. Individuals having significant neuromuscular
increase the risk for thrombosis, and therefore also add to
disease will have alveolar hypoventilation due to neuromus-
the vascular load on the heart.114,116 Eventually the indi-
cular incompetence (weak respiratory muscles or deficient
vidual with COPD develops pulmonary hypertension and
neurotransmission).93,108 Dead-space ventilation is increased
cor pulmonale.115
TABLE 8-7. COMPLICATIONS ASSOCIATED WITH INCREASED RISK FOR

MORTALITY IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE
● Respiratory infections/fever ● Decreased 6MWT (< 350 meters)
● Hypoxemia (PaO2 < 50 mm Hg) ● Decreased VO2max
● Pulmonary hypertension ● Decreased FEV1 (< 40% pred)
● Cor pulmonale ● Corticosteroid effects
● Hyperinflation (bullae) ○ Osteoporosis
● Spontaneous pneumothorax ○ ↑ Risk of fracture
● Polycythemia/thrombosis/emboli ○ Myopathies
● Sleep apnea (PaCO2 > 50 mm Hg) ● Comorbidities (diabetes, cardiovascular disease)
● Asthma ● Depression
● Decreased body weight
The inflammatory response also induces hypertrophy of ventilation (Vd) is increased. There is an increase in V/Q
smooth muscle cells and a goblet-cell metaplasia, resulting mismatch and hypoxemia worsens as activity progresses.97
in hypersecretion and excess mucus production. The risk Examination of aerobic capacity and physiologic response
of infection in the lungs is high and many individuals con- (heart rate [HR], blood pressure [BP], O2 saturation, dyspnea
tract pneumonia. Secondary complications may occur from scores, etc) to exercise can assist in describing the impact of
the medical use of corticosteroids and include myopathies ventilatory pump dysfunction on activity and define the risk
and osteoporosis. These events may lead to poor activity for mortality as well as provide information for development
tolerance and back pain. Declining activity impairs exercise of an exercise prescription. Aerobic training and VMT are
capacity and increases the risk for mortality especially when known to improve dyspnea scores and PImax (17%) and offer
the 6-Minute Walk Test (6MWT) performance falls below small improvements in FEV1 (7%), and are therefore impor-
350 meters.117 Intolerance to activity is one of a variety of tant interventions to consider in the POC.120
factors that affect the risk for mortality in those with COPD As disease worsens, the hyperinflation leads to an eleva-
(Table 8-7). tion in the pressure load at rest as well as during exercise.
Dynamic hyperinflation disrupts the mechanics of The chest wall and lung tissue elastic forces are stiff and
breathing during exercise (Figure 8-9).97 As exercise pro- work against any respiratory muscle effort to further expand
gresses, more and more air becomes trapped in the lungs, the chest.51,52 In order to breathe while the lungs are hyper-
resulting in an increase in end-expiratory lung volume that inflated, the individual with COPD must inspire at the end
creates changes in the dimension of thoracic cage. Bucket range limits of chest expansion where muscle contraction
handle motion is lost when the chest becomes round with is inefficient. Thus, the respiratory muscles must work very
alterations in the length tension of the intercostals muscles. hard against high restrictive forces, eventually leading to
The diaphragm becomes flattened and loses its mechanical respiratory muscle fatigue. Ventilation cannot be sustained
efficiency as well. Measured changes in chest wall expansion and only small volumes of new air move to areas of the lungs
from maximal inspiration to maximal expiration will be that are viable for gas exchange.51,121 Dyspnea, the sensation
diminished. As exercise progresses, individuals with COPD of breathlessness, may be present with activity and may lead
compensate with excessive neck accessory and abdominal to a sedentary lifestyle.51 Individuals with severe disease and
muscle contraction. They may also display Hoover’s sign, an those who have complications may be in respiratory distress
inward retraction of the rib cage resulting from abnormal at rest. These individuals, with end-stage COPD, will benefit
alignment of the intercostals muscles.101,118 De Oca and col- from interventions focused on techniques for breathing con-
leagues demonstrated that PImax and PEmax were reduced by trol, energy conservation, and relaxation to assist in support-
50% to 39% predicted in individuals with severe COPD and ing independence in functioning.
found little diaphragmatic contribution during exercise.119
Neuromuscular Conditions:
They reported that in individuals with severe COPD, the
ability of accessory muscles to generate good changes in ven- Pathophysiologic Consequences
tilatory pressure was related to exercise capacity. and Complications
When TV (or Vt) enhancement is diminished, new Several neurological conditions result in ventilatory
air does not reach the alveoli and physiologic dead-space pump dysfunction (see Table 8-3). These conditions fall into
300 Chapter 8
Figure 8-9. COPD and exer-
cise limitation. (Adapted
from Cerny FW, Zhan S.
Chronic obstructive pulmo-
nary disease. In: LeMura L,
von Duvillard SP, eds. Clinical
Exercise Physiology Application
and Physiologic Principles.
Philadelphia, PA: Lippincott,
Williams & Wilkins; 2004:157-
168.)
2 categories: progressive and acute injury/illness with recov- Acute Conditions

ery. Progressive neuromuscular diseases include; muscular Spinal Cord Injury, Guillain-Barré Syndrome, and
dystrophy, Parkinson’s disease, ALS, Huntington’s disease, Myasthenia Gravis
and multiple sclerosis (MS).92 Neuromuscular disorders aris- Ventilatory pump disruption in neuromuscular disease is
ing from an acute event or acute disease include: SCI, GBS, eminent in those with progressive disease; however, with an
myasthenia gravis, cerebral vascular accident, brain injury, acute injury to the nervous system cardiorespiratory recovery
and cerebral palsy. Progressive disease will arise gradually is variable and depends on the extent of damage to the ner-
until the ventilatory pump function is significantly impaired vous system, number of comorbidities, and age.72,124-126 For
while acute events typically require immediate medical example, the incidence of respiratory complications in those
intervention to assist ventilation until recovery stabilizes with a motor-complete SCI is highest in those with injuries at
breathing and ventilation support is no longer necessary or C1 to C4 (84%) compared to those with injuries at C5 to C8
is managed with a good respiratory care routine. Despite the (60%) or T1 and below (65%).74 Reduced pulmonary function
time of onset of respiratory dysfunction (early in acute or (FVC), respiratory muscle strength (PImax and PEmax) and
late in progressive), most individuals with neuromuscular longer hospitalizations are related to level of injury, with the
conditions have restrictive disease (FEV1/FVC > 0.85% and greatest impairment involving those with the highest levels
FVC < 80% predicted) due to limited chest expansion result- of injury.66,127 Pneumonia (25% to 51%) and atelectasis (40%
ing from respiratory muscle weakness and poor breathing to 42%) are among the most common respiratory complica-
mechanics.122,123 Ventilatory capacity is initially reduced tions found in individuals with neurological conditions.75,128
and eventually, over time, ventilatory load is increased with Secondary conditions or comorbidities that increase the risk
the onset of chest wall restriction and secondary illness for respiratory failure include: obesity, pregnancy, asthma,
(pneumonia).
upper airway obstruction, dysphagia, surgery, cardiovascu- present with sleep disturbances. 75,112,144 Most individuals
lar disorders (diabetes, atherosclerosis, cor pulmonale), and with SCI will have impaired cough function and many will
prior history of smoking.73,128-131 need lifetime respiratory management programs.
GBS is one of the most common causes of acute flaccid tet- Individuals with SCI or intracranial lesions (stroke and
raplegia. It is an inflammatory demyelinating polyradiculo- brain injury) have acquired nervous system conditions
neuropathy with an incidence of 0.6 to 1.5/100,000 people.75,76 that may result in permanent loss of ventilatory function.
Myasthenia gravis is an autoimmune disorder of neuromus- Recovery may be incomplete and may range from severe to
cular transmission where antibodies are directed against ace- mild limitations. People living with chronic acquired neu-
tylcholine receptors, a condition that affects 0.5 to 14.2 per rological conditions will need to manage muscle overuse,
100,000 people. Approximately 25% to 50% of patients with aging, and comorbidities that may contribute to further
GBS75,78 and 15% to 27% of those with myasthenia gravis weakening of the respiratory muscles later in life.4 Each
will require mechanical ventilation because of rapid progres- individual will need an individualized evaluation and POC
sive weakness involving the respiratory muscles.78 Factors for lifetime management of ventilatory pump dysfunc-
predicting respiratory failure in GBS are: rapid onset of tion.4,10 Lifelong management of respiratory impairment
weakness to hospitalization (< 7 days), an inability to lift the may include: recognizing risks associated with respiratory
head, and having a VC that is less than 60% predicted when tract infections and respiratory muscle fatigue, incorporat-
recorded in the supine position.10,132 Myasthenia crisis is an ing caregiver or self-assisted cough, positioning for optimal
event related to an exacerbation that produces significant V/Q in bed and in upright, using an abdominal binder or
respiratory and oropharyngeal muscle weakness, leading to positioning to improve breathing mechanics, and respiratory
intubation and will be preceded by infection in 38% of indi- muscle strength training.4,10,13,86,105,135,137,141
viduals.73 Some individuals may have autonomic dysfunc- Stroke
tion, which increases the risk for respiratory failure.133 Stroke results from hemorrhage or thrombus leading to
Even when acute neurological injuries are mild, poor infarction of brain tissue. There are approximately 5.4 mil-
cough function increases the risk for pulmonary complica- lion stroke survivors in the US.145 After stroke, presence of
tions.74,134 Individuals with tetraplegia or motor-complete an abnormal respiratory pattern (tachypnea and Cheyne-
SCI between C4 and T4 may demonstrate paradoxical Stokes) increases the risk for mortality.146 Disruption of cor-
breathing patterns and have poor or even negative chest tical inhibition of respiratory drive and increased sensitivity
expansion.135-139 Once the individual with weak or impaired to CO2 appears to be responsible for producing abnormal
respiratory mechanics contracts a respiratory illness, the respiratory patterns.71,146,147 About 25% of individuals with
ventilatory load is increased to an already weakened system, acute cerebral infarction require mechanical ventilation
predisposing the individual for respiratory muscle fatigue because of decreased cognition, poor airway protection or
and failure.75,93 High RR and CO2 retention are signs of hypoxemia.71 Approximately 47% of those with a cerebral
impending failure resulting from an imbalance between vascular accident who are admitted to the intensive care
ventilatory load and capacity.110 Monitoring of respira- unit (ICU) develop pneumonia, with 31% being nosocomial
tory status is a priority and intubation is performed in the pneumonias.72 Risk factors associated with an increased risk
early stages of the disease when VC < 20 mL/kg ideal body for pneumonia include abnormal chest radiograph, mechani-
weight, PImax > –30 cm H2O, PEmax < 40 cm H2O or there is cal ventilation, multiple stroke locations, involvement of the
> 30% reduction in VC, PImax, or PEmax.78 Individuals who posterior cerebral region, age greater than 60 years, dyspha-
have RRs > 35 breaths per minute at rest require mechanical gia, facial muscle weakness, and decreased level of cognition
ventilation.140,141 (Glasgow Coma Scale < 10).72 Turkington and colleagues
Most individuals with GBS and myasthenia gravis will be found 80% of those with acute stroke have some degree of
able to recover enough ventilatory capacity to be discontin- obstructive sleep apnea (OSA).148 Individuals with sleep
ued from the ventilator and return to normal functioning apnea are known to have elevations in CO2 with diminished
within 1 year.76,128 Plasma exchange and immunoglobulin levels of alertness. CO2 retention can potentially impair
therapy may decrease the time on mechanical ventilation by learning for patient education and effective participation in
as much as 50% for those with GBS.75,133 Individuals with rehabilitation. Thus, respiratory status is critically tied to the
motor complete SCI at C5 and below will recover up to 60% success of the rehabilitation program and overall functional
of their VC by the end of the rehabilitation period.135,137 outcome for those with stroke.
Regardless of the mechanism of injury, individuals will begin Hemiparesis disrupts the mechanics of breathing by
a ventilator discontinuation program when there is a stable decreasing the chest wall excursion (CWE) on the paretic
medical status if the VC reaches > 10 to 15 mL/kg ideal body side by as much as 50% during voluntary deep breath-
weight (≥ 500 to 1000 mL).142 The person with a neurologic ing.147,149 TV breathing may, or may not, be significantly
condition will be able to sustain ventilation for activities of lower; however, the diaphragm and intercostals muscle acti-
daily living (ADL) when the VC reaches 30% predicted vation is lower on the paretic side.71,147,150,151 Respiratory
(> 1500 mL).76,140,143 Individuals who are successful in venti- muscle strength (PImax and PEmax) is 40% to 60% lower
lator discontinuation may continue to display signs of respi- in individuals with hemiplegia in comparison to healthy
ratory muscle fatigue, bulbar weakness, CO2 retention, and age- and gender-matched controls.152 Lanini and colleagues
302 Chapter 8
reported lower PImax (53.41 ± 21.4 vs 99.4 ± 8.4 cm H2O) and Multiple Sclerosis and Parkinson’s Disease
PEmax (61.6 ± 16 vs 121.8 ± 18.1 cm H2O) in 8 males with MS is a demyelinating disease of the central nervous
hemiplegia at 26 days after onset of initial symptoms.147 system with an initial onset arising in individuals between
Inability to breathe deeply may decrease lung and chest wall 15 and 50 years of age; mean 30 years of age. Approximately
compliance over time.152 Lower lung volumes and respira- 400,000 individuals in the US are affected by the disease with
tory muscle strength may also limit force-generating capacity about 10,000 new cases each year. Twenty percent of indi-
for effective coughing, increasing the risk for pneumonia. viduals who have MS and die before age 50 will succumb to
Fugl-Meyer and colleagues demonstrated that measures pneumonia or influenza.157,158 On average, the first episode
of ventilatory function (lung volumes and pressures) were of respiratory failure occurs about 6 years after the onset of
related to the degree of motor impairment and were lower for MS.71 Factors contributing to onset of respiratory failure
those with the most severe hemiparesis.152 include bulbar dysfunction, abnormal motor control (pre-
Progressive Conditions senting as apneustic breathing or apnea), fever or elevations
in temperature that may exacerbate poor nerve conduction
Respiratory muscle weakness often does not produce
and loss of respiratory muscle functions.71
symptoms in the early stages of progressive neuromuscular
disease.71 Progressive disease results in a gradual loss of limb Pulmonary impairment and respiratory muscle weak-
function and motor control in most muscles throughout the ness are present both in mild and advanced stages of MS,
body, including bulbar muscles.111 As a result people with with greater loss of expiratory than inspiratory muscle
progressive neuromuscular disease may not complain of weakness.65 Respiratory muscle weakness is related to sys-
dyspnea or difficulty breathing because the loss of motor temic weakness and overall disability.67 Buyse and colleagues
function to the extremities limits their need to increase observed individuals with MS who had higher disability
ventilation.67 Respiratory muscle strength deficits result in scores (Expanded Disability Status Scale) had significant
a corresponding loss of lung volumes but FVC is not sig- lower VCs.67 They reported 70% had saturations less than
nificantly affected until the respiratory muscle pressures fall 92% at night. Loss of conditioning, hypoxemia, hypercapnia,
below 50% predicted.71,153 Chest wall and lung compliance steroids, and increases in tumor necrosis factor may lead to
gradually decreases as the individual with neuromuscular further declines in respiratory muscle performance during
disease fails to breathe deeply. Microatelectasis develops, an exacerbation.71 Fortunately, there are numerous reports
making it harder to expand the chest.154 Eventually, shallow demonstrating that respiratory muscle training can improve
breathing results in increased dead-space ventilation and lung volume and flows, respiratory muscle strength, respira-
CO2 retention. Sleep disturbances (hypoventilation, insom- tory muscle endurance, and cough in those with MS.158-160
nia, and decreased rapid eye movement sleep) begin when VC Less research has been performed on ventilatory function
falls below 60% predicted or inspiratory pressure is greater in Parkinson’s disease, as a large portion of the population is
than –34 cm H2O (less negative) and will precede devel- older than 80 years of age at the time of onset.161 Pneumonia
opment of daytime hypercapnia.155 There are a variety of is a common respiratory complication. Parkinson’s disease is
subtle changes that can be detected by effective monitoring a neurodegenerative disorder involving subcortical gray mat-
of respiratory status in those with a progressive neurological ter in the basal ganglia. The substantia nigra loses its ability
condition.131,156 to produce dopamine, which is a neurotransmitter that is
Duchenne Muscular Dystrophy important in the regulation of motor actions. Coordination
is lost throughout the body and affects smooth interaction of
DMD is the most common dystrophy in childhood and
inspiratory and expiratory muscle performance. As a result,
occurs in 1 of every 3000 male births. It is caused by an
more than 58% of individuals with Parkinson’s disease have
X-linked recessive disorder causing a defect in the gene that
a decrease in the PEFR.162 The PImax declines to about 30%
produces dystrophin, a cytoskeleton protein. Ultimately
predicted and PEmax drops to 35% predicted in advanced
this defect results in impaired function of the sarcoplasmic
stages of the disease.163 Loss of lung volumes (FVC and
reticulum calcium pumps and myosin molecule. Significant
FEV1) and PImax and PEmax are correlated to measures of
respiratory muscle weakness begins between ages 7 and
bradykinesia and rigidity.164
12 years and leads to progressive lowering of lung functions.
Death occurs by age 20 to 23 years. Recently, many individu- Early in the disease, inspiratory muscle endurance is
als with DMD have been offered noninvasive mechanical decreased despite nearly normal values for PImax. Loss of
ventilation when the FVC falls below 40% predicted to help endurance in the respiratory muscles may be due to the
prevent hypercapnia and improve daytime alertness and impaired nervous system’s ability to sustain repetitive acti-
quality of life.68 The American Thoracic Society (ATS) has vation during periods of high ventilatory demand as neu-
published a consensus statement directing the methods for rotransmitter levels are depleted.71 Over time as the disease
monitoring respiratory status and the application of ventila- progresses, neck and intercostal muscle activation during
tion support.131 Once the individual with DMD is confined inspiration becomes dominant, increasing the energy cost
to a wheelchair, or has a VC that falls below 80% predicted, of breathing. Additionally, lack of segmental movement
the ATS recommends biannual visits to the pulmonologist. and loss of rotational dissociation between the upper and
lower body decreases chest wall movement. The chest wall
becomes stiff, and breathing for coughing and deep breath- documented. In many individuals there is an inability of the
ing is poorly coordinated.71 Reports state anywhere from peripheral muscle to generate enough force to significantly
12% to 65% of individuals with Parkinson’s disease have increase O2 consumption. In most cases local muscle fatigue
upper airway obstruction.163,164 Sabaté and colleagues evalu- occurs prior to reaching near maximal age-predicted HRs.
ated58 individuals with Parkinson’s disease and documented Additionally, overuse of weak muscles may result in poor
postural deformity, vertebral arthrosis, and loss of passive recovery after exercise and lead to loss of function. Therefore,
mobility of the cervical column in individuals with ventila- aerobic capacity assessment and development of an indi-
tory obstruction.164 Individuals with Parkinson’s disease vidualized exercise program need to be a carefully monitored
may benefit from a program of posture correction, chest wall component of healthy living for persons with a chronic neu-
mobilization, and cough assist as well as general condition- romuscular disorder.
ing to improve aerobic capacity.165 PNF approaches to trunk Summary: Pathogenesis and Consequences
mobilization and cough assist, specifically the counter-rota-
of Neuromuscular Incompetence
tion and costophrenic assist techniques, are interventions
that may help address the ventilatory impairments seen in Neuromuscular conditions arise from an inability to
individuals with Parkinson’s disease.100 Individuals confined transmit nervous system impulses to activate muscle. When
to a wheelchair will need good seating and positioning to there is damage to the nervous system this can affect
prevent poor alignment of the cervical column. mechanics of breathing, disrupt sleep, and may decrease the
ability to swallow effectively. Respiratory muscle weakness
Post-Polio Syndrome
results in a loss of lung volume and capacities leading to
PPS is a chronic condition that arises as age and overuse
alveolar hypoventilation (Figure 8-10).31 Symptoms appear
affect muscles initially affected by polio. Technically, it is
and interfere with function when the FVC drops below 50%
not progressive in nature but arises and worsens if muscles
predicted in most cases. Loss of adequate alveolar ventila-
and joints are not protected from overuse. Approximately
tion limits activity in mild to moderate disease while those
440,000 polio survivors in the US may be at risk for PPS,
with severe neuromuscular incompetence may be unable
with 25% to 65% of individuals experiencing muscle weak-
to breathe without some form of mechanical ventilation.
ness in late life.166,167 Thirty-nine to 42% of individuals with
Factors contributing to ventilatory failure and increased
PPS have symptoms of respiratory insufficiency, most com-
risk for mortality in neuromuscular conditions are listed in
monly in those who required mechanical ventilation during
Table 8-8.
the acute recovery period.69,166 PPS may result in respiratory
Most individuals with neurological conditions lose the
compromise if respiratory muscle weakness or bulbar dys-
ability to breathe deeply and in some cases the sigh reflex
function goes undetected.168 Individuals having PPS may be
may be absent.156 The loss of sigh mechanisms or deep
offered surgical options to assist in stabilization of joints or
breathing capacity can change the alveolar surface tension
tendon transfers to assist in restoring function. The effects
and increase the potential for atelectasis.10 When alveoli
of anesthesia on recovery of respiratory function after an
lose their surface tension, atelectasis develops and the lungs
operation can lead to prolonged recovery times and need for
become stiff, increasing the ventilatory load to already weak
mechanical support.169 Declines in physical function due to
inspiratory muscles. Because the chest wall does not expand
new weakness (overuse) and pain are often the primary com-
fully, it also becomes stiff over time. Postural deformities
plaint for individuals with PPS as well as for those living with
(most commonly scoliosis and kyphosis), occurring from
chronic neurologic conditions. It is important to consider
muscle imbalances and spasticity, will compromise normal
respiratory status prior to proceeding with any elective sur-
chest wall movement.176-178 Paradoxical breathing causes a
gery. A plan for a respiratory care program and conditioning
negative chest wall expansion, which will also lead to stiff-
during the rehabilitation period will be important in order to
ness of the chest wall.4,135
maximize full functional recovery.
Hypoventilation is the end result of decreased lung vol-
Ventilation Limitations to Exercise in umes and chest wall movement. To enhance VE and respond
Chronic Neuromuscular Disease to increases in ventilatory demand (activity or infection), the
Many individuals with neuromuscular conditions sur- individual increases RR. Elevation of RR, as a compensa-
vive the acute phase or, in the case of chronic progressive tion for small TV, increases dead-space ventilation, reduc-
disease, some individuals are able to engage in exercise ing alveolar gas exchange. Retention of CO2 or hypercapnia
that postpones the decline in ventilatory pump function.122 occurs when there is significant loss of ventilation and respi-
Several reports have demonstrated an increased work of ratory muscle strength drops below 25% predicted.71,179
breathing during aerobic activity and suggested there may Hypercapnia is also associated with sleep apnea and pro-
be ventilation limitations to exercise in those with PPS,123,170 duces changes in mental status and decreased levels of alert-
MS,171 Parkinson’s disease,165 stroke,172 and traumatic brain ness.68,131,144,180 In progressive diseases, early symptoms
injury.122,173 Aerobic training programs appear to improve such as fatigue and decreased level of alertness are subtle
ventilatory capacity in individuals with chronic neuro- signs that suggest there is difficulty with breathing. These
logic conditions.174,175 Ventilatory limitations to exercise signs appear when there is mild CO2 retention. Later, as the
for individuals having neurological conditions are not well disease progresses the person with progressive neurological
304 Chapter 8
Figure 8-10. Factors contributing to respiratory insufficiency in individuals with neuromuscular conditions. ERV, expiratory reserve volume; FRC, func-
tional residual capacity; FVC, forced vital capacity; IRV, inspiratory reserve volume; RR, respiratory rate; RV, residual volume; TLC, total lung capacity; TV,
tidal volume; V/Q, ventilation perfusion. (Adapted from Peat M, ed. Current Physical Therapy. Philadelphia, PA: BC Decker; 1988.)
disease becomes severely limited, avoids activity, and uses muscles or proper cough-assist technique.100,184,185 Poor
compensatory breathing strategies at rest. Eventually, severe cough limits the ability to clear mucus from the airway and
hypoventilation and CO2 retention may cause respiratory increases the risk for pneumonia. Glottis control is also
acidosis and lowers the pH of the body.181 Respiratory failure essential for coughing and for protection of the airway.186
is imminent and regular monitoring of respiratory status is Bulbar muscle weakness and obligatory supine positioning
recommended.131 increase the risk for aspiration of foreign matter into the
Those individuals with progressive neuromuscular dis- lungs.4,10,75,76 Pulmonary infections and atelectasis leads to
ease with PImax > –30 cm H2O (less negative), PEmax < 40 cm hypoxemia and fever, increasing the work of breathing and
H2O or those with a VC below 20 mL/kg body weight are potential for respiratory muscle fatigue.
at risk for ventilatory failure and will soon need some Musculoskeletal Disorders:
mechanical ventilation support.72,78 Interventions focused
on preventing decline in pulmonary status begin with
Pathophysiologic Consequences and
airway clearance and breathing retraining and are recom- Complications
mended when VC drops (45 to 30 mL/kg BW; [FVC = 65% Musculoskeletal conditions that impact on posture and
to 40% pred]).73 Noninvasive mechanical ventilation at night CWE may result from either primary conditions of the
is now being offered early in the disease process to avoid skeleton and its articulating surfaces (osteoporosis, arthritis,
hypercapnia and sleep apnea and should be considered when AS), or from systemic diseases that destroy connective tissues
the FVC falls below 40% predicted.68 It becomes critical for throughout the body (sarcoidosis, scleroderma). Secondary
health professionals to monitor decline in respiratory status conditions such as neuromuscular disease, surgical pain,
as well as loss of function as the disease progresses.131 Early scars (burns, wounds), or obligatory positioning after trauma
intervention that includes mobility, wheelchair positioning, (management of complex fractures and injuries) may also
cough-assist techniques, and strategies to enhance inspira- result in postural deformities, remodeling of skeletal align-
tory volume and glottis control may postpone the need for ment and loss of CWE. Pectus carinatum (pigeon chest)
full-time mechanical support and prevent life-threatening and pectus excavatum funnel chest) may develop as a result
respiratory complications. of underlying pathology and are associated with long-term
The inability to inspire at least 1500 mL of air may con- conditions (COPD, cystic fibrosis, and neuromuscular dis-
tribute to ineffective flow rate for spontaneous and assisted ease).187 These deformities signal muscle imbalance and
coughing.10,24,26,182,183 Coughing is also dependent on good, unequal chest pressures that contribute to inefficient breath-
forceful expulsion of air using contraction of the abdominal ing mechanics.
Severe restriction of CWE can result in decreased pul-
monary function when the pump handle and bucket handle TABLE 8-8. COMPLICATIONS ASSOCIATED
motions are impaired.188,189 Additionally, when postural WITH INCREASED RISK FOR MORTALITY IN
alignment is significantly altered there may be an internal
torsion and compression of lung tissue that leads to obstruc- NEUROMUSCULAR CONDITIONS
tion of airflow and atelectasis.190 If the gastrointestinal ● Respiratory infections/fever
organs are compressed then aspiration may occur, increasing
● Respiratory muscle weakness
the risk for pneumonia or pulmonary fibrosis. Distortion
of the pulmonary vasculature may restrict blood flow and ○ Impaired mechanics-fatigue
lead to V/Q mismatch, hypoxemia, and pulmonary hyper- ○ ↓ Inspiratory and expiratory capacity
tension.191 Exercise-induced pulmonary hypertension may
occur before any hypertrophy to the right heart or evidence ○ Diaphragm paralysis
of right heart failure. Pulmonary pressure increases propor- ● Decreased VC
tionally when the lateral curvature of the spine is greater
than 70 degrees.187
● Ineffective cough
Primary conditions of the skeleton include: kyphosis, ● Increased dead-space ventilation
kyphoscoliosis, and idiopathic scoliosis. Surgery involv- ● Hypoventilation/mechanical ventilation
ing the thoracic cage is an acute condition that results in
reduced anteroposterior diameter, diminishes lateral costal ● Hypercapnia
expansion, and imposes abnormal posturing, which can tem- ● Aspiration (bulbar weakness, obligatory position-
porarily compromise ventilation.31,85 Skeletal deformities ing)
occurring in the thoracic region affect CWE and ventilatory
capacity as they become severe.80,192 Postural deformities
● Sleep apnea
may arise from an unknown cause (idiopathic scoliosis)193 ● Paradoxical breathing
or as a secondary disorder associated with osteoporosis ● Postural deformities
(especially vertebral wedge fractures),189 chronic muscle
imbalance or pain syndrome (neurological conditions), post- ● ↑ Atelectasis
surgical or traumatic event involving fracture and/or bone ● ↓ Residual muscle/deconditioning/↓ CV health
repair (eg, rib fractures, pelvic obliquity, cardiothoracic sur-
gery). In the case of idiopathic scoliosis, pulmonary function ● Immobility
is compromised as the lateral curvature approaches 60 to ○ Risk of thrombosis/emboli
70 degrees and mechanics of inspiratory muscles becomes
○ Risk of pressure sores
impaired when the curve is greater than 90 degrees.31,188,193
Eighty-two percent of deaths in those with clinically sig- ○ ↓ Stimulus to breathe
nificant scoliosis (> 40 degrees curvature) are associated with
respiratory complications.194 Interventions designed to limit
the progression of the curvature are applied initially until Connective tissue disorders may limit ventilation and
eventually a surgical correction is necessary. occur with systemic diseases (scleroderma, sarcoidosis, poly-
AS is a chronic inflammatory disease affecting the sacro- myositis, systemic lupus, rheumatoid arthritis) or as a result
iliac joint and spine. It is progressive and eventually involves of soft tissue destruction (burns, scars) related to trauma
the shoulder, hips, and other LE joints. About one-third of or medical interventions.31,188 In the case of systemic dis-
individuals with AS have severe disease with severe kyphosis ease, the primary pulmonary involvement occurs in the
and spine deformity associated with pathologic fractures lung parenchyma and often results in pulmonary fibrosis.
of the vertebrae.188 Approximately 1.2% of those with AS In this case, the restrictive pattern of pulmonary function
have pulmonary impairment of the upper lobes of the lungs is due to poor lung expansion and increases the work of
as a result of the mechanical restrictive process and pain breathing, especially during activity.4,94,96,195 For individu-
that limits anterior CWE.194 The disease also affects lung als with systemic connective tissue disorders, life-threaten-
parenchyma in addition to decreasing CWE, so there is ing pulmonary complications result from poor lung tissue
often pulmonary fibrosis in those with AS. As with other diffusion, gas transfer impairments, and pneumonia (see
restrictive lung tissue disorders, small lungs are seen on chest Chapter 9).194,196 Because painful joints, tight skin, or weak
X-ray along with pulmonary function tests that confirm a respiratory muscles may also limit chest wall movement and
restrictive pattern. Both ventilatory pump dysfunction and increase the work of breathing, it is important to evaluate the
noncompliant lung tissue contribute to the overall pattern extent to which these structures limit ventilation. Specifically
of restrictive respiratory dysfunction. When lung paren- addressing pain and tightness may improve the ease of
chyma is noncompliant, the patient must work harder for breathing for many. Strengthening weak respiratory muscles
each breath, leading to ventilatory pump fatigue or impaired and providing aerobic conditioning will be important to
mechanics appear as a secondary event.4 maximizing overall functional outcome.
306 Chapter 8
Outcome measures such as the Baseline Dyspnea Index
EXAMINATION OF (BDI)204; Modified Medical Research Council (MMRC)
VENTILATORY PUMP DISORDERS dyspnea scale; and BODE Index (BODE stands for body
mass index [BMI], obstruction to airflow [FEV1], dyspnea
[MMRC], and exercise [6MWT distance]),205,206 St. George’s
Examination involves history taking, review of systems,
Respiratory Questionnaire (SGRQ), 207 or the Chronic
and selecting and implementing tests and measures used
Respiratory Questionnaire (CRQ)208 are used to quantify the
to determine a physical therapy diagnosis, prognosis, and
effect of dyspnea on function and health-related quality of
POC.92 Although the therapist performs a comprehensive
life (HRQoL) in individuals with COPD.209 When a person
exam and a screen of all major systems, in this chapter we
with a history of repeated admissions has acute ventilatory
will focus on those examinations that assist in defining the
compromise the therapist should ask “What activities were
extent of the ventilatory pump disorder and limitations that
you able to do after your last hospitalization?” and “What
may be addressed by physical therapy. It is not unusual for
kind of therapy did you have during your last admission?”
individuals with ventilatory pump disorders to be referred
The answers to these questions and a review of prior func-
to physical therapy with a primary problem other than ven-
tional status can assist in developing realistic goals and POC.
tilation (paralysis, immobility due to trauma or postsurgical
pain). So often the examination of ventilatory pump function Past medical and surgical history should include prior
is a component of a larger pathologic process affecting physi- hospitalizations and procedures with special attention on
cal functioning. The examination begins with a review of the factors that affect ventilatory capacity. Old scars, fixed pos-
patient/client history. tures, and muscle imbalance may be difficult to correct in a
new episode of care. The therapeutic plan will may need to
be modified if comorbidities (hypertension, heart failure,
Patient/Client History aberrant conduction, etc) are serious. The current condi-
The history-taking process will review general demo- tion and chief complaint is determined by interviewing the
graphics, including age, gender, and ethnicity, as well as individual, family, and medical team to identify the reason
height and weight.3 All of these factors will influence nor- for admission, patient/family goals, and desired medical out-
mal lung and ventilatory muscle functions. Measures of comes. During the interview the therapist observes patient
pulmonary impairment (FVC, FEV1, PEFR, and PCFR) and status (color, posture, accessory muscle use, phonation etc).
respiratory muscle performance (PImax, PEmax, MVV) are Medical information to review prior to conducting formal
typically compared to expected values reported in the litera- tests and measures includes: baseline vital signs, oximetry
ture.3,27,36,197-199 The severity of disease and the loss of ven- and arterial blood gases, complete blood count, pulmonary
tilation will be relative to the age, gender, height, and other functions tests, sputum and blood cultures, imaging and
demographics. The therapist can use this information to chest radiographs, cardiac diagnostics, renal/urinary tests,
determine whether signs and symptoms are associated with swallowing tests as well as nutritional and hydration status.
these features or may be explained by other factors (pain, The therapist will need to be familiar with any contraindi-
anxiety, deconditioning, etc). Individual characteristics may cations and precautions to activity prior to performing the
also influence measures of chest wall expansion,200 predicted physical exam.203,210,211 Medications can alter pain, breath-
work capacity (6MWT, bike, or treadmill workload),28,201,202 ing, ventilatory muscle performance and may introduce
physiologic responses to activity tolerance testing (HR and symptoms that affect overall functional performance.212
BP),203 and risk for acquiring conditions known to affect O2 and ventilatory support should also be determined. The
ventilation (scoliosis, sarcoidosis). use of O2 and mechanical ventilation usually indicates the
A review of the family history, lifestyle, and general health person with a ventilatory pump disorder also has impaired
status should reveal whether the person is malnourished or respiration/gas exchange (see Chapter 9).115,141 If a person
obese and overeating, or has ongoing habits, such as smoking develops a pulmonary infection, acute respiratory failure or
or alcohol abuse, that may work against optimal ventilation. has a condition that requires ongoing management of airway
The support system (family, caregiver, insurance coverage, clearance, then the primary problem is a gas-exchange prob-
access to experts) will influence the person’s ability to imple- lem and not ventilatory pump dysfunction. These conditions
ment an optimal POC. It will also be important to identify are discussed in Chapter 9.
the individual’s expected life roles. Does the person have a
physically demanding job or participate in leisure activities Systems Review
with high ventilatory requirements? Do the activities include
arm work? Many individuals with ventilatory pump dysfunc- The first thing to consider prior to performing a systems
tion have symptoms only with activity so it is important to review is to determine whether the reason for breathing dif-
take a good activity history. Ask the client “What activities ficulty is ongoing or recent and if the symptoms are worse in
are hard for you and what makes it difficult?” This kind of supine or sitting or with activity. A functional sitting position
questioning can help the therapist determine what type of is preferred when screening vital signs and ventilation. Any
aerobic capacity test to perform and prioritize functional support devices (abdominal binders, seating systems, body
testing. jackets, O2) and any use of upper extremity or back support
should be noted. Measures may be significantly altered when Common categories from which tests and measures are
body position changes or support is removed. chosen to examine a patient with a ventilatory pump disor-
The cardiovascular and pulmonary system should be der are Posture, Ventilation and Respiration/Gas Exchange,
assessed prior to screening other systems. General screen- and Aerobic Capacity and Endurance. Testing Cranial Nerve
ing of the HR, BP, RR and O2 saturation can quickly define Integrity may be indicated as well as measures of Self-Care
whether there are contraindications to other examinations. and Home Management (including ADL and instrumental
These values are compared to recent vitals recorded in the ADL [IADL] and/or Environmental, Home, and Work (Job/
medical record. The RR will be most closely associated with School/Play) Barriers.
identifying severity of ventilatory pump dysfunction. Rates Posture
above 30 breaths per minute at rest suggest low TV and
indicate severe loss of ventilatory capacity.3 Gas-exchange Posture gives clues to the adaptations the patient may
impairments often precede ventilatory pump dysfunction have made over time due to an altered breathing pattern.
in those with COPD while those with neurological diseases Individuals with primary pulmonary disease (COPD), as
may have gas-exchange deficits well after ventilatory muscle breathing becomes distressed, will appear differently from
weakness has been identified. Screening for arterial O2 satu- individuals with ventilatory pump dysfunction arising from
ration can identify if there is hypoxemia. secondary disorders (neuromuscular conditions or musculo-
Once the cardiovascular and pulmonary system screen- skeletal conditions). Those with severe COPD will typically
ing is complete, the other systems are examined grossly. lean forward and support their arms on furniture, bed rails,
General screening of integumentary system can reveal scars or bedside tables.218
or wounds that may restrict breathing. If wound healing is a Posture is typically observed in a standing or sitting
problem, this may suggest poor immunity and increased risk position. The person with muscular weakness from a neu-
for pulmonary infections.213 Conversely, high ventilatory rological condition will often be observed in a sitting posi-
demands raise metabolic requirements and steal circulation tion and will likely display a posterior pelvic tilt, thoracic
necessary for wound healing.213,214 Some wounds will confer kyphosis, and forward head. The position may be fixed or
an obligatory posture and may not support good ventilation flexible depending on the whether the condition is chronic
to all areas of the lungs. Musculoskeletal and neuromuscular or acute. The seating system may be adjusted to support ven-
screening may reveal pain or restrictions in range of motion tilation and prevent deformities that work against breathing.
(ROM), weakness, and spasticity that contribute to inef- Rounded shoulders with kyphosis and severe habitual poste-
ficient movement strategies. Energy cost will be higher for rior tilt limit anterior chest wall expansion.105 Additionally,
simple tasks. Breathlessness may be related to poor move- excessive diaphragm action without good opposition from
ment patterns or anxiety and not necessarily caused by the intercostals can lead to pectus excavatum (funnel chest).
pulmonary impairments.215 Communication, affect, cogni- Therefore a posture exam is critical to identify conditions
tion, language, and learning style are also part of the sys- that may be corrected by good seating position and therapeu-
tems review. For those with ventilatory pump dysfunction, tic interventions to correct chest wall limitations and muscle
decreased cognition or poor affect may be an early sign of imbalance.219 Severe kyphosis in individuals with diseases
CO2 retention.216 The individual may also have undiagnosed affecting spine mobility is associated with limitations in lung
sleep apnea.180,217 function.80
The position of comfort should be noted at the beginning
of the physical exam. The person with severe ventilatory
Tests and Measures pump dysfunction who has a neuromuscular condition will
The approach to selecting tests and measures will depend be more comfortable in supine with the head of bed at about
on the underlying cause of impaired ventilation and whether 15 to 30 degrees while the individual with severe COPD will
the problem is acute with a sudden onset or progressive. be more comfortable upright and leaning forward with arms
Individuals with COPD can have an acute exacerbation on supported.
top of a long history of gradually worsening ventilatory sta- When examining posture, the abnormal postures are
tus. People with chronic neuromuscular disease may have documented and the change with and without arm support
no complaints of breathing disorders and may be unaware may be observed. The therapist can rate dyspnea and breath-
that the ventilatory reserve is marginal, especially if they are ing pattern and measure RR before and after, including arm
too weak to physically increase O2 demand. Those with acute support, use of abdominal binder, back rest, head rest or with
conditions may have ventilatory pump dysfunction that can a walker if standing. Counting aloud after maximal inspira-
be addressed with early mobility and pain management strat- tion is another method for examining the effects of various
egies (postsurgical patients) or they may require prolonged postures on ventilation. The higher the number counted in
rehabilitation after a severe trauma with muscle paralysis one breath, the greater the ventilation support offered by the
(SCI, brain injury). Therefore, the acuity of the illness and the specific position or equipment.4
underlying pathology contributing to impaired ventilation
Ventilation and Respiration/Gas Exchange
will influence which tests and measure will be important in
assisting goal setting and directing the physical therapy POC. Tests and measures within this category may include
examination of chest wall movement, identification of
308 Chapter 8
A B
Figure 8-11. Surface markings of the lungs (anterior [A] and posterior [B] aspects). The underlying bronchopulmonary segments
are also shown. (Adapted from Cherniak RM, Cherniack L. Respiration in Health and Disease. 3rd ed. Philadelphia, PA: WB Saunders;
1983; and Frownfelter D, Dean E, eds. Cardiovascular and Pulmonary Physical Therapy: Evidence and Practice. 4th ed. St. Louis, MO:
Mosby Elsevier; 2006:695-717.)
breathing patterns, auscultation of breath sounds, and assess- costal expansion (bucket handle motion). Hand placement
ment of airway clearance ability. between the sixth to fourth rib allows the therapist to note
Chest Wall Movement movement in the middle thoracic lung fields (left lingular
divisions and the right middle lobes).218
Chest wall examination includes palpation, examination
Posteriorly, the hands may be placed over the thorax
of scars, and trigger points as sources of pain, detecting any
between the inferior angle of the scapula and the tenth rib to
asymmetrical movement. The purpose of this exam is to
palpate expansion of the chest wall under the superior and
identify when more objective assessments may be needed
posterior division of the lower lobes. The posterior upper
(CWE measures, auscultation, or muscle performance tests).
lobes may be palpated bilaterally on the shoulders and poste-
The therapist will examine painful areas by rotating the
rior aspect of the scapula above the spine of the scapula (T2).
index finger over critical areas such as the interchondral and
These same surface landmarks may be used to identify the
sternocostal articulations. Areas that are stressed during a
lung fields during auscultation.12
surgical procedure may be painful. The insertion of muscles
such as the pectoralis major, serratus anterior, sternocleido- A more objective assessment of chest wall movement is to
mastoid or trapezius may be tender. Any reproducible trigger use a tape measure to document the excursion from maximal
point can help diagnose the cause of pain and assist in ruling inspiration to maximal expiration. The 3 regions that should
out pain from pulmonary pleurisy or angina. be assessed are upper chest wall expansion (axillary level;
second intercostals space or angle of Louis), middle chest
The therapist uses surface landmarks to identify the
wall expansion (xiphoid level) and lower chest wall expan-
region of the lungs for examination (Figure 8-11). The hands
sion (half way between xiphoid and umbilicus).138,220,221 A
are placed over the anterior surface of the upper chest with
standard tape measure is used at each site and pulled gently
thumbs aligned over the sternum and manubrium above
with firm pressure circumferentially around the thoracic
the fourth rib. Separation of the thumbs is observed as well
cage. The tape should be level all around. The subject is then
as upward movement of the chest wall. The upper thoracic
asked to inspire and expire and the difference in expansion
cage moves more in the anterior posterior dimension (pump
recorded.
handle) motion and may be diminished if there is pain from
surgical incisions (sternotomy). The hands are also placed Chest wall expansion may be measured with TV breath-
on the lateral rib cage between ribs 7 and 10 to detect lateral ing (functional excursion) or with VC breathing (maximal
excursion). Measures taken during TV breathing indicate
resting movement while measures taken during VC breath-
ing will give an indication of the potential for expansion
during deep breathing or exercise.221 Measuring CWE after
exercise in those with COPD may demonstrate decreases
in movement of the chest wall resulting from dynamic
hyperinflation.222
Respiratory and Breathing Pattern
Respiratory pattern is a description of the variation
between RR, TV, and pause characteristics. Descriptions of
respiratory pattern include tachypnea (> 20 breaths/minute),
bradypnea (< 10 breaths/minute), hyperventilation, Cheyne-
Stokes, Biot’s, Kussmaul’s, etc.223
The examination of breathing pattern is an examina-
tion that describes how the individual is moving air in the
lungs.135 The therapist observes ventilation and rates the
pattern of breathing by applying a number to 4 regions of Figure 8-12. Physiology of normal breath sounds. (Adapted from
the thorax (neck, chest, diaphragm, abdomen) according to Frownfelter D, Dean E, eds. Cardiovascular and Pulmonary Physical
the amount of activity observed in the region. Normally, the Therapy: Evidence and Practice. 4th ed. St. Louis, MO: Mosby Elsevier;
2006.)
breathing pattern involves equal expansion of the chest and
diaphragm regions. Therefore, a normal breathing pattern is
2 chest and 2 diaphragm with no rating applied to the neck will result in decreased breath sounds over the vesicular
or abdomen. If the person uses neck muscles, diaphragm, regions. The individual with asymmetrical weakness due to a
and chest then the rating is applied using 4 points according neuromuscular condition may have less audible sounds over
to dominance or respiratory muscle action in the 3 regions. the vesicular regions on the more involved side. Adventitious
A possible rating would be 1 neck, 1 chest, and 2 diaphragm. sounds such as rhonchi indicate airway narrowing and may
This would indicate the individual has begun using neck be due to secretions or postural torsion in those with severe
accessory breathing and the chest wall motion or intercostals kyphoscoliosis. Rales may indicate an inflammatory process
action is diminished relative to normal. such as pneumonia is evolving.
Abdominal muscle action is often observed in those with The person with COPD may have distant sounds and a
COPD who have hyperinflation. Active contraction of the more prolonged expiratory phase than heard in the healthy
abdomen is used to move a flattened diaphragm up in the individual. During auscultation bronchial sounds are com-
thoracic cage at the end of expiration.52 In this case, the mon if there is lung consolidation (hollow over vesicular
breathing pattern may be 1 neck, 1 diaphragm, and 2 abdo- areas) or there may be an absence of sound if there is atel-
men. This is because the lungs are hyperinflated, causing the ectasis.221 Since lung consolidation and atelectasis may
intercostal action and chest component to be minimal. be early signs of respiratory compromise in individuals
Auscultation with ventilatory pump dysfunction, the auscultation session
Auscultation is important for confirming the ventila- should include an examination of voice-transmitted sounds
tory characteristics in the individual with ventilatory pump (egophony, bronchophony, and whispered pectoriloquy).218
dysfunction. Lung sounds may be characterized as normal, Sounds are transmitted more clearly when there is lung
abnormal or adventitious.221 For the person with ventila- consolidation.
tory pump dysfunction, comparing abnormal auscultatory Airway Clearance
characteristics to normal is important. Auscultation can be An effective cough, which is imperative to efficiently
also be useful for determining the region of the lungs where clear pulmonary secretions, is elicited by a deep inspiration
pathology or infectious processes may be affecting venti- followed by closure of the glottis, then a strong contraction
lation and can assist in the differential diagnosis of spe- of the abdominals causing rapid expulsion of air. Cough
cific lung disorders.221,224 Chapter 9 presents a discussion of can be assessed for effectiveness, control, quality, frequency,
adventitious lung sounds related to impaired gas exchange. and sputum. The therapist should observe the 4 phases of
When performing auscultation on an individual with coughing.225 Phase 1 involves good deep inspiration. Phase
ventilatory pump dysfunction who does not yet demonstrate 2 is glottis closure prior to forceful contraction of abdomi-
significant gas-exchange deficits, the therapist can listen for nal and intercostals muscles in phase 3. During phase 3 the
inspiratory and expiratory time over bronchial, broncho- muscle contractions create a force, putting pressure behind a
vesicular, and vesicular regions (Figure 8-12). closed glottis. In phase 4 the glottis opens as air is forcefully
Decreased Ti indicates respiratory muscle mechanics are expelled.100
impaired and is common in those with neuromuscular con- Cough effectiveness can be quantitated by measuring
ditions or postsurgical pain. Ventilatory pump dysfunction PCFR. Individuals having a PCFR of less than 160 L/min
310 Chapter 8
the exam.227 For individuals with neurological conditions,
TABLE 8-9. EXAMPLES OF swallowing dysfunction may be associated with weakness or
AEROBIC CAPACITY TESTING tone disorders related to the injury.228 Examination of the
spinal accessory nerves (cranial nerves XI) involves testing
● Bedside monitor with position changes muscles (trapezius and sternocleidomastoid) that may act as
● Sitting tolerance testing stabilizers of the head and neck or as accessory muscles to
support ventilation. A thorough examination of all the cra-
● Functional monitor/work-related tasks
nial nerves will also assist in identifying visual skills neces-
● Chair test sary for communication.
● Walking velocity/distance Aerobic Capacity
○ Velocity for over known distance Aerobic capacity may be very low in some individuals
○ 2-Minute Walk test or 3-Minute Walk test with ventilatory pump dysfunction. In some cases the person
with a neurological disorder may not be able to use periph-
○ 6MWT eral muscles to perform a formal exercise test. For these
● Modified stress test (arm, bike, or treadmill) individuals time sitting with or without support (binders,
chair supports, arm support, mechanical ventilation) may be
○ Modified protocol (predetermined end point:
a method for documenting physiologic response to activity.
HR, BP, workload)
The therapist can record signs of respiratory muscle fatigue
○ Endurance test (time at specified RPE, % VO2 or weakness.
or % HR) A test of aerobic capacity is performed in a manner that
● Formal stress test offers an appropriate progressive challenge of the neuromus-
cular system. The test will introduce an activity level that
RPE: rating of perceived exertion; VO2: O2 consumption.
raises the energy requirement and metabolic need for O2 and
thus ventilation. Examples of aerobic capacity testing are pre-
sented in Table 8-9. The goals of the exam are to determine
(2.7 L/sec) are below the threshold necessary for secretion whether the individual can participate safely in activity, to
clearance.226 This typically occurs when the FEV1/FVC is identify the “limiting factor” or the symptom (shortness of
below 60% predicted.4,99 breath [SOB], dizziness, leg fatigue) that causes the person to
Position the person in his or her preferred coughing pos- stop activity, and to gather information about how the body
ture to perform the exam, and ask the individual to inhale adapts to exercise (normal physiologic response or com-
deeply and cough forcefully. The cough can be graded as pensatory response).203 The information provided can help
“functional” if the individual is able to cough 2 to 6 times the therapist see whether the ventilatory pump is limiting
per breath.100,135 Document the position and any additional tolerance to activity and then decide which factors related to
trunk or arm motions used to assist the effort. The cough ventilatory pump dysfunction (respiratory muscle weakness,
may be “weak functional” if there is some expulsion of air, stiffness in the chest wall, hyperinflation) can be addressed
enough to partially clear secretions. Look to see which phase in the therapeutic POC.
of coughing is impaired and document what you observe Safety during activity involves analysis of all vital signs
“lacks inspiratory volume” or “poor glottis closure” or (HR, BP, RR, arterial O2 saturation) and signs and symp-
“unable to generate adequate abdominal muscle force.” The toms. In some cases electrocardiogram (EKG) and hemo-
proper treatment can be selected based on these observa- dynamic monitoring may be required (cardiac conditions,
tions. A “nonfunctional” cough will not generate enough history of recent medical instability). Because the individual
force to move secretions. with a ventilatory pump disorder may have comorbidities,
Cranial Nerve Integrity it is important to detect limitations to activity due to other
Examination of the cranial nerves will detect any prob- underlying conditions (heart disease, heart failure, periph-
lems with swallowing dysfunction that may lead to aspira- eral artery disease, extremity pain, etc). Impaired diaphrag-
tion and pneumonia. Dysphagia and impaired gag reflex are matic movement may also limit venous return and preload
predictors of the need for mechanical ventilation in indi- resulting in poor enhancement of cardiac output during
viduals with progressive neuromuscular disease.78 Therefore, activity.
examination of the glossopharyngeal, vagus, and hypoglos- If the ventilatory pump is limiting activity, the person will
sal nerves (cranial nerves IX, X, and XII) are a priority. Any display an increase in accessory muscle use and RR that is out
patient who has been intubated may have acquired damage of proportion to activity challenge.29 As exercise progresses
to the vocal cords and glottis. Examination of these nerves and ventilatory pump dysfunction worsens, the individual
includes listening to voice quality, observing swallowing of will complain of increasing SOB. There will be earlier and
a variety of substances, assessing elevation of the soft palate more dramatic elevations in RR, intercostals muscle retrac-
and position of the uvula during vocalization, and checking tion, blue-gray appearance, and decreased O2 saturation.
for a gag reflex. Movement of the tongue is also included in The risks of aerobic capacity testing must be balanced with
the purpose of the test and information needed to develop is respiratory. In this case the physical therapy diagno-
a sound therapeutic program. Therefore, submaximal test- sis is impaired ventilation and respiration associated with
ing is typically performed in those with ventilatory pump respiratory failure (Practice Pattern 6F will be discussed in
dysfunction. The 6MWT was originally developed for use in Chapter 9). Ventilatory pump dysfunction and failure occur
those with COPD and is the standard test used today.201,229 when respiratory muscle performance is affected, which
Recording measures of respiratory demand during activ- may be evident by diminished percentage predicted FVC,
ity can assist the medical team in understanding the risk PImax, PEmax, poor cough, abnormal breathing strategies or
of activity, adjusting medications and help therapist select abnormal rise in RR and extreme fatigue with ambulation.
interventions to improve activity tolerance. The response to Oxyhemoglobin desaturation is rare and elevation in CO2
exercise can be reexamined after offering support (O2, ven- more common unless the person has both ventilation and
tilator, abdominal binder, chair modifications). Most indi- gas-exchange impairments (advanced COPD).
viduals with ventilatory pump dysfunction will be limited Ventilatory pump dysfunction is distinct from ventilatory
by dyspnea or fatigue. Therefore, a Borg scale may be used pump failure. Ventilatory pump dysfunction occurs when
to measure rating of perceived dyspnea (RPD) or rating of respiratory muscle performance limits exercise training and
perceived exertion (RPE).29,230 higher functioning. Ventilatory pump failure results when
respiratory muscle function limits routine ADL.4,141,221
Ergonomics, Environmental, Home, and
When determining a POC for the individual with ven-
Work Barriers tilatory pump dysfunction, the therapist must review the
Examination of daily tasks performed in the home or examination findings to determine how pathologic processes
work environment will assist in deciding what accommoda- are impacting on respiration. Specifically, the therapist must
tions may be necessary for successful reintegration back to decide whether the ventilatory capacity diminished or if the
home and community-life roles. Routine tasks can be simu- load to the ventilatory muscle increased as a result of pathol-
lated in the clinic and measures of dyspnea, RR, RPE, RPD or ogy. Impaired respiratory muscle performance (low predict-
other physiologic indices limiting performance documented. ed PImax, PEmax, MVV, FVC) suggests ventilatory capacity
The therapist can draw on information from the interview is reduced. Limited chest wall expansion and restriction to
and responses to outcome measures to determine which passive movement, postural deformities, poor body posi-
tasks to simulate. An activity log may be used to document tioning, dynamic hyperinflation or structural narrowing of
routine tasks with a rating of the symptoms and a qualifier airways increase the ventilatory load. The therapist selects
defining the importance of the activity to the individual. interventions to effect body structure and function with the
Reviewing a log can be helpful in identifying which activities ultimate goal of decreasing the work of breathing. Reducing
are most challenging and a priority for instruction on energy the work of breathing may be documented by noting lower
conservation and task simplification strategies.231 dyspnea, RR, RPE or RPD values, more efficient breathing
patterns, deeper and more controlled breathing for activity.
The end result is improved activity tolerance, functional level
EVALUATION, DIAGNOSIS, and decreased dependence in ventilatory support. Examples
of goals for individuals with ventilatory pump dysfunction
AND PROGNOSIS are listed in Table 8-10.
Individuals with dyspnea and SOB are either limited

by ventilation (ability to move air into the gas-exchanging
regions of the lungs) or they may be limited by respiration
INTERVENTIONS
(the ability to move gas between the pulmonary circulation The therapist will select procedures and techniques to
and alveoli). After a review of the health condition and com- produce changes in ventilatory load or ventilatory capac-
ponents of body structure and function, the therapist looks ity. The application of any intervention requires a clinical
at the physical therapy examination findings to determine decision-making process that is ongoing and evaluative. The
whether the person has a problem with ventilation or a prob- individual’s response to each procedure or technique must be
lem with gas exchange. In many cases both may be present. observed, measured, and documented. This process has been
According to The Guide to Physical Therapist Practice, a referred to as “response dependent care.”232 This process is
person will have a physical therapy diagnosis of impaired essential during the acute stage or whenever the prescriptive
ventilation and respiration associated with ventilatory pump parameters of treatment are progressed. Responses to moni-
dysfunction or failure (practice pattern 6E) if muscle per- tor and document include RR, dyspnea, RPD or RPE, symp-
formance and/or breathing mechanics are the core reason toms of respiratory muscle incompetence (see Table 8-6), O2
for symptoms of dyspnea or poor tolerance to activity.92 saturation, HR, and BP.
If the person is experiencing oxyhemoglobin desaturation Airway clearance techniques and body positioning
and/or dyspnea due to destruction of the lung tissue, pul- are examples of interventions to reduce ventilatory load.
monary circulation or mucous and inflammation in the Intervention to improve ventilatory capacity may include
bronchioles and lung parenchyma then the primary problem enhancing respiratory muscle function to wean a patient
312 Chapter 8
TABLE 8-10. SAMPLE THERAPEUTIC GOALS*

COPD NEUROMUSCULAR
● Increase 6MWD by 50 feet with RPD ● Apply effective manual cough techniques to clear secretions
< 3/10 and O2 Sat > 90%. and prevent pneumonia (include caregiver or self-assist; describe
● Demonstrate pursed-lipped technique used to cough̶abdominal thrust, costophrenic
breathing and efficient coordi- assist).
nated breathing 90% of time when ● Increase chest wall expansion at xiphoid by one-half inch
performing dressing, household ● Decrease neck breathing and increase diaphragm component of
chores, and work-related tasks (spe- breathing pattern to 1 neck 3 diaphragm (or by 10%) when sit-
cific to patient goals). ting more than 4 hours.
● Increase PImax by 10 cc H2O in ● Increase participation in upper extremity activities by 20% of
order to prevent respiratory muscle time in therapy (or routine tasks at home) with RR < 20 with ade-
fatigue and lower risk for pneumo- quate posture support and seating.
nia (may use FVC or MVV as mea-
sures). ● Increase efficiency of transfers, bed mobility and ambulation
(select task and level) with RPD < 3/10 and decreased time/
● Postexercise chest wall expansion
increased distance.
will increase by 2 cm (demonstrat-
ing less hyperinflation with activity). ● Demonstrate proper use of coordinated breathing strategies dur-
ing ADL 90% of the time.
● Climb 12 steps with railing using
proper pacing to allow RPD < 3/10 ● Increase FVC 50 mL to improve reserve for activity (ambulation)
and O2 Sat > 90%. and inspiratory volume for coughing to lower risk for pneumonia.
6MWD: 6-Minute Walking Distance; RPD: rating of perceived dyspnea; O2 Sat: O2 saturation; PImax: maximal inspiration; RR: respiration
rate.
*Specific level of assist, person, goal-oriented tasks, and time frame to be added or modified according to context.
from a ventilator, using an abdominal binder to improve dia-

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211. Hergenroeder AL. Implementation of a competency-based assess- adults. J Strength Cond Res. 2007;21(1):91-95.
ment of interpretation of laboratory values. Acute Care Perspectives.
2006;15(1):7-15.
318 Chapter 8
During the admission, Mr. Fortnight was also diagnosed
CASE STUDY 8-1 with OSA and placed on CPAP ventilation via a mask with
O2 to assist his breathing. At the time of the initial physical
Jane L. Wetzel, PT, PhD therapy appointment he used the CPAP machine at night.
A review of his medical record showed the following
results from the pulmonary function tests performed dur-
EXAMINATION ing his admission: FVC (2.8 liters; 60% predicted); FEV1
(1.5 liters; 43% predicted; post-bronchodilator 2.0 liters; 57%
predicted); FEV1/FVC (0.53; 70% predicted) with diffusion
History capacity (DLCO) (20.50 mL/min/mm Hg; 61% predicted).
Current Condition/Chief Complaint

Mr. Fortnight was a 64-year-old obese, White, English-
Clinician Comment COPD is a term applied
to a variety of lung disorders. Specific tests and measures
speaking male referred to home physical therapy services
were reviewed in the medical record to determine the sever-
after a recent 3-week hospitalization for pneumonia and
ity of lung disease and type of impairment. Both FVC and
acute exacerbation of COPD. At the time of the initial
FEV1 were reduced; however, FEV1 was decreased more
physical therapy visit, Mr. Fortnight complained of “trouble
than FVC and the ratio of FEV1/FVC was less than 0.70,
breathing and having no energy” for most household activi-
suggesting obstructive disease.1 Therefore, the tissues were
ties. He reported a new onset of neck pain since using his
the primary component affected.
continuous positive airway pressure (CPAP) machine and
couldn’t seem to keep the CPAP mask on all night. Mr. Fortnight also had impaired ventilatory pump dysfunc-
tion as well since his FVC was decreased. Mr. Fortnight’s
History of Current Complaint tests indicated that he had stage II COPD (FEV1/FVC = 0.53
He was hospitalized after multiple visits to his physician [70% predicted] and FEV1 = 43% predicted).2 See Table 8-5
for a chronic cough and fever. A bronchoalveolar lavage earlier in the chapter.
was performed on day 2 of his admission. He was placed Prior to visiting Mr. Fortnight, the therapist reviewed the
on broad-spectrum antibiotics initially while awaiting the results of pulmonary function and the classification accord-
results of a sputum culture. The culture indicated he had bac- ing to the Global Initiative for Chronic Obstructive Lung
terial Streptococcus pneumonia. Chest radiographs revealed Disease GOLD criteria (see Table 8-5).2 The therapist also
an enlarged heart and consolidation in the right lower lobes referred to the Respiratory Impairment Classification to
(posterior basal division and lateral basal division). project potential function limited by dyspnea.3,4
RESPIRATORY IMPAIRMENT CLASSIFICATION3,4

Test/Observation Class 1 Class 2 Class 3 Class 4
0% Impaired 20% to 30% Impaired 40% to 50% Impaired 60% to 90% Impaired
Dyspnea Consistent with None at rest; occurs None at rest; occurs Dyspnea present at
activity demands during routine ADL. during routing ADL. rest and with activi-
Person can ambu- Person can walk ties such as climb-
late and keep pace 1 mile at his own ing stairs or walking
on level without pace but cannot 100 yards on level
SOB. Slow pace for keep pace with
stairs/hills others on level
FEV1 Not < 85% predicted 70% to 85% pre- 55% to 70% pre- < 55% predicted
dicted dicted
FVC Not < 85% predicted 70% to 85% pre- 55% to 70% pre- < 55% predicted
dicted dicted
O2 saturation Not applicable Not applicable Usually ≥ 88% at Usually < 88% at
rest and after rest and after
exercise exercise
Social History/Environment Two years prior to the physical therapy appointment, he
developed hemoptysis. A fiber optic bronchoscopy revealed
Mr. Fortnight lived alone in a 2-story house with 4 steps
significantly inflamed hemorrhagic mucosa in left upper
to enter. There was a railing on both sides of the entrance
lobe.
steps to enter the home and a railing to assist with the ascent
Mr. Fortnight had previous diagnoses of hyperuricemia
of the interior staircase. There were 3 bedrooms, including
and gouty arthritis at age 44 years, hypertension and hyper-
his bedroom, on the second floor with full bath. There was
lipidemia at 52 years, low back pain 54 years, Type II diabetes
a small bathroom with sink and toilet downstairs on the
at age 56 years, and renal insufficiency. Past surgical history
ground floor.
also included surgical repair of hernia at age 49 and tonsil-
He reported he was unable to climb the stairs to his bed-
lectomy age 12.
room as he had done prior to his hospitalization. He had
been sleeping on a couch located on the ground floor since Reported Functional Status
he returned home from the hospital. His house was messy, including a pile of dirty dishes are
He had 2 daughters who lived out of state, and a son and in the sink. He reported he had been unable to get upstairs to
2 close friends who lived nearby. He liked to bowl and golf. the bathroom to bathe. He reported he could walk only 40 to
Prior to the hospital admission, he was able to ride a golf cart 50 feet around his home at a time. He leaned on furniture as
and play 9 holes of golf. He golfed every other weekend. He he walked from one room to another. Mr. Fortnight reported
noted that 5 years prior he was able to walk and play 18 holes that, prior to his last exacerbation, he was able to manage
of golf. On most weekends, he spent time watching sports on stairs but needed increased time for ascending the flight of
television. stairs in his home, including one rest break when part way up
Employment/Work (Job/School/Play) and the use of the right railing. Prior to his last admission, he
reported he could walk 5 to 6 blocks before becoming SOB.
He was anxious about his recovery, especially with regard
to his job. Mr. Fortnight worked as a salesman in charge of Medications
marketing and advertisement for a large corporation. He Mr. Fortnight’s medical record showed the following
reported that he needed to return to work as soon as possible; medications5:
he was concerned that his sales region might be changed • Low-flow O2 (2LPM) via nasal cannula
during his absence to one with a lower potential for com-
missions. Further, the company had not been performing • Cefuroxime and erythromycin
as well lately but he reported that he could not consider a • Spiriva (tiotropium)
career change at the moment. As part of his job duties, Mr. • Ventolin (albuterol)
Fortnight needed to entertain clients during golf and dinner
events. He was also expected to participate in fundraising • Glucophage (metformin)
activities sponsored by his corporation. • Zyloprim (allopurinol)
Social/Health Habits • Zocor (simvastatin)
Mr. Fortnight smoked 2 packs of cigarettes per day, and • Diovan (valsartan)
had for 25 years. He tried smoking cessation classes with- • Cordarone (amiodarone)
out much success. He drank beer and smoked cigars with
his coworkers when golfing and bowling. He thought cigar
smoking was less harmful than cigarette smoking. He report- Clinician Comment Spiriva is a muscarinic
ed he would drink several martinis when out for dinner. receptor antagonist or anticholinergic agent. It primarily
acts on receptors located on smooth muscle cells and sub-
Medical/Surgical History
mucosal glands to inhibit smooth muscle contraction and
Mr. Fortnight was recovering from bacterial pneumonia mucus secretion, thereby causing vasodilation and secre-
(streptococcus) complicated by atelectasis and asthma. He tion management. Sore throat and dry mouth are common
had 2 prior admissions for coronary artery disease (CAD) side effects.
and COPD exacerbations and progressive worsening of
Ventolin is a short-acting beta2 agonist that works spe-
dyspnea. The first admission, 7 years prior to the physical
cifically on beta2 receptors in smooth muscle to cause
therapy appointment, was for an episode of respiratory aci-
relaxation. Because it is a beta2 specific drug it has little
dosis and severe SOB. During that admission, he received
effect on the heart. Ventolin is provided as an inhaler to
instruction in management strategies for asthma and a refer-
Mr. Fortnight to control wheezing, SOB and chest tightness.
ral to a smoking cessation program.
Using the inhaler 15 minutes prior to vigorous activity
On a subsequent admission, 4 years prior to this physi- such as climbing stairs may assist breathing.6 The therapist
cal therapy appointment, Mr. Fortnight was diagnosed with should observe the respiratory response to exercise and note
dilated cardiomyopathy due to significant CAD. A 3-vessel if there is increased distress in the period immediately post
bypass was performed. After his recovery, his cardiac ejec-
tion fraction improved from 35% to 50%.
320 Chapter 8
exercise. Side effects of Ventolin are tremors, dizziness, and Other Clinical Tests Identified in Chart
headaches. Review
Glucophage is a biguanide that acts to decreases hepatic Complete Pulmonary Function Testing
glucose production and absorption from the gastrointesti-
nal system. It also increases insulin sensitivity and glucose
uptake in peripheral cells. Hypoglycemia is a side effect PRE- POST-
that may be triggered by exercise.7,8 Prior to activity the Lung BRONCHO- BRONCHO-
therapist should review when the individual last took his Volume/ DILATOR DILATOR
Compart-
medication and when the medication peaks as well as ment Predicted Actual % Actual %
food intake to avoid hypoglycemia with Mr. Fortnight. Mr.
Fortnight should be asked to check his blood glucose with a FVC (L) 4.67 2.80 60%
glucometer before performing an exercise tolerance test or SVC (L) 4.67 3.10 66%
activity on stairs. Values below 100 mg/dL fasting would
suggest Mr. Fortnight may need carbohydrate supplementa- FEV1 3.48 1.5 43% 2.0 57%
tion prior to exercise.8 Observing for signs and symptoms FEV1/FVC .75 .53 705
of hypoglycemia during all treatment sessions, keeping a
PEFR (L/s) 7.40 3.84 52% 4.19 56%
source of carbohydrates available, and encouraging good
hydration would be critical for safe and effect treatment of TLC (L) 7.21 8.43 110%
Mr. Fortnight. FRC (L) 4.07 4.97 1225
Zyloprim is a xanthine oxidase inhibitor that is used to
RV (L) 2.41 3.46 135%
reduce the production of uric acid in the body. Elevated lev-
els of uric acid may cause gout attacks. Side effects include IC (L) 3.08 1.97 64%
gastrointestinal distress and drowsiness. RV/TLC 33 41 124%
Zocor is an inactive lactone that is hydrolyzed after inges- ratio (%)
tion to a β-hydroxyacid form. The biosynthesis of choles-
Diffusion
terol is limited by interfering with enzymatic actions. Side
effects include rhabdomyolysis, which is a process where DLCO 33.60 20.50 61%
skeletal muscle is damaged and myoglobin is released into mL/min/
the bloodstream. The myoglobin load can lead kidney mm Hg
damage. Statin dosage is also related to respiratory muscle Respiratory Pressures
strength due to induced muscle myopathy.9 Renal insuf-
ficiency may be due to rhabdomyolysis, hyperglycemia or MIP ‒108 ‒88 81%
dehydration. The therapist must be cognizant of fragile (‒ cc H2O)
kidney function and avoid muscle-damaging exercise. MEP 227 140 61%
Symptoms of muscle soreness may be due to rhabdomyoly- (+ cc H2O)
sis or eccentric myofibrillar damage.10
MIP: maximal inspiratory pressure; MEP: maximal expiratory pres-
Diovan is an angiotensin II receptor antagonist that blocks sure; SVC: slow vital capacity.
the action of hormones that act to constrict blood vessels.
Vasodilation occurs and increases blood flow to organs and
muscles while lowering BP. Side effects include headaches, Clinician Comment Prior to visiting Mr.
dizziness, back and joint pain, and excessive fatigue. Fortnight, the therapist reviewed the results of pulmo-
Cordarone is an antiarrhythmic that works by relaxing nary function and the classification according to GOLD
overactive heart muscle. It is may prevent serious, life- criteria (see Table 8-5).2 The therapist also referred to the
threatening ventricular arrhythmias. Side effects include Respiratory Impairment Classification to project potential
constipation, headache, loss of appetite, and sleeplessness. function limited by dyspnea.3,4 Mr. Fortnight’s FEV1 (43%)
was below 55% predicted but moved to 57% after using his
bronchodilator. His FVC was 60% predicted. The pulmo-
nary function tests indicated that Mr. Fortnight had the
potential to achieve Respiratory Impairment Classification
level 3 functionally if he used his bronchodilator. The FEV1
improved from 43% to 57% after bronchodilator use. The
DLCO was 61% predicted and indicated supplemental O2
might be needed to maintain a safe level of O2 saturation
during activity.11
Sleep Study BLOOD CHEMISTRY ADMISSION D/C
Apnea is defined as a complete cessation of airflow for at
least 10 seconds. Mr. Fortnight’s sleep study identified that he Hemoglobin (g/dL) 20 19
had 28 events in an hour. This placed him in the moderate Hematocrit (%) 56 54
sleep apnea category, as determined by the apnea hypoventi-
Platelet (cells/μL) 460,000 300,000
lation index.12 Further, there were 18 episodes of oxyhemo-
globin desaturation of greater than 4% lower than baseline. White blood cells 12500 8500
(cells/ccm)
Clinician Comment Sleep apnea was a new Glucose (g/dL random) 220 150
diagnosis for Mr. Fortnight. He most likely had OSA result- Creatinine (mg/dL) 1.5 1.3
ing from obesity, having a short wide neck, and poor sleep-
ing position. The number of apnea episodes are reduced Blood urea nitrogen 22 20
when the individual loses weight12 and learns to sleeps on (mg/dL)
his side with the head slightly elevated rather than supine
with head flat.13 Mr. Fortnight will need education in the
importance of weight loss and proper sleeping position.
Clinician Comment Laboratory val-
ues indicated that Mr. Fortnight was in partially com-
Sleeping position or mask position may also be contributing
pensated (HCO3 – = 32 mEq/L) respiratory acidosis
to his neck pain.
(pH = 7.32; PaCO2 = 68 mm Hg), and had hypoxemia
(PaO2 = 56 mm Hg; O2 Sat = 87%).14 His white blood cells
were elevated, signaling an infection was likely. Elevated
Chest X-Rays
creatinine and blood urea nitrogen indicated the possibil-
A chest X-ray taken at discharge revealed an enlarged ity of mild renal insufficiency, but may also have indicated
heart, elevated aortic arch, flattened diaphragms with 7 ribs that Mr. Fortnight was dehydrated.18 His hematocrit and
showing above the right hemidiaphragm. Ribs were horizon- hemoglobin were elevated, suggesting mild polycythemia.
tal in appearance. The right lower lobes (lateral and posterior Individuals with Type II diabetes mellitus have impaired
divisions) were clear without infiltrates. fibrinolysis so Mr. Fortnight may have had an increased
risk for clot development.
Clinician Comment The pulmonary func-
tion tests results identified in the chart review indicated
increased FRC, RV, and TLC typically seen with an indi- Cardiac Studies
vidual with obstructive airways disease. These lung vol- A heart catheterization study completed 4 years prior to
ume measures and the flattening of the diaphragm with the physical therapy appointment indicated Mr. Fortnight
horizontal ribs on the chest X-ray indicate hyperinflation at had diffuse CAD in most coronary arteries with major ste-
rest.14 The RV/TLC ratio indicates that air trapping is wors- nosis in the left main (75%), left diagonal (80%), and left cir-
ening when the increase in RV is greater than the increase cumflex (84%) and an ejection fraction of 35% post-coronary
in the TLC. As FRC and RV increase, the IC decreases. The artery bypass grafting (CABG), which improved to 50% by
IC decrease is due in part to the changes in length tension of discharge. During the most recent hospital admission, an
the intercostals muscles and diaphragm, resulting in a loss echocardiogram was performed and revealed an ejection
of contractile force.15,16 The respiratory muscle pressures fraction of 55%. Electrocardiogram (EKG) showed normal
(MIP = 81% predicted and MEP = 61%) confirm weakness sinus rhythm with right ventricular hypertrophy and no evi-
to both the inspiratory and expiratory muscles.17 dence of myocardial infarction.
Clinician Comment Cardiac pump failure

Lab Values or pulmonary hypertension could have been contraindica-
tions to exercise. There were no comments in the medical
ARTERIAL BLOOD GASES ADMISSION D/C record history about pulmonary hypertension and no com-
FIO2 Room Air 24% ments about blood-streaked sputum. The ejection fraction
was 55% and the EKG demonstrated normal sinus rhythm,
PaO2 (mm Hg) 56 65 indicating good cardiac function. Exercise can improve
PaCO2 (mm Hg) 68 55 the fibrinolytic process, augment the immune system,
improve glucose uptake, and reverse deconditioning for Mr.
pH 7.32 7.40 Fortnight.8 Activity and endurance training are important
‒
HCO3 (mEq/L) 32 29 for Mr. Fortnight to return to his social and occupation
roles.
O2 Saturation (%) 87 93
322 Chapter 8
At discharge the oxyhemoglobin saturation was acceptable have limited venous return and increased the vascular
at rest when Mr. Fortnight was placed on supplemental O2 load in the venous system. Increased capillary hydrostatic
(2LPM). The blood gas values were compensated (pH = 7.40) pressure can cause a shift to extracellular compartments.
and PaO2 increased as the lung consolidation resolved. Any Monitoring Mr. Fortnight’s weight should be included in
gas-exchange problems at rest are related to obesity and the POC to note any increase in extracellular fluid, which
poor ventilatory pump mechanics. During activity, there is could occur with heart failure. Routine auscultation before
a risk for worsening of gas exchange due to dynamic hyper- and after exercise may help the clinician detect earlier signs
inflation, ventilation perfusion mismatch, and respiratory of heart failure (rales, S3 heart sounds) that contraindicate
muscle fatigue. Mr. Fortnight would need to be told to keep exercise. This activity may induce cardiac decompensation.
hydrated because his creatinine and blood urea nitrogen Mr. Fortnight’s high resting HR may have been due to anxi-
were still elevated. Hematocrit and hemoglobin were still ety, poor O2 use, or deconditioning. The BP was normal for
elevated so fatigue was less related to O2-carrying capacity his age20 but was controlled by Diovan. The therapist con-
or blood quality. The white blood cells were in the normal firmed Mr. Fortnight had taken his medication on the day
range by discharge and he no longer had a fever, indicating of the initial physical therapy visit. Mr. Fortnight’s report
the infection was controlled. At discharge, Mr. Fortnight of his typical BP matched the measured BP as well as the
was instructed to establish a regular time for taking glu- measures recorded in his medical record.
cophage, to eat regular meals, and to monitor his glucose
Dyspnea ratings were added to his systems review to docu-
intake prior to activity. He was placed on a low-salt and
ment the impact of impaired respiratory mechanics on the
low-calorie diet. Weight loss may reduce sleep apnea events
ventilatory pump at rest. Although dyspnea would likely
and decrease the work of breathing.12
limit Mr. Fortnight’s activity, it was important to recognize
Mr. Fortnight would likely be limited in activity because that each person differs in ability to cope with symptoms of
of reduced expiratory airflow caused by poor elastic recoil dyspnea and fatigue. Ultimately, the use of breathing con-
that could lead to dynamic hyperinflation. The airway trol, pacing and coping with symptoms may override Mr.
resistance due to asthma could be managed by proper use Fortnight’s pulmonary impairments and permit increased
of an inhaler prior to activity. Obesity and deconditioning physical functioning.
may also contribute to the dyspnea limited exercise.
Fatigue ratings at rest were also included to document base-
The interview and the chart review had not identified any line effects of O2 uptake in the periphery. These symptoms
contraindications to exercise and physical therapy for Mr. were likely limitations to activity for Mr. Fortnight. and
Fortnight. Next in the examination was the systems review. resulted from impaired O2 transport. It was important to
gather baseline symptoms reflecting cardiopulmonary sta-
tus prior to performing tests and measures to avoid causing
Systems Review excessive fatigue.
Cardiovascular/Pulmonary (Resting Values)

• HR = 88 Integumentary
• BP = 138/86 • Old scar over the anterior chest wall from prior ster-
notomy
• RR = 18
• Foot calluses medially over first toe and metatarsal
• Dyspnea rating = 0/10 (CR 10 Borg scale for dyspnea)19
• Flaky skin around heels and longitudinal arch
• Fatigue rating = 1/10 (CR 10 Borg scale for RPE)
• O2 saturation = 93% on 2LPM Clinician Comment Calluses and dry skin are
• Edema = 1+ pitting edema bilateral ankles common in individuals with Type 2 diabetes.
• Change in weight = 277 pounds (279 pounds at dis-
charge); loss of 2 pounds
Musculoskeletal
Clinician Comment Bilateral ankle edema • Height = 71 inches (5 feet, 11 inches)
can occur with obesity, heart failure or renal insufficiency. • Weight = 277 pounds
Fluid shifts may occur because of positional changes when • Gross ROM = within functional limits except mild hip
standing upright for prolonged period of time or with flexion contractures bilaterally
immobility. Mr. Fortnight did not move around much
so muscle contraction did less to assist venous return. • Gross strength = generalized weakness throughout bilat-
Additionally, impaired diaphragmatic mechanics could eral upper and LEs
Neuromuscular Tests and Measures
Gait
Arousal, Attention and Cognition
Short steps, waddling with lateral weight shifting, occa-
sional reaching for furniture. Mini-Mental Exam: Score 24; Difficulty with serial 7s and
spelling “world” backward and complex commands.22
Balance Trails A = 35 seconds; Trails B = 78 seconds (low average
• Intact static and dynamic sitting balance for both).23
• Dynamic standing balance impaired.
Locomotion, Transfers, and Transitions Clinician Comment Individuals with OSA
• Preferred to sit on chairs with high seat height and arm- and hypoxia may have attention and learning deficits.
rests. The most consistently affected cognitive functions in those
with sleep apnea are vigilance, sustained attention, con-
• Moved in a routine path from living room through the
trolled attention, efficiency of information processing, and
dining room to the kitchen holding furniture.
response time.24 Learning and memory may also be affect-
Communication, Affect, Cognition, ed. Mr. Fortnight demonstrated low average functioning for
Language, and Learning Style attention. This finding suggested that a component of the
POC would need to include monitoring of Mr. Fortnight’s
Mr. Fortnight was anxious about returning to work. He ability to remember exercises and recall important facts
was alert during 80% of the physical therapy visit but had about disease management (eg, proper use of inhaler).
occasional lapses in attention. Mr. Fortnight had a sense of
humor. He demonstrated interest in managing his recovery
by asking questions about diet, energy for activity, and use
Anthropometric Characteristics
of O2.
BMI = 38.5; falls in the “obese” category.25
Clinician Comment Mr. Fortnight had diffi-

culty remaining attentive during the interview and systems Clinician Comment Obesity imposes mechan-
review. In planning the Tests and Measures portion of the ical effects whereby fat mass makes the chest wall stiffer
examination, his arousal, attention, and cognition needed and less compliant. Obesity also reduces lung compliance
to be assessed. and increases airway resistance, especially in the supine
Obesity may impose an increased ventilatory load to the position.26 The person who is obese adjusts to increased
respiratory muscles, adding a restrictive component to the elastic and resistive loads by decreasing TV and increas-
disorder.21 Obesity also increased his risk for comorbidities ing RR.27 The therapist noticed Mr. Fortnight had shallow
such as diabetes and atherosclerosis, as well as increased breaths with a relatively high RR at rest. In severe obesity
the overall demand to working muscles raising the metabol- hypoventilation syndrome individuals have hypoxemia and
ic requirement for activity. Since obesity can be a contrib- hypercapnia, resulting in abnormal ventilatory control and
uting factor to sleep apnea as well as breathing disorders, an inability to compensate for low TV with high RR.28 Mr.
anthropometric measures were indicated. Additionally, his Fortnight was still compensating while awake and sitting
posture and his level of pain needed to be assessed. upright.
The systems review indicated additional tests and mea-
sures of integument, ROM, and muscle performance were
indicated. Further tests and measures of his ventilation Pain
and gait were indicated from the systems review but were Mr. Fortnight rated his neck pain at rest as 4/10 on the
also factors to consider prior to any aerobic capacity testing. numeric rating scale. Pain increased to 6/10 with cervical
The therapist planned an exercise tolerance test as part of flexion, rotation, and lateral flexion (right [R] > left [L]).
the examination, expecting the performance to be limited
by dyspnea and fatigue since cardiac dysfunction, pulmo- Posture
nary hypertension, and anemia were ruled out as potential Mr. Fortnight had a barrel chest appearance, slight-
activity limitations during the chart review and no red flags ly rounded shoulders, forward head, and mild thoracic
for testing were revealed in the review of systems. Given kyphosis.
that regaining function was a prime consideration for Mr.
Fortnight, a more thorough baseline needed to be defined
for self-care and home management as well as work, com-
Clinician Comment Kyphosis of the thoracic
spine is correlated with FVC and FEV1.29 The therapist also
munity, and leisure reintegration.
examined the mobility of the spine and shortened muscle
groups that may be contributing to rounded shoulders.
324 Chapter 8
In addition, decreased chest expansion can occur after Range of Motion (Including Muscle Length)
CABG. Mr. Fortnight strictly followed sternal precautions Cervical Range of Motion
that caused abnormal habitual postures that could still
be correctable. Although only preliminary evidence exists, MOTION ACTIVE PASSIVE
exercises directed toward correcting these deformities may RANGE RANGE̶SLIGHT
improve respiratory pressures and efficiency of breathing.30 OVERPRESSURE
Flexion Full Full
Integumentary Extension 35 degrees 40 degrees

Mr. Fortnight’s skin color had a gray tinge. There were no Right lateral 30 degrees* NT
skin abrasions from the CPAP mask. Upon further inspec- flexion
tion of Mr. Fortnight’s feet, additional calluses laterally over Left lateral flexion 40 degrees 45 degrees
the fifth toe and middle of the transverse arch were noted.
Mr. Fortnight wore gym shoes with a firm heel counter, Rotation right 50 degrees* NT
undercut heel, and a rubber insole he purchased from the Rotation left 55 degrees 60 degrees
pharmacy. Inside the shoes the toe box was worn on the lat- *= painful 6/10.
eral and medial sides. Aside from callused areas, peripheral
sensation was intact. Upper and Lower Extremity
Circulation Range of Motion
Radial pulse was regular with strong upstroke at a rate of Mr. Fortnight had AROM that was within normal limits
88 beats per minute (bpm). Dorsalis pedis pulse was weak bilaterally except for the measurements indicated here.
but palpable bilaterally. Auscultation of the heart revealed no
pathological sounds. MOTION ACTIVE PASSIVE
(BILATERAL) RANGE RANGE
Ventilation
Auscultation of the lungs identified clear lung fields Shoulder flexion 165 degrees 170 degrees
with diminished sounds in the right lower lobes; lateral Shoulder abduction 160 degrees 165 degrees
and posterior divisions. There were no wheezes heard since
Shoulder external 75 degrees 80 degrees
Mr. Fortnight used his inhaler prior to the therapy session.
rotation
Respiratory pattern was shallow. The breathing pattern dem-
onstrated excessive movement of the upper chest and shoul- Hip extension ‒15 degrees ‒15 degrees
ders and decreased lower costal expansion. The chest wall Ankle dorsiflexion* 0 0
was over-expanded with little movement in the lower costal
*Same ROM with knee flexion and fully extended.
region. His cough was functional and Mr. Fortnight reported
he produced about 2 tablespoons of white/yellow mucous a Muscle length tests indicated shortening in bilateral ster-
day. Mr. Fortnight could count aloud to 20 in one breath. nocleidomastoids, scalenes, upper trapezius R > L, levator
scapulae R > L, pectoralis major, hip flexors and gastroc-sole-
us muscles. Pain was reproduced with palpation at the origin
Clinician Comment Examination of pain, of the sternocleidomastoid muscle and with lengthening of
integumentary, circulation, and ventilation are prioritized
the upper trapezius. Since Mr. Fortnight sleeps on his left
early in the set of tests and measures and always before
side, the right lateral flexors and trapezius were shortened.
activity. It is important to establish a good baseline for
vitals, to screen for signs and symptoms of heart failure (S3 Chest Wall Expansion
heart sounds, rales, increased body weight or 1 to 2 pounds • Axillary: 1.20 inches (3.0 cm; 3.3 cm = age-based
overnight) and identify any contraindications to exercise norm)31 change with VC breathing
(abnormal pulse rate or rhythm). ROM, muscle perfor-
• Xiphoid: 1.15 inches (2.9 cm; 4.1 cm = age-based norm)
mance, and activity examinations may need to be modified
change with VC breathing
to protect the skin and minimize pain. An aerobic capac-
ity test should be pain free in order to fully examine the Muscle Performance (Including Strength,
status of the cardiovascular and pulmonary systems. The Power, and Endurance)
selection of exercise mode for activity tolerance testing may
be influenced by pain or skin breakdown, especially if the All manual muscle tests were within functional limits
extremities are involved. Since Mr. Fortnight has neck pain, except bilateral:
the therapist prioritized this cervical ROM exam prior to • Hip abductors = 4/5
extremity exam for this measure. • Dorsiflexors = 4/5
• Plantar flexors = 3/5
Five times sit to stand (STS) = 14.2 seconds (age-based • Timed Up and Go (TUG) test = 8 seconds (low risk for
performance > 11.4 seconds indicates below average in LE falls)37
power).32,33
Short Performance Physical Battery
Score = 8 (mild limitations)38
Clinician Comment The 5 times STS test
exhibits moderately high correlations with 1-repetition
maximum isotonic leg press strength in older adults and is Clinician Comment One of the goals of physi-
thus used as a functional test of strength.34 Bohannon per- cal therapy for Mr. Fortnight would be to prevent mobil-
formed a meta-analysis (13 papers meeting inclusion crite- ity disability and future hospitalizations. Individuals with
ria) and reported that individuals with times exceeding the a gait speed below 0.6 m/s are known to have 3 times
following have worse than average performance: 11.4 sec- greater risk than those who walk 1.0 m/s or faster.39 Mr.
onds (60 to 69 years), 12.6 seconds (70 to 79 years), and Fortnight was approaching a risk threshold that would
14.8 seconds (80 to 89 years).33 The STS is reliable, valid, greatly increase his chances of a future hospitalization. Mr.
and able to identify individuals with balance deficits.35 In Fortnight has an SPPB score of 8. Guralnik et al reported
this case the STS test was selected to assist in quantifying that individuals with SPPB scores of 7 to 9 had a relative
LE power since the manual muscle tests were 5/5 for most risk of 1.6 for developing ADL disability over a 4-year peri-
muscle groups. Manual muscle testing had reached a ceil- od when compared to scores of 10 to 12.38 A 1-point change
ing and would not show incremental improvement. The in SPPB score represents a meaningful difference in the
therapist also wanted to measure functional performance risk for future mortality and nursing home admissions.40
and would include the STS results in the Short Performance Recently, the SPPB was selected as an outcome measure
Physical Battery (SPPB) test.36 The score on the SPPB would to justify the impact of physical therapy as a cost-effective
be used to document risk for mobility disability. General measure for managing physical performance and prevent-
muscle weakness may be a side effect of Zocor. ing long-term disability in individuals with COPD.41
Gait, Locomotion, and Balance Aerobic Capacity/Endurance Conditioning

Gait
Seated Step Test
• 4-meter walk = 6 seconds (67 m/sec) Results were as follows42:
• Ambulated independently 40 feet without device. Mr.
Fortnight used a wide-based gait, short step length, and
WORKLOAD HR BP O2 DYSPNEA RPE
occasional foot slap. He was limited by dyspnea and
AND TIME SAT
fatigue (RPD = 4/10; RPE = 6/10; O2 saturation = 92%
[O2 2 LPM]). He said he didn’t think he could walk any Rest 88 138/ 93% 0/10 1/10
more that session. 86 (2L)
• He reported he used a cane in his right hand when walk- 6 inch step/ 96 144/ 92% .5/10 2/10
ing from the house to the garage to get to the car. 7 min 84
• He reported that prior to his more recent hospitalization, (2.3 METs)
his walking distance capacity was limited to 4 to 5 blocks 12 inch 115 150/ 92% 2/10 4/10
because of SOB. step/7 min 84
Locomotion, Transfers, and Transitions (2.9 METs)
• Independent supine to sit; STS using armrests. 18 inch/2 min 130 156/ 90% 5/10 6/10
• He reported that he needed the cane to help when lower- (3.5 METs) 88
ing himself onto the low seat of his car and again when 18 c arms NT
rising from the low car seat.
(3.9 METs)
• He managed stepping up and down curbs with assist
from the cane or by leaning on objects or companions. Postexercise 92 136/ 93% 0/10 2/10
As during the interview, he reported that he was unable 2 minutes 84
to climb flight of stairs. METs: metabolic equivalents; O2 Sat: O2 saturation; RPE: rating of
perceived exertion.
Balance
• Sitting balance: Intact static and dynamic. Interpretation: Adaptive HR and BP throughout with
• Standing balance: Static held semi-tandem posture for mild oxyhemoglobin desaturation from 93% to 90% while
12 seconds, full tandem for 8 seconds (> 10 seconds = using 2 LPM O2. Mr. Fortnight was limited by LE fatigue
normal). (RPE 6/10). Test terminated because of fatigue. Postexercise
326 Chapter 8
recovery 90% complete in 2 minutes with lungs clear and
Mr. Fortnight to be well rested for the test. Recently the
without wheezes or rales. No S3 noted.
2MWT was found to be significantly correlated with the
Two-Minute Walk Test 6MWT (r = 0.937, p < 0.01) and VO2max (r = 0.555, p < 0.01)
Results with cane on R (conducted on second visit). in individuals with COPD.43 The 2MWT also demonstrat-
Distance 63 meters with 3 standing pauses (Norm = ed responsiveness to rehabilitation as significant improve-
130 mean for 70-year-olds)43 ments are reported after rehabilitation for 2MWT distance
(17.2 ± 13.8; moderate effect size 0.61) and change in 2MWT
are significantly correlated with change in 6MWT (r = 0.70,
ACTIVITY HR BP O2 SAT DYSPNEA RPE
p < 0.05).
(2 LPM)
Rest 84 134/86 94% 0/10 1/10
Peak 2 112 NT 92% 3/10 6/10 Self-Care and Home Management
minutes A more specific survey of his self-care and home manage-
ment further showed Mr. Fortnight was limited by fatigue
Post-1 96 145/88 92% 2/10 4/10
and dyspnea for most household chores. He could not wash
minute
dishes to clean up after eating. His son helped with laundry
Post-5 82 132/84 94% 0/10 1/10 and general household cleaning duties (vacuuming and dust-
minutes ing). Mr. Fortnight sat on a chair to shave and wash up. He
O2 Sat: O2 saturation; RPE: rating of perceived exertion. could not reach his feet to dry them after bathing. He was
unable to don socks and so walked barefoot or wore only
slip-on shoes.
Interpretation: Adaptive HR response to exercise with
mild oxyhemoglobin desaturation. The test was limited by Work, Community, and Leisure
fatigue. Recovery was complete within 5 minutes. There were Reintegration
no adverse physiologic responses. The below average distance Mr. Fortnight was dependent on his son to take him gro-
covered by Mr. Fortnight was below threshold for commu- cery shopping and to medical appointments. He had little
nity functioning. energy for carrying shopping bags or emptying trash. His
memory was sometimes “foggy” so he depended on his son
Clinician Comment The therapist chose the to help him remember what the health care professionals rec-
seated step test to examine the cardiovascular and pulmo- ommended. He did not perform any outdoor maintenance
nary response to exercise. A graded exercise test (seated step to his home. Mr. Fortnight was unable to return to work or
test) was used in addition to endurance walking (2-Minute participate in golf outings.
Walk Test [2MWT] conducted on second visit, session 2).
Physiological responses from the graded exercise toler- Clinician Comment Mr. Fortnight’s report of
ance testing were reliable and results compare well with activities limited by fatigue matches the results of aerobic
self-reported measures of functional status.44 Because Mr. capacity testing. His activity level was limited by fatigue to
Fortnight had balance deficits and the exam was being 3.5 METs. He had decreased walking endurance (63 meters
conducted in the home setting, this test was feasible and with 3 pauses). MMRC dyspnea rating = 3 (stops for breath
allowed an accurate examination of BP response to activ- after about 100 m or after a few minutes on the level).45
ity. It is easier to measure BP during this test than during a
The MMRC Dyspnea Scale is a 5-point self-report scale
walking activity. Monitoring of BP during a walk test may
that examines SOB with routine activity. The MMRC is
invalidate the results and interpretation of walk distance.
reliable and has concurrent validity with the Oxygen Cost
The limiting factor for Mr. Fortnight was fatigue. The
Diagram, the BDI, and the SGRQ in persons with COPD.45
presentation of fatigue supported the hypothesis of decon-
The MMRC requires less than 2 minutes to complete and is
ditioning and generalized weakness as major findings.
therefore easier for clinicians to administer. Additionally,
Dyspnea and oxyhemoglobin desaturation likely contrib-
the results of the MMRC are useful in applying the BODE
uted to fatigue since less than optimal blood quality was
Index score.46,47 The BODE Index is used widely to predict
delivered to the muscles. The HR and BP were adaptive
risk for mortality in persons with COPD by classifying the
and suggested that activities at 3.5 metabolic equivalents
individual according to FEV1 % predicted, 6MWT distance,
(METs) would be safe and that his medications were appro-
MMRC dyspnea scale, and BMI. The higher the BODE
priate for controlling BP during activity. Fatigue may also
Index score, the greater the risk for mortality and hospital-
be a side effect of Diovan.
ization.47,48 Mr. Fortnight had an estimated BODE Index of
Since Mr. Fortnight could manage only 40 feet during the 6 out of 10. His risk for hospitalization was about twice that
initial exam, a 2MWT was selected as an outcome mea- of someone with a BODE score of 0 to 2.48
sure. The test was conducted on the second visit to allow
Practice Patterns 6B: Impaired Aerobic Capacity/Endurance
BODE Index
Associated With Deconditioning; 4B: Impaired Posture; 4C:
VARIABLE POINTS ON BODE INDEX Impaired Muscle Performance; and 5G: Impaired Motor
Function and Sensory Integrity Associated With Acute or
0 1 2 3 Chronic Polyneuropathies.49
FEV1 (% pre- ≥ 65 50 to 64 36 to 49 ≤ 35
dicted)
Disability, and Health Model
6MWT (meters) ≥ 350 250 to 150 to ≤ 149
See ICF Model on p 328.50
349 249
MMRC 0 to 2 3 4 Prognosis
Dyspnea Scale 1
Mr. Fortnight had a good prognosis for reversing his
BMI > 21 ≤ 21
deconditioning and improving his functional abilities from
household level to limited community ambulation including
Mr. Fortnight was at risk for rehospitalization and had stair climbing.
a moderate risk for long-term mobility disability (BODE Mr. Fortnight’s goal of returning to work was dependent
Index = 6, SPPB Score = 6, Gait Speed = 0.67 m/sec). He on consistent follow through with therapeutic exercise pro-
had stage II COPD with an FEV1 of 43% predicted, which gram as well as disease management and risk-prevention
improved to 57% predicted with appropriate bronchodi- strategies.
lator use. He required education on sources of infection
(dirty dishes), fall prevention (foot wear, wet feet), proper Plan of Care
use of inhaler, and functional/aerobic training in order to
return to independence in ambulation of 5 blocks and stair Intervention
climbing.
Mr. Fortnight required a detailed therapeutic plan to
return to limited community ambulation, manage stair
ambulation, and implement strategies to prevent falls, infec-
EVALUATION tion, and mobility disability. The therapeutic plan would
include gait, locomotion, and balance training, assistive
device training, aerobic conditioning, respiratory muscle
Diagnosis training, resistive exercise (hip abductors, dorsiflexors, plan-
tar flexors), flexibility and stretching (anterior chest wall,
Practice Pattern
cervical muscles), posture exercises, energy conservation
Mr. Fortnight was post-hospitalization for pneumonia strategies, breathing control techniques, sleep position, and
and acute exacerbation of his COPD. He was newly diag- environmental reorganization. Further, Mr. Fortnight would
nosed with sleep apnea, had a new onset of neck pain, and need to learn to incorporate energy conservation and breath-
was deconditioned. He had several comorbidities (hyperten- ing control during his ADL and instrumental ADL (IADL)
sion, gout, renal insufficiency, diabetes, and obesity) that training. Education was indicated on proper use of inhaler
required monitoring and modification of therapeutic ses- prior to exercise, importance of using assistive devices to
sions. Mr. Fortnight had no contraindications to activity but prevent falls, modification of environment (removing dirty
was at risk for mobility disability and rehospitalization. dishes, throw rugs, unstable furniture) and home exercise
Mr. Fortnight had poor posture, obesity, and hyperin- program.
flation restricting air flow into the lungs. There was also
some lung tissue impairment and V/Q mismatch resulting Proposed Frequency and Duration of
mild gas-exchange dysfunction at rest and with activity. Physical Therapy Visits
Ventilation and gas exchange was worse at night as obstruct- Mr. Fortnight would be scheduled for physical therapy,
ed airways caused apnea and severe arterial O2 desaturation. 3 times per week for 4 weeks, in his home. Each session
CPAP was required to prevent CO2 retention and hypoxia. length would be 45 minutes.
These findings are consistent with Practice Pattern
6E: Impaired Ventilation and Respiration/Gas Exchange
Anticipated Goals
Associated With Ventilatory Pump Dysfunction or Failure.49 1. Mr. Fortnight will correctly perform flexibility exercises
Since his lungs became clear and pneumonia resolved, the to increase anterior chest wall motion and improve pos-
remaining gas-exchange problems were primarily resulting ture (1 week).
from hypoventilation. Although the lungs were hyperinflated, 2. He will use pursed lip breathing, pacing and coping
the airways collapsed easily and the abnormal mechanics of strategies with verbal cuing during exercise sessions 60%
breathing limited the volume of new air reaching the alve- of the time (1 week).
oli which caused hypoventilation. Mr. Fortnight also fit in
328 Chapter 8
ICF Model of Disablement for Mr. Fortnight

Health Status
• COPD exacerbation
• Sleep apnea
• S/P Pneumonia

Function
• Walking limited to house • Work-medical leave
• Ventilation • Unable stair climbing • Unable to golf
• Gas exchange • Difficult transfers; low seats • Watches TV
• Obesity • ↓ Endurance for • MMRC = 3
• Poor posture housework
• Deconditioning • Assisted outside home
• Strength • SPPB score = 8
• Balance • Gait speed = 0.67 m/sec

• Age = 64 years • Lives alone
• Comorbidities/medications • Unclean household
• Sleep habits/difficult CPAP mask • Home bound for therapy
• Motivated to return to work • Limited exercise equipment
• Anxiety over loss of work • Son willing to assist
• Diet/calorie restriction
• Coping ability?
3. Mr. Fortnight will be able to repeat preliminary instruc- rehabilitation program. Mr. Fortnight understood, and
tions for home safety and his own health management agreed with, the POC.
follow through with the instructions > 90% of the time
(1 week).
4. He will lift 5 pounds against gravity weight-training INTERVENTION
exercises for hip abduction, red Theraband against grav-
ity for dorsiflexion, and perform 5 unilateral toe raises
through full ROM (2 weeks). Coordination, Communication, and
5. His neck movements will be symmetrical, without Documentation
symptoms (3 weeks).
Prior to the initial physical therapy visit in Mr. Fortnight’s
6. He will be able to walk 90 meters with RPD ≤ 2/10 and home, the therapist coordinated with the home health agency
RPE ≤ 4/10 during the 2MWT with only one rest break for a complete review of Mr. Fortnight’s medical record. The
(3 weeks). schedule of Mr. Fortnight’s treatment sessions were set-up to
7. He will be able to climb 12 stairs with 2 rests and RPD best manage his fatigue as well as to not interfere with the
<3/10 (3 weeks). visits by his home health nurse.
8. Mr. Fortnight will achieve a time of < 12.5 seconds on Communication with the referring physician, Mr.
the 5 times STS test (3 weeks). Fortnight’s home health nurse and Mr. Fortnight’s fam-
9. He will have no loss of balance when walking around ily highlighted his primary limiting factor of fatigue and
obstacles or when bending forward to retrieve items potential hypertensive response with activity. Consequently,
from the floor (4 weeks). consistent vital signs monitoring occurred, especially during
activity. The therapist’s concerns regarding Mr. Fortnight’s
10. Mr. Fortnight will be independent in IADL ≤ 3 METS fatigue and his Diovan medication were communicated to
performed slowly while incorporating breathing control his referring physician in a phone call and his physician
techniques > 90% of the time (4 weeks). adjusted the dose. The therapist planned to follow-up with
11. Mr. Fortnight will demonstrate an SPPB score of ≥ 10 and Mr. Fortnight’s physician by phone to report Mr. Fortnight’s
gait speed of ≥ 80 m/sec in order to decrease the risk of responses to exercise after the medication adjustment at the
mobility disability and rehospitalization. reexamination.
12. Mr. Fortnight will increase the TUG to ≤ 6 sec to Any patient-related instructions would be provided in
decrease the risk for falls. writing to address Mr. Fortnight’s mild cognitive impair-
ment. Mr. Fortnight and his son were informed of the impor-
Expected Outcomes (4 Weeks) tance of cleanliness in the house, creation of a fall risk-free
1. Mr. Fortnight will be independent in all ADL with RPD home environment and Mr. Fortnight’s consistent participa-
< 3/10 including stair climbing to the second floor bath- tion in the therapeutic recommendations. Specifically these
room in his home. were: use of an assistive device for ambulation, adjustment
2. He will be independent with moderate distance com- of Mr. Fortnight’s sleep position, and his compliance with
munity ambulation with an assistive device and have a the home exercise program. The therapist communicated
lower risk for falls, mobility disability, and rehospitaliza- with the nutritionist to ensure that Mr. Fortnight’s weight
tion. loss plan would still offer calories required for exercise and
overall energy. The adjusted nutritional supplements were
3. Mr. Fortnight will be modified independent in return to
adequate to support his anticipated increased activity level
work for 4 hour sessions, 20 hours per week.
without increasing sugar or offering excessive protein load
4. Mr. Fortnight will be minimally assisted with IADL for to his kidneys.
grocery shopping, household management (gardening Documentation included the initial evaluation, treatment
and lawn care) and supervised for activities that are sessions and reexamination using the home health agency
≤ 4 METs applying energy conservation and breathing forms and in accordance with professional standards.
control strategies 100% of the time.
5. Mr. Fortnight will use safe practices when transporting
O2 and apply self-monitoring of breathlessness and O2
saturation 100% of the time. Mr. Fortnight and his son were educated on the risk of
infection including the importance of regular hand washing
Discharge Plan and keeping away from individuals with colds or viral infec-
It was anticipated that Mr. Fortnight would be able to tions. Mr. Fortnight was educated in energy-conservation
meet or exceed the anticipated goals and expected outcomes techniques, signs and symptoms of infection as well as the
in 4 weeks. With the anticipated improved function after benefits of exercise for improving immunity51 and oxida-
4 weeks of physical therapy in his home, Mr. Fortnight would tive capacity for function.52 Safety in bathing (drying the
be able to successfully transition to an outpatient pulmonary feet), footwear and proper foot inspection was reviewed.
330 Chapter 8
Additionally, Mr. Fortnight was taught proper timing and Description of the Intervention
use of the inhaler, how to use breathing control and coordi- Seated position, AROM Chin tucks (capital flexion); chin
nated breathing strategies with routine activities, and how lifts (capital extension), cervical rotation, lateral neck flexion.
to manage a sudden attack of SOB. Although Mr. Fortnight Mode
continued to use a cane in his right hand for ambulation, Trunk mobility exercises
instruction on the use of a wheeled walker to manage fall risk Intensity
and to increase walking distance and physiologic tolerance Moved to point of moderate tension on opposite (upper-
for community ambulation was also provided.53 most) side with lateral trunk leaning.
Duration
Procedural Interventions Hold for 5 seconds and release
Frequency
Therapeutic Exercise Prescription
Perform 5 repetitions for each exercise, daily, and prior to
Flexibility Exercises/Warm-up Exercises aerobic exercise.
Mode Description of the Intervention
Seated LE exercises Seated position, AROM lateral trunk lean, flexion and
Intensity extension, trunk rotation with flexion/extension reaching
Performance to the point of moderate tension with arms to the floor with flexion and up into shoulder
Duration flexion and abduction with trunk extension.
Hold for 5 seconds and release. Progression
Frequency Added coordinated breathing so Mr. Fortnight exhaled on
flexion and inhaled on extension. During lateral trunk flex-
Perform 5 reps to each muscle group daily and especially
ion hold, a pause with deep inspiration was added to actively
prior to aerobic exercise.
recruit intercostals and further open the rib cage.
Mode
Seated hurdle position, one leg out straight and the other
Upper extremity and anterior chest mobility exercises
bent with heel down and under the chair slightly. Stretching
to the hamstring on outstretch leg and stretching to the Intensity
soleus on bent leg. Lean forward with flat back. Move to the point of moderate tension in pectoralis major
Progression and soft tissues of the anterior chest.
In standing at countertop resting hands lightly for bal- Duration
ance, stand in stride position to apply stretch to gastroc-sole- Hold for 5 seconds
us with knee extended while bending knee to stretch soleus Frequency
on contralateral LE. Heels should remain in contact with the Perform 5 repetitions each during treatment session.
ground. Hold as above and switch leg position. The sets were Description of the Intervention
progressed from 1 set to 2 sets. Anterior chest mobility using AROM, passive positioning
and PNF. While seated and performing trunk flexion and
rotation, Mr. Fortnight incorporated the butterfly position
Clinician Comment Seated position provides of the arms (shoulders abducted, scapula retracted, elbows
stability when balance deficits are present. The therapist flexed with hand behind head). He inhaled with shoulder
asked Mr. Fortnight to extend the position further at the abduction and with trunk extension and exhaled with shoul-
end of the fourth repetition and hold a new position during der adduction and trunk flexion. Rotation was added as Mr.
the fifth repetition. Mr. Fortnight should exhale as he flexes Fortnight began to understand the motion. Breathing actions
forward and inhale as he returns to upright to begin to assisted in mobilizing soft tissues around costosternal, costo-
build energy efficient coordinated breathing with activity. chondral, and costovertebral articulations.
When Mr. Fortnight was erect and seated with arms in
the open butterfly position the therapist resisted adduction
Mode and closing of the butterfly position near the end of range
Head and neck mobility exercises abducted position. Contract-relax commands were offered to
Intensity assist in reeducation to the scapular retractors and shoulder
Moved to the point of moderate tension with each muscle abductors while inhibiting the pectoralis major and anterior
group with pain scale < 3/10. deltoid.54
Duration Mr. Fortnight also had a positioning program using
Hold for 5 seconds and release supine lying over a towel roll which was positioned longitu-
Frequency dinally along his spine.55 Mr. Fortnight lay in this position
in bed in the morning to apply a stretch to the anterior chest.
Perform 5 repetitions in each direction, daily.
The positional stretch was progressed by moving the arms used to strengthen the dorsiflexors. Ventilatory muscle
into shoulder abduction and flexion above the head. strengthening was performed using a threshold loading
Posture Training device and using higher loads as BP permitted. Mr. Fortnight
was instructed to exhale with effort and lifting to avoid the
Posture awareness training in sitting followed the flexibil-
effects of a Valsalva maneuver. Physiological monitoring of
ity and AROM exercises for the spine and upper extremity/
HR, BP, RPE, RPD, and O2 saturation occurred throughout
anterior chest. A mirror was used to assist Mr. Fortnight in
during therapeutic visits.
self-correction of poor positioning of the upper thorax.
Progression
Once Mr. Fortnight demonstrated proper form for each
Clinician Comment Seated stretching allows exercise the weights were increased to low repetition and
muscles to warm up prior to strength and endurance exer- high intensity (as long as resting BP was below 160/105). The
cise and minimize the risk of injury.25 Individuals with reps will be 6 reps each using a daily adjusted progressive
diabetes have shortening of the connective tissue.56 Aging, resistive exercise protocol.58
immobility and medications may also contribute to loss of Aerobic Capacity/Endurance
elasticity in muscle groups.20,57 Cervical and trunk stretch-
ing may help lengthen the accessory muscles and increase
AROM to the thoracic cage to decrease work of breathing. Mode
Mobility of the spine preceded flexibility and strengthening Walking program for exercise using wheeled walker.
exercises to muscles of the scapula and shoulder. Alignment Intensity
of the thoracic spine improved kinematics for posture RPE < 4/10
exercises. Duration
Twenty minutes performed in 2 10-minute bouts with
rests as needed. Mr. Fortnight ambulated a distance of
Strength, Power, and Endurance Training 900 meters total while using the wheeled walker.
Mode Frequency
Active exercise against gravity, lifting body weight for Two times daily; 5 days per week.
resistance, using light cuff weights and extremity positioning Description of the Intervention
to challenge stronger muscles. Exercise walking with a wheel walker was selected to
Intensity permit a natural movement pattern in a safe manner so that
Moving and holding position; light weight without losing a higher intensity challenge could be imposed on the cardio-
proper form. vascular system. A wheeled walker also permitted the use of
Duration accessory muscles for ventilation support.53 He performed
Hold for 5 seconds pursed-lipped breathing with diaphragmatic control during
Frequency ambulation and continued to use 2 LPM O2, which could be
transported on the walker. Mr. Fortnight walked in a long
Mr. Fortnight performed 5 to 10 repetitions of resistance
pathway from the kitchen, through the dining room to the
exercise 2 to 3 days per week.
living room and back. The therapist spoke to Mr. Fortnight
and his son about the feasibility of buying an exercise bike.
In the sitting position Mr. Fortnight performed scapu-
Progression
lar retraction exercises with chin tucks and moving naval
Decreased number of rests and bouts until Mr. Fortnight
toward spine to actively engage postural muscles. In supine,
could ambulate for 400 meters without a rest break. Walking
Mr. Fortnight was taught pelvic tilt exercise and progressed
was then performed daily with a focus on increasing the total
to bridging and to bridging with heel taps and then with one
distance and number of minutes of ambulation.
leg extended. In the side-lying position Mr. Fortnight was
taught proper technique for active hip abduction to strength- Mode
en the hip abductors. Abductors were also trained eccentri- Upper extremity repetitive lifting task
cally in a standing position, with one leg flexed and resting Intensity
on padded dining room chair he contracted and released the RPE = 3/10
abductors to shift body weight onto the bent LE. Duration
Quadriceps strengthening for leg power was performed 10 minutes
using seated squats. The seat height was gradually lowered Frequency
as Mr. Fortnight improved. Toe raises were performed while Once daily
standing at the counter, with light upper extremity contact Description of the Intervention
for balance. Toe raises were performed first bilaterally, From the sitting position, place hands on either side of a
then shifting body weight toward one side and eventually cane. Raising arms from lap above shoulder height to prede-
progressing toward unilateral toe raises over the course of termined heights marked on a poster mounted on the wall.
12 visits. Standing anterior/posterior weight shifting was The activity simulates the upper limb exercise test.59 All
332 Chapter 8
physiologic measures were monitored to assure the activity Description of the Intervention
was a safe cardiovascular challenge. On examination Mr. Fortnight could hold a semi-tandem
Progression standing posture for 12 seconds and a full tandem for 8 sec-
Increased number of repetitions, height of lift and lifting onds. Mr. Fortnight practiced holding the full tandem stance
time. Light weights were added to increase the challenge. and alternating which foot was forward. He ambulated in
a heel-to-toe manner for as many steps as possible both
forward and backward and eventually around obstacles. To
Clinician Comment The therapeutic program increase the challenge, the therapist would place objects on
was established using ATS evidence-based guidelines for chairs or the floor for Mr. Fortnight to reach down and pick
pulmonary rehabilitation.60 These guidelines recommend up. Breathing control without breath holding and proper use
using high intensity (> 60% VO2 peak) to achieve optimal of a cane as necessary was used during this activity.
benefits to enhance peripheral oxidative capacity. Upper
extremity aerobic training is recommended by the guide- Functional Training in Self-Care and Home
lines. Repetitive cane lifting was designed to decrease Management Activities of Daily Living and
dependence on the accessory muscles for breathing and Instrumental Activities of Daily Living
improve diaphragm action.61 The goal was to improve Mr.
Fortnight’s ability to carry packages with less dyspnea. Self-Care
Additionally, individuals with COPD have low muscle Mr. Fortnight practiced getting into and out of the tub
mass in the muscles of ambulation. Changes in strength using proper set-up, towel placement, prechecking water
and aerobic capacity can be achieved through participation temperature, drying feet, and donning shoes. He practiced
a program lasting 8 to 12 weeks, 2 to 3 times per week for dressing while seated and transferring in and out of bed. In
40 to 90 minutes. the bedroom the therapist made suggestions for placement of
a chair to sit while reaching for clothing, reviewed methods
for using the dressing stick and donning shoes. A light was
placed next to the bed, as was automated motion-activated
Gait and Locomotion Training
timed on-off lighting in the halls and bathroom. His son
Mode installed grab bars near the toilet and tub and a bath bench
Walking program using cane for community function, was added.
including stairs.
Home Management
Intensity
RPE < 3/10; RPD < 2/10 and O2 saturation > 90% Mr. Fortnight used a stool and sat while washing dishes
and modified the shelves in the kitchen, improving the ease
Duration
of putting dishes away. He practiced carrying bags of grocer-
10 minute; 60 to 80 feet
ies from the kitchen to the dining room in preparation for
Frequency future shopping trips. Breathing control (diaphragmatic,
Twice daily. pursed-lip breathing) and coordinated breathing were incor-
Description of the Intervention porated into each task. Mr. Fortnight used a 1:2 (inhalation
Mr. Fortnight used a straight cane in his right hand dur- to exhalation) ratio and energy conservation strategies to
ing functional ambulation training. He practiced pacing pace activities.
and breathing control while keeping physiological measures
below threshold intensity levels. The goal was to increase
Functional Training in Work (Job/School/
walking distance without regard to speed. Stair climbing Play), Community, and Leisure Integration
using a railing with the right hand, and cane transferred to or Reintegration, Including Instrumental
the left hand, and incorporating breathing control was also Activities of Daily Living, Work Hardening,
practiced. Mr. Fortnight practiced breathing control and and Work Conditioning
coordinated breathing with all transfers.
Balance, Coordination, and Agility Training Job Reintegration
Mode Task simulation was implemented and modifications
for efficient energy conserving movements at work. Mr.
Body positioning, moving outside base of support: static
Fortnight practiced correct posture. A wireless earpiece for
and dynamic
phone calls, ergonomically designed seat height, desk, and
Intensity
computer, full-length armrests to the office chair, and mov-
RPE < 3/10 ing file drawers were recommended. Timing of meals and
Duration preparing a quick supply of glucose in the desk drawer were
5 minutes: hold position up to 30 seconds for static discussed.
balance.
Frequency
4 times per week.
Community Reintegration Subjective
A wheeled walker was kept in the car and used when
walking distances for shopping, restaurants with poor light- “I feel I know how to control my breathing and I have
ing, and for exercise ambulation outside the home. Because more energy for most of my day.”
Mr. Fortnight preferred using a cane, safety education was
provided. It is expected that Mr. Fortnight will continue to Objective
improve strength, balance, and walking endurance as he pro-
gresses in an outpatient pulmonary rehabilitation program. Pain
Leisure Reintegration Mr. Fortnight reported that his neck pain improved from
Mr. Fortnight was encouraged to continue golfing and 4/10 to 0/10.
would take a motorized golf cart. He used pursed-lipped Posture
breathing and pacing strategies to improve oxygenation and
His posture was aligned with scapulas retracted over a
decrease fatigue. Mr. Fortnight learned to avoid riding in the
more erect thoracic spine.
cart with a friend who was a heavy smoker and placed his O2
in a small rolling cart along with 1 or 2 clubs as needed when Ventilation
moving from motorized cart to the green. Respiratory muscle strength (MIP and MEP) improved.
Prescription, Application, and, as Chest expansion measures improved 1 cm in the xiphoid
Appropriate, Fabrication of Devices and region.
Equipment (Assistive, Adaptive, Orthotic, Range of Motion
Protective, Supportive, or Prosthetic) His neck ROM was within normal limits for all motions.
Adaptive Devices Muscle Performance
• Automatic motion-sensitive lighting His LE muscle grades have improved to 5/5 throughout
• Wireless earpiece for phone calls except for plantar flexion 4/5. He could perform the STS test
in 11.6 seconds.
• Bath bench
Aerobic Capacity/Endurance Conditioning
• Grab bars
Mr. Fortnight’s 2MWT distance improved to 105 meters
Assistive Devices without rest breaks. The test was performed with a cane in
• Cane his right hand as at the initial evaluation. Mr. Fortnight was
• Wheeled walker limited only by dyspnea.
• Rollator for O2 ACTIVITY HR BP O2 DYSPNEA RPE

• Long-handled reacher SAT
(2
Orthotic Devices
LPM)
• Selection of shoes with extra depth, undercut heels
Rest 78 132/82 96% 0/10 0/10
• Evaluation for foot orthotics vs inserts in extra-depth
shoe Peak 2 118 NT 94% 3/10 2/10
min
Support Devices
Post-1 94 138/80 94% 2/10 1/10
• CPAP at 10 cm H2O at night minute
• Supplemental O2, 2 LPM pulsed at rest; continuous for
Post-5 76 132/84 96% 0/10 0/10
exercise and walking
minutes
O2 Sat: O2 saturation; RPE: rate of perceived exertion; NT: not tested.
REEXAMINATION
Mr. Fortnight’s program was progressed regularly and a
Clinician Comment Mr. Fortnight’s symp-
toms of fatigue were decreased through medication adjust-
formal reexamination occurred after 4 weeks of treatment
ment and aerobic training that may have reversed decon-
and discharge was anticipated.
ditioning. The dyspnea-limiting symptoms were likely due
to dynamic hyperinflation, which shortened the inspiratory
muscles limiting the enhancement of TV necessary for ven-
tilation during exercise.62
334 Chapter 8
Self-Care and Home Management Therefore, Mr. Fortnight was encouraged to attend formal
Mr. Fortnight was independent in climbing 12 steps exercise at a community center program once he completed
with railing on the R side with RPD < 3/10 and O2 satura- his pulmonary rehabilitation program.
tion > 90%. He incorporated breathing control and pacing
strategies during ambulation, transfers, and for all bathing,
dressing, and household tasks. Mr. Fortnight can sleep in his
bed upstairs and wear the CPAP mask through the night. He
OUTCOMES
could reach down and dry his feet after bathing and put on
socks and shoes. His energy level improved and the house- Five months after discharge and having participated in
hold environment was free from risk for infection and falls. pulmonary rehabilitation, Mr. Fortnight was able to return
There was less dependence on his son for many tasks. Mr. to work for 30 hours a week, manage household chores,
Fortnight could attend medical appointments independently. and ambulate, safely and independently, with a cane for
300 meters during a 6MWT.
Work, Community, and Leisure
Reintegration
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Individuals With
9
Gas-Exchange Disorders
Jane L. Wetzel, PT, PhD and Brian D. Roy, PT, DPT, MS, CCS
• Air Quality: Environment and Oxygen

CHAPTER OBJECTIVES • Epidemiology
• Describe the path of an oxygen (O2) molecule from air in ◦ Age-Related Changes and Gas Exchange
the lungs to its binding on a hemoglobin (Hgb) molecule. ◦ Incidence and Prevalence of Pathology Affecting
• Discuss the factors in ventilation perfusion matching. Gas Exchange
• Answer the question: What effect does air quality have ▪ Pneumonia
on gas exchange? ▪ Atelectasis
• Compare and contrast the contributing factors in altered ▪ Chronic Obstructive Pulmonary Disease
alveolar gas exchange for a patient with an acute disor-
▪ Asthma
der, such as pneumonia, and a patient with a chronic
disorder, such as asthma. ▪ Cystic Fibrosis
• In the first learning objective, now categorize the type of ▪ Pulmonary Edema and Pulmonary Emboli
gas-exchange disorder that could occur in each step in • Pathophysiology of Gas-Exchange Disorders
the process as the O2 molecule moves from the lung air
◦ Acute Disorders
space to the Hgb molecule.
▪ Pneumonia
• Identify the factors that can impair the ability of a
patient to have an effective cough. ▪ Atelectasis
• Discuss breathing exercise techniques that can be imple- ▪ Pulmonary Edema
mented to improve lung volume and gas distribution. ▪ Acute Respiratory Distress Syndrome
▪ Pleural Effusions and Empyema
▪ Pneumothorax
CHAPTER OUTLINE
▪ Pulmonary Vascular Disorders
• Physiologic Requirements for Normal Gas Exchange ◦ Chronic Disorders
◦ Ventilation and Airway Opening ▪ Chronic Obstructive Pulmonary Disease
◦ Gas Exchange ▪ Emphysema
◦ Perfusion and Blood Quality ▪ Chronic Bronchitis
◦ Ventilation Perfusion Matching ▪ Asthma
• Factors Influencing Gas Transfer ▪ Cystic Fibrosis
◦ Exercise ▪ Interstitial Lung Diseases
338 Chapter 9
• Examination of Gas-Exchange Disorders ◦ Therapeutic Exercise
◦ Patient/Client History ◦ Education
◦ Systems Review • References
◦ Tests and Measures Gas exchange is the ability to move O2 and carbon diox-
ide (CO2) to and from the pulmonary circulation. The gas-
▪ Observation
exchange process is called respiration and is distinct from
▪ Arousal, Attention, Cognition ventilation, which involves changes in the dimensions of
▪ Posture the lung and chest wall to create movement of air in and out
of the atmosphere.1 The primary role of the cardiovascular
▪ Ventilation and Gas Exchange
and pulmonary system is to move O2 to the working muscle
▫ Chest Wall Exam to support metabolic processes providing energy for move-
▫ Mediate Percussion ment.2,3 Therefore, evaluation of all movement-related dis-
orders must first consider the patient’s ability to breathe and
▫ Respiratory Rate and Pattern
transport O2 to organs and tissues in order for metabolism to
▫ Dyspnea take place. A patient who cannot breathe adequately cannot
▫ Oximetry move or move efficiently. This chapter will describe the cellu-
lar, tissue, and organ changes associated with the pathophysi-
▫ Auscultation
ology of acute and chronic gas-exchange disorders and the
▫ Cough role of physical therapy in evaluation and treatment of indi-
▫ Ventilatory Flow, Forces, and Volume viduals who have problems with gas exchange. Abbreviations
and terminology related to pulmonary function and respira-
▪ Circulation
tory muscle performance are listed in Table 8-2.
▪ Range of Motion
▪ Muscle Performance
▪ Gait, Locomotion, and Balance PHYSIOLOGIC REQUIREMENTS FOR
▪ Aerobic Capacity/Endurance NORMAL GAS EXCHANGE
▪ Assistive and Adaptive Devices
▪ Orthotic, Protective, and Supportive Devices Ventilation and Airway Opening
▪ Ergonomics, Environmental, Home, and Work
An adequate ventilatory pump is needed to keep blood O2
Barriers
content in inspired air elevated and to clear CO2 from the
• Evaluation, Diagnosis, and Prognosis lungs. Gas exchange and ventilation are interdependent as
• Interventions CO2 and O2 stimulate central and peripheral chemoreceptors
signaling ventilation.2 A negative pressure is created in the
◦ Positioning
lungs when the muscles of inspiration contract. This causes
▪ Bronchial (Postural) Drainage air to move from the atmosphere to the alveoli. Pulmonary
▪ Positioning to Decrease Work of Breathing function (forced vital capacity [FVC], forced expiratory vol-
ume in 1 second [FEV1], FEV1/FVC) and respiratory muscle
◦ Airway Clearance Techniques
performance tests (maximal inspiration [PImax], maximal
▪ Cough expiration [PEmax], maximum voluntary ventilation [MVV])
▪ Manual Techniques are conducted to determine loss of ventilation. If ventilation
is poor and respiratory pattern is shallow, the air will not
▫ Percussion
reach the gas-exchanging regions of the lungs and the alveoli
▫ Vibration will not receive an adequate volume of good oxygenated air.
▪ Suctioning When breathing is shallow there is increased dead-space ven-
tilation and a majority of the inspired volume reaches only
◦ Breathing Control Maneuvers and Breathing
the conducting zone in the lungs, where gas exchange does
Retraining
not occur.2 A simple act like deep breathing can improve
▪ Breathing Exercises to Improve Lung Volume and the volume and quality of the air in the alveoli and thereby
Gas Distribution enhance gas exchange.
▪ Breathing Exercises to Decrease the Work of In addition to ventilation, airways must be kept clear to
Breathing and Dyspnea allow the volume of air to move unobstructed to the alveoli.
In healthy individuals, the airways are kept clear by captur-
▪ Techniques to Conserve Energy and Decrease the
ing foreign pathogens as air passes over mucosal tissues, nose
Work of Breathing
hairs and over cilia supporting a layer of mucus.4 Forceful
Individuals With Gas-Exchange Disorders 339
BOX 9-1. EQUATION USED TO CALCULATE DIFFUSION (DLCO)

The volume of gas (Vgas) moved per minute is represented by:
Vgas = (A/T)D(P1 ‒ P2)
A = Surface area (clinically; the entire lungs [L])

T = Thickness of the membrane
D = Diffusion constant for the gas
P = Pressure of gas on either side of the membrane
Normal DLCO = 25 mL/min/mm Hg
Carbon monoxide (CO) testing is performed as this gas equilibrates rapidly.
expiratory muscle contraction or coughing can generate a

high flow, expelling any trapped particles. In this way, infec-
tion is prevented and inflammation in the tissue is kept low,
allowing for optimal gas exchange.5 Airways must also be
stable enough during coughing and deep breathing to remain
open. In individuals with lung disease, high flow rates occur-
ring with coughing and exercise can cause dynamic airway
collapse of alveoli and bronchioles, obstructing the flow of
air.6
Gas Exchange
Once the air reaches the alveoli, gas transfer depends on
diffusion. Diffusion of O2 from the alveolar sacs to the pul-
monary circulation depends on; the surface area (A) of the
alveolar capillary membrane; the thickness of the alveolar/
capillary interface (T); the driving pressure of gas (D).2,5,7
Diffusion of the lung (DL) is usually examined with a tracer
gas, carbon monoxide (CO), and the test is abbreviated
DLCO in the medical record (Box 9-1). The test indicates Figure 9-1. Diagram of the alveolar capillary membrane. Venous blood
how well all these factors are working together. If any or all returning to be oxygenated.
of these factors are impaired, then gas exchange is altered.
The surface area of the lungs is approximately the size of
a tennis court in the healthy individual. If the lung surface gases is called a pressure gradient, which is a force that favors
is decreased by disease or hypoventilation, then less gas is gas movement in a specific direction. CO2 in venous blood
transferred into the blood leading to lower arterial saturation has a PvCO2 of 45 mm Hg and the PaCO2 is 40 mm Hg,
of oxyhemoglobin (SaO2). To reach the Hgb molecule in the creating a difference that favors elimination of CO2 from
pulmonary circulation, the O2 must transfer across the sur- the blood. O2 in the venous blood has a PvO2 of 40 mm Hg
factant lining on the interior of the alveoli, move through the while the partial pressure of alveolar O2 (PaO2) is about
epithelial membrane, through the interstitium, then across 104 mm Hg, creating a wide gradient favoring movement of
the endothelial membrane of the capillary, across the blood O2 into the blood as it passes through the lungs.2
plasma and into the red blood cell (RBC) to the Hgb molecule Once the O2 passes across the alveolar capillary mem-
(Figure 9-1).5 brane, the plasma in oxygenated arterial blood has a PaO2 of
The partial pressures of O2 and CO2 in the alveoli and 100 mm Hg. This level of PaO2 is important for Hgb affinity
in the blood plasma are different. The partial pressure in and saturation. Saturation refers to having O2 occupy each of
the alveoli is represented by Pa while the partial pressure in the 4 Hgb molecule-binding sites. If PaO2 decreases then the
the arterial blood plasma is represented by Pa. Venous blood affinity of Hgb for O2 also decreases and some of the sites on
also carries gas, and the partial pressure in venous blood is the Hgb do not accept O2, resulting in desaturation.8 SaO2 is
represented by Pv. The difference between partial pressure of expressed as a percentage based on the ratio of the amount of
340 Chapter 9
Hgb is 15 g/dL and is 97% saturated at a PaO2 of 100 mm Hg,
then the CaO2 = 19.7 mL O2 per 100 mL of blood. Normally
the CaO2 ranges from 17 to 20 mL/dL.8
Good cardiac output (CO) and CaO2 are required for
delivery of adequate O2 to be available to tissues. Ultimately,
the volume of O2 consumed (VO2) is equal to CO times the
difference between CaO2 and CvO2 (called the aVO2 dif-
ference). Therefore, VO2 = CO × aVO2 diff (CaO2 – CvO2).8
In this way the quality of the blood and good gas transfer
determines the amount of O2 available to the working muscle
and the amount of work that can be performed. The content
of O2 returning in the venous (CvO2) blood is much lower
than CaO2 and diminishes according to the amount of O2
extracted for metabolism.
The mechanisms regulating blood flow through the pul-
Figure 9-2. Oxyhemoglobin dissociation curve. (Reprinted with per- monary circulation determine perfusion. If there is poor
mission from Carroll RG. Integrated Physiology. Philadelphia, PA: Mosby alveolar oxygenation in a region of the lung, then the pul-
Elsevier; 2007.)
monary blood vessels respond by vasoconstriction to shunt
blood to more viable areas for gas exchange.5 The vasocon-
O2 bound to Hgb relative to the O2-carrying capacity of the striction may be well tolerated in healthy individuals but may
Hgb. The relationship between PaO2 in blood plasma and increase pressure in the pulmonary vasculature in those with
SaO2 is represented by the oxyhemoglobin dissociation curve lung pathologies. The increased pressure creates a stress to
(Figure 9-2). It is clear that a PaO2 of 60 mm Hg results in the right heart and cor pulmonale may develop. Gravity also
SaO2 of 90% and then the curve drops off steeply. Hgb has a influences perfusion and increases hydrostatic pressure in
high affinity for O2 at high PaO2 levels (ie, 60 to 100 mm Hg the lower lung fields (in the most downward position). Thus
or higher) but is less likely to combine with O2 at lower levels body positioning changes affect blood flow and can be used
(ie, < 60 mm Hg) and therefore less saturated. Therefore, as as a therapeutic intervention.1,5
the oxyhemoglobin molecule moves to the peripheral circu-
lation near the cells where partial pressure of O2 is low, the Ventilation Perfusion Matching
Hgb affinity for O2 decreases and O2 is released to the cells
Ventilation is also influenced by gravity, causing upper
favoring energy production. The O2 saturation of Hgb in
alveoli to be more fully distended, or stiffer, than lower air-
venous blood (SvO2 is about 70% to 75%).9
ways. Because lower airways are more compliant they can
more readily accept new air. This new air in combination
Perfusion and Blood Quality with increased perfusion in the most gravity-dependent
The pulmonary capillary blood volume and flow must position of the lung results in improved opportunity for gas
be adequate as it passes by the alveoli. In addition there exchange. Therefore, the best matching of ventilation to per-
must be sufficient RBCs with available Hgb to carry O2. The fusion (V/Q) is near the most gravity-dependent positions.5
O2-carrying capacity is determined by the amount of Hgb In the upright person the most gravity-dependent region
present in the blood.5 Hematocrit (Hct) and Hgb must be would be the base of the lungs. The ratio of V/Q across the
within normal ranges. If the O2-carrying ability of the blood lungs is 0.8 and allows gas exchange to provide normal PaO2
is hindered then gas transfer at the tissue level is altered or to the blood.10 When ventilation is in excess of perfusion
inhibited. Individuals with anemia may have fully saturated (blood clot) in a region of the lung, the ratio is high. If the
Hgb but poor O2-carrying capacity. The person with anemia perfusion is in excess of ventilation (dead space) in a region
may be tired and have activity intolerance due to poor blood of the lung, then the ratio is low. As V/Q ratios move further
quality and not necessarily poor tissue oxygenation due to apart from the norm, then low PaO2 (hypoxemia) develops.5
gas-exchange problems.
The content of O2 in the arterial blood (CaO2) is the
sum of oxyhemoglobin and dissolved O2.2 Approximately FACTORS INFLUENCING GAS TRANSFER
1.34 mL of O2 can bind to 1 gram of Hgb to create oxyhe-
moglobin. Oxyhemoglobin binding depends on its satura-
tion level (oxyhemoglobin = Hgb × 1.34 × SaO2). The PaO2 in
Exercise
plasma is important because it affects Hgb saturation. Only Changes in DL will have a large affect on PaO2 and cause
0.003 mL of O2 are dissolved in plasma per mm Hg PaO2 a decrease in gas transfer. Normally there is a long and suf-
(dissolved O2 = 0.003 × PaO2). This means the majority of ficient time course of blood flow through the pulmonary
O2 is transported to the working muscle as oxyhemoglobin. circulation, approximately 0.75 seconds with the PaO2 of
Therefore, CaO2 = (Hgb × 1.34 × SaO2) + (0.003 × PaO2).2,8 If 100 mm Hg being achieved in 0.25 seconds (Figure 9-3).8
TABLE 9-1. ESTIMATED FRACTION OF

INSPIRED OXYGEN (FIO2) WITH LOW FLOW
DEVICES AND CORRESPONDING PARTIAL
PRESSURE OF ARTERIAL OXYGEN (PAO2)
OXYGEN DELIV- ESTIMATED AVAILABLE
ERY DEVICE FIO2 PAO2 (MM HG)
Room Air 0.21 104
Nasal Cannula (L/min)
1 0.24 119
2 0.28 140
3 0.32 158
Figure 9-3. O2 time courses in the pulmonary capillary when diffusion is
normal and abnormal. Under normal conditions, blood reaches a partial 4 0.36 182
pressure of O2 (PO2) of 100 mm Hg within 0.25 seconds even though the
time course of travel through the capillary is 0.75 seconds. When there is a 5 0.40 239
limitation in diffusion, the time to reach a PO2 of 100 mm Hg is prolonged, Mask (L/min)
as noted by the “abnormal” line. When diffusion is severely limited, blood
exiting the pulmonary capillary will not achieve a normal PO2 level, as 5 to 6 0.40 239
indicated by the “grossly abnormal” line. The time course is shortened
during exercise (as noted by the arrow) and may result in below-normal 6 to 7 0.50 311
PO2 levels when limitations in diffusion are present. (Reprinted with
permission from West JB. Respiratory Physiology. 4th ed. Baltimore, MD: 7 to 8 0.60 384
Williams & Wilkins Co; 1990.)
Mask With Reservoir (L/min)
7 0.70 456
This time is necessary for O2 to move from the alveoli into 8 0.80 528
the capillary and for CO2 to move into the alveoli from
the blood. The pulmonary transit time is reduced during 9 0.90 601
exercise, resulting in O2 desaturation of arterial blood when 10 1.00 673
pathology is present.8,10,11
and pulmonary edema and may be the cause of death in com-

AIR QUALITY: petitive mountain climbers. An older individual with mar-
ginal gas exchange may find they need supplemental O2 with
ENVIRONMENT AND OXYGEN sudden acute changes in altitude. Those with pulmonary
pathology will need special arrangements for O2 support
The air arriving in the alveoli in the healthy individual is when flying on airplanes. Air pollution, occupational atmo-
a mixture of gases (nitrogen [N2], O2 and CO2). Seventy-eight sphere (hay, animal dander, coal dust) can also change the
percent of the inspired air is N2, which is inert, while 21% is composition of inspired air and stimulate an immune reac-
O2 and .04% is CO2. Thus the fraction of inspired O2 (FiO2) tion in the lungs. Over time the lung tissues become scarred
is 21% in room air and is adequate to offer a PaO2 of about or develop fibrosis, impairing gas-exchanging processes.
104 mm Hg. Individuals with gas-exchange deficits will often Exercise in cold, dry air is known to trigger bronchospasms
require increases in the FiO2 to raise the PaO2 in order to or asthmatic events.8
widen the O2 pressure gradient between the alveoli and the
arterial blood. Supplemental O2 increases the PaO2 and ulti-
mately the PaO2. Since supplemental O2 is delivered by nasal
cannula, mask or the ventilator, the liter flow or FiO2 may
EPIDEMIOLOGY
be documented. Table 9-1 offers a guide to the amount of O2
Gas-exchange deficits ultimately result in hypoxemia and
delivered with low-flow devices seen in practice. Increasing
may also produce hypercapnia. There are 4 major causes
the FiO2 increases the PaO2, which will improve the gradient
of hypoxemia: hypoventilation, diffusion, shunt, and V/Q
to aid in overcoming the impaired diffusion due to thickened
inequality.12 Hypoventilation occurs with severe ventila-
membranes or to improve V/Q matching.
tory pump dysfunction and failure and is discussed in detail
The environment also affects air quality and therefore gas
in Chapter 8. Diffusion deficits result when the blood-gas
exchange. The PaO2 decreases when an individual moves to
barrier is thickened as seen in disorders such as asbestosis,
high altitude. This can produce hypoxic vasoconstriction
342 Chapter 9
sarcoidosis, pneumoconiosis, alveolar cell carcinoma or col- Incidence and Prevalence of Pathology
lagen disease. Shunts are the result of a significant portion
of pulmonary circulation not passing through ventilated Affecting Gas Exchange
regions of the lung. The arterial blood in shunt disorders
lacks normal SaO2 either because of an anatomical shunt Pneumonia
(congenital heart diseases) or physiologic shunt (inflam- Pneumonia is an acute pulmonary disorder that con-
matory processes). The shunt fraction is the percentage of tinues to be a major cause of morbidity and mortality. In
deoxygenated blood in the arterial system and is normally the United States pneumonia and influenza combined are
3% to 4% in healthy individuals but increases with disease. the eighth leading cause of death.16,17 Pneumonia has been
Finally, V/Q inequalities may cause hypoxemia and result attributed to an overwhelming majority of deaths despite
from disorders that affect lung tissues or vascular conditions the widespread availability and use of antibiotics. More than
or both. Chronic obstructive pulmonary disease (COPD) is 56,000 people died from complications of pneumonia in
a primary disorder whereby V/Q mismatch is the cause of 2008.17 Approximately 50% of pneumonia cases are believed
hypoxemia. Vascular and respiratory systems are impaired in to be caused by viruses and tend to result in less severe ill-
individuals with severe COPD. Individuals with pulmonary ness than bacteria-caused pneumonia. Mycoplasmas are the
hypertension, emboli, or pulmonary edema may also lose smallest free-living agents of disease in man, with character-
good equality of gas exchange in some regions of the lungs.13 istics of both bacteria and viruses. The agents generally cause
Many diseases and disorders may present with more than a mild and widespread pneumonia. The most prominent
1 of the 4 causes of hypoxemia. A few of the most common symptom of mycoplasma pneumonia is a cough that tends
conditions leading to gas-exchange deficits are pneumonia, to come in violent attacks, but produces only sparse whitish
atelectasis, COPD, asthma, cystic fibrosis (CF), pulmonary mucus. Mycoplasmas are responsible for approximately 15%
edema, and pulmonary emboli (PE). Neuromuscular and to 50% of all adult cases of pneumonia and an even higher
chest wall disorders may have gas-exchange deficits due to rate in school-aged children.18 An estimated 40,000 deaths
hypoventilation and are discussed in Chapter 8. There are occur yearly from pneumococcal pneumonia. The mortality
also age-related changes in gas exchange that may contribute rate is highest among children, elderly, and the black race.
to earlier impairment when pathology is present. There are approximately 7.4 deaths per 100,000 for older
individuals aged 65 to 79 years and 17.4 deaths per 100,000
Age-Related Changes and Gas for those over 80 years of age.19
Exchange Atelectasis
Atelectasis occurs when all or part of the lung collapses.
There is a loss of elastic recoil in the lungs of the older
Atelectasis can occur in a wide variety of acute and chronic
individual. In addition the chest wall stiffens as costal car-
conditions and may lead to pneumonia. Acute respira-
tilage calcifies and the vertebral discs narrow. Movement of
tory distress syndrome (ARDS) is a severe form of atelec-
air is limited, especially during exercise, resulting in lower
tasis caused by extensive lung inflammation resulting from
absolute tidal volume (TV) and minute ventilation (VE) at
pulmonary infections, pulmonary edema, trauma, and/or
peak exercise.14 Submaximal exercise requires greater respi-
sepsis. There are approximately 1.5 to 75 cases of ARDS per
ratory muscle effort in order to sustain ventilation. Thus
100,000 persons and an estimated 150,000 to 190,000 adults
the older individual will have a higher submaximal respira-
in the United States are affected.20,21 The mortality rate in
tory rate (RR) than younger individuals performing similar
individuals with ARDS is 25% to 70%.21-23 Mortality rate is
work. Residual volume (RV) increases as airways do not
higher in older individuals and may approach 90% if sepsis
recoil and unstable airways trap air. In the older individual,
is present.21
the alveolar-capillary surface area and total gas-exchanging
surface area of the lung is reduced, increasing the physi- Postoperative conditions have the greatest risk for atelec-
ologic dead space. Compared to younger counterparts, the tasis. The effects of anesthesia, procedural effects and pain
older individual has a reduced DL, decreased pulmonary lead to an increased V/Q mismatch, decreased functional
capillary blood volume, and a wider V/Q mismatch.15 The residual capacity (FRC) and a decreased diaphragmatic
resting PaO2 declines 5 to 10 mm Hg by age 75 but does not excursion.24,25 On average the FRC is decreased 20% after
affect SaO2 or CaO2.14 During exercise, only a small number most postsurgical conditions and drops as much as 30% with
of older individuals have arterial hypoxemia. In the vascular upper abdominal surgeries.25 The SaO2 is 90% or less is in
system, some may experience increased pulmonary artery 35% of postoperative conditions.25
pressures and mild pulmonary edema that could lead to V/Q Chronic Obstructive Pulmonary Disease
mismatch and DL deficits.14 Exercise in older individuals is COPD is increasing. The term COPD is a concept refer-
limited more by decreased CO than by mild differences in ring to flow-obstructing diseases. The 2 common disease
gas exchange. The slight changes in PaO2 may place older states in this category, which frequently coexist, are emphy-
individuals at increased risk for hypoxemia when medical sema and chronic bronchitis. The United States morbidity
conditions (anesthesia, surgery) or lung pathology are also rate of COPD is 4% and it is exceeded only by myocardial
present.
infarction (MI), cancer, and cerebrovascular accident.26 CF.35 Risk for mortality is highest in people infected with
Variations in death rates from COPD may be related to Pseudomonas aeruginosa, Pseudomonas cepacia, and in those
smoking (type and manufacturing), pollutants, occupational with a VO2 peak of less than 28% predicted.35,37 An esti-
exposures, childhood respiratory infections, climate, and mated 50% of cases with bronchiectasis in the United States
genetics. Deaths due to COPD have been on the rise in the result from CF.38
United States overall, but while the death rate of men has
Pulmonary Edema and Pulmonary Emboli
stabilized, the rate of death due to COPD for women is ris-
ing.27 COPD is the second leading cause of hospitalization Because the pulmonary circulation participates in gas
for adults in the United States.16 Almost 2% of all hospital- exchange, it is important to recognize that pulmonary edema
izations in 1998 were attributed to COPD.28 The cost to the and PE contribute to gas-exchange impairments. Pulmonary
United States in 2009 was approximately $109 billion in care edema occurs when exudates build up in the interstitial space
for those affected by COPD.16 because of heart failure or organ system failure, resulting in
Female smokers are nearly 13 times as likely to die from high volumes and pressures in the circulation around the
COPD as women who have never smoked. Male smokers lungs. As the pressure builds in the pulmonary circulation,
are nearly 12 times as likely to die from COPD as men who proteins and other particulates seep out of the vascular sys-
have never smoked.29 Smoking-related diseases, includ- tem and into the interstitial space. The oncotic force draws
ing cancers, premature births due to maternal smoking, fluid into the space, increasing the distance between vascular
second-hand exposure as well as COPD, claim approximately circulation and alveoli for gas exchange.2 O2 desaturation of
438,000 United States lives each year.30 Tobacco use is the Hgb is common in severe heart failure.39 In the United States
cause of 87% of deaths from lung cancer and approximately there are about 5.7 million people with heart failure, result-
171,000 deaths from lung cancer in the United States in ing in 300,000 deaths per year.
2010.31 PE create dead-space ventilation where alveoli filled with
air are not seen by the pulmonary circulation and can-
Asthma not participate in gas exchange. There are approximately
Asthma, a reversible obstructive lung disease, was esti- 650,000 cases of PE per year. It is estimated there are about
mated to affect 23 million United States citizens in 2008.32 9 postoperative PE per 1000 surgical discharges.40 There
Acute attacks of asthma leading to emergency room visits are about 200,000 deaths per year in the United States, and
and hospital admissions affect 12.7 million United States 10% of adults who present with an acute massive PE die
citizens, of whom 4.1 million are children.32,33 Children within 1 hour of onset.41-43 Massive PE account for 4% to
under age 15 years accounted for approximately 32.7% of all 5% of all cases and nonmassive PE 95% to 96%. Nonmassive
hospital discharges that were asthma related in 2006. Overall, PE are more stable, with a systolic arterial pressure above
asthma is the third leading cause of hospitalization among 90 mm Hg, so the death rate is less than 5% in the first
children, leading to total health care costs of approximately 3 to 6 months of anticoagulant therapy.43,44 Anticoagulation
$20.7 billion.16 In adults, there were more than 3600 deaths therapy, preventive devices (pneumatic devices, stockings),
attributed to asthma in 2006 or a rate of 1.2 per 100,000 after lower extremity (LE), exercise and an appropriate activity
adjusting for age. Approximately 64% of the deaths were regimen are critical to prevent deep vein thrombosis (DVT),
women.34 a primary cause of PE.
Cystic Fibrosis
CF is an inherited, multisystem condition that primarily
affects the lungs. Among inherited disorders, it is the second
PATHOPHYSIOLOGY OF
leading cause of death in children in the United States, behind GAS-EXCHANGE DISORDERS
only sickle cell anemia.35 A mutation of ΔF508 accounts for
two-thirds of all CF alleles worldwide and occurs primarily The major causes of hypoxemia—hypoventilation, dif-
in Caucasian individuals of European descent. The result is fusion, shunt, and V/Q inequality—are present in a variety
impaired structure, function or production of cyclic adenos- of cardiovascular and pulmonary disorders.12 In many
ine 5’-monophosphate–dependent transmembrane chloride cases there will also be hypercapnia as poor oxygenation
channel protein, also called CF transmembrane conductance of tissues leads to increased anaerobic metabolism and
regulator (CFTR) protein.35 There is impaired chloride ion excess production of CO2. The Guide to Physical Therapist
transmission across epithelial cells and excessive sodium Practice refers to impaired respiration/gas exchange as being
reabsorption, resulting in thick mucus that blocks ducts and associated with airway clearance dysfunction (Pattern 6C),
tubes throughout the body. ventilatory pump dysfunction or failure (Pattern 6E), and
An estimated 30,000 people have CF in the United States respiratory failure (adults and neonate; Pattern 6F and 6G).45
and in 2004, 41% were adults.36 The mean age of survival is However, as mentioned previously, there can be impaired gas
now about 37 years.36 Mortality is associated with complica- exchange in severe cardiovascular pump failure (Pattern 6D).
tions from the obstructive airways disease, with respiratory Mechanisms of hypoventilation that cause hypoxemia and
failure as the primary cause of death in 90% of those with poor gas exchange are primarily associated with ventilatory
344 Chapter 9
TABLE 9-2. STAGES OF INFLAMMATION

INFLAMMATORY RESPONSE TO INJURY
Stage 1 Increased blood flow to the area including blood and plasma volume bringing the essential cells
and proteins to the site
Stage 2 Increased permeability of blood vessels allowing fluid and cells into tissues, (acute inflammatory
exudate)
Stage 3 Release of cells, proteins, macrophages, T lymphocytes, neutrophils, and inflammatory mediators to
break down damaged tissue to liquefy and remove and then repair/reconstruct the damaged tissue.
Reprinted with permission from Porth CM. Inflammation and healing. Chapter 20. In: Porth CM, ed. Pathophysiology: Concepts of Altered
Health States. 7th ed. Philadelphia: Lippincott, Williams & Wilkins; 2005.
pump disorders (Pattern 6E). The focus of this chapter will Pulmonary inflammation has been studied for years and
be directed toward the pathophysiology of acute and chronic only recently has there been recognition of the central role
conditions leading to gas-exchange impairments associated that inflammation plays in most pulmonary-related disor-
with airway clearance (Pattern 6C) dysfunction and respira- ders (Figure 9-4). The complexity of the processes involved
tory failure (Pattern 6F). in the inflammatory response and similar clinical manifesta-
tions observed in individuals affected by pulmonary disease
Acute Disorders have made recognition, diagnosis, and subsequent manage-
ment of individual pulmonary disease pathologies chal-
The hallmark of an acute process begins with inflamma- lenging.7 Next, the pathophysiology of common conditions
tion. Inflammation is defined as “a local response to cellular are described to clarify how the inflammatory processes
injury that is marked by capillary dilatation, leukocytic infil- contribute to pulmonary disorders and to assist therapists
tration, redness, heat, and pain and that serves as a mecha- in differential diagnosis for sound clinical decision making.
nism initiating the elimination of noxious agents and of
damaged tissue.”46 This local response is similar whether the Pneumonia
local area is the lung, the kidney or the dermis. The inflam- Pneumonia is an inflammatory reaction in the lungs in
matory response is mediated by a variety of factors that are response to foreign substances that pass through the upper
influenced by the specific tissues and structures affected.47 airways and reach the bronchioles and alveoli. Antigens
In the pulmonary system the site of inflammation is most may also arrive via the pulmonary circulation, with protein
commonly the large airways, the smaller airways, and bron- and chemical mediators leaking into the interstitial fluid
chioles or the lung parenchyma. Additionally, the response between the alveoli and pulmonary capillaries. These foreign
differs to some degree depending on the precipitant. substances may be bacterial, viral, fungal, or mechanical.21
There are 3 major stages of cellular and systemic activity Bacterial or typical pneumonia occurs when the inflamma-
associated with inflammation (Table 9-2).47 These stages tory response exists extracellularly in the alveoli, outside
allow the body to defend itself against all types of noxious the interstitial space, leading to mucus production that may
stimuli including allergens such as pollen or cigarette smoke obstruct airways.49 Viral or atypical pneumonia exist in the
and infecting organisms such as bacteria, viruses, and alveolar septum and interstitial space and, therefore, patients
fungi.47,48 In the pulmonary system these defenses occur and produce limited sputum. The elderly, immunocompromised,
are mediated on both a short-term basis, such as in response pediatric and postsurgical populations are most at risk.49 An
to an acute allergen or infection, or on a long-term basis, such airway clearance program may be efficacious for bacterial
as in individuals who have chronic diseases like emphysema pneumonia where mucus exists extracellularly but would
or chronic bronchitis.48 not be effective for viral pneumonia. The role of the physical
Acute inflammation is the result of a stimulus that acti- therapist should be focused on preventing all types of pneu-
vates an immune response sending chemical mediators to monia (encouraging immunization and avoiding treating
move to the site. As exudates and cell products are released immunocompromised individuals when the therapist is ill).
at the site, swelling appears. Once the injury or infection Bacterial pneumonia results in an inadequate white blood
resolves, the acute process subsides. If there is extensive cell (WBC) response to the area of infection. When an
necrosis and little to no regeneration of tissue or the inflam- organism enters the lung, alveolar macrophages isolate the
matory process is repeated over and over, then the process material and then phagocytosis occurs.50 Normal muco-
becomes chronic inflammation. During chronic inflamma- ciliary transport of mucus and exudates may be altered or
tion macrophages, lymphocytes, and plasma cells promote slowed, contributing to the pneumonia or infection. The
the growth of endothelial cells and fibroblasts.48 This process small bronchioles and alveoli become clogged with exudate
stiffens lung tissues, creating noncompliance and cellular and infection sets in. The 4 stages of pneumonia are listed
dysfunction. in Table 9-3.50
Figure 9-4. Immune
response and pulmonary
disease. (Adapted from Wells
CL. Pulmonary pathology. In:
DeTurk WE, Cahalin L, eds.
Cardiovascular and Pulmonary
Physical Therapy: An Evidence-
Based Approach. New York:
McGraw-Hill; 2004.)
TABLE 9-3. PATHOGENIC STAGES OF PNEUMONIA50

PATHOGENESIS OF PNEUMONIA
Stage 1 Edematous: vascular enlargement and alveolar exudate
Stage 2 Red hepatization: erythrocytes, fibrin, and inflammatory cells move into the alveoli
Stage 3 Gray hepatization: large numbers of macrophages move into the alveoli
Stage 4 Resolution: destruction and removal of exudate and rebuilding of normal lung begins
The major determinant of abnormal pulmonary gas and progressive loss of lung volumes. Atelectasis is usually a
exchange in patients with pneumonia is illustrated by increas- symptom of some other condition involved either directly or
es in intrapulmonary shunt along with mild to moderate V/Q indirectly in the lung.21
mismatch.51 Hypoxia may or may not be evident, depend- Acquired atelectasis is usually due to airway obstruction
ing on the health of the remaining lung tissue. Treatment and lung compression.21 Obstruction may be due to a mucus
with specific antibiotics depends on the organism found in plug, external compression from fluid (pleural effusion),
cultures, whether the pneumonia is community, hospital tumor mass, exudates or deficient transpulmonary pressure
or nursing home acquired, and the overall health of the (loss of surfactant, imbalance or pleural pressures within the
individual.21 In some people the cough may be diminished thorax due to respiratory muscle weakness, pain or defor-
or weakened. Individuals with dysphagia may aspirate fluid mity).53 Primary atelectasis occurs in premature infants in
into the lungs.21 A speech therapy evaluation, determination whom there is insufficient surfactant production in under-
of oral management of food consistency, positioning during developed lungs. Insufficient surfactant can also occur with
eating, and bulbar exercises to improve swallowing control the aspiration of gastric contents, use of anesthesia, high con-
are important strategies to prevent aspiration pneumonia.52 centrations of O2, smoke inhalation, and interstitial fibrosis.
Atelectasis The primary complication of atelectasis is hypoxia since
the surface area available for gas exchange is reduced. The
Atelectasis is a collapse of the lung parenchyma, which degree of hypoxia depends on the amount of lung tissue
can be localized to specific alveoli, patches of alveoli, lung affected and the health of the remaining lung. Hypoxia also
segment(s) or can involve a complete lobe(s). It is usually stimulates vasoconstriction of the pulmonary vessels.5 As
caused by gradual and progressive loss of lung volume lead- vasoconstriction occurs in hypoxic areas, other portions of
ing to inadequate intra-alveolar stretch tension, which reduc- the pulmonary circulation develop an increase in circula-
es the production of surfactant.49 The decrease in surfactant tion that causes a rise in hydrostatic pressure. The hydro-
reduces the surface tension among alveoli, resulting in col- static pressure in the circulation around marginal but viable
lapsing of alveoli and bronchioles, obstruction of airflow, regions of the lung may lead to further alveolar collapse and
346 Chapter 9
Figure 9-5. Mechanisms involved in devel-
opment of ARDS. (Adapted from Porth CM.
Disorders of ventilation and gas exchange.
In: Porth CM, ed. Pathophysiology: Concepts of
Altered Health States. 7th ed. Philadelphia, PA:
Lippincott, Williams & Wilkins; 2005:689-724.)
extension of atelectatic condition. A right to left shunt occurs ARDS).21 Medical management is focused on optimizing
within 24 to 48 hours if atelectasis is massive enough as pul- cardiac performance, electrolyte regulation, treating the
monary edema and ARDS develop.21 Therefore it is critical cause of the primary illness, and improving gas exchange
to find strategies to recruit more alveoli and improve venti- and transport of O2 to the tissues. Severe hypoxia can lead to
lation in postsurgical or infectious conditions. Changes in respiratory distress and failure.
position, deep breathing, ventilation support, postural drain-
Acute Respiratory Distress Syndrome
age, and mobility programs may improve alveolar ventilation
and are good preventive strategies. Adult ARDS is characterized by diffuse pulmonary
microvascular injury. The initial site of damage may be
Pulmonary Edema the alveolar-capillary units, alveolar spaces, alveolar walls
Pulmonary edema is a reaction where extravascular fluid or neighboring lung tissue.21 Injury to the cell inactivates
is drawn into either the interstitial tissue or the alveoli or surfactant and causes fluids, proteins, and blood cells to leak
both.21 The factors that can contribute to keeping the inter- into the interstitium creating pulmonary edema (Figure 9-5).
stitium and alveolus dry are a pulmonary circulation plasma In ARDS, the alveolar epithelial barrier breaks, allowing
oncotic pressure (25 mm Hg) that is greater than hydrostatic flooding of the alveolar space and making it difficult or
pressure (7 to 12 mm Hg), connective tissue and cellular bar- impossible for O2 to diffuse into the capillaries. Hypoxia is
riers that are somewhat impermeable to plasma proteins, and largely related to intrapulmonary shunting.55,56
an adequate lymphatic system.54 Normally when fluid builds Mechanical ventilation is usually required to maintain
in the interstitium, the lymphatic flow increases. Pulmonary ventilation and gas exchange during the healing process
edema appears when the lymphatics are overwhelmed and while the medical team works on treating the underlying
the interstitial fluid and pressures back up until eventually condition causing the ARDS. Underlying causes may include:
the alveolar capillary membranes leak and flood the alveoli. chest trauma, sepsis of the lung or other organs, complica-
The causes of pulmonary edema may be cardiogenic or tions of cardiopulmonary bypass, aspiration, drowning,
noncardiogenic. Cardiogenic pulmonary edema is the result smoke/chemical inhalation, drug overdose, and emboli.21
of elevated filling pressures on the left side of the heart from Massive atelectasis and severe pulmonary edema (described
cardiovascular disorders (valve impairment, MI, cardiomy- previously) may result in ARDS. The earliest sign of ARDS
opathy, congestive heart failure [CHF], etc). Noncardiogenic is an elevated RR and shortness of breath (SOB) appearing
causes may include excess fluid retention resulting from within 12 to 48 hours. Physical therapists can assist the medi-
impaired sodium and water excretion in renal disorders or by cal management team by offering positioning programs and
decreased serum and albumin associated with liver disease, intervening early to encourage deep breathing and mobility
lymphatic obstruction or tissue injury (acute lung injury or when feasible.
Pleural Effusions and Empyema
Normally there is approximately 5 mL of pleural fluid dis-
tributed throughout the intrapleural space. The fluid helps
to decrease the work of breathing by promoting the sliding
of the visceral pleura against the parietal fluid.7 If the fluid
in the pleural space increases or decreases the lungs cannot
expand as effectively. When lung movement is altered, atel-
ectasis and its own ramifications may occur. In its extreme,
pleural effusions can cause shunting of blood from hypoven-
tilated areas and hypoxia may result.
Pleural effusions are classified into 2 groups: transudates
and exudates. Transudate is a water fluid that leaks out of the
pulmonary circulation when there is an elevation in micro-
vascular hydrostatic pressure or decrease in oncotic pres-
sure (ascites, CHF, renal disorders).25 High pressures force
fluid out of the pulmonary capillaries.21 Exudates are due
to pleural inflammation, in which there exists an increased
permeability of the pleural surface to proteinaceous fluid
(infection, malignancy or trauma). Exudate is a fluid with a
high concentration of protein and cellular debris that escapes
from the pulmonary vasculature.21 Lymphatic blockage may
also contribute to a build-up of pleural fluid. Both transu-
dates and exudates will alter lung compliance.25
Positioning changes, breathing exercises, and increased
activity can assist in preventing further complications.25 A
pleural effusion can compress lung tissue if it is large, causing
atelectasis. If the fluid becomes infected the pleural effusion
Figure 9-6. Open PTX and tension PTX. (Adapted from Porth CM.
evolves into an empyema or pus in the pleural space.53 It Disorders of ventilation and gas exchange. In: Porth CM, ed.
may be inappropriate to place the good lung in a dependent Pathophysiology: Concepts of Altered Health States. 7th ed. Philadelphia,
position because of the need to avoid fluid shifts and spread PA: Lippincott, Williams & Wilkins; 2005:689-724; figure p.692.)
of infection. Fever may be present with empyema and the
individual develops fatigue, weakness, and malaise. A tho-
life-threatening situation if not reversed with a chest tube
racocentesis may be performed using a needle to remove the
immediately.53,57
exudate, or a thoracoscopic procedure may be required to
remove tissue, sample or remove fluid. Sometimes a chest For individuals who require high-pressure mechani-
tube or pigtail catheter is inserted into the pleural space to cal ventilation to maintain open airways, there is a risk of
drain large amounts of fluid.25,57 a closed PTX. An example of this would be a patient with
ARDS who receives high-pressure ventilation (> 70 cm H2O)
Pneumothorax to open stiff, collapsed airways.58 Pressure ventilation can
A pneumothorax (PTX) is free air between the visceral induce barotraumas to the compliant portions of the lung,
and parietal pleurae. There are different types of PTX includ- creating a closed PTX.59
ing traumatic, spontaneous, and tension.53 When air leaks Iatrogenic PTX is a traumatic complication often caused
into the pleural space, the change from a normally negative by some medical procedure.57 Spontaneous PTX is a condi-
pressure to a more positive pressure causes pulmonary col- tion where air enters the pleural space and collapses the lung
lapse. The collapse, like in atelectasis, can lead to shunting with no apparent trauma. This can occur in high altitudes
of blood from nonventilated regions because of hypoxic or in deep sea diving. Spontaneous PTX can also occur in
vasoconstriction. Symptoms may include dyspnea, shock, disease states where weakened lung tissues, like bullae in
life-threatening respiratory failure, and circulatory collapse. patients with emphysema, are easily subject to changes in
In trauma, the lung collapse may be due to an open PTX, pressures.57 Physical therapists should respond quickly and
a condition where a penetrating chest wound allows air from report any signs and symptoms of severe SOB with high
the atmosphere to enter the pleural space yet some air can RRs in people who are admitted with traumatic injuries,
still escape to the atmosphere. Lung collapse may also be who are on high-pressure ventilation or who may have had
due to tension PTX. A tension PTX allows air to enter the significant cardiothoracic surgery. It will be important to
pleural space but not leave (Figure 9-6).53 The air increases check chest tube placement is secure and sutured in prior to
in the pleural space with each breath, causing ipsilateral mobility and changes in position.59 Once the PTX is resolved
collapse, mediastinal shift to the opposite side, collapse to segmental breathing and prescriptive body positioning may
the contralateral lung, and cardiac compromise. This is a be employed.1,25
348 Chapter 9
TABLE 9-4. WELL'S CLINICAL PREDICTION RULE FOR DEEP VEIN THROMBOSIS61
CLINICAL PRESENTATION SCORE
● Active cancer [within 6 months of Dx or receiving palliative care] 1
● Paralysis, paresis, or recent immobilization of lower extremities 1
● Bedridden for more than 3 days or major surgery in the last 4 weeks 1
● Localized tenderness in the center of the posterior calf, popliteal 1
space, or along the femoral vein in the anterior thigh, groin
● Entire lower extremity swelling 1
● Unilateral calf swelling [more than 3 mm larger than uninvolved side] 1
● Unilateral pitting edema 1
● Collateral superficial veins [nonvaricose] 1
● An alternative diagnosis is as likely [or more likely] than DVT ‒2
Interpretation Total Points Probability of DVT
‒2 to 0 Low probability of DVT [3%]
1 to 2 Moderate probability of DVT [17%]
3 or more High probability of DVT [75%]
BOX 9-2. PHYSIOLOGIC FACTORS DVT anywhere in the body. LE venous thrombosis usually
starts in the calf veins. Fatty emboli can form after fractures
CONTRIBUTING TO DEEP VEIN THROMBOSIS53 but are rare. Fatal PE can result from a thrombus originating
● Venous stasis in the axillary or subclavian veins, veins of the pelvis, or from
around indwelling central venous catheters. Individuals
● Venous endothelial injury who have a diagnosis of cancer, CHF, paralysis, or are status
● Hypercoagulability post-LE surgery are at increased risk for developing throm-
bosis. The role of the physical therapist is preventing PE by
identifying the signs of DVT early using prediction rules
(Table 9-4) and good observation skills.60,61 Checking the
Pulmonary Vascular Disorders
prothrombin time, platelet, and international normaliza-
A pulmonary embolism is a blood clot, emboli or throm- tion ratios in the medical chart can also assist the physical
bus that has lodged itself in the pulmonary vasculature. It therapist in identifying individuals at risk for blood clots or
prevents blood flow to the lung tissue distal to the blockage, bleeding disorders.62
mechanically obstructing the pulmonary circulation and
stimulating neurohumoral reflexes leading to vasoconstric-
tion.53 The size of the clot determines the amount of lung
Chronic Disorders
parenchyma affected. Obstruction of the vasculature may Chronic respiratory system disorders may follow acute
produce dead-space ventilation, V/Q, shunting, and systemic conditions when there is destruction of alveolar tissue and/
hypoxia. This may cause a fall in O2 content of the coronary or the pulmonary circulation, fibrosis, chronic inflammation
blood supply. If the affected area is large enough, there may of the bronchial wall leading to hypertrophy and hypersecre-
be a sudden increase in pulmonary artery pressure (pulmo- tion of mucus.53 Common chronic conditions include COPD,
nary hypertension), leading to right ventricular strain and asthma, CF, and bronchiectasis and interstitial lung diseases.
heart failure.53 This increased right ventricular pressure Individuals with chronic CHF may also have impairments in
may shift leftward causing pressure within the left ventricle gas exchange.
and a decreased CO. Reflex bronchospasm may increase the
work of breathing and diminishes pulmonary compliance.53
Chronic Obstructive Pulmonary Disease
Almost all PE arise from DVT in the LEs and are due to a According to the Global Initiative on Obstructive Lung
variety of physiologic causes (Box 9-2). Disease (GOLD), “COPD is a disease characterized by air-
Thrombosis in the veins is triggered by venostasis, hyper- flow limitation that is not fully reversible.63 The airflow
coagulability, and vessel wall inflammation, known as limitation is usually progressive and is associated with an
Virchow’s triad. All clinical risk factors for DVT and PE have abnormal inflammatory response of the lungs to noxious
their basis in one or more of the three. PE can arise from particles and gases.” COPD includes several pathological
subsets (chronic bronchitis, asthma, and emphysema) that
often are found coexisting in individuals with respiratory
symptoms.64 Yet, obstruction to airflow is a problem that
reaches beyond COPD and shifts among conditions that
differ in pathogenesis and reversibility. For example, airflow
obstruction in asthma is reversible, and the degree of airflow
obstruction in emphysema and chronic bronchitis may be
diminished resulting in fluctuations in gas-exchange impair-
ment with each condition (Figure 9-7).
Asthma is commonly described as reversible, yet some
individuals with COPD have some asthma and may show
partial reversibility of airway obstruction when bronchodila-
tor medication is employed. Thus the 2 conditions coexist.64
Chronic bronchitis is defined as the presence of a productive
cough for 3 months over 2 successive years.64 Part of the year
these individuals may be free of symptoms. Emphysema is
defined as abnormal permanent enlargement of air spaces
distal to the terminal bronchioles.64 The enlargement can Figure 9-7. Schema of COPD. (Reprinted with permission from Celli BR,
progress to actual holes in the lung parenchyma with loss of Snider GL, Heffner J, et al. Standards for the diagnosis and care of patients
with chronic obstructive pulmonary disease. Am J Respir Crit Care Med.
lung elasticity and collapse of small airways. When diagnos- 1995;152:S77-S120.)
ing people with respiratory system disorders, the physician
uses the most common clinical characteristics to label the
disease process knowing that there may be more than one the mechanics of ventilation are disturbed, causing alveolar
subset of conditions involved and differences in the airflow hypoventilation and poor gas exchange. Hypercarbia may
limitation. be seen as CO2 accumulates within the poorly ventilated
Emphysema areas of the lung. If the emphysema is severe, bullous for-
mations can occur and the individual has an increased risk
Emphysema is the anatomic destruction of alveolar walls
for spontaneous or ventilator-induced PTX.65 Peripheral
and elastic parenchymal tissue distal to the terminal bron-
muscle wasting is also seen in individuals with emphysema,
chioles.65 It can be caused by either the lack of proteolytic
and COPD is related to corticosteroid dosage and increased
enzyme inhibitor or too much proteolytic enzyme, leading
tumor necrosis factor production.21,67
to enzymatic destruction of lobule support structures.50,65
Smoking and α1-antitrypsin deficiency are 2 factors that Chronic Bronchitis
are known to contribute to enzymatic destruction in the Chronic bronchitis is defined by the clinical signs and
lung.53 The destruction of alveolar lung tissue and evolution symptoms of an excessive productive cough lasting for
of large air spaces result in a decrease in surface area for gas 3 months and for 2 consecutive years.21,64 Cigarette smok-
exchange. There is V/Q mismatching and shunting of blood. ing, pollution, and industrial fumes are closely linked to
There is a decreased elastic recoil and loss of alveolar surface this disease. Inflammation in the airways causes edema
tension that results in a loss of the radial traction forces that and hyperplasia of submucosal glands and epithelial goblet
hold open the distal bronchioles.53,57 Imbalances in transpul- cells.53 The glands enlarge and the cells increase contributing
monary pressures and bronchiole closure cause early airway to over-production of mucus. Initially, hypersecretion begins
collapse on expiration.2 The loss of alveolar tissue elasticity, in the large airways and later progresses to involvement of
air trapping, and collapse all contribute to pulmonary func- small airways.68 Chronic bronchitis is confirmed when expi-
tion deficits that may be measured with spirometry. The ratory flow decreases and FEV1/FVC ratio < 75%.21 Hypoxia
FEV1 should be about 80% of the FVC. Airflow obstruction can result if the obstruction is severe enough and exudate
is significant when FEV1/FVC falls below 0.70 post-broncho- begins to occlude small airways. Infection occurs when there
dilator.21,63 Hyperinflation of lung develops and there is an is impaired ciliary function and retention of mucous in the
increased in RV. During activity or exercise the air trapping lungs causing an inability to clear foreign particles adequate-
worsens, causing dynamic hyperinflation, further increasing ly.53 Patients with chronic bronchitis develop higher levels of
the RV, impaired breathing mechanics, and dyspnea.66 CO2 retention, have a barrel chest, a blue-gray appearance,
Hypoxemia is imminent because of the loss of surface area and often rely on the hypoxic signals in peripheral chemore-
in poorly ventilated regions of the lung. Hypoxic vasocon- ceptors to signal breathing during end stages of the disease.53
striction and damage to the pulmonary circulation impair
perfusion. Thus, both impaired perfusion and ventilation Asthma
result in V/Q mismatch and shunting.53 Pulmonary hyperten- Asthma is a chronic disorder of the airways that is
sion and cor pulmonale appear when capillaries are damaged characterized by reversible airflow obstruction and airway
and the vessel intima thickens.21 As air trapping progresses inflammation, persistent airway hyperactivity, and airway
350 Chapter 9
airways into the blood. The water content of the mucociliary
BOX 9-3. TYPES OF ASTHMA21 blanket is decreased and viscous mucus begins to obstruct
● Extrinsic: IgE mediated external allergens, foods, the airways.53 Lung infections are prevalent and over time
pollutants, pollen, dust, animal dander. result in structural changes in the bronchial wall leading to
bronchiectasis. More than 50% of individuals with bronchi-
● Intrinsic: Nonallergic, no known trigger, asso- ectasis have CF.21
ciated with chronic and recurrent infection.
Over-secretion of mucus in the bronchioles will cause
Hypersensitivity to a bacteria or virus.
dyspnea and eventual hypoxia. During exercise individuals
● Occupational: Work exposures to dust, gases, with severe CF lung disease develop increased end expiratory
acids, molds, vapors, etc. lung volume due to air trapping from dynamic hyperinfla-
tion.73 Thus impaired breathing mechanics may explain the
increased dyspnea with aerobic exercise. Exercise intolerance
remodeling.69 Cellular infiltration occurs along with epithe- may also be related to skeletal muscle dysfunction caused by
lial disruption, mucosal edema, and mucus plugging.21 There hypoxia, corticosteroids or abnormal CFTR function or gen-
is typically an event that triggers an immune system response otype in skeletal muscles.74,75 More than 90% of individuals
sending many cells and cell mediators to the airways (mast with CF have pancreatic insufficiency and develop diabetes
cells, neutrophils, T cells, eosinophils, and epithelial cells).53 as adults. Thus, glucose monitoring will be necessary prior to
The response may be stimulated by extrinsic, intrinsic or exercise and throughout the therapeutic exercise program for
occupational irritants (Box 9-3).21 Clinical manifestations many adult individuals with CF.68 Diabetes and malabsorp-
of asthma are recurrent episodes of bronchospasm, dyspnea, tion syndrome result in poor nutrition status that can impair
and wheezing.53,68 During an episode the individual strug- exercise tolerance in individuals with advanced CF.76
gles to breathe and hyperventilates, causing excess removal
of CO2. This causes hypocapnia and respiratory alkalosis Interstitial Lung Diseases
because excess CO2 is removed from the blood. Later during Interstitial lung diseases are the result of long-term
the attack the respiratory muscles fatigue and the individual inflammatory conditions that produce fibrosis and stiffen-
hypoventilates and develops hypercapnia and a respiratory ing of the interalveolar structures of the lungs. Interstitial
acidosis as CO2 accumulates in the blood.68 Hypoxia occurs lung diseases may be due to occupational and environmen-
because of V/Q mismatch and widening of the diffusion gra- tal exposures, sarcoidosis, hypersensitivity pneumonitis,
dient. It is important for the physical therapist to recognize radiation or pulmonary fibrosis.53 Approximately two-thirds
early signs of an attack and encourage proper use of inhalers of the cases of pulmonary fibrosis are idiopathic (arising
and timing of medications. Patients with asthma should be from an unknown cause) while the remaining one-third
tested for allergens and educated in avoiding environmental arise from healing after active conditions (ARDS, systemic
triggers. Monitoring the peak expiratory flow rate (PEFR) sclerosis, tuberculosis).21 Hypoxemia is common across all
and knowing baseline reactivity prior to exercise is critical to interstitial disease as fibrosis leads to a loss of compliance,
ensure a safe and efficacious therapeutic session.68 and decreased ventilation and surface area for diffusion and
Exercise-induced asthma (EIA) is a condition that physi- severe dyspnea with activity.21 Severe arterial O2 desatura-
cal therapists may encounter in practice. This condition tion limits safe activity. Supplemental O2 is effective as long
occurs when there is exposure to cold, dry air during rapid as the DLCO is above 40% predicted.77
ventilation (as in exercise). EIA is confirmed when there is a As the disease progresses, there is fibroblast proliferation,
drop of 10% of FEV1 or PEFR from baseline during the first deposition of collagen, and destruction of elastic tissue in the
5 minutes after an 8- to 10-minute bout of moderately intense capillaries within the pulmonary vasculature.21,53 The indi-
(VO2 70% to 85% max) aerobic exercise.70 The therapist can vidual presents with a dry cough, fatigue, and severe dyspnea
suggest using a scarf around the mouth and nose to warm that is out of proportion to activity. The lungs are small on
the air, premedicating with bronchodilators 30 minutes prior x-ray because of reduced volumes.25 The pulmonary function
to exercise, avoiding activities that are higher in ventilation examination reveals significant restrictive disease (FEV1/FVC
flow (soccer, sprinting, hockey, etc) or trying to use broncho- ratio > 85).10 Energy conservation strategies become necessary
provocation strategies during warm-up periods for individu- when DLCO falls below 40% predicted and supplemental
als with refractory EIA.21,71 O2 becomes less effective during activity.77 Individuals with
Cystic Fibrosis significant interstitial disease may require a lung transplant.
CF is an inherited chronic disease of the exocrine glands

that affects the respiratory, hepatic, digestive, and reproduc-
tive systems.53 Exocrine gland dysfunction leads to abnormal EXAMINATION OF
mucus secretion and obstruction in the bronchi, bile ducts,
pancreatic ducts, small intestine, cervix, and vas defer-
GAS-EXCHANGE DISORDERS
ens.72 In the lungs the chloride ion is secreted into the air- The physical therapy examination is a process that
way through CFTR protein-modulated channels.68 There is involves a screen of all major systems. Many individuals with
increased sodium absorption and water movement from the
gas-exchange disorders have multisystem involvement either (snoring, apnea) or heart failure (orthopnea or paroxysmal
from the disease process (CF, CHF, sarcoidosis) or from the nocturnal dyspnea).88
medical management required (radiation, corticosteroids). Medical information to review prior to performing the
This section of the chapter will focus on physical therapy physical examination should include reports of baseline vital
examinations directly related to gas-exchange disorders. An signs (including oximetry), arterial blood gases, complete
example of the entire physical therapy examination process blood count, pulmonary functions tests (including DLCO),
across all systems is presented in the case at the end of the sputum cultures, imaging and chest radiographs, cardiac
chapter. diagnostics (echocardiography, electrocardiogram [EKG],
catheterization reports) nutritional support, and renal/uri-
Patient/Client History nary tests.89 The therapist should note the type of mechani-
cal ventilation support as well as O2-delivery devices (mask,
History taking begins with a review of the general demo- nasal cannula, etc), method of O2 delivery (pulsed or con-
graphics such as age, gender, height, weight, language, race, tinuous flow), and prescription (liters/min). All medications
culture, and education.45 These factors are used to interpret need to be reviewed for their purpose, potential side effects,
respiratory function63,78 and tests of physical work capacity and the time course for effectiveness. Does the individual
(ie, 6-Minute Walk Test [6MWT]).79 Measures of pulmo- have postsurgical pain after lung transplantation or bullec-
nary impairment (FVC, FEV1, PEFR), respiratory muscle tomy? How is this pain being managed? Is there an asthmatic
performance (PImax, PEmax, MVV) and diffusing capacity component to the lung disorder? Will the individual need to
(DLCO) are compared to expected values reported in the have a rescue inhaler available or premedicate prior to partic-
literature.63,78,80-84 Gathering facts related to growth and ipating in an activity examination? The therapist should note
development is especially important in children who may whether medications influence the cardiac response as this
have gas-exchange disorders related to CF,6,76 asthma,85 or can influence the interpretation of physiologic responses.
prematurity (respiratory distress syndrome or bronchopul- Clinical outcome tools are important for individuals
monary dysplasia).25 Body weight records may reveal trends with gas-exchange impairments. Disease-specific tools (St.
that a child is undernourished. Although adults are fully George’s Respiratory Questionnaire90 or Chronic Respiratory
grown, it is important to check and see whether changes in Questionnaire91) may be necessary because many functional
body weight have occurred since admission. outcome measures (Functional Independence Measure,92
The therapist should review the known social and work SF-3693,94) may have ceiling effects in higher-functioning
history as well as the individual’s living environment prior individuals with gas-exchange problems. Presently, meth-
to the personal interview.45 It is critical to avoid exhaustive ods used to examine outcomes depend on physiological
questioning during the physical exam. The overall goal of tests and questionnaires.95 Physiological tests include test-
history taking is to determine which activities are included ing lung function, exercise capacity, and physical activity.
in the person’s everyday work and leisure routine and iden- Questionnaires typically focus on symptoms that limit activ-
tify any signs, symptoms or medical limitations that may ity and factors known to influence health status and quality
interfere with activity participation. Family history can also of life. Many elements included in the questionnaire portion
be reviewed to help identify familial diseases, lifestyle pat- of the outcome tools need to be documented prior to devel-
terns,86 and the quality of the support system for the person oping a bias about the individual and should be considered
with a gas-exchange disorder. Educating and recruiting sup- prior to the physical examination.95 Therefore, outcome tools
port to assist the family in implementing strategies to help are selected early in the history-taking portion of the exam.
reduce risk factors is important for management of diabetes, Several outcome tools for individuals with gas-exchange dis-
smoking cessation, obesity, and other modifiable conditions. orders are listed in Table 9-5.
The therapist should also learn if there are environmental
exposures (dust, animals or occupational inhalants) that may
be compromising the long-term health of the individual.
Systems Review
History of present illness will include a review of the med- The systems review is a brief examination designed to
ical chart and the recent course of the disease. The therapist screen all major systems that may affect the ability of the
should determine the reason for the present hospitalization individual to participate in purposeful movement.45 Once
and the chief complaint. Is the hospitalization or reason for cognition and communication are established, measures may
referral because of severe dyspnea or infection, or related be taken to examine each system. The first major system to
comorbidities such as heart failure? What medical manage- screen is the cardiovascular/pulmonary system. The heart
ment procedures have been offered to manage the signs and rate (HR), blood pressure (BP), RR, SaO2, and presence of
symptoms or to stabilize the current medical condition? If a edema should all be measured at rest. Any contraindications
surgery was performed, postoperative protocols are noted. to physical therapy examinations must be identified imme-
Are there any contraindications to activity or conditions that diately, and individuals who are not appropriate for testing
would require a modification of the physical therapy exami- referred back to the physician. The therapist should be famil-
nation?59,62,86,87 Additionally, questions about sleep pattern iar with normal and abnormal values for each measure and
are important for detecting early signs of CO2 retention use appropriate terminology to document resting data.
352 Chapter 9
TABLE 9-5. OUTCOME ASSESSMENT TOOLS FOR INDIVIDUALS WITH GAS-EXCHANGE DISORDERS
OUTCOME DESCRIPTION AND PURPOSE ADMINISTRATION
TOOL
Dyspnea BDI/TDI96 Eight of 9 items describing routine activities. Individual is Interview
asked to describe the amount of breathlessness at base-
line and change in breathlessness over time.
MRC-Scale97,98 Individual selects a grade from a list of descriptors indicat- Self-administered
ing activities that cause dyspnea
Borg-Scale The individual rates the amount of perceived dyspnea at Self-administered
(CR10)99 rest and during activity
Symptom CAP-Sym100 An 18-item measure that assesses the annoying symp- Self-administered
Measure̶ toms of pneumonia during the past 24 hours using a
Pneumonia
6-point Likert scale.
Health Status SGRQ90 A disease-specific questionnaire that examines the fre- Self-administered
and Quality quency and severity of symptoms, activity impact, and
of Life
psychosocial impact (76 items)
CRQ91 A disease-specific measure of physical-functional and Interview
emotional limitations due to chronic lung diseases.
Individual is asked to recall the 5 most important activities
that caused breathlessness in the last 2 weeks.
SOLQ101 Disease-specific questionnaire designed to measure phys- Self-administered
ical function, emotional function, coping skills, and treat-
ment satisfaction of individuals with COPD. May be used
to predict hospitalization and mortality.102
QWB103,104 This scale measures well-being based on social preferenc- Interview
es for mobility, physical activity and social activity. There
are 4 levels to measure physical activity and 5 levels to
measure social activity and mobility. Symptoms that impair
function are scored. Validated in COPD103 and CF.104
SF-3693 Generic health survey. There are 36 items requiring the Self-administered
individual to self-assess psychological, physical, and social
aspects of their quality of life.
Multi- BODE105,106 Prognostic indicator for individuals with COPD. Utilizes Scores from physi-
Dimensional 4 components (BMI, FEV1, MMRC, 6MWT) to describe cal exams and
Tools
severity of disease and function. questionnaires.
6MWT: 6-Minute Walk Test; BDI: Baseline Dyspnea Indexes; BMI: body mass index; BODE: body mass index, airflow obstruction, dyspnea,
exercise capacity; CAP-Sym: Community-Acquired Pneumonia Symptom Questionnaire; CRQ: Chronic Respiratory Questionnaire; MMRC:
Modified Medical Research Council; MRC-Scale: Medical Research Council Scale; QWB: Quality of Well-Being Scale; SGRQ: St. George s
Respiratory Questionnaire; SOLQ: Seattle Obstructive Lung Disease Questionnaire; TDI: Transition Dyspnea Indexes.
The integumentary system screen may be performed prior During the neuromuscular screen the therapist examines
to the musculoskeletal or neuromuscular systems review. gross movement involving balance, gait, locomotion, trans-
It is important to identify wounds or incisions that should fers, transitional movements, and motor control or motor
not be stressed during examination of range of motion learning considerations.45 The systems review may conclude
(ROM) or functional movement. The therapist should note with more detailed testing of cognition, affect, language and
the presence and quality of scar formation and document communication, and overall appraisal of learning style.
the location and size of any incision or wound. The color, Information from the interview and the system review
temperature, and integrity of the skin should be noted. The begins to direct the physical therapist to the categories of
musculoskeletal system screen includes a gross examination tests and measures indicated. Even before the exact test and
of ROM, strength, postural symmetry, height, and weight. measures are selected, the physical therapist has started to
This is followed by a screen of the neuromuscular system. gather information just by observing the patient (Table 9-6).
TABLE 9-6. CLINICAL OBSERVATIONS A

General Observe the level of mentation and
appearance note any presence of confusion or dis-
orientation. Also look for facial charac-
teristics that may suggest psychologi-
cal distress or anxiety. The therapist
should notice the use of any accessory
muscles, nasal flaring, and self initi-
B
ated pursed-lip breathing, which may
be signs of air hunger.
Color Observe the skin, lip, and gum color
for signs of cyanosis (blue-gray color-
ation)
C
Chest wall Note the initial body position, any
and posture RR and TV abnormalities (hyper/
hypoventilation); chest wall motion
and deformity. Observe any abnormal
movement or lack of movement of
the chest wall. Check for abnormal Figure 9-8. Normal digit configuration (A) and digital clubbing (B).
diaphragm motion (belly breathing), Note that the angle between the nail and the proximal skin exceeds
paradoxical chest movement, and 180 degrees. (C) Also note that the distal phalangeal depth (DPD) is great-
er than the interphalangeal depth (IPD). (Adapted from Wilkins RL, Krider
presence of any asymmetrical head SJ. Clinical Assessment in Respiratory Care. St. Louis, MO: Mosby; 1985.)
and trunk positions during breathing
(see Chapter 8).
Neck The therapist should observe the individual with gas-exchange disorders is generated. Specific
neck for excessive accessory muscle tests and measures may be similar to those selected for ven-
use (see Chapter 8). While the per- tilatory pump dysfunction (chest wall excursion, posture,
son is lying supine with the head respiratory muscle strength, and cough). This is especially
and neck at a 45-degree angle, the true if gas-exchange impairment is due to hypoventilation.
therapist can observe jugular venous If the ventilatory pump is failing then gas exchange worsens
distention.107 The presence of jugular and the problem may progress to respiratory failure (Practice
venous distention signifies CHF or pul- Pattern 6F).45
monary vascular fluid overload.89,107 Gas-exchange impairment can also occur in conditions
such as pulmonary edema, pulmonary fibrosis or lung tis-
Phonation Listen to the voice and note whether sue diseases where respiratory muscle is strong but the lung
it is loud or quiet. How many words condition increases the ventilatory demand. The selection
can the person speak before taking a of tests and measures from the category of Ventilation
breath? Are there audible secretions in and Respiration/Gas Exchange will figure prominently.
the airway during speech? Additional tests and measures may also be indicated from
Nail beds Look for clubbing of the fingers, a the categories of: Arousal, Attention and Cognition, Posture,
broadening of the distal finger tips and Aerobic Capacity/Endurance. Other measures may be
with an increased Lovibond angle indicated from the categories of Circulation, Range of
(Figure 9-8) may indicate chronic Motion, and Muscle Performance.
hypoxia and Mees lines, a white dis-
Arousal, Attention, and Cognition
coloration of the nail with transverse
lines, may be seen in renal failure, Elevations in CO2 are often associated with decreased
heart disease, and pneumonia.108 attention and cognitive processing.109 Therefore, the clini-
cian should include such examinations as the Mini-mental
exam110 and the Trails Making test to further exam cognitive
functioning.111 Arousal may be decreased and result in slow-
Tests and Measures er responses to stimuli. Attention can be tested by asking the
individual to perform the Digit Span Test where a series of
Observation numbers is repeated forward and backward. Walking while
After completion of the systems review screening and talking (or locating objects) is a means of testing divided
observation period, a list of specific tests and measures for the attention.112
354 Chapter 9
Posture Mediate Percussion
Posture should be assessed for the presence of increased Mediate percussion is another screening tool used to dif-
anterior-posterior diameter of the chest, kyphosis, and sco- ferentiate between solid or fluid- and air-filled spaces in the
liosis. These abnormal postures can often be the result of thorax. Percussion is performed by tapping the dominant
long-term pulmonary disease. A more rigid chest wall will middle finger onto the opposite distal middle finger while
also contribute to restrictive disease. Chest wall expansion over an intercostal space.7,88,107 Normal resonant sound and
measures are reliable and can be taken at a xiphoid and vibration is heard and felt over the first to eleventh intercos-
axillary sites and compared to norms in the literature.113-116 tal spaces and should be the same bilaterally.7 When hyper-
Impaired posture may contribute to loss of ROM in the cervi- resonance is noted, this may indicate fluid or increased air, as
cal spine and shoulders. with a large pleural effusion or a tension PTX. When a dull or
flat sound is noted, it may indicate consolidation, collapse, or
Ventilation and Gas Exchange solid tissue and may suggest a dense pneumonia, atelectasis,
For individuals with gas-exchange impairments, the or tumor.88,107,119 When abnormalities are noted, this indi-
examination ventilation and gas exchange is performed early cates a need for further examination to confirm a diagnosis.
in the physical exam. Examination of ventilation includes The sensitivity of chest percussion is very low and therefore
assessment of posture and chest wall assessment (see Chapter the inter- and intra-rater errors are high.120
8), which will be followed by a detailed examination of venti- Respiratory Rate and Pattern
latory mechanics and breathing pattern (see Chapter 8), res-
RR is normally 12 to 18 breaths per minute. Respiratory
piration, and auscultation. Baseline measures for breathing
pattern describes the variation between RR, TV, and pause
pattern, RR and pattern, dyspnea, SaO2, and auscultation are
characteristics. Descriptions of respiratory pattern include
taken in the initial position and may be repeated with chang-
tachypnea (> 20 breaths/minute), bradypnea (< 10 breaths per
es in positions. Aerobic capacity examination is performed
minute), hyperventilation, Cheyne-Stokes, biots, Kussmaul’s,
after all baseline measures are completed so the therapist
etc.121 Tachypnea or rapid RR can be caused by exertion, fever,
may screen findings for any contraindication to exercise.
pain or hypoxia, and ventilatory pump disorders. Bradypnea
Chest Wall Exam or slow RR can be caused by medications, especially narcot-
Palpation is used to examine the chest wall. The purpose ics, hypothermia or injuries to the brain stem. When the RR
of this manual examination is to detect abnormalities in the at rest is below 8 or above 30 at rest, this is a sign of medical
chest wall movement or lung parenchyma and identify spe- instability and a contraindication to treatment.59,122
cific locations where more detail examination (auscultation) Dyspnea
is required. The hands are placed on the chest over the upper
Dyspnea is the sensation of feeling breathless and may
lobes, middle lobes, and lower lobes as the person inhales
be examined using the Borg scale (ratio or ordinal),99,123
and exhales maximally (Figure 9-9).107 The individual is
VAS,88,124 numeric rating scale,125 ventilatory response
also asked to speak. Normal vibrations from the voice may
index,126 or as part of a survey examining perception of
be felt and these are called vocal fremitus. If vocal fremitus
dyspnea during routine activity (Modified Medical Research
or vibration is not felt then this could indicate consolidation,
Council [MMRC] Dyspnea Scale97 or Baseline Dyspnea
effusion, or lung collapse. If pulmonary secretions are pres-
Index96). Dyspnea is typically measured at rest and again
ent in the airways, stronger vibrations may be felt. This is
during functional activity or aerobic capacity examina-
called tactile fremitus. More detailed examinations of vocal
tions. The Modified Borg scale of dyspnea has been widely
sounds may be examined with a stethoscope.
used clinically in a variety of respiratory conditions to
Tracheal position is palpated to determine any devia-
quantify the sensation of breathlessness at rest and during
tions. If the trachea is not midline this could indicate PTX
activity.86,123,127
or collapse. The trachea would shift toward the collapsed
lung.107 Many times with PTX or chest wall trauma air can Oximetry
leak under the subcutaneous tissues of the chest and neck. If Gas-exchange deficits are routinely examined by measur-
the therapist finds bubbling and crackling felt under the skin ing the SaO2 using a pulse oximeter at rest, with changes
this may be subcutaneous emphysema. The condition should in position and during activity. SaO2 monitors or pulse
be immediately reported to the physician. A chest tube may oximeters are hand-held devices that indirectly measure
need to be surgically inserted to reverse the air leak. SaO2 of the arterial blood by reading the pulsatile change in
Pain is easily assessed during palpation. If pain is elic- light absorption of the blood (SpO2 = refers to the indirect
ited during gentle palpation of the ribs, sternum, clavicle, pulsatile estimation of SaO2). The monitoring unit displays
scapula, or spine it should be assessed using a visual analog a digital percentage readout of a calculated estimate of the
scale (VAS), numerical pain scale or other pain scale.72,117,118 amount of Hgb that is saturated with O2. For adults without
Fractures may be felt if the chest wall is displaced or flail lung disease the normal SpO2 is greater than 95%. Normative
chest is present.25 values may vary according to age and race.87 The accuracy of
SaO2 may be limited by motion artifact, nail polish, poor per-
fusion, and will be less precise as SaO2 decreases (Box 9-4).128
Figure 9-9. Manual screening examination of the chest
A wall. (A) Anterior aspect. (B) Posterior aspect. (Adapted
from Cherniack RM, Cherniack L. Respiration in Health
and Disease. 2nd ed. Philadelphia, PA: WB Saunders,
1972, in Hillegass E. Essentials of Cardiopulmonary Physical
Therapy. 3rd Ed. W.B. Saunders Company; 2010.)
The physical therapist will need to review the quality of the Individuals may qualify for supplemental O2 if the PaO2 is
oximeter with respect to motion artifact. Perfusion may be greater than 55 mm Hg and the SaO2 or SpO2 is greater than
affected by changes in temperature, vasospasm, and gripping 88% if one of the following conditions is met129:
actions (using a walker, handrails or arm crank handles). • Peripheral edema secondary to CHF
Alternative placement of the oximeter sensor (forehead, ear-
• Cor pulmonale documented on an EKG or by an echo-
lobe) may help improve readings.
cardiogram, gated blood pool scan, or direct pulmonary
Medicare guidelines for reimbursement of supplemental artery pressure measurement
O2 at home are: PaO2 less than or equal to 55 mm Hg, SaO2
less than or equal to 88% or SpO2 less than or equal to 88%. • Hct greater than 56%
356 Chapter 9
◦ Whispered pectoriloquy: The person is instructed to
BOX 9-4. LIMITATIONS TO ACCURATE whisper the words “one, two, three” while the exam-
PULSE OXIMETRY116,121,130 iner listens through the diaphragm of the stetho-
scope over areas of suspected tissue abnormality. The
● Excessive motion at the probe placement sounds will be clearly and distinctly auscultated over
● Abnormal hemoglobins areas of lung consolidation or will sound faint or
muffled over normal healthy tissues.
● Ambient light exposure to the probe
◦ Bronchophony: The individual says “99” while the
● Intravascular dyes examiner auscultates over areas of suspected tissue
● Low vascular perfusion abnormality. The voice sounds are clear over areas of
consolidation and indistinct over normal lung tissue.
● Skin pigmentation
◦ Egophony: Here the person is asked to say “E” (as
● Nail polish or nail coverings with finger probe
in “sweet”) and “A” (as in sway) over consolidated
used
regions.
● Inability to detect saturations below 83% with • Abnormal breath sounds: Sounds are considered abnor-
the same degree of accuracy and precision seen mal if bronchial or bronchovesicular sounds are heard
at higher saturations over peripheral lung tissue. Normally, there would be
● Inability to quantitate the degree of hyperox- quiet air movement over the majority of the lung paren-
emia present chyma but these sounds become loud and tubular when
there is lung consolidation or pathology.88 There may
also be decreased or absent lung sounds that could indi-
Auscultation cate hypoventilation in a region due to muscle weakness,
Auscultation is one of the most important examinations PTX, hyperinflation or airway obstruction.107
for patients with gas-exchange disorders and is more reli- • Adventitious breath sounds: Additional extraneous
able when performed by an experienced therapist.131 Recent sounds heard throughout inspiration or expiration usu-
chest x-ray results should be reviewed prior to auscultation ally described in the following ways may be continuous
to determine potential areas of compromise. Lung ausculta- or discontinuous.133 Continuous sounds may be high
tion may provide important information regarding the type pitched (wheezes or sibilant rhonchi) or low pitched
and location of various lung pathologies when interpreted (wheeze or sonorous rhonchi) and usually indicate a
with information from medical diagnostics (chest x-ray narrowing of the airway due to either bronchospasm,
reports).132 inflammation or mucus. Discontinuous sounds may
A stethoscope is used over the chest wall areas that cor- be moist sounding (coarse rales) or dry sounding (fine
respond to anatomical structures in the pulmonary system rales). The discontinuous sound arises from a “snap-
(see Chapter 8; Figure 8-11). Normal breath sound charac- ping open” of alveoli. Differences exist in terminology
teristics vary according to the anatomical region and are when describing lung sounds but can be summarized
labeled “bronchial” (heard over the trachea; manubrium), in simple terms by applying the term wheezes to con-
“bronchovesicular” (heard over the main stem bronchi; first tinuous sounds and rales or crackles to discontinuous
and second intercostals spaces), or “vesicular” (heard over sounds.89,133 Moist rales typically indicate the presence
peripheral lung tissues).107 The inspiratory time is shorter of pneumonia or interstitial fluid associated with CHF
and expiratory time longer when auscultation is over proxi- while fine rales are typically a sign of interstitial fibro-
mal structures and inspiratory time longer and expiratory sis. When documenting the presence of adventitious
shorter for distal structures (see Chapter 8, Figure 8-12). sounds, describe the phase within the respiratory cycle
In addition to appreciating normal sound quality, timing, where the sound is heard (eg, late inspiratory crackles
and pause characteristics, the examination also includes an or inspiratory and expiratory wheezes).88 Adventitious
assessment of voice-transmitted sounds, abnormal breath lung sounds and their interpretation are summarized in
sounds, and adventitious sounds. Table 9-7.
• Voice sounds: Spoken words are muffled and indistinct Although auscultation and interpretation of breath
and whispered words are usually not heard at all during sounds may appear to be subjective, this examination pro-
auscultation in the healthy individual. However, the spo- cedure has met the rules of Evidence-Based Medicine with
ken sounds become clear or more distinct when heard success.134,135 The accuracy of using lung sounds in deter-
over abnormal lung tissue. These abnormal voice sounds mining a diagnosis has revealed that wheezes can predict
may indicate increased densities due to fluid or solid asthma (likelihood ratio [LR] + 6). Fine inspiratory crackles
masses.107 The presence of pathologies typically cause are common in pulmonary fibrosis (LR + 5.9) and fine or
consolidation of lung tissue so sounds are transmitted coarse inspiratory crackles are consistently identified in
easily, becoming more distinct and audible.7,88,89,119 The chronic bronchitis (LR + 14 to 20). Voice-transmitted sounds
voice sounds included in the examination are: (bronchophony, egophony, and pectoriloquy) are consistently
TABLE 9-7. ADVENTITIOUS LUNG SOUNDS

ATS ACCP DEFINITION AND SOUND CLINICAL
TERMINOLOGY TERMINOLOGY CHARACTERISTICS INTERPRETATION
Coarse crackle Coarse rales Discontinuous bursts of popping bubbles Pulmonary edema
heard on inspiration; moist low pitch sounds Resolving pneumonia
that are interrupted
Fine crackle Fine rales Discontinuous brief bursts of high pitched Alveoli snapping open
sounds (softer and shorter); dry crackling of Interstitial fibrosis
cellophane wrap
Wheeze high- Sibilant rhonchi Continuous high-pitched musical sounds Airway narrowing
pitched wheeze varying in duration; whistling Asthma
Rhonchus low- Sonorous Continuous low-pitched musical snoring Sputum obstruction in
pitched wheeze rhonchi sound airways
Stridor Stridor High-pitched monophasic sound heard dur- Upper airway mechanical
ing inspiration obstruction or stenosis
Pleural rub Pleural rub Squeaking or grating sound; can be either Rubbing of pleural sur-
inspiratory or expiratory. Sounds like 2 pieces faces due to scar tissue
of leather rubbing together or fibrosis
ACCP: American College of Chest Physicians; ATS: American Thoracic Society.
Data adapted from Cahalin LP. Pulmonary evaluation. In: DeTurk WE, Cahalin LP, eds. Cardiovascular and Pulmonary Physical Therapy:
An Evidence-Based Approach. 2nd ed. New York: McGraw-Hill; 2004:221-269; Hillegass EA. Examination and assessment procedures.
In: Hillegass EA, ed. Essentials of Cardiopulmonary Physical Therapy. 3rd ed. St. Louis, MO: Elsevier; 2011:534-567; Butler SM. Clinical
assessment of the cardiopulmonary system. In: Frownfelter D, Dean E, eds. Cardiovascular and Pulmonary Physical Therapy: Evidence
and Practice. 4th ed. St. Louis, MO: Mosby Elsevier; 2006; Watchie J. Cardiopulmonary assessment. In: Watchie J, ed. Cardiovascular and
Pulmonary Physical Therapy: A Clinical Manual. 2nd ed. St. Louis, MO: Saunders Elsevier; 2010:273-297; and Pulmonary terms and symbols.
A report of the ACCP-ATS Joint Committee on Pulmonary Nomenclature. Chest. 1975;67:5-10.)
associated with lung consolidation and pneumonia (LR + 4.1) Table 8-5).63 The individual with a low percentage predicted
if fever and cough are also present.134,136,137 FEV1 (stage 4 GOLD criteria) will have less reserve for activ-
Cough ity and is at greater risk for gas-exchange impairments. The
FEV1 measure is considered the most important value in the
The cough should be examined for ability to clear secre-
diagnosis of airway obstruction.129,139 The FEV1 decreases
tions. Detailed examination of all 4 phases of coughing (see
as obstruction increases and improves as obstruction is suc-
Chapter 8) should be performed.138 Glottis control and abil-
cessfully treated.139 Measures of PEFR can help monitor the
ity to close the nasal passages should be present to allow the
onset of bronchospasm in individuals with asthma.
individual to build pressure before releasing a forceful exha-
Restrictive diseases such as obesity, scoliosis, chest trau-
lation. The cough should be characterized as “strong func-
ma, neuromuscular disorders including spinal cord injuries
tional” (able to effectively clear moderately thick secretions),
and pain can reduce FVC. Pneumonias and disorders where
“weak functional” (requires several less forceful efforts to
fluid or excessive secretions fill the alveoli and inhibit air
clear thin secretions) or “nonfunctional” (unable to clear
entry may reduce the FVC as can interstitial lung diseases,
secretions; requires suctioning or specific inspiratory and
pulmonary fibrosis, and CHF.139 The low FVC is nonspecific,
expiratory assist). Any sputum expectorated should be cap-
but can be used as a measurement pre- and then postinter-
tured and the quantity, consistency, and color of the sputum
vention. If a therapist plans to implement a respiratory care
should be recorded (Table 9-8).
program, the FVC and measures of PImax and PEmax may
Ventilatory Flow, Forces and Volume help monitor progress.
The ability to ventilate well is examined with spirometry
and tests of respiratory muscle performance (see Chapter 8).
Circulation
The physical therapist may wish to examination ventilatory Normal temperature is 98.6°F or 37°C.121 Elevation of
capacity in individuals with gas-exchange impairments. It temperature generally indicates infection. The 3 Ws are used
is especially important to review the percentage predicted when considering the source of infection: Wind: suspecting
FEV1 to determine the degree of disease severity in indi- infection in the respiratory system. Wound: suspecting infec-
viduals with COPD (GOLD classification; see Chapter 8, tion in integumentary integrity. Water: suspecting infection
in the urinary system.140-143
358 Chapter 9
TABLE 9-8. EXAMINATION OF SPUTUM

COLOR CAUSES
Red Blood (hemoptysis)
Rusty Lobular pneumonia, pneumococcus, mycoplasma
Green Pseudomonas infection
Brown Anaerobic infection/lung abscess
Yellow Infection, Haemophilus
Pink frothy Pulmonary edema
Black Specks from smoke inhalation, coal dust
CHARACTERISTIC
Thin (mucoid) Moves easily, not infectious
Mildly thickened (mucopurulent) Slightly discolored, suspicion of infection
Thick (purulent) Difficult to mobilize; needs hydration
Foul-smelling, copious Long-term infection; Pseudomonas
QUANTITY
Indicate the volume of sputum expectorated in mL over 24 hours
Airway clearance techniques may be indicated when sputum volume > 20 to 30 mL/day
Data adapted from McCool FD, Rosen MJ. Nonpharmacologic airway clearance therapies: ACCP evidence-based clinical practice guide-
lines. Chest. 2006;129:250S-259S; Middleton S, Middleton PG. Assessment and investigation of patients problems. In: Pryor JA, Prasad SA,
eds. Physiotherapy for Respiratory and Cardiac Problems Adults and Paediatrics. 4th ed. London: Churchill Livingstone Elsevier; 2008.
Many individuals with gas-exchange disorders have or murmurs.89,150 A loud S2 sound that may be split with an
abnormalities in the heart and systemic circulation. accent on the P2 component will be present with pulmonary
Therefore, the pulse quality and characteristics are exam- hypertension.150 In some cases, individuals with cardiac
ined. Individuals who smoke may have damaged the periph- disorders will develop pulmonary edema, which results in a
eral circulation and may have decreased or absent peripheral gas-exchange disorder as a secondary condition.39
pulses. When palpating the pulse quality the therapist should
Range of Motion
determine if the pulse is regular or irregular and observe for
pulsus alternans (variation between strong and weak pulse) Upper extremity (UE) ROM may be limited by changes in
and pulsus paradoxus (decreased pulse strength during posture (kyphosis).151 Additionally, the habitual use of a for-
inspiration or drop in systolic BP with inspiration).39 These ward lean with weightbearing on the UEs may result in hip
may be signs of cardiac muscle dysfunction. Individuals with flexion contractures. Cervical and trunk ROM in all direc-
heart failure may have changes in fluid volume. Daily body tions (rotation, lateral bending as well as flexion and exten-
weight must be examined to detect early signs of cardiac sion) should be examined in detail. In addition to examining
decompensation, which may result in pulmonary edema.144 ROM in the extremities, chest wall expansion measurements
Patients, after open heart surgery, can gain substantial are taken at 3 sites and the difference recorded and compared
weight because of intraoperative fluids given. Excessive fluid to norms in the literature.114,115,152
overload can greatly affect the cardiopulmonary system and Muscle Performance
result in hypoxia due to impaired-gas exchange. Unexplained
Many individuals with gas-exchange deficits are pre-
weight loss or gain could be a serious sign and would need
scribed steroids to reduce inflammation. The literature has
referral for further medical workup.145-149
identified that the dosage of steroids may introduce a myopa-
Auscultation of the heart is an examination that is
thy that can be at least partially reversed with strength train-
recorded under the circulation section of the physical ther-
ing.67,153 Stability muscles (quadriceps, calf) and respiratory
apy examination.45 When fluid accumulates it may result
muscles are known to have the greatest loss of strength.67 Yet
in incomplete closure of the heart valves or it may cause
the strength deficits may not be detectable by manual mus-
pressure changes in the heart that result in abnormal
cle testing. Hand-held dynamometer or isokinetic devices
heart sounds. Individuals with gas-exchange disorders often
may assist in quantifying peripheral muscle strength.154,155
develop cor pulmonale, which may cause an S3 heart sound
Respiratory muscle performance should also be quantified
using PImax and PEmax and MVV testing according to ATS 179
difference is approximately 86 meters. A regression equa-
standards.81,156,157 tion for estimating VO2 peak from the 6MWT distance is as
follows180:
Mean peak VO2 = 4.948 + (0.023 × 6MWT distance)
Walking ability can be examined for gait quality as well (Standard error of estimate 1.1 mL/kg/min)
as endurance. The therapist will note posture, use of any
GXT protocols commonly used in persons with gas-
breathing and pacing strategies and assistive device, assess
exchange disorders include the Godfrey protocol (CF)181 and
loss of balance or instability, and determine the individual’s
the Massachusetts Respiratory Hospital.182 These protocols,
capacity to safely manage household and community dis-
designed for persons with gas-exchange deficits, use the
tances. The walk distance over 2, 3 or 6 minutes may be used
FEV1 to assist in setting the workload stages.183 The Godfrey
to quantify baseline endurance and risk for mobility dis-
protocol also considers the child’s growth stage and age.181
ability.79,158-161 Formal testing of balance and mobility using
GXT offers greater cardiovascular challenge since a maxi-
such tools as the Timed Up and Go,162 Berg Balance Test,163
mal effort is provoked. Yet, individuals with gas-exchange
and the Stair Climb Power Test164 can be helpful for defin-
disorders are typically limited by ventilation (VE) or serious
ing functional impairments in patients with COPD.164,165,166
declines in SaO2 prior to reaching the limits of CO during
Aerobic Capacity/Endurance the GXT.3,8
Exercise testing stresses the systems involved in O2 deliv- In the acute stage, after a pulmonary exacerbation, the
ery and consumption required for human movement.3 The aerobic capacity is measured by examining responses to
exercise test may examine aerobic capacity using a maximal changes in position, functional training, and walking.184,185
effort or a submaximal effort. A maximal graded exercise A 2-Minute Walk Test (2MWT) may be more feasible at this
test (GXT) is designed to evaluate the maximal ability of stage but does not adequately measure endurance required
an individual to deliver and consume O2. It is called a test to manage community-level distances.160,168,172 Recording
of maximal aerobic capacity or VO2max.3,8 The therapist physiologic responses during activity can assist the medical
should determine if there are any contraindications to exer- team in adjusting medications and help the therapist select
cise prior to testing aerobic capacity. The endpoint of a VO2 interventions to improve activity tolerance. The response
max test will either be symptom limited (fatigue, SOB) or to exercise can be reexamined after offering support (O2,
physiologically limited (EKG abnormality, undesirable BP, ventilator) or educating the patient in breathing strategies
O2 desaturation). O2 consumption (VO2) is either measured (pursed-lip breathing [PLB], breathing control, pacing).186
or estimated.86 Individuals with gas-exchange disorders Energy-conserving techniques and breathing strategies may
will typically be limited by poor oxygenation resulting lower the physiologic work during functional activities.119
in a decrease in SaO2 (physiologic limitation) or extreme It is important to assess tasks typically included in the indi-
SOB and cyanosis (symptom limited).66,167 Individuals with vidual’s daily routine and then document strategies used to
pulmonary hypertension may also be limited by a drop in manage symptoms. The MET level can be documented and
systolic BP (physiologic limitation) and dizziness (symptom a progressive set of more demanding tasks examined with
limitation).167 a functional monitor. The therapist records the manifesta-
A submaximal test, such as the 6MWT, examines the tion of symptoms (rate of perceived exertion (RPE), rate of
cardiorespiratory responses using a workload that is well perceived dyspnea (RPD), color, accessory muscle use or
beneath a maximum effort and is often used clinically to chest discomfort) and records the physiologic responses (HR,
safely estimate aerobic capacity in people with known dis- SaO2, RR, BP, EKG) for each stage of work.
ease.168,169 Most daily activities are performed at submaxi- Assistive and Adaptive Devices
mal levels of exertion and therefore submaximal functional
Many individuals with gas-exchange deficits will require
tests appear to translate to physical ability required for daily
supplemental O2. It will be important for the therapist to
functioning.168,170 The goal of any exercise test is to measure
examine the effectiveness of O2 support equipment and
the symptomatic and physiologic response to movement and
devices (see Table 9-1). Additionally, the method of trans-
determine overall limitations to performance so they may be
porting O2 delivery devices should be examined and record-
treated with therapeutic interventions or medication.167
ed as part of any functional assessment. Does the person use
In clinics offering pulmonary rehabilitation, the 6MWT the O2 device properly? Are there changes in the physiologic
and the shuttle-walking test are submaximal tests used to responses with different carrying devices (supported on
examine aerobic capacity and endurance.79,168,171,172 The walker vs carrying over shoulder)?187
6MWT is recognized as a valid and reliable test that may
be used to estimate VO2 (r = 0.81, p < 0.0001)173 in persons Orthotic, Protective, and Supportive
with end-stage pulmonary disease.168,169,174-177 The 6MWT Devices
distance and estimated VO2 may be used clinically to Some individuals will require a form of mechanical venti-
describe functional capacity, evaluate the benefits of medi- lation. The therapist should note the mode of ventilation and
cation, make decisions for transplantation, and offer prog- whether there will be good ventilatory support for ambula-
nostic value.3,37,79,169,178 The minimal clinically important tion. Because many individuals with gas-exchange deficits
360 Chapter 9
are being mobilized while they are receiving mechanical ven- Determining the physical therapy prognosis will require
tilation188,189 the therapist should note the TV, RR, VE, FiO2 the therapist to consider the medical history (exacerbations)
and number and method of ventilator-supported breaths.190 and severity of lung disease (FEV1 and DLCO). Prognosis in
Familiarization with alarms and interdisciplinary communi- individuals with CF is affected by low aerobic capacity (28%,
cation will also be important so the therapy session is offered 8-year survival with VO2 peak ≤ 58% pred) and presence of
safely with confidence and assurance. Tolerance to activity Pseudomonas cepacia.37 The BODE score utilizes the 6MWT
for individuals who are receiving mechanical ventilation is distance, FEV1, MMRC, and the BMI to provide a measure
examined by noting the SaO2, VE, and BP. The VE is usually of risk for mortality and risk of hospitalization.193,200 The
4 to 5 L/min with a RR of 18 breaths/minute or less.191 If the physical therapy program may improve these risks if the
VE rises above 20 L/min then early mobility is not being tol- individual can comply with recommendations to lose weight,
erated. Pressure support ventilation can affect cardiac output participate in a conditioning program, and learn strategies to
and may cause variations in BP.59 Pneumatic compression manage dyspnea.
devices and stockings may be required to prevent DVTs and The severity of lung disease (FEV1) is not expected to
to control edema. change with physical therapy. However, the proper use of
Ergonomics, Environmental, Home, and medications may partially reverse airway obstruction in
some individuals. The 6MWT should be performed after
Work Barriers bronchodilation medications are taken.79 The physical thera-
The ability to work efficiently at a low energy cost is pist may consider the level of functioning prior to the last
an important part of the physical therapy examination. exacerbation as a guide to determining functional prognosis
Therefore, routine tasks may be simulated during the physi- for most individuals with gas-exchange deficits. A person
cal therapy examination and evaluated for the physiologic with poor lung function who has already participated in
stress imposed, breathing strategies employed, and efficiency pulmonary rehabilitation will be less likely to achieve sub-
of performance. The therapist can then identify items to stantial functional improvement. Outpatient pulmonary
include in the educational session that may improve self- rehabilitation is typically approved for 18 to 36 visits. Sample
management of symptoms and improve safety and efficiency goals are presented in Table 9-9.
for returning to work and participation in activities in and
around the home.
INTERVENTIONS
EVALUATION, Mobilization and exercise are the most efficacious inter-
ventions to offer individuals with gas-exchange disorders
DIAGNOSIS, AND PROGNOSIS because these interventions enhance all steps in the O2
transport system.201 Recent evidence suggests early mobi-
Individuals with gas-exchange disorders may have lization in critically ill persons can reduce hospitalization
impairments in aerobic capacity/endurance,66,192 posture, and decrease the length of stay.188 A physiologic treatment
BMI,193 balance deficits,165,166 decrease muscle performance hierarchy of interventions to enhance the O2 transport
(respiratory muscle and peripheral muscle),153,194,195 poor system in individuals having gas exchange deficits is listed
chest wall and spine mobility,115,196 impaired airway clear- in Table 9-10.105 Body positioning, breathing control and
ance,6,197 abnormal breathing strategies,186 knowledge coughing maneuvers (active airway clearance strategies) are
deficits regarding disease management (pacing, breathing among the most effective treatments. Suctioning and pos-
strategies, energy conservation)186,198 and education on safe tural drainage are less effective in enhancing O2 transport
and effective use of supplemental O2.199 The physical ther- but may be the best option for individuals who are extremely
apy diagnosis may be “Impaired Ventilation, Respiration/ weak, medically paralyzed or cognitive unable to participate.
Gas Exchange, and Aerobic Capacity/Endurance Associated
Many interventions discussed in Chapter 8 are appropri-
with Airway Clearance Dysfunction” (Practice Pattern 6C)
ate for individuals with gas exchange disorders. There is an
or “Impaired Ventilation and Respiration/Gas Exchange
increased ventilatory load when airway clearance problems
Associated with Respiratory Failure” (Practice Pattern 6F).45
exist. The respiratory muscles may or may not be weak
Individuals with ventilatory pump failure will spiral down
depending on the chronicity of the illness and ability of the
from Practice Pattern 6E (Chapter 8) to Practice Pattern
muscle to adapt to a load. Individuals with cystic fibrosis
6F. Dyssynchronous or paradoxical breathing, RR > 35 at
with mild to moderate disease may actually have higher than
rest and O2 desaturation are signs that the individual with
normal MIP values.202 The respiratory muscles have adapted
ventilatory pump failure (Practice Pattern 6E) has moved
to the excessive demands required for removing secretions,
to respiratory failure (Practice Pattern 6F).45,59 Many indi-
yet the FEV1 may be reduced due to obstruction. FEV1 is
viduals with pulmonary exacerbations will also fall under
highly related to peak work capacity (r = 0.79; p < .001) for
Practice Pattern 6B: Impaired Aerobic Capacity/Endurance
people with cystic fibrosis.202 Interventions that remove
Associated With Deconditioning.
airway obstruction (bronchodilators, breathing control, and
TABLE 9-9. EXAMPLES OF TABLE 9-10. INTERVENTIONS TO

PHYSICAL THERAPY GOALS IMPROVE OXYGEN TRANSPORT
EXAMPLES OF GOALS* ● Mobilization and exercise
• Increase ventilation of _______ lobes as ● Body positioning
measured by air entry upon auscultation (no ● Breathing control maneuvers
adventitious sounds) and improved chest x-ray.
● Coughing maneuvers/active airway clearance
• Vital capacity will increase to __ mL as measured
on incentive spirometer. ● Relaxation and energy conservation
• Demonstrate effective cough to independently ● ROM exercises (cardiopulmonary indications)
clear pulmonary secretions.
● Postural drainage positioning
• Demonstrate proper technique for airway
clearance (active cycle breathing, positive ● Manual techniques for airway clearance
expiratory pressure, flutter, etc). ● Suctioning for airway clearance
• Demonstrate proper breathing retraining strategies Reprinted with permission from Frownfelter D, Dean E, eds,
(deep breathing, diaphragmatic breathing, pursed- Cardiovascular and Pulmonary Physical Therapy Evidence and
lip breathing). Practice. 4th ed, Dean E, Optimizing outcomes: relating interven-
tions to an individual s needs, 247-261, Copyright Elsevier 2006.
• Recite and demonstrate correct application of
energy-conservation techniques, home exercise
program, and self-monitoring.
(hypoventilation, diffusion, shunt, and V/Q inequality) and
• Independent and safe with bed mobility and determines the physiology imposed by therapeutic changes
transfers with dyspnea < 3/10 and SpO2 > 90%. in position.1,12,203-205 Prescriptive body positioning may
• Increase 6MWT by __ feet with RPD < 3/10 and improve the mechanics of breathing in hypoventilation,
SpO2 > 90%. V/Q matching and may improve the pressure and flow of
• Demonstrate pursed-lipped breathing and the pulmonary circulation and lymphatic circulation.1,10,206
efficient coordinated breathing 90% of the time Positioning is also used in postural drainage to allow gravity
when performing dressing, household chores, and assistance in mobilizing secretions.6,207,208
work-related tasks (specific to individual goals). Gravity has an impact on perfusion since blood tends to
• Independently climb 12 steps with railing using flow most easily toward the dependent position.5 Ventilation
proper pacing to allow RPD < 3/10 and O2 Sat is also influenced by gravity as the pleural pressure is most
> 90%. negative in the uppermost region of the lung.5 Negative
intrapleural pressure causes alveoli to become distended and
POSTSURGICAL CONDITIONS air enters the area of least resistance.10 Therefore, the resting
• Adhere to all sternal/postsurgical precautions volume is greatest in the uppermost portions of the lung. For
during mobility example, if an individual is left side-lying for a prolonged
period, the air volume will be best in the right lung. The open
• Utilize pillow correctly during coughing.
airways allow gravity to work to drain mucous from bron-
• Demonstrate proper posture in sitting/standing chopulmonary segments.209 Areas of atelectasis may open if
independently. present in the right lung.
• Independently perform deep/segmental breathing
Bronchial (Postural) Drainage
with pain < 2/10.
In accordance to bronchopulmonary anatomy and the
*Each goal will include The patient will... and a time frame.
physiology of body positioning, each lung segment can be
positioned optimally to against gravity. This may maximize
ventilation to that lung segment and drain secretions with
airway clearance) are likely to improve exercise capacity and
the help of gravity (Table 9-11 and Figure 9-10).207
therefore participation in the therapeutic program.
Positioning to Decrease the Work of
Positioning Breathing
Several positions can assist in reducing the work of
Position changes can have a significant impact on the
breathing, including leaning against a wall between distances
gas exchange capability in the individual with a pulmo-
walked or part way up the stairs as well as forward leaning
nary impairment. When positioning is used as an inter-
while on a walker; sitting with hands on knees; or standing or
vention, the therapist identifies the causes of hypoxemia
sitting with arms resting on a table, countertop, or bench.210
362 Chapter 9
TABLE 9-11. CONTRAINDICATIONS/PRECAUTIONS FOR POSTURAL DRAINAGE6,194

CONTRAINDICATIONS/PRECAUTIONS FOR POSTURAL CONTRAINDICATIONS/PRECAUTIONS FOR
DRAINAGE TRENDELENBURG POSITION (HEAD DOWN
POSITION)
● Intracranial pressure (ICP) > 20 mmHg: ask for clearance Avoid Trendelenburg in the following situations.
before changing positioning ● If ICP increases are to be avoided (such as
● Head and neck injuries that are not stabilized or recent after eye surgery)
spine surgery ● Uncontrolled hypertension
● Acute untreated pneumothorax ● Distended abdomen (may be present with
● Active hemorrhage: watch risk of bleeding a shunt)
● Empyema: pus in the pleural cavity ● Esophageal surgery
● Bronchopleural fistula ● Hemoptysis 20 to surgery or lung carcinoma
● 48 hours post-renal transplant: must lay on surgical side ● Uncontrolled aspiration
● Pulmonary edema with CHF ● Acute CHF
● Large pleural effusion: you may compress the heart ● Recent food consumption (meal or stomach
excessively in some positions tube feeding within 30 min)
● Pulmonary embolism: watch coagulation status/clots ● Postoperative craniotomy
● Rib fracture/stress fracture with osteoporosis history:
consult physician with osteoporosis
● Surgical wound or healing issues
These positions can conserve energy and enhance the Cough

use of accessory muscle breathing and may increase dia-
Common causes of an ineffective cough include weak-
phragmatic excursion.211 In people with chronic obstructive
ness, paralysis or lack of motor control/performance, pain,
diseases, the diaphragm becomes flattened because of the
sedation, or depression of the central nervous system. Cough
continual air trapping and increased anterior-posterior chest
is assessed for strength, quality, frequency, and sputum pro-
wall diameter. The diaphragm loses its contractile efficien-
duction. If the cough is not effective enough to clear secre-
cy.212 The forward leaning position causes the abdominal
tions, alternate types of assisted coughing should be utilized.
contents to move up into the thoracic region placing the dia-
Postsurgically, pain may interfere with coughing. Increasing
phragm into a more responsive position to contract, allowing
inspiratory volume with breath stacking and segmental
better ventilation to occur.211
breathing may be followed by pillow-splint coughing.211 Huff
coughing (Table 9-12) may be used when glottis closure and
Airway Clearance Techniques Valsalva is contraindicated.
Over-production of goblet cell and mucus gland secre- Individuals with muscle weakness will need to use a
tions may be the result of pulmonary disorders like chronic cough-assist technique (abdominal thrust, costophrenic
bronchitis, asthma, bronchiectasis, and CF.213 Pulmonary assist, counter-rotation assist).138,214,215 Selection of cough-
infections such as pneumonia increase WBC formation assist technique may be determined by examining the effec-
and pus, which then accumulate in the alveolar spaces.53 tiveness of cough performance (peak flow cough rate) and
Impaired mucociliary transport of normal as well as abnor- reviewing contraindications that may exclude abdominal
mal pulmonary secretions can occur most markedly in pressure (vena cava filters, incisions, internal bleeding) or
smokers but also with individuals who have had general costal pressure (rib fractures). The peak cough flow rate
anesthesia.1 In smokers, the cilia are chronically slowed normally ranges from 6 to 20 L/s and will need to reach a
or altered. In patients undergoing general anesthesia, the minimum of 2.7 L/s to be minimally effective.138,216,217 To
mucociliary transport is temporarily altered. The longer the improve cough effectiveness, the therapist will emphasize
anesthesia time is, than the greater the risk for postoperative development of each of the stages of cough when teach-
pulmonary complications.184 ing coughing.215 Glottis control exercises are important
for people who have dysphagia or recurring pneumonia.52
Inspiratory volume enhancement with breath stacking is
more effective when glottal control is adequate.218,219
Figure 9-10. Postural drainage positions. (1) Left and
right anterior apical segments of the upper lobes: in
a semifowler’s position, with a 45-degree trunk tilt
backward. (2) Left and right posterior apical segments
of the upper lobes: trunk forward lean 45 degrees. (3)
Left and right anterior segments of the upper lobes:
full supine lying, with the head of the bed (HOB)
flat. (4) Posterior segment of the right upper lobe:
left side-lying, one-quarter turn from prone with the
HOB flat. (5) Posterior segment of the left upper lobe:
right side-lying, one-quarter turn from prone, with
the HOB the elevated 30 degrees. (6) Left and right
superior (apical) segments of the lower lobes: full
prone lying with the HOB flat. (7) Right middle lobe:
left side-lying, one-quarter turn from supine, with the
HOB in Trendelenburg position 15 degrees. (8) Lingula
of the left upper lobe: right side-lying, one-quarter
turn from supine, with the HOB in Trendelenburg
position 15 degrees. (9) Lateral segment of the left
lower lobe: full right side-lying with the HOB in
Trendelenburg position 30 degrees. (10) Lateral seg-
ment of the right lower lobe: full left side-lying with
the HOB in Trendelenburg position 30 degrees. (11)
Left and right anterior segments of the lower lobes:
full supine lying with the HOB in Trendelenburg posi-
tion 30 degrees. (12) Left and right posterior segments
of the lower lobes: full prone lying in Trendelenburg
position 30 degrees. (Adapted from Frownfelter D,
Dean E, eds. Cardiovascular and Pulmonary Physical
Therapy: Evidence and Practice. 4th ed. St. Louis, MO:
Mosby Elsevier; 2006.)
Manual Techniques not effective with his or her hands. Mechanical percussors
(air compression and electrical devices) are also available.
Percussion The evidence describing the best rate and force of percussion
Percussion is applied to the chest wall using cupped hands is equivocal and therefore the application of percussion is
and a rhythmic striking of the chest wall directly over the individualized. Percussion is credited for releasing secretions
involved lung segment. It can be 1-handed or 2 depend- from the bronchial walls and into the airway. It is most ben-
ing on the segment. Percussion can be performed for up to eficial when combined with bronchial drainage and breath-
5 minutes or longer but usually for 1 to 2 minutes or until ing control techniques. Contraindications and precautions
secretions are mobilized and coughing occurs spontaneously. are listed in Table 9-13.207,209,220
Hand-held plastic percussors can be used if the therapist is
364 Chapter 9
TABLE 9-12. SECRETION MOBILIZATION TECHNIQUES

SECRETION MOBILIZATION DESCRIPTION
TECHNIQUE
FET, also called huff coughing. The individual inhales deeply and then releases air through an open glottis. The
Performed to mobilize secre- air is released slowly for low-volume and quickly for high-volume huffing.
tions without prematurely col- Low-volume huffing occurs from deep inspiration to TV and mobilizes secretions
lapsing airways.221 in peripheral airways.
● Low volume High-volume huffing is quick and forceful and mobilizes secretions in upper air-
● High volume ways.
After breathing at low to mid-lung volumes or tidal breaths, the patient is
instructed to take a mid-to-large deep breath from the diaphragm followed by a
forceful expulsion of air through an open mouth, inhibiting glottis closure (huff).
Active cycle breathing The individual is instructed in a sequence of breathing designed to alternate
rest phase diaphragmatic breathing with deep lateral costal breathing and dia-
phragmatic breathing. Deep breathing is facilitated to encourage inspiration to
different levels or volumes prior to using a low-volume huff. A 3- to 4-second
pause occurs at the top of each deep inspiration. After several low-volume huffs
are performed (mobilizing secretions from peripheral airways) from a position of
deep inspiration, then 1 to 2 larger, more forceful high-volume huffs are used for
expulsion of mucus. The technique may be performed in a variety of positions.
Autogenic drainage222 The technique begins with several breaths moving air from the bottom of TV and
Breathing control occurs in stag- exhaling deep into ERV. Each inspiration is below normal TV levels. As mucous is
es to mobilize secretions from felt in the peripheral airways the individual inhales using slightly larger breaths
peripheral airways to upper air- from above TV exhaling through TV into the ERV using a mid-volume breath with
ways. The goal is to use air flow pauses at the top of inspiration. As secretions are felt, after several mid-volume
and intrapulmonary pressure to breaths, the person takes large-volume breaths, gradually increasing the inspira-
mobilize secretions without col- tory volume into the IRV. Expiration is performed with and open glottis using an
lapsing airways that are fragile, FET that gradually increase the volume and peak flow on expiration. Cough is
resulting in trapping mucous. suppressed as long as possible to avoid trapping mucus.
PEP The individual inhales deeply and then exhales slowly into a mask or mouthpiece.
Exhaling against resistance dur- Valves releasing the expired air are under pressure. Usually low pressure is 10 to
ing the expiratory phase slows 20 cm H2O. The person inhales a full TV followed by an inspiratory hold (3 to
breathing, controls pressure and 4 seconds) and exhales slowly. After about 10 breaths or to tolerance, the indi-
introduces a back pressure to vidual is asked to perform an FET. This sequence can be repeated about 5 times
keep small airways open longer for up to 20 minutes. The device can be used with bronchodilator therapies and
increasing time for oxygenation. is portable.
Flutter valve PEP223 The individual inhales deeply and then exhales slowly into a pipe-like device
housing a metal ball. As exhaled air moves forward, the ball moves and sends a
vibration down the airways to assist in loosening of mucus. This is repeated for
5 to 10 breaths until secretion are mobilized. The patient then performs a high-
volume huff followed by a cough to clear the airway. This can be performed for
10 minutes or to tolerance.
Oscillatory PEP (Acapella, Smiths The individual inhales deeply and then exhales slowly into a small plastic foot-
Medical)223 ball-shaped device. As expired air enters the device, a magnetic system opens
The device combines the resis- and closes, creating vibrations in the pulmonary airways to assist in loosening
tive capability of a PEP device of mucus. The technique is applied in the same manner as the PEP and Flutter
with the vibrating capability of a devices. A valve may be adjusted to change pressure and 2 sizes are available
Flutter valve. (child and adult).
ERV: expiratory reserve volume; FET, forced expiratory technique; IRV: inspiratory reserve volume; PEP, positive expiratory pressure.
Data adapted from Downs AM. Clinical application of airway clearance techniques. In: Frownfelter D, Dean E, eds. Cardiovascular and
Pulmonary Physical Therapy Evidence and Practice. 4th ed. St. Louis, MO: Mosby Elsevier; 2006:341-376; Pryor JA. Physiotherapy for airway
clearance in adults. Eur Respir J. 1999;14:1418-1424; and Wetzel JL. Management of respiratory dysfunction. In: Field-Fote EC, ed. Spinal
Cord Injury Rehabilitation. Philadelphia, PA: F.A. Davis; 2009:337-392.
TABLE 9-13. CONTRAINDICATIONS AND PRECAUTIONS FOR

PERCUSSION, VIBRATION, AND SHAKING
● Osteoporosis ● Subcutaneous emphysema
● Osteomyelitis ● Coagulopathy
● Long-term steroid use ● Frank hemoptysis
● Rib fractures or flail chest ● Bony metastases to the ribs
● Recent epidural spinal infusion or spinal anesthesia ● Reactive airways (unable to modify with
● Compromised integumentary on the chest wall breathing control techniques)
(burns, grafts, open wounds) ● Elevated intracranial pressure (ICP)
● Pain ● Tuberculosis
Data adapted from Downs AM, Bishop KL. Physical therapy associated with airway clearance dysfunction. In: DeTurk WE, Cahalin L, eds.
Cardiovascular and Pulmonary Physical Therapy: An Evidence-Based Approach. 2nd ed. New York: McGraw-Hill Co.; 2011:499-527; Downs
AM. Clinical application of airway clearance techniques. In: Frownfelter D, Dean E, eds. Cardiovascular and Pulmonary Physical Therapy
Evidence and Practice. 4th ed. St. Louis, MO: Mosby Elsevier; 2006:341-376; and Downs AM. Physiological basis for airway clearance
techniques. In: Frownfelter D, Dean E, eds. Cardiovascular and Pulmonary Physical Therapy: Evidence and Practice. 4th ed. St. Louis, MO:
Mosby Elsevier; 2006:325-339.
Vibration Breathing Control Maneuvers and

The therapist applies vibration-generating movement
from the shoulders through the UEs to the hands, which are Breathing Retraining
placed over the region of the thorax approximating the lung The purpose of any breathing exercise is primarily to
segment involved. The vibratory oscillations from the hands increase lung volume, redistribute ventilation, and therefore
are transmitted onto the person’s rib cage and ultimately to affect gas exchange. Breathing control can help in normaliz-
the airways to move secretions to where they can be more ing RR and breathing pattern to decrease the work of breath-
easily be coughed out or retrieved. ing and minimize dyspnea. Some techniques are also used
The maneuver is used with deep breathing and the vibra- to assist in managing pain.224 The entire respiratory care
tions are applied upon exhalation. It is the air movement program is progressed in a logical sequence. It is critically
along with the vibrations that mobilize secretions. The best important to provide airway clearance and pain reduction
frequency of the oscillations to actually move secretions is strategies before initiating chest mobilization and breathing
unknown and may vary with the individual. People with retraining.225 This approach will optimize results for session.
asthma tolerate it quite well but may need to be instructed to
control exhalations in order to manage airway reactivity. The Breathing Exercises to Improve Lung
technique should be performed for 6 to 10 breaths, to toler- Volume and Gas Distribution
ance or when secretions are mobilized and coughing occurs. Breathing exercises begin with subtle changes in position
It is usually performed after percussion and enhanced with that may challenge the respiratory muscles to become more
bronchial drainage. Contraindications and precautions for active. Typically a position supine with the head of bed elevat-
vibration are listed in Table 9-13. ed 15 to 30 degrees allows the diaphragm to move freely.186,226
Suctioning The therapist can offer active assistance and manual cues to
the diaphragm by placing one hand over the epigastric region
Suctioning techniques are a necessary intervention to at the costophrenic angle opposite ribs 6 through 8.186 At the
remove abnormal pulmonary secretions and maintain opti- end of expiration the therapist applies a “squeeze” and lifts the
mum ventilation and oxygenation in patients who are unable diaphragm slightly higher in the thoracic cavity before ask-
to clear these secretions independently. The person performing the individual to inhale. This improves the length tension
ing this technique should be competent in assessing the need and active contraction of the diaphragm. Active contraction
for suction.59 The decision to perform this procedure should of the diaphragm may be improved by asking the individual
be based on clinical signs and symptoms and review of contra- to “sniff” as he or she inhales.210 Breath stacking is used to
indications and should not be undertaken as a matter of rou- increase the inspiratory volume with each sniff or inspiratory
tine.59 Suctioning should take no longer than 10 to 15 seconds. effort. Two to 3 breaths are taken on top of the initial breath to
Before suctioning the individual is encouraged to take deep increase chest wall expansion and inspiratory volume. As the
breaths, either actively or passively through artificial means. individual gains control and begins deep breathing on his or
Susceptibility to hypoxemia should be monitored for episodes her own, maximal inspiratory hold maneuvers are included.
of bradycardia, desaturation, and/or hypotension. Indications The individual inhales slowly and deeply through the nose to
and complications for suctioning are presented in Table 9-14. total lung capacity and holds this volume for 2 to 3 seconds.
366 Chapter 9
TABLE 9-14. INDICATIONS AND COMPLICATIONS FOR SUCTIONING

INDICATIONS FOR SUCTIONING COMPLICATIONS FOR SUCTIONING
● Altered hemodynamics ● Apnea, laryngospasm,
● Artificial ventilation patients with increased airway pressures, bronchospasm
adventitious breath sounds, and reduced oxygen saturation ● Atelectasis
● Change of color (cyanosis, pallor) ● Elevated intracranial pressure
● Copious, retained secretions in people who cannot cough ● Hypoxemia with suctioning
effectively ● Mechanical trauma
● Deteriorating arterial blood gas values or SaO2 ● Pathogens/contamination
● Diminished/absent breath sounds on auscultation ● Vasovagal response causing
● For assessing airway patency, cough reflex stimulation, and cardiac arrhythmias
sputum specimen
● Individuals with feelings of secretions in the chest
● Paradoxical chest movement
● Preset TV on the ventilator not being delivered
● Secretions in artificial airways
● Tachypnea
Adapted from Ciesla ND, Kuramoto JD. Physical therapy associated with respiratory failure. In: DeTurk WE, Cahalin LP, eds. Cardiovascular
and Pulmonary Physical Therapy: An Evidence-Based Approach. 2nd ed. New York: McGraw-Hill; 2011:585-642.
Figure 9-11. Segmental breathing. (Reprinted with permission from

Frownfelter D, Dean E, eds. Cardiovascular and Pulmonary Physical Therapy:
Evidence and Practice. 4th ed. St. Louis, MO: Mosby Elsevier; 2006.) Figure 9-12. Incentive spirometry using a flow-oriented spirometer.
As the individual breathes the therapist notes areas of incision may need to be supported with a pillow or layers of
chest expansion and decides which areas are not expand- towels. The person is taught to hold the pillow firmly but not
ing well and why, such as when the respiratory muscles are forcefully over the incision. The level of pressure should be
weak and unable to offer adequate force. Facilitation is then maintained as the person inhales. Initially, small to moderate
applied. Positioning, quick stretch, tapping, and tactile cues breath sizes are used. The therapist should check the incision
can be applied to segmental muscles (intercostals) and acces- for drainage or stress to the skin before asking for deeper
sory muscles (pectorals, serratus anterior, latissimus dorsi breathing.
and neck accessories). Lateral costal expansion exercises Areas that are not expanding well can be facilitated
work well to facilitate the intercostals muscles and encourage with segmental breathing (Figure 9-11). During segmental
expansion of the lower lobes. breathing the therapist uses specific positioning to maxi-
If the therapist decides that pain is limiting chest wall mize ventilation to the affected lung segment, while using
expansion and inhibiting the respiratory muscles, then dif- tactile stimulation over that affected segment with cues for
ferent breathing techniques are offered. The session begins PImax (Figure 9-12). Stretch may or may not be used on end
by finding a comfortable position for the individual. The expiration.
Incentive spirometry uses a hand-held device with a • The use of adaptive equipment such as the following: use
mouth piece attached to a closed chamber with balls or a a rolling walker during ambulation to aid in balance,
disc that rises as flow or volume is increased. The person is decrease accessory muscle breathing and decrease the
asked to exhale fully then inhale maximally while a disc or work of the posture musculature; use a shower/tub chair
ball rises within the spirometer cylinder (see Figure 9-12). to sit on rather than standing during shower time; use a
The disc/ball rises to the measured maximal lung volume reacher to pick up things on the floor rather than bend-
achieved. The maneuver is performed for 10 repetitions, fol- ing forward.
lowed by a huff/forced exhalation technique or cough. The • Planning and preparing activities such as the following:
individual is instructed to repeat this hourly while awake. establish a routine; schedule and organize the day; pri-
There is no evidence that incentive spirometry will reduce oritize tasks and eliminate unnecessary ones; organize
postoperative complications in individuals with cardiac and the work area and avoid lifting overhead; adjust work
upper abdominal surgeries.227 Incentive spirometry may still height and avoid sustained positions.
be effective in providing feedback for teaching deep breath-
ing and for individuals who are not able to routinely ambu- • Pacing and breathing strategies with all activities; utili-
late or transfer bed to chair.228 zation of aforementioned breathing exercises to decrease
the work of breathing with ADL and instrumental ADL
Breathing Exercises to Decrease the Work (IADL); pacing activities throughout the day; taking
of Breathing and Dyspnea rest in-between activities, such as stopping half way up
• PLB: The individual expires passively through pursed a flight of stairs to rest; avoid Valsalva with movement
(almost closed) lips. This creates a back pressure or posi- and utilization of the exhalation during movement
tive pressure, preventing premature alveolar collapse. technique.
This may maximize O2 distribution and help to reduce • Relaxation techniques: Jacobson’s progressive relaxation
dyspnea. PLB decreases air trapping and reduces breath- exercise,186 Benson’s relaxation response,230 imagery,
lessness by lengthening the time of expiration and total biofeedback,130,138 yoga, meditation, hypnosis, massage,
respiratory cycle time.198,229 There is little evidence to and chest wall mobilization.186
suggest incorporating diaphragmatic breathing during
activity improves dyspnea in people with COPD and Therapeutic Exercise
may actually cause dyssynchronous breathing.198
• Paced breathing: Low-frequency breathing is performed Pulmonary rehabilitation guidelines recommend strength
with activity to normalize the inspiratory/expiratory training, aerobic training, unsupported UE endurance train-
ratio. Normal breathing ratio is 2/4. With activity such ing, and education to improve health-related quality of life
as walking, a patient is asked to inhale to a count of and decreased hospitalizations for people with COPD.231,232
2 while taking 2 steps, then exhale to a count of 4 while LE exercise training that is high intensity (60% to 80% VO2
taking 4 steps. This can be translated to other activities. peak) will lead to greater physiologic improvements than
exercise that is lower in intensity.233,234 Clinical benefits
• Exhalation with activity: Movement occurs only dur- are possible with both low- and high-intensity aerobic exer-
ing exhalation. Individuals who have contraindications cise.199,231,235 Components of an exercise prescription to
to breath holding or Valsalva are taught to “exhale on improve cardiorespiratory fitness follows the FITT principle
effort” to avoid fluctuations in BP.210 (Frequency, Intensity, Time, and Type)86:
• Coordinated breathing: The individual is instructed to • Frequency: 3 to 5 times per week
exhale when flexing the trunk or reaching down to tie
• Intensity: 60% VO2 peak or may be guided by SpO2
shoes, pick up an object from the floor or bending down
≥ 90% with RPD = 4/10 to 6/10
to place dishes in a dishwasher. During trunk exten-
sion and reaching overhead, the person is instructed • Time: 20 to 60 minutes
to inspire. In this way the chest wall mobility assists in • Type: activities that exercise large muscle groups in
expanding the chest for inspiration or compressing the continuous repetitive movement (bike, treadmill [TM],
abdominal contents for expiration. Breathing is more corridor walking). Include unsupported UE endurance
efficient and tasks are easier to accomplish.186 exercise.236
Techniques to Conserve Energy and • Progression: increase intensity and/or time slowly over
Decrease the Work of Breathing a number of weeks. Initially time is increased using
moderate intensity 50% to 60% VO2 peak to encourage
Activities of daily living (ADL) alone can cause dyspnea compliance.231,232,235 Begin to increase intensity using
during gas-exchange impairment. Specific tasks related to an interval training strategy.237 Interval training can
self-care, home management, and community functions that help avoid limitations due to dynamic hyperinflation.238
increase dyspnea level are modified to minimize demands A minimum of 20 sessions at least 3 times per week is
for O2. Energy conservation techniques can include the necessary.
following:
368 Chapter 9
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CASE STUDY 9-1
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EXAMINATION
two oscillating positive pressure devices: Acapella versus Flutter.
Respir Care. 2003;48(2):124-130.
224. Levenson CR. Breathing exercises. In: Zadai CC, ed. Pulmonary
History
Management in Physical Therapy. New York: Churchill Livingstone
Inc; 1992. Current Condition/Chief Complaint
225. Wetzel JL. Management of respiratory dysfunction. In: Field-Fote
Ms. Garden was an 80-year-old female who was referred
EC, ed. Spinal Cord Injury Rehabilitation. Philadelphia, PA: F.A.
Davis; 2009:337-392. for physical therapy evaluation and intervention by inpatient
physical therapy on her first postoperative day following
emergency coronary artery bypass surgery.
374 Chapter 9
History of Current Complaint previous MI. Active diagnoses of hyperlipidemia, periph-
Ms. Garden came to the emergency room the day prior eral vascular disease, and hypertension were present. At 80
complaining of dizziness, sweating, and profound weakness years old, she was postmenopausal.
of 1 week’s duration. She could not recall any episodes of In all likelihood, her abdominal aneurysm was being moni-
palpitations, chest pain, or dyspnea. Two days prior she had tored. Surgery is considered when the diameter becomes
a colonoscopy and polypectomy and reported she had not greater than 5 cm.
taken any of her medications for 4 days. In the emergency
room, she was diagnosed with a probable subendocardial MI.
A cardiac catheterization showed 80% occlusion of the Reported Functional Status
stent in her left anterior descending artery, 90% occlusion of
the circumflex artery, and 60% occlusion of the right coro- She reported that during the week prior to going to the
nary artery (RCA). Her unstable angina and severe hypoten- emergency room, she had experienced increasing fatigue and
sion were treated with an intra-aortic balloon pump (IABP) inability to do her usual daily chores. Her usual activities
by way of the left femoral artery while she was prepared for included daily housework, grocery shopping, and cooking.
surgery. At 80 years old, she still drove herself to run errands.
She underwent surgery to place 4 coronary artery bypass Medications
grafts (CABGs) using the left internal mammary artery Preoperative medications: atenolol, aspirin, Zocor (simv-
(LIMA) and the right saphenous vein. At the time of the astatin), Plavix (clopidogrel bisulfate), Altace (ramipril)
referral for physical therapy on postoperative day 1, she had
Postoperative medications: atenolol, Altace, aspirin,
been weaned and extubated from the ventilator. The IABP
Losartan, Zocor, morphine, oxycodone, Colace (docusate),
had been discontinued in the operating room 8 hours prior.
intravenous (IV) nitroglycerin, IV vancomycin
Social History/Environment Other Clinical Tests
Ms. Garden was married and lived with her husband in a
A review of her medical record showed the following post-
ground-floor condominium. She had worked as a secretary
operative lab values:
before her retirement. She attended bingo 3 times per week.
She enjoyed shopping and cooking. • WBCs 12.06 K/cmm
• RBCs 3.32 m/cmm
Social/Health Habits
• Hgb 10.3 gm/dL
She smoked 4 cigarettes a day. Until the recent past, she
had smoked one pack of cigarettes per day and had done so • Hct 29.9%
since the age of 18. She reported that she would drink alcohol • Electrolytes
at social events.
◦ Sodium 141; chloride 108
Family History ◦ Potassium 4.2; CO2 27
She had 4 living siblings who were without significant
medical history. Ms. Garden’s mother had been healthy all
her life and died in her 90s. A brother and Ms. Garden’s
Clinician Comment What had been learned
from the interview and chart review was that Ms. Garden
father died at a young age of cardiac disease. Ms. Garden’s
had a recent decline in function, but she did not participate
2 grown children were healthy.
in regular exercise. Given her advanced age, she was fully
Medical/Surgical History independent with ADL and IADL, including all mobility. She
Ms. Garden had been diagnosed previously with periph- wanted to continue with her independence, which included
eral vascular disease. Three years prior she had an anterior driving. Ms. Garden had a supportive husband who was
MI that was treated with angioplasty and stent placement willing and able to help her once she returned home. She had
in her left anterior descending artery. A thallium stress test 2 adult children who lived close by. She lived on the ground
performed 4 months prior was unremarkable. She was man- floor, so she did not have stairs as a physical barrier.
aged medically for anemia, hyperlipidemia, and hyperten- Her preoperative medications were mostly cardiac in
sion. Three months prior to this admission, an abdominal nature. She had an extensive history of smoking and chron-
aneurysm, with a diameter of 3.8 cm, was documented on ic bronchitis, yet she was not currently being followed by a
computed tomography (CT) scan. She had chronic bronchitis pulmonologist. Her lab values were all within normal limits
for 10 years. (WNL) except for a low Hct and Hgb. These low values
likely reflect a normal loss of blood products during surgery.
Clinician Comment Even prior to this recent They were not critical but did need daily monitoring with
cardiac event, Ms. Garden had significant risk factors for respect to interpreting her BP and blood O2 levels. Namely,
cardiac disease.1-3 In addition to a 62 pack-year history a low Hct could contribute to a low BP measure and a low
of smoking, she had a positive family history. She had a Hgb value could lead to poor blood O2-carrying capability.
Her medical history, again, was mainly cardiovascular in The systems review in acute care, and especially in critical
nature, given her ongoing coronary artery disease, MIs, care, often is the initial physical therapy examination. In
stents, peripheral vascular disease, aneurysm, and hyper- these settings, the systems review may be as much as can be
tension. With the sternotomy for the CABG surgery, she accomplished in the first session. In acute and critical care,
was at high risk for postoperative pulmonary complica- the patient evaluation can be ongoing and may evolve daily.
tions, especially given her previous tobacco use.4 Goals may need to be added or even dropped when there is
a clearer understanding of the patient’s status.
Systems Review
The findings in the review of systems appear as follows:
REVIEW OF SYSTEMS Height: 5 feet, 3 inches; Weight: 135 pounds preop; 148 pounds postop
CARDIOVASCULAR/ Resting HR: 81; BP: 129/54; RR: 20, on 5l/min nasal cannula
PULMONARY
NOT IMPAIRED IMPAIRED
MUSCULOSKELETAL
Gross ROM □ ⊠ 90 degrees flexion at right knee o/w WNL
General strength □ ⊠ Left hip flexion 3‒/5; o/w 3+/5 UE and LE
Gross symmetry/posture □ ⊠ Head and trunk flexed forward
INTEGUMENTARY
Continuity of color □ ⊠ Pale
Skin integrity □ ⊠ Median sternotomy incision; saphenous vein inci-
sion from right medial thigh from groin to medial
malleolus; chest tube insertion sites (inferior and
left lateral to the xiphoid)
Pliability □ ⊠ Taut at LEs due to 1 to 2+ edema
Presence of scar ⊠ □
NEUROMUSCULAR
Gait □ ⊠
Locomotion/transfers/transitions □ ⊠
Balance □ ⊠
Motor function ( motor control, ⊠ □
motor learning)
COMMUNICATION/LEARNING
Communication □ ⊠ Lethargic and sleepy likely due to pain medication
recently given
Orientation ⊠ □
BARRIERS TO LEARNING □ None □ Language □ Vision ⊠ Other: hard of hearing
READINESS FOR LEARNING ⊠ Accepting □ No interest □ Denying □ Refuses
PREFERRED LEARNING STYLE □ Pictures ⊠ Read ⊠ Listen ⊠ Demonstrate
EDUCATION NEEDS ⊠ Disease process ⊠ Safety ⊠ Assistive devices ⊠ ADL
⊠ Exercise program ⊠ Other: sternal precautions; smoking
⊠ Other: energy conservation; safety; pain ⊠ Other: symptom recognition
376 Chapter 9
Clinician Comment Patients having cardiac is likely due to incisions and edema and less likely to
surgery can gain as much as 30 pounds of extra water joint impairment; strength, which should resolve rapidly
weight after being on cardiopulmonary bypass depending once she mobilizes and is most likely due to bed rest and
on the length of the surgery and bypass time. This process recent immobilization; integument due to incision sites
often leads to increased postoperative pulmonary complica- and edema common after heart surgery; cognition, which is
tions.5,6 Surgeons may opt to perform surgery off the bypass presumed due to anesthetic effects and sedation for incision
pump if the vessels that are occluded are minimal and more pain. Cognition deficits should resolve in time, but direc-
anterior. Though Ms. Garden gained only 13 pounds, the tions, instructions, and questions would likely need to be
additional fluid could still be significant. repeated. She had specific learning needs that would need
to be addressed. Her hearing loss needed to be considered
The IV nitroglycerin needed to be considered with regard
when giving verbal instructions.
to interpreting her vital signs. Nitroglycerin is a potent
medication for BP and arrhythmia control. In addition, she Her gait, locomotion, and balance were presumed to be
would need to be closely monitored for orthostatic hypoten- impaired in the systems review. Before assisting Ms. Garden
sion since she was also on beta blockade. This intervention out of bed, however, to more thoroughly examine her
would reduce her BP and lower her HR. Beta blockade used functional mobility, her circulation and respiration/gas-
in combination with pain medications, especially mor- exchange status needed to be examined. Pain and impaired
phine, can have a vasodilatory effect and further reduce BP. ROM and muscle performance noted in the systems review
also needed further examination. Her need for supplemen-
This systems review revealed impairments of gas exchange,
tal O2 and her hemodynamic response would then be moni-
given she requires 5 L/minute (40% FiO2) of supplemental
tored during any functional mobility testing. The decision
O2 via nasal cannula, which may be purely because of pul-
to test her aerobic capacity would be made after judging her
monary volume overload common after heart surgery and/
response to the tests and measures noted previously.
or postoperative pulmonary complications; ROM, which
Tests and Measures

The tests measures categories that needed to be addressed
are summarized in the following chart.
NOT EXAMINED
NOT EXAMINED
NOT IMPAIRED
NOT IMPAIRED
IMPAIRED
IMPAIRED
Aerobic capacity and endurance ⊠ □ □ Motor function □ ⊠ □

Arousal, attention and cognition ⊠ □ □ Muscle performance ⊠ □ □
Assistive and adaptive devices ⊠ □ □ Orthotic, protective and supportive devices □ □ ⊠
Circulation ⊠ □ □ Pain ⊠ □ □
Community and work integration ⊠ □ □ Posture ⊠ □ □
Cranial nerve integrity □ □ ⊠ Range of motion ⊠ □ □
Environmental, home, work □ □ ⊠ Reflex integrity □ □ ⊠
Ergonomics and body mechanics □ □ ⊠ Self-care and home management ⊠ □ □
Gait, locomotion and balance ⊠ □ □ Sensory integrity □ ⊠ □
Integumentary integrity ⊠ □ □ Ventilation, respiration and circulation ⊠ □ □
Joint integrity and mobility □ ⊠ □
Circulation which may have been a result of the following: secre-
• HR/rhythm: 81 normal sinus on EKG tion retention, pain that limited adequate ventilatory
pump, chronic bronchitis, and tobacco use (possible CO2
• Heart sounds: Normal S1 and S2; possible S4 noted but
retention), pain medication-induced decreased ventilatory
inconsistent
pump, or all in combination.
• BP via right radial arterial line: 129/54 (while on IV
The decrease in her left chest wall excursion might have
nitroglycerin)
been due to atelectasis/collapse and pleural effusion. Left
• Anginal equivalent: extreme fatigue and diaphoresis pleural effusions are very common in patients having
• Body temperature: 100.2 degrees F CABG, especially those who received a LIMA graft. LIMA
grafts can disrupt the lymphatics in the chest and can cause
• Cardiac output (CO): 3.2 liters/min via continual moni-
increased pain often elicited in the shoulder and/or scapu-
tor through pulmonary arterial monitor
lar region.7 Pleural effusions can lead to further lobar col-
lapse due to compression of the alveolar spaces. Increased
Clinician’s Comment Initial low-grade tem- resonance is often felt with mediate percussion over large
peratures immediately postoperative may be indicative of areas of fluid such as a pleural effusion.
postoperative pulmonary complications. Her anginal equiva-
lent was not the classic substernal chest, jaw or arm pain. Her
reported symptoms would need to be monitored closely since
she may experience angina postoperatively without ischemic
Integumentary Integrity
events. An S4 heart sound can commonly be heard with Wound sites: all incisions were attended to by nursing. Ms.
patients having chronic coronary artery disease and hyper- Garden had minimal serous drainage from her sternotomy
tension. It would be important to monitor her heart sounds incision. For the saphenous vein harvest incision in her right
especially after exercise. If an S3 were to be noted, then Ms. LE, there was minimal serous drainage in the region of her
Garden might be showing signs of heart failure, of which she knee. Her left groin incision site for the IABP access was
was at risk during the acutely postoperative period. sutured closed but showed reddening with 1 to 2+ edema
present.
The entry sites for the mediastinal chest tubes sites were
Ventilation and Respiration/Gas Exchange clean, dry, and intact as was the single left pleural chest tube
Her RR was 20 to 28 breaths per minute. site. The insertion of the temporary pacing wires into the
Breath sounds were absent at the left lower lobe at all seg- mid-diaphragm region was also clean, dry, and intact. The
ments and bronchial above this area. A few crackles were right radial arterial line was sutured in place. The placement
noted at the right lung base. Otherwise, breath sounds were site for the Swan-Ganz catheter to the pulmonary artery
diminished throughout all lung fields. Upper airway rhonchi through the right jugular vein was clean, dry, and intact.
were also noted.
Mediate percussion over the left lower lobe region was Clinician’s Comment Chest tubes used for
hyperresonant. drainage of surgical sites can lead to further splinting of
Her breathing pattern was shallow with obvious splinting. the chest because of pain and increase the incidence of
She showed decreased chest wall excursion at her lower lung atelectasis. Patients can ambulate with chest tubes off suc-
fields with left more limited than right. Excursion of mid- tion as long as there is no evidence of PTX or air leak seen
and upper lung fields were grossly normal. on the Pleur-Evac container. Otherwise, extension tubing
Arterial blood gases analysis showed 90/45/7.38/26. SaO2 or portable suction devices attached to the Pleur-Evac are
was 94% on 5 liters/min flow of O2 via nasal cannula (40% indicated.
FiO2), as was her SpO2. Her SpO2 dropped to 87% when the A Swan-Ganz catheter, however, is an invasive line into
supplemental O2 was removed for 1 minute while at rest. the heart and ends in the pulmonary artery. Ambulation
Ms. Garden’s cough was weak, throaty, and nonproduc- away from the bedside may not be recommended when a
tive but congested sounding. Swan-Ganz catheter is in place because the line would need
Her chest x-ray showed a left lower lobe collapse and right to be clamped and disconnected from the monitor. More
lower lobe atelectasis; as well as left pleural effusion with important, a tensioned line could cause the catheter to be
pulmonary vascular congestion. pulled from within the pulmonary artery back into the right
Her maximal inspiratory volume with the incentive spi- ventricle—a displacement that could cause life-threatening
rometer was 500 mL. ventricular arrhythmias. Arterial lines are invasive to an
artery and if dislodged can result in rapid blood loss. Again,
ambulation away from the bedside may not be recom-
Clinician’s Comment Ms. Garden showed mended in most instances. Care with all invasive lines and
adequate oxygenation but only with high amounts of
tubes is crucial in the care of the patient who is critically ill.
supplemental O2 to maintain it. Her CO2 was high normal,
378 Chapter 9
Pain Aerobic Capacity/Endurance
Using the 0 through 10 faces pain scale, Ms. Garden rated Ms. Garden was able to stand in the walker with a mod-
her premedicated pain level from her chest and LE incisions erate assist of 1, march in place 20 times, rest, and then
as 8/10. After taking 2 Percocets (oxycodone and acetamino- march in place another 20 times. Her CO remained steady at
phen), she rated her pain in the same regions as 3/10. 2.8 to 3.2 L/min throughout the activity. She continued to use
supplemental 5 L/min flow of O2 by nasal cannula. She rated
Range of Motion
her RPE using the Borg scale, 6 to 20, at rest, while march-
No changes in her ROM examination were seen compared ing, and during a seated recovery. The results are shown as
to the systems review. Only her right knee flexion was symp- follows.
tom-limited to 100 degrees. All other joints showed WNL
movements. She also had a decrease in chest wall excursion HR BP SpO2 RPE RR
as noted earlier.
Rest (seated) 88 123/52 94% 7/20 20
Muscle Performance
Peak (standing) 105 113/55 92% 15/20 28
Her left hip flexion strength was 3/5. All other UE and
LE manual muscle tests were 3+ to 4/5. She showed limited Recovery 86 132/64 96% 8/20 23
cough strength resulting in ineffective airway clearance. (seated)
Clinician’s Comment Her right groin was Clinician’s Comment The drop in BP with
likely inflamed and sore from the IABP placement previ-
exercise may have been orthostatic. It may have been due
ously. She showed signs of deconditioning due to bed rest.
to the IV presser and pain medication, or a combination.
CO remained at 2.8 to 3.2 L/min, most likely due to the
increase in HR with activity to compensate for a lower BP.
Ms. Garden was able to roll to the left using her LE to help
and with minimal assist of 1. To roll to her right, she required
moderate assist of 1. To move from right side-lying to a sit-
ting position, she needed minimal/moderate assist of 1 but EVALUATION
with maximal cues to avoid use of her UEs. The limitation
of UE use was required in order to maintain sternal precau- Diagnosis
tions of less than 10 pounds of resistance with the UEs as in
pushing, pulling, or lifting. She was able to move from sitting Practice Pattern
to standing, and then complete a step transfer to a chair with
Ms. Garden was an 80-year-old female in intensive care
moderate assist of 1.
following emergent CABG ×4 after an acute MI. The pri-
She showed independent head and trunk control to main-
mary, and most acute impairments, that needed to be
tain her sitting balance. Her standing balance was fair. She
addressed were her postoperative pulmonary complications
required moderate assist of 1 to maintain her standing bal-
of atelectasis and lobar collapse. If not resolved quickly, she
ance while moving. She was able to maintain static standing
might develop pneumonia. Her cardiovascular issues would
balance with only minimal assist of 1.
be addressed concurrently. Based on her history, systems
With the use of a rolling walker, Ms. Garden ambulated review, and tests and measures, Ms. Garden was classi-
5 feet to bedside chair with moderate assist of 1. She was fied into 2 preferred practice patterns using the American
breathing supplemental O2 with a flow of 5 liters/minute Physical Therapy Association Guide to Physical Therapy
using a nasal cannula and maintained an SpO2 of 93%. Practice. Once the major pulmonary impairments were
resolved then the cardiovascular pump dysfunction would
Clinician’s Comment Her need for moderate become the primary diagnosis.
assistance when rolling right was consistent with her left • Impaired Ventilation, Respiration/Gas Exchange, and
hip flexor weakness and impaired ability to use the left Aerobic Capacity/Endurance Associated With Airway
LE to assist with turning. Her ambulation away from the Clearance Dysfunction (6C)
bedside was limited by the invasive right radial arterial • Impaired Aerobic Capacity/Endurance Associated With
line and right jugular Swan-Ganz catheter, not her hemo- Cardiovascular Pump Dysfunction (6D)
dynamic response.
Since she tolerated moving from the bed to the bedside
chair, it was decided to let her rest a few minutes and then Clinician’s Comment Her impaired gas
assess her aerobic capacity. exchange may have been also compounded by inadequate
ventilatory pump due to the sternotomy.
International Classification of Functioning, INTERVENTION
Disability and Health Model of Disability
See the ICF model on p 380.
Prognosis Documentation
Ms. Garden had a good inpatient physical therapy prog- • Coordinate care with nursing, respiratory, and nutrition
nosis. She could be expected to improve her pulmonary services
function, decrease her work of breathing, and eliminate the • Coordinate pain medication with nursing
need for supplemental O2. She could be expected to regain
• Communicate and document O2 needs at rest and with
sufficient functional mobility to safely return home with her
activity to nursing, respiratory therapy, case manager,
husband.
and physicians
Plan of Care • Document progression toward goals and communicate

discharge needs to physicians, nursing, and case manager
Intervention • Coordination and communication of care are acceptable
to the patient
Proposed Frequency and Duration
of Physical Therapy Visits • Patient and family have a full understanding of goals
and expected outcomes
Ms. Garden would be scheduled daily to twice daily physi-
cal therapy for the anticipated 5 days of continued inpatient • Documentation occurs regarding the patient’s response
care. to and progression of therapy
Anticipated Goals • Discharge needs are met (home with husband)
1. Effective cough to independently clear her own pulmo-
nary secretions (2 days). Patient-/Client-Related Instruction
2. Afebrile (3 days). Ms. Garden would be instructed in the following:
3. No need for supplemental O2 (4 days). • Use of an incentive spirometer and flutter device
4. Active ROM (AROM) of right LE: WNL with pain • Diaphragmatic breathing, PLB, paced breathing
< 3/10; all strength > 3+/5 (4 days).
• Effective coughing and huffing techniques
5. Left lower lobe without collapse as measured by improved
air entry upon auscultation and improved chest x-ray • Posture awareness
(4 to 5 days). • Sternal precautions for 6 to 8 weeks: No lifting
6. Vital capacity to at least 1500 mL as measured on incen- > 10 pounds; limit pushing and pulling with UEs; no
tive spirometer (4 to 5 days). driving; avoid sitting behind airbags while a passenger
7. Independent with self-care (4 to 5 days). in a car; use lap seat belt only; no prone lying
• Symptom recognition
Expected Outcomes (5 days)
1. Independent and safe with bed mobility and transfers • Disease process/progression
with pain < 3/10 (5 days). • Energy conservation with all activities
2. Independent and safe with ambulation > 500 feet or • Pain control and medication timing
5 minutes, 3 times per day (TID) while maintaining: • Initiation of smoking cessation
RPE < 15; SpO2 > 92%; RR < 30 bpm; HR and systolic
BP rise no greater than 30 points from resting values (5 • Independent AROM UE and LE exercises for warm-up
days). prior to ambulation
3. Independent with all deep breathing, airway clearance • Functional mobility with a sternal incision
and coughing techniques; all sternal precautions; symp- • Progressive home walking/endurance program using the
tom recognition; energy conservation techniques; home RPE scale as a guide
exercise program and self-monitoring (5 days).
Discharge Plan Procedural Interventions
It was anticipated that Ms. Garden would achieve the Ms. Garden would receive direct intervention in the
anticipated goals and expected outcomes on or before her following:
sixth postoperative day and be discharged to home. • Therapeutic exercise
• Functional training in self-care and home management
380 Chapter 9
ICF Model of Disablement for Ms. Garden

Health Status
• Left lower lobe collapse, left pleural effusion, and
atelectasis
• Subendocardial MI
• S/p CABG
• 62 pack-year history of smoking
• Medically managed for anemia, lipidemia, and
hypertension
• Chronic bronchitis, ×10 years
• Abdominal aneurysm, 3.8 cm

Function
• Assistance needed for bed • Played Bingo at her church
• Impaired mucociliary mobility and transfers
transport due to anesthesia • Assistance needed for safe
and tobacco use standing
• Decreased cough strength/ • Impaired walking tolerance
effectiveness
• Assistance needed for ADL
• Pulmonary secretion
• Unable to perform usual
retention
IADL
• Decreased aerobic capacity/
• Unable to drive due to
endurance
sternotomy precautions
• Abnormal HR/BP response
to O2 demands
• Abnormal pulmonary
response to O2 demands
• Decreased strength left hip
flexion
• Pain

• Age = 80 years • One-level, ground floor condominium
• Liked her driving independence
• Enjoyed shopping and cooking
• Family history of cardiac disease
• No experience with regular exercise
• Airway clearance Frequency
• Aerobic capacity/endurance training Daily to twice daily by PT for 5 days and as needed.
Mode
• Prescription/application/fabrication of assistive devices
and equipment Incentive spirometry device.
Intensity
Therapeutic Exercise Maximal inspiratory effort by patient.
Flexibility and Strength Exercises: Duration
10 breaths.
Mode
Frequency
AROM
Independently once an hour while awake (with reinforce-
Intensity
ment by PT, nursing, and respiratory therapy) for 1 week and
RPE < 15/20
as needed.
Duration
Mode
3 sets of 10 to 20 repetitions
Oscillatory positive expiratory pressure device.
Frequency
Intensity
Daily to twice daily by PT, but encouraged to do indepen-
Maximal inspiratory effort and exhalation for 3 to 4 sec-
dently 3 times per day, prior to ambulation
onds by patient.
Duration
Ms. Garden would be shown and would practice the
10 breaths.
following exercises while seated: knee flexion/extension,
Frequency
hip flexion, ankle pumps, shoulder flexion, and horizontal
abduction/adduction without extension. Daily to twice daily by PT and independently every hour
while awake (with reinforcement by nursing and respiratory
therapy) for 1 week and as needed.
Clinician’s Comment Shoulder ROM/chest Mode
wall mobility exercises should be initiated to prevent pecto-
ralis tightness, promote inspiratory effort, and improve pos- Modified postural drainage and chest percussion and/or
ture. Patients with sternal incisions tend to flex forward and vibration as indicated to left lower lobe region, in right side-
limit the mobility of the UEs, which further contributes to lying, head of bed flat if tolerated.
improper spinal alignment and restriction of the chest wall. Intensity
To patient’s tolerance; keep SpO2 > 92%; RR < 30.
Duration
Functional Training ~2 minutes of percussion followed by 6 to 10 maximal
Mode breaths with vibration upon exhalation.
Bed mobility and transfer training to bathroom. Frequency
Intensity Daily to twice daily by PT for 5 days as needed (with rein-
With assistance progressing to independence forcement by nursing and respiratory therapy as indicated).
Duration
N/A Clinician’s Comment All techniques may
Frequency be used individually or in combination depending on the
Daily to twice daily by PT, with reinforcement by nursing. specific need. Examination is ongoing during an episode
of care. Focus of the interventions can change during each
Injury Prevention interaction with the patient. Many techniques are adjunct
• Education of sternal precautions with bed mobility, to hands-on skilled therapy. Patient and caregiver educa-
transfers, self-care, and home management; tion is key to the improvement of pulmonary function.
• Safety awareness
Airway Clearance Techniques Mode
and Breathing Maneuvers Coughing/huffing techniques.
Mode Intensity
Maximal inspiratory hold maneuvers with lateral costal Forceful enough to mobilize secretions.
and/or segmental expansion. Duration
Intensity 1 to 3 efforts or until secretions are mobilized.
Maximal inspiratory effort by patient with a 2- to 3-sec- Frequency
ond breath hold. Daily to twice daily by PT and independently once an
Duration hour while awake for 1 week and/or after all airway clearance
10 breaths techniques and breathing maneuvers are performed.
382 Chapter 9
Clinician’s Comment Nasotracheal suction- Clinician comment If Ms. Garden could not
ing may be indicated if her cough remains ineffective; her achieve SpO2 > 88% on room air at rest, then supplemental
temperature and WBC count continue to rise, her SpO2 O2 would likely be indicated for home. If she had a room air
drops < 90% on same FiO2, or she exhibits increased respi- SpO2 > 88% at rest but desaturated below 88% with activi-
ratory distress. Suctioning techniques may be indicated if ty, then supplemental O2 would be added and titrated to the
pulmonary secretions are not cleared by: airway clearance, least amount to keep her > 88%. With this information, her
breathing maneuvers, effective coughing/huffing, and func- physician would then be able to prescribe the correct type
tional mobility. and amount of home O2. Evaluation of her supplemental
Positioning may be used to maximize ventilation and O2 needs would be ongoing during each intervention and
perfusion as able. Many patients with cardiac disease may finalized at discharge to home.
not tolerate bed flat side-lying because of dyspnea and the
increased workload on the cardiopulmonary system. Sitting
for airway clearance techniques of deep breathing maneu-
vers and coughing may be the optimum position for Ms.
REEXAMINATION
Garden. Alternate side-lying and modified positioning with
emphasis on the left lower lobe should be encouraged every Subjective
2 hours when she is in bed.8,9
“I’m ready to go home.”
Aerobic Capacity/Endurance Training Objective

Mode Ms. Garden was seen twice a day for physical therapy dur-
Progressive ambulation with breathing maneuvers. ing her hospital stay. She was reassessed on postoperative day
Intensity 6 just prior to her discharge to home.
With RPE < 15/20; SpO2 > 92%; RR < 30; HR and systolic Circulation
BP rise < 30 from resting values.
HR/rhythm: 76 bpm, normal sinus rhythm
Duration
Heart sounds: Normal S1 and S2
Up to 10 minutes of walking.
BP: 132/65 mm Hg
Frequency
Afebrile
Daily to twice daily by PT for 5 to 10 days (3 to 4 times per
day total with nursing and family reinforcement), then reex- Ventilation and Respiration/Gas Exchange
amination once home by Home Health physical therapist. Her chest x-ray was markedly improved. All lung fields
Description of the Intervention were clear to auscultation, including the left lower lobe. Ms.
Ms. Garden will progress from marching in place, to gait Garden had been breathing room air without supplemental
training with a rolling walker and assistance as indicated O2 for 24 hours. She was able to maintain SpO2 levels at 96%
for balance, safety, and energy conservation, and further at rest. Her RR was 18 to 20 breaths/minute at rest. She was
progression to complete independence on level surfaces if close to achieving 1500 mL with her incentive spirometer.
able. The following strategies will be incorporated into this
intervention: Integumentary Integrity
• Posture awareness reinforced during gait and functional Mediastinal staples were removed on postoperative day
mobility 3. All incisions were healing without signs of redness or
swelling.
• Paced and PLB maneuvers with energy expenditure
• Diaphragmatic breathing during all activity
Pain
Ms. Garden reported that she was aware of her chest inci-
Prescription/Application of Devices and sions with deep breathing. Her hip symptoms were less than
Equipment 3/10 with transfers and bed mobility. She reported she was
able to complete most of her self-care without symptoms.
Assistive Devices
A rolling walker will be prescribed for home use if she Range of Motion
cannot achieve functional independence by the time she is She was able to complete all exercises with normal ROM,
medically cleared from the hospital. including right hip flexion.
Supportive Devices Muscle Performance
Supplemental O2—titrate O2 to keep SpO2 > 92%. Right LE was able to demonstrate > 3+/5 strength
throughout.
Gait, Locomotion and Balance • Incentive spirometer to 2000 mL
Ms. Garden was able to walk on a level surface without • Pain free
gait deviations. She also demonstrated that she was able to • Smoking cessation
ascend and descend a flight of stairs with 2 to 3 rests on the
• Bingo, as tolerated
stairs to avoid fatigue.
Ms. Garden was able to walk 625 feet in 6 minutes in the REFERENCES
hospital hallway while keeping a pace to allow RPE < 15.
Her SpO2 remained above 92%. Her HR rose to 92 bpm but 1. Hillegass EA. Examination and assessment procedures. In:
returned to her resting rate of 76 bpm after 8 minutes of sit- Hillegass EA, ed. Essentials of Cardiopulmonary Physical Therapy.
3rd ed. St. Louis, MO: Elsevier; 2011:534-567.
ting rest.
2. U.S. Department of Health and Human Services. The Health
Consequences of Smoking: A Report of the Surgeon General. Atlanta,
Assessment GA: U.S. Department of Health and Human Services, Centers
for Disease Control and Prevention, National Center for Chronic
Ms. Garden was able to achieve all the anticipated goals Disease Prevention and Health Promotion, Office on Smoking and
established at the time of her initial evaluation. She also had Health; 2004. http://www.cdc.gov/tobacco/data_statistics/sgr/2004.
Accessed February 2, 2011.
good understanding of the educational items identified in
3. Centers for Disease Control and Prevention (CDC). Annual smok-
her treatment plan. She was aware of the sternal precautions ing-attributable mortality, years of potential life lost, and produc-
to follow for the next 6 to 8 weeks. tivity losses—United States, 1997-2001. MMWR Morb Mortal Wkly
Rep. 2005;54:625-628.
4. Hulzebos EHJ, Van Meeteren NLU, De Bie RA, Dagnelie PC,
Plan Helders PJM. Prediction of postoperative pulmonary complica-
tions on the basis of preoperative risk factors in patients who
Ms. Garden would be discharged from inpatient physical had undergone coronary artery bypass graft surgery. Phys Ther.
therapy in anticipation of her discharge to home. 2003;83(1):8-16.
5. Clark SC. Lung injury after cardiopulmonary bypass. Perfusion.
2006;21(4):225-228.
OUTCOMES 6. Conti VR. Pulmonary injury after cardiopulmonary bypass. Chest.

2001;119:2-4.
7. Berrizbeitia LD, Tessler S, Jacobwitz IJ, et al. Effects of sternotomy
Upon discharge to home, Ms. Garden had a program of and coronary bypass on postoperative pulmonary mechanics.
exercise and activity to follow on her own. It would be antici- Comparison of internal mammary and saphenous vein bypass
grafts. Chest. 1989;96:873-876.
pated that by 4 weeks after her surgery and before outpatient 8. Ross J, Dean E. Body positioning. In: Zadai CC, ed. Pulmonary
cardiac rehabilitation would be recommended to begin, the Management in Physical Therapy. New York, NY: Churchill
following outcomes would be expected: Livingston Inc; 1992:79-98.
• Independent at home with ADL and minimal assist with 9. Dean E. Body positioning. In: Frownfelter D, Dean E, eds.
IADL (shopping, groceries, laundry) Practice. 4th ed. St. Louis, MO: Mosby Elsevier; 2006:307-324.
• Independently ambulating > 30 minutes daily on level
surface at her normal/comfortable pace without dyspnea
and RPE < 13
Individuals With
10
Localized Musculoskeletal and
Connective Tissue Disorders
• Basic Tissues
CHAPTER OBJECTIVES ◦ Epithelial Tissue
• Compare and contrast the connective tissue character- ◦ Connective Tissue
istics in fibrous connective tissues, cartilage, and bone. ▪ Extracellular Matrix
• Identify the general water holding function of proteo- ▪ Fibrous Connective Tissue
glycan structure and how differences in proteoglycan
▪ Cartilage
concentration can affect tissue properties.
▪ Bone
• Summarize the effect of physical stress on tissues using
the physical stress theory. ◦ Nervous Tissue
• Identify muscle adaptation to lengthening or shortening ◦ Muscle Tissue
loads. ◦ Tissue Damage and Healing
• Define the tissue pathology distinctions between ten- ▪ Basic Tissues’ Shared Events
donitis and tendinopathy.
▪ Immediate Response
• Summarize how the differences in vascularity impact
▪ Inflammation
healing for each component of a joint: capsule, liga-
ments, synovium, articular cartilage, tendon, muscle, ▪ Tissue Repair/Regeneration
and bone. ▪ Maturation/Remodeling
• Identify nerve structure characteristics that allow nerves ▪ Tissue Health
to glide with body movements and factors that can com-
◦ Physical Stress Theory
promise neural mobility.
• Muscles
• Discuss the information that can be gathered on a first
encounter with a patient in an out-patient setting before ◦ Morphology (Gross Anatomy and Histology) and
the formal interview begins. Physiology
▪ Muscle Response to Loading
▫ Lengthening and Shortening Loads
CHAPTER OUTLINE ▫ Resistive Loads
• Epidemiology ▪ Muscle Nutrition and Healing

386 Chapter 10
◦ Muscle Disorders ◦ Peripheral Nerve Disorders
▪ Contusion ▪ Compression
▪ Strain ▪ Traction
▪ Tear/Rupture ▪ Neural Immobility
▪ Overuse Injuries ▪ Hypersensitivity
▪ Stretch Weakness • Musculoskeletal Examination
• Tendons ◦ Examination
◦ Morphology and Physiology ▪ History
▪ Tendon Response to Loading ▫ Patient Interview
▪ Tendon Nutrition and Healing ▪ Systems Review
◦ Tendon Disorders ▪ Tests and Measures
▪ Tendonitis ▪ Summary
▪ Tendinopathy • References
▪ Tear/Rupture
• Bone There are those who might think that the inclusion of a
chapter on musculoskeletal disorders is an odd choice for a
◦ Morphology and Physiology text that presents a view of patients from a largely cardiovas-
▪ Bone Response to Loading cular and pulmonary perspective. Admittedly, a thorough
▪ Nutrition and Healing examination to identify muscle imbalances, joint dysfunc-
tions or altered alignment in the spine and extremities may
◦ Bone Disorders (Nonsystemic) seem beyond what is required for care when a patient is
▪ Fractures referred to physical therapy during a hospital admission for
▪ Stress Fractures a cardiac pump dysfunction. But what happens when that
patient’s status improves and is referred later to outpatient
▪ Skeletal Alignment cardiac rehab? Mr. Cedar, one of the patient cases in Chapter
▫ Spinal 5, is an example of someone who was not able to succeed with
- Kyphosis traditional cardiac rehab because of an orthopedic disorder.
It is not known how many patients don’t bother to pursue, or
- Scoliosis fail to succeed in, cardiovascular or pulmonary rehabilitation
▫ Extremity because of musculoskeletal disorders.
- Valgus/Varus On the other hand, any perplexity regarding a muscu-
loskeletal chapter inclusion in this text is exceeded only by
• Joints the bewilderment of physical therapists guided to take vital
◦ Joint Morphology and Physiology signs on patients with musculoskeletal disorders. Noting
▪ Ligaments vital signs is the standard for the examination of the car-
diac and pulmonary systems in the systems review from the
▪ Synovium Patient/Client Management Model.1 The need to take vital
▪ Articular Cartilage signs can be opinioned by therapists treating patients with
▪ Joint Response to Loading musculoskeletal disorders as being a big waste of time.2 But
what about Mrs. Mason from the introduction in Chapter 1?
▪ Joint Nutrition and Healing She was referred to an outpatient physical therapy facility
◦ Joint Disorders because of a pelvic fracture. Her challenged pulmonary sta-
▪ Joint Effusion tus from sarcoidosis absolutely needed to be considered dur-
ing her examination and the establishment of her treatment
▪ Adhesive Capsulitis
plan.
▪ Ligament Sprain/Rupture So despite the diversity of specialty settings within physi-
▪ Osteoarthritis cal therapy, each therapist is responsible for the basic compe-
tencies required to examine all the systems within the scope
• Peripheral Nerves
of the Patient/Client Management Model. The process of
◦ Morphology and Physiology completing the full evaluation also requires an understand-
▪ Nerve Responses to Loading ing of how the systems overlap and influence the patient’s
ability to achieve the expected outcomes.
▪ Nerve Nutrition and Healing
Individuals With Localized Musculoskeletal and Connective Tissue Disorders 387
Figure 10-1. Embryonic and fetal development of tissues. Primary germ layer formation is one of the first events of embryonic
development. Ectoderm is the most superficial of the layers. Mesoderm is the middle layer. Endoderm is the deepest layer. The
primary germ layers specialize to form the 4 primary tissues. (Adapted from http://classes.midlandstech.edu.carterp/Courses/
bio210/chap04/chap04.html and Kørbling M, Estove Z. Adult stem cells for tissue repair—a new therapeutic concept? New Engl J
Med. 2003;349(6):570-582.)
This chapter will present the essential pathophysiology

for local musculoskeletal and connective tissue disorders. BASIC TISSUES
The physiology of the structures involved and the basic tis-
sues that comprise them will begin the chapter. How these Before the significance that an injured joint, or altered
structures respond when injured as well as how they are alignment, can have on functional endurance, or perfor-
affected by compromised cardiovascular and pulmonary mance, the features of the musculoskeletal structures involved
status will also be discussed. Special considerations for the need to be understood. The joints, musculotendinous units,
examination of local musculoskeletal and connective tissue and peripheral nerves are grouped together only because of
dysfunction will be outlined. The chapter will conclude with their basic commonality as structures of the musculoskeletal
a patient case. system. In fact, each structure is quite different from the oth-
ers. Basic to them all, however, are the body’s basic 4 tissues.
And, even though it will be shown later in the chapter that
each of the structures in the musculoskeletal system actually
EPIDEMIOLOGY contains more than one of the basic tissues, knowledge about
the organization and physiology of basic tissues will aid in
How unusual is the situation for Mr. Cedar, Mrs. Mason, the understanding of the physiology and pathophysiology of
and others to be in a more-than-one medical diagnosis situ- the musculoskeletal system.
ation? That is difficult to quantify from the dizzyingly array
Specialized cells and tissues in the human body develop
of statistics for health status in the United States. The sheer
from the germ layers of the embryo. These layers in the
numbers for 2 separate categories of diagnoses—chronic
embryo are derived from the germ cells (ova and sperm). The
obstructive pulmonary diseases (COPD) and musculoskel-
outer germ layer (ectoderm) contributes to the formation of
etal disorders—suggest a significant overlap could easily
nervous tissues, most glands and the epidermis. The middle
exist. In Chapter 8 it is noted that nearly 14 million adults in
layer (mesoderm) develops into connective tissues. The inner
the United States have a pulmonary pump dysfunction in the
layer (endoderm) contributes to the tissues of the intestinal
form of COPD. What are the chances that all these patients
tract.5
have perfectly functioning joints, optimal alignment, and
In the distribution of characteristics from the germ layers,
normal strength? Certainly some will have musculoskeletal
4 basic tissues develop. They are epithelial tissue, connective
complaints that will lead to referrals for physical therapy.
tissue, nervous tissue, and muscle. Each of these basic tissues
Conversely, in the latest available statistics from the
has a distinctive cell type. In addition, the tissue character-
National Ambulatory Medical Care Survey, musculoskeletal
istics are further defined by the substances, or structure,
complaints were the number 2 reason for physician office
between the cells as well as by the fluids that nourish the tis-
visits in a survey of all office visits.3 It is estimated that 1 in
sue and carry off waste products (Figure 10-1).5
4 Americans have a musculoskeletal disorder according to a
report on the United States Bone and Joint Decade.4 It could
reasonably be assumed that many of these musculoskeletal Epithelial Tissue
disorders will occur in individuals with a cardiovascular or Epithelial tissue forms into continuous cellular sheets that
pulmonary dysfunction. cover the outside of the body as well as line most internal
body regions.5,6 Any of the germ layers of the embryo gives
388 Chapter 10
Figure 10-3. Portion of a collagen molecule showing individual alpha

chains coiled to form a triple helix. Within each chain, the amino acids are
similarly arranged in a helix, with glycine (G) facing the center of the triple
helix. The other amino acids are represented by the dots. (Adapted from
Culav EM, Clark CH, Merriless MG. Connective tissues: matrix composition
and its relevance to physical therapy. Phys Ther. 1999;79:311.)
Extracellular Matrix
The properties of epithelial, nervous, and muscle tissues
are distinctive because of what lies within the cells of these
tissues as well as how the cells are arranged. Connective tissue
differs. The properties of connective tissues are determined
Figure 10-2. Principal components of connective tissues. (Adapted from
by the amount, type, and arrangement of the large quanti-
Culav EM, Clark CH, Merriless MG. Connective tissues: matrix composition
and its relevance to physical therapy. Phys Ther. 1999;79:310.) ties of intercellular substances manufactured by the discrete
connective tissue cells.9 These intercellular substances, called
the extracellular matrix, surround the cells. The “blast” ver-
rise to this simple tissue. For example, the membranes of the sion of the cell produces the extracellular matrix until it is
heart, blood vessels, and lymphatic vessels are called endo- surrounded. Then it becomes somewhat trapped when the
thelium but these linings actually arose from mesoderm.5 matrix matures. For example, fibroblasts, chondroblasts,
Simple epithelial membranes of contiguous cells have near and osteoblasts—types of connective tissue cells—produce
absence of intercellular substances. Glands can develop from the extracellular matrix that will mature to become fibrous
epithelium; secretory cells can be situated within the tissue. connective tissue, cartilage, and bone, respectively (Figure
Epithelium can be categorized by cell shape, the number and 10-2). In mature connective tissue, the “blast” version of the
arrangement of cell layers, and the type of dominant cell. cell, now trapped within the matrix, matures to the “cyte”
Epithelial tissue is avascular. These tissues rely on nutrition version. The fibrocyte, chondrocyte, or osteocyte remains
from underlying connective tissue to which the epithelial within the extracellular matrix to maintain its respective
tissue is attached by tightly bonding with an intervening tissue as well as aid in repair if the tissue becomes damaged
basement membrane. because of injury or disease.
The discussion of integument disorders treated by physi- Fibrous Connective Tissue
cal therapists is beyond the scope of this chapter. It should
In connective tissues where fibroblasts are the dominant
be noted, however, that in the treatment of musculoskeletal
cell type, the 3 major components of the extracellular matrix
disorders consideration is given to skin mobility. As well,
are the fibers themselves along with proteoglycans and gly-
the mobility of tissues below the basement membrane—the
coproteins. Collagen and elastin are the major protein fibers
dermis, subcutaneous tissue/superficial fascia, and deep
produced by fibroblasts.
fascia—is assessed. As will be shown later in the chapter,
Collagen is formed from triple chains of amino acids
musculoskeletal tissues need to adapt to mechanical loads.
where every third acid in each chain is glycine. The smaller
Skin as an epithelial tissue, along with the underlying tissues,
glycine molecule allows a bend in each chain wherever the
needs to adapt to mechanical loads as well.7
glycine appears, which leads to the characteristic helix shape.
Intermolecular bonds between 3 helix chains, wound togeth-
Connective Tissue er, create collagen’s ability to resist tensile loads (Figure 10-3).
Connective tissues arise from the embryonic mesoderm The assembly of triple helix chains into fibrils, and then
and constitute a large portion of total body mass. Their fibers with more crosslinks, further aids collagen’s resilience
general role is connecting and nourishing other tissues. to elongation (Figure 10-4). The 19 distinct types of collagen
Connective tissue can range from ordinary loose or dense are defined by the amino acids used to make the chains and
tissues to the highly specialized tissues of cartilage and whether the triple chains in the helix are all alike or differ in
bone.5 Most connective tissues are “strong, resilient and 1 or 2 of the chains.9
capable of repairing themselves.”8 Elastin fibers are also made from fibroblasts. These fibers,
as the name suggests, are highly extensible to tension forces.
Figure 10-4. Representation of colla-
gen synthesis, secretion, and assembly.
(Adapted from Culav EM, Clark CH, Merriless
MG. Connective tissues: matrix composition
and its relevance to physical therapy. Phys
Ther. 1999;79:312.)
Generally, they will recoil to their original length when ten- ligaments in high stress regions, need to withstand high-ten-
sion is released. For these properties, connective tissue with sion forces. These fibrous connective tissues will, therefore,
elastin has a large distribution throughout the body. Elastin have a higher proportion of collagen fibers to elastin. Other
can be organized in concentric sheets to accommodate pres- ligaments that need to be more flexible will have greater
sure changes, as in the aorta, or as individual fibers to allow amounts of elastin (Figure 10-5).
stretching in multi-directions, as in skin. The amount of elas- A proteoglycan in the extracellular matrix of fibrous con-
tin fibers, and their orientation, will depend on the amount nective tissue consists of a strand of protein—the protein
of stretch to be withstood, and the direction, respectively.9,10 core (PC)—on which repeating side chains of disaccharides
The ratio of collagen to elastin within a fibrous connective attach—the glycosaminoglycan chains (GAG chains). The
tissue can vary. Tendons connecting muscles to bone, and PC can vary in type and size but specific proteoglycans have
390 Chapter 10
A B
Figure 10-5. Mechanical behavior of 2 ligaments experimentally tested in

tension to failure: one with a high percentage of collagen fibers and the
other with a high percentage of elastic fibers. (A) Load-elongation curve
for a human anterior cruciate ligament (90% collagen fibers) tested in ten-
sion to failure. (B) Load-elongation curve for human ligamentum flavum
(60% to 70% elastic fibers) testing in tension to failure. At 70% elongation
the ligament failed abruptly. (Reprinted with permission from Frankel VH,
Nordin M. Basic Biomechanics of the Skeletal System. Philadelphia, PA: Lea
& Febiger; 1980.)
Figure 10-6. Representation of an aggrecan monomer with

keratan sulfate (KS) and chondroitin sulfate (CS) GAG side
chains attached to the PC. The monomer is attached to
hyaluronan and is stabilized at this binding region by link
protein. Numerous monomers attach to hyaluronan to form
the large proteoglycan aggregate. (Adapted from Phys Ther.
1999;79:308-319, with permission of the American Physical
Therapy Association. Copyright © 1999 American Physical
Therapy Association.)
specific PCs. The properties of a proteoglycan are largely The function of the fibrous connective tissue will dictate
defined, however, by the number and type of the GAG side the proportion of fiber to proteoglycan concentration as well
chains. Of note is the water-holding capacity of the side as the orientation of the fibers. In general, ligaments and
chains. The review article on connective tissue matrix by tendons, which are dense regular connective tissues, have
Culav et al explains: lower proportions of proteoglycans to fibers because the
All GAGs are negatively charged and have a propen- need to withstand compression forces is less. The presence of
sity to attract ions, creating an osmotic imbalance proteoglycans in these tissues helps to keep the fibers apart
that results in the PG-GAG absorbing water from to limit undesired crosslinks (Table 10-1). In some instances,
surrounding areas. This absorption helps maintain the underside of a tendon may have a bit more proteoglycans
the hydration of the matrix; the degree of hydration in its tissue to withstand the compression that occurs as the
depends on the number of GAG chain and on the tendon comes in contact with underlying bone.9,11
restriction placed on the PG swelling by the sur- Nonconnective tissue cells can be found within the con-
rounding collagen fibers…9(pp313-314) nective tissue matrix. Mast cells containing heparin and
histamine, macrophages, white blood cells [WBCs]), and
Proteoglycans can aggregate onto single strands of hyal-
lymphocytes are located within the matrix and are ready for
uronan to form large molecule complexes. The best known
activation if the tissue is damaged by injury or disease.8
of these is aggrecan (Figure 10-6). A glycoprotein—link pro-
tein—aids in the stability of aggrecan. Other glycoproteins
help stabilize the components of the extracellular matrix.
TABLE 10-1. CLASSIFICATION OF FIBROUS CONNECTIVE TISSUE

DENSE
Dense Regular Characteristics Dense parallel arrangement of collagen fibers
Higher collagen to proteoglycan ratio
Compactness of tissue leads to limited vascular supply
Properties High tensile strength
Withstands unidirectional stress
Little extensibility
Increased healing time after trauma
Tissue examples Tendons, ligaments
Dense Irregular Characteristics Dense but multidirectional arrangement of collagen fibers
Higher collagen to proteoglycan ratio but lower than dense regular tissue
Improved vascularity compared with dense regular tissue
Properties Withstands multidirectional stress
Improved healing time compared to that of dense regular tissue
Tissue examples Aponeuroses, joint capsules, periosteum, dermis of skin, fascial sheaths
(under high degree of mechanical stress)
LOOSE
Loose Irregular Characteristics Sparse, multidirectional framework of collagen and elastin fibers
Higher proteoglycan to fiber ratio
Greater vascularity compared with the other connective tissue types
Properties Lowest ability to resist stress
Designed to withstand multidirectional low stress
Best ability to heal of the fibrous connective tissue types
Tissue examples Superficial and some deep fascia, nerve and muscle sheaths, endomysium,
supportive framework of the lymph system and internal organs
Adapted from Grodin JA, Cantu RI. Myofascial Manipulation: Theory and Clinical Management. Berryville, VA: Forum Medicum Inc; 1989.
Cartilage remained at the bone ends. Children have cartilaginous

growth plates between the bone ends and the long bone shaft
As noted previously, a greater proportion of proteoglycans
(Figure 10-7).
to fibers is found in connective tissue that is subjected to high
Cartilage can grow by expanding from within. This
compressive forces. The second portion of the quote noted
interstitial growth occurs by division of young chondral cells
previously from Culav et al describes cartilage as, “[the] lim-
within the matrix. Each newly divided cell will secrete more
ited expansion [due to the constraint of surrounding collagen
matrix around itself. This swelling-from-within growth that
fibers] provides rigidity of the matrix and, where PG content
cartilage can do does not occur in bone.
is high, endows the tissue with the ability to resist compres-
sive forces.”9(p314) Cartilage is structured to withstand high Appositional growth used by cartilage and bone simply
compressive forces. adds another layer of tissue to the outside of what has already
formed. Appositional growth creates an interesting contrast
There are variations of cartilage types. Cartilage is a semi-
for tendons and ligaments inserting into cartilage and those
rigid tissue but it can also be flexible where needed as in the
into bone. Tendons and ligaments inserting into cartilage
elastic cartilage of the ear and the epiglottis of the throat.
continue the blending of collagen fibers into fibrocartilage as
Tendon insertions and the intervertebral discs are reinforced
the cartilage grows outwardly. Tendons or ligaments attach-
with collagen fibers in a tough form of cartilage identified
ing to bone, on the other hand, become gradually embedded
as fibrocartilage. The long bones of the body began as car-
in the ever increasing outer rings of bone. These embedded
tilage that was gradually replaced by bone. Hyaline cartilage
collagen fibers are called Sharpey’s fibers (Figure 10-8).5
392 Chapter 10
A B
Figure 10-8. (A) Tendon insertion (patellar tendon of rat). (B) Ligament
insertion (anterior cruciate of rat). (Reprinted with permission from Cormack
DH. Introduction to Histology. 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2001.)
Bone, however, is clearly different from cartilage in that

bone has a highly calcified and unyielding extracellular
matrix. As a specialized connective tissue, bone arises from
embryonic mesoderm. The formation of bone, osteogenesis,
occurs in 1 of 2 ways. The flat bones of the skull are formed
by bone tissue developing directly in the mesenchyme mem-
brane in a process called intramembranous osteogenesis. The
majority of bone tissue, including long bones, grows on an
Figure 10-7. Comparison of the cartilaginous epiphyseal growth
intervening and temporary model of cartilage. This process
plate in still lengthening childhood bone with the no longer length-
ening epiphyseal line in adult bone. of bone formation is called endochondral osteogenesis.5 The
final bone tissues, regardless of the osteogenesis process fol-
lowed, are the same.
Cartilage is avascular. It relies on nutrients from capillar- As noted previously, a less obvious difference between
ies outside the cartilage to diffuse throughout the cartilage, cartilage and bone is that bone has a better structure in
a relatively long distance of travel for such essential compo- place for its nutritional needs. Osteocyte lacunae are inter-
nents to cartilage health. Another nutrition challenge for car- connected by tiny canals called canaliculi (Figure 10-9).
tilage occurs when deposits of insoluble calcium salts cause Tissue fluids rich in nutrients and oxygen travel through the
calcification of the matrix. When this calcification occurs, it canaliculi. These interconnecting canals may serve also as a
interferes with diffusion and, thus, the nutrition of the entire network for transmitting signals with changes in bone load-
cartilage. Bone, on the other hand, is able to calcify without ing and unloading. The fluids of the canaliculi are refreshed
disruption of its tissue nutrition. by nearby capillaries which were incorporated into the bone
structure during development. Osteocytes, with surround-
Bone ing calcified matrix, grow appositionally around a vascular
Aside from the commonalities as connective tissue, bone supply to eventually form Haversian systems (Figure 10-10).
shares additional characteristics with cartilage. First, once All bone, therefore, is not far from a vascular supply, which
osteocytes, like chondrocytes, become embedded in the further ensures the delivery of adequate available nutrition
encasing extracellular matrix, each resides within a small from capillaries via the canaliculi.
space called a lacuna. And, despite the obvious difference in
the composition of the extracellular matrix between cartilage
and bone, discussed next, the extracellular matrix of both are
Nervous Tissue
reinforced by collagen fibrils. Second, bone’s outer surface is The cells and tissue of the nervous system arise from
covered by a fibrous layer called periosteum that is similar the mid-dorsal embryonic ectoderm. Specifically, a flat and
to the perichondrium for cartilage. The highly vascular- elongated neural plate forms that then folds and connects
ized periosteum, however, becomes incorporated into bone, dorsally to become the neural tube. The brain and spinal
which creates an essential difference in the overall nutrition cord develop from the neural tube and become the central
of bone compared to cartilage. nervous system (CNS). The peripheral nervous system (PNS),
which innervates the trunk, limbs, and head arises from the
Figure 10-9. Osteocytes in lacuna with canaliculi. (Adapted
from Cormack DH. Introduction to Histology. Philadelphia, PA:
J.B. Lippincott Co; 1984.)
Figure 10-10. Bone widening occurs when new Haversian

systems are added to the periphery diaphysis. Periosteal
vessels become incorporated in the new Haversian canals.
(Adapted from Cormack DH. Introduction to Histology.
Philadelphia, PA: J.B. Lippincott Co; 1984.)
Figure 10-11. A representation of a neuron. The

long length of the axon, compared to that of the
cell body, defines its function to connect with
other neurons—even in other parts of the body.
(Adapted from Widmaier EP, Hershel R, Strang KT.
Vander, Sherman, Luciano’s Human Physiology: The
Mechanism of Body Function. 9th ed. New York:
McGraw-Hill; 2004.)
neural crest, an extension of nervous tissue that appears signals along the outer membrane of the cell toward the cell
along both sides of the neural tube. body. The signal continues along the outer membrane of the
The basic structure of nerve cells reflects their specialized cell body and then the long extension of the cell, the axon,
function to carry excitatory signals along nervous system until branching at the axon end connects with dendrites of
pathways that interconnect all parts of the body. Branching other nerve cells (Figure 10-11). The transmission of current
dendrites, at one end of the nerve cell, transmit electrical from one nerve cell to another, the synapse, can lead to the
394 Chapter 10
Figure 10-13. The neural structure of the stretch reflex. (Adapted from
Cormack DH. Introduction to Histology. Philadelphia, PA: J.B. Lippincott
Co; 1984.)
Muscle Tissue
The fourth basic tissue formed from germ layers is muscle.
Figure 10-12. Section of the spinal cord, ventral view. The arrows indicate The fetal muscle cells arise from the mesoderm layer. The
the direction of transmission of neural activity. (Adapted from Widmaier
EP, Hershel R, Strang KT. Vander, Sherman, Luciano’s Human Physiology: The predominant characteristic of muscle tissue is the ability to
Mechanism of Body Function. 9th ed. New York: McGraw-Hill; 2004.) use energy to contract. Aiding in this function is the forma-
tion of long multinucleated muscle fibers from small nucle-
ated muscle cells during fetal development. In addition, fetal
electrical charge continuing along the second nerve or inhib- muscle cells differentiate along 3 pathways to form striated
iting the nerve to accept other charges. cardiac and skeletal muscle, and nonstriated smooth muscle
In the brain and spinal cord, cell bodies will cluster (see Figure 1-10).
together. These areas were labeled gray matter because of All 3 muscle types rely on actin and myosin filaments for
their gray appearance in tissue cross sections. White mat- contractile properties though how the filaments are arranged
ter are areas with predominately dendrites and axons. The differ. Each muscle type has a network structure to disperse
outer edge of the brain, called the cortex, is largely gray a depolarizing signal to all fibers to initiate a contraction.
matter with white matter seen in the central regions of the Each has a structure for the wide release, and reabsorption,
brain. The reverse arrangement occurs in the spinal cord, of calcium ions.
with gray matter central and white matter on the periphery In skeletal muscle, the myofilaments within the muscle
(Figure 10-12). fiber, the myofibril, are arranged in a repeating pattern.
A characteristic common both to gray and white matter Within the unit of the repeating pattern, the sarcomere,
is that there is very little connective tissue present. Without the myosin molecules bundle to form thick filaments. A
the supporting structure of an extracellular matrix and con- myosin filament bundle is surrounded by an arrangement
nective tissue layers, the tissues of the CNS are soft. The of nonbundled lighter actin filaments. One end of the actin
nerve tissue of the PNS differs from that of the CNS by the filaments are attached to interconnecting proteins, the Z-line
incorporation of connective tissue layers into the structure of (Figure 10-14).
peripheral nerves that provide resilience. A single actin filament is encircled by end-to-end chains
Afferent nerves transmit electrical impulses generated by of tropomyosin that block the myosin-binding sites on the
sensory receptors, afferent endings, to the spinal cord and actin filament. When calcium ions are released, the cal-
brain. Cell bodies for afferent nerves cluster in the cranial cium binds with the troponin molecules on the tropomyosin
ganglia for cranial nerves and the posterior dorsal root gan- chains. This causes the tropomyosin chain to reconfigure,
glia for peripheral nerves. which then moves the chain off the binding sites on the actin
Efferent nerve cell bodies are located in the motor cortex filament. A myosin cross-bridge binds with the now available
of the brain and anterior horn of the spinal cord. Efferent site on the actin filament, causing the energized cross-bridge
nerves transmit signals from the brain and spinal cord to rotate and the myofilaments to slide past each other.
largely to muscle fibers (Figure 10-13). The presence of adenosine triphosphate (ATP) energizes
the cross-bridge for rotation and force generation. ATP then
Figure 10-14. Organization of muscle monofila-
ments and Z-line/disc.
enables the myosin cross-bridge to release from the bond and

re-energize. This prepares the myosin cross-bridge to bond
again on the actin filament with more sliding of the myofila-
ments past each other (Figure 10-15).
The calcium ions are released from, and reabsorbed back
into, the sarcoplasmic reticulum. Corresponding to the
endoplasmic reticulum within most other cells in the body,
the sarcoplasmic reticulum creates a sleeve-like network of
tubes outside each myofibril. Two pairs of tubes, the termi-
nal cisternae, surround the muscle fiber at the level of the
junction of the A bands and the I bands on the sarcomere.
Anastomosing tubes, the sacrotubules, span the region cor-
responding to the A band (Figure 10-16).
The connective tissue outer layer of the myofibril, the sar-
colemma, sends projections of tissue, the T-tubules, to nestle
between a pair of terminal cisternae. When the sarcolemma
is depolarized, the signal is carried along the T-tubules,
which then activates the release of calcium ions from the
sarcoplasmic reticulum (Box 10-1).
Tissue Damage and Healing Figure 10-15. The I-Band and H-Band regions narrow as thick filaments
slide past thin filaments. The actual fibers don’t shorten but the sarco-
Basic Tissues Shared Events mere length does. (Adapted from Widmaier EP, Hershel R, Strang KT.
Vander, Sherman, Luciano’s Human Physiology: The Mechanism of Body
The differences in the structure of the basic tissues also Function. 9th ed. New York, NY: McGraw-Hill; 2004.)
lead to differences in the specific events that occur when each
tissue is damaged by injury or disease. Variations in the paths
and rates of healing also exist. There are, however, consider- Damage to tissues from an injury or disease will trigger a
able commonalities. Since, the basic tissues migrated during series of overlapping events within the first hours and days.
fetal development and layered to form the components of The healing and recovery sequences that follow will proceed
the musculoskeletal system—the joints, musculotendinous over weeks and months. The multilayered process can be
units, and peripheral nerves—an understanding of those roughly defined as occurring with an immediate response
basic commonalities is useful. Important variations to note and the 3 phases of inflammation, tissue repair/regeneration,
will appear in later sections of the chapter. and maturation/remodeling.
396 Chapter 10
Figure 10-16. A drawing showing the myofibrillar striations
in relation to the sarcoplasmic reticulum and transverse
tubules location on a muscle fiber. (Adapted from Cormack
DH. Introduction to Histology. Philadelphia, PA: J.B. Lippincott
Co; 1984.)
BOX 10-1. THE SLIDING FILAMENT THEORY OF MUSCLE CONTRACTION

1. Local currents depolarize the adjacent muscle cell plasma membrane to its threshold potential, generating
an action potential that propagates over the muscle fiber surface and into the fiber along the T-tubules.
2. Action potential in the T-tubules triggers release of Ca2+ from terminal cisternae of the sarcoplasmic reticulum.
3. Ca2+ binds to troponin on the thin filaments, causing tropomyosin to move away from its blocking posi-
tion, thereby uncovering cross-bridge binding sites on actin.
4. Energized myosin cross-bridges on the thick filaments bind to actin.
5. Cross-bridge binding triggers release of adenosine triphosphate (ATP) hydrolysis products from myosin,
producing an angular movement of each cross-bridge.
6. ATP binds to myosin, breaking linkage between actin and myosin and thereby allowing cross-bridges to
dissociate from actin.
7. ATP bound to myosin is split, energizing the myosin cross-bridge.
8. Cross-bridges repeat steps 4 to 7, producing movement (sliding) of thin filaments past thick filaments.
Cycles of cross-bridge movement continue as long as Ca2+ remains bound to troponin.
9. Cytosolic Ca2+ concentration decreases as Ca2+ is actively transported into sarcoplasmic reticulum by
Ca2+-ATPase.
10. Removal of Ca2+ from troponin restores blocking action of tropomyosin, the cross-bridge cycle ceases,
and the muscle fiber relaxes.
Sequence of events in skeletal muscle fiber contraction.
Reprinted with permission from Widmaier EP, Hershel R, Strang KT. Vander, Sherman, Luciano s Human Physiology: The Mechanism of
Body Function. 9th ed. New York: McGraw-Hill; 2004. Copyright McGraw-Hill Education.
Immediate Response fluids leaking from damaged vessels. Nearby cells with a lost
blood supply due to damaged capillaries will also lose the
When an injury occurs, the crushed cells spill their con-
ability to survive and maintain their outer cell walls, thus
tents into the area of injury along with blood and lymphatic
more cellular debris is added. A disease process in tissues
can begin with lyzing of otherwise healthy cells creating a mechanical integrity to the injured tissues to allow a gradual
similar “pool” of cellular debris. One immediate damage resumption of function.
control response, actually signaled by the presence of cellular The distinction between tissue repair and tissue regenera-
debris, begins with the conversion of prothrombin, in the tion is an important one. Tissue regeneration means that the
leaked blood and lymph exudate, into thrombin. Fibrinogen, damaged tissue is replaced by tissue that eventually will be
also in the cellular debris, will be activated by the thrombin indistinguishable, or nearly so, from that which was dam-
to form fibrin-based clots. The clot formation ensures that aged. Repair tissue is the creation of a scar tissue patch that
any continued bleeding into the area not already curtailed is unlikely to be an exact match to the mechanical properties
by vasoconstriction, another immediate damage control of the original tissue.12 So, time, along with the size of the
response, is stopped. The fibrin and the cellular debris create injury area and the tissue type, will determine the extent to
a gel-like seal over the area.12 The region of tissues damaged whether tissue repair will dominate. Tissue regeneration may
by invading disease will undergo a similar effort at contain- be progressing well but simply becomes overrun by the faster
ment by fibrin clots.13 repair offered by collagen-producing fibroblasts.
Inflammation The phase of regeneration and repair continues for 4 to
6 weeks, until the entire area of injury has a stabilizing struc-
A chemical signal, chemotaxis, from the cellular debris ture in place, whether regeneration tissue or scar tissue. The
and the process of clot formation sets off local and system structural organization and overall strength of the new tissue
reactions that lead to inflammation. Bradykinin, a vasodila- can be enhanced by the gradual introduction of mechanical
tor, is activated locally. It, in turn, stimulates the release of forces in the form of controlled movements.14-17
potent prostaglandins, which improve the ability of arriving
neutrophils and monocytes to enter interstitial spaces by Maturation/Remodeling
increasing the permeability of capillary walls. The charac- The final stage of healing allows the new tissues to mature
teristic signs of inflammation—tissue redness, swelling, and and strengthen. The initial collagen fibers in repaired tissues
tenderness—result from the vasodilation, increased presence are gradually replaced by a stronger form. Bone, a regenerat-
of fluids in the interstitial spaces, and the stimulation of ed tissue, undergoes remodeling to achieve its final optimum
nociceptors by bradykinin and prostaglandins. structure. The process of maturation and remodeling can go
In an example of the overlapping of events, the clearing on for more than 1 year depending on the tissue.
of cellular debris as a step preceding tissue repair is under- The final tissue properties that are restored will vary.
way even while the inflammatory phase is just developing. Largely collagen-based tissues may recover only about 75% of
Macrophages located in the extracellular matrix of the their original strength.18 Regenerated fractured bone, on the
injured tissues begin digesting the cellular debris within an other hand, can become indistinguishable in appearance or
hour of the injury.13 Within a few hours after injury, and structural properties from the original bone. All of the basic
with the phase of inflammation now well underway, these tissues have shown enhanced recovery of structural proper-
macrophages will be joined by neutrophils and monocytes ties with gradually increasing mechanical loads.7,14-17
that have followed the chemotaxis signal to the area. The
mature neutrophils will begin phagocytosis immediately on Tissue Health
arrival at the periphery of the debris. The monocytes, on the A number of factors can impede the recovery of injured
other hand, arrive but then need a period of 8 to 12 hours to tissues. A compromised cardiovascular or pulmonary sta-
change into mature macrophages. The ability of the neutro- tus may diminish the adequate delivery of essential oxygen
phils to begin phagocytosis immediately is advantageous to and nutrients to the tissue rebuilding site. Disruption of
control bacteria, which may be present when inflammation is early capillary formation will delay the stages of healing.12
associated with a disease process, in a timely manner. When Medications useful for controlling inflammatory processes
time is not as critical, macrophages have the advantage of in one part of the body may interfere with the tissue build-
greater capacity for phagocytosis as well as the ability to ing in another.19 Smoking adversely affects bone and wound
phagocytize larger particles—including spent neutrophils. healing as well as increase rates of postoperative complica-
Macrophages can also phagocytize necrotic tissues.13 The tions with surgeries requiring microvascular repair.20,21 The
effects of inflammation may last nearly a week. Gradually, information on tissue injury and healing gives rise to several
however, the symptoms fade as a transition occurs from the questions: Can the causes of tissue injury be identified? What
task of cleaning up cellular debris to one of tissue rebuilding. can be done to aid injured tissues? Is there any way to help
tissues resist physical stress and avoid injury? A theoretical
Tissue Repair/Regeneration framework for the answers to these questions can be found
Clearing of the cellular debris stimulates vascular growth. in the Physical Stress Theory (PST).
During angiogenesis capillary buds form on the edge of
cleared debris and become vessels. This in turn provides
a blood supply for the tissue rebuilding work of tenocytes,
Physical Stress Theory
osteocytes, and myocytes. Tissue regeneration efforts can be Mueller and Maluf theorized that an adaptive response
challenged, however, by the body’s need to quickly restore could be predicted in all biological tissues relative to the
398 Chapter 10
BOX 10-2. SUMMARY OF FUNDAMENTAL PRINCIPLES FOR PHYSICAL STRESS THEORY

BASIC PREMISE: CHANGES IN THE RELATIVE LEVEL OF PHYSICAL STRESS CAUSE A PREDICTABLE
ADAPTIVE RESPONSE IN ALL BIOLOGICAL TISSUE
Fundamental Principles:
A. Changes in the relative level of physical stress cause a predictable response in all biological tissues.
B. Biological tissues exhibit 5 characteristic responses to physical stress [Figure 10-17]. Each response is predict-
ed to occur within a defined range along a continuum of stress levels. Specific thresholds define the upper
and lower stress levels for each characteristic tissue response. Qualitatively, the 5 tissue responses to physical
stress are decreased stress tolerance (eg, atrophy), maintenance, increased stress tolerance (eg, hypertrophy),
injury, and death.
C. Physical stress levels that are lower than the maintenance range result in decreased tolerance of tissues to
subsequent stresses (eg, atrophy).
D. Physical stress levels that are in the maintenance range result in no apparent tissue change.
E. Physical stress levels that exceed the maintenance range (ie, overload) result in increased tolerance of tis-
sues to subsequent stresses (eg, hypertrophy).
F. Excessively high levels of physical stress result in tissue injury.
G. Extreme deviations from the maintenance stress range that exceed the adaptive capacity of tissues result in
tissue death.
H. The level of exposure to physical stress is a composite value, defined by the magnitude, time, and direction
of stress application.
I. Individual stresses combine in complex ways to contribute to the overall level of stress exposure. Tissues are
affected by the history of recent stresses.
J. Excessive physical stress that causes injury can occur from 1 or more of the following 3 mechanisms: (1) a
high-magnitude stress applied for a brief period, (2) a low-magnitude stress applied for a long duration, and
(3) a moderate-magnitude stress applied to the tissue many times.
K. Inflammation occurs immediately following tissue injury and renders the injured tissue less tolerant of stress
than it was prior to injury. Injured and inflamed tissues must be protected from subsequent excessive stress
until acute inflammation subsides.
L. The stress thresholds required to achieve a given tissue response may vary among individuals depending
on the presence or absence of several modulating variables. Factors that can influence thresholds for tissue
adaptation and injury are summarized in Box 10-3 and include movement and alignment, extrinsic, behav-
ioral, and physiological factors.
Reprinted from Phys Ther. 2002;82:383-403, with permission of the American Physical Therapy Association. Copyright © 2012 American
Physical Therapy Association.
level of physical stress to which the tissues were exposed.19 adaptations—decreased tissue tolerance—that occur with
The authors of the PST offer an overview of the fundamental decreased physical stress. Similarly, effects of training on tis-
principles of tissue adaptations for the tissues, and the organ sues presented in Chapter 5 illustrate the specific increased
systems composed of those tissues, most relevant to the scope tissue tolerances that develop as a result of graded increased
of practice for physical therapists. The evidence-based shared physical stress.
reactions of the tissues and organ systems have been identi- The overview offered by the PST can be used as the van-
fied (Box 10-2). tage point from which to view the effect that compromised
Also integral to the PST are those factors that will further cardiovascular and pulmonary systems have on musculo-
affect tissue adaptation (Box 10-3). Systemic pathology, poor skeletal structures. From the perspective of the PST, any
control of alignment of fractured bone ends, and medica- compromise of the cardiovascular and pulmonary systems
tions are consistent with the impediments to tissue healing has the potential to affect tissue physical stress tolerance,
mentioned previously. and thus, contribute to the development of a musculoskeletal
As physical stress levels increase or decrease from a level disorder. In addition, systemic pathology, along with the
that maintains tissue integrity level, predictable outcomes other factors listed in Box 10-3, can affect the recovery from
can be outlined (Figure 10-17). Chapter 4 discussed the tissue a musculoskeletal disorder.
BOX 10-3. FACTORS AFFECTING THE LEVEL OF PHYSICAL STRESS ON

TISSUES OR THE ADAPTIVE RESPONSE OF TISSUES TO PHYSICAL STRESS
● Movement and alignment factors ● Psychosocial factors
○ Muscle performance (force generation, length) ● Physiological factors
○ Motor control ○ Medication
○ Posture and alignment ○ Age
○ Physical activity ○ Systemic pathology
○ Occupational, leisure, and self-care activities ○ Obesity
● Extrinsic factors
○ Orthotic devices, taping, assistive devices
○ Footwear
○ Ergonomic environment
○ Modalities
○ Gravity
Reprinted from Phys Ther. 2002;82:383-403, with permission of the American Physical Therapy Association. Copyright © 2012 American
Physical Therapy Association.
MUSCLES
Morphology (Gross Anatomy and
Histology) and Physiology
Observations on skeletal muscle morphology (gross anat-
omy and histology) and physiology (including biochemis-
try) provide insight into muscle function. The long fibers
of skeletal muscle can be arranged to run along the entire
length of a muscle and parallel with the tendon line of
pull. This strap-like arrangement of fibers allows for an Figure 10-17. The effect of physical stress on tissue adaptation. Biological
increased range of action. It does so, however, at the expense tissues exhibit 5 adaptive responses to physical stress. Each response
of power.22 Conversely, a muscle can consist of shorter fibers is predicted to occur within a defined range along a continuum of
aligned obliquely to the line of pull, as in a triangular or pen- stress levels. Specific thresholds define the upper and lower stress
levels for each characteristic tissue response. The relative relationship
nate arrangement. This muscle would be found where the between these thresholds is fairly consistent between people, whereas
required degree of shortening through the tendon is lower the absolute values for thresholds vary greatly. (Reprinted from Phys Ther.
but muscle power higher.23 Multiple variations in skeletal 2002; 82(4):383-403, with permission of the American Physical Therapy
muscle fiber arrangements occur between these 2 extremes Association. Copyright © 2002 American Physical Therapy Association.)
to reflect the myriad of action, power, and stabilization func-
tions required of skeletal muscle.
Initially, whole muscles in animals were classified by Three current methods of muscle fiber typing differenti-
appearance. The “slow” muscles of endurance appeared ate by identifying myosin ATPase hydrolysis rates, myosin
darker because of the greater concentration of myoglobin heavy chain isoforms or metabolism enzymes.24 There
and capillaries than in the observed “fast” white muscles.24 are variable correlations, however, between the fiber types
Later fibers within muscle were identified as slow-twitch or identified in each typing method (Figure 10-19).24 Given
fast-twitch fibers. Muscle cross sections were stained to high- the 7 human fiber types identified with analyzing myosin
light the increased number of mitochondria in, or capillaries ATPase hydrolysis rates, and the variable correlations with
around, the Type I slow-twitch fibers. The fast-twitch Type the fibers identified in the other methods of fiber typing,
II fibers were seen to have greater cross-sectional diameters, what can be said about human muscle fiber types that would
high concentrations of glycolytic enzymes, and large glyco- be accurate?
gen stores (Figure 10-18).25
400 Chapter 10
Figure 10-18. Drawings of muscle cross sections. (A) Appearance
of a muscle cross section if the capillaries had been stained. The
small-diameter oxidative fibers are surrounded by capillaries. (B)
Staining the mitochondria highlights the large numbers of mito-
chondria in the small-diameter oxidative fibers. (Adapted from
A B
Widmaier EP, Hershel R, Strang KT. Vander, Sherman, Luciano’s
Human Physiology: The Mechanism of Body Function. 9th ed. New
York: McGraw-Hill; 2004.)
The heterogeneity of fiber types within a skeletal muscle

contrasts with the homogeneity of motor units.26 Multiple
motor neurons, of various activation thresholds and trans-
mission speeds, are situated to deliver electrical activation
signals to a muscle. A motor unit consists of one motor neu-
ron and the multiple muscle fibers its branches innervate. All
the fibers within one motor unit are the same fiber type. The
neuron of the motor unit appears to determine the muscle
fiber type of the motor unit.27
Muscles contract and offer resistance under 3 different
loading conditions.
If the force developed by the muscle is greater than
Figure 10-19. Comparison of 3 different skeletal muscle fiber type clas- the load on the muscle, a shortening (concentric)
sification: histochemical staining for myosin adenosine triphosphatase contraction occurs. When the force developed by
(mATPase), myosin heavy chain identification, and biochemical identi- the muscle and the load are equivalent, or the load is
fication of metabolic enzymes. Note: in humans, MHCIIb are now more immovable, a fixed length, or isometric contraction,
accurately referred to as MHCIIx/d. The question marks indicate the poor
correlation between biochemical and myosin heavy chain or mATPase results. The third type of contraction occurs when
fiber type classification schemes. (Reprinted from Phys Ther. 2001;81:1810- the load on the muscle is greater than the force devel-
1816, with permission of the American Physical Therapy Association. oped by the muscle and the muscle is stretched, pro-
Copyright © 2001 American Physical Therapy Association.) ducing a lengthening (eccentric) contraction.28(p93)
Muscle fiber lengths are variable in these 3 muscle con-
It would be safe to say that there are Type I fibers that traction scenarios. What is consistent about the physiology
rely on aerobic/oxidative pathways for energy metabolism. of a contraction is the sarcomeres’ attempt to shorten with
And that, on the other side of the fiber type spectrum, there cyclic cross-bridge formation noted earlier (see Box 10-1).28
are fibers, Type II, that use anaerobic/glycolytic metabolism. With an established human muscle morphology, and the
Then there appears to be muscle fiber types to cover the number of muscle fibers essentially fixed at birth, how can
spectrum in between.24 muscle performance in patients be altered? What are the
A muscle with an even distribution of aerobic/oxidative effects of different types of loading on a muscle? And, how is
fibers and anaerobic/glycolytic fibers would yield a muscle muscle performance changed by altered cardiovascular and
of average performance ability. Skewing the distribution of pulmonary function?
these fibers types in either direction would produce a muscle Muscle Response to Loading
more prepared for endurance events or one for speed and
power. But what determines the distribution? Can the dis- Lengthening and Shortening Loads
tribution be altered? What role do the fibers in the middle of Much of what is known about muscle lengthening comes
the spectrum play? from animal studies. The consistency of results across animal
species encourages the tendency to extrapolate the findings
to human muscle. Adult animal muscles immobilized in a a little more relaxed on release. This effect of less stiffness
lengthened position—defined as longer than resting length and more relaxation with cyclic load and release, called hys-
but not beyond normal muscle range of length—adapted by teresis, will be seen for about 5 to 6 cycles in a session before
adding serial sarcomeres.29 This stretch-induced myofibril- reaching a plateau.34
logenesis has also been reported in animal models when Passive stretching of innervated muscles also offers a mild
muscles were indirectly lengthened during distraction osteo- training effect. Initiation of the muscle spindle can occur,
genesis procedures.30 These results suggest that the increase which increases tension in the muscle with subsequent mild
in tissue tension, when the muscle is held beyond its resting hypertrophy.27
length, is relieved by the addition of the sarcomeres.31 In adult animals, immobilization of muscles in the short-
When adult animal muscles are immobilized in a shortened position had a fiber-type effect as well. Acknowledging
ened length, serial sarcomeres numbers decrease. Again, this the challenge of comparing animal to human fiber typing
may be an adjustment to maintain an optimal tension. When and the variations in typing that exist, a decrease in Type
immobilization ends, lengthened and shortened muscles can I fibers was seen and an increase in Type II fibers noted.31
return to preimmobilized conditions. Animal studies have Again, this is difficult to study to the same degree in humans.
shown that immobilized shortened muscles may recover It may be safe to say, however, that the possibility exists that
normal peak tension values after 120 days of resumed unre- Type I fibers may be more affected by disuse or shortening.
stricted movements.32 As cited in Chapter 4, animal research has added the obser-
The theory of optimal tension also seems to explain the vation that anti-gravity muscles are even more affected by
difference that occurs in the same lengthening experiment disuse.
with young animals. The musculoskeletal unit in young Resistive Loads
animals immobilized in a lengthened position adapted by
Motor unit recruitment for muscle concentric contrac-
lengthening the tendon. This adaptation occurred to such
tions is dependent on the force required, the size of the motor
an extent that, in the first 5 days, the muscle belly decreased
unit, and the threshold for activation. For low-intensity
the rate of sarcomere addition compared to what would have
activities, and the lower threshold required for activation,
been expected by animals’ normal growth. By 2 weeks, the
slow-twitch/oxidative motor units, type I, are activated first.
continued tendon lengthening resulted in a decrease in the
31 As the muscle force required for a task increases, the larger-
number of sarcomeres in the lengthening muscle.
sized motor units with greater activation thresholds—those
In the young animal, therefore, the disparity between the
of fast-twitch/oxidative/glycolytic fibers—will be activated
tendon and muscle length adaptation becomes part of the
and added to the contraction force. With the highest force
developmental experience and may not be reversed. There is
activity, activation of all motor units is required, including
not a lot of opportunity to study the same effect in humans.
fast-twitch/glycolytic fibers (Figure 10-20). A muscle task
It might not be unrealistic, however, to note any disparities
requiring the highest levels of motor unit activation will also
in the symmetry of muscle to tendon length in an adult who
be a task for which fatigue occurs more quickly because of
reports a prolonged immobilization in childhood for an
the reliance on Type II fibers.
orthopedic condition or injury.
Muscles can adapt to gradually increasing loads. Exercise
With the exception of serial casting and splinting, the
training to improve Type I fiber endurance will need to use
passive stretching exercise treatments performed by physical
activities of relatively low intensity that can reasonable be
therapists and physical therapist assistants use an intermit-
increased in duration, over time, to intervals longer than 5 to
tent lengthening to muscles. What is known about the effects
6 minutes. For many patients, this would be accomplished
of intermittent passive stretching? It is believed that light to
with a progressive ambulation program. The training effect
moderate passive stretch in passive range of motion exercises
at the muscle level would be seen by the increased presence of
primarily affects muscle fibers and not the perimuscular
mitochondria, increased myoglobin content, and increased
connective tissues. It has been proposed that stretch-induced
capillary network in Type I muscle cells. Strength gains seen
myofibrillogenesis is still the result of therapeutic intermit-
in an improved ability to step up a stair or climb a flight of
tent passive stretching even though the calculated sarcomere
stairs suggest that Type II fibers have been recruited.
lengthening is less than that used in the animal muscle
Activation of Type II fibers with the goal of strengthen-
lengthening studies noted previously.30
ing can occur with repeated functional tasks, movements
What are the effects of moderate or greater intermittent
against gravity or resisted motion against increasing loads.
passive stretching? Animal studies have shown that cyclic
Initial strength gains in a resistance exercise program of 2 to
stretching of muscle at 50% of failure length resulted in
6 weeks’ duration will occur because of improved effective-
muscle more resilient to lengthening before failure.33 Greater
ness in neural coordination of the motor unit activation
length before failure has been attributed to the increase in
in the exercising muscle as well as the improved relaxation
muscle length from serial sarcomeres. The viscoelastic prop-
in the antagonists.26 Continued training, greater than 6 to
erties of muscle and the perimuscular connective tissues are
10 weeks, can lead to hypertrophy of the exercising muscle
also a factor. Viscoelastic tissues will return from a stretched
fibers. This largely anaerobic work stimulates the addition
position a little more relaxed. In repeated cycles of stretching
of increased parallel sarcomeres, contractile proteins of actin
the muscle will be less stiff to the stretching load and, again,
and myosin and, as a result, increased cross-sectional area.
402 Chapter 10
The recovery of muscle function following short-
A duration unloading appears to be completed in a
shorter time span than the duration of unloading,
whereas unloading periods of 4 to 6 weeks result in
a recovery period lasting as long as the unloading
period or longer.37(p771)
In comparisons of injured limbs, the rate of strength
recovery has been shown to be determined by the length of
disuse regardless of the retraining exercise mode selected.
Despite the evidence that strength gains can be made with
retraining, surveyed patients have reported continued func-
B tion deficits in the injured limb compared with the uninjured
limb for significant periods postinjury.37
Muscle Nutrition and Healing
Skeletal muscles have a good system of nutrient delivery.
In addition, the extensive capillary network will meet the
increase in oxygen demand required by exercising trained
muscles. Adequate vascularization is a factor in muscle
recovery from exercise as well. Patients with a diminished
capacity to deliver adequate amounts of oxygenated blood to
exercising muscle will have limited exercise tolerance as well
as decreased ability to recover from an exercise session.
Similarly, a healthy, trained muscle is less likely to be
injured. When an injury does occur a conditioned muscle
has a better support network in place to aid healing than does
an injured deconditioned muscle. Even in healthy muscles,
however, there is a challenge to healing. Muscle tissue has the
healing situation where despite effective attempts by satel-
Figure 10-20. (A) Diagram of a cross section through a muscle composed lite cells to regenerate muscle cells the process is overrun by
of 3 types of motor units. (B) Tetanic muscle tension resulting from the fibroblastic repair.
successive recruitment of the 3 types of motor units. Note that motor unit
3, composed of fast glycolytic fibers, produces the greatest rise in tension Satellite cells regenerative efforts have been shown to be
because it is composed of the largest-diameter fibers and contains the enhanced with injections of growth factors. High concen-
largest number of fibers per motor unit. (Reprinted with permission from trations of growth factors have been required, however, to
Widmaier EP, Hershel R, Strang KT. Vander, Sherman, Luciano’s Human
detect any significantly improved regeneration. Researchers
Physiology: The Mechanism of Body Function. 9th ed. New York: McGraw-
Hill; 2004. Copyright McGraw-Hill Education.) will continue to explore the use of gene therapy to deliver
regenerative enhancing growth factors to improve the extent
of regenerative healing in injured muscle tissues.38
High-performance training can influence fibers in the
middle of the metabolic spectrum to show adaptive changes. Muscle Disorders
Longer intervals of heavy resistance training have shown
a transition of Type IIx fibers to Type IIa fibers, which are Contusion
more resistant to fatigue.35,36 In high-performance train- A muscle contusion occurs when a blunt force into a
ing, some Type I fibers can shift from a slow to a fast ver- muscle belly crushes the muscle fibers between the force and
sion of myosin to become faster in order to deliver the force the underlying bone. The scenarios of a hit from a tackle in
required.24 At the extremes of performance muscle training, football, or someone being hit by a forcefully thrown firm
however, muscles make a more thorough adaptation when ball, come to mind. But this is also the injury that can occur
the specificity of training is for high aerobic or high anaero- to muscle when someone falls against a piece of furniture or
bic performance, but not both.26 onto the ground.
There is an element of tissue injury with strengthening. The force of the impact crushes muscle fibers, and their
The entire resistive training program relies on the body’s supporting structures, resulting in torn cell membranes in
ability to build itself back stronger when confronted with a the region of the direct impact. A lighter force may dam-
proportional challenge. age more superficial tissue and, perhaps, outer layer muscle
The length of time required to recover muscle strength cells with the result of little more than a colorful but tender
from immobilization or disuse atrophy is dependent on the bruise on the skin surface and mild impairment of muscle
length of time the limb was unloaded. contraction. Greater forces will also yield ecchymosis, which
might have a delayed appearance of a few days to reflect
the injury to deeper muscle fibers closer to the underlying
bone. Depending on the extent of the contusion, injured
muscle fibers are unable to contract or will contract weakly.
Disrupted capillaries bleed and nociceptors on nerves still
intact on the periphery of injured region are stimulated by
chemicals released by damaged cells.
Along with the neutrophils and macrophages that come
into the area to clean up the cellular debris, muscle satellite
cells are activated. Regeneration of damaged myofilaments
by the satellite cells will have time to occur where there
has been limited damage to a muscle fiber. Satellite cells
are capable of regenerating areas of more extensive damage
to an area of muscle fibers but succumb to the area being
more quickly patched by fibrous scar tissue. This patch will
become more of a pulley to the still intact contracting sar-
comeres adjacent to the region of injury. Depending on the Figure 10-21. The Blix curve depicting muscle length-tension relation-
extent of the damage, the overall potential for muscle tension ship. Note that the greatest contractile force is developed when the
may be diminished. muscle is at its resting length, about halfway between its extremes of
length. As the muscle is passively stretched beyond its resting length, its
Following a brief period of rest that corresponds to the contractile force gradually diminishes, but the passive resistance of the
initial inflammatory phase, the introduction of controlled connective tissue components gradually develop more tension so that
motion will aid muscle recovery. Graded movements “pro- the total tension in the muscle increases. (Reprinted with permission from
duces more rapid disappearance of the hematoma and Salter RB. Textbook of Disorders and Injuries of the Musculoskeletal System.
2nd ed. Baltimore, MD: Williams & Wilkins; 1983.)
inflammatory cells; more extensive, rapid, and organized
myofiber regeneration; and more rapid increase in tensile
strength and stiffness.”39 mechanisms that help to avoid a sustained contraction to
Gentle stretching assists with maintaining previous sarco- this degree of failure. Muscle fiber strains will occur, how-
mere numbers.40 Pliability of perimuscular connective tissues ever, when the resisting or passive muscle is overwhelmed
is enhanced along with the same for the fibrous connective just enough to cause mild to moderate muscle tissue injury.
tissue patch. A progression of submaximal isometrics then A strain doesn’t happen only with attempted feats requir-
active movements initiates a restoration of muscle strength. ing incredible strength—or with repeated contractions in a
Minimum loading, such as would be achieved by fatiguing muscle. A strain can occur with the simple task of
normal weightbearing activity, appears necessary tightening a quadriceps muscle while attempting to slowly
for unimpaired muscle fiber repair and/or regenera- control the lowering of the body’s center of gravity so that the
tion and is particularly important to the maturation other foot can reach down 8 inches to a stair.
of newly formed myofibers.41(p1407) Muscles subjected to a single exercise session of repetitive
Resistance exercise will assist with the restoration of eccentric loads for which the muscles have not been trained
strength toward the recovery of functional activities. can experience delayed onset muscle soreness (DOMS).
Symptoms will include muscle discomfort that increases
Strain in the first 24 hours following the exercise session, “peaks
A simplified definition of a muscle strain could be illumi- between 24 and 72 hours, subsides and eventually disappears
nated by a standard stress-strain graph of muscle’s material by 5-7 days postexercise.”43 Range of motion deficits and
properties. But muscle is unique for a material property test alterations in muscle recruitment and sequencing have been
because it can generate its own internal tension by muscle reported. No one theory adequately explains DOMS. The
contraction. Contracting muscle is able to resist the length- cause may be a collection of factors including muscle or peri-
ening force, the stress, applied. A better method of displaying muscular connective tissue damage. Gentle exercise to aid
muscle’s material properties might be to consider the passive the break-up of forming adhesions, remove noxious waste,
elements to strain with the active resistance to strain muscle and trigger an endorphin release has been proposed for treat-
can provide (Figure 10-21). ment. Recommended to avoid DOMS would be a gradual
43
What happens when the resisting and actively contracting introduction of an activity requiring eccentric loading.
muscle becomes the unyielding object that then meets an Muscle tissues injured by strain will improve along the
irresistible force in the form of a stress beyond the muscle’s course described in healing of muscle contusions. There are
ability to resist? A laboratory study that subjected an electri- areas in the body where muscle inserts into a fascial sheet
cally stimulated maintained muscle contraction to a length- of tissue. Strain at these muscle and connective tissue junc-
ening stress to failure showed that the tissue failure occurred tions, such as abdominal muscle layers, may take longer to
initially in the muscle fibers, not the connective tissue heal because of the relative decrease in fascial blood supply
42
layers. Fortunately, functioning muscles have protective compared with muscle.
404 Chapter 10
Stretch Weakness
Each muscle has a defined length that allows the muscle
to generate optimal tension. Generally, this optimal tension-
generating length is near the muscle’s resting length. What
happens in muscles that adapt to a longer resting length
as the result of altered posture combined with the effect of
gravity’s pull? Or in muscles otherwise utilized for sustained
periods of time at a length beyond resting length?
Muscles in a prolonged position of lengthening can be
presumed to adapt with the addition of serial sarcomeres.
The muscle is now longer and its length tension curve has
shifted to the right (Figure 10-22). What happens when this
muscle is now asked to generate force in the position of its
previous resting length? The muscle tests weaker, and is
Figure 10-22. Anatomic muscle length adaptation. Lengthened muscle actually weaker, for activities in this position. The muscle,
develops greater peak tension at longer length. The same muscle in a in its adaptation to the lengthening load, is now weaker
shortened position develops less tension than the control muscle in a
when asked to work in a more anatomically aligned position.
normal position. (Adapted from Phys Ther. 1982;62(12):1799-1808, with
permission of the American Physical Therapy Association. Copyright © This observed phenomena, called muscle stretch weakness,
2001 American Physical Therapy Association.) was described by the Kendalls in their work with post-polio
patients47 and reinforced by researchers since.31
Asking the lengthened muscle to spend more time in a
Tear/Rupture more appropriate anatomical position will require it to con-
As noted previously, muscles have protective mechanisms tract in a less strong and shortened position. Over time, as
to prevent extensive muscle fiber damage from excessive was shown in animal studies, it is theorized that the muscle
loads. Even with these protective organs, however, muscles adjusts to this new length with removal of serial sarcomeres.
can sustain severe strains and tears. The optimal muscle strength is restored at a more anatomi-
cally appropriate resting length and the muscle can now gen-
The descriptors of “partial thickness tear” and “full thick-
erate its optimal tension in the range required for the task.44
ness tear” are more frequently heard to describe tendon inju-
ries but apply to muscle tears as well. The torn muscle fibers There is a metabolic energy requirement when attempt-
will retract. A reparative connective tissue patch heals over ing to maintain optimal postural alignment such as correct
the area. The restoration of the previous optimal muscle ten- shoulder girdle alignment when involved in a sustained
sion will be diminished. This defect in the preinjury muscle arms forward task (driving or keyboarding) or arms forward
morphology may, or may not, affect general functioning of movement task (bell ringing, choir conducting, scrubbing
the involved limb depending on the extent of the tear. walls). Impaired cardiovascular and pulmonary status may
make this adjustment in largely postural and stabilizing
A complete muscle rupture will affect function. The
muscle difficult. Further, a severely deconditioned patient
extent to which function is impaired will be a factor whether
may be challenged to activate and maintain postural muscles
a surgical repair is attempted. In addition, the muscle’s health
for the simple tasks of sitting or standing with erect posture.
and the tear location are factors affecting whether a success-
ful surgical outcome is possible.
Overuse Injuries TENDONS
Muscle overuse injuries occur when the force required
of a muscle might be adequate for the task but not for an
increased duration of the task. Muscle fatigue occurs with Morphology and Physiology
the repetition of the task over a longer duration. The muscle Tendons connect skeletal muscle to bone. They serve as
fatigue can lead to a slight, or not so slight, erosion of opti- the pulleys that transmit the force from contracting muscle
mal joint position. Decreased muscle control due to fatigue to the bone with the intent to move, or stabilize, the bone.
can also lead to inappropriate loading of other structures not Tendons are made of tough, dense connective tissue.
prepared, or designed, for the load. In a simple description, the connective tissue layers sur-
Researchers have identified inadequate hip stabilization rounding muscle fibers, and bundles of muscle fibers, con-
and control of the femur as contributors to altered hip and tinue on past the end of the contractile portion of the muscle
patellofemoral biomechanics.44,45 Decreased strength in and converge at the musculotendinous junction to form the
scapular stabilizing musculature has been linked to shoul- tendon. The actual structure of the musculotendinous junc-
der impingement during simulated work tasks with arms tion, however, shows an overlapping of the tendon tissues
overhead.46 with the myofilaments to spread out the concentration of
tensile forces.48 The tendon, short or long, continues on in
a strap configuration—rounded cord or flattened band—to
anchor onto bone. At the bone insertion site, the tendon can
move through zones of the dense tendon tissue to fibrocar-
tilage then mineralized fibrocartilage to bone.49,50 Or, the
tendon can insert into concentric layers of bones by Sharpey’s
fibers mentioned earlier in the chapter.5,50 Generally, the
structure of the tendon to bone junction minimizes fiber
stress and failure.49
Tendon Response to Loading
In a musculotendinous unit, the tendon needs to with-
stand tensile loads whether the muscle is contracting or
lengthening. While the tensile load may be low when a
muscle undergoes a gentle passive stretch, the load on the
tendon increases dramatically with muscle contraction.
Strain analysis shows that tendon tissue begins to undergo Figure 10-23. The crimped configuration of the collagen fibers and fibrils
microscopic failure at lengths greater than 4% of resting at rest begins to flatten with strains up to 2%. With continued lengthen-
length (Figure 10-23). ing, intramolecular sliding of collagen triple helices allows tendons to
Tendons vary in their ability to transmit loads from the lengthen linearly with the strain. If the increased length remains less than
4%, the tendon will show an elastic property and will return to its start-
contracting muscle to the bony attachment related to the dif- ing length when the load is removed. Strains greater than 4% will lead to
ferences that exist in tendon thickness and collagen content. microscopic failure. Lengthenings greater than 8% to 10% result in mac-
A gradual increase in loading will result in an increased roscopic failure from the damage to fibrils by collagen molecule slippage.
cross sectional area due to an increase in collagen fiber size. (Reprinted with permission from Sharma P, Maffulli N. Tendon injury and
tendinopathy: healing and repair. J Bone Joint Surg Am. 2005;87:187-202.)
Tendon stiffness, thus the ability to resist lengthening strain,
also improves.
As would be predicted by the PST, under-loading of
tendons will have the opposite effect. Cross-sectional area Tendon Disorders
decreases. Collagen fiber size and content declines. Cyclic
load testing will show a hysteresis pattern that reflects soft- Tendonitis
ening of tendon tissue that will reduce its ability to avoid Though the term tendonitis is conventionally used for any
microinjury due to tissue fatigue.51 tendon reactivity, the term is appropriate in limited situa-
tions. A tendon that experiences a low increase in the regu-
Tendon Nutrition and Healing
lar load required of it may experience a discrete episode of
Blood supply to tendons is a somewhat patched network. inflammation that would be appropriately called tendonitis.
The extensive capillary system of the contractile muscle will This might be a single session of repetitive movement or, per-
supply, at best, the third of the tendon close to the myoten- haps, the rubbing of a tendon. With these limited scenarios,
dinous junction. At the other end of the tendon, some blood the inflammatory process would ensue. It might reasonably
supply is available just for the distinct portion of the tendon be assumed that a complaint of decreased function or pain
inserting into the bone. Modest vascularity is available from was due to inflammation of the tendon when the recovery
synovial sheaths and paratendons.49 Regions of hypovascu- of the tendon corresponded to the expected time frame for
larity have been identified in tendons at 1 cm or a range of healing from an inflammatory event, 3 to 7 days. The only
2 to 7 cm from the bone attachment.49 With one source of way to be absolutely certain that the complaint was due to
blood supply at one end, another at the other end, and a third tendonitis would be to analyze the actual tendon tissues and
for the area in between, it may not be surprising that areas identify the increased presence of neutrophils, monocytes,
of tendon hypovascularity have been identified. Tendon and and macrophages that accompany the inflammatory process.
ligaments insertions through a zone of fibrocartilage have an After the inflammatory phase, controlled stretching of
additional challenge to vascularity.50 the tendon will promote increased collagen synthesis and
The metabolism for tendons is an adaptation to the less improve fiber alignment. This aids in the restoration of ten-
than direct or effusive blood supply. It also reflects the pul- don resistance to tensile loading.52
ley function tendons perform. Tenocytes have oxidative and
glycolytic ability. The anaerobic pathways are well developed; Tendinopathy
tendons consume 7.5 less oxygen than skeletal muscle. The The accurate term to describe the more common presen-
advantage of a low metabolic rate—lower oxygen require- tation of a painful and poorly functioning tendon would be
ment—in the tendon means that there is a reduced possibility tendinopathy. Rather than the inflammatory process seen in
of tissue ischemia when the tendon is under sustained loads tendonitis, tendinopathy appears to be a process of tendon
with accompanying poor profusion. The lower metabolic rate degeneration. What are the possible factors that might cause
of tendons unfortunately also means that there is a slower a tendon to begin a degenerative process? The patient may
rate of healing.49 describe a series of events that resulted in repetitive excessive
406 Chapter 10
loading of the tendon. Tendons can also be used in positions The presence of tendon degenerative changes was found
that are less than optimal, leading to uneven loading. in 100% of 74 patients with an Achilles tendon rupture.61
What is known about tendinopathy has come from stud- Degenerative changes were found in 97% of 891 sponta-
ies of tendon ruptures. It has been shown that long before neously ruptured tendons compared with 33% of control
the tendon ruptured, the tissues of the tendon had changed. tendons.62 More degenerative changes are found in tendons
The tendon tissues are observed to have “lost their normal that rupture than those simply painful because of overuse.60
glistening-white appearance and to have become gray-brown These histological studies suggest that significant tissue
and amorphous.”49(p191) The histology of tendinopathic degeneration can precede a tendon rupture.
tissues show an absence of inflammatory cells but the pres- As with muscles, tendons can sustain tears that range
ence of disordered and haphazard healing along with fiber from partial thickness tears, full thickness tears to full ten-
thinning and disorientation. The histology suggests that the don ruptures. The decision whether to repair a tendon tear
tendon may not have had enough time to heal adequately.49 or rupture surgically will be dependent on how much of the
The exact intrinsic cause of tendinopathy is not yet known tendon is torn, where the tear is located within the tendon,
but there are several theories. It is possible that tissue-dam- and the extent to which function would be affected with-
aging oxygen-free radicals are formed in the tendon when a out a surgical repair. Postsurgical management of repaired
muscle relaxes and the tendon is reperfused with oxygenated tendons requires a balance between maintenance of joint
blood after a period of relative hypovascularity during tensile mobility with the need for repaired tendons to progress well
loading. This oxidative stress theory appears supported by through the repair stage of healing before any significant
the increased concentration of antioxidant enzymes found in tensile loads are applied.
examined tendinopathic tendons.53 Oxidative stress has also With either a partial thickness tear left to heal with some
been linked with an increased presence of spontaneous cell acceptance of a diminished pulley force or with a surgical
death in tendinopathic tendons.54 Hypoxia and localized cell repair, both are dependent on the adequate perfusion of
hyperthermia have also been proposed as explanations for tissues and delivery of nutrients. Healing occurs from cell
degeneration. An increase in prostaglandins with cyclic load proliferation by local tenocytes within the tendon. For ten-
is another avenue of investigation.55 dons within a synovial sheath, fibroblasts from the sheath
Initially, tendinopathy might not be painful. Patients can and synovium can take over. Better tendon healing and
also make unconscious adjustments in how activities are per- more normal gliding results from the former, for tendons in
formed to avoid any symptoms. For some patients, the first a synovial sheath, while disruption of gliding can occur with
indication that degenerative tissue changes have occurred in the latter. Tendon-dependent variations in these healing pat-
a tendon may be when the tendon finally ruptures. With this terns exist.49
possibility of not identifying the tendinopathy until after Strategic mechanical loading during the maturation/
the fact, patients with pain and decreased function who are remodeling phase of healing in animal studies is credited
referred to physical therapy with suspected tendinopathy are with improving “the tensile strength, elastic stiffness, weight
fortunate. What is the best method to treat tendinopathy? and cross-sectional area of tendons…by an increase in col-
Curwin and Stanish described an eccentric exercise pro- lagen extracellular matrix synthesis by tenocytes.”49(p191)
tocol to address tendinopathy.56 Once the contributing fac- Postoperative protocols with early introduction of controlled
tors are addressed, an exercise is identified that produces movements have been shown to be beneficial.63-66
an eccentric load to the ailing tendon.48 The amount of
load needs to be gauged so the patient can complete 3 sets
of 10 repetitions. The goal is to have manageable symptoms BONE
reported during the performance of the third set but not
during the first 2 sets. When mild symptoms are no longer
reported during the third set, then the load in the exercise Morphology and Physiology
needs to increase.57 This symptom-to-load criteria leads to a The calcified extracellular matrix of bone tissue makes
tendon load that is adequate to ensure a gradually improved it uniquely suited to provide the skeletal framework for the
tendon status with performance of functional tasks in 6 to body. In this role, however, skeletal bone needs to find a
8 weeks.48 This approach has had successful outcomes in the balance between the competing needs of the adequate rigid-
treatment of Achilles and patellar tendinopathy as well as ity required to withstand loading and the lightness to aid
with lateral epicondylitis in the forearm.48,56,58 Success with energy-efficient movement. Bone finds the balance through
a similar eccentric protocol has been reported.59 the integration of 2 bone types.
Tear/Rupture In osteogenesis, small spicules of bone called trabeculae
Though tendons are designed to withstand high ten- connect to form a somewhat porous network of bone called
sile loads, a tendon can rupture. A greater risk for rupture cancellous bone. As the trabeculae continue appositional
occurs with a quickly, or unevenly, applied load.49 And, as growth, a less porous and denser bone develops called corti-
mentioned earlier, it is believed that tendon ruptures can be cal bone (Figure 10-24). Though the bones of the skeleton do
precipitated by undetected degenerative tendinopathy.60 begin with a genetic blueprint,67 bone physiology attempts to
Figure 10-25. An image of trabecular bone structure in the proxi-

Figure 10-24. Key stages in the process of conversion of cancellous bone mal femur scanned on a GE Nanotom5 system (NanoCT System).
to compact bone (developing skull). (A) Soft tissue spaces fill in with (Reprinted with permission from Dr. Karl Jepsen and Erin Bigelow,
concentric lamellae that accumulate and become a Haversian system. (B) Orthopaedic Research Laboratories, University of Michigan.)
Developing cranial bone (stage 1 in A). (C) Growing cranial bone (stage 3
in A). (Adapted from Cormack DH. Introduction to Histology. Philadelphia,
PA: J.B. Lippincott Co; 1984.)
the widening curve needed in cranial bones to accommodate
brain growth. In this situation, osteoclasts work on one side
keep the skeleton light by creating the compact cortical bone of the bone to remove the narrow curve while osteoblasts
only where required. work on the other side to widen the curve.
Cortical layers at bone ends and the perimeter of long
bones resist torsion and bending forces. The porous but Bone Responses to Loading
resilient scaffolding of cancellous bone can shock-absorb to Bone needs to adapt to a variety of loads placed on it.
accommodate compressive loading.68 The architecture of the Musculotendinous attachments place a traction stress during
trabeculae in cancellous bone offers an observable blueprint muscle contraction, weightbearing activities cause compres-
of loading stress (Figure 10-25). Further, the extensive vas- sion stress, and weightbearing with direction changes can
cularity in the regions of cancellous bone assists the body’s create compression combined with torsional stress, to name a
use of skeletal bone as a mineral repository. The calcium, few. The bone’s adaptation is also a form of bone remodeling
phosphorus, sodium, and magnesium stored in bone can be but one that accommodates a changing mechanical stress.
withdrawn to maintain extracellular fluid concentrations for The adaptation can reflect the magnitude and as well as the
nerve conduction and muscle contraction.68 direction of the mechanical load.
Even with the excellent network of canaliculi and the Bone may be the musculoskeletal tissue that has received
proximity of blood vessels around which the Haversian the greatest research scrutiny over the longest period of time.
systems form, the extracellular matrix of bone can weaken Long before the PST was proposed, biomechanical research
over time.5 Bone remodeling is the process by which bone on bone was based on the understanding from Wolff’s Law
maintains itself by removing weakening sections of matrix that bone grows according to the stresses and strains placed
and replacing it with new bone. Within the structure of the on it. Numerous animal experimental models have been pur-
Haversian system, osteoclasts will absorb layers of bone and sued to define bone’s mechanical properties. To summarize
osteoblasts will rebuild new bone. In this mode of remodel- the commonalities found from these animal research mod-
ing, both cell types work nearby on the same layer of bone, els, as well as state concepts of bone adaptation that could
leaving behind only a cement line marking the outer wall of be expressed in mathematical terms, Turner67 proposed the
the replaced bone layer. Bone remodeling can also take the following 3 rules for bone adaptation to mechanical loads:
form of reshaping bones to accommodate growth as with
408 Chapter 10
the initial induced electronic potential will fade. But if the
load is lifted and repeated, and lifted and repeated again and
again, as in dynamic loading, then the electronic potential
will be induced with each repeated loading. The generation
of piezoelectric signals that then travel along the network of
canaliculi is believed to be a factor in the stimulation of bone
formation. The absence of loading signals may favor bone
absorption over formation as noted in the deconditioning
effects on bone with immobilization and bed rest surveyed
in Chapter 4.
Second, once a sufficient level of loading occurs in either
magnitude or frequency, or both, bone is stimulated to adapt.
The second rule suggests that past a certain point more load-
ing or exercise within a period of time does not lead to more
bone formation.67 The notion that more may not be better in
terms of duration or within a period of time is consistent with
the PST. Even an initially tolerable load can pass a point of
tolerance if continued for too long a duration. An increased
but tolerable load that is repeated within an insufficient time
to for the tissue to adapt may lead to injury.19 Insufficient
time for bone to adapt to an increased load will be explored
again in the section on stress fractures later in the chapter.
As with other body tissues, once bone tissue adapts to a
routine level of loading no further adaptation is stimulated.
Figure 10-26. Stress distribution in a femoral neck subjected to bend- This isn’t to suggest that bone remodeling isn’t continuing
ing. When the gluteus medius muscle is relaxed (top), tensile stress because it does. Even without a change in the load the bone
acts on the superior cortex and compressive stress acts on the inferior
cortex. Contraction of this muscle (bottom) neutralizes the tensile stress.
remodeling process that replaces areas of declining matrix
(Adapted from Frankel VH, Nordin M. Biomechanics of bone. In: Nordin M, continues. In terms of an unchanging routine load, however,
Frankel VH, eds. Basic Biomechanics of the Musculoskeletal System. 3rd ed. an equilibrium in the bone can be reached. Increasing bone
Philadelphia, PA: Lippincott Williams & Wilkins; 2001.) formation requires the unusual load event to occur.
The amount and orientation of collagen fibers within
bone will adapt to the mechanical loading environment. The
1. Bone adaptation is driven by dynamic, rather than static, area between concentric rings in an osteon (aka Haversian
loading. system) will contain collagen fibers. The space between the
2. Only a short duration of mechanical loading is necessary layers of bone in cancellous bone allows a greater the area for
to initiate an adaptive response. Extending the load- collagen fibers than in compact bone (see Figure 10-24). The
ing duration has a diminishing effect on further bone orientation of fibers can assist the resistance to mechanical
adaptation. loads.69 Even within a single bone the orientation of fibers
3. Bone cells accommodate to a customary mechanical can adjust to the loading forces. Strain gauge data in equine
loading environment, making them less responsive to radius were compared to the collagen fiber orientation. Fibers
routine loading signals. were oriented obliquely in areas of compression located in the
distal segment, and longitudinally in areas of tensile loading
The application of these rules to patient situations does
found in the proximal.69-71
require a bit of extrapolation, but the rules are still useful.
In humans the loading forces can vary with the same bone
First, there are probably no patient situations that would
also. In the proximal femur during weightbearing activities,
correspond to the static loading of bone used in animal
the superior aspect of the femoral neck undergoes tension
research models—with the possible exception of spinal
loading while the underside, the inferior aspect, compres-
cord-injured patients weightbearing in a standing table. In
sion (Figure 10-26). In adult humans the tension side of bone
patients without paralysis, however, even static standing
undergoes the greater stress because adult bone is less resil-
is actually a dynamic process. Maintaining static standing
ient to tensile loading. Fortunately, contracting muscle can
balance is a control of the normal occurrence of side-to-side
counter the tensile stress placed on bone. In the example of
and forward-to-back perturbations. Each slight shift in body
the proximal femur, a stabilizing contraction of the gluteus
position reloads bone and meets the definition described in
medius reduces the tensile loading on the superior aspect of
Turner’s rules of dynamic loading.
the femoral neck.72
With the initial loading of bone, it is believed that an
Bone needs to keep a balance between having adequate
electronic potential, a piezoelectric signal, is induced. If the
stiffness to resist loading forces but with an accommodating
load doesn’t change, and in other word remains a static load,
resilience to those same forces. In other words, bone needs to
Figure 10-27. Blood supply of an adult long bone (tibia).
(Adapted from Cormack DH. Introduction to Histology.
Philadelphia, PA: J.B. Lippincott Co; 1984.)
give a little. In certain circumstances bone shows an amazing bone will continue to have a blood supply even if the supply
ability to accommodate a distraction force. from a main artery is disrupted. The superficial periosteum
Strategic application of traction on a growing jaw is a is supplied by periosteal arteries. “The metaphyseal arteries
standard procedure in successful orthodontia. Gymnasts are former periosteal arteries that became incorporated into
who accentuate lumbar hyperextension during major bone bone tissue” when the bone ends widened (Figure 10-27).5
growth years have an unintended lengthening of poste- Incorporated periosteal vessels in Haversian systems,
rior vertebral structures leading to spondylolisthesis.73,74 now Haversian vessels, run longitudinally through bone and
Orthopedists are able to induce distraction osteogenesis are supplied by the main arteries via blood vessels running
by scoring through the periosteum and cortex of bone and through obliquely angled canals in bone called Volkmann
gradually lengthening the fracture callus.75-78 canals (Figure 10-28). Osteocytes within lacunae, and work-
ing osteoblasts and osteoclasts, receive oxygen and nutrients
Nutrition and Healing
from the Haversian vessels via the tissue fluid running
Bone is not as challenged as other connective tissues for through the interconnecting canaliculi.
nutrition. Integral to its structure is the incorporation of a Bone may patch defects with woven bone in the regenera-
rich blood supply. Bones are vascularized by a main nutrient tive phase of healing. This is a mineralized bone that has a
artery and by metaphyseal and epiphyseal arteries at bone less organized pattern. It has less mechanical strength than
ends. The terminal branches of all 3 artery types will create the more organized bone that replaces it in the remodeling
an anastomosing network. This ensures that most parts of phase.
410 Chapter 10
Figure 10-28. A longitudinal and transverse section
through secondary Haversian bone. Note the orienta-
tion of the vascular channels (Haversian and Volkmann’s
canals) relative to the secondary osteons. Cement lines
demarcate the boundary of each secondary osteon.
(Adapted from Loitz-Ramage BJ, Zernicki RF. Bone biol-
ogy and mechanics. In: Magee DJ, Zachazewski JE, Quillen
WS, eds. Scientific Foundations and Principles of Practice
in Musculoskeletal Rehabilitation. St. Louis, MO: Saunders
Elsevier Inc; 2007.)
Bone Disorders (Nonsystemic) into pieces and cause extensive damage to the soft tissues in
the region of the fracture.72
Fractures Bone fractures can be classified by descriptions of the
fracture line, location within the bone, and whether the frac-
Fractures happen. Even the strongest of bone can be ture was open or closed to name a few. More highly specified
placed in a challenging situation where the forces being fracture patterns observed for distinct bone segments have
absorbed exceed the bone’s ability to resist. From a high- been described in more elaborate classification systems.79-81
velocity, high impact of a knee into a car dashboard during Fracture classification schemes aid in communication about
a motor vehicle accident to a more slowly evolving fall to the the fracture as well as facilitate comparison of interventions
floor onto an outstretch hand, fractures occur. and outcomes.
In adult long bones a fracture generally begins on the ten- Bone fracture healing follows the general shared pattern
sion side rather than the compression side. Younger bones for the 4 basic tissues with a few key differences. The major
may have greater ability to withstand tension but less com- task the fracture bone needs to accomplish is to span the
pression.72 But what really happens to bone tissue when it fracture gap, ultimately with bone.
fractures?
The immediate ends of fractured bone suffer a disruption
Under tension forces, the bone segment lengthens and in blood supply and die. Once inflammation develops, the
then fails when osteons separate at the cement lines.72 With processes begin to span the gap. Trabecular bone just past
compression loads, the bone fails because of “oblique crack- the dead bone begins to send columns of bone along the
ing of the osteons.”72 medullary canal across the gap. From the rich vascularity of
The speed with which the load is applied to the bone is the endosteum of the medullary canal on the inner surface
a factor in the type of fracture and the extent to which the of bone and the periosteum on the outer surface of bone,
surrounding soft tissues are injured. A misstep that leads osteoprogenitor cells arrive and proliferate. In the region
to a fall but allows the person enough time to reach for sup- behind the fracture with vascularity, the osteoprogenitor
port slows the fall. The slower speed of loading creates an cells differentiate to osteoblasts. On the superficial outer
outcome different from one from a motor vehicle accident. region where vascularity is lower, chondroblasts are formed.
In the former, the lower loading speed allows some of the A chondral sleeve forms around the fracture area and offers
energy building in the bone while under load to dissipate modest structural support. The osteoblasts aid the efforts
through the initial crack created in the bone. The more of the trabecular bone on the inner and outer surfaces of
slowly loaded bone to failure will have bone ends with little fractured bone as well as assist with the remodeling of the
displacement and little soft tissue damage. In the latter sce- chondral sleeve (Figure 10-29).5
nario—the motor vehicle accident—the quick loading allows Through endochondral ossification, the chondral sleeve
greater energy to build up in the bone under load that is then is replaced with cancellous bone. Remodeling continues
released abruptly when the bone fails. The bone may break until the thickening of the cancellous bone creates cortical
bone around the bone’s perimeter. In an example of tissue
regeneration, a healed bone segment previously fractured
generally becomes indistinguishable from the bone tissue
adjacent to it.
Effective fracture healing requires stabilization in the
early stages of tissue rebuilding to span the fracture gap.
If the initial efforts of trabecular bone to span the gap or
if the process of angiogenesis to revascularize the area are
disrupted by excessive movement or delayed by poor nutri-
tion or cardiovascular pulmonary status, then the avascular
chondral sleeve may begin to dominate.
The chondral sleeve formation in the regions of relatively
decreased vascularity may extend deep into the fracture area
and across the gap. If continued disruption occurs, the carti-
lage may mature over the bone ends rather than serving as a
scaffolding for ossification.
External fixation and surgical internal fixation have been
utilized by orthopedists to ensure fracture fixation.82 In
an effect to allow modest load sharing to enhance woven Figure 10-29. Healing fracture of a rib (later stage). Cancellous bone
bone callus formation, however, a shift toward less rigid is indicated in black; cartilage is shown lightly stippled. Arrowheads
fixation has been proposed.83 This might take the form of an indicate direction of trabecular growth in internal and external callus.
(Adapted from Cormack DH. Introduction to Histology. Philadelphia, PA:
unlocked intramedullary nail. J.B. Lippincott Co; 1984.)
In addition, efforts have been made to keep much of the
overlying soft tissue intact, which augments the blood supply
for the periosteum (see Figure 10-27). specific for an imminent stress fracture. A fracture may be
During the remodeling/maturation stage, intermittent detected on magnetic resonance imaging (MRI) sooner than
bone loading may be introduced to enhance bone healing. will show up on radiographs.69
The rationale is explained in the 3 rules for bone growth Most studies tracked participants who had engaged in
discussed earlier. Intermittent bone loading has been shown weightbearing activities of running, jumping or dancing.
to be beneficial in animal models.84,85 Those subjects with initially lower fitness levels were more
Stress Fractures vulnerable to stress fractures. Though not directly applicable
to the sudden initiation of weightbearing with a walking
Bone stimulated by an abrupt increase in physical activity program for a deconditioned patient, a few observations from
or the initiation of a new activity will undergo remodeling these studies are worth noting.
to meet the new demand. In the initiation of the remodel- The tibia accounted for 41% to 55% of stress fractures. For
ing process, bone can become caught in the situation where the same level of activity, women sustained stress fractures
the osteoclastic resorption of bone outstrips the osteoclastic at a rate 2 to 10 times higher than men. Older participants
formation of new bone. This results in a weakened bone that or white participants had higher rates of fractures. High
is vulnerable to injury, which describes the bone pathophysi- arches, greater varus and valgus angulation at the knee, or leg
ology that can lead to a stress fracture.86 New terms would length differences were each significant risk factors.86 These
describe the remodeling imbalance noted previously as the observations suggest that patients beginning new repetitive
“stress reaction” with the “stress fracture” as the resultant weightbearing activities should be started gradually and with
structural failure of bone.69 Though more stress fractures supportive shoes to reduce foot and lower extremity align-
have been reported in lower extremities, most bones of the ment variations.
extremities have had reported stress fractures as well as ribs
and the spine.86 Skeletal Alignment
The bone pathophysiology can manifest as pain with Altered skeletal alignment can affect a person’s ability to
activity that is relieved with rest. Tenderness to palpation move efficiently. The energy expenditure required for move-
over the bone is noted. A history of a recently started new ment may increase in cases of severe malalignment. Increased
activity or activity increase accompanies the complaint. muscle control needed to optimize efficient movements may
Prevention of a stress reaction from leading to a stress frac- lead to muscle fatigue sooner than expected in routine activi-
ture is challenged by the difficulty to confirm the diagnosis ties. The potential for development of muscle imbalances
with an effective time period. may increase. The PST notes that movement and alignment
Radiographs can show bone changes of early lucent zones are factors in the level of physical stress experienced by
but generally the complaint occurs before radiographic bone tissues.19 For a patient with any cardiovascular or pulmo-
changes are detected.86 Bone scans are very sensitive to areas nary compromises, alignment-impaired movement offers yet
of increased bone activity. Increased activity, however, is not another stressor to optimum performance. What may seem
412 Chapter 10
an inconsequential alignment variation for a patient during signs are negative. It is not normal for one of these curves to
a critical event requiring hospitalization may need to be con- progress radically after skeletal maturity.
sidered as the patient works to recover function. Assertions by Kendall et al91 decades ago for prescriptive
Spinal exercises to address scoliosis and recent advocacy for other
exercise interventions have not yet proven the case for exer-
In normal development of the spine, balanced curves form
cise as a sole intervention. Bracing for moderate curves and
in the cervical, thoracic, and lumbar spines as viewed from
surgical correction for fast progressing curves are the current
the side. Viewed from behind, the spine should be straight
interventions standards.87,92
and in midline from the base of the skull to the sacral base. In
forward bending, the right and left contours of the thorax— The extent of the curve at spinal maturity will predict the
the rib cage—will be symmetrical. Spinal alignment may be curve progression.
altered by degenerative tissue, paralysis, congenital disorders Curves less than 30 degrees at bone maturity are
or trauma.87 unlikely to progress, whereas curves measuring
Kyphosis from 30 degrees to 50 degrees progress an average of
Kyphosis is the exaggeration of the curve in the tho- 10 to 15 degrees over a lifetime. Curves greater than
racic spine. Postural kyphosis may be observed in a patient 50 degrees at maturity progress steadily at a rate of
challenged to stand erect against gravity. The weakness in 1 degree per year. In most patients, life-threatening
postural muscles is an aftereffect of prolonged bed rest or effects on pulmonary function do not occur until
deconditioning. Restoration of adequate postural strength the scoliotic curve is 100 degrees or greater.93
will reduce a postural kyphosis and related potential for In the adult, altered alignment of the scapula “high” on
ventilatory pump compromise. Even in able-bodied subjects, an upper thoracic curve means the stabilizing musculature
standing with increased trunk flexion, measured at 25 and is at a biomechanical disadvantage. Generally, when there is
50 degrees from the vertical, increased metabolic energy a postural fault of a downwardly rotated scapula, scapular
expenditure from that required in erect standing.88 stabilizers are weaker.46 When this altered position occurs
Though a less flexed trunk posture may be more energy along with underlying altered spinal alignment, the scapula
efficient, it may not be possible when the kyphosis reflects does not have the option of becoming correctly aligned. A
structural changes in the spinal segments of the thoracic scapular position can be improved with strengthening of
spine. Structural kyphosis may be present due to “degen- scapular stabilizers but may always have a “built-in” disad-
erative diseases (such as arthritis), developmental problems vantage due to the variation in position atop the spinal curve
(the most common example being Scheuermann’s disease), and rotated ribs.
osteoporosis with compression fractures of the vertebrae, Extremity
and/or trauma.”89
Valgus/Varus
Scoliosis
In the lower extremities, varus and valgus angulation at
Scoliosis is a lateral curvature of the spine in one direction the knee can appear mild while the patient is in a stance posi-
accompanied by rotation in the opposite direction. To clarify, tion. In the single-leg stance position or in walking, however,
a spine will side bend to the left if the left side height of the an increased varus angulation can appear because of degen-
vertebral body, or bodies at several spinal levels, is less than erative changes in the medial compartment of the knee. The
that of the right. The involved vertebral segments will rotate same could occur for increased valgus with lateral compart-
right. The right rib cage, if the curve is located in the thoracic ments involved. Inadequate hip stabilization strength may
spine, will show a rib projection (a rib hump) posteriorly dur- also manifest as increased knee valgus due to the femur’s
ing forward bending. Ribs on the left project anteriorly and tendency to medially rotate with the decreased control. This
may crowd together depending on the severity of the curve. situation is further challenged by increased hip antever-
A congenitally malformed vertebral level or multiple sion and/or ankle valgus/foot varum. Increased knee valgus
levels can be diagnosed in infancy, especially when the child angulation in military recruits had a strong correlation with
begins to move against gravity. The most common form of increased stress fracture rates during basic training.86
scoliosis, however, appears during adolescent bone growth No studies were identified with measures of the energy
and is termed “idiopathic” because no single cause has been expenditure of gait in subjects with increased varus or val-
identified. Evidence links adolescent idiopathic scoliosis with gus angulation at the knee, ankle or foot. Less than optimal
a genetic sex-linked trait that does not appear every gen- alignment of the lower extremity, which may lead to less
eration or is expressed variably.87 Calcium transport deficits, stability of the foot at propulsion, can be analogous to the
variations in platelet morphology and physiology, and altered additional effort required to walk in loose sand. Improving
special orientation have each been correlated with idiopathic the lower extremity biomechanics might require improving
scoliosis.90 muscle strength at the hip. An intervention could also be
With idiopathic scoliosis, 90% of the curves are right as simple as having the patient wear supportive shoes with
rotated. When a left-rotated curve is first diagnosed, it can weightbearing tasks such as standing transfers at bedside or
prompt radiograph and MRI studies to rule out other pathol- walking in hospital corridors.
ogy. Idiopathic scoliosis curves are not painful. Neurological
Figure 10-30. Cross section of a knee joint as an
example of a synovial joint. (Adapted from Cormack
DH: Introduction to Histology. Philadelphia, PA: J.B.
Lippincott Co; 1984.)
near the knee joint. Articular cartilage covers the bone ends
JOINTS along the complete length of the articulating surfaces. A
fibrous joint capsule completely surrounds and encases the
Joint Morphology and Physiology articulating bone ends. The capsule is lined with a special-
ized connective tissue membrane, the synovium. Ligaments
In the skeleton, joints hold articulating bone ends together are reinforcing thickened bands of the fibrous joint capsule
and allow varying amounts of movement. Joints can be or may appear separately within the joint.
classified by the degree of movement permitted, as in the
following: Joint Capsule
• Synarthrosis (little or no movement) The joint capsule consists of dense ordinary connective
tissue (see Table 10-1). The multidirectional arrangement of
• Amphiarthrosis (slight mobility)
fibers helps the capsule withstand the equally multidirec-
• Diarthrosis (variety of movements) tional stresses that occur with functional movements. The
They may also be classified by the structure of how the presence of elastin-like fibers in the joint capsule aids the
joint is held together—fibrous, cartilaginous or synovial. capsule’s need to stretch and accommodate the full ampli-
Most joints of the human adult musculoskeletal system are tude of joint movement. Further, the ability of the joint cap-
diarthrodial synovial joints.22 sule to expand also allows for “enlargement of the joint space
A synovial joint can be viewed as a functioning unit of in the effused joint.”94
components derived from nearly all the possible variations of The thickness of the joint capsule varies from the thick
connective tissue. A cross section of a representative synovial dense capsule of the knee to the thinner capsule of the gleno-
joint, the knee, allows identification of the essential compo- humeral joint, at the shoulder, with redundant folds.94 The
nents (Figure 10-30). fibers of the capsule continue in a cross-hatched or random
The bones at the distal femur and at the proximal tibia pattern as the fibers blend with the fibrous periosteum of
are constructed of mostly cancellous bone with cortical bone the articulating bones. Joint capsules are well innervated.50
just along the bone ends and the perimeters. The trabecular Myelinated and unmyelinated fibers connect with pressure-
architecture of the femur and the tibia will mirror the pattern sensitive mechanoreceptors in the form of free nerve endings
of compression, tensile, and torsion loading of these bones and pacinian corpuscles.5
414 Chapter 10
arthrokinematics. Ligaments separate from the joint cap-
sule, such as the anterior and posterior cruciates, also check
unwanted movements of the joint. They also play a role to
guide the desired arthrokinematic movements required for
knee osteokinematic movements.
The role of ligaments to provide joint stabilization is
reflected in the stronger structure for ligament insertion into
bone. As with tendons, ligaments can have direct or indi-
rect insertions into bone. The insertion type varies between
ligaments and can also vary between the proximal and distal
attachments in the same ligament.50
The fibers of the superficial layer in direct insertions will
become continuous with the fibers of the periosteum. Over
the span of 1 mm, the deep fibers transition through 4 zones.
The first zone consists of the ligament, or tendon, fibers. In
the second zone, the fibers become continuous with those
in a fibrocartilaginous layer. The third zone is mineralized
fibrocartilage where minerals appear between the collagen
fibrils. Even though chondrocytes in this zone are sur-
rounded by mineralized matrix, the lacunae are intact, which
Figure 10-31. Ligaments of the knee. (Adapted from Johnson MW. allows continuous activity by the chondrocytes.50 The fourth
Acute knee effusions: a systemic approach to diagnosis. Am Fam zone is bone where the fibers from the ligament become the
Physician. 2000;61(8):2391-2400.) collagen fibers between bone layers. The distinct tissue line
that marks the nonmineralized layer from the mineralized,
the tidemark, is located between the second and the third
Ligaments zones.50
Within the multidirectional fiber architecture of the joint Indirect insertions have a larger superficial layer that runs
capsule there are areas of more dense fibers aligned in a more parallel with, and blends into, the fibers of the periosteum.
parallel pattern. These cord-like thickenings within the joint The deeper fibers, Sharpey’s fibers, insert obliquely into bone
capsule are the joint ligaments. Other ligamentous straps of without a transition layer. There is still a tidemark between
dense regular connective tissue can exist outside of the cap- nonmineralized and mineralized tissue.
sule but are also considered joint ligaments. Ligaments are innervated with mechanoreceptive afferent
In a simplified view of their function, ligaments connect nerve endings to detect tensile forces and pressure. There are
bone to bone. The medial and lateral collateral ligaments also ligamentous equivalent of Golgi tendon-like organs to
in the knee are examples of ligaments that exist within the detect when a ligament is approaching its length limit during
structure of the joint capsule. Others, such as the anterior tensile loading.96
and posterior cruciate ligaments of the knee, do truly con-
Synovium
nect from one bone to another across the joint space without
being a part of the joint capsule (Figure 10-31). Ligaments can The joint capsule is lined with a richly vascularized layer
be named “by their points of bone attachment (coracoacro- of connective tissue, the synovial membrane. The synovium
mial), their shape (deltoid), their gross functions (capsular), is not strictly continuous and has different consistencies
their relationships to a joint (collateral) or their relationships depending on the location in the joint cavity.5,97
to each other (cruciates).”95 This generally soft tissue has an outer layer, the intima,
Ligaments provide stability to the joint by serving as that faces the joint cavity. The intima lies on top of the under-
checks against unwanted directions of movements and, thus, lying supporting layer of fibrous, alveolar or adipose tissue.
reinforce the intended planes of movement. The medial and Irregular dense fibrous tissue covers tendons, ligaments, and
lateral collateral ligaments of the knee limit the varus and other areas subject to pressure. Loose connective tissue, alve-
valgus movements of the tibia on the femur in open chain olar, lies in regions of the joint cavity that have synovial folds
movements and the femur on the tibia in closed. The collater- and villi. The areas of the synovium with alveolar tissue have
als do not limit flexion and extension except at extreme end some ability to move independent of the fibrous capsule.5
ranges for the knee. Intra-articular fat pads are covered with synovial adipose
Movements that can be described, and measured, by tissue. These tissues of the supporting layer then merge with
the joint angles created when 2 bones move in a joint such those of the fibrous capsule.
as flexion and extension are termed osteokinematic move- The fluid secreted by the synovium provides lubrication
ments. Another type of movement describes the movements for joint surfaces and a method of transport for nutrients
of the joint surfaces to one another within the joint. These to the articular cartilage. The cells of the synovium, the
are rocking, sliding, and rotation movements and are termed synoviocytes, secrete the additional hyaluronic acid and
glycoproteins that give the synovial fluid its excellent friction the deeper layers. The aggregates of proteoglycans help to
reducing quality. The highly viscous fluid fills the joint cav- prevent displacement of proteoglycans during tissue defor-
ity. Usually the joint cavity has a narrow intra-articular space mation with loading.98
and only a thin film of synovial fluid is required between It is tempting to believe that the differences in
articulating surfaces. matrix composition and organization among zones
The generally loose arrangement of tissues allows the reflect differences in mechanical function. That is,
fluid of the joint cavity to infiltrate into the deeper layers of the superficial zone may primarily resist shearing
the synovium. As well, the nutrients and fluids delivered by forces, the transitional zone may allow the change
capillaries within the supportive layer are able to disperse in orientation of collagen fibrils from the superficial
through the interstitial spaces in the loose tissues and move zone to the radial zone, and the radial zone may
into the joint cavity. primarily help to resist and distribute compressive
Innervation of the synovium appears to be with slowly loads. The zone of calcified cartilage would then
conducting fibers without specialized endings. This means provide a transition in material properties between
that the synovial membrane may be able to transmit only hyaline (articular) cartilage and bone, as well as
diffuse sensation that may be interpreted, in turn, as dif- anchor the hyaline cartilage to the bone.99(p419)
fuse pain in situations of increased pressure or nociceptive In addition to the belief that the properties of the chondro-
chemicals. cytes and the content of the surrounding matrix are different
Articular Cartilage for each layer, it is believed that it is also important to con-
Articular cartilage covers the surfaces of articulating bone sider the properties of the matrix relative to its proximity to
ends in synovial joints. Anyone who has ever cut up a whole chondrocytes within layers. So within each layer the matrix
roasted chicken has observed the pearlized smooth cover- regions have been identified. Pericellular matrix surrounds a
ings on the surfaces of bone ends that appear after cutting chondrocyte. A wider layer around a single chondrocyte or
through the thick and tough fibrous capsule. This pristine small clusters of 2 to 3 chondrocytes is the territorial matrix.
white coating on articulating bone ends is the articular Fibers here form a fibrillar basket around chondrocytes that
cartilage. The smoothness of the articular cartilage surface, may provide protection from mechanical loads. The remain-
along with a thin film of synovial fluid, aids the ease of joint ing matrix, the interterritorial matrix, is the largest matrix
movements. region within zones. Fiber alignment in the interterritorial
zone is consistent with that of the chondrocyte alignment:
The chondrocytes in articular cartilage are arranged in
parallel at the superficial layer and perpendicular to the joint
4 layers. These layers appear between a most superficial layer,
surface at the redial zone.99
the lamina splendens, and the underlying subchondral bone.
The lamina splendens, so named for its bright appearance in So though articular cartilage could be summed up as
phase-contrast studies, is a clear film layer of fine fibrils with “aneural, largely avascular and acellular,”94 it is also a
chondrocytes. It is believed that the lamina splendens can be uniquely complex tissue with amazing ability to resist
sheared off with joint trauma. mechanical loads.
The 4 zones begin with the tangential zone. Here the Joint Response to Loading
chondrocytes are flattened and, along with the collagen Joint capsules are designed to accommodate multidirec-
fibers in the zone, are arranged parallel with the subchondral tional stresses. The configuration of the fibers of the capsule
bone. Collagen fibers and proteoglycans have a stronger asso- insertion to bone, however, is consistent with a relatively low
ciation than usual in this zone, which may aid in resisting need to withstand tensile loading. This is no doubt because
shearing forces.50 of the greater load being borne by the stronger arrangement
The chondrocytes in the next zone, the transitional zone, of fibers in the reinforcing ligaments within the capsule. As
are a full rounded shape and are dispersed, along with col- presented earlier, the fiber-bone insertion structure for liga-
lagen fibers, throughout this large volume layer. In the next ments also reflects this. Ligaments, therefore, were designed
layer, the radial zone, the chondrocytes stay rounded but are to withstand tensile loads.
larger and tend to align themselves in vertical columns 4 to Ligaments, and tendons, show characteristics of a visco-
8 cells high. The fourth layer, the calcified layer, the chondro- elastic substance with the ability to have an initial reaction
cytes are surrounded by mineralized matrix. to a load but then gradually accommodate to the load over
As the zones move from superficial to deep, the density of time. The extent to which ligaments can withstand tensile
chondrocytes will decrease. The reverse occurs with regard loads, and under varying circumstances, has been widely
to collagen fiber size showing greater fiber thickness as fibers studied.18,100-102 We owe a lot of our current understanding
move deeper in the zones. The proteoglycan concentration of ligament properties under loading to these early studies.
also increases. The aggregates of proteoglycans are com- And, we need to extrapolate from these studies what needs to
pressed and held somewhat contained by the surrounding be considered for interventions moving forward because it is
collagen fibers. The water-holding capacity of proteoglycans not likely that any of these studies will be repeated.
enhances the articular cartilage’s ability to resist compres- A summary of what has been learned about ligaments and
sion even though the overall water content has decreased in exercise is depicted in Figure 10-32. Ligaments exposed to
416 Chapter 10
Figure 10-32. Summary of the homeostasis responses of the compo-

nents of the bone-ligament-bone complex when subjected to different Figure 10-33. Typical tensile stress-strain curve for connective tissues
levels of physical activity. (Reprinted with permission from Woo SLY, and articular cartilage. The drawings at the right of the curve show
Maynard J, Butler D, et al. Ligament, tendon and joint capsule inser- the configuration of the collagen fibrils at various stages of loading
tions to bone. In: Woo SL-Y, Buckwalter JA, eds. Injury and Repair of and stretch. (Reprinted with permission from Mow V, Rosenwasser M.
the Musculoskeletal Soft Tissues. Rosemont, IL: American Academy of Articular cartilage biomechanics. In: Woo SL-Y, Buckwalter JA, eds. Injury
Orthopaedic Surgeons; 1988.) and Repair of the Musculoskeletal Soft Tissues. Rosemont, IL: American
Academy of Orthopaedic Surgeons; 1988.)
gradual increases in exercise show increased structure—size

and weight—and mechanical load when evaluated in load to occurs with a low coefficient of friction (COF) that is even
failure testing. Immobilization on the other hand results in lower than a skate gliding on ice.94 “The lower the COF, the
greater than 50% loss within weeks when the same load to lower the resistance to sliding…[M]ore force is needed to
failure property is assessed. Recovery from the structural and produce motion when the COF is high.”94 And similar to
mechanical property losses has been seen to occur in the lig- pressure of the skate blade on ice creating a fluid layer just in
ament structure to near control levels. Recovery of strength front of the blade, articular cartilage will also extrude a film
at the insertion site takes longer and has not yet been seen to of fluid to decrease friction under loading conditions.94
return to control levels. The articular cartilage further assists keeping friction
The other component in the joint closely linked with the forces low by providing a softer rather than a harder sur-
fibrous capsule and reinforcing ligaments is the synovial face. The elasticity of articular cartilage on both ends of the
lining. The loose tissue of the synovium is not thought of as articulating bones allows accommodation to the shape of
providing much resistance to tensile loading. It is, however, joint surfaces. The surfaces become more congruent.94,98,103
responsive to greater than usual loading of the joint as will Joint Nutrition and Healing
be seen in the section on joint disorders, specifically, joint
As has been discussed previously, access to adequate
effusion and synovitis.
vascularity affects a tissue’s ability to heal. In general, joint
Articular cartilage also shows viscoelastic properties structures have good access to blood and nutrients with a few
(Figure 10-33). While tendons and ligaments are able to show notable exceptions, though it should be noted that variations
tensile stress-relaxation and creep because of loading of col- in vascularity do exist between joints.94
lagen and elastin fibers, articular cartilage shows these same
The simple fact that cartilage is avascular starts to high-
viscoelastic properties in compression because of movement
light the disparities within joint structures with regard to
of interstitial fluid.103
nutrition. With this reminder of tissue physiology, the dif-
Under compression loading, deformation occurs at the ficulty for articular cartilage to have adequate oxygen and
top elastic layers to improve joint congruency with the result nutrients is apparent. Nutritional components are released
that fluid is pushed out of the tissues, weeps, onto the joint by capillaries into the supportive layer of the synovium. By
surface. As soon as the load is released, the fluid is reabsorbed diffusion the oxygen and nutrients move through the syno-
back into the cartilage layers. Under larger compressive loads vial layers, combine with the synovial fluid, and float across
for longer duration, the articular cartilage top layers again the joint space to the articular cartilage where, by continued
deform with fluid movement out of the tissues. A slower diffusion, the nutrients move through the articular cartilage.
deformation occurs slowly over time at the lower zones. If The process of mechanical loading—the pushing out and
the duration of loading continues but there is not a change in then pulling back in of fluid—may improve the flow of nutri-
the size of the load, however, the amount of deformation— ents and metabolites into the cartilage.98 Even with this pos-
greater at the top layers, less at the deeper—redistributes to sible enhancement to simple diffusion, articular cartilage’s
be shared among all the zone layers. relative avascularity impairs its ability to repair itself.
Despite the forces pressing joint surfaces together dur- Less obvious is the avascularity for ligaments, or tendons,
ing loading, the slipperiness between the surfaces means that have attachments to bone through a zone of fibrocarti-
the sliding and gliding of joint arthrokinematic movements lage. Short distance vascularity may exist for the portion of
Figure 10-34. Side view of the posterior cruciate ligament (pcl) in
a 33-year-old man. A number of vessels penetrate at various levels
in the ligament, where they split upward and downward, but not
into the osseous attachments. F: femur; T: tibia. (Adapted from
Scapinelli R. Studies on the vasculature of the human knee joint.
Acta Anat (Basel). 1968,70(3):305-331.)
the attachment on the bone side from blood vessels in the The presence of cell injury within the joint will stimulate
bone. Surrounding tissues may provide access to a capillary events that lead to an increase in synovial fluid. The exact
network for the mid-sections of ligaments, or tendons, on mechanisms for this response in the joint to inflammation
the other side of the fibrocartilage. The region of fibrocar- are not completely understood.105 It has been suggested that
tilage remains avascular (Figure 10-34). Though healing of synoviocytes increase production of synovial fluid.106 Fluid
ligaments injured in the fibrocartilage layer is still theoreti- from the blood capillaries in the synovium are another iden-
cally possible, surgical repair of ligaments tears in or near the tified source.97
fibrocartilage zone have proved frustrating. Despite initial A general characteristic of inflammatory chemotaxis is
success with healing restoration of the insertion site struc- the increased permeability of capillary walls to plasma pro-
ture, the measured strength after 1 year was, at most, 50% of teins, which then move from the capillaries into the tissue
that measured on the uninjured side.102 interstitial spaces. The presence of these proteins in the tis-
In contrast, the synovium has a rich vascular and lym- sues disrupts the osmotic balance, prompting fluid from the
phatic supply.5 The areas of the synovial lining with fibrous capillaries to flow into the tissues to dilute the now protein-
tissue have slightly less vascularity than the portions of the rich region and restore osmotic balance. An increase of fluid
lining with alveolar or fatty tissues.94 Injured areas of the within the loose cellular structure of the synovium would
synovium regenerate easily.5 then flow into the joint space.
These events with inflammation support the proposal
Joint Disorders that the source of increased synovial fluid is fluid from the
capillary network in the synovium. In addition, however,
Joint Effusion increased synoviocyte production of proteins with inflam-
mation may also add to an osmotic imbalance that, in turn,
The amount of lubricating synovial fluid contained within
increases fluid flow from the capillaries in the synovium and
the fibrous joint capsules of synovial joints is generally small.
adds to the fluid volume in the joint space. With prolonged
In certain circumstances, however, the fluid volume can
inflammation the synovium can undergo hypertrophic and
increase, and increase dramatically. Faced with traumatic
proliferative changes.105
injury to joint structures, overuse conditions, or the presence
of systemic disease, a rise in synovial fluid volume will be The filling of the joint space with synovial fluid expands
seen, and seen literally since the previous small joint space redundant folds of the capsule. Since fluid does not compress,
expands markedly to accommodate the increase in fluid. the usual amplitude of joint movements are reduced. Any
movements of the joint that meets the fluid-resisted capacity
The marked expansion of the joint space, now overfilled
of the capsule will further stretch an already distended capsule
with synovial fluid, is termed a joint effusion. The discus-
and be painful. Joint effusions can be characterized by the joint
sion here will be limited to joint effusion due to an increase
position the joint assumes when maximally effused such as the
in synovial fluid. Note, however, that joint effusions also
around –20 degrees of extension seen in the knee joint.104
occur with bleeding into the joint space as with traumatic
Even before maximum effusion levels are reached, it has been
injury, a hemophilia event or the result of oral anticoagulant
shown that a joint effusion also has the capacity to prompt an
therapy.104
inhibitory effect on supportive joint musculature.107,108
418 Chapter 10
Adhesive Capsulitis difference in trend was found with the use of high-grade
mobilization techniques compared with low-grade mobiliza-
Adhesive capsulitis is characterized by painful and lim-
tion in the treatment of glenohumeral adhesive capsulitis.114
ited passive and active range of motion of a joint. Generally
thought to be a disorder of the glenohumeral joint, it has Ligament Sprain/Rupture
been reported to occur at the hip, wrist, and ankle.109 Ligaments can be subjected to joint movements or outside
Whether a spontaneous onset or linked with joint injury, the forces that result in a tensile stress to the ligamentous tissues.
actual mechanism of tissue disorder of adhesive capsulitis is The amount of injury will depend on the direction of the
not well understood. force as well as the position of the joint at the time. Ligament
In a stark contrast with the development of a distended sprain can range from the following115:
effused joint in reaction to inflammation, the joint capsule • Grade I (mild, no increased laxity)
in adhesive capsulitis becomes thickened with the loss of
redundant folds and joint space recesses. A “proliferation of • Grade II (moderate, slight but not significant laxity)
inflammatory infiltrate may precede the initiation and pro- • Grade III (severe, significant laxity to complete
gression of the fibrous thickening process.”109 Phases of the disruption)
process have been identified. Depending on the direction, magnitude, and rate of the
For the glenohumeral joint, 3 distinct phases have applied load, the tension on the ligamentous arrangement
been described in staging this condition. The first around a joint will occur in a load-sharing pattern.116 The
is an early painful phase, or “freezing stage,” with result may be that more than one ligament in the joint may
a duration of 2 to 9 months. This is followed by an be injured.
intermediate stiffening or adhesive phase, which has Since some ligaments are structures within the joint
a duration of 4 to 12 months. In this phase, patients fibrous capsule, the applied load may generate tissue reac-
typically experience increasing stiffness, but less tions in the joint capsule as well as the synovium. In addition,
pronounced pain. The final phase is known as the collagen fibers in the ligamentous tissue can sustain a tensile
recovery, or “thawing” phase, which lasts anywhere load to the extent that some fibers fail. Even after healing, the
from 5 to 24 months. Here, patients display a grad- ligament may offer less resistance to loading. Clinical testing
ual return of movement.109 of ligament resilience may show that less force is required to
The return of movement reverses the observed capsular lengthen the ligament. The result is greater movement of the
pattern of movement loss. In the glenohumeral joint, lateral joint in the direction tested. A hypermobile joint may lead to
rotation is limited most, followed by abduction then medial altered within-the-joint biomechanics during loading situa-
rotation.109,110 In the ankle, dorsiflexion has near full restrictions. The resultant unwanted movement(s) challenge joint
tion while plantarflexion is decreased by almost 50%.109 stability and create further irritation of joint structures. An
Arthrokinematic movements are the generally unob- effused joint adopts a loose-pack position rendering the joint
served movements that occur between joint surfaces that less stable when functioning in what was once its more stable
are, nevertheless, essential for the observed osteokinematic closed-pack position.97
movements to occur. A hypomobile glenohumeral capsule Because of the fibrocartilage layer for some tendon inser-
will restrict the ability of the humeral head to glide inferiorly tions, surgical repair may not be attempted. Reconstructive
in the glenoid fossa thus thwarting an important assist by the surgery to replace an excessively hypermobile or ruptured
rotator cuff muscles to shoulder movements. A hypomobile ligament, such as the anterior cruciate ligament of the knee,
ankle capsule will show a decrease in an anterior-to-posterior can restore stable joint biomechanics.
gliding movement of the talus within the ankle mortise, Osteoarthritis
which results in a limitation of ankle dorsiflexion.
What is the long-term effect of repeated episodes of joint
Joint mobilization techniques follow these arthrokinema-
effusion, inhibited protective muscular support or altered
tic movements, also called accessory movements, to restore
biomechanics in a joint due to ligamentous laxity? Add to
joint movement. Small repeated oscillations are applied at
that the effect of increased compression loading such as
mid-range or end range of the available capsular mobil-
occurs to the weightbearing joint in workers who stand for
ity for the restricted accessory movement in the joint.111,112
job tasks on cement floors.
The property of tissue hysteresis explains the treated tissue’s
The degenerative process in osteoarthritis has several
response to become less stiff, and more relaxed, as a result of
components. Radin described that excessive compression
the application, and release, of the tensile load for the specific
loading in weightbearing joints is shock-absorbed not by the
mobilization performed.
articular cartilage but by the underlying trabecular bone on
Use of mobilization techniques and exercises in the treat-
both sides of the joint.117 The bone responds during remod-
ment of patients with glenohumeral adhesive capsulitis who
eling to heal the trabecular microfractures in addition to
also undergo one intraarticular corticosteroid injection,
refortifying the bone. The result is a stiffer trabecular bone
lead to range of motion gains being made more quickly
structure. Now the articular cartilage is subjected to higher
when compared to patients who also receive the injection
stress due to the stiffer-than-before subchondral bone. As the
and follow a home program of the exercise.113 A significant
Figure 10-35. PNS organization. (Adapted from
Cormack DH. Introduction to Histology. Philadelphia, PA:
J.B. Lippincott Co; 1984.)
PST predicts, the articular cartilage begins to show degenera- This layer, as well as the extracellular matrix between axons
tive changes though the total impact may not be clinically within the bundle, provides strength. The bundle, called a
apparent for years. fascicle, will organize with other fascicles to form nerves with
“The harder the surface, the higher the friction.”97 The further resilience-enhancing connective tissue layers and the
superficial layer on articular cartilage, the lamina splendens, extracellular matrix (Figure 10-35).
may shear off with increased surface friction. This exposes Second, most axons in the PNS will be wrapped with
the top zone of articular cartilage to the increased friction, segmental, concentric, layered sheaths of myelin formed by
which in turn begins to erode the surface. The previously individual Schwann cells. The spaces between the segments,
smooth articulating surfaces will not be able to maintain the the nodes of Ranvier, allow axons to branch as well as allow
protective lubricating layer of fluid with joint movements, an electrical impulse to skip from node to node for faster
which further increases the surface to erosion. transmission (Figure 10-36).
Incongruity of joints can contribute to the development of The connective tissue layers around nerve units offer
osteoarthritis. Joints with greater contact area are less likely other advantages. Loose connective tissue—the extracellu-
to develop arthritis.117 A function of articular cartilage is to lar matrix with fibers mentioned previously—extend to the
provide a more congruous surface. Changes in the exposed surrounding layers to fill in the spaces within fascicles and
outer surface of the articular cartilage alter its ability to between fascicles in a nerve. This offers a little biological pad-
conform. The decreased contact surface becomes another ding, thus, protection from compression. This loose lattice of
contributor to increased surface loading. elastin and collagen fibers also allows axons and fascicles to
Graduated loading of articular cartilage after it has slide independently of each other within one nerve to accom-
undergone changes with immobilization may restore loading modate varying tensions.
tolerance.97 “Therapists should recognize that after immobi- Bilateral nerve roots branch off from the spinal cord at
lization or unloading (rest), articular cartilage is less stiff and every vertebral segment. At cervical and lumbar/sacral levels,
less capable of tolerating high loads, loads normally within the nerve roots divide and regroup with nerve roots from
the physiological capacity of healthy cartilage.”97 adjacent levels. The dividing and recombining occurs in
Degenerative changes in articular cartilage have little abil- several more stages until the pattern of brachial and lumbar/
ity to reverse. The avascularity of articular cartilage deprives sacral plexuses is formed (Figure 10-37). This structural pat-
it of the ability to produce an inflammatory response and tern of dividing and regrouping of nerve axons continues on
subsequent repair.97 past the plexus.
A single nerve axon does not stay in just one peripheral
nerve fascicle throughout the axon’s length.118 Instead, there
PERIPHERAL NERVES is repeated dividing and regrouping of axons (Figure 10-38).
Despite all the regrouping, however, axons intended for the
same nerve branch will be sorted to end up in the same fas-
Morphology and Physiology cicle just before the fascicle branches off the larger nerve.119
This variable path for each axon may minimize the overall
The nervous tissue of the PNS differs in 2 ways from
effect from a partial nerve injury but may also complicate a
that of the CNS. First, when nerve axons in the PNS bundle
nerve’s effort to repair itself.118
together, a connective tissue layer surrounds the bundle.
420 Chapter 10
From 12th
A thoracic
1st lumbar
Iliohypogastric
Ilionguinal
2nd lumbar
Genitofemoral
3rd lumbar
Lat. femoral
cutaneous
4th lumbar
To Psoas
and Iliacus
Femoral
5th lumbar
Accessory obturator
Obturator
Lumbosacral trunk
Figure 10-37. (A) Brachial plexus. (continued)
When a soft tissue injury occurs, the nerve tissue in the

region would have increased exposure to bradykinins and
Figure 10-36. Myelin formed by Schwann cells. (Adapted prostaglandins during the immediate response and inflam-
from Widmaier EP, Hershel R, Strang KT. Vander, Sherman, matory phase. In the natural turnover of ion channels every
Luciano’s Human Physiology: The Mechanism Of Body Function.
9th ed. New York: McGraw-Hill; 2004.) few days, exposed axons might then reflect accommodation
to the new environment, with a greater percentage of ion
channels to detect nociceptive chemicals.121 The greater
Along with the structural pattern of dividing and regroup- number of ion channels for nociception on the nerve would
ing seen in the plexus and the fascicles, neural tissues share change the balance of the types of stimuli being relayed to
another pattern. the dorsal root ganglion. The dorsal root ganglion, in turn,
would reconfigure its receptors to accommodate this change
A nerve trunk runs an undulating course in its
in input.
bed, the fasciculi run an undulating course in the
epineurium, and the nerve fibers run an undulating Nerve Responses to Loading
course in the inside the fasciculi. This means that Peripheral nerves are able to slide within fascicles and
the length of a nerve trunk, and its contained nerve have undulations to allow accommodation to length changes.
fibers between any 2 fixed points on the limb, is How adequate are these properties to prevent overstretching
greater than a straight line joining those points.119 in everyday activities? Sunderland, a pioneer and esteemed
The gradual straightening of these waves when a nerve nerve researcher, believed that generally the tensile forces
is slowly tensioned minimizes overstretching of peripheral generated with normal limb movements would not be likely
nerve tissues. to compromise nerve fibers within the fasciculi.119 From
Axonal transport within a neuron and impulse propaga- his mechanical properties’ view of overstretching, perhaps
tion along a neuron share an energy source but their mecha- his view is accurate. More has been learned since about the
nisms for energy access differ. This makes it possible to block changes in peripheral nerves as a result of lower stresses. The
the action potential without affecting axoplasmic flow. A answer to the question may now be, “Well, it depends.”
nerve under the inhibiting effect of a blocking agent, such as First, the extent to which a fascicle can slide within a nerve
procaine, cannot conduct impulses but the axonal transport structure is variable. Tissue of the interfascicular epineu-
function is maintained.120 rium with loose connections to the outer perineurium does
Ion channels are located along nerve axons. These chan- allow sliding of one fascicle independent of others within
nels can open or close to ions that may excite the neuron. a nerve.118 Areas of perineural tissue with greater amounts
An even distribution of separate ion channels for electri- of adipose tissue also aid gliding. In areas where the nerve
cal, chemical, mechanical or temperature stimuli could be branches or vessels exit or enter the nerve, however, the
altered in only a few days to reflect a change in the local nerve epineurium has greater attachment to the perineurium. The
tissue environment.121 result is that less nerve sliding is available at these points.122
Figure 10-37 (continued). (B)
B Lumbar plexus.
Figure 10-38. Fascicular plexus formations

Second, there are areas in the body where peripheral in a 3 cm length of the musculocutaneous
nerves are more challenged to slide to accommodate tensile nerve reconstructed from a serially sectioned
specimen. (Adapted from Sunderland S. The
forces. Nerves are held more adherent by the adjacent tissues anatomy and physiology of nerve injury.
at sites where nerves must pass over, thus closely, to bony Muscle Nerve. 1990:13:771-784.)
structures. Movement of the radial nerve is diminished as
it passes at the elbow. The common peroneal nerve has less
mobility at the head of the fibula.121,118
Third, combinations of movements can challenge the
nerves’ ability to accommodate length requirements. The
median nerve bed has to adapt to a length 20% longer when
the shoulder is abducted 90 degrees and the elbow and wrist
move from fully flexed positions to fully extended.121 This is
the same movement as reaching sideways from a low car to
retrieve a ticket from the machine at a parking structure. The
tingle one can feel at the ventral aspect of the wrist and hand
is the median nerve registering the effects of a tensile load.
Generally, peripheral nerves will glide, when able, to
reduce tensile stress. In the example of reaching for the park-
ing garage ticket, imagine the person reaching is also wearing
mittens connected by a string. As he reaches out for the tick-
et, the string needs to slide toward the reaching side to enable
the elbow and wrist to extend. Similarly, the median nerve
glides toward the elbow—convergence—from the “slack” at
the shoulder and neck. When the arm is brought back into
the car, the median nerve glides proximally—divergence.118
In those areas where attachments may limit the extent of challenges nerve length, peripheral nerves do have the abil-
convergence and divergence for the nerve, or for a task that ity to adjust to modest change in length demands. Because
422 Chapter 10
Figure 10-39. Physical stresses placed on peripheral nerve.
Tensile stress applied longitudinally to peripheral nerve creates
an elongation of the nerve (an increase in strain). The transverse
contraction that occurs during this elongation is greatest at the
middle of the section undergoing tensile stress. (Adapted from
Topp KS, Boyd FS. Structures and biomechanics of peripheral
nerves: nerve responses to physical stresses and implications
for physical therapist practice. Phys Ther. 2006;86(1):92-109.)
nervous tissue has viscoelastic properties, along with the Less widely considered have been nerve injuries within
connective tissue layers, it can adjust to small increments of the category of preneurapraxias. In a number of injury sce-
elongation with creep and stress-reduction. narios involving other tissues, it is reasonable to surmise that
When a peripheral nerve is elongated, a transverse con- portions of a fascicle might also have been injured or exposed
traction occurs that narrows the diameter in the middle of to inflammatory agents. The change in ion channels, lead-
the section undergoing the tensile load (Figure 10-39). The ing to adjustments made at the dorsal root ganglion, are not
decrease in cross-sectional area increases pressure within always considered.
the nerve and intrafascicular microcirculation is compro- A mantra-like guideline to direct interventions has been
mised.119 In the example of reaching for the ticket at a park- identified based on nerve physiology and the environment
ing garage, the tingle felt in the wrist and hand at the extreme required for nerve healing.
end of the reach is likely due to microcirculation compromise • Nerves want space.
from pressure within the median nerve with elongation.
• Nerves want movement.
Nerves are extraordinarily sensitive to ischemia.118,119,121
• Nerves want oxygen.123
Nerve Nutrition and Healing
The need for space is based on the notion that an ailing
Nerves rely on, and have, a robust blood supply. The vas nerve is less tolerant of conditions of possible compression or
nervorum is a complex system of arteries with anastomosing elongation. The space is the absence of compression or elon-
arterioles running longitudinally in the epineurium. Blood gation. Because of the ion channel changes, the nerve is even
flows through this network to supply capillaries to the axons more sensitive to mechanical stress than before the injury.
within the fascicules. The vas nervorum keeps all nerve Nerves conduct signals but, as has been discussed previ-
components adequately oxygenated even if some of the feeder ously, nerves also move. They are designed to move. Not
arteries are damaged.118,121 Further, the arteries that enter moving, especially in injured nerves, may contribute to addi-
segmentally along the nerve are coiled to better accommo- tional nerve changes. Alterations in axoplasmic flow due to
date the mobility required of peripheral nerves.118,121 injury may gradually resume with gentle nerve gliding move-
Special features of the blood supply create a barrier at the ment. Nerve glides can be identified that gently allow the
perineurium to bacteria. This allows nerves to pass through involved nerve to move. These glides can even be performed
areas of infection without impairment of nerve function.121 without disturbing adjacent tissues if indicated for the heal-
The barrier at the perineurium, however, does not allow lym- ing of those other tissues.
phatic vessels to cross. This means that any edema within a Nerves are highly sensitive to ischemic situations. “The
nerve will take longer to resolve.120 action potential and the axoplasmic flow both require a
The rich blood supply is required for effective nerve source of energy; they access a common pool of an ATP. In an
function because nerves are extremely sensitive to ischemia. anoxic nerve, both axoplasmic flow and the action potential
Microvascular ischemia can occur with the increased trans- will stop within 15 minutes.”121 Any compromise of cardio-
verse contraction pressure from nerve elongation as well as vascular or pulmonary status will affect nerve healing.
with nerve compression. As with other tissues, increasing the
duration of small elongation or compression loads will have
more of an ischemic effect as would increasing the amount of
Peripheral Nerve Disorders
elongation or pressure.
Compression
Classification of severe nerve injuries has long been estab-
lished. Stages of healing have been well defined for these Nerves face compression forces in everyday activities.
injuries (Figure 10-40). Severely injured nerves degenerate From arms leaning on chair armrests to sitting on hard
from the point of injury and distally. Nerve healing takes the surfaces, nerves encounter pressure. Further, some nerves
form of nerve regeneration from the point of injury after the are subject to greater compression exposure because of their
stage of degeneration is completed. Simply having the nerve location such as the median nerve in the carpel tunnel.
regenerate along its complete length is a daunting task but it The organization of fascicles with a nerve can minimize
is not the only challenge. The new nerve needs to be able to or increase the effect of compression. Nerves with several
conduct electric signals as well as tolerate gliding to accom- small fascicles surrounded by a large amount of epineurium
modate to tensile stress. padding are less vulnerable to compression than are nerves
Figure 10-40. Sequence of events with peripheral nerve
damage. An injury across an axon will disrupt the connec-
tion between the neuron (N) and its target cell (T). Distal to
the injury site, the axon degenerates and Schwann cells (S)
proliferate. If the neuron cell body survives the degeneration,
the proximal portion of the axon will regenerate to span the
injury site and be guided to the target cell. As the regen-
eration occurs, the Schwann cells reestablish their support-
ing association with the new axon. (Adapted from Lundborg
G, Rydevik B, Manthorpe. Peripheral nerve: the physiology
of injury and repair. In: Woo SL-Y, Buckwalter JA, eds. Injury
and Repair of the Musculoskeletal Soft Tissues. Park Ridge, IL:
American Academy of Orthopaedic Surgeons; 1988.)
with 1 or 2 large fascicles with only a small relative volume Held briefly the nerve tissue recovers without irreversible
of connective tissue matrix.120,121 Most nerves, however, are changes. It will take longer for the edema to resolve than
able to tolerate low compression forces for brief durations with other tissues because of the lack of lymphatic vessels
and recover. within the nerve. Compression pressures that are enough to
The exact parameters of safe nerve compression are diffi- block axonal transport may produce a deficit that lasts for
cult to define. The functional positions noted previously, and days after. Compressive position held longer, or in situations
others, can approach or exceed the limit of 20 to 30 mm Hg, of repetitive compression, neurapraxia—a demyelinating
which is known to impair nerve blood flow.118 conduction block—can occur.120 High-compression forces
Simply placing the hand on a computer mouse was can sever axons.
shown to increase the tunnel pressure from the rest- Traction
ing 5 mm Hg to 16 to 21 mm Hg, and actively using
Elongated nerves initially suffer the effects of compres-
the mouse to point and click increased the tunnel
sion with the increased pressure from transverse contraction.
pressure to 28 to 33 mm Hg, a pressure high enough
The resultant impaired microvascularity leads to endoneu-
to reduce nerve blood flow.118
rial edema as described previously. A nerve held for a short
At the compression level of 20 to 30 mm Hg, the first sign duration at a length 6% to 8% greater than its resting length
of impaired microvascularity is seen in a reduced blood flow will experience transient changes in blood flow.118 Healthy
to endoneurial tissues. The impaired capillary flow reduces adults have reported intolerance to positions identified in
the oxygen supply for the endothelial cells of the capillaries. cadaver studies as being only 8% greater than resting lengths.
As noted in the events of inflammation for the basic tissues, “Common positions used to assess the neurodynamics of
this anoxic situation leads to increased capillary perme- the upper limb may result in nerve strain that approaches or
ability. Fluid and proteins leak from the capillary into the exceeds the 11% strain that is known to result in long-term
endoneurial tissues causing edema in the endoneurial tis- damage.”118 Neural mobility will be compromised in nerves
sues. After 2 to 4 hours of low pressure conditions, the fluid that have had an impedance of blood flow from a previous
pressure of the endoneurium can increase more than 3 times episode, or episodes, of elongation stress.
the baseline level.120 A local metabolic conduction block The electrophysiology properties of nerve can be affect-
occurs.120 ed even with gradually increasing tensile loads. Extreme
424 Chapter 10
Figure 10-42. Categories of nerve injuries. (Reprinted with permission from Butler DS, Tomberlin
JP. Peripheral nerve: structure, function, and physiology. In: Scientific Foundations and Principles of
Practice in Musculoskeletal Rehabilitation, Magee DJ, Zachazewski JE, Quillen WS, eds, Copyright
Saunders Elsevier Inc 2007.)
injury is immobilized. The opportunity for the development

of fiber crosslinks in connective tissues is enhanced when
fibers are held static.34 The crosslinks will further stiffen
the connective tissues in and around fascicles. Instructions
Figure 10-41. Changes occurring in the vari-
ous components of a nerve trunk as it is stretch to move fingers, or toes, when a patient is in an arm, or leg,
to structural failure. Only one fasciculus in cast can assist with the maintenance of neural mobility even
the nerve is represented. (Adapted from when the joint movements seem far removed from the immo-
Sunderland S. The anatomy and physiology
bilized region.
of nerve injury. Muscle Nerve. 1990:13:771-784;
and Sunderland S. Nerves and Nerve Injuries. A sciatic nerve with inadequate ability to slide to accom-
Edinburgh, Churchill Livingston: 1979.) modate the length flexibility of the surrounding hamstring
muscle fibers can be subject to intolerable elongation with
“normal” stretches. The same situation can occur for recov-
elongation stress can lead to axonal injury and functional ering fascicles or partial fascicles within a nerve with “nor-
impairment. The classic studies by Sunderland depict the mal” movements.
sequence of events as a nerve continues to experience an Consider the impact on nerve mobility for a critically
increasing tensile load (Figure 10-41). The nerve undergoes ill patient who spent days lying in bed in a state of relative
layer by layer failure of its structure: axon, endoneurium, immobility. The simple act of sitting up on the side of the bed
perineurium, epineurium. Beginning with the loss of axonal could require more ease of mobility from the sciatic nerve
continuity, the neuron(s) will need to undergo degeneration than it may be ready to provide. Sitting on the side of the bed
and regeneration to recover. Each additional layer of fail- and performing ankle pumps with an extended knee could
ure within the nerve adds to the nerve’s recovery challenge further challenge nerve mobility.
(Figure 10-42). What would be the impact on a patient’s movements
Neural Immobility over the few days following a surgical or medical procedure
during which a fascicle or partial fascicle was held inadver-
The mechanical property of nerve mobility can be tently in an elongated or compressed position? Well into the
impaired with exposure to mechanical stresses. Repetitive inflammatory phase, the swollen tissues of the fascicle might
episodes of prolonged elongation or compression, even at not allow the usual ease of gliding. The symptoms from nerve
low loads, can cause edema in nerves. Chronic edema from ischemia might not be the first possibility that comes to mind
inflammation leads to fibrotic changes in the connective tis- when the patient reports pain. Making this link to what
sues located within and between nerve fascicles. The loss of might be occurring at the tissue level is challenged further
this loose tissue will lead to a decreased ability for fascicles because with a gentle tug on the fascicle the ischemia might
to slide independently of each other within a nerve when take a few minutes to develop. There can be a delay between
encountering varying tensile loads. the brain’s interpretation of the incoming stimuli and the
A single episode of increased compression or elonga- patient’s report of pain.
tion will also result in an inflammatory episode within How is the concept of neural mobility best incorporated
the injured neural connective tissue layers. The resulting into patient care? Recognizing that a neural mobility deficit
decreased nerve mobility can occur whether or not it was is possible is the first step. For the sciatic nerve scenario
apparent that other tissues in the region were also injured mentioned previously, the remedy could be as simple as an
in the episode. The probability that nerve mobility could intervening range of motion exercise in supine to check the
become impaired increases when a regional musculoskeletal ease and comfort of hip flexion before asking the patient
to sit up for the first time. The guideline of testing the ease
of the movement with passive then active-assistive exercise
has served physical therapists, and their patients, well even
before the effects of decreased neural mobility were identi-
fied. There are identified patterns in limbs where nerves have
more or less ability to be compliant with mobility demands.
Guidelines for careful mobility testing and interventions
are available.124 The ability of a fascicle or nerve to recover
from a single episode of increased load, or repetitive loads,
is affected by the patient’s cardiovascular and pulmonary
status. Further, systemic pathologies of note for impaired
neuronal function are diabetes mellitus, hypothyroidism,
alcoholism, immune deficiency syndromes, and rheumatoid
arthritis.121
Hypersensitivity
Many physical therapists have a biomedical perspective
regarding pain and will search for a cause of the pain when
pain is reported. The focus is on anatomical and biomechani-
cal principles to explain the causes of pain. This perspective
has been effective for many patients but not all. There is
a growing awareness that hypersensitivity of the nervous
system offers an explanation for the examination and treat-
ment of patients with pain complaints that persist long after
any sign of other tissue injury is evident. This may also offer
assistance for the management of patients whose report-
ed symptom intensities far outweigh noted tissue injury.
Further, research has established a link between altered pain
beliefs and altered movement performance in patients with
increased and prolonged reports of pain.125 Figure 10-43. Adapted Moseley’s Pain Sciences Quiz (2003). (Reprinted
from J Pain, 4(4), Moseley L, Unraveling the barriers to reconceptualiza-
An evolving biopsychosocial perspective on pain strongly tion of the problem in chronic pain: the actual and perceived ability of
acknowledges interactions between the brain and the body, patients and health professional to understand the neurophysiology, pp
specifically with regard to the nervous system. Pain is an 184-189, Copyright 2003, with permission from Elsevier.)
output. David Butler has offered the following insights to go
along with the notion that pain is an output:
• Pain is a critical protective device. to baseline but instead continues getting better and better
at responding to any stimulus? What if it doesn’t even need
• Pain depends on how much danger your brain thinks a stimulus but just fires on its own? Abnormal impulse-
you are in, not how much you are really in. generating sites can form on a neuron, producing ectopic dis-
• Pain is one of many systems designed to get you out of charges (Figure 10-44).121 With increased messages coming
trouble. in from the periphery, other parts of the nervous system—the
• Tissue damage and pain often do not relate. dorsal root ganglion and the brain—reconfigure and the ner-
vous system can become hypersensitive.128 What has been
• As pain persists the nervous system becomes better at effective to turn down this hypersensitivity?
producing pain.126
The use of functional MRIs to plot the areas of the brain
Pain as an output can take a bit of getting used to for with increased activity has helped evaluate the effectiveness
clinicians. In a study that assessed the pain knowledge of of interventions. Of most significance is the improvement in
clinicians and patients, untrained clinicians fared no better functional movements that are matched with decreased brain
than patients in accurately answering a questionnaire (Figure neurotag activity in patients after the patients participate in
10-43).127 an education session about the physiology of pain.129
Axons in the region of a musculoskeletal injury can begin Further, patients have shown improvements in under-
the process of ion channel changes to respond to environ- standing and managing their chronic low back pain that were
ment of inflammation. Over the days and weeks of recovery, greater after an educational session on the physiology of pain
perhaps with restoration of normal movements including and nociception than after a session on anatomy and physi-
neural mobility, the ion channel balance reverts back to the ology of the lumbar spine.130 Simple drawings can assist the
baseline state. What will happen if a neuron does not return explanation of pain physiology (Figures 10-45 and 10-46).131
426 Chapter 10
Figure 10-44. Possible abnormal impulse-
generating sites represented on one neuron.
(Reprinted from Butler DS. The Sensitive Nervous
System. Adelaide, Australia: Noigroup; 2000,
with permission from Noigroup Publications.)
Figure 10-45. The alarm message meets the spinal cord. Alarm messages com-
ing to the spinal cord from tissue nerves are dampened when met by inhibiting
chemicals activated by descending pathways from the brain. (Reprinted from
Butler D, Moseley L. Explain Pain. Adelaide, Australia: Noigroup; 2003, with permis-
sion from Noigroup Publications.)
Figure 10-46. Altered CNS at

the spinal cord. Enhanced sen-
sitivity of the alarm system is
nearly always a main feature
in persistent pain. (Reprinted
from Butler D, Moseley
L. Explain Pain. Adelaide,
Australia: Noigroup; 2003, with
permission from Noigroup
Publications.)
history related to the presenting complaint. In the inpatient

MUSCULOSKELETAL EXAMINATION setting, a chart review, and discussions with nurses, the
patient’s family, and attending physician may precede inter-
The Guide to Physical Therapist Practice identifies the viewing the patient. There are patient cases in this text to
elements of the patient/client management model. Whether identify the process with a hospitalized patient. This chapter
in an inpatient or outpatient setting, the examination of will highlight examination considerations for a patient seek-
patients begins with gathering information about the current ing outpatient physical therapy services for a musculoskeletal
complaint. This may also require identifying past medical complaint.
Examination The same question can be repeated with the substitution
of instrumental activities of daily living (IADL) or work
History tasks. As well the actual physical demands of the patient’s job
tasks should be surveyed, including what is required for the
Patient Interview patient to commute to work. Commutes can vary markedly.
Therapists in an outpatient clinic who are able to greet a One patient may describe his commute as walking from his
new patient in the waiting area, walk with the patient back house to a car parked in the driveway, driving to work, and
to a private treatment room, and get the patient settled com- parking close to the work building. Another has a commute
fortably for the interview, start the examination with several consisting of walking several blocks to a bus stop, descend-
advantages. The physical therapist is able to offer a welcom- ing a flight of steps to a train, balancing while standing in a
ing greeting using the patient’s surname and then establish, full commuter train, ascending a flight of stairs, and walking
right from the start, how the patient would prefer to be several more blocks to the work building.
addressed. It is always worth asking, “Would you like for me If the patient has a regular fitness program, the same
to call you Mr. Halo?” question outlined before can be used again to assist gathering
The therapist is able to observe the patient’s ability to a clear picture of the patient’s functional status.
stand from sitting, navigate through doorways/corridors Then establish what the patient’s functional status was
and walk the distance to the treatment room. Walking with before the recent complaint started. It should not be assumed
the patient allows an initial impression of the patient’s gait that the patient was 100% before the injury.
to be made. Asking a question such as, “Did you have any Technically a thorough pain survey belongs in the tests
trouble finding us?” and observing whether the patient’s gait and measures portion of the examination. Many patients
changes as he answers introduces whether difficulty with referred to outpatient physical therapy with a musculoskel-
dual tasking might need to be considered. The availability of etal complaint report pain so a detailed survey of symptoms,
a private treatment room enhances the patient’s experience including aspects of pain behavior, will generally be an
right away since respect for the patient’s privacy has been indicated measure to be completed. Knowing that, it makes
identified as an important consideration in patient satisfac- sense to complete this survey during the interview. As well,
tion.132 Another transfer is observed as the patient sits in the the pain survey at this point will identify whether modifica-
treatment room chair. Small treatment rooms exist where tions need to be made during examination testing to avoid
the process of just getting to the chair provides insight into aggravating tissues with reported high irritability.133
whether the patient is proficient with maneuvering in very An evaluation form that has the topics to be covered
tight spaces. during the interview ordered in a manner that makes the
Offer to have the patient sit in a comfortable chair with interaction flow smoothly is invaluable. Being familiar with
armrests but also mention that if standing or walking in the evaluation form, to know exactly the best place to record
the room would make the patient more comfortable during each piece of information, also makes the entire examination
the interview, he is free to do so. After asking what brings process easier. Whether a student in the clinic for the first
the patient to physical therapy, let the patient have an oppor- time, or an experienced clinician confronted with a brand
tunity to talk for a few minutes without interruption. The new form format, taking time to learn the form, so that where
conversation can be redirected as needed in a few minutes. to record findings is automatic, is recommended.
Letting the patient talk can lead to the successful gathering of
needed information even if the order in which the informa-
Systems Review
tion is reported seems random. The process of the interview, along with the systems
At the end of the interview, it is important to have learned review, helps determine whether the patient is a candidate for
the nature of the complaint including the body part involved, physical therapy. The information gathered will help identify
what functions are impaired, and for how long. Identifying which tests and measures will be required in the examination
past medical history, medications, and general health helps to best establish the patient’s status. In an outpatient setting
to establish what other factors may be affecting the physical the systems review may not look to be an actual separate sec-
stress of tissues. tion of the examination. The systems review is, however, a
Since functional activities will be one standard against distinct critical thinking step.
which to judge patient progress, the use of functional surveys Several components of the systems review are already
and outcome measures are useful. As well a series of specific established by the time the patient interview is completed.
questions can be asked with the format of, “If 100% was the Generally it has already been established by the patient’s
level where you are able to perform dressing, bathing and report that range of motion and strength are impaired. The
generally taking care of just yourself in your home inde- creation of a mental checklist begins that will include range
pendently—and performing those tasks in the manner you of motion and muscle performance measures of the affected
think you should be able to perform them—what percentage limb in the next step of the examination. A screen of the
are you able to do now?” Note what aspects of those tasks are gross range of motion and strength of the uninvolved limbs
difficult for the patient and why, as well as what tasks can’t be can be completed.
done to reach the 100% level.
428 Chapter 10
Gross screening of deficits in balance, gait, transfers, and Wise strategies make musculoskeletal examinations suc-
transitions has also occurred with observation of the patient cessful. When a patient reports symptoms during the inter-
in the waiting room, walk to the treatment room, and in the view that suggest neural mobility might be a possible
treatment room. The patient may be judged to be cleared of contributing impairment, plan the examination accordingly.
neuromuscular deficits or tests and measures in these areas If the testing of neural mobility initially appears to be nega-
are added to the mental list. tive, build in a little time between neural mobility tests to
Decisions on whether further testing is required to estab- allow a delay of symptoms to be noted.
lish deficits in the patient’s communication, affect, cognition, When it is possible for the patient to tolerate more specific
and language have also been made based on the interview. testing, completing the critical thinking process will make
Again, “cleared” or “need for further testing” will be decided. establishing the treatment plan more specific. Deciding
The patient’s preferred learning style can be a simple ques- impingement is present for a shoulder complaint is only part
tion to complete this component of the systems review at of the equation. Is there impingement because the glenohu-
this point. meral capsule lacks ease of movement to allow unrestricted
Questions whether the patient has any scars or open sores inferior gliding or is the supraspinatus too weak to adequate-
can be asked and screened if present. Additional notation of ly depress the humeral head? If it is a combination of both,
scars or altered integument not screened from the patient do findings suggest one is a larger contributor to the altered
report can be noted throughout the examination. glenohumeral biomechanics than the other? The answers
The patient has been resting during the interview, so tak- to these questions determine whether the intervention will
ing resting vital signs then completes the systems review. have a main emphasis on improving glenohumeral accessory
Vital signs measured with activity can be recorded during movement or strengthening the supraspinatus.
the next aspect of the examination. Summary
Tests and Measures A thorough examination guides the evaluation to estab-
Most outpatient physical therapy departments have an lish the diagnosis and prognosis including the plan of care.
array of initial evaluation forms for each body part. In Using these to develop the indicated intervention ensures
essence, the next step in the critical-thinking process—which the best opportunity for a good outcome. The following
tests and measures are indicated for this patient—can be case will demonstrate how the elements of the patient/client
usurped by these forms. Sometimes not all the tests listed management model are used along with an understanding of
on the form are appropriate for a particular patient exami- musculoskeletal tissue pathophysiology to provide a success-
nation. Or there is a list of special tests that do not make a ful outcome for a patient referred to physical therapy with a
distinction in whether range of motion, muscle performance musculoskeletal complaint.
or joint mobility are being examined. It is important to have
a clear plan for which tests and measures are absolutely indi-
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432 Chapter 10
CASE STUDY 10-1 Family history of diabetes is less of a predictor for progres-
sion from impaired glucose tolerance to Type II.2 There was
no evidence of glucose tolerance testing in Mr. Halo’s online
Debra Coglianese, PT, DPT, OCS, ATC medical record.
Crohn’s disease is an inflammatory bowel disease charac-
terized by diseased sections of bowel through all layers of
EXAMINATION the bowel wall in the involved sections. Healthy sections of
bowel will exist between the diseased ones. A family history
History of Crohn’s occurs in 20% to 25% of the cases.3

Mr. Halo was a 51-year-old White male who was referred Medical/Surgical History
to physical therapy by his primary care physician with a Mr. Halo reported he was diagnosed with Crohn’s disease
chief complaint of bilateral shoulder pain, left greater than when he was 36 years old. He reported that his status with
right. He also noted left elbow and wrist symptoms. Mr. Halo regard to his Crohn’s disease was stable and controlled with
associated the onset of symptoms with the increased lifting medications. He was diagnosed with associated osteopenia
required to move his daughter home from college. He has 2 years prior to his initial physical therapy evaluation.
had similar symptoms, however, with regular ringing of large Mr. Halo reported episodes of left wrist pain associated
hand bells as a member of a hand bell choir. with bell ringing for several years “off and on.”
Social History/Environment He noted that he had seasonal allergies.
Mr. Halo was employed as a software consultant. He
worked from an office in his home. The majority of his work Clinician Comment The strongest risk factor
tasks occurred at a computer station. He was active with for Crohn’s disease development is having a relative with
the hand bell choir at his church. He lived with his wife and the disease.4 Mr. Halo’s mother was diagnosed at age 79
2 daughters. years, whereas his diagnosis occurred when he was 36 years
He reported that he lived in a 2-story home with a base- old. This is consistent with the findings that the age of
ment. Both flights of stairs had sturdy rails. He reported diagnosis of the child is younger than the age of diagnosis
stairs posed no barrier for him. of the parent.4
Social/Health Habits and Family History His more recent diagnosis of osteopenia was not surpris-
ing. Reduced bone mineral density is prevalent in patients
Mr. Halo rated his health as good despite his reported
with Crohn’s disease.5 Risk factors identified are the altered
complaint. He had no smoking history and consumed only
intestinal absorption characteristic of Crohn’s disease that,
an occasional glass of wine.
in turn, affects all aspects of adequate nutrition. The
He completed a 1-hour workout at his gym 2 times per
usual prolonged use of corticosteroids to medically manage
week. His workout included use of aerobic equipment as well
Crohn’s may have been a factor also in his decreased bone
as an upper and lower extremity resistance training program.
density.
In good weather he liked to ride his bike for fitness.
His father was 83 years old and had coronary artery dis-
ease (CAD) and Type II diabetes. His mother was diagnosed
with Crohn’s disease at 79 but was stable. Reported Functional Status
He reported unrestricted ADL, IADL, and work tasks. Mr.
Clinician Comment Already the interview Halo followed a regular exercise program, noted earlier.
has gathered a good amount of information to help under- Medications
stand Mr. Halo’s situation. He had an acute complaint that
might be superimposed on a more chronic musculoskeletal Mr. Halo reported the following medications:
complaint. It was possible that he had an acute tendonitis • Sulfasalazine, 1 gram, 2 times per day, along with folic
but it was also possible that there was an underlying tendi- acid
nopathy. He had a largely sedentary job that he offset with • Calcium supplement
a regular exercise program.
• Allegra (fexofenadine HCL), 60 mg, 1 to 2 times per day
What risks did he have for his health because of his family
medical history? He had a higher risk of CAD due to the • Flonase (fluticasone propionate), 2 times per day
presence of a family history of CAD.1 Though his father • Multivitamins
has Type II diabetes, Mr. Halo may not be at more risk.
Clinician Comment Sulfasalazine is a pro- and concentration (mean corpuscular hemoglobin concen-
drug and breaks down in the colon to 2 active metabolites, tration) of hemoglobin in his red blood cells.
sulfapyridine and 5-aminosalicylic acid. Mr. Halo was Mr. Halo met the desirable range of < 200 mg/dL for cho-
receiving a standard dose.6 lesterol, greater than or equal to 40 mg/dL for high-den-
Disease-modifying anti-rheumatic drugs, such as sulfasala- sity lipoprotein, and optimal < 100 mg/dL for low-density
zine, can be folic acid antagonists and supplemental folic lipoprotein.7
acid, 1 mg once daily, may be prescribed. Prostate antigen assay is considered normal at 4 ng/mL
Mr. Halo took a calcium supplement to improve calcium and less but a range of 4 to 10 ng/ml can also be normal.
absorption related to his osteopenia. The prostate-specific antigen should not rise more than
0.75 ng/mL per year.3
Allegra is an antihistamine prescribed to treat seasonal
allergies. Mr. Halo was taking a standard dose.6 Mr. Halo had 10 colonic mucosal biopsies taken during his
colonoscopy and all 10 were assessed as WNL.
Flonase is a corticosteroid used in a nasal spray to relieve
the discomfort of hay fever and other nasal allergies. Mr. Thus far there were no red flags that would indicate Mr.
Halo was using a standard dose.6 Halo might not be a candidate for physical therapy. The
review of systems was completed next.

A review of Mr. Halo’s online medical record listed the Systems Review
following information within the year prior to his initial
physical therapy evaluation.
Seated, resting:
HR: 60 beats per minute
LAB VALUES
Respiration rate: 12 breaths per minute
WBC 6.2 Blood pressure: 138/78 mm Hg
Red blood cell 4.49 m/uL Edema: None noted.
Hemoglobin 12.7
Hematocrit 40.1% Clinician Comment The normal range for
heart rate in adults is 60 to 100 bpm. Conditioned adults
Mean corpuscular volume, mean cor- WNL may have heart rates 50 to 60 bpm.3 Mr. Halo’s heart rate
puscular hemoglobin, mean corpus- was in the low portion of the normal range and may have
cular hemoglobin concentration, red reflected his conditioning from regular aerobic exercise.
blood cell distribution width
The normal breathing rate for adults is 10 to 20 breaths per
Cholesterol 179 mg/dL minute. A ratio of 4:1 is suggested for pulse rate to respira-
High-density lipoprotein 40 tion rate.3 Using this ratio, a predicted respiration rate for
Mr. Halo would be 15 breaths per minute. Again, he was at
Low-density lipoprotein 90 the lower portion of normal range and, again, might be due
Prostate-specific antigen 0.8 ng/mL to his fitness.
Colonic mucosal biopsies (10) all WNL His systolic blood pressure measure was in the prehyperten-
sion range, 120 to 139, while his diastolic measure was in
the normal range.8 With these blood pressure values, Mr.
Halo had only a 5% risk of developing CHD.7
Clinician Comment Mr. Halo’s WBC was
within the normal range for adults, 4.5 to 11.0.3 With the Mr. Halo had no signs of peripheral edema.
normal range of red blood cells for adult males as 4.5 to
5.3 106/mm3, Mr. Halo was slightly below the normal
range.3 Similarly, his hemoglobin was measured as slightly Integumentary
low since, for adult males, < 4 mL is considered significant.3
Mr. Halo showed no sign of skin disruption, areas of
Anemia is defined as a hematocrit of < 41% in males,
altered skin color or presence of scar formation.
though a range of 37% to 49% is suggested as within normal
limits (WNL). Mr. Halo was slightly anemic.3 Musculoskeletal
The size (mean corpuscular volume) and the distribution Gross Symmetry/Posture
(red blood cell distribution width) of his red blood cells were
• Mr. Halo sat and stood with mildly slumped posture and
WNL as were the amount (mean corpuscular hemoglobin)
asymmetrical positioning of shoulder girdle.
434 Chapter 10
• Mild anterior translation in lower cervical segments
to determine what positions or activities were associated
occurred when he was seated but not in standing.
with his symptoms. Findings in the system review suggested
Gross Range of Motion that his posture needed to be evaluated further. He may
• Bilateral shoulders showed WNL active range of motion have had altered biomechanics in his shoulder and shoul-
except for a slight decrease in combined movements on der girdle due to faulty movement patterns adopted with
the left. sustained arms-forward tasks such as keyboarding.
• Bilateral elbow and wrist showed WNL active range of His active range of motion for the left shoulder from the
motion. systems review needed to be compared to the available
passive range of motion. It was possible that a contribution
Gross Strength to symptoms might be cervical movement restrictions or
• Five of 5 strength in manual muscle testing screen of altered upper extremity neural mobility. Additional muscle
bilateral upper extremities without reproduction of performance measures needed to consider scapular posi-
symptoms during testing. tion with manual muscle testing. Finally, joint integrity
and mobility for the left glenohumeral joint needed to be
• Patient noted “awareness” of left shoulder symptoms
determined.
2 minutes after gross strength screen completed.
Mr. Halo had resting cardiovascular and pulmonary mea-
• Height: 6 feet; Weight: 174 pounds
sures that were mostly normal. He reported that he followed
Neuromuscular a regular aerobic exercise program without complaint. He
probably did not have an aerobic capacity deficit but his
Mr. Halo showed no deficits in balance, gait, transfers or
response to exercise needed to be measured. There was not
transitions.
time at the initial evaluation to complete this test.
Communication, Affect, Cognition, At the first follow-up visit, his resting vital signs were taken
Language, and Learning Style and matched those noted previously. He rode the station-
• Mr. Halo was alert and oriented to person/place/time. ary bicycle at a moderate pace for 5 minutes as a warm-up
prior to treatment. His reported a rate of perceived exertion
• He wished to continue with his activities including hand that was ~13/20. His postexercise vital signs showed a heart
bell ringing. rate of 84 bpm and blood measure of 140/80 mm Hg. His
• He reported no learning barriers. He preferred to have response to increased aerobic demand was documented as
exercises written out after demonstration and practice. normal with no further aerobic capacity testing indicated.
Clinician Comment Mr. Halo’s cardiovascu-

lar/pulmonary status, at rest, was unimpaired. He showed Tests and Measures
no sign of integumentary or neuromuscular deficits. His
body mass index was 23.6, which placed him in the normal Pain
weight range.9 There seemed to be no impairments in his
Mr. Halo reported:
ability to communicate, or comprehend instructions, in
physical therapy treatments. • P1: “ache but not a sharp pain” at anterolateral left
humerus, with occasional symptoms on the right. He
One effective upper extremity screening tool uses the active noted this symptom always occurred on the left the
ranges of shoulder flexion, then abduction followed by a com- morning after ringing bells or any lifting tasks. Symptom
bined movement of shoulder adduction, medial rotation, and intensity was a 2 to 3/10.
extension.10 The combined shoulder movement, performed
with a bent elbow, has the patient reach up and behind on • P2: “tenderness” was reported at left lateral epicondyle
his posterior thorax along the spine, as high as is comfortable. and associated with bell ringing.
Combining each of the movements of shoulder adduction, • P3: “nagging ache” at the left posterior shoulder girdle
extension and medial rotation as described individually11 that he reported had occurred “off and on for years.”
allows, when combined, the hand of the upper extremity These symptoms would also occur with long hours of
being tested to reach to the mid- to lower thoracic spine. keyboarding.
Mr. Halo’s left shoulder showed modestly decreased range
compared to the right with the screening tool described pre-
viously. And, though he was able to complete the manual
Clinician Comment This is an example of
a thorough pain survey. The location, type, and behavior
muscle testing12 without complaint at the time of applied
of each pain complaint is listed. Each individual pain
resistance, his symptoms in the left shoulder were mildly
complaint is recorded and “named.” Having a designa-
reproduced after testing.
tion for each pain is useful during the physical examina-
The next step in the examination was to select the indicated tion.10 When a symptom is reproduced, the P1 , P2, or P3
tests and measures. A survey of Mr. Halo’s pain was needed
designation can be recorded rather than writing out “repro- Range of Motion (Including Muscle
duced the-ache-but-not-sharp-pain at….” Length)
The patient rates the pain intensity on an 11-point scale • Passive range of motion for bilateral shoulders, elbows,
where “0/10” represents no pain and “10/10” is the worst and wrists were all WNL except medial rotation for left
pain one can imagine, pain so bad no movement is possible. shoulder.
An 11-point, 0 to 10 pain scale is as valid and reliable as the • Muscle length tests showed that the left supraspinatus
much-studied Visual Analog Scale.13 length was 50% of right on medial rotation length test.
An association has been showed between upper extremity Mild symptoms were reproduced on the left during the
musculoskeletal complaints and keyboarding, especially muscle length test.
in situations when spending increased time keyboarding
• Bilateral wrist extensors showed WNL length and with-
against a deadline.14 No study could be located that defined
out symptoms.
the musculoskeletal complaints associated with hand bell
ringing. Similar complaints to those reported by Mr. Halo, • Active range of motion, cervical spine was pain free,
however, have been reported by music teachers whose upper symmetrical, and patient’s optimum (mild limit at
extremities also maintain sustained arms-forward posi- extension, moderate limits for bilateral side bending).
tions as well as arms-forward movement positions.15
Power, and Endurance)
Posture (Standing) Despite the ability to hold against resistance at a 5/5 man-
ual muscle testing level, Mr. Halo had difficulty maintaining
• Right shoulder girdle dropped greater than expected for his left scapular position during movement testing of left
right handedness. shoulder medial rotation.
• Left scapula mildly abducted and elevated compared to
right. Clinician Comment The results of the pas-
• Mild thoracic spine scoliotic curve, left, with trace lum- sive range of motion testing and closer observation of
bar compensatory curve, right with forward bend. left scapular control gave more information. Decreased
• When asked to demonstrate posture for bell ringing shoulder medial rotation due to decreased length of supra-
tasks using a 5-pound weight as the bell, his left scapula spinatus and presence of reactivity has been described by
downwardly rotated. Sahrmann.20 Further, altered scapular control has been
identified as a sign of a faulty timing or movement pat-
• When asked to demonstrate posture with keyboard tern between scapulohumeral muscles and scapuloaxial
tasks, his shoulder girdle moved into a greater pro- muscles.20
tracted position.
Clinician Comment In right-handed persons Joint Integrity and Mobility

the right shoulder girdle tends to be slightly dropped com-
Accessory movement testing in bilateral glenohumeral
pared to the left. Mr. Halo showed this asymmetry but with
joints showed 3/6 mobility. Trace resistance was noted in
a greater magnitude than expected for only a handedness
the left glenohumeral joint for lateral glides and posterolat-
pattern.12 The finding noted previously with corresponding
eral glides. The left humeral head had a slight decrease in
asymmetry of scapular positions suggested to the evaluat-
anterior-posterior vs posterior-anterior glide with shoulder
ing physical therapist to rule out, or in, the presence of an
assessed in neutral.
underlying spinal curvature. The Adam’s forward bend test
confirmed the presence of spinal curvature.16
Altered scapular positions are important to note with Clinician Comment Joint mobility can be
the report of shoulder pain.12 Subjects with kyphosis and graded on a 0 to 6 scale where 3/6 is normal mobility. Grade
rounded shoulders have reported increased incidence of of 0, 1, and 2 are grades of hypomobility with “0/6” indicat-
interscapular pain.17 Forward head posture is associated ing no movement as in an ankylosed joint. Grades 4, 5,
with increased incidence of cervical, interscapular, and and 6 are grades of hypermobility with 6/6 representing the
headache pain.17 mobility of a grossing unstable joint.21
Mr. Halo’s altered scapular position could be considered
abnormal when compared to a research sample.18 The
inability to maintain the scapula in upward rotation with Cranial and Peripheral Nerve Integrity
upper extremity forward and overhead has been shown Upper extremity neural provocation and mobility testing
to be greater in subjects with 3 or more of 6 identified were negative.
impingement signs.19
436 Chapter 10
Clinician Comment The neural mobility test- Plan of Care

ing used with Mr. Halo were patterns for the median,
radial, and ulnar nerves.22 They did not reproduce his Intervention
symptoms and so it was fair to conclude that he did not Mr. Halo would benefit from instruction in management
have a neural immobility component to his complaint. strategies to reduce the reactivity in his left supraspinatus.
That said, however, the quality of the testing used then These would include identification and practice with symp-
compared with the more specific technique the evaluating tom-relieving positions and postures as well as regular use
therapist has learned since is great. Based on the groans of ice packs. He needed education regarding how to position
heard around the room during the lab sessions in a con- himself in his work space to reduce the postural strain from
tinuing education course, Mobilization of the Nervous keyboarding. He needed practice with posture corrections
System, one wonders if anyone can be taken to the ends required to provide a stable scapula for upper extremity
of the refined patterns without any neural elongation and movement tasks.
ischemic symptoms.23,24 In a study of asymptomatic men, He would benefit from therapeutic exercise to lengthen
evoked sensory responses were monitored and increased shortened postural musculature and strengthen supporting
with each component addition during neural mobility musculature. Gradual length stretching of his left supra-
testing for the median nerve.25 The point to remember spinatus would assist with tissue healing along with pulsed
is not whether any symptoms are produced with neural ultrasound for 1 to 2 sessions. Once the tendon was able to
mobility testing but whether the reported symptoms are begin tolerating mild overpressure, he could then progress to
reproduced. strengthening of the supraspinatus with attention to scapular
stabilization. Ultimately, he would need to practice simulated
bell ringing with his scapular position controlled.
EVALUATION Clinician Comment It was still not clear

whether he had a tendonitis or a tendinopathy. There was
a pattern of increased symptoms after activity rather than
Diagnosis symptoms preventing activity. The use of ice packs and
positioning were to reinforce self-management strategies in
Practice Pattern the event a component of his symptoms was due to activities
Mr. Halo showed signs and reported symptoms consistent that irritated his supraspinatus tendon.
with supraspinatus reactivity in his left shoulder. He also had A Cochrane Systematic Review of shoulder pain interven-
altered spinal and shoulder girdle mechanics for sustained tions was not able to support or refute the efficacy of com-
arms forward tasks, such as keyboarding, and forward- mon interventions for shoulder pain, including undefined
movement tasks, such as bell ringing with heavy bells. The physical therapy.26 Further, a clinical science review for
altered mechanics probably led to mild impingement of his tendonitis was unable to locate retrospective randomized
left supraspinatus. controlled trials, or in sufficient number, to provide evi-
These findings placed him in the musculoskeletal practice dence for diagnosis, etiology or treatment of tendonitis.27
pattern 4D—Impaired joint mobility, motor function, mus- Attention to shoulder positioning to aid healing is based
cle performance, range of motion associated with connective on identified microvascularity changes in rotator cuff with
tissue dysfunction. shoulder in different positions.28 The use of ice packs to
International Classification of Functioning, reduce inflammation and aid healing is a recommended
management strategy for Mr. Halo’s shoulder tendon
reactivity.29 There is poor evidence to include, or exclude,
See ICF model on p 437. pulsed ultrasound as an intervention for nonspecific shoul-
der tendonitis.30
Prognosis The exercise chosen for lengthening of the supraspinatus
Mr. Halo had an excellent physical therapy prognosis. He actually provided small eccentric loading of the tendon.
could expect improved awareness and control of his shoulder The exercise was not specifically chosen to provide the
girdle posture. His improved posture along with decreased eccentric load since the therapist had not been aware of
reactivity in his left supraspinatus should allow him to con- Curwin and Stanish’s work with tendinopathy at the time
tinue with his current activities with symptoms controlled. of Mr. Halo’s treatment. The therapist had noticed patients
with supraspinatus reactivity were able to move on to mild
strengthening once symptoms resolved with performance of
this exercise and mild overpressure was tolerated. The next
step in the lengthening series added a 1-pound weight that,
again, provided a small increase in the eccentric load.
ICF Model of Disablement for Mr. Halo

Health Status
• Crohn’s disease
• Osteopenia

Function
• Unable to maintain correct • Can complete work tasks
• Mild thoracic spine curve shoulder girdle posture for but with symptoms
left with mild to trace keyboarding tasks • Prolonged hours of
lumbar curve right • Unable to complete lifting keyboarding can lead to
• Altered left scapular tasks without symptoms the symptoms
position, elevated and next day • Unable to participate in
abducted hand bell choir without
• Tissue reactivity at left symptoms the next day
supraspinatus tendon
• Length deficit, left
supraspinatus tendon
• Decreased scapular
stabilization, left

• Age = 51 years • No mobility barriers in home, home office, or
• Manages his Crohn’s disease well community
• Regular exercise program
• Participates with his spouse in a church hand
bell choir
438 Chapter 10
Raising the height of the terminal is not enough to correct Expected Outcomes (4 weeks)
spinal posture and head position.31 To ensure improved Mr. Halo would report unrestricted, and pain free, par-
head and neck position, patients must be shown the associ- ticipation in sustained arms-forward activities of keyboard-
ated lumbar and pelvic positioning required for best seated ing and driving, as well as with the arms-forward movement
posture.32 activity of bell ringing.
Because fatigue in scapular stabilizers can decrease shoul- Discharge Plan
der strength by 50% with 2 minutes of upper extremity
It was anticipated that Mr. Halo would achieve the antici-
arm-forward work, Mr. Halo needed attention to his scapu-
pated goals and expected outcomes defined in the plan of
lar position with any strengthening exercises identified.33
care. He could expect to be discharged to a home exercise and
Further, since fatigue can alter scapulohumeral rhythm he
management program.
needed instruction, and practice, with self-monitoring of
his posture with keyboarding and bell ringing tasks.33
Stretching needed to include posterior shoulder muscu-
lature34 and pectoralis minor,20,35 as well as relaxation
INTERVENTION
of upper trapezius with upper extremity movement.20,34
Strengthening of supporting scapular musculature was Coordination, Communication, and
indicated to prevent the shoulder impingement.18,20,29,34
Documentation
The findings from the examination and the proposed
Proposed Frequency and Duration of treatment plan were discussed with Mr. Halo. An initial
Physical Therapy Visits evaluation summary was entered into the Mr. Halo’s online
Mr. Halo would be scheduled for 4 appointments over a medical record and forwarded to his primary care physician.
4-week time span. Specifically, he would be seen 2 times for All aspects of his physical therapy treatment were recorded in
the first week and then once the second week. During the his paper outpatient physical therapy record.
third week, Mr. Halo would follow his exercise program at
home. He would be scheduled to return for one follow-up Patient-/Client-Related Instruction
visit, and probable discharge, during the fourth week.
Mr. Halo received verbal instruction on, and had the
Anticipated Goals opportunity to practice, symptom-relieving positions for
1. Mr. Halo would be knowledgeable regarding use of his left shoulder. He was instructed in the use of ice packs.
symptom-relieving postures and use of ice packs to The management instructions, as well as those for identified
decrease tendon reactivity (1 week). exercises for his home program, were written out for him
and accompanied by hand-drawn illustrations. Prepared
2. Mr. Halo would report changes in his work station, and
handouts illustrating recommended guidelines for computer
awareness of his body in it, to allow correct posture with
station set-up were reviewed with, and given to, Mr. Halo.
performance of his job tasks (1 week).
3. Left supraspinatus would tolerate length stretching
without an increase in symptoms afterward (1 week).
4. Mr. Halo would be independent in length stretch to left Therapeutic Exercise
supraspinatus (1 week).
Posture Training
5. Mr. Halo would self-correct his posture during treat-
ment sessions (2 weeks). Mode
Posture correction practiced at mirrors.
6. Left supraspinatus would show full length, without
Intensity
symptoms, and be tolerant of over-pressure (2 weeks).
Correction to position of mild tension.
7. Mr. Halo would be independent in a program of general
Duration
upper extremity mobility exercises (2 weeks).
5 to 10 minutes.
8. Mr. Halo would tolerate initial supraspinatus strengthen- Frequency
ing exercises with scapular position controlled (2 weeks).
During the first 3 physical therapy follow-up sessions.
9. Mr. Halo would be able to demonstrate sustained arms- Description of the Intervention
forward activity—keyboarding—with optimal posture Mirrors were arranged around Mr. Halo, seated on a stool,
maintained (4 weeks). so that he was able to look forward into one mirror and see
10. Mr. Halo would be able to demonstrate simulated heavy his reflection from the side from the second mirror. Initially,
hand bell ringing with left scapular position controlled he held the corrected posture position for a slow count to
(4 weeks). 5 in sets of 3 to 4 repetitions and then gradually increased to
holding for 30 to 60 seconds. Then he practiced the corrected Initially he was taught an exercise progression of isomet-
posture with simulated work tasks, driving, and bell ringing. ric lateral rotation. With these exercises, he held a piece of
latex band, tensioned without slack, between his hands with
Clinician Comment This strategy of holding a forearms supinated. In the first set of 6 repetitions, he was
corrected posture position allowed elongated muscles with instructed to position his shoulder girdle in the corrected
probable stretch weakness to practice the new “shortened” position and hold his left hand still while the right hand
length. Mr. Halo needed to expend an increase in muscular moved into lateral rotation—a distance of about 1 inch. He
work to hold the “shortened” position and then gain endur- needed to watch his left hand to ensure it did not move with
ance as well as awareness to be able to apply to functional the increase in load being applied through the band. Then
situations. he did the opposite for 6 repetitions—hold the right and
move the left. Then he laterally moved both for 6 repetitions.
When he was able to complete this progression 2 times and
Flexibility Exercises experienced no symptoms, he was progressed to a different
exercise.
Mode
In this exercise, the hand position changed so that he was
Muscle length exercise
holding the band as if he were holding onto a bar, forearms
Intensity
pronated. He corrected his shoulder girdle, began to supinate
To a position of mild discomfort only, <2 to 3/10 his forearms “as if the thumbs were moving to the outside
Duration position” and applied mild stretch to the band. With this
One set of 8 repetitions with 5-count hold at muscle length position maintained, he was to reach for the ceiling with
end range. hands aligned over his upper chest and slowly lower. This
Frequency exercise was performed for 2 sets of 4 repetitions. This exer-
During treatment sessions and then 1 to 2 times per day cise would serve as the warm-up exercise.
with home exercise program. Then “Arms Overhead with Theraband” had him begin as
Description of the Intervention with the now warm-up exercise, “Reach for the Ceiling with
The lengthening exercises began with a mild length Theraband,” movement but then maintain the tension in the
stretch to the left supraspinatus. With Mr. Halo in supine and band while moving his arms over his head to the point of
arm abducted to 90 degrees with elbow bent and on a pillow, tightness with special attention to maintaining the arm posi-
he was prompted to maintain his shoulder girdle position in tion. Once back over his head, he would hold this position for
the corrected position and then let his hand fall forward into 5 counts, and return to the ceiling position before bringing
medial rotation. arms back over his head again for another 5 counts. Then he
Once the reactivity in the left supraspinatus allowed a full returned to the reach for the ceiling position before bending
length stretch and was tolerant of mild overpressure, then a his elbows and bringing his arm back to the starting position.
full program of shoulder stretches were identified and prac- He was to perform 6 to 8 sets of 2 repetitions of this exercise.
ticed for his home program. Included were alternate shoulder
flexion, leading with thumb and then repeated leading with
back of hand, quadrant, lateral rotation, and medial rotation, Clinician Comment The reasoning for these
each with a 1-pound weight to apply mild overpressure at last 2 exercises is that the position of arms, hands, and
end range. Also included were a posterior shoulder stretch Theraband require activation of the rotator cuff muscles.
(supine) and inferior shoulder stretch (seated), each using the Rather than the possibility of these muscles firing ineffec-
right hand to provide mild overpressure. tively or stopping a contraction, the exercise ensures—as
long as the correct position is maintained and the band has
Strengthening Exercise some tension—that through the available range of motion,
Mode the humeral head will be controlled. Sometimes, at the
Supine strengthening exercise with Theraband. point where the rotator cuff muscles might have shut off if
Intensity left to their own choice, the upper extremity will begin to
Limited to ensure symptom intensity held < 2/10. shake to indicate fatigue in the muscles at that point in the
Duration range. Patients are cautioned not to progress too far into
10 minutes “the shake zone.”
Frequency
Once daily
Description of the Intervention Manual Therapy Techniques, Including
Mr. Halo was positioned in supine hook-lying with pad- Mobilization/Manipulation
ding under each elbow so that the elbow was slightly abduct-
ed from the side of his body and elevated off the table slightly
Mr. Halo’s right shoulder was mobilized with small ampli-
higher than his shoulder. Elbows were bent 90 degrees and
tude movements toward the end, and to the end (Grade III
hands slightly more abducted over the elbows.
440 Chapter 10
to IV–) of the available capsular mobility in the following Range of Motion
movements and positions:
• Left supraspinatus length now WNL and without symp-
• Inferior glide with glenohumeral joint flexed 5 degrees
toms
less than pain-free flexion range.
• Mr. Halo was independent with identified range of
• Lateral glide with glenohumeral joint flexed to 90 degrees.
motion exercises.
• Posterior-lateral glides with glenohumeral joint posi-
tioned at end range of pain free flexion. Muscle Performance
Small oscillations were delivered 2 every seconds until • Left scapular stabilization improved in upper extremity
20 were completed. Two sets of 20 oscillations were com- movements
pleted in each of the 3 positions noted previously. Following • Manual muscle testing of left supraspinatus at
each mobilization set, the “after” mobilization range was 5/5 strength without symptoms afterward.
compared with the “before” to ensure joint mobility had
• Mr. Halo was independent with identified upper extrem-
improved.
ity strengthening exercises.
Functional Training in Work (Job/School/
Play), Community, and Leisure Integration Assessment
or Reintegration, Including Instrumental
The tissue reactivity in Mr. Halo’s left supraspinatus ten-
Activities of Daily Living, Work Hardening,
don decreased to absent with palpation as well as with length
and Work Conditioning and strength testing. He reported he was able to complete
Description of the Intervention work tasks and participate in hand bell ringing with symp-
See Patient-/Client-Related Instruction. toms in control. He was independent in his home exercise
and management programs. All the anticipated goals and
expected outcomes established at the initial evaluation were
REEXAMINATION met.
Plan
Subjective
Mr. Halo was discharged to the identified home exercise
“I participated in a week-long program of bell ringing and management program.
without any pain in my shoulder.”
Objective OUTCOMES
Pain Mr. Halo was not asked to complete any formal outcome
• Reactivity to palpation of left supraspinatus tendon measures.
decreased to absent.
• Symptoms, left shoulder, controlled, 1 to 2/10, after Clinician Comment A review of the evidence
lifting tasks or hand bell choir practice/performance supports the use of a general health status questionnaire
including recent 1-week hand bell conference/workshop. and a shoulder-specific questionnaire for Mr. Halo.36
• “Awareness” level symptoms only, 1/10, at left wrist and The Functional Status Questionnaire (FSQ) is an example
elbow after week-long workshop. of a general health status questionnaire.37,38 Using Mr.
Posture Halo’s report to score the section of the FSQ on Intermediate
ADL, his score at the initial evaluation would have been 93,
• Able to maintain optimum shoulder girdle posture for whereas at discharge, he had a score of 100. These are esti-
identified supine and seated postural and shoulder- mated scores and reflect a change only in the items directly
strengthening exercises. related to Mr. Halo’s report of increased control of symp-
• Mr. Halo is able to correct his posture to optimum and toms with bell ringing and lifting activities. All of the other
maintain keyboarding tasks for 20 minutes by patient scales within the FSQ would have been scored as 100 at the
report. initial and discharge appointments based on his report.
• He is able to ring hand bells, including lower note heavy • General Health Status Questionnaire
bells, and maintain corrected posture for an entire piece, • FSQ
2 to 5 minutes, by his report.
11. American Academy of Orthopaedic Surgeons. Joint Motion:
• Intermediate ADL Method of Measuring and Recording. Edinburgh, UK: Churchill
◦ Initial = 93 Livingstone; 1965.
12. Kendall FP, McCreary EK, Provance PG, Rodgers MM, Romani
◦ Discharge = 100 WA. Muscles: Testing and Function with Posture and Pain. 5th ed.
The Disabilities of the Arm, Shoulder, and Hand (DASH) is Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
a shoulder-specific questionnaire.39 In a systematic review 13. Bijur PE, Latimer CT, Gallagher EJ. Validation of a verbally admin-
istered numerical rating scale of acute pain for use in the emergency
of the literature for shoulder questionnaires the DASH department. Acad Emerg Med. 2003;10(4):390-392.
received the best ratings for its clinimetric properties.40 14. Bernard B, Sauter S, Fine L, Petersen M, Hales T. Job task and
Further, it showed reliability and validity with a broad psychosocial risk factors for work-related musculoskeletal disor-
spectrum of upper extremity disorders.41 Again, using Mr. ders among newspaper employees. Scan J Work Environ Health.
Halo’s report to score the standard questionnaire as well as 1994;20(6):417-426.
15. Fjellman-Wiklund A, Sundelin G. Musculoskeletal discomfort of
the Sports and Performing Arts supplement to the DASH, music teachers: an eight-year perspective and psychosocial work
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Shoulder-Specific Questionnaire: DASH. 16. Côté P, Kreitz BG, Cassidy JD, Dzus AK, Martel J. A study of the
diagnostic accuracy and reliability of the Scoliometer and Adam’s
INITIAL DISCHARGE forward bend test. Spine (Phila Pa 1976). 1998;23(7):796-802.
17. Griegel-Morris P, Larson K, Mueller-Klaus K, Oatis CA. Incidence
Standard 22.5 0 of common postural abnormalities I the cervical, shoulder and
thoracic regions and their association with pain in two age groups
Sports/Performing 12.5 0 of healthy subjects. Phys Ther. 1992;72(6):425-431.
Arts Module 18. Ludewig PM, Cook TM. Alterations in shoulder kinematics and
associated muscle activity in people with symptoms of shoulder
impingement. Phys Ther. 2000;80(3):276-291.
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time period required to show improvement in his symp- Comparison of 2-dimensional scapular position and orientation
toms suggested that he had tendonitis. On the other hand, between subjects with and without shoulder impingement. J Orthop
Sports Phys Ther. 1999;29(10):574-583.
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assisted with a tendon that might have been headed toward Syndromes. St. Louis, MO: Mosby; 2002.
a more tendinopathy situation. 21. Paris S, Loubert P. Foundations of Clinical Orthopedics. 3rd ed. St.
Augustine, FL: Institute Press; 1999.
22. Magee DJ. Orthopedic Physical Assessment. 5th ed. St. Louis, MO:
Saunders Elsevier; 2008.
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Baltimore, MD: The Neuro Orthopaedic Institute; 2010.
24. Butler DS. The Sensitive Nervous System. Adelaide, Australia:
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1992;13(10):1311-1315.
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1998;30(8):1183-1190.
5. Habtezion A, Silverberg MS, Parkes R, Mikolainis S, Steinhart AH.
28. Gross MT. Chronic tendonitis: pathomechanics of injury, factors
Risk factors for low bone density in Crohn’s disease. Inflamm Bowel
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6. Medline Plus. U.S. National Library of Medicine and National
29. Kamkar A, Irrgang JJ. Whitney SL. Nonoperative management of
Institutes of Health. http://www.nlm.nih.gov/medlineplus/dru-
secondary shoulder impingement syndrome. J Orthop Sport Phys
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30. Philadelphia Panel. Philadelphia Panel evidence-based clinical
7. National Cholesterol Education Program. Detection, Evaluation
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Individuals With
11
Systemic Musculoskeletal and
Connective Tissue Disorders
◦ Osteoporosis and Exercise

CHAPTER OBJECTIVES ◦ Outcomes
• List the factors that place women at greater risk for ◦ Physical Therapy Management
osteoporotic fractures than men. ▪ Examination
• Outline the ratio of osteoblastic activity to osteoclastic ▪ Physical Therapy Intervention Considerations
before the age of 25 years and after age 30.
• Rheumatoid Arthritis
• Discuss the various roles exercise can play in osteoporo-
◦ Overview and Epidemiology
sis management.
◦ Pathophysiology
• Outline the progression of events that occur with rheu-
matoid arthritis in an involved joint. ◦ Diagnosis
• Identify body organs—other than joints—that can be ▪ Subclassification of Rheumatoid Arthritis by
involved in rheumatoid arthritis. Pathology
• Identify 4 subcategories of rheumatoid arthritis and the ▫ Lupus
disease process for each. ▫ Scleroderma
• Discuss the evidence that changed the perception of the ▫ Gout
role of exercise in managing patients with rheumatoid
▫ Ankylosing Spondylitis
arthritis.
◦ Medical Intervention
◦ Rheumatoid Arthritis and Exercise
CHAPTER OUTLINE ◦ Outcomes
◦ Physical Therapy Management
• Osteoporosis
▪ Examination
◦ Overview and Epidemiology
▪ Additional Considerations
◦ Pathophysiology
▪ Focus on Function
◦ Diagnosis
▪ Exercise Prescription
◦ Medical Intervention
• References

444 Chapter 11
Systemic musculoskeletal diseases are those that affect osteoporotic vertebral body fractures are most prevalent, hip
connective tissue throughout multiple organ systems, includ- fractures are associated with the greatest mortality and mor-
ing the musculoskeletal system. Many of the consequences bidity. Mortality following a hip fracture has been reported
of musculoskeletal and connective tissue symptoms, which to be as high as 33% in the first year following fracture.12
include limitations in functional activity performance, loss Among those who survive a hip fracture, only 25% regain
of independence, social isolation, depression, and a decrease their previous level of function.13
in the ability to work and generate income occur among
individuals with systemic musculoskeletal diseases. Two of Pathophysiology
the most common systemic musculoskeletal diseases seen in
physical therapy clinics are discussed below. A third com- Normal bone tissue is continuously remodeling. This
mon musculoskeletal disease is discussed in the context process occurs as osteoblasts produce new bone tissue by
of a case. Together, they exemplify the thought processes creating a protein matrix that later calcifies, and osteoclasts
required of a physical therapist to manage patients with these reabsorb bone tissue by stimulating production of acids and
complex, multi-organ disorders. enzymes that dissolves older bone.
Peak bone mass occurs between the ages of 25 and
30 years. Prior to achieving peak bone mass, net osteoblas-
OSTEOPOROSIS tic activity exceeds net osteoclastic activity. After achiev-
ing peak bone mass, anatomic and physiologic aging cause
osteoclastic activity to exceed osteoblastic activity, thus there
Overview and Epidemiology is greater bone removal than replacement. This disequilib-
rium eventually leads to osteoporosis. The presence of spe-
Osteoporosis is defined as a condition characterized by a
cific medical conditions can also cause the balance between
decrease in bone mass and micro-architectural deterioration
osteoblastic and osteoclastic activity to be disrupted in favor
of bone leading to bone fragility and greater risk of bone frac-
of osteoclastic activity. Trabecular, or cancellous, bone has a
ture.1,2 Approximately 10 million Americans over the age of
greater turnover rate than cortical bone. Areas such as the
50 have osteoporosis, and an additional 34 million have low
vertebral body, hip, and wrist, which have relatively higher
bone mineral density.3 In 2005, an estimated $17 billion was
percentages of trabecular bone than other bones, are there-
spent on health care costs for osteoporotic fractures alone.3
fore most susceptible to osteoporotic fractures.1
After achieving peak bone mass between the ages of 25 and
The disequilibrium between osteoblastic and osteoclastic
30 years, men lose approximately 0.5% to 1% of total bone
activity is accentuated in postmenopausal women, since the
mass per year.4,5 Before undergoing menopause, women have
onset of menopause is associated with a reduction in estro-
similar rates of bone loss. However, this loss is accelerated
gen, and estrogen is responsible for the inhibition of bone
immediately following menopause because of a decrease in
reabsorption.14 In some medical conditions, such as those
the production of estrogen. During the 6 years after undergo-
that are treated pharmacologically with glucocorticoids, this
ing menopause, bone loss can occur at a rate 3 to 10 times
disequilibrium is compounded by a disruption of the micro-
greater than what occurs during the premenopausal years.6
architectural integrity of bone tissue, resulting in a reduction
By the age of 65 to 70, men and women once again lose bone
in the quality and quantity of the bone tissue that is formed.2
mass at a similar rate.7 Men, however, are protected from
osteoporosis by their larger bones and increase in bone mass Osteoporosis is classified by etiology as either primary or
at peak bone age, even when taking body size into account.7 secondary. Primary osteoporosis is associated with biological
changes that take place throughout the life span, and includes
Women are therefore at greater risk for osteoporotic
Type I and Type II forms. Type I primary osteoporosis occurs
fractures than men. It has been estimated that up to 60%
in postmenopausal women in conjunction with a decrease in
of women over the age of 50 will sustain at least one osteo-
estrogen, whereas Type II primary osteoporosis is associated
porotic fracture in their lifetime.8 For a man, this lifetime
with the aging process. Secondary osteoporosis is character-
risk is estimated to be 20%.9 While the incidence of osteo-
ized by bone loss caused by medical conditions including cer-
porotic fractures is difficult to determine directly, in one
tain metabolic and nutritional disorders, the intake of some
model it was determined that at least 90% of all hip and
medications, and immobilization with resultant loss of muscle
spine fractures among elderly White women are attributable
function. Primary osteoporosis is therefore far more preva-
to osteoporosis. Smaller percentages of fractures attributable
lent than secondary osteoporosis. The common risk factors
to osteoporosis occur among other populations, and among
for osteoporosis are numerous, and are listed in Table 11-1.
fractures in other bones.10
Specific causes for many of these risk factors are unknown.
Osteoporotic fractures occur most often in the hip,
vertebral body, and wrist. In relation to hip fractures, inci-
dence increases exponentially after age 70. In contrast, the Diagnosis
incidence of vertebral body fractures increases beginning The presence of osteoporosis alone is not associated with
around age 60, but at a much less dramatic rate than that of pain or functional limitations. The primary pathologic
hip fractures; and the incidence of wrist fractures increases concern with osteoporosis is that the associated bone loss
until around age 70 and then decreases slightly.11 Whereas increases the likelihood of sustaining a fracture, which
Individuals With Systemic Musculoskeletal and Connective Tissue Disorders 445
TABLE 11-1. COMMON RISK FACTORS FOR OSTEOPOROSIS

FACTOR CATEGORIES RISK FACTORS
Demographic risk factors ● Female sex
● Age
● Low body weight (less than 127 pounds)
● Family history of osteoporosis
● Caucasian or Asian race
Medical risk factors ● Long term use of corticosteroids
● Antiseizure medication
● Gonadotropin hormone medication
● Immunosuppression medication
● Excessive use of aluminum-containing antacids
● Medication to treat some gastrointestinal diseases, such as Cushing s syndrome
● Excessive thyroid hormone medication
● Certain anticancer medications
● Treatments that decrease estrogen levels
● Paralysis
● Prolonged immobilization
● Chronic kidney, liver, lung or gastrointestinal disorders
● Hypogonadism
● Turner s or Klinefelter syndrome
● Myeloma
● Postmenopause, amenorrhea
● Anorexia Nervosa
● Low testosterone levels in men
Lifestyle risk factors ● Inadequate physical activity
● Low calcium/vitamin D intake
● Excessive use of alcohol
● Current cigarette smoking
frequently does result in significant pain and loss of func- reduction in the T-score, the risk of hip fracture increases
tion. The diagnosis of osteoporosis is often not made until a approximately 2.6 times.8
pathological fracture occurs, as the occurrence of the patho- T-scores of between –1 and –2.5 identify an individual as
logical fracture prompts an investigation of the underlying being osteopenic, or “preosteoporotic.” Osteoporosis is diag-
cause. Osteoporosis is therefore referred to as the “silent nosed when an individual has a T-score of –2.5 or less. An
disease” because it is asymptomatic until a fracture occurs. individual with a T-score of –2.5 or less who has sustained
Osteoporosis can be identified through the quantifica- a fracture is considered to have “established” osteoporosis.
tion of bone loss. Bone loss is detected by evaluating bone All patients with known risk factors for osteoporosis
mineral density, or bone mass using radiography. The gold should be screened for bone loss. DXA scans are therefore
standard for determining bone mass is a dual-energy X-ray recommended for the following individuals:
absorptiometry (DXA) scan of the hip and spine. Results are • All women aged 65 years or older
reported using T-scores. T-scores are reported in standard
• Women considering medication for osteoporosis
deviations, and represent the amount to which the individual
deviates from an average 30-year-old of similar sex and race/ • Postmenopausal women under age 65 with one or more
ethnicity. A 1 standard deviation reduction in the T-score is additional risk factors
equivalent to a 10% to 20% decrease in bone mineral den- • Postmenopausal women who present with a fracture2,11
sity.2 In relation to osteoporosis of the hip, for every 1-point
446 Chapter 11
Medical Intervention increasingly more difficult. Irrespective of age, premeno-
pausal women respond more favorable to exercises directed
One key to preventing osteoporosis is to build bone mass at addressing osteoporosis than postmenopausal women.18
during the skeletal growth years and early adulthood.15-17 Most clinical studies addressing the effect of exercise on
At-risk individuals include those who did not achieve suffi- osteoporosis measured outcomes related to bone density.
cient levels of exercise at this key stage in bone development, While measures of low bone density are strongly predictive
as well as those with nutritional deficiencies, including eating of fractures, bone density changes per se do not change levels
disorders. of pain or functional limitations.
An adequate intake of nutrients, especially calcium and To stimulate osteogenesis through exercise, workloads
vitamin D, is fundamental to preventing and treating osteo- must exceed the daily strains experienced when perform-
porosis. For older adults, who are at a higher risk of osteopo- ing usual activities.21 Some types of exercises have a greater
rosis, current recommendations include between 1000 and effect on maintaining or increasing bone mineral density
1500 mg of calcium, and between 800 and 1000 international than others; however, the exact type and intensity of exercise
units (IU) of vitamin D per day.2 Many older adults, espe- that is required to optimize net bone reabsorption has not yet
cially those who are institutionalized, do not get sufficient been determined. Most of the studies that were performed
amounts of calcium and vitamin D to maintain bone health.9 on humans included only women as subjects; therefore the
If a physical therapist suspects that a patient with osteoporo- generalizability of these study results to men is questionable.
sis has a dietary deficiency, a consultation with a nutritionist In those studies that did include men, results suggested that
is recommended. outcomes from exercise were equivocal22 if not better for
Among women, the extent to which bone mass can men than for women.23
be maintained or increased depends on the individual’s Some broad exercise considerations are especially appli-
menopausal status: premenopausal women are more likely cable to individuals who have or are at-risk for developing
to demonstrate gains in bone mass with exercise than post- osteoporosis. Patients must first recognize that they need to
menopausal women.18 While exercise remains a component perform specific exercises, because simply increasing activ-
of the medical management of postmenopausal women and ity level is not sufficient to increase, maintain or minimize
all other patients with osteoporosis, once significant bone loss of bone mass.21 Furthermore, to maintain the benefits of
loss has been identified in postmenopausal women, the focus exercise, an exercise program must be performed on an ongo-
of the medical management is on pharmaceutics while also ing basis throughout the lifespan, because improvements
maintaining an appropriate intake of calcium and vitamin in bone density are reversed when the exercise program
D.19 is discontinued.24,25 It is therefore important to consider
Many patients with osteoporosis are managed pharma- motivational factors when prescribing an exercise program
cologically with bisphosphonates (alendronate, ibandronate, for treatment of osteoporosis. A patient is more likely to
risedronate, zoledronate). Those patients who do not toler- adhere to an exercise regimen if it is enjoyable or meets that
ate bisphosphonates can often manage their bone loss with patient’s recreational goals. Finally, the effects of exercise on
selective estrogen receptor modulators (raloxifene) or with bone mass can occur only if the individual ingests adequate
calcitonin. Short-term treatment with parathyroid hormone amounts of calcium and vitamin D.
(teriparatide) can be an option for patients with severe dis- The evidence supports the implementation of exercise
ease.2,9 One other option for patients with severe disease for the treatment and prevention of osteoporosis. In a 1999
is Denosumab, which is typically administered at 6-month meta-analysis, the authors concluded that there is a small
intervals by injection.20 improvement of approximately 1% with either endurance or
Once a fracture has occurred, treatment is similar to that strengthening exercises on hip and spine bone density in pre-
provided to a patient who does not have osteoporosis. Since and postmenopausal, nonosteoporotic women.26 In 2 more
bone stock is compromised in patients with osteoporosis, recent critical reviews, the authors concluded that exercise
these patients present with an increased risk of delayed heal- results in a slight improvement in bone mineral density in
ing, and in the case of surgical intervention, a decrease in the postmenopausal women27 and a small reduction in fracture
ability of the bone stock to support the surgical procedure risk in older adults.28
that was performed. Specific exercise recommendations have been outlined in
2 separate position papers. The Canadian Academy of Sports
Osteoporosis and Exercise and Exercise Medicine recommend performing weightbear-
ing endurance exercises for 30 to 60 minutes 3 to 5 days per
Bone responds to alterations in mechanical stress in a week, and strength training 3 days per week.29 Similarly, the
manner similar to that of other connective tissue. Inactivity Belgium Bone Club recommends 15 to 60 minutes of weight-
decreases bone strength, whereas muscle contraction and bearing endurance exercises and a series of strength train-
the gravitational force involved with weightbearing act as a ing exercises performed 2 to 3 times per week. The exercise
stimulus to increase bone strength. Loss of bone mass can program should be performed at an intensity of 70% to 80%
therefore theoretically be reversed with exercise; however, functional capacity or maximum strength. All strengthening
with advancing age, the restoration of bone mass becomes exercises should be site-specific.30
One additional concern for patients with osteoporosis motion, and posture. Emphasis is placed on alignment, joint,
involves the increase in the kyphotic curvature of the spine and muscle impairments that affect pain and/or function.
that accompanies vertebral body fractures. Thoracic kypho- The examination of posture is especially important if the
sis has been shown to have an adverse effect on functional patient is female and over 50 years of age, since osteoporotic
activities, especially those activities that involve mobility vertebral fractures are often asymptomatic34 and therefore
tasks.31 In one study, exercise, consisting of stretching, pos- undiagnosed. Undiagnosed patients who have experienced
ture retraining, respiratory muscle strengthening, and walk- a loss of height or an increase in their kyphotic curvature
ing was effective in reducing the kyphotic curvature in might benefit from a medical referral for a work-up for pos-
subjects with demonstrated osteoporosis of the spine.32 sible osteoporosis, since these changes are often associated
with vertebral body osteoporotic fractures in older adults.
Outcomes Since patients with osteoporosis are at increased risk
of fracture following a fall, fall risk is also often evaluated
Depending on the age and sex of the patient, the etiology/ during the physical examination. Several assessment tools,
type and extent of osteoporosis, and the drug regimen, it is such as the Tinetti Balance Test, the Berg Balance Scale, and
possible to increase bone mass. Nevertheless, for many post- the Timed Up-and-Go Test are commonly used by physical
menopausal women, exercise-related treatment goals focus therapists to assess risk for falls. Nevertheless, none of these
on preventing or minimizing further bone loss and subse- aforementioned tools have been shown to be highly predic-
quent fracture, and countering the effects of prior fractures. tive of falls in at-risk patients.35 Test results might be better
In most cases, drug therapy is required to reverse bone loss used to identify areas requiring intervention than simply to
in this population.19 For males, females who are premeno- identify those at high risk for subsequent falls.
pausal, and those who have developed osteoporosis because Finally, any examination procedure that could potentially
they were immobilized, reversal of bone loss by performing cause a fracture must not be performed. For example, the
strenuous exercises and increasing activity levels is a more examination of joint accessory motion in joints composed
realistic goal.33 Outcomes for individuals with osteoporosis of bones with osteoporotic changes is not routinely recom-
from other causes have not been studied. mended in patients with osteoporosis.36
Physical Therapy Management Physical Therapy Intervention

Considerations
Examination As with any other patient with a musculoskeletal con-
The physical therapy examination procedures performed dition, interventions for the patient with osteoporosis are
on a specific patient vary from patient to patient, depending determined through a process of integrating examination
on the specific goals, symptoms, and physical presentation findings and patient goals. There are several issues, however,
of each individual. For example, for an older female patient listed below, that are directly related to the management of
with a known lumbar vertebral body osteoporotic fracture, the patient with osteoporosis.
the history would focus on the presence and nature of lumbar Since fractures often result from falls,11 ensuring a safe
pain and changes in lumbar curvature, and subsequent func- environment and monitoring the patient during exercise to
tional limitations. The physical examination would focus prevent falls is an important component of injury prevention.
on the physical properties of the lumbar spine and lower This includes guarding and providing balance support when
extremities, such as posture, range of motion and strength, indicated. The physical therapist also considers implement-
and the results of pain-provocation tests. Nevertheless, the ing an intervention consisting of fall reduction strategies. If
physical therapy examination and evaluation of a patient balance is impaired, exercises to improve balance and pro-
with a diagnosis of osteoporosis follow the same history prioception are a component of the patient’s program, even
taking, systems review, and testing procedures as for most though these exercises are not likely to have a direct impact
musculoskeletal conditions, with several additional consid- on bone mass. The therapist also considers other strategies to
erations described next. reduce the number and impact of falls, such as providing the
During the history portion of the examination, the thera- patient with gait assistive devices and hip pads.
pist obtains information regarding the severity of the osteo- Patients with osteoporosis are at risk of fracture from
porosis, to determine the patient’s risk for fracture during resistive and aerobic exercises. Nevertheless, resistive and/or
activities of daily living (ADL) as well as during a prescribed aerobic exercises are necessary for bone loss to be minimized
exercise program. The therapist also solicits medical and or reversed. There is currently no protocol for determining
musculoskeletal information that would affect the patient’s safe exercise parameters from the perspective of avoiding
strengthening and weightbearing exercise program. For fractures in osteoporotic individuals. Physical therapists
example, a known cardiac history would potentially modify therefore evaluate the medical and physical status of the
the prescription for load in a strengthening exercise program. patient, including the extent of bone loss, and make a judg-
The physical examination includes specific tests, such as ment regarding the maximal amount of exercise that the
anthropometric measures, ergonomics and body mechanics, patient can safely tolerate. For example, patients with severe
gait, locomotion and balance, muscle performance, range of osteoporosis should not engage in high-impact exercises.
448 Chapter 11
When uncertain as to whether the patient can tolerate a spe- invades the pannus and forms scar tissue within the joint
cific exercise, the therapist does not prescribe that exercise space. This fibrous tissue eventually calcifies, resulting in
to the patient. bony ankylosis. The end result of these processes is a joint
Certain spinal movements increase compressive forces on that is stiff, weak, painful, and deformed.
the vertebral bodies, increasing the likelihood of compression Since the primary tissue affected by RA is the joint
fractures. To prevent vertebral body fractures, the therapist synovium, the hallmark finding in RA is joint redness,
instructs the patient to avoid positioning in spinal flexion, as swelling, stiffness, and pain. Nevertheless, other organs are
well as resisted rotation, while exercising.37 For similar rea- commonly affected. Anemia is prevalent among individuals
sons, the therapist discourages flexed posture positions and with RA. Rheumatoid nodules and dermal vasculitic lesions
twisting while lifting during ADL with patients with known often form in the skin. The eyes can become affected by
osteoporosis. keratoconjunctivitis sicca, episcleritis, and scleritis. As liga-
ments become weakened, cervical spine instability, as well
as peripheral nerve entrapment, is a common occurrence.
RHEUMATOID ARTHRITIS Interstitial lung disease and pericardial effusion is present in
many individuals with RA, although these latter 2 conditions
are often asymptomatic.38,40
Overview and Epidemiology Muscle is also targeted in patients with RA. From a meta-
Rheumatoid arthritis (RA) is a chronic, multi-systemic bolic perspective, the disease process associated with RA
disease affecting almost 1% of the population of North results in a catabolic state. Therefore, generalized muscle
America.38 It is nearly 3 times more common among women weakness is a common finding.41,42 Other conditions con-
than men.38 Researchers have estimated that there is a 50% tributing to muscle weakness in patients with RA include
probability of work disability within 4.5 to 22 years following side effects of the medications used to treat the condition,
diagnosis.39 The most apparent manifestation of RA is the and deconditioning secondary to pain and fatigue.
gradual destruction of articular cartilage and bone. Joints
that are most often affected include the hands, wrists, shoul- Diagnosis
ders, elbows, cervical spine, and hips; and to a lesser extent,
In 1987, the American Rheumatism Association published
the knees, and ankles and feet.38
a list of 7 specific criteria that identifies the presence of RA.43
RA is characterized as an autoimmune disease. This diagnostic classification system was in common usage
Autoimmune diseases are those in which the body’s immune until recently. In response to the finding that patients who
system responds to a “false alarm,” inappropriately trigger- are diagnosed and treated early have better outcomes, new
ing an inflammatory response and fighting the body’s own criteria for diagnosing RA were developed in 2010.44 These
proteins when there is no foreign substance to fight off. In criteria are provided in Table 11-2.
the case of RA, the targeted structure is the joint. The exact
RA is therefore a medical diagnosis that is determined by
cause(s) of RA is unknown. Genetic factors have been impli-
the presence of a combination of signs, symptoms, and medi-
cated, since RA is more likely to occur among family members
cal tests. Nevertheless, clusters of signs and symptoms indicat-
of individuals with RA. Environmental triggers that have yet
ing the presence of RA are identifiable by physical therapists
to be identified may also play a role in the etiology of RA.38
during the evaluation of musculoskeletal pain. It is therefore
Onset can begin at any age, but RA most often becomes imperative that when a physical therapist identifies some of
symptomatic in individuals between the ages of 35 to these signs and symptoms that indicate that the patient might
50 years. During this range in age, many patients are raising have RA, the therapist refers that patient to a rheumatologist
families and making significant career inroads. The impact for diagnosis and medical management. In the case of the
of this disease on functional activity performance and qual- aforementioned RA diagnostic criteria, categories A and D can
ity of life therefore can be severe. be observed by a physical therapist (see Table 11-2).
Pathophysiology Subclassification of Rheumatoid Arthritis

by Pathology
The primary target of the autoimmune process associated
There are more than 100 different types of diseases clas-
with RA is the synovium, resulting in a joint capsule that is
sified as RA, each with a different pattern of targeted organ
thickened and inflamed.40 As synovial fluid levels increase,
damage, and resultant differences in signs and symptoms.
the joint swells. This inflammation also causes contractile
An accurate diagnosis within these subcategories is often
tissue surrounding the joint to spasm, shorten, and lose
difficult, since many patients do not present with typical
strength, eventually causing the corresponding joint to sub-
symptoms for a particular sub-category of RA, and most sub-
lux. Over time, the synovial tissue becomes weakened from
categories are characterized by joint swelling and destruc-
the enzymatic action of inflammation on collagen tissue.
tion. It is also unclear from a physiological perspective how
Pannus, a flap consisting of granulation tissue, forms within
these different subcategories differ from one another. Several
the joint and eventually attacks adjacent bone and cartilage,
of these rheumatoid subcategories are described next.
causing these structures to erode.40 Fibrous tissue gradually
TABLE 11-2. THE 2010 ACR/EULAR CLASSIFICATION CRITERIA FOR RHEUMATOID ARTHRITIS
CLASSIFICATION CRITERIA FOR RHEUMATOID ARTHRITIS (RA) SCORE
A. Joint Involvement
1 large joint 0
2 to 10 large joints 1
1 to 3 small joints (with or without involvement of large joints) 2
4 to 10 small joints (with or without involvement of large joints) 3
> 10 joints (at least 1 small joint) 5
B. Serology (At least 1 test result is needed for classification)
Negative RF and negative ACPA 0

Low-positive RF or high-positive ACPA 2
High-positive RF or high-positive ACPA 3
C. Acute-Phase Reactants (at least 1 test result is needed for classification)
Normal CRP and normal ESR 0

Abnormal CRP or abnormal ESR 1
D. Duration of Symptoms
< 6 weeks 0
> 6 weeks 1
Target population: Patients who have at least one joint with definitive clinical synovitis and in whom the synovitis is not better explained
by another disease. Add the score of categories A to D; a score of > 6 (out of possible 10) is needed for classification of a patient as having
definite RA. ACR: American College of Rheumatology; EULAR: European League Against Rheumatism; RF: rheumatoid factor; ACPA: anti-
citrullinated peptide antibody; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate.
Adapted from Aletaha D, Neogi T, Silman AJ, et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/
European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010;62(9):2569-2581.
Lupus individual to individual, and can cause symptoms ranging

Lupus is a sub-category of RA characterized by a red, but- from mild to severe.45
terfly-shaped rash that appears across the nose and cheeks. In the more mild form, termed localized scleroderma,
In addition to its effects on joints and skin, lupus also affects symptoms are usually limited to the skin, although muscles
the kidneys, heart, and blood-forming organs, nervous sys- and bones also can be affected. Skin symptoms consist
tem, eye, mucous membranes, lungs and, to a lesser extent, of whitish, hard, oval-shaped patches that sometimes are
the gastrointestinal and peripheral vascular systems. Patients accompanied by a purple ring (morphea-type lesions), or
with lupus are especially susceptible to infection, and have lines of thickened skin (linear-type lesions). Both of these
increased risk for kidney failure and greater sun sensitivity.45 skin lesions limit joint motion, since they produce scarring
Lupus is 10 times more common in women than men. that infiltrates bone and muscular tissue.46
It is also more prevalent among people of African ancestry. The more severe form of scleroderma is called systematic
Symptoms generally begin to appear between the ages of scleroderma. In some cases of systematic scleroderma, skin
15 and 45 years. lesions are limited to the face, hands, and fingers. In other
cases, onset is rapid, skin thickening occurs throughout the
Scleroderma body, and arthritic symptoms resembling those of RA are
Scleroderma is an autoimmune disease that is charac- present. Reduced function can occur in joints, muscles and
terized by the production of excessive collagen. Signs and hands. Other organs, including the gastrointestinal track,
symptoms of this condition are caused by inflammation lungs, heart, and kidneys are often targeted.46 Pulmonary
and resultant fibrosis of multiple tissues, including the skin, hypertension is especially prevalent in this population, and
blood vessels, synovium, skeletal muscle, and certain internal is a common cause of mortality.47
organs such as the kidneys, lungs, heart, and gastrointestinal
system. The finding most characteristic of this rheumatic Gout
condition is skin thickening and tightening, beginning at the Gout is a form of inflammatory arthritis caused by an
distal extremities and progressing proximally. As with other increase in serum uric acid or a decrease in the ability to
rheumatic diseases, symptoms of scleroderma vary from excrete uric acid from the blood secondary to an abnormality
450 Chapter 11
in purine metabolism.48 This increase in uric acid in the used in the early stages of the disease. If RA symptoms are
blood causes urate crystals to form in joint synovium and mild, these medications can be used throughout the patient’s
surrounding tissues.48,49 The lifetime prevalence of gout lifespan. Steroids have traditionally been used in more
is estimated to be approximately 2%48; affecting primarily severe cases to control joint inflammation; however, the side
older men.48,49 effects of long-term steroid use can be severe. More recently,
Gout is characterized by a sudden onset of excruciating a different class of medication, called disease modifying
joint pain accompanied by joint swelling, warmth, and rubor. antirheumatic drugs (DMARDs), has been developed. These
The joint most commonly affected by gout is the first meta- medications interrupt the autoimmune reaction, thus reduc-
tarsophalangeal joint.48,49 About 50% of patients with initial ing many of the symptoms of RA. Often, different patients
onset of gout have recurring symptoms. Recurrent gout can react differently to the same medication. Finding an effective
result in chronic arthritis with associated pain and joint stiff- drug regimen therefore often involves a series of medication
ness.49 Acute gout is most often treated with anti-inflamma- trial and error.
tory medication. With individuals who have recurrent flares,
management consists of medications to reduce the levels of Rheumatoid Arthritis and Exercise
serum uric acid, such as allopurinol or febuxostat.48 With
proper medical management, an individual with chronic For many years, most therapists believed that patients
gout can live a normal life.49 with RA should perform only exercises that place small
amounts of stress on joints, such as active range of motion
Ankylosing Spondylitis and isometric strengthening. The goal was to minimize the
Ankylosing spondylitis is characterized by back pain and loss of range of motion and muscle strength that commonly
stiffness, beginning in the lower lumbar and pelvic regions, occurs with disease progression. Therapists were reluctant to
and progressing up the spine. In addition to spinal pain and prescribe more aggressive exercises, such as resistance train-
stiffness, patients with ankylosing spondylitis often experi- ing, for patients with RA because they believed that these
ence eye symptoms, fever, and fatigue. At the end stages of exercises would increase pain, accelerate joint destruction,
the disease, the shoulders, hips, and knees become affect- or exacerbate the disease process. Unfortunately, for patients
ed. Ankylosing spondylitis is more common in men than with RA, as with most other chronic conditions, more
women,50 with symptoms usually beginning before the age aggressive exercises often are required to improve functional
of 40. Unlike most other rheumatic conditions, patients with levels and quality of life. This incongruity was the catalyst for
ankylosing spondylitis are negative for rheumatoid factor a number of recent studies evaluating outcomes of exercise
(RF), one of the blood markers that help diagnose RA. for patients with RA have been performed.
With ankylosing spondylitis, the vertebrae gradually The results of these studies have been synthesized in
ossify as the disease progresses, resulting in a characteristic several recent literature reviews addressing the safety and
bamboo-like appearance to spinal structures on radiographs. effectiveness of exercise in patients with RA.41,51-59 One of
The spine also becomes progressively more osteoporotic, and the early reviews51 addressed the efficacy of all types of ther-
therefore is more susceptible to fracture. Frequently, as with apeutic exercise. Based on a review of 17 studies, the authors
many other forms of RA, the ligaments of the atlantoaxial concluded that there was good evidence that therapeutic
joint become lax, potentially resulting in spinal cord or brain exercise benefits patients with RA by reducing pain, increas-
stem compression. ing muscle strength, and improving functional status. They
In the early stages, ankylosing spondylitis often is misdi- further concluded that the exercise program should include
agnosed as mechanical low back or sacroiliac joint pain. It functional training and either high- or low-intensity exercise.
therefore should be suspected in any patient who is less than This critical review was helpful in dispelling the belief
40 years of age and reports pain and stiffness in the mid- or low that exercise can be detrimental to patients with RA, as it
back for longer than 3 months, especially if the patient is male. demonstrated that exercise does not increase pain or exacer-
bate joint destruction. Nevertheless, it was not useful in pin-
Medical Intervention pointing the specific effects of high- vs low-intensity exercise,
or in determining which type of exercise is most beneficial.
There is currently no cure for RA. Pharmacological man- As a reaction to these concerns, 3 additional critical reviews
agement is the primary treatment for this condition. The were performed, specifically addressing moderate- and/or
main goal of pharmacological management is to control high-intensity exercise programs.
intra-articular swelling, thereby minimizing the progressive
In a literature review performed by Hakkinen,54 only
destruction of articular structures. Once the joint has been
moderate- or high-intensity strengthening exercises were
destroyed, the only recourse is joint surgery. Early pharma-
studied. These exercises were effective in increasing muscle
cological treatment is therefore crucial to minimize pain and
strength, and did not cause adverse effects on pain or disease
loss of function.
progression in the short term. Only one study in this review
Several classes of medications are used to control the followed subjects for a relatively long period of time. The
inflammatory component of RA. The most often prescribed authors therefore could not draw firm conclusions regarding
class of medications is commonly known as nonsteroidal long-term effects on function or disease progression.54
anti-inflammatory drugs (NSAIDs). These drugs often are
A landmark critical review53 included only studies in Several recommendations can be extrapolated from com-
which a randomized controlled trial was performed, the bining our knowledge of exercise physiology with the infor-
exercise program was performed at an intensity of more than mation acquired from these publications:
60% of the identified maximal heart rate for at least 20 min- • Regular physical activity is not detrimental to patients
utes, exercises were performed at least twice a week, and the with RA, and should be incorporated into their lifestyle.
exercise program lasted 6 weeks or longer. Six studies met
• An individually tailored supervised program of high-
these criteria. The authors concluded that these exercise pro-
intensity exercises can be beneficial to patients with RA,
grams increased aerobic capacity and muscle strength. There
unless there is extensive joint damage in large joints.
were no adverse effects on pain or disease activity; however,
the effects on function and radiologic changes were unclear. • The specific type of high-intensity exercise program that
52
A 2005 review included those studies that evaluated the will produce optimal gains in function and pain reduc-
effects of long-term moderate- or high-intensity exercises, tion is unknown; however, it is likely that patients will
and therefore provided greater insight into the effects of obtain different benefits from different types of exer-
these exercises on function and disease progression. The cises. The optimal exercise program therefore includes
authors concluded that moderate- or high-intensity exer- both strengthening and endurance type of exercises, and
cises improve aerobic capacity, muscle strength, functional is based on the functional goals and the motivational
ability, and psychological well-being. Furthermore, these level of the individual patient.
exercises did not appear to have an adverse effect on disease • While the specific benefits of aquatic exercises for
activity or radiologic evidence of progression of joint dam- patients with RA are not known, this method of exercis-
age of the small joints such as the hands and feet. However, ing might provide the patient with joint impairments
damage to large weightbearing joints with preexisting joint a means of performing high-intensity exercise without
damage, especially the joints of the shoulder and subtalar unduly affecting pain levels.
region, could not be ruled out. This issue was addressed in a
• Pain often is increased during or after exercise. Physical
subsequent clinical trial, in which investigators studied high-
therapy interventions to manage pain can improve the
intensity exercises with respect to progression of damage in
patient’s tolerance to exercise.
large joints. These investigators concluded that high-intensi-
ty exercises were safe, except for a subpopulation of subjects • The exercise program should be modified, based on
55
with preexisting extensive joint damage. These conclusions changes in the medical status and the functional goals
related to the efficacy of aerobic and/or strengthening exer- of the individual patient, but the intensity of exercise
cises have been confirmed in several subsequent systematic should not be decreased simply because the patient is
reviews of exercise and RA. In each of these reviews, the experiencing a flare.
authors concluded that exercise has no adverse effects. 56-60 • When joint damage and/or structural impairments are
For many patients, RA is characterized by flares and present, the involved joints should be provided with
remissions. Flares are characterized by an increase in symp- external support when exercising muscles surrounding
toms, usually accompanied by joint inflammation, and can these joints. External support can be provided through
be confirmed with blood tests. Traditionally, the manage- the use of equipment such as braces, tape, assistive devic-
ment of a patient with RA who is in a flare has been different es, and parallel bars. Changes in the manner in which
from when that patient is in remission. The goals of exercise the specific exercise is being performed to provide more
during a flare were to maintain range of motion and mini- protection to the joint can also be implemented.
mize loss of strength without incurring additional damage • Moderate- or high-intensity exercises involving joints with
to joint structures. Most often, this entailed an exercise pro- preexisting extensive joint damage should be avoided.
gram consisting of active range of motion exercises, pacing of
daily activities, and advice to remain relative sedentary. In a To investigate the possibility that the optimal type of
2000 randomized clinical trial, these assumptions were chal- exercise program varies across patients with different sub-
lenged. In this study, the effects of an intensive exercise pro- categories of RA, a number of studies restricted subjects to
gram consisting of isokinetic and isometric strength training a specific RA type. In a 2007 critical review,62 the authors
concluded that exercise is recommended for patients with
were evaluated among subjects experiencing a flare. Subjects
Sjögren’s RA and mild to moderate lupus; however, there
assigned to the exercise group received strengthening exer-
was insufficient evidence to recommend a specific type of
cises performed at 70% maximum voluntary contraction.
exercise. Several studies have addressed this issue specifically
They also exercised on a stationary bicycle at 60% maximum
in relation to ankylosing spondylitis. These studies were per-
heart rate. Exercises were adjusted based on pain tolerance
formed despite the wide acceptance of the belief that exercise
and fatigue. Disease activity over the 24-week follow-up peri-
is a key intervention for patients with ankylosing spondylitis.
od was similar in both groups, indicating that high-intensity
For the most part, these studies focused on different practice
exercise did not have a short-term adverse effect on patients
61 settings for administering exercises (home vs clinic) and the
with RA experiencing a flare. Long-term effects, including
addition of other interventions to an exercise program. Three
those on articular structures, were not evaluated.
recent papers have been published that critically analyzed
452 Chapter 11
this literature.50,63,64 In the 2 earlier literature reviews, the Radiographs are viewed to determine the extent and nature
authors concluded that exercise was effective in reducing of joint destruction.
pain,65 improving spinal mobility50,63 and/or improving RA is a chronic condition. Most patients with RA become
overall well-being.50 In the most recent critical review,64 the accustomed to living with a certain amount of pain, discom-
authors simply recommended home exercises and posture fort, and limitations in functional activities. Therefore, they
training for patients with ankylosing spondylitis. None of are most likely to seek help from a physical therapist when
the 3 reviews could provide information about the optimal they experience a change in status, either from a medical or
type of exercise, although in the one good-quality random- a psychosocial perspective. In the subjective component of
ized controlled trial that was included in these reviews, the examination, the therapist therefore identifies the reason
positive outcomes were experienced among subjects who the patient is currently seeking physical therapy services and
received functionally based exercises, and exercises designed the functional goals that the patient would like to achieve as
to address range of motion, strength, and endurance impair- a result of this episode of care.
ments using normal movement patterns and proprioceptive The physical therapy inspection includes an evaluation
neuromuscular facilitation (PNF) techniques. In this study, of the patient’s posture, joint alignment, and joint appear-
subjects were also provided with patient education, including ance. During the palpation examination, swelling, soft tissue
instructions in home-based exercises.65 Studies published tenderness, and muscle spasm are assessed. Passive range of
after these 2 earlier critical reviews also reported improve- motion, strength, and neurological integrity of all relevant
ments in spinal mobility,65,66 function,66 and work capac- joints also are evaluated. In most cases, this physical exami-
ity67 with a comprehensive exercise program. nation is conducted from more of a global and functional
perspective than that which occurs with many other mus-
Outcomes culoskeletal conditions. For example, since multiple joints
are often involved with patients with RA, and since attain-
The clinical course for individuals with RA has been cat- ing normal joint range of motion often is not a feasible goal
egorized as follows: Irrespective of treatment, approximately unless there is a specific reason to do otherwise, a range of
5% to 10% of patients will experience remissions for relatively motion examination of a swollen and painful knee would be
long lengths of time. Approximately 15% will experience a described in functional terms rather than with quantitative
slow progressive course, with short episodes of flares. For the goniometric measurements. Similarly, since muscle weakness
remaining majority, the disease is unrelenting and progres- is usually pervasive, it is often impractical to test and describe
sive, resulting in significant joint deformity.68 the results of a manual muscle test for specific muscles or
Historically, for patients who fall into these last 2 catego- muscle groups. Strength is therefore also often described in
ries, long-term outcomes were dismal. The disease process functional terms, rather than designating specific grades of
eroded joints and soft tissue, and the reduction in functional muscle strength to each muscle or muscle group.
levels were marked. Recently, major inroads in the pharma-
cological management of RA have changed this scenario by Additional Considerations
preventing disease progression and subsequent joint destruc- RA is often accompanied by numerous medical condi-
tion. As a result, for patients who are successfully managed tions in addition to those associated with joint swelling that
pharmacologically, daily pain levels are more tolerable, and can be addressed within the context of a physical therapy
functional levels decline more slowly. Outcomes from exer- episode of care. Patients with RA often experience increased
cise are far less dramatic, but they complement the effects levels of fatigue, general malaise, and anemia. It is unclear
of medication to improve quality of life for patients with the extent to which these conditions are a consequence of the
RA beyond the levels attained in the absence of an exercise effect of pain on activity level, a direct effect of the disease
regimen. process, or a combination of both. Nevertheless, the physical
therapy evaluation addresses endurance and aerobic capac-
Physical Therapy Management ity, and the effects of these evaluation findings on function.
Furthermore, patients with RA also often develop osteoporo-
Examination sis.7,69-73 If risk factors for osteoporosis are present, bone loss
can be determined by a physician, and if present, identified
RA is a systemic disease requiring a detailed physical
by the physical therapist as a condition that affects the physi-
therapy history and systems review. Interview questions
cal therapy plan of care. Finally, cardiac conditions are com-
focus on prior medical, surgical, and physical therapy inter-
mon among patients with RA.74-76 A detailed history of the
ventions involving the patient’s rheumatic condition, and the
patient’s cardiac status is performed to identify any known
current status of all aspects of the patient’s medical manage-
preexisting cardiac conditions
ment. Within the review of symptoms, the physical therapist
addresses the potential medical comorbidities associated Focus on Function
with RA, including cardiac and gastrointestinal conditions, During the evaluation process, impairments identified
and considers how these conditions might affect physical during the history and physical examination process are
therapy interventions. A detailed review of the current signs integrated with the patient’s functional goals. For example, if
and symptoms, and functional limitations, is also essential. a patient reports ankle pain producing difficulty ambulating
more than 2 blocks, then the evaluation focuses on identify- of bone mass consistent with osteoporosis, then strengthen-
ing the lower extremity impairments that contribute to pain ing and weightbearing exercises might also be appropriate,
and functional limitations. An intervention program is then depending on the extent to which the patient is at risk for a
designed to address the specific impairments and functional pathological fracture and the amount of joint destruction.
limitations identified, taking into consideration any medical Often, the patient will experience soreness after perform-
precautions. In the above example, if the ankle pain is caused ing an intensive exercise program. While there is no research
by joint instability secondary to RA, then the intervention to help determine whether or how postexercise pain or
options include strengthening and stabilization exercises, soreness can be used to modify the intensity of the exercise
as well as the provision of assistive devices to improve func- program for a particular patient, one common guideline is
tion, patient education addressing self-management of the that the patient’s pain should return to the preexercise level
patient’s condition, and bracing to control joint laxity. within 2 hours of exercising for the exercise program to be
Exercise Prescription considered safe.41
It is important to recognize that an intensive exercise pro-
The long-term goal of physical therapy for patients with gram will be effective only if it is performed on an ongoing
RA is to decrease pain and minimize loss of function basis. After cessation of active training, the improvements
throughout the course of the patient’s life. Physical therapy in physical function have been shown to disappear.41,54 To
intervention often includes patient education, use of physical optimize adherence, the exercise regimen is determined tak-
agents, provision and instruction in the use of assistive and ing into consideration the patient’s interests and motivational
protective devices, and specific prescription of therapeutic levels. To improve motivation, the patient, with guidance
exercise. Exercise is a key component to the physical therapy from the physical therapist, might benefit from identifying an
management of the patient with RA. The exercise prescrip- optimal time of day to exercise. Ideally, the exercise program
tion most often targets joint pain and stiffness through range is performed after morning stiffness has subsided, but before
of motion exercises, muscle weakness through strengthening fatigue has set in. The exercise program is modified based
exercises, and decreased endurance through aerobic condi- on patient feedback regarding the intensity and duration of
tioning exercises. soreness following past exercise sessions. Since many of these
Several concerns must be considered before prescribing an concerns require ongoing input from a physical therapist,
exercise program for a patient with RA. The most important patients with RA who are performing intensive exercises
of these considerations has to do with the possibility that the should receive ongoing supervision at a level appropriate for
disease process produced laxity in the upper cervical liga- that particular patient. Given adherence to a well-designed
ments. An estimated 40% to 80% of individuals with RA have home exercise regimen, the patient with RA should benefit
radiographic evidence of instability, and 7% to 13% experi- with gains in functional levels and a reduction in pain levels.
ence signs of neurological deficits.77 If upper cervical liga-
ment instability is present, then anterior dislocation of the
atlas or superior migration of the odontoid process of the axis
into the foramen magnum could occur with exercises that
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CASE STUDY 11-1
57. Cairns AP, McVeigh JG. A systematic review of the effects of dynamic
exercise in rheumatoid arthritis. Rheumatol Int. 2009;30(2):147-158. Susan L. Edmond, PT, DSc, OCS
58. Hurkmans E, van der Giesen FJ, Vliet Vlieland TP, Schoones J, Van
den Ende EC. Dynamic exercise programs (aerobic capacity and/
or muscle strength training) in patients with rheumatoid arthritis.
Cochrane Database Syst Rev. 2009;4:CD006853. EXAMINATION
59. Baillet A, Zeboulon N, Gossec L, et al. Efficacy of cardiorespiratory
aerobic exercise in rheumatoid arthritis: meta-analysis of random-
ized controlled trials. Arthritis Care Res. 2010;62(7):984-992. History
60. Scarvell J, Elkins MR. Aerobic exercise is beneficial for people with
rheumatoid arthritis. Br J Sports Med. 2011;45(12):1008-1009. Current Condition/Chief Complaint
61. Van den Ende CH, Breedveld FC, le Cessie S, et al. Effect of inten-
sive exercise on patients with active rheumatoid arthritis: a ran- Ms. Icon was a 43-year-old female who had referred her-
domized clinical trial. Ann Rheum Dis. 2000;59(8):615-621. self to physical therapy for treatment of diffuse musculoskel-
62. Strombeck B, Jacobsson LTH. The role of exercise in the rehabilita- etal pain and limitations in functional activities secondary to
tion of patients with systemic lupus erythematosus and patients with
fibromyalgia. Ms. Icon recently experienced an exacerbation
primary Sjögren’s syndrome. Curr Opin Rheumatol. 2007;19:197-203.
63. Ammer K. Physiotherapy in seronegative spondylarthropathies. A of pain, primarily in her shoulders and neck. Ms. Icon also
systematic review. Eur J Phys Med Rehabil. 1997;7:114-119. reported systemic fatigue. Ms. Icon’s goal was to experience
64. Elyan M, Kahn MA. Does physical therapy still have a place in less pain and fatigue with her current activity level.
the treatment of ankylosing spondylitis? Curr Opin Rheumatol.
2008;20(3):282-286.
65. Kraag G, Stokes B, Groh J, Helewa A, Goldsmith CH. The effects Clinician Comment Fibromyalgia is a chronic
of comprehensive home physiotherapy and supervision on patients condition that is characterized by dull constant pain in
with ankylosing spondylitis: an 8-month followup. J Rheumatol. multiple muscles, ligaments and tendons located on both
1994;21(2):261-263. sides of the body, above and below the waist. Other symp-
66. Fernández-de-las-Peñas C, Alonso-Blanco C, Alguacil-Diego IM,
Miangolarra-Page JC. One-year follow-up of two exercise interven-
toms include systemic fatigue and an inability to think
tions for the management of patients with ankylosing spondylitis: a clearly. This latter symptom is commonly called brain fog.
randomized controlled trial. Am J Phys Med Rehabil. 2006;85:559- Fibromyalgia is characterized by a lack of stage 4, restor-
567. ative sleep. It is believed that this contributes to the fatigue
67. Ince G, Sarpel T, Durgun B, Erdogan S. Effects of a multimodal and brain fog associated with this condition.1 An estimated
exercise program for people with ankylosing spondylitis. Phys Ther.
2006;86(7):924-935.
2% of the population of the United States is affected by
68. WebMD. Rheumatoid arthritis progression. http://www.webmd. fibromyalgia. The cause or causes of fibromyalgia are
com/rheumatoid-arthritis/guide/ra-progression. Reviewed by unknown; however, risk factors include female sex, increas-
David Zelman February 7, 2012. Accessed February 26, 2012. ing age, a family history of fibromyalgia, sleep disorders
69. Hansen M, Florescu A, Stoltenberg M, et al. Bone loss in rheu- and rheumatic disease.
matoid arthritis influence of disease activity, duration of the
disease, functional capacity and corticosteroid treatment. Scand J
Rheumatol. 1996;25(6):367-376.
70. Haugeberg G, Ørstavik RE, Uhlig T, Falch JA, Halse JI, Kvien TK. Social History/Environment
Bone loss in patients with rheumatoid arthritis: results from a
population-based cohort of 366 patients followed up for two years.
Ms. Icon lived with her husband and 2 children aged
Arthritis Rheum. 2002;46(7):1720-1728. 10 and 15 years. English was her primary language. She was
71. Huusko TM, Korpela M, Karppi P, Kautiainen H, Sulkava R. employed as a 2nd grade public school teacher. Her husband
Threefold increased risk of hip fractures with rheumatoid arthritis sustained a spinal cord injury 20 years ago, and has been a
in central Finland. Ann Rheum Dis. 2001;60:521-522. wheelchair user since then. Ms. Icon was therefore respon-
72. Kroger H, Honkanen R, Saarikoski S, Alhava E. Decreased axial
bone mineral density in perimenopausal women with rheumatoid
sible for most housekeeping activities.
arthritis—a population based study. Ann Rheum Dis. 1994;53:18-23. Ms. Icon lived in a one-story house in a residential neigh-
73. Sambrook PN, Eisman JA, Champion GD, Yeates MG, Pocock NA, borhood. In the past, she had enjoyed taking walks on dirt
Eberl S. Determinants of axial bone loss in rheumatoid arthritis. paths near her home, but states that she has not done so in a
Arthritis Rheum. 1987;30(7):721-728.
while due to schedule constraints.
74. Bacon PA, Townend JN. Nails in the coffin: increasing evidence
for the role of rheumatic disease in the cardiovascular mortality of Social/Health Habits
rheumatoid arthritis. Arthritis Rheum. 2001;44:2707-2710.
75. del Rincón ID, Williams K, Stern MP, Freeman GL, Escalante A. Nonsmoker, social drinker
High incidence of cardiovascular events in a rheumatoid arthritis
cohort not explained by traditional cardiac risk factors. Arthritis
Rheum. 2001;44(12):2737-2745. Ms. Icon reported that she began experiencing insidious
76. Turesson C, Matteson EL. Cardiovascular risk factors, fitness and onset of dull, constant multiple joint pain above and below
physical activity in rheumatic diseases. Curr Opin Rheumatol.
2007;19:190-196.
the waist and systemic fatigue 15 years ago, approximately
77. Dryer SJ, Boden SD. Natural history of rheumatoid arthritis of the 3 months after giving birth to her first child. She first attrib-
cervical spine. Clin Orthop Rel Res. 1999;366:98-106. uted these symptoms to the increase in activities associated
456 Chapter 11
with caring for an infant, but sought medical attention about
The appropriate course of action was, therefore, to continue
2 months after the onset of symptoms when they did not
with the examination with the intent to “treat”; neverthe-
subside. When first evaluated for these symptoms, her gen-
less, it was important to recognize that new medications to
eral practitioner told her that there was “nothing physically
manage fibromyalgia had been developed since she last saw
wrong with her.” When Ms. Icon continued to seek a medical
a physician for her condition. Ms. Icon might, therefore,
diagnosis and treatment, she was referred to a psychologist
benefit from a referral to a physician for pharmacological
for counseling. Counseling did not reveal a psychological
management.
cause for her physical pain or fatigue, nor did it produce a
change in her symptoms. Ms. Icon then became discouraged
and decided not to pursue additional medical or psychologi-
cal management. Systems Review
Five years later, Ms. Icon experienced an exacerbation
of symptoms, and returned to her general practitioner. He Cardiovascular/Pulmonary
referred Ms. Icon to a rheumatologist, who diagnosed her Seated, resting:
with fibromyalgia. At that time, she was told that there was Heart rate: 73 bpm
no effective treatment for fibromyalgia. Blood pressure: 120/85 mm Hg
Otherwise, medical history was significant for 2 normal Respiration rate: 12 breaths per minute
(vaginal) deliveries.
Integumentary
No discolorations or breaks in the integument were
Clinician Comment Ms. Icon’s diagnosis was observed.
based in part on her report of constant bilateral multiple
joint pain and systemic fatigue. Atypical of fibromyalgia, Musculoskeletal
she did not report difficulty with cognition. Strength and AROM grossly assessed in the upper extrem-
ities and lower extremities and the spine: All were within
functional limits, except for moderate limitations in bilateral
Reported Functional Status shoulder elevation and neck lateral movements.
Ms. Icon reported that she was able to perform all neces- Height: 5’4”
sary ADL including instrumental ADL. Specifically, she was Weight: 138 pounds (BMI 23.7)
able to teach her 2nd grade class, but reports that she was Neuromuscular
extremely fatigued by the end of the day. She was able to
No impairments in balance, gait, locomotion, transfers or
shop for her family and perform housecleaning activities, but
transitions were observed.
reported an increase in pain and fatigue afterward, especially
when she tried to perform too many activities in a short peri- Communication, Affect, Cognition,
od of time. Pain was located primarily in her neck and both Language and Learning Style
shoulders and to a lesser extent in her low back and knees. All
Ms. Icon was alert and oriented to person, place and time.
symptoms diminished following 2 to 3 hours of rest.
She engaged in conversation easily, followed all commands,
Medications and demonstrated motivation to adhere to a home program.
Over the counter ibuprofen as needed.
Other Clinical Tests Clinician Comment The systems review was
unremarkable. This case was an example of a patient with
No other medical tests were performed.
a systemic condition. As such, it is likely that Ms. Icon
had multiple impairments throughout her musculoskeletal
Clinician Comment Since Ms. Icon had system, however a complete musculoskeletal examination
referred herself to physical therapy, it was especially impor- was not reasonable. In this case, the patient reported
tant to consider whether to “treat,” “refer and treat,” or functional limitations primarily affecting 2 domains: sys-
“refer.” Ms. Icon presented with signs and symptoms of temic fatigue and pain in the neck and shoulders. While a
insidious onset of neck and bilateral shoulder pain consis- screening examination of the entire musculoskeletal system
tent with a known diagnosis of fibromyalgia. Even though was performed, the physical examination focused on these
she was experiencing an exacerbation of symptoms, she 2 concerns.
had been diagnosed with fibromyalgia prior to beginning Her pain and posture needed further examination. Tests
physical therapy. The subjective report was consistent with and measures for her neck and shoulder range of motion,
the signs and symptoms associated with this medical diag- joint integrity and mobility, and muscle performance need-
nosis. Based on the information provided at this point in ed to be included. Finally, her aerobic capacity/endurance
the examination, there were no “red flags.” needed to be established.
Tests and Measures Rotation 0 to 50 0 to 50
Firm end feel Firm end feel
Pain
She described her pain as a diffuse ache located in her Pain with Pain with
neck and both glenohumeral joints. Any activity increased overpressure* overpressure*
symptoms, including carrying packages and housework. * Pain is described by the patient as a stretching sensation.
Symptoms returned to baseline within 2 to 3 hours. Rest
decreased symptoms. Pain at rest was reported to be a 2 on
a visual analog scale, and increased to a 6 with activities of Shoulder Passive Range of Motion
daily living, especially any movements into shoulder eleva-
tion such as reaching for objects on top shelves. LEFT RIGHT
Pain was reproduced with palpation of the cervical para- Flexion 0 to 150 0 to 155
spinals, upper trapezeii, scalenes, and sternocleidomastoid Firm end feel Firm end feel
muscles. Pressure algometry revealed tenderness in 13 of
18 tender points. Pain with Pain with
In addition, during the palpation examination, no edema resistance** resistance**
or effusion was noted in neck or shoulders. Bilateral spasms Extension WNL WNL
were palpable and were accompanied by reproduction of pain
in cervical paraspinals, upper trapezeii, scalenes, and sterno-
Abduction 0 to 130 0 to 135
cleidomastoid muscles. Firm end feel Firm end feel
Pain with Pain with
Clinician Comment Fibromyalgia is charac- resistance** resistance**
terized by the presence of tender points—specific anatomi- Lateral Rotation 0 to 60 0 to 60
cal locations where slight pressure causes pain. Eighteen
tender points have been identified. The presence of pain Firm end feel Firm end feel
with pressure on at least 11 of these 18 tender points using Pain with Pain with
a pressure algometer is indicative of fibromyalgia. These overpressure* overpressure*
18 tender points are the back of the head, between the scap-
ulae, the top of the shoulders, the front sides of the neck, the
Medial Rotation WNL WNL
upper chest, the lateral elbow area, the upper hips, the sides Horizontal Adduction WNL WNL
of the hips, and the inner knees.2 Ms. Icon met this criterion * Pain is described by the patient as a stretching sensation.
for diagnosing fibromyalgia syndrome.
** Pain is described by the patient as a sharp.
Special Tests
Posture
Shoulders
Patient demonstrates slight forward head. • Shoulder painful arc: Negative bilaterally within avail-
Range of Motion (Including Muscle able range
Length) • Apley scratch test: Decreased lateral rotation bilaterally
Neck Passive Range of Motion
Clinician Comment Ms Icon showed
Forward Bending 0 to 35 decreased passive range of motion in her neck for the ranges
Firm end feel of forward bending, and bilateral side bending and rota-
tion. Her shoulders had a range of motion deficit for passive
Pain with overpressure* range of motion in flexion, abduction and lateral rotation.
Backward Bending WNL
LEFT RIGHT
Joint Integrity and Mobility
Side Bending 0 to 30 0 to 30
Cervical Spine
Occiput–C2 distraction: hypomobile, pain free
Pain with Pain with C2–T2 P-A Glides: WNL, pain free
overpressure* overpressure*
458 Chapter 11
Glenohumeral Joints Manual Muscle Testing Shoulders
LEFT RIGHT
LEFT RIGHT
Scapular Musculature N N
Distraction Hypomobile, Hypomobile,
pain free pain free Flexion G G
Anterior Glide Hypomobile, Hypomobile, Extension N N
painful painful Abduction G G
Posterior Glide Hypomobile, Hypomobile, Horizontal Abduction N N
painful painful
Horizontal Adduction N N
Inferior Glide Hypomobile, Hypomobile,
painful painful Lateral Rotation G G
Acromioclavicular Joints WNL WNL Medial Rotation N N
N = Normal, 5/5; G = Good, 4/5.
Sternoclavicular Joints WNL WNL
Scapulothoracic Joints WNL WNL Resisted Isometric Testing Neck
Forward Bending Strong, pain free
Special Tests Backward Bending Strong, painful
Neck
LEFT RIGHT
• Vertebral artery test: Negative bilaterally
Side Bending Strong, painful Strong, painful
• Alar ligament test: Negative bilaterally
Rotation Strong, painful Strong, painful
Shoulder
• Anterior apprehension test: Negative bilaterally Resisted Isometric Testing Shoulders
• Load and shift maneuver: Negative bilaterally
LEFT RIGHT
• Sulcus test: Negative bilaterally
Flexion Strong, pain free Strong, pain free
• Hawkins test: Negative bilaterally
Extension Strong, pain free Strong, pain free
• Crank test: Negative bilaterally
Abduction Strong, pain free Strong, pain free
Clinician Comment On passive intervertebral Adduction Strong, pain free Strong, pain free
movement testing, Ms. Icon shows decreased motion at her Lateral Rotation Strong, pain free Strong, pain free
suboccipital joints. She also shows a decrease in all gleno-
humeral accessory joint motions. Medial Rotation Strong, pain free Strong, pain free
Horizontal Strong, pain free Strong, pain free
Abduction
Muscle Performance (Including Strength, Horizontal Strong, pain free Strong, pain free
Adduction
Manual Muscle Testing Neck Special Tests
Shoulder/Scapula
LEFT RIGHT • Drop arm test: Negative bilaterally
Capital Extension N N • Supraspinatus test: Negative bilaterally
Cervical Extension N N • Yergason’s test: Negative bilaterally
Combined Neck Extension N N • Speed’s test: Negative bilaterally
Capital Flexion N N • Lateral scapular slide test: Increased scapular movement
bilaterally
Cervical Flexion N N
Cervical Rotation N N
Clinician Comment Ms. Icon showed
N = Normal, 5/5. decreased strength in bilateral shoulder flexion, abduction
and lateral rotation.
Cranial and Peripheral Nerve Integrity EVALUATION
• Upper Quarter Myotomal Screen: WNL
Special Tests Diagnosis
• Slump Test: Negative
Practice Pattern
• Spurling’s test: Negative bilaterally
Ms. Icon was a 43-year-old female second grade teacher
Sensory Integrity with a known medical diagnosis of fibromyalgia. Symptoms
• WNL bilateral upper extremities had been present for 15 years. At the time of her initial exami-
nation, she reported fatigue with activities of daily living and
Reflex Integrity a recent increase neck and bilateral shoulder pain. Symptoms
• WNL Biceps, Brachioradialis and Triceps reflexes could have been attributable directly to fibromyalgia; however
this patient also demonstrated decreased range of motion and
Aerobic Capacity/Endurance accessory motion, and strength in both shoulders, which is
• 6-Minute Walk Test: 430 meters. Patient reported mild also consistent with mild adhesive capsulitis. She also pre-
fatigue after testing. sented with tenderness, spasm and decreased range of motion
in her cervical paraspinal muscles, consistent with a muscle
strain. Symptoms of fibromyalgia with resultant decrease
Clinician Comment Tests of endurance are in activity level and impaired posture were likely causes of
commonly used to quantify impairments in patients with
neck pain and shoulder adhesive capsulitis. Suboccipital joint
several types of conditions, including cardiac and pulmo-
hypomobility likely contributed to impaired posture.
nary disease, neuromuscular disorders and arthritis. To
These findings placed her in the musculoskeletal practice
date, no tests of endurance have been validated on patients
pattern of the following:
with fibromyalgia. The 6-Minute Walk Test was used
because it is a functional test that quantifies limitations • Pattern B: Impaired posture
in endurance, and because data on healthy subjects are • Pattern D: Impaired joint mobility, motor function,
available for comparison. Ms. Icon should have been able muscle performance and range of motion associated
to walk 618 meters during the 6-Minute Walk Test.3 Her with connective tissue dysfunction
performance is approximately 70% of this expected value • Pattern E: Impaired joint mobility, motor function,
and indicates decreased walking tolerance. muscle performance and range of motion associated
The physical examination revealed signs and symptoms with localized inflammation
consistent with musculoskeletal pain. No “red flags” had
been identified. There was therefore no need for referral. If International Classification of Functioning,
symptoms did not subside with physical therapy manage- Disability, and Health Model
ment, or if, upon questioning, the patient expressed interest See ICF Model on p 460.
in being evaluated for pharmacological treatment, then a
referral to a physician would be indicated.
Prognosis
This patient appeared to have symptoms consistent with
fibromyalgia (tender points with associated pain and Prognosis was good for reducing the signs and symptoms
fatigue), but also had impairments that were consistent of fibromyalgia and musculoskeletal symptoms in the neck
with localized musculoskeletal pain. Specifically, Ms. Icon and shoulder. Given the patient’s physical findings, lack of
had decreased range of motion and accessory motion, and comorbidities and excellent motivation, it was anticipated
decreased strength in the glenohumeral joint, which is that she would benefit from physical therapy.
consistent with adhesive capsulitis. She also had tender-
ness, spasm and decreased range of motion in her cervical Plan of Care
paraspinal muscles. These latter findings, in conjunction
with pain with resisted isometric testing, are indicative of Intervention
cervical pain of muscular origin. These 2 musculoskeletal
• Patient education regarding correct posture and strate-
disorders could have arisen as a result of the fibromyalgia.
gies to maintain correct posture with activities of daily
Conversely, they could have developed independent of her
living.
primary diagnosis, possibly in part because of Ms. Icon’s
impaired posture. • Patient education regarding pacing oneself with daily
Based on the patient’s diagnosis, reported symptomatology, activities
and tissue irritability, the therapist determined that the • Home exercise instruction: stretching, strengthening
patient should be able to tolerate a moderately vigorous and aerobic exercises
physical therapy program. • Passive range of motion to neck and bilateral shoulders
460 Chapter 11
ICF Model of Disablement for Ms. Icon

Health Status
• Fibromyalgia

Function
• Decreased ability to perform • Unable to pursue regular
• Bilateral neck and shoulder instrumental ADL and work fitness program due to
pain tasks comfortably symptoms
• 13/18 tender points
• Impaired posture
• Decreased ROM at neck and
shoulders

• Age = 43 years • Has a path near her home to use with a walking
• Motivated to begin an exercise program program
• Cares for her 2 young children
• Her spouse has a spinal cord injury
• Employed as a teacher
• Bilateral shoulder strengthening exercises 6. Neck and bilateral shoulder accessory motion to be
• Joint mobilization/manipulation to upper cervical spine WNL (4 weeks).
and bilateral glenohumeral joints. 7. Bilateral shoulder strength to be WNL (5 weeks).
• Soft tissue mobilization to affected cervical musculature 8. Patient to experience a decrease in neck and bilateral
shoulder pain to a 0 on a 1 to 10 visual analog scale at rest,
Clinician Comment The physical therapist and a 2 with activity on a visual analog scale (5 weeks).
hypothesized that by addressing all of the patient’s impair- 9. Patient to walk 618 meters during the 6-Minute Walk
ments in conjunction with a program for managing fibro- Test (6 weeks).
myalgia, the patient’s pain would diminish and she would 10. Patient to experience no fatigue with current activity
experience an improvement in her functional levels. This level (6 weeks).
hypothesis was corroborated by a critical review stat-
ing that the best evidence supports treating patients with Expected Outcome (6 weeks)
adhesive capsulitis with stretching and stretching exercises, 1. Patient will report minimal pain and fatigue and report
and with joint mobilization/manipulation4; and a different unrestricted ADL, instrumental ADL, and work tasks.
critical review in which the authors supported manag- 2. Patient to be independent managing her fibromyalgia
ing patients with nonspecific neck pain with exercise and symptoms.
manual therapy.5
Treatment of fibromyalgia consists of instruction in tech- Discharge Plan
niques to get adequate sleep, reduce stress, and pace oneself Patient to continue with home exercise program and self-
with daily activities. Exercise is also an integral component measures. Patient to return to physical therapy if symptoms
of a treatment plan for fibromyalgia.1,6 return or if other symptoms attributable to fibromyalgia arise.
Several recent critical reviews have addressed the efficacy of
exercise in the treatment of fibromyalgia. There is strong evi-
dence supporting the implementation of an aerobic exercise I
NTERVENTION
program to manage symptoms and improve physical func-
tion,7-10 as well as for performing strengthening exercise to
achieve these same objectives.8-10 The evidence suggests that Coordination, Communication, and
aerobic exercises are superior to resistance exercises, when Documentation
both are performed at moderate to high intensity levels,10
although optimal outcomes are likely achieved when differ- Document all aspects of Ms. Icon’s physical therapy care in
ent types of exercises are included in an exercise program. 9 her outpatient physical therapy record. Provide patient with
written instructions describing each of her home exercises.
Proposed Frequency and Duration of Patient-/Client-Related Instruction

Instruct in home exercise program. Provide patient educa-
This patient was scheduled for physical therapy 3 times
tion regarding correct posture and benefits of maintaining
per week for 3 weeks, and then 2 times per week for 3 weeks
correct posture with activities of daily living. Provide patient
for a total of 15 visits. The expected time frame to meet all
education regarding need to pace self with activities, and to
goals was therefore 6 weeks.
the need to continue with home exercise program once dis-
Anticipated Goals charged from physical therapy.
1. Patient to demonstrate good understanding of self-
management of fibromyalgia (1 week). Procedural Interventions
2. Patient to demonstrate correct posture and awareness of
mechanisms to maintain appropriate posture with daily Therapeutic Exercise
activities (2 weeks). Aerobic Capacity/Endurance
3. Patient to be independent with a home exercise program Conditioning or Reconditioning
and demonstrate knowledge of appropriate progression Mode
of exercise program following discharge from physical Walking on a dirt pathway near her home (home exercise).
therapy (3 weeks). Intensity
4. Patient to experience a decrease in neck and bilateral During each walk, the patient maintains a heart rate of
shoulder pain to a 1 on a 1-10 visual analog scale at rest, 70% of her maximum heart rate (which is approximately
and a 4 with activity on a visual analog scale (3 weeks). 110 beats per minute). As the patient becomes more condi-
5. Neck and bilateral shoulder range of motion to be WNL tioned, she should be able to walk greater distances while
(4 weeks). maintaining 70% of her maximum heart rate.
462 Chapter 11
Duration Description of the Intervention
Begin with 10 minutes and gradually increase to The patient grasps the back and sides of her lower neck
30 minutes. with both hands. While holding the lower part of her neck
Frequency still, the patient bends her head forward slightly.
Begin with 3 times per day, but as duration increases, Mode
decrease frequency to 2 then 1 time per day. Active/passive movements, shoulder reaching (home
Description of the Intervention exercise)
Before beginning the walking exercise, the patient spends Intensity
5 minutes gradually increasing her walking speed. She The patient moves her arms until she feels a stretch in her
spends 5 minutes gradually decreasing her walking speed shoulder.
after ending her walking exercise. Duration
Progression for Duration The patient initially holds the stretch for 15 seconds. Over
• Week 1 and 2: The patient walks for 10 minutes. the course of approximately 1 week, the patient increases the
hold time to 30 seconds.
• Week 3 and 4: The patient walks for 20 minutes during
1 walk and for 10 minutes during the 2nd walk. Frequency
The patient performs this exercise 5 times, 3 times per day.
• Week 5 and 6, and after discharge: The patient walks for
30 minutes.
The patient positions herself on her back holding onto a
Progression for Frequency: dowel with her arms by her side and her palms facing upward
• Week 1 and 2: The patient walks 3 times per day: once shoulder-width apart. With her elbows straight, the patient
in the morning, once in the afternoon, and once in the moves the dowel up in front of her and then tries to keep mov-
evening. ing it over her head until she feels a stretch in her shoulders. The
• Week 3 and 4: The patient walks 2 times per day: once in patient holds this position. Afterward, the patient moves the
the morning and once in the evening. dowel as high in front of her as she can, and then moves it down
toward her left side until she feels a stretch in her shoulder. The
• Week 5 and 6, and after discharge: The patient walks
patient holds this position. The patient repeats this exercise on
1 time per day.
the right side. Finally, the patient brings her arms back down to
Flexibility Exercises her side, still holding onto the dowel. She then bends her elbows
Mode to 90 degrees, and holding her elbows by her side, moves her
Active/passive movements for neck (home exercise). hands out away from her trunk to the left. The patient holds
Intensity this position. The patient repeats this exercise on the right side.
The patient moves her neck until she feels a stretch in her Strengthening Exercise
neck muscles. Mode
Duration Resistive movements of the shoulder
Initially, the patient holds the stretch for 15 seconds. Over Intensity
the course of approximately 1 week, the patient increases the The patient repeats this exercise until she feels fatigue
hold time to 30 seconds. in her shoulder muscles or until the exercise becomes fairly
Frequency difficult to perform, whichever happens first, up to 3 sets of
The patient performs this exercise 5 times, 3 times per day. 10 repetitions.
Description of the Intervention Duration
The patient positions herself on her back with her head on About 5 minutes.
a pillow that is shallower (scooped out) in the center than at Frequency
the edges. The patient rolls her head to the left side until she Once a day.
feels a stretch in her neck muscles, and holds this position. Description of the intervention
The patient repeats this exercise on the right side. The patient stands with her back against the wall with
Mode arms at her side, holding a 5-pound weight with her left
Active/passive movements for neck (home exercise) hand. The patient slowly brings her arm up and forward, and
Intensity back down to her side. The patient repeats this exercise on
The patient moves her neck until she feels a stretch in her the right side.
neck muscles. Mode
Duration Resisted movements of the shoulder.
Initially, the patient holds the stretch for 15 seconds. Over Intensity
the course of approximately 1 week, the patient increases the The patient repeats this exercise until she feels fatigue
hold time to 30 seconds. in her shoulder muscles or until the exercise becomes fairly
Frequency difficult to perform, whichever happens first, up to 3 sets of
The patient performs this exercise 5 times, 3 times per day. 10 repetitions.
Duration Administer soft tissue mobilization techniques to bilateral
About 5 minutes. cervical paraspinals, upper trapezeii, scalenes and sternoclei-
Frequency domastoid musculature.
Once a day.
Description of the Intervention Clinician Comment For this patient, all exer-
The patient stands with her back against the wall with cises should be performed on a daily basis. This patient will
her arms at her side, holding a 5-pound weight with her left therefore be instructed to perform all exercises at home.
hand. The patient slowly brings her arm up and out to the The therapist will review the exercises during physical ther-
side, and back down to her side, keeping her palms up. The apy visits, and ensure that the patient is performing them
patient repeats this exercise on the right side. correctly. By instructing the patient in home exercises, vs
Mode having her perform them in the clinic, the patient can max-
Resisted movements of the shoulder imize the effect of the exercise program and better utilize
Intensity clinic time for patient instruction and manual techniques.
The patient repeats this exercise until she feels fatigue
in her shoulder muscles or until the exercise becomes fairly
difficult to perform, whichever happens first, up to 3 sets of REEXAMINATION
10 repetitions.
Duration Ms. Icon was reevaluated after 4 weeks of treatment.
About 5 minutes.
Frequency Subjective
Once a day. The patient reported that she had been adhering to her
Description of the Intervention home exercise program.
The patient lies on her stomach on a bed with her left arm
out to the side, elbow bent to 90 degrees, and forearm off the Objective
bed, fingers pointing toward the floor, holding a 5-pound
weight with her left hand. The patient slowly brings her hand
Posture
up and toward her head, keeping her elbow bent to 90 degrees WNL
and her upper arm on the bed. The patient repeats this exer- Pain
cise on the right side.
Mode She stated that the interventions were effective in reduc-
ing pain to a 1 at rest and a 4 with her usual activities. No
Active movements, scapular stabilization
pain was reported with palpation of the cervical paraspinals,
Intensity
upper trapezeii, scalenes, and sternocleidomastoid muscles.
The patient performs the exercise until she feels her arm Pressure algometry revealed tenderness in 5 of 18 tender
getting tired or the exercise becomes noticeably more dif- points. No spasm in cervical area to palpation.
ficult to perform.
Duration Range of Motion
About 5 minutes. Neck PROM was WNL for all movements, no pain with
Frequency overpressure.
Once a day. Shoulder Passive Range of Motion
The patient is instructed to perform this exercise only if LEFT RIGHT
she feels as though she will not lose her balance. The patient Flexion 0 to 170 0 to 165
places a small theraball on a low table and stands next to the
table. The patient bends forward and positions her left hand
on the top of the theraball, her elbow slightly bent, and her Pain with Pain with
trunk over the ball, putting weight on the ball. Next, the overpressure overpressure
patient moves her trunk to the left and right, and forward Extension WNL WNL
and backward, while balancing with her hand on the thera-
ball. The patient repeats this exercise on the right side. Abduction 0 to 150 0 to 150
Manual Therapy Techniques, Including Firm end feel Firm end feel
Mobilization/Manipulation Pain with Pain with
Administer grades III and IV joint mobilization distrac- overpressure overpressure
tion techniques to suboccipital joints and grades III, IV and
Lateral Rotation 0 to 70 0 to 70
V mobilization / manipulation distraction, anterior, poste-
rior and inferior glides to bilateral glenohumeral joints. Firm end feel Firm end feel
464 Chapter 11
LEFT RIGHT Assessment

Lateral Rotation No pain with No pain with Patient was independent with home exercises, and demon-
overpressure overpressure strated good understanding of correct posture and self-mea-
sures. Patient demonstrated improvement in all impairments,
Medial Rotation WNL WNL
and has subsequently experienced a decrease in pain and
Horizontal Adduction WNL WNL fatigue with functional activities. Goals related to neck and
posture impairments have been met. Patient experienced
Joint Integrity and Mobility improvements in shoulder range of motion and strength, but
still requires additional therapy to address residual impair-
Cervical Spine: WNL
ments. Fibromyalgia symptoms of pain and fatigue improved
Glenohumeral Joints as well, but patient would benefit from additional physical
LEFT RIGHT therapy to continue to address these areas.
Distraction Hypomobile, Hypomobile,

pain free pain free
Plan
Anterior Glide Hypomobile, Hypomobile, Discontinue interventions to cervical spine.
pain free pain free Continue physical therapy 2 times per week for an addi-
tional 2 weeks. Address residual shoulder impairments
Posterior Glide Hypomobile, Hypomobile, (strength, range of motion and accessory motion), and
pain free pain free reinforce independence with continuing Ms. Icon’s home
Inferior Glide Hypomobile, Hypomobile, program once discharged.
pain free pain free
Muscle Performance OUTCOMES

• Manual Muscle Testing Neck: WNL
Ms. Icon attended 3 more visits, but cancelled her final
Manual Muscle Testing Shoulder session. Her husband had become ill, and she needed to care
LEFT RIGHT for him. She reported that she was “doing fine.” No final
reevaluation was performed.
Flexion G G
Extension N N
Abduction G G REFERENCES
Horizontal Abduction N N 1. Mayo Clinic. Diseases and conditions: fibromyalgia. http://www.
mayoclinic.org/diseases-conditions/fibromyalgia/basics/defini-
Horizontal Adduction N N tion/con-20019243. Accessed February 2009.
2. Wolfe F, Smythe HA, Yunus MB, et al. The American College of
Lateral Rotation G G
Rheumatology 1990 Criteria for the classification of fibromyalgia:
Medial Rotation N N report of the multicenter criteria committee. Arthritis Rheum.
1990;33:160-172.
N = Normal, 5/5; G = Good, 4/5. 3. Enright PL, Sherrill DL. Reference equations for the six-minute
walk in healthy adults. Am J Respir Crit Care. 1998;158:1384-1387.
Resisted Isometric Testing Neck 4. Kelley MJ, McClure PW, Leggin BG. Frozen shoulder: evidence and
a proposed model guiding rehabilitation. J Orthop Sports Phys Ther.
Forward Strong, pain free 2009;39:135-148.
Bending 5. Hurwitz EL, Carragee EJ, van der Velde G, et al. Treatment of
Backward Strong, pain free neck pain: noninvasive interventions: results of the Bone and Joint
Bending Decade 2000-2010 Task Force on Neck Pain and its Associated
Disorders. Spine. 2008;35:S123-S152.
LEFT RIGHT 6. Clauw DJ. Fibromalgia: a clinical review. JAMA. 2014;311:1547-1555.
7. Brosseau L, Wells GA, Tugwell P, et al. Ottawa panel evidence-
Side Bending Strong, pain free Strong, pain free based clinical practice guidelines for aerobic fitness exercises in the
management of fibromyalgia: part 1. Phys Ther. 2008;88:857-871.
Rotation Strong, pain free Strong, pain free 8. Brosseau L, Wells GA, Tugwell P, et al. Ottawa panel evidence-
based clinical practice guidelines for strengthening exercises in the
Special Tests management of fibromyalgia: part 2. Phys Ther. 2008;88:873-885.
• Lateral Scapular Slide Test: WNL 9. Busch AJ, Webber SC, Brachaniec M, et al. Exercise therapy for
fibromyalgia. Curr Pain Headache Rep. 2011;15:358-367.
Aerobic Capacity/Endurance 10. Busch AJ, Webber SC, Richards RS, et al. Resistance exer-
cise training for fibromyalgia. Cochrane Database of Syst Rev.
6-Minute Walk Test: 550 meters; patient reported mild 2013;12:CD010884.
fatigue after testing.
Individuals With Motor Control and
12
Motor Function Disorders
Lisa Brown, PT, DPT, NCS
• Compare and contrast the treatment considerations

CHAPTER OBJECTIVES versus exercise benefit for programs based on walking,
treadmill walking, bicycle ergometry or arm crank
• Identify major components in the central nervous sys- ergometry for patients with neuromuscular disorders.
tem and summarize the role each plays toward the pro-
• Contrast the benefits with the detriments of adaptive
duction of human movement beginning at the premotor
and assistive devices use during exercise sessions.
area.
• Discuss the change in energy requirements to be consid-
• List the pathways by which sensory information from
ered during exercise for patients post-stroke, post-spinal
the body’s periphery influence, modify or coordinate
cord injury, and with traumatic brain injury.
motor responses.
• Identify the physiologic factors that contribute to the
• Identify the 3 most frequent problems that reduce
distinct complaints of weakness, fatigue, and decon-
functional capacity in individuals with neuromuscular
ditioning in patients with multiple sclerosis.
disorders.
• Compare and contrast the exercise guidelines for
• Contrast deficits produced from a lesion at the premotor
patients with amyotrophic lateral sclerosis and those
cortex versus the motor cortex.
with Guillain-Barré syndrome.
• Outline the possible motor control deficits that can
occur with a lesion in the cerebellum.
• Describe the variations from normal movement charac-
teristic of a sensory system dysfunction.
CHAPTER OUTLINE
• Answer the question: How is deconditioning just as • Normal Movement
possible in patients with nonprogressive neuromuscular
◦ Supplemental and Premotor Cortex
disorders as those with progressive disorders?
◦ Cerebral Cortex
• Discuss how spasticity could change over time indepen-
dent of underlying central control of movement deficits. ◦ Basal Ganglia and Diencephalon
• Describe the effect that the autonomic nervous system ◦ Cerebellum
can have on the response to exercise or exercise toler- ◦ Brainstem
ance.
◦ Spinal Cord
• List the general factors to be considered when prescrib-
◦ Peripheral Nervous System
ing exercise for an individual with neuromuscular dis-
orders. ◦ Sensory System
◦ Conclusion

466 Chapter 12
• Neurological Impairments Affecting Motor Control ◦ Degenerative Diseases
◦ Premotor Cortex ▪ Parkinson’s Disease
◦ Motor Cortex ▫ Impairments Affecting Mobility
◦ Subcortical ▫ Intervention
◦ Spinal Cord/Lower Motor Neuron ▪ Multiple Sclerosis
◦ Peripheral Nervous System ▫ Impairments Affecting Mobility
◦ Sensory System Dysfunction ▪ Amyotrophic Lateral Sclerosis
• Key Impairments Affecting Movement and Exercise ▫ Pathology
Capacity ▫ Impairments Affecting Mobility
◦ Aerobic Deconditioning ▫ Intervention
◦ Abnormal Tone and Spasticity ▪ Guillain-Barré Syndrome
◦ Fatigue ▫ Pathology
◦ Autonomic Nervous System ▫ Impairments Affecting Mobility
◦ Conclusion • Summary
• Patient/Client Management • References
◦ Examination
▪ Patient/Client History The light turns red and the crossing sign appears. You
▪ Systems Review have less than 12 seconds to cross a busy road before the
traffic emerges again. For an individual with a healthy neu-
▪ Tests and Measures romuscular system this may seem like an easy task, but what
▫ Aerobic Capacity and Endurance if the individual has a history of a stroke with hemiplegia?
▫ Motor Function and Performance What systems are affected that may affect their ability to
cross this busy street in a safe and efficient manner? This
▫ Tone/Spasticity chapter will briefly review the physiology of normal motor
▫ Fatigue function, and examine the physiology of abnormal motor
▪ Sensory Integrity function within a variety of neurological diagnosis. The
impact on movement and exercise prescription for these spe-
▫ Orthotic and Prosthetic Devices cialized populations will be presented. Now let’s see if we can
▫ Adaptive and Assistive Devices figure out how to help this individual cross the street.
◦ Evaluation/Diagnosis/Prognosis Movement arises from the interaction of the individual,
the task at hand, and the environment. How the individual
◦ Intervention presented above moves next needs to take into consideration
• Diagnostic-Specific Response to Exercise the constraints of the task at hand, the environment around
◦ Introduction him, and the limitations posed on the individual by the neu-
romuscular disorder. When we consider the individual there
◦ Traumatic Injury are 3 main factors that control movement. First, movement
◦ Stroke is driven by cognition, broadly defined as attention, plan-
▪ Pathology ning, problem solving, motivation, and emotion. Second,
perception is the integration of sensory information from
▪ Impairments Contributing to Decreased Mobility the environment and body systems to interpret and regulate
▪ Intervention movement. Lastly, action is the motor output that is pro-
◦ Spinal Cord Injury duced by the individual to accomplish the task (Figure 12-1).1
The understanding of motor control in its entire complexity
▪ Pathology is beyond the scope of this chapter. Designing an exercise
▪ Impairments Affecting Mobility program for individuals with neurologic deficits can be chal-
▪ Intervention lenging because of the complex and varied patterns of not
only neurological, but also physiological and musculoskeletal
◦ Traumatic Brain Injury limitations, that affect our patients. We will focus our discus-
▪ Pathology sion primarily on the systems that influence movement at the
▪ Impairments Affecting Mobility level of the individual.
▪ Intervention
Individuals With Motor Control and Motor Function Disorders 467
NORMAL MOVEMENT
The process underlying human movement is a complex
coordination of neurological systems. The multiple systems
involved each has a primary purpose, and also overlap and
provide redundancy in the system that becomes important
when we talk about injury and recovery. This section will
provide a general overview of the primary systems involved
in the production of human movement.
The nervous system can be divided into 2 primary sys-
tems: the central nervous system (CNS) and the peripheral
nervous system (PNS). The CNS consists of the brain and
spinal cord, while the PNS contains cranial and spinal nerves
that extend outside of the brain and spinal cord.2 For organi-
zational purposes, we will start at the top of the CNS.
Supplemental and Premotor Cortex

The supplemental and premotor cortex regions are respon-
sible for higher order motor planning with projections to the
Figure 12-1. Movement emerges from the interactions between the
motor cortex.2 The parietal and premotor areas are primarily individual, the task, and the environment. (Adapted from Shumway-Cook
involved in the identification of targets in space, choosing A. Motor Control: Translating Research Into Clinical Practice. 4th ed., North
the action plan necessary to complete the intended task, and American Edition, Lippincott Williams & Wilkins).
then programming the movement. Premotor areas transmit
output information to the motor cortex that then continues
on to the brainstem, and spinal cord via the corticospinal and brainstem, and cortex.1 The hypothalamus is important in
corticobulbar tracts.1,3 the control of autonomic, neuroendocrine, and limbic cir-
cuits (Figure 12-2).2
Cerebral Cortex
Cerebellum
The cerebral cortex is considered the highest level within
the complex motor control system of the CNS. The cerebral The cerebellum is connected to the brainstem by tracts
cortex can act hierarchically affecting levels below it, and in known as “peduncles.” It receives inputs from the brainstem,
parallel with other systems when acting independently on spinal cord, and cerebral cortex, and produces outputs to
spinal motor neurons. There are multiple areas and pathways the brainstem. The function of the cerebellum is simply the
in the cerebral cortex that determine strategies for move- modulation of the motor output of the corticospinal and
ment.3 The primary motor cortex lies in the frontal lobe and descending motor tracts with sensory signals.1,2
controls movement on the contralateral side of the body.
The primary somatosensory cortex is in the parietal lobe Brainstem
and controls sensation on the contralateral side of the body.
These sensory and motor areas are topographically orga- The brainstem is the next level of neural processing. The
nized and known as the motor and sensory homunculus or brainstem is composed of the midbrain, pons, and medulla
“little man” so that motor function for the foot is represented and contains many of the cranial nerves.2 The brainstem
adjacent to the motor area for the leg.2 contains ascending and descending pathways transmitting
sensory and motor information, with all descending motor
pathways originating in the brainstem with the exception of
Basal Ganglia and Diencephalon the corticospinal tract. It receives sensory information from
The basal ganglia (BG) is located at the base of the cerebral the skin and muscles of the head and neck, and vestibular
cortex. The BG receives information from the cerebral cor- and visual systems. The brainstem contains nuclei control-
tex, and sends information back to the motor cortex through ling motor output to the neck, face, and eyes, and are vital for
the thalamus. The primary functions of the BG include postural control and locomotion.1
higher level cognitive aspects of motor control such as the
planning of motor strategies. Spinal Cord
The diencephalon is the next caudal structure and is made
up of the thalamus and the hypothalamus. The thalamus is The spinal cord is the level involved in the initial recep-
considered a relay center used to process information from tion and processing of information from the muscles, joints,
multiple input pathways from the spinal cord, cerebellum, and skin. The spinal cord consists of central gray matter
468 Chapter 12
Figure 12-3. General motor organization. (Adapted from Blumenfeld H.

Neuroanatomy Through Clinical Cases. 2nd ed. Sinauer Associates Inc).
motor endplate of the axon, and the muscle fibers innervated

by the motor nerve axon. Schwann cells protect axons in the
PNS by creating myelin with large-diameter axons, and by
providing support to small diameter axons. Approximately
25% of peripheral nerve fibers are myelinated, which speeds
the rate of action potential conduction.3
Sensory System
The skin, muscles, and joints contain receptors that
transmit sensory information via afferent axons to the spinal
cord. The afferent fibers then travel in the spinal column and
ascend to the brainstem. Fibers that run along the posterior
or dorsal column of the spinal cord synapse on the dorsal
column nuclei in the medulla to cross over to the contralat-
Figure 12-2. Corticospinal tract. (Adapted from Blumenfeld H. eral hemisphere of the brain. These fibers then continue to
Neuroanatomy Through Clinical Cases. 2nd ed. Sinauer Associates Inc.) ascend and synapse in the thalamus before finally ending in
the primary sensory motor cortex. Dorsal column sensory
neurons carry information about proprioception, vibration
surrounded by white matter that contains the ascending sense, kinesthetic sense, and light touch. This provides sen-
and descending pathways. The dorsal (posterior) horn of sory input from joints and muscles contributing to motor
the spinal cord contains mainly sensory neurons while the and postural control. Sensory neurons that carry informa-
ventral (anterior) horn contains mainly motor neurons. tion about pain, temperature sense, and crude touch enter the
Lower motor neurons controlling the arms and legs reside spinal cord and immediately synapse in the gray matter of
in the ventral horn.2 Both reflexive and voluntary control of the spinal cord to cross over and ascend in the anterolateral
posture and movement is controlled through motor neurons white matter via the spinothalamic tract. The sensory neu-
(Figure 12-3).1 rons synapse next in the thalamus before continuing to the
primary somatosensory cortex. Descending somatosensory
output modulates activity of the skeletal muscles.2,3
Peripheral Nervous System Visual and vestibular systems also provide key informa-
The PNS includes motor and sensory components of tion necessary for postural control and locomotion. The
cranial and spinal nerves, and peripheral aspects of the visual system allows object identification to determine move-
autonomic nervous system. Axons in the peripheral nervous ment and visual proprioceptive information about where the
system extend from cell bodies originating in the brainstem, body is in space. Sensory information from the visual system
spinal cord, or dorsal root ganglia. The motor system, also is processed from the image detection on the retina, through
termed lower motor neuron (LMN), includes alpha motor the optic nerve to the optic chiasm where information travels
neurons located in the anterior horn cells of the brainstem through the optic tract. The optic tract forms synapses on
and spinal cord, axons that arise from the anterior horn neurons in several regions that, in turn, project to the visual
cells and form the spinal, peripheral, and cranial nerves, the cortex. The vestibular system provides sensory information
about the position and motion detection of the head in space. systems. For example, a neurological injury such as a stroke
This information contributes to the coordination of motor has a direct effect on the individual at the level of the motor
responses and gaze stabilization to maintain postural sta- cortex. Weakness (action), neglect (perception), or attention
bility. The peripheral vestibular system consists of sensory to task (cognition) can all affect the way the individual now
receptors that transmit information via the eighth cranial moves post-stroke. This can pose a challenge to the perfor-
nerve. The central vestibular system consists of 4 vestibular mance of daily tasks, such as effectively crossing the street.
nuclei located in the medulla.2 Despite the variability for potential lesion location and
severity, the 3 most frequent problems that reduce func-
Conclusion tional capacity in individuals with neuromuscular disorders
(NMDs) are altered motor function, fatigue, and difficulty
There are several parallel pathways and feedback loops that exercising, and accessing activity all contributing to a seden-
connect all of these systems to produce and control move- tary and unhealthy lifestyle.5
ment. The corticospinal tract is a key motor pathway that
begins in the primary motor cortex and descends through
the brainstem, crossing over at the junction between the
Premotor Cortex
medulla and the spinal cord, to reach the spinal cord and A lesion at the level of the associated or limbic cortices
control movement. Lesions occurring above this cross-over does not tend to produce profound motor deficits, but can
junction will produce weakness on the opposite side of the alter the volitional or motivational control of movement.2
body, while lesions below this junction in the spinal cord
cause weakness on the same, or ipsilateral side. Motor Cortex
Upper motor neurons (UMN) project from the cortex
to the brainstem or spinal cord and then form synapses on An insult to the motor cortex and UMNs of the cortico-
LMNs located in the brainstem motor nuclei and anterior spinal tract can result in impairments along the descending
horns of the spinal cord. LMN cranial nerves in the brain- motor pathways. Abnormal central motor function causes a
stem, and anterior spinal roots in the spinal cord then proj- distortion in the central motor excitatory drive. This may in
ect out of the CNS to control muscle cells in the periphery.2 turn impair the ability to recruit and modulate motor neu-
Functional demands drive patterns of innervation that play rons, decreasing force production. This irregular activation
a role in determining the characteristics of a muscle. Muscle promotes abnormal movement patterns, or synergies, during
fibers can be classified based on speed of shortening and functional tasks such as walking.1 Individuals with more
morphological characteristics.3 Type I muscle fibers, or slow significant damage to the corticospinal tract show increased
oxidative slow-twitch muscle fibers, are fatigue-resistance activation in premotor and supplemental motor cortices of
fibers. Type II fibers can be further classified as either Type the affected hemisphere during functional tasks.6 These
IIa or Type IIb. Type IIa fibers are referred to as fast oxidative changes in pattern of brain activation appear to correlate
fibers, are faster and bigger than Type I fibers, and are also with a decrease in functional outcomes. As motor recovery
fatigue resistant. Type IIb lack aerobic enzyme and fatigue and function improve, there is a reduction in abnormal acti-
easily.3,4 vation patterns.6
Muscle function can be defined in terms of strength,
speed, and fatigue resistance. While the typical ratio of slow- Subcortical
twitch muscle fibers to fast is 50% to 50%, the characteristics
can depend on the activity patterns to which the muscle is At the sub-cortical level the cerebellum and basal ganglia
subjected. The ability of a muscle to produce force is deter- affect the coordination of motor output. A lesion at either
mined by the descending motor control of the UMN system, of these structures will affect the timing of a movement
the number of motor units recruited, the order of motor unit resulting in either delayed initiation or termination, and the
recruitment, type of muscle fibers available for innervation, ability to grade and scale force produced. Pathology in the
and the amount of tension placed on the muscle.4 cerebellum can affect the accuracy of movement (dysmetria),
and tends to be more prominent when multiple joints are
involved across a larger trajectory at a faster speed (such as
walking across the street) versus single-joint movements per-
NEUROLOGICAL IMPAIRMENTS formed over a smaller range at a slower speed.1 The ability to
AFFECTING MOTOR CONTROL coordinate eye and head movements, postural sway, and the
timing of equilibrium responses may also be affected. Loss
of input from the cerebellum is thought to cause hypotonia
Noted earlier in the chapter, “normal” movement is driven
or asthenia (generalized weakness).3 Pathology in the basal
by the interaction of the individual with the environment
ganglia can result in impaired timing of movements and
while completing a specific task. Altered, or “abnormal”
movements that are either too small (hypokinetic/bradyki-
movements at the level of the individual can be influenced
netic) or too large (hyperkinetic).1
by pathology affecting the action, perception, or cognitive
470 Chapter 12
Spinal Cord/Lower Motor Neuron another term used when there is no motor function present.
The term hemi describes weakness on one side of the body,
A lesion at the level of the LMN from the anterior horn “para” describes weakness in the lower limbs, while the terms
of the spinal cord to the peripheral nerve will cause muscle “tetra” or “quad” describe weakness noted in all 4 limbs.1,2
weakness and atrophy. Lesions at the neuromuscular junc- For example, our patient who has had a cortical stroke with
tion, and subsequent alterations in the mechanical properties mild to moderate weakness on the right side of the body may
of the muscles and joints themselves can further contribute be described as having “hemiplegia.” Weakness from UMN
to motor weakness.2 and LMN lesions can also lead to secondary neuromuscu-
lar impairments affecting exercise participation, including
Peripheral Nervous System muscle disuse atrophy, cardiovascular deconditioning, and
contractions.1 Specific muscle groups such as hip flexors and
Disorders arising from the PNS are broadly classified as plantar-flexors have been noted to have a direct impact on
either neuropathies when the lesion is confined to the nerve, gait speed when weak, which may in turn contribute to an
or myopathies, when the pathology occurs in the muscle. A increase in disability.7,8 Therefore, a thorough understand-
lesion of the sensory function will either follow a peripheral ing of the function of the motor system in the presence of
nerve distribution or a dermatomal pattern when the spinal a neurological deficit is a critical element throughout the
nerve or dorsal root ganglion is affected. The most com- course of care.
mon symptoms of a peripheral sensory lesion are tingling,
prickling, burning, or paresthesias. When motor function
is involved, paralysis or paresis will occur in muscles inner-
Aerobic Deconditioning
vated by the nerve distal to the lesion. Weakness will occur in Reduced exercise performance and fitness can occur with
a myotomal pattern, affecting all muscles innervated by that muscle or neurological injury, loss of muscle tissue size and
spinal level. Typically symptoms of peripheral nerve motor quality, or deconditioning. Individuals with both progressive
impairments would be weakness, muscle cramping, fas- as well as stable neuromuscular disorders tend to have some
ciculations, and hypotonicity. Deep tendon reflexes (DTRs) aspect of all of these deficits from either the pathology itself
will also be diminished. In the autonomic nervous system or as a result of disuse from a more sedentary lifestyle affect-
preganglionic nerve fibers are myelinated. In the presence ing overall mobility.5 Individuals with NMD tend to live a
of demyelination or axonal degeneration, abnormalities in more sedentary lifestyle and often present with a decreased
vascular control and sweating will occur.3 amount of resting energy expenditure compared to able-
bodied individuals. During even basic activities of daily liv-
Sensory System Dysfunction ing (ADL), however, movements are less efficient and there
is an increased energy cost of physical activity, especially in
Disorders affecting the sensory system pathways can more demanding tasks such as walking.9 Secondary effects
have a profound impact on movement and motor control. include cardiopulmonary compromise in the presence of
Disruption of sensory function in the dorsal column path- NMD including a reduction in max and peak volume of
ways will result in difficult maintaining postural control oxygen consumed (VO2), pulmonary ventilation, work rate
during voluntary and involuntary functional tasks. The lack or capacity, and endurance, which places an increased risk
of joint and motor position feedback can cause movements for hypertension (HTN), cardiovascular disease (CVD), and
that are ataxic, uncoordinated, and inefficient. Impairments diabetes mellitus (DM).10 Most aerobic interventions studied
in the visual system that can affect mobility are visual fields in slowly or rapidly progressing disorders demonstrate the
cuts that may contribute to tripping and falls. Impairments of potential for a positive response to aerobic exercise training.
the vestibular system may cause deficits in gaze stabilization, Short-term cardiovascular adaptations can be made with
postural control, and balance especially in complex environ- sub-maximal training similar to able-bodied individuals.9,10
ments and during dynamic activities.1 The severity of risk and impact of cardiovascular decon-
ditioning varies depending on the neurological diagnosis
and is discussed in more detail later in this chapter.
KEY IMPAIRMENTS AFFECTING
MOVEMENT AND EXERCISE CAPACITY Abnormal Tone and Spasticity
Changes in muscle tone occur as a consequence of a UMN
Motor weakness is one of the most common and consis- or LMN lesion. Muscle tone is defined as the muscles resis-
tent consequences both of UMN and LMN lesions. Weakness tance to passive stretch.1 Everyone has a certain amount of
can be caused by a lesion at any level in the neuromuscular muscle tone. The spectrum of muscle tone ranges from low,
system and is commonly classified by the severity and loca- or hypotonic, to high, or hypertonic (Figure 12-4). On one
tion of the distribution. The term “paresis” is used to describe end of the spectrum, hypotonicity is defined as a reduction
a mild to moderate, or partial weakness, while “plegia” in the stiffness of a muscle to lengthening.1 Hypotonicity
denotes a more severe or total loss of movement. Paralysis is is typically associated with lesions in the cerebellum and is
Figure 12-4. Range of muscle tone. (Adapted from Shumway-Cook

A. Motor Control: Translating Research Into Clinical Practice. 4th ed.,
North American Edition, Lippincott Williams & Wilkins.)
thought to be due to a decrease in input from the cerebel-

lum to the motor cortex.3 The high end of “hypertonicity”
is classified as either spasticity or rigidity. Levels of hyper-
tonicity are caused by a lesion of the corticospinal pathways
contributing to an amplified amount of alpha motor neuron
excitability that results in an increase in resting muscle tone,
and an elevated level of excitatory afferent input elicited by a
quick muscle stretch.1
Spasticity is further defined as a velocity-dependent reflex
response to muscle stretch. The role of spasticity in function-
al movements has been debated and the thought process has
evolved. The evidence suggests that there is not a causal rela-
tionship between the level of spasticity an individual presents
with and central control of movement.11-13 The presence
of spasticity changes the physical property of the muscle
over time. An increase in muscle fiber size variability and Figure 12-5. Fatigue. (Adapted from Lou J, Weiss MD, Carter GT.
extracellular matrix material may present clinically with an Assessment and management of fatigue in neuromuscular disease. Am J
Hosp Palliat Care. 2010;27(2):145-157.)
increase in muscle stiffness. This may alter the resting align-
ment of the affecting limb, placing it in a shortened position
and at increased risk for developing contractures.1 This may central activation failure (CAF), will not be able to develop its
contribute to inefficient gait patterns and deconditioning. maximal force capacity.14 Peripheral fatigue develops when
there is muscle weakness or sensory loss from disorders of
Fatigue the LMN units, or from morphological changes at the level
of the muscle.15,20 Peripheral muscle fatigability is described
Fatigue is a universal complaint among individuals with
as the failure to sustain the force of a muscle contraction over
neuromuscular disorders and is a complex multidimen-
time.15 This declining force during contraction is mainly
sional impairment with both physiological and psychologi-
attributed to changing intracellular ion levels negatively
cal aspects. More than 60% of individuals with neurological
affecting contractile forces (Figure 12-5). Severity of motor
disorders suffer from fatigue, often described as sleepiness,
fatigue is measured by the percentage of decline in force pro-
weakness, exercise intolerance, or exhaustion.14-19 It influ-
duction.14 In individuals with neurological disorders, even
ences movement and performance in ADL, as well as overall
the sense of “normal” fatigue can be amplified by the patho-
health and quality of life. Physiologic fatigue can result from
logical changes that occur throughout the motor systems.15
pathology that affects motor neuron pathways responsible
Fatigue can vary depending on the task performed, the type
for the force-producing capability of a muscle or for the
of muscle power utilized (voluntary versus electrical stimula-
perceived effort of the task.14,15 Fatigue can be characterized
tion, isometric versus dynamic, sustain versus intermittent,
by the amount of a time a muscle can sustain a certain force
high versus low forces), and the contractile properties of the
(endurance), or by the amount of decline in force or power
muscles.20 How each individual perceives and responds to
output over a period of time.20 Fatigue can be brought on
fatigue can also have an influence. Subjective complaints can
by physical activity or stress and may stem from central or
be influenced by motivation, coping mechanisms, overall
peripheral mechanisms. The term “central fatigue” refers
well-being, and social circumstances.15
to fatigue that arises from the loss of voluntary activation
of muscles during activity or exercise due to a disruption in In addition to motor dysfunction, other factors that may
input from anywhere along the central nervous system, such contribute to fatigue in individuals with neuromuscular dis-
as a lesion in the motor cortex in multiple sclerosis (MS).14 A orders that need to be considered are reduced respiratory and
muscle receiving sub-optimal input from the CNS, known as cardiac function, chronic pain, sleep disorders, depression,
472 Chapter 12
malnutrition, and dehydration. Hypoventilation is more include examination, evaluation, diagnosis, prognosis, and
prominent in supine positions so may be first noted as com- intervention, are designed to maximize outcomes.24
plaints of morning somnolence, headaches, restlessness,
and fatigue.21 Pulmonary function tests including forced Examination
vital capacity (FVC) reflect both inspiratory and expiratory
muscle strength and may be important to monitor in supine Patient/Client History
as well as seated positions for the most accurate assessment of
The history includes information about the individual’s
respiratory function in individuals with NMD.
current and past medical history. This information is gath-
ered from the patients/clients themselves, caregivers, mem-
Autonomic Nervous System bers of the health care team, and the medical record. The
Autonomic nervous system dysfunction can be present information obtained can also include items like general
with most neurological pathologies and must be taken into demographics, social history, occupation, growth and devel-
consideration when developing an exercise prescription. opment, living environment, functional status, and activity
The autonomic nervous system is a component of the PNS levels, family history, medications, and social habits. The
that controls autonomic functions such as heart rate (HR), patient/client history should also contain a review of relevant
sweating, smooth muscle contraction in the walls of blood laboratory and diagnostic tests results.24 This information
vessels and bronchi, sex organs, and the pupils.2 The efferent can be used to identify potential health risks and comorbidi-
autonomic pathways are divided into the sympathetic and ties of the individual to help determine the health restorative
parasympathetic pathways. The sympathetic division stems and preventive needs of the patients/clients and their impli-
from the spinal levels T1 through L2 and controls the “fight cations for response to physical therapy intervention.1
or flight” response. When stimulated, the neurotransmitter Systems Review
norepinephrine is released, increasing HR, blood pressure
The systems review is a brief overview of the general
(BP), pupil size, and bronchodilation. The parasympathetic
health of the patient/client. Key elements of the systems
division stems from parasympathetic ganglion in the cranial
review include a brief appraisal of the cardiopulmonary,
nerves and at S2 to S4. When stimulated, acetylcholine is
integumentary, musculoskeletal, and neuromuscular sys-
released to produce the opposite effect, decreasing HR and
tems. It is also a point to determine the communication
BP. Neurons in the cerebral cortex, basal forebrain, hypothal-
style, cognition, language, and learning style of the patient/
amus, midbrain, pons, and medulla contribute to autonomic
client.24
control, along with afferent sensory information from the
The cardiopulmonary system requires particular atten-
periphery.2,3 Response to exercise or exercise tolerance can
tion when working with individuals with neuromuscular dis-
be blunted in the presence of autonomic dysfunction, includ-
orders. Various cortical as well as spinal cord injuries (SCIs)
ing the use of HR as a measure of response or perceived exer-
above the level of T6 can be associated with dysfunction of
tion. Abnormal autonomic responses can be mild to severe
the autonomic nervous system.25,26 In particular, regula-
depending on the contributing pathology.
tion of sweating, HR, and BP may be impaired when there
is pathology along the neuromuscular system. This may
Conclusion present itself clinically as bradycardia, diaphoresis, supine
When considering an exercise prescription for an individ- and orthostatic hypotension, and in severe cases can cause
ual with NMD, you must take into consideration the specific cardiac arrest.3
diagnosis, the subsequent limitations that affect movement, Resting HR, orthostatic BP, resting respiratory rate, and
the rate of the disease progression, and the amount of clini- arterial saturation with pulse oximeter are all baseline mea-
cal involvement to estimate the best potential for response to sures that should be included prior to the initiation of testing.
treatment.22,23 For example, in a disease like amyotrophic Tests and Measures
lateral sclerosis (ALS) that is characterized by a rapid pro-
The next step in the examination process is driven by the
gression, the goal may be to slow or stabilize the disease,
information gathered in the history and systems review. The
while in slowly progressing diseases such as Parkinson’s
physical therapist chooses relevant tests and measures to
disease (PD), there is evidence, which we will explore further,
determine the underlying impairments contributing to the
that there is the potential for positive and significant gains in
individual’s functional limitations that are affecting his or
strength and aerobic capacity.
her activity and participation levels. The key elements related
to mobility and the ability to participate in exercise are dis-
cussed below in more detail.
PATIENT/CLIENT MANAGEMENT Aerobic Capacity and Endurance
The patient/client management process established by the Maximal exercise testing is considered the gold stan-
American Physical Therapy Association (APTA) is described dard for assessing aerobic capacity. Many individuals with
in the Guide to Physical Therapy Practice. The 5 key elements neuromuscular disease with deficits in gait and balance, or
TABLE 12-1. BASELINE RANGES ESTABLISHED IN INDIVIDUALS WITH A HISTORY OF STROKE,

MULTIPLE SCLEROSIS, TRAUMATIC BRAIN INJURY, AND PARKINSON'S DISEASE
PATIENT POPULATION MEAN WALKING DISTANCE (M) ± SD
Sub-acute stroke244 215.8 ± 91.6 m
Chronic stroke245,246 384 to 398, 378.3 ± 123.1 m
Parkinson s diseases H&Y5-3,247,248 391.6 to 394.1 ± 98.4 to 99.9 m
Multiple sclerosis EDSS 2.0 to 6.535 368.6 to 393.8 m
Chronic TBI33 403 to 417 ± 105 to 106 m
H&Y: Hoehn and Yahr Staging Scale; EDSS: Expanded Disability Status Scale; SD: standard deviation; m: meters.
who suffer from pain or extreme fatigue, may not be able to medications to improve mobility and often need to time
participate in accurate maximal exercise assessment. Sub- activity around their medication schedule.
maximal exercise testing can overcome many of these obsta- Treadmill testing is the most common option for indi-
cles and is an effective assessment of aerobic capacity and viduals who are ambulatory and have only minor impair-
performance.27 Individuals who do require cardiovascular ments in balance. Treadmills with front and side rails should
monitoring, are prescribed anti-anginal medication, or are be used for safety, but subjects should be encouraged to
considered to be at hemodynamic risk should be tested in a minimize use of the upper extremities (UEs) during test-
setting with trained medical personnel present or cleared by ing. Ramping treadmill protocols start at a slow comfortable
their physician for sub-maximal testing. Contraindications pace until a comfortable walking speed is achieved. At fixed
to exercise testing include labile angina, angina at rest, and intervals the speed or grade is gradually increased over a
frequent premature periventricular contractions (PVCs) at period of 6 to 12 minutes. Treadmill testing is the preferred
rest.27 method of testing when possible since it is easier to achieve
Measures of exercise response that can easily be examined VO2max walking a treadmill than seated on a cycle or at an
in all clinical settings includes HR, BP, respiratory rate (RR), arm ergometer.30,31
rating of perceived exertion (RPE), arterial saturation using Cycle ergometer testing can be used for individuals with
a pulse oximeter, breathlessness, and ratings of fatigue and impaired balance or ambulation preventing effective partici-
pain. The Borg scale is one of the most common and consid- pation in a timed walk test. Testing with a cycle ergometer
ered the best tools used to rate levels of perceived exertion.28 requires decreased energy cost compared to treadmill test-
There are a variety of sub-maximal exercise tests that ing. The UEs require less motion or stability, making it easier
can be performed in a clinical setting and are appropri- to obtain an accurate BP. For individuals with hemiparesis,
ate for individuals with neuromuscular disorders. Factors foot straps can be used to secure the weaker extremity. Work
to consider when selecting an appropriate testing measure intensity is adjusted by changes in resistance and/or pedaling
include consideration of the individual’s primary and sec- rate and typically calculated in watts or kilopond meters per
ondary pathology, mobility, the use of assistive devices for minute (kpm/min–1).29,30 A disadvantage to cycle ergometer
balance or gait, cognitive status, and level of independence.27 testing is that quadriceps muscles often fatigue before the
Individuals should be familiarized with the testing equip- individual reaches maximum oxygen uptake.
ment and provided at least one practice attempt to improve Arm ergometry testing is the least effective method of
the validity of the test results. A typical protocol for exercise assessment for aerobic capacity, but can be used as an option
testing includes a low-load warm-up period, a progressive for individuals who are nonambulatory or have less than
uninterrupted exercise with increased loads at consistent minimal use of their lower extremities (LEs). Protocols for
time intervals, followed by a recovery period.29 Adequate rest arm ergometer testing require that the individual is seated in
should be allowed between practice and test attempts, and an upright position with the fulcrum of the handle adjusted
verbal encouragement should be standardized. to shoulder height. Cycle speed should be maintained at
Submaximal exercise testing can be symptom limited, or 60 to 70 revolutions/minute with a work increase of 10W at
have predetermined end points often defined by peak HR of each 2-minute stage.29 BPs can be monitored mechanically
120 beats per minutes (bpm) or 70% of predicted HR max. A at slower speeds, but are often less accurate at higher speeds.
peak metabolic equivalent (MET) level of 5 may also be used An option can be to test the individual intermittently with
as an endpoint.29 1-minute rest breaks between stages to assess BP.
Pay special attention to medications the individual may The 6-Minute Walk Test (6MWT) is a commonly used
be taking and their effects on exercise response, mobility, measure of endurance and functional mobility outside of the
and fatigue. For example, beta blockers suppress normal HR home for ambulatory individuals with NMDs (Table 12-1).32
and BP response to exercise, while individuals with PD take The 6MWT is a reliable and valid measure utilized across
474 Chapter 12
a neurological impairment can be challenging, but has been
Modified Ashworth Scale for Grading documented in several studies using HHD.39-43
Spasticity LE motor strength and endurance assessment can be
initiated during observation of a functional task. The 5 or
Grade Description 10 times Sit to Stand Test is a simple and practical test of
0 No increase in muscle tone function and endurance that correlates well with LE manual
and dynametric strength measures.44,45 A cut-off score of
1 Slight increase in muscle tone,
12 seconds appears to discriminate between healthy and
manifested by a catch and release
hemiparetic individuals.45
or by minimal resistance at the end
When abnormal movement patterns or synergies are pres-
of the range of motion when the
ent, a subjective descriptive analysis of resting alignment or
affected part(s) is moved in flexion
start position of the limb, the ability of the patient to frac-
or extension tionate movements at each joint in gravity or gravity mini-
1+ Slight increase in muscle tone, mized positions, and the patterns of movement that emerge
manifested by a catch, followed by is often used as an initial measure of mobility. While impair-
minimal resistance throughout the ment level assessment tools such as the Fugl-Meyer Lower
remainder (less than half) of the Extremity Assessment (FM-LE) can be utilized to objectively
ROM quantify movement patterns, correlation to complex motor
2 More marked increase in muscle behaviors such as walking are not as predictive as measures
tone through most of the ROM, but of LE strength.46
affected part(s) easily moved Measures of motor performance can provide more sig-
nificant information related to functional limitation such as
3 Considerable increase in muscle gait. The upright motor control test (UMCT) is a measure of
tone, passive movement difficult paretic LE motor control. The 2 major sections of the test are
4 Affected part(s) rigid in flexion or the flexion control test and the extension control test. The
extension flexion control test is used to assess flexion control of the
nonweightbearing extremity for purposes such as advance-
Figure 12-6. Modified Ashworth Scale. (Reprinted from Phys Ther. ment of the limb in the swing phase of gait. The extension
1987;67(2):206-207, with permission of the American Physical Therapy
Association. Copyright © 1987 American Physical Therapy Association.) control test evaluates LE extension control of a single weight-
bearing extremity with application for single-limb stance
potential in gait. Muscle groups are graded as strong (actively
diagnostic groups.33-38 Timed walking tests can be utilized completing a full motion within a given time frame), mod-
safely when maximal exercise testing is contraindicated.27 erate (actively completing a partial to full motion within a
Results correspond to functional ADL and can be used to given time), weak (only partial to no motion is noted over
detect change in functional ability following intervention.27 the allotted amount of time), or unable to perform.47 UMCT
Improvements in walking distance can be attributed to scores are significantly associated with measures of gait
improvements in cardiac output, in mechanics of ventilation, speed and can be predictive of later walking outcomes.48
or in muscular conditioning.38 Tone/Spasticity
Motor Function and Performance The evaluation of muscle tone in the presence of a neuro-
The assessment of muscle strength impairment and logical insult is performed to identify the lesion location and
endurance can be challenging depending on the ability of the to differentiate the role of muscle stiffness and contracture as
patient to isolate movement for the most accurate assessment. it relates to a functional problem.49 The most utilized mea-
Examination methods of strength need to be practical in surement scale for assessment of hypertonicity in the clinical
terms of time, training, and equipment needed to be feasible setting is the modified Ashworth Scale (MAS). The MAS is
in a clinical setting. an ordinal scale ranging from 0 (no change in muscle tone),
When a patient is able to isolate movement, the primary to 4 (rigidity; Figure 12-6). The MAS is currently the clinical
measure of muscle strength used in the clinical setting is standard for assessment of spasticity that does not require
manual muscle testing (MMT). MMT is a reliable measure instrumentation, but consistent training to necessary to
of muscle strength, but is less discriminatory than hand-held maintain reliability. Limitations of the MAS are the weak
dynamometry in grades > 3/5.39 correlation to functional limitations, and the lack of proce-
The second most common method of strength assessment dural standardization.50,51
in a clinical setting is HHD. The standard devices are porta- The Tardieu Scale has been suggested as an alternative to
ble, easy to use, relatively inexpensive, and considered a valid the MAS as it assesses and compares the response of passive
and reliable measure of muscle strength especially when test- stretch at both slow and fast speeds. Tardieu also included the
ing muscles that are naturally or pathologically weak.39 The importance of maintaining a constant position of the limb
ability to accurately quantify muscle strength in presence of segment proximal to the muscle group being tested. The scale
has been further developed to include parameters to define use of neuroprosthetics is a developing field. While a discus-
the strength and duration of the stretch reflex, the angle at sion of the complexities of LE bracing components is beyond
which the stretch reflex is activated, and the speed necessary the scope of this chapter, we will address the implications for
to trigger the stretch reflex. Reliability and validity are not gait quality and efficiency as it relates to aerobic capacity and
well defined at this point.52 training.
Fatigue Abnormal gait patterns that arise because of motor neu-
ron lesions contribute to an increased risk for falls, and an
The effects of fatigue can be assessed in a clinical setting
increase in energy expenditure during slow gait speeds.49
either subjectively or objectively. Subjective fatigue of the
Individuals who use an AFO demonstrate improvements—
individual should be assessed using a questionnaire or other
an increase in step length gait velocity and cadence, a
source of patient-reported outcome measure. The Fatigue
decrease in double limb stance time, and more symmetrical
Severity Scale (FSS) is a commonly used assessment tool
single-limb stance times and step lengths—that all contrib-
across neurologic diagnosis, especially in individuals with
ute to improved efficiency of gait.57 Individuals wearing an
MS and PD.18,53-55 The 9 item scale measures fatigue and
articulating AFO or posterior leaf spring (PLS) demonstrate
the severity of its impact of daily activities and participa-
even more significant improvements in step length and gait
tion, and can clarify the relationship between fatigue and
velocity compared to those who use a solid AFO.58 The use
depressive symptoms.56 The self-administered questionnaire
of neuroprosthetics for foot drop are an increasingly popular
asks participants to rate their fatigue on a 7-point scale when
option despite the expense and limited coverage by insur-
answering statements such as, “My motivation is lower when
ance companies. Commercial neuroprosthetics are used
I am fatigued,” and “Fatigue interferes with my work, fam-
primarily in individuals with hemiparesis to activate ankle
ily, or social life.” The FSS has high validity, reliability, and
dorsiflexion in swing. Correction of this component of gait
internal consistency.53,56
allows an increase in gait velocity and overall function and
Another common subjective measure is the single-item
participation levels.59 A thorough team-based examination
visual analog scale (VAS). Subjective reports of fatigue tend
performed in a brace clinic that includes a physical therapist
to be more practical for clinical use, are widely available,
can assist when determining the most appropriate bracing
and easier for the patient to understand and participate in.
options for each patient.
The main limitations are that the assessment relies on the
individual’s interpretation of fatigue and may not correlate Adaptive and Assistive Devices
with severity of physical fatigue measured in an exercise Assistive devices such as a single-point cane or walker are
protocol.21 frequently used to improve the safety of walking when a sig-
nificant gait disorder or history of falls in noted. While these
Sensory Integrity
devices can improve safety, balance, and gait economy, they
A thorough examination of the sensory system is neces- can also interfere with postural responses in a fall and place
sary when considering an exercise program in the presence increased strength and metabolic demands on the individu-
of a neurological deficit. Sensory impairments within the al.60-62 This high amount of variability in the effectiveness of
somatosensory, visual or vestibular systems can have a pro- an assistive device demonstrates the importance of a skilled
found impact on mobility, postural control, and locomotion. assessment by a physical therapist to establish the needs and
Critical components of a somatosensory examination should goals of each patient.
include items for discriminative touch, proprioception, pain, Safety is always of the highest priority. Since difficulty
and temperature. A comprehensive visual exam should with gait is consistent among individuals with NMDs, it is
include information on visual acuity, visual fields, depth important that we take into account the changes in efficiency
perception, and oculomotor control. Vestibular function that are noted when prescribing an assistive device. A single-
examination can include tests of gaze stabilization, postural point cane is often recommended with mild gait deviations
control, balance, and dizziness.1 While deficits in sensation and minimal risk for falls are noted. Gianfrancesco et al
may not be a primary predictor of gait speed potential, it is measured individuals with MS walking with and without a
certainly a contributing factor.7,8 Sensation related to fall risk cane at self-selected and fast walking speeds. When a cane
and injury potential needs to be considered when establish- was introduced, subjects showed significantly improved gait
ing the mode of intervention that may provide the maximal symmetry and variability at self-selected walking speeds, and
aerobic and strengthening benefits. improved velocity at faster walking speeds compared to gait
Orthotic and Prosthetic Devices without a device.63 The least-supportive devices like a single-
LE orthotic devices are frequently prescribed to individu- point cane may improve gait parameters including velocity
als with neurological disorders. They are indicated in the better than other more supportive devices64 in the absence
presence of weakness or abnormal muscle tone to improve of a balance disorder of fall risk. There is little scientific evi-
alignment, positioning, and provide stability during func- dence for the support of assistive devices for improvements
tional activities such as transfers, standing, and gait. The in gait or balance with individuals with PD.65
most common types of LE orthotics utilized are ankle-foot In general, walkers and wheeled walkers are indicated for
orthotics (AFO) and knee-ankle foot orthotics (KAFO). The individuals with moderate to severe disability.66 While the
476 Chapter 12
intension is to improve safety and decrease fall risk, these
devices significantly alter gait parameters such as step length DIAGNOSTIC-SPECIFIC
and velocity. This translates to a decrease in gait speed with
increased energy demands demonstrated by a higher VO2.67
RESPONSE TO EXERCISE
This is most likely due to the increased economy of walking
with these types of devices that can contribute to fatigue and Introduction
decreased activity tolerance. Careful assessment of the most
Dysfunction of the adult nervous system can be caused by
appropriate device is necessary to maximize safety, activity
traumatic, slowly or rapidly progressing degenerative disor-
tolerance, and participation.
ders. The pattern of neuronal loss can be distinctive to the
disease and produce a range of impairments affecting func-
Evaluation/Diagnosis/Prognosis tion and ADL. The ability to adequately prescribe an exercise
Once all the necessary data are collected in the examina- intervention depends on our knowledge of the underlying
tion, the physical therapist formulates a clinical judgment. pathology, risk for primary and secondary impairments, and
The results of the tests and measures performed influence potential for recovery or disease progression. This section
the evaluation process along with an appreciation for the loss will attempt to outline this information for the most com-
of function, social considerations, and overall health and mon disorders of the neuromuscular system.
physical function.
Traumatic Injury
Intervention A traumatic injury to the neuromuscular system can be
A well-rounded exercise program will include both aero- described as an initial insult to the nervous system followed
bic and strengthening components. Fatigue also plays a by a period of recovery of function.
prominent role in neurological disorders and should be con-
sidered when designing an intervention plan. Stroke
Strength training refers to exercises that improve the
force-generating capacity of the muscle.3 The ability to Pathology
improve muscle strength and the capacity to which the Stroke remains one of the third leading causes of death
improvement can occur is discussed is further detail within in the United States behind heart disease, and is a leading
the diagnostic groups. There is a better understanding that cause of disability.69,70 The average incidence is about 114 per
strength training does not increase abnormal tone or exac- 100,000, with approximately 4 million stroke survivors alive
erbate synergistic movement patterns, and is strongly advo- in the United States.3 Risk factors for ischemic strokes
cated for individuals with neurological pathology.1,11 include HTN, atrial fibrillation, DM, age, and smoking.70
Cardiovascular fitness and participation in exercise is an The term “stroke” refers to hemorrhagic events and ischemic
important and necessary lifestyle behavior for individuals infarcts to the brain. Ischemic strokes make up about 87%
with neurological disorders who are more prone to seden- of all stroke types and occur when there is inadequate blood
tary lifestyles and the development of cardiovascular and supply to the brain. Ischemic strokes occur in either small
pulmonary disorders. Aerobic and endurance training focus vessels, resulting in more focal deficits, or large vessels that
on improvements of aerobic capacity, and the duration that a typically involve multisystem impairments. A blockage of the
person can maintain a certain activity.68 A regular exercise blood vessel can be caused by either an embolus or narrow-
routine decreases the risk of secondary risk factors that occur ing of the vessel known as stenosis.
with a sedentary lifestyle and disability, and can improve of Residual impairments post-stroke are due to injury or
maintain functional abilities. death of the brain tissue supplied by that vessel. A stroke
Fatigue contributes to a more sedentary lifestyle that can in the middle cerebral artery (MCA) may present with
affect general fitness and well-being of individuals with contralateral weakness in the UE greater than the LE, con-
NMDs. Fatigue is treatable and can often be at least partially tralateral sensory and vision loss, and language or visual
reversible. Management of fatigue is an important compo- spatial disorders. A stroke affecting the region supplied by
nent of patient care and can be achieved through a variety of the anterior cerebral artery (ACA) may present with contra-
recognized treatment options. Symptomatic treatment of the lateral weakness in the LE greater than the UE, contralateral
underlying disease is important to control the physiologic sensory loss, abulia, and aphasia when the left hemisphere is
component of fatigue. Medications and cognitive behavioral involved. The most common deficits consistent with a stroke
therapy have also shown a positive response by providing involving the posterior cerebral artery (PCA) include hom-
coping strategies and decreasing fatigue levels. onymous hemianopsia, memory loss, visual hallucinations,
A regular aerobic or resistance exercise routine even at low topographic disorientation, and sensory loss. Small-vessel
intensities can prevent deconditioning and muscle wasting, lacunar infarcts often present with pure motor hemiplegia
improve efficiency of movement, and decrease fatigue across or hemisensory loss, or dysarthria. Border zone infarction
many neurological diagnosis.15,21 presents with deficits in more proximal body structures such
as the shoulder and hips, rather than distal body structures A consistent goal among stroke survivors is to return
likes the hands and feet. Strokes that occur in the brainstem to home and community activities through walking. Yet,
may present with impairments in cranial nerve function, ambulatory activities are reported well below that of healthy
oculomotor deficits, and ipsilateral ataxia, bilateral hemipa- but sedentary age-matched peers.82 Functional gait speed in
resis, and hemisensory loss.2,3,71 stroke can be classified using the following self-selected gait
Hemorrhagic strokes make up the remaining 13% and speed parameters83,84:
occur when a cerebral blood vessel ruptures, resulting in • Physiologic: 0.1 m/s
bleeding into the brain tissue.72 The largest risk factor is high • Household ambulation: < 0.4 m/s
BP. These types of strokes occur in a younger population
and are more fatal, with approximately 38% dying within • Limited community ambulation: 0.4 to 0/8 m/s
the first 30 days, but there is better recovery potential for • Community ambulation: > 0.8 m/s
those who survive.70,72 Symptom presentation depends on The energy requirements of a hemiparetic gait pattern
the mechanism of the stroke, and the region of the brain that have been reported to be as much as 55% to 100% more than
is affected. There may also be the indirect territories affected age-matched controls.74 Regardless of age, stroke survivors
around the region of the stroke, or from nerve fibers that often present with a higher metabolic cost of walking dem-
pass through the region of the stroke.72 The most common onstrated by dramatically lower peak VO2 than their age-
locations affected by hemorrhages are the putamen (50%), matched healthy peers, and commonly have a limited fitness
thalamus (15%), pons (10), cerebellum (10%), and the lobar reserve related to their poor walking economy.85-87 This can
(15%). According to the American Heart Association, the contribute to feelings of fatigue that have been reported in up
primary impairments observed after stroke are weakness or to 97% of individuals who have suffered a stroke, regardless
numbness in 50% of patients, and impaired ability to walk of neurological recovery.14
without a device or assistance in 30%.70 With the increased effort necessary for gait and a com-
Many risk factors for stroke are shared with coronary pounding sense of fatigue, a decreased level of activity can be
artery disease and are modifiable. These include HTN, DM, a natural progression.
high cholesterol, obesity, cigarette smoking, and cardiac Regardless of age, cardiovascular fitness affected by gait
disease.2,73 performance is markedly impaired within 4 to 6 weeks post-
Impairments Contributing to Decreased stroke.76 The high-energy cost of walking also decreases
Mobility participation in ADL, leading to a spiral of continued pro-
gression of weakness, muscle atrophy, impaired cardiovascu-
Stroke is the leading cause of long-term disability in the
lar fitness, and eventual disability.76
United States.70 While individuals post-stroke may present
While most treatment and recovery occurs in the first few
with a variety of deficits, motor function impairments such
weeks and months after stroke, many patients are left with
as weakness and discoordination are the most prominent
residuals deficits that limit activity. There is a high preva-
that contribute to disability.74 Damage to the primary motor
lence of extreme sedentary lifestyles after stroke contributing
cortex after a stroke affects central motor activation causing
to deconditioning, and recurrent stroke. The prevalence of
a loss of force production and excessive muscular cocontrac-
cardiac disease in stroke survivors has been reported to be as
tion.75 After stroke there is often an increased activation of
high as 75%.73,74,88 Recurrent strokes account for up to 25%
the secondary motor areas but these projections have less
of all new strokes annually.3 Baseline aerobic capacity is often
excitatory effect.6 This decreased ability to produce a consis-
lower than in age-matched peers, and reduced activity levels
tent and coordinated force then results in further weakness
may then contribute to an increased energy cost of move-
due to a reduction in the number of recruitable motor units,
ment, with further deconditioning leading to an increased
a decreased amount of lean muscle mass in the paretic limb,
risk for cardiovascular disease and recurrent stroke.79
a 20% to 25% increase in intramuscular fat in the hemiparetic
limb compared to the nonparetic limb, a loss of Type I muscle Considering the prominence of cardiac disease, risk
fibers, and a diminished capacity for oxidative metabolism in for recurrent stroke, and the strong association between
the paretic limb.74,76-78 Muscle weakness and atrophy with an strength, fitness levels, and gait speed to activity and partici-
increased prevalence of fast-twitch muscle fibers on the con- pation, the evaluation and intervention of muscle weakness,
tralateral limb are strong predictors of gait deficit severity.75 aerobic capacity, and gait should be high priorities through-
These central and peripheral impairments to motor function out the rehabilitation process.89
produce a grossly inefficient hemiparetic gait pattern with Intervention
greater oxygen consumption necessary to sustain self-selected The design of an intervention program for a person with
walking speeds, contributing to aerobic deconditioning.79,80 a stroke is multifaceted. There is the primary drive for func-
An alteration in tone may cause an increased stiffness in tional recovery, the basic principles of which include repeti-
the muscle with subsequent connective tissue changes such tive skilled training to promote reorganization of movement
as contractures.11 Loss of range of motion (ROM), especially representations within the motor cortex.90 Walking capacity
at the ankle and hip, can contribute to a decrease in gait post-stroke is directly correlated to paretic leg strength and
speed and efficiency.81 cardiovascular fitness.91 Understanding the factors that
478 Chapter 12
contribute most to mobility help up when designing an exer- per week, for 20 to 30 minutes per session, at an intensity
cise program. of 55% to 90% HR max. For someone just starting an aerobic
Improvements in muscle strength can be made in stroke program an appropriate intensity would be to work at 40% to
by 10% to 75%. The main target of a resistance program is to 50% HR max and to then build up to as close to 90% HR max as
affect peripheral contributions to motor weakness at the level tolerated.29 Duration can start with a few minutes and build
of the muscle. An increase in the volume of muscle fibers intermittently. Fitness training is safe and feasible and can be
and increases in the rate of torque development and motor most effective post-stroke when performed for > 30 minutes
unit discharge can increase the strength of a hemiparetic 3 times per week while maintaining a HR > 70% age-adjusted
muscle.90 Improvements in strength of key LE muscle groups HR max (220 – age %)7 as the ultimate goal.95 The most ben-
contribute to improved gait quality, speed, and efficiency on efits are seen when training is provided for > 12 weeks.
the 6MWT.89 Strength of knee flexors and extensors alone Walking at a fast walking speed, and treadmill walking
can predict home vs. community walking ability, while hip with or without a harness, are considered the most effective
flexion and soleus muscle strengths have been associated modes of cardiovascular training.89,90,97-99 Aerobic training
with faster gait speeds.81,83 The principle of strength train- with a treadmill improves cardiovascular fitness, gait speed,
ing is the same for stroke as for able-bodied individuals. The and tolerance, and may produce sub-cortical reorganization
American College of Sports Medicine (ACSM) recommenda- in acute and chronic stroke survivors.80,88 For more severely
tions for strengthening in stroke include lifting a load that deconditioned individuals post-stroke, exercise with short
allows 8 to 12 repetitions through the available ROM before bouts of 2 to 3 minutes of treadmill walking followed by
fatigue performed 2 to 3 times per week with rest in between rest breaks appears to have positive benefits.97 Home- or
for recovery. The key element that is often overlooked is to clinic-based task-specific walking programs also resulted
increase the intensity through increased resistance as the in improvements in walking speed and endurance that
ability to generate force improves.92 Strength training alone were sustained several months after the intervention was
has not been shown to alter the organization of the cortical completed.99,100
motor map, but when combined with task-specific practice For individuals who do not have the balance necessary
has been shown to improve function.90 It was thought at for treadmill walking or are unable to achieve speeds that
one time that strengthening in the presence of spastic- would produce a cardiovascular benefit during overground
ity or hypertonia would cause a further increase in muscle walking, an arm-leg ergometer, recumbent bike, or arm bike
tone. We understand now that this is not the case, and that may also be able to provide a cardiovascular benefit, but
strengthening is a safe an effective intervention in the pres- to a lesser degree. Cycle ergometry appears to be the most
ence of abnormal muscle tone.13 Strengthening can also pro- common method of aerobic training for individuals post
vide the element necessary to tolerate and achieve the high stroke.94 Hemiparetic limbs may also be comfortably secured
intensity needed for aerobic conditioning or skill acquisition to arm and leg pedals to better participate in the reciprocal
during repetitive task practice.90 movement, and have demonstrated potential for improved
Aerobic exercise should be an important component of sub-maximal effort when involved in the training protocol.79
stroke rehabilitation given the significant adverse health Programs focusing on a combination of aerobic training
consequences of deconditioning, and the increased risk of and strengthening are more beneficial for improving the
recurrent stroke that is associated with physical inactivity.70 efficiency of gait than strengthening programs alone.90,101
The trend in current clinical practice, however, shows that Combining the 2 training modalities significantly improves
the levels of cardiovascular stress induced in current reha- VO2 peak, walking economy, and exercise tolerance.86
bilitation programs is not at a high enough level to induce Exercise and plasticity response depend on the dose of
an aerobic training effect.93 This is an important point to stimulus delivered, the specificity of the mode of interven-
consider as training workload is considered more predictive tion provided, and the context of the task being practiced.
of treatment response than age, previous fitness levels, or Combining these primary elements of exercise for individu-
lesion location.79 als with stroke can provide functional and health benefits
Pang et al studied 480 subjects with mild to moderate that can improve activity and social participation.
stroke who participated in an aerobic exercise program for
20 to 40 minutes, 3 to 5 days per week while working at an Spinal Cord Injury
intensity of 50% to 80% of their HR reserve with significant
improvements in peak VO2 and peak workload.94 Aerobic Pathology
conditioning in stroke can also improve independence in
SCI is a relatively rare but catastrophic and expensive
ambulation and increase walking speeds and endurance.86,95
event with an incidence of approximately 40 cases per mil-
An increase in gait speed by as little as 0.16m/s is more likely
lion in the United States or 10,000 to 12,000 new cases
to produce a meaningful improvement in level of disabil-
annually. There are an estimated 232,000 to 316,000 people
ity.96 As a preventive measure it has been shown to decrease
currently living with SCI.3,102 From health care costs to lost
systolic BP, and the risk of recurrent stroke.79,89 Many stud-
wages, the estimated cost of management of SCI is approxi-
ies follow exercise protocols recommended by ACSM. The
mately $4 billion annually.103 The average age at the time of
ACSM suggests an aerobic exercise frequency of 3 to 5 times
Figure 12-7. International Standards for Neurologic Classification of Spinal Cord Injury. From http://www.asia-spinalinjury.org/elearning/ASIA_ISCOS_
high.pdf.
injury is 40.7 years with more than 80% of cases being male. The mechanism of injury can determine the type and
Approximately 35% to 40% of SCIs are caused by a motor severity of the injury. Most traumatic SCIs are caused by
vehicle accident (MVA), while greater than 20% are related to compression or displacement of the spinal cord due to
falls, and 15% are related to acts of violence such as gunshot excessive flexion, extension or rotational forces. Incomplete
wounds. Less than 10% of SCIs are sports related such as lesions typically fall into 5 categories:
while diving or playing contact sports. Other causes of SCI 1. Anterior cord syndrome is the most common pattern
can be infection, tumor, thrombosis, or spinal degeneration. and is typically caused by an excessive flexion injury,
The incidence of SCI has decreased over the years with the MS, or anterior spinal artery infarct that disrupts the
implementation of preventive safety strategies such as seat- anterolateral pathways. Loss of pain and temperature
belt and drunk driving laws.3,102,104 sensation can be noted with damage to the spinotha-
The American Spinal Injury Association Impairment lamic tract, and bilateral loss of motor function is pres-
Scale (ASIA) is an impairment level scale used when grad- ent with corticospinal tract injury.2,3 Proprioception is
ing injury severity in SCI. Motor and sensory function are typically spared.105
identified at certain spinal levels and lesions are classified as 2. Posterior cord syndrome is a rare extension injury seen
either complete or incomplete. Complete lesions are defined more in the elderly population. Patients will present clin-
as having no sensory or motor function below the level of ically with a loss of proprioception often causing a wide
the lesion including the lowest sacral segment. Incomplete base of support during gait. Motor function and pain
lesions implies some sensory and motor function below the and temperature sensation are intact. Larger lesions may
level of the lesion including the lowest sacral segments.105 encroach the corticospinal tracts, causing weakness.2,105
ASIA classification can change over time, and can be used
3. Central cord syndrome is often caused by degenerative
when determining prognosis102 (Figure 12-7; ASIA Scale).
narrowing of the spinal canal, tumor, or hyperextension
480 Chapter 12
injury of the cervical spine. Clinical presentation nerves that transmit information to the muscles.3 Weakness
depends on the size of the lesion. Smaller lesions may can be a product of the SCI itself as well as muscle structure
include the spinothalamic tracts with loss of pain and and contractile properties changes that occur because of
temperature sensation. Larger central cord lesions may deconditioning. Within 1 month of injury, muscle fibers
present with anterior horn cells and corticospinal tract below the level of the lesion are smaller, have less contractile
damage.2 UEs are more affected than lower extremities.3 property, and produce lower peak contractile forces. Muscle
4. Brown-Séquard syndrome is most commonly caused by fibers begin to transform toward the fast-type phenotype
a stab or gunshot wound, and results in deficits on only and fatigue more rapidly.109,110 These factors contribute to
one side of the spinal cord. Damage to the lateral corti- a decline in motor function, which then exacerbates muscle
cospinal and posterior spinothalamic tracts will cause wasting and deconditioning, further impairing the daily
weakness, loss of proprioception, kinesthesia, and vibra- energy expenditure in SCI.25 Muscle weakness or paralysis
tion on the ipsilateral side of the lesion. Loss of pain and can be extensive enough that voluntary exercise may be
temperature is noted slightly below the level of the lesion ineffective, or even impossible. Other effects of SCI that can
on the contralateral side of the lesion due to damage of restrict participation in exercise or are a cause of prolonged
the anterolateral fibers.2 immobility are autonomic dysreflexia, fatigue, respiratory,
and cardiovascular complications.
5. Conus medullaris and conus equina syndrome are the
Autonomic dysreflexia (AD) can occur in spinal cord
result of damage to the base of the spinal cord and can
lesions above the level of T6. AD is associated with an elevated
present clinically with weakness, loss of sensation, and
risk of CVD due to abnormal BP, HR variability, and a blunted
reflexive bladder.3
HR response to aerobic exercise.25 Individuals with autonom-
Patients with a SCI are further classified by level of injury ic dysfunction are at severe risk for both supine and orthostat-
and categorized as either having paraplegia if the injury ic hypotension.3 Symptoms of AD include headaches, HTN,
affects the thoracic and lumbar regions only, or tetraplegia bradycardia, diaphoresis, anxiety, and piloerection and can be
if the injury is in the cervical region with all 4 limbs, and caused by noxious stimulation such as bowel or bladder dis-
trunk including respiratory muscles are involved. There is an tention, tactile stimulation, or elevated BP during activity or
approximately equal incidence of injuries that result in either exercise.3 Signs for AD should be monitored carefully because
paraplegia or tetraplegia,3 with trend toward a decrease in when uncontrolled it can cause stroke, seizures, intracerebral
rates of motor complete (ASIA A or B) injury.106 hemorrhage or cardiac insult.102 Considerations for exercise
People with SCI have a close to normal life expectan- and the use of HR measures as a gauge of intensity may not
cy. Because of a more sedentary lifestyle, however, CVD be accurate in SCI because of AD.111 AD in individuals with
becomes the leading cause of death ahead of respiratory paraplegia presents as a lower HR complexity at rest and with
disease, renal conditions, DM, and smoking in people who exercise, and an exaggerated HR response during physical
survive a traumatic SCI greater than 1 year.107 The preva- activity.110,112 Individuals with tetraplegia may not be able
lence of asymptomatic and symptomatic CVD in SCI can be to sufficiently activate the sympathetic nervous system to
as high as 50% compared to 5% to 10% in able-bodied, age- provide enough central circulatory support during increased
matched peers.25 Risk factors for CVD in SCI include lipid activity levels. This will contribute to peak HR levels that
disorders, metabolic syndrome, obesity, physical inactivity, will typically max out at about 120 beats per minute.113
accelerated aging, and DM.25,108,109 Other risks for CVD can Deconditioning due to skeletal muscle paralysis will also con-
be caused by the low BP and stroke volume in individuals tribute to altered autonomic cardiovascular modulation.114
with tetraplegia causing left ventricular hypertrophy, as well Daily energy expenditure is lower in SCI because of lack
as a decreased volume and circulatory dysregulation in the of motor function, but also because of lack of opportunity
LEs.109,110 The risk for CVD is accelerated in this popula- and accessibility to physical activity. While individuals with
tion and corresponds to the level of the injury, with a 16% paraplegia seemingly have more options for exercise, and the
increased risk for individuals with tetraplegia, a 70% increase ability to achieve peak VO2, they are only marginally more fit
risk for individuals with paraplegia, and a 44% increased risk than individuals with tetraplegia.110 Metabolic and skeletal
for individuals with complete injuries.25 Many studies have muscle abnormalities due to deconditioning can be partially
also observed a direct association between level of injury and reversible in SCI through endurance training.25 Considering
peak oxygen uptake and the level of peak work obtained dur- the dramatic decline in activity levels of most individuals
ing physical activity, so that the higher the injury level the post-SCI, and the significant increased risk of CVD, initia-
more blunted the response to physical activity.110 tion of a cardiovascular fitness program is appropriate even
Impairments Affecting Mobility in the acute stages of recovery with maintenance a priority.
While SCI is a devastating injury with a variable presen- Cardiovascular fitness testing can be performed safely
tation, the most prominent deficit affecting mobility and with most individuals with SCI. Exercise stress testing is an
participation in exercise is the loss of motor function. Motor important first step to rule out CVD, provide an objective
function can be impaired from damage to the long cortico- peak HR for the exercise prescription, and provide informa-
spinal tracts that carry information from the motor cortex to tion on the baseline exercise tolerance of the individual.115
the spinal cord, and damage to anterior horn cells, and spinal Most sub-maximal fitness tests are conducted on a treadmill,
with a cycle ergometer, or during overground walking but For individuals with paraplegia, options for training can
this may not be feasible for many individuals with SCI. The be more accessible with the use of the UEs. Arm ergometry,
most common mode of exercise and cardiorespiratory testing wheelchair ergometry, and swimming are the most common
in SCI is with an arm-crank ergometer.110 The 6-Minute Arm modes of aerobic training, as they are accessible to those
Test (6MAT) is a sub-maximal arm ergometry test that is with residual or full UE muscle function. The magnitude of
considered a reliable and inexpensive option for many clinic fitness achieved is typically inversely proportional to the level
settings and can be performed on people with paraplegia and of the injury.109 Individuals with tetraplegia can achieve the
tetraplegia. Aerobic parameters used if signs of AD are not same gains in peak oxygen uptake using UE ergometry with
present are to work at 60% to 70% of age-predicted HR max, assistance given to affix their hands to the device.109 Hybrid
or 11 to 15 on a Borg rating scale of perceived exertion.116 training, or the use of an arm ergometer combined with
Consideration for the level of the injury needs to be functional electrical stimulation (FES) cycling at moderate
made as physiologic responses to exercise are different from and high intensity is a safe and feasible mode of cardiovas-
those without a SCI as discussed above, and risks of poorly cular training demonstrating superior improvements in VO2
designed programs are greater.109 peak, stroke volume, LE muscle mass and strength compared
Other tests that should be considered prior to implement- to voluntary leg cycling or arm ergometry alone.119-122 For
ing an exercise program are bone-mineral density testing to individuals with long-standing muscle atrophy and decon-
establish fracture risk, blood and glucose testing for base- ditioning, strengthening of quadriceps muscles prior to the
line lipid and DM screening, and pulmonary function tests initiation of leg cycle FES enhances participation.
(PFT) to provide an objective baseline measure of ventilatory Electrically stimulated muscle contraction is utilized as
impairment, which inversely correlates to the level of the a method of strengthening in SCI through indirect stimula-
spinal cord lesion.115 tion of the intact peripheral nerve. This method of exercise
requires a functionally intact LMN system. There are several
Intervention forms of electrically stimulated modes of exercise, including
Major challenges to designing an endurance program for arm ergometry, leg cycling, leg exercise combined with UE
individuals with SCI is the reduced capacity to engage in exercise, lower body rowing, electrically stimulated standing,
large muscle endurance exercise because of LE weakness, a and bipedal ambulation with and without orthoses.109 A sys-
limited ability to stimulate and regulate the autonomic, car- tematic review performed by Nightingale et al on the benefits
diovascular systems, and temperature regulatory systems to of FES gait revealed limited evidence for improvements in
support a high intensity of aerobic exercise. Secondary effects aerobic capacity or improvements in energy expenditure dur-
of the reduced activity levels that can further challenge activ- ing gait, with stronger evidence supporting improvements
ity is bone loss due to decreased exposure to weightbearing in LE strength after training with FES.123 While the current
activities, skeletal and cardiac muscle atrophy, early-onset evidence is inconclusive, the trend is toward support of the
muscle fatigue, reduced lean mass, and an increase in fat intervention for multiple variables, with limitations primar-
percentages.117 Individuals who rely of manual or power ily in the amount of available literature and the inconsistency
wheelchairs for mobility are at a higher risk for developing in the methodology of assessment.
these secondary effects of deconditioning. Despite these Jacobs and Nash et al used a circuit resistance training
limitations, with a well-designed program persons with SCI (CRT) program combining resistance exercise and high-
have the potential to benefit from exercise intervention to speed, low-resistance arm ergometry with people with motor
improve strength and aerobic capacity, and reduce the risk complete paraplegia. The purpose was to target both arm
of health problems related to inactivity. Participation may strength for UE injury prevention and cardiovascular endur-
need to include adaptive equipment or the use of electrical ance. After 12 to 16 weeks of 30- to 45-minute routines
stimulation to achieve an aerobic benefit. performed 3 times per week, the subjects demonstrated
Individuals with tetraplegia have a 16% higher risk for significant increases in peak VO2, time to fatigue, and
developing cardiovascular illnesses compared to individu- peak power output during arm testing, with no adverse
als with paraplegia.25 More profound muscle weakness and effects.124,125
loss of muscle mass combined with autonomic dysfunction Recommended prescription guidelines for aerobic train-
contribute to the elevated risk. Initiation of a cardiovascular ing are to work at an intensity of 40% to 80% of HR reserve,
fitness routine early after injury may decrease this risk and or 20 to 30 beats above resting HR, if stress test was not
reduce symptoms of orthostatic hypotension. Arm ergome- performed, for > 30 minutes of continuous exercise. A
try alone may be a challenge because of small muscle mass frequency of 2 to 3 times per week is suggested with the
and easy peripheral fatigability. Tawashy et al presented most appropriate modality, which may include an arm or
positive effects of a UE circuit training program performed wheelchair ergometer, treadmill training, seated aerobics,
for a total of 30 minutes, 3 times per week, to minimize UE swimming, electric stimulation leg cycle ergometry, or cir-
fatigue and boredom and to better facilitate improvements in cuit resistance training.115 In the presence of autonomic dys-
aerobic capacity.118 Exercise intensity cannot be predictably function in SCI, use of self-ratings of perceived exertion can
monitored with HR responses, so rating perceived exertion be inconsistent when correlated with physiologic responses
may be more accurate. to exercise. This may not be a valid method of measuring
482 Chapter 12
exertion in the presence of tetraplegia more so than paraple- 1.7 million people sustain a TBI with approximately 50,000
gia.126 Adapted sports-related activities are recommended deaths, 275,000 hospitalizations, and 80,000 to 90,000 people
to enhance participation. Exercise response during power left with permanent disability. With approximately 5.3 mil-
wheelchair competition has the potential to reach or even lion people currently living with disability caused by TBI,
surpass cardio-respiratory fitness training thresholds when the estimated cost of direct and indirect medical costs com-
performed for more than 30 minutes.127 The mechanisms bined with lost productivity is $60 billion. The groups most
for improved aerobic capacity post-SCI are more likely due to at risk are men, young children, adolescents, and the elderly.
improved muscle strength and oxygen perfusion than actual Falls and MVAs account for more than half of all TBIs,
changes in cardiovascular response of HR, stroke volume, or with assaults, sports-related injuries, and other occurrences
cardiac output.128 accounting for the rest.129,130
Manual wheelchair users are more susceptible to chronic TBIs can be categorized as either focal, which tend to be
overuse injuries of the UEs due to the repetitive strain placed caused by a contact force, or diffuse, which tend to be caused
on them during daily mobility with a wheelchair. Resistance by noncontact, acceleration-deceleration, or rotational forces.
training should focus on UE and trunk muscles for joint Primary damage is a direct result of the injury, while second-
protection, injury prevention, and promotion of improved ary brain damage occurs because of the body’s reaction to
mobility and function. Recommendations for resistance the trauma. Secondary brain damage can continue for days
training are to work at an intensity of 50% to 80% one rep- to weeks after the initial injury and is influenced by medical
etition maximum (1RPM), for 2 to 3 sets of 10 reps at least management.129
2 times per week. Free weight, Nautilus equipment, and Focal brain injuries typically result in cortical contusions
Therabands are all considered appropriate modalities.115 or lacerations that are classified according to the location of
There are several unique risks in SCI that need to be the intracranial hemorrhage. Epidural hematoma (EDH) is
considered prior to implementing an exercise program. As typically formed when the middle meningeal artery ruptures
mentioned previously, autonomic dysfunction is common between the dura and the skull. This is a rapidly expanding
in lesions above the T6 spinal level, with more severe com- hemorrhage that forms a lens-shaped biconvex hematoma
plication noted with complete SCIs. Symptoms of AD that and can cause significant compression of the brain within
need to monitored for are cardiac and circulatory dysfunc- hours of impact.2 Subdural hematoma (SDH) can be chronic
tion, clotting disorders, altered insulin metabolism, resting or acute and typically occurs after a shearing type injury that
and exercise immunodysfunction, orthostatic hypotension, disrupts the bridging veins between the arachnoid and dura
osteoporosis, joint deterioration, and thermal dysregulation space. This venous injury forms a crescent-shaped hematoma
at rest or with exercise.109 Exercise in temperature-con- and can takes days to weeks to present clinically depending
trolled environments, hydration throughout exercise routine, on the age of the person and the velocity of the impact.2,3
observing for signs of heat stress, bowel and bladder empty- Diffuse axonal injury (DAI) is a more widespread injury
ing prior to exercise, and careful observation of HR and BP that indicates a more severe injury and accounts for 40% to
responses to exercises are needed to decrease complications 50% of hospital TBI admissions.129 DAI is typically caused
from autonomic dysfunction. by acceleration-deceleration and rotational forces, and is
More than 50% of sublesional bone is lost within the the predominant reason for loss of consciousness post-TBI.
first 6 months after an SCI, leaving the patient at an The shearing injury of the axons impairs transport of pro-
increased risk for fracture. Bone-mineral density testing tein from the cell body and causes swelling of the axon and
should be considered, especially in individuals who have axonal death. A secondary process of axonal injury occurs
been nonweightbearing for extended periods of time.109,115 causing a loss of ion gradients across cell membranes. This
Musculoskeletal-overuse injuries may be undetectable in metabolic cascade can cause cell death, or apoptosis, over a
areas where sensation or pain is diminished. Injuries may be period of days, week, or even months after injury.131 DAI can
detectable in the presence of swelling, increased spasticity or be seen throughout the brain regardless of the site of the ini-
muscle spasms, warmth or erthema.109 When using high- tial injury, and is more often in midline structures including
intensity electrical stimulation in the presence of sensory loss the parasagittal white matter of the cerebral cortex, corpus
there is an increased risk of skin burns. Close monitoring of callosum, basal ganglia, brainstem, and cerebellum.3
skin with frequent replacement of electrodes can decrease The increase in volume in the intracranial space caused
this risk. by either lesion type has secondary effects that can cause
further brain damage. Normal intracranial pressure (ICP)
Traumatic Brain Injury in adults is less than 15 mm Hg.2 Intracranial hemorrhage
can cause an increase in blood volume or swelling of the
Pathology brain, which can trigger an elevation in ICP. Severely elevated
ICP can cause a decrease in blood flow with further brain
Traumatic or acquired brain injury (TBI) is defined as an
ischemia, or a mass effect shifting brain tissue and causing
injury to the head that disrupts the normal function of the
herniation of brain tissue and compression of periventricular
brain. TBI is currently the leading cause of death and life-
structures.2,3
long disability in the United States. Each year approximately
TABLE 12-2. CLASSIFICATION OF TRAUMATIC BRAIN INJURY SEVERITY

CRITERIA MILD MODERATE SEVERE
Structural imaging Normal Normal or abnormal Normal or abnormal
Loss of Consciousness (LOC) 0 = 30 min > 30 min and < 24 > 24 hours
hours
Alteration of consciousness/mental a moment up to > 24 hours. Severity
state (AOC)* 24 hours based on other criteria
Post-traumatic amnesia (PTA) 0 = 1 day > 1 and < 7 days > 7 days
Glasgow Coma Scale (best available 13 to 15 9 to 12 <9
score in first 24 hours)
Reprinted from Management of Concussion/mTBI Working Group. VA/DoD Clinical Practice Guideline for Management of Concussion/
Mild Traumatic Brain Injury. J Rehabil Res Dev. 2009;46(6):CP1-68.
TBI is primarily classified as mild, moderate, or severe disorders, pain, depression, and deconditioning.19,134,137 The
based on structural imaging, the duration of loss con- greatest amount of fatigue is typically reported within the
sciousness (LOC) and the Glasgow Coma Scale (GCS) first 6 months of injury, with improvements noted between
(Table 12-2).129 Impairments generally reflect both the focal 6 and 12 months post-TBI.19 After 12 months there is another
and diffuse nature of the injury. trend of increased complaints of fatigue that are most likely
due to the effects of deconditioning due to impairments in
Impairments Affecting Mobility
mobility.
After a TBI variable patterns of deficits are observed. Cycle ergometry, both upright and recumbent, are more
Common impairments affecting mobility and participation commonly used during graded exercise modalities in the
in exercise include weakness, motor control abnormalities, presence of balance and gait impairments. While both cycle
altered cognition, and impaired balance.49 Fatigue and poor and treadmill testing are reliable measures in TBI, treadmill
sleep patterns are also prominent.132 Spasticity does not testing is recommended when safe and feasible as it elicits a
appear to contribute to decreased economy of movement higher peak VO2 and is more functional.30,135 In the clini-
post-TBI.12 Predictors of return to ambulation include the cal setting submaximal testing such as the 6MWT are more
patient’s ability to ambulate at admission to rehabilitation, accessible. The 6MWT is a reliable measure of gait speed and
and the duration of post-traumatic amnesia.133 aerobic capacity in individuals with TBI.33 Age-predicted
Individuals following a TBI rapidly develop secondary HR max is a reliable measure of cardiovascular response and
sequelae related to the decreased level of mobility that comes fitness in individuals with TBI, and can be utilized during
with prolonged hospitalization. Mossberg et al studied the the 6MWT as a measure of aerobic capacity.135
aerobic capacity of individuals post-TBI with minimal physi-
cal impairments and found that they presented with signifi- Intervention
cantly lower peak responses for HR and VO2, had impaired Despite the variability in residual deficits in body struc-
pulmonary efficiency, and overall decreased levels of cardio- ture and function post-TBI, many individuals consistently
vascular fitness contributing to complaints of fatigue and adopt a sedentary lifestyle confirmed by a decline of peak
decreased levels of participation.134,135 TBI survivors are aerobic capacity to only 65% to 74% of their age-matched
also 3 times more likely to die from circulatory conditions peers,135,136 and a reduction in pulmonary function by 25%
such as heart disease, stroke, and high BP as a consequence to 40%.17 This trend toward deconditioning contributes to
of a prolonged sedentary lifestyle. Despite these secondary an increased risk of cardiovascular and cardiopulmonary
complications, individuals with moderate to severe TBI pro- disorders. Incorporating a lifelong program of aerobic train-
vide consistent responses to maximal exercise testing, and ing may play an important role overall physical capacity and
can safely perform at sub-maximal and peak aerobic train- in long-term mortality in TBI.138
ing.30 Improvements in aerobic capacity are associated with Aerobic training in the presence of TBI has not been well
improvements in aerobic efficiency.136 documented, but the few studies to date demonstrate posi-
Fatigue has been reported as one of the most consistent tive effects in physical endurance and metabolic capacity.17
impairments experienced by individuals who have suffered a Mossberg et al followed 40 individuals with chronic TBI who
TBI, with 50% to 80% reporting symptoms.19,54 Complaints participated in a standard physical therapy program with the
of fatigue are not necessarily correlated to injury severity addition of only 15 to 20 minutes of low-intensity aerobic
or age at the time of the injury. Primary fatigue in TBI may exercise utilizing either a motorized treadmill, stair climber,
be caused by impaired excitability of the motor cortex, and recumbent or stationary bike. All participants demonstrated
hypopituitarism.19 Secondary fatigue may result from sleep improvements in cardiorespiratory fitness with increased
484 Chapter 12
walking tolerance and decreased sub-maximal HR.139 This Parkinson s Disease
finding supports the benefits of aerobic condition regard-
PD is a slowly progressive neurodegenerative disease
less of the modality used. While general fitness training has
affecting as many as 1 to 1.5 million United States citizens.
demonstrated consistent improvements in cardiovascular
The average onset occurs in the fifth decade with an increas-
conditioning and exercise capacity, there is limited evidence
ing incidence and prevalence as the population ages. Patients
translating into improvements in functional capacity.137
may notice initial subtle symptoms such as difficulty with
The evidence supporting the use of treadmill training
writing, an asymmetrical resting tremor, or slowness of
with and without body weight support to promote neurologi-
movements. The diagnosis is made by exclusion and assess-
cal recovery is inconclusive in individuals with TBI.140 This
ment for cardinal clinical features that include resting
is most likely due to the very small samples sizes and extreme
tremor, muscular rigidity with a “cogwheeling” resistance to
variability of impairments and deficit severity in TBI. When
passive movement, bradykinesia, and loss of postural control.
the primary purpose of treadmill training is to utilize it as a
Diagnosis can often be confirmed by a positive response to
method of aerobic condition, response is more consistently
levodopa or a dopamine antagonist.142,143
favorable. Individuals who trained on a treadmill demon-
PD is caused by a degeneration of dopaminergic neurons
strated greater VO2 than those who trained on mechanical
in the substantia nigra pars compacta of the basal ganglia.
stairs or a bike ergometer. The need for more focused atten-
The pattern of neuronal loss tends to be in the ventrolateral
tion to task with a stationary bike or stair climber to main-
tier followed by the medial ventral tier, which is the opposite
tain a high intensity may play a role in the varied responses.
of normal aging.144 Dopamine has both an excitatory and
Stationary cycling and mechanical stair climbing tend to be
inhibitory effect on the thalamus.2 This loss of dopamine
more self-paced and exercise performance can be more con-
has a net inhibitory effect on the thalamus, and is thought to
sistently challenged using a treadmill.141 Specific research
play a key role in the slow movement and delayed initiation
has not been conducted to compare the effects of training
of movement seen in PD.3,145 There is a suspected preclinical
with or without body weight support when balance safety is
period of 5 to 15 years as symptoms typically do not present
a concern and body weight support is available.
themselves until approximately 30% to 40% of dopaminergic
A combined aerobic and resistance program performed at
neurons of the substantia nigra pars compacta and 70% to
an intensity of 60% to 80% age-adjusted HR max for 25 min-
80% of dopamine depletion in the striatum occurs.142,146
utes 2 to 3 days per week for 12 weeks demonstrated improve-
While movement is not lost, depletion of dopamine in the
ments in aerobic capacity, peak VO2, peak power output,
striatum is thought to impair the learning of new movement
and respiratory efficiency.141 Circuit training is thought to
sequences and causes a loss of reflexive or automatic move-
be particularly effective in the presence of TBI when atten-
ment.3 Learning becomes extremely task specific, as does the
tion and motivation are limited. Bhambhani et al used a
ability to task shift as the dysfunction in the basal ganglia
protocol combining intermittent upper and lower body
progresses.20 Dopaminergic neurons that remain often con-
high-resistance, short-duration weight-lifting exercises with
tain characteristic cytoplasmic inclusions called Lewy bod-
treadmill, cycle or arm ergometry. Subjects were encouraged
ies and can be found in all affected brainstem areas. Lewy
to maintain an HR at or above 60% of their HR reserve, and
body neuritis has been shown to correlate with the degree
at 12 weeks subjects presented improvements in peak power
of cognitive impairments seen in patients with PD.2,144 As
output, and peak VO2.31
this degeneration progresses, gait and balance disturbances
Individuals post-TBI with a higher number of residual become more prominent, leading to falls, a decline in mobil-
symptoms and limited community integration are less likely ity, and an increased risk of mortality.146
to exercise, and also have higher levels of perceived disability
Disease staging is measured using the modified Hoehn
and handicap. The design of an individualized and motivat-
and Yahr (H&Y) Staging Scale, which is a 7-point ordinal
ing program that meets the need of the person is associated
scale ranging from 1 (unilateral disease involvement) to
with decreased impairment, elevated mood, and perceptions
5 (wheelchair bound or bedridden unless aided). The H&Y
of better health.138
scale has shown a high correlation in neuroimaging studies
with dopaminergic loss, and with motor impairments, dis-
Degenerative Diseases ability, and quality of life measures (Figure 12-8).147
Degenerative diseases of the nervous system can affect Impairments Affecting Mobility
gray matter, white matter, or both. Progression can be slow Bradykinesia is one of the most classic clinical features of
and over a period of decades with close to normal life expec- PD that affects mobility. This hallmark sign of basal ganglia
tancy, or rapid over a period of months to just a few years disorders refers to an overall slowness of movement and
leading to death. The understanding of the pathology as is a result of the excessive inhibition to the thalamus sup-
well as the pattern of progression can be important when pressing the motor cortical regions, and abnormal projec-
considering the goals of an exercise-based intervention. The tions to brainstem locomotor areas contributing to posture
following section will explore a variety of the most common and gait abnormalities.3,145 Patients with bradykinesia also
disorders across the spectrum of disease progression. have difficulty planning, initiating, and executing tasks.148
Bradykinesia is related clinically to decreases in muscle
Hoehn and Yahr scale Modified Hoehn and Yahr scale

1: Unilateral involvement only usually with 1.0: Unilateral involvement only
minimal or no functional disability
2: Bilateral or midline involvement without 1.5: Unilateral and axial involvement
impairment of balance 2.0: Bilateral involvement without impairment of
balance
2.5: Mild bilateral disease with recovery on pull test
3: Bilateral disease: mild to moderate disability 3.0: Mild to moderate bilateral disease; some
with impaired postural reflexes, physically postural instability; physically independent
independent
4: Severely disabling disease, still able to walk or 4.0: Severe disability; still able to walk or stand
stand unassisted unassisted
5: Confinement to bed or wheelchair unless aided 5.0: Wheelchair bound or bedridden unless aided
Figure 12-8. Comparison between the original and modified Hoehn and Yahr scale. (Reprinted with permission from Goetz CG, Poewe W, Rascol O, et
al. Movement Disorder Society Task Force report on the Hoehn and Yahr staging scale: status and recommendations. Mov Disord. 2004;19(9):1020-1028.)
activation acceleration rates presenting as decreased gait Autonomic dysfunction can affect the quality of life and
speed, and difficulty rising from a chair.149 participation levels of individuals with PD.155 Symptoms
Rigidity usually appears unilaterally in the initial stages of of autonomic dysfunction are thought to be the result of
PD and can be felt in both agonist and antagonist muscles. It damage to the postganglionic sympathetic efferences and
starts proximally in an upper limb and eventually spreads to loss of Lewy bodies in the peripheral sympathetic nervous
all extremities and the trunk. One of the early signs of rigid- system.156 Symptoms can include orthostatic hypotension,
ity is loss of associated movements in one UE with decreased lightheadedness, weakness, mental “clouding,” syncope, or
arm swing during gait that may affect gait speed. Axial urinary and gastrointestinal dysfunction.155,156 Triggers
rigidity limits rotation and extension of the trunk and spine, may be heat, some foods, alcohol, and exercise. Medications
further limiting variability of movement during functional may also be a factor as amantadine and dopamine agonists
tasks such as walking.3,148 can contribute to orthostatic hypotension.156 If symptoms of
Bradykinesia and rigidity, among other symptoms related AD are noted early in the disease process, consideration for a
to PD, are thought to manifest themselves at a sub-clinical secondary cause, or other diagnosis such as multiple systems
level for years prior to actually diagnosis and true functional atrophy (MSA) should be made.148,156
decline.142 While functional mobility may not be grossly Intervention
affected in the pre- or even early stages of PD, research has Despite neurological deficits in movement and respiratory
shown that people with a diagnosis of mild to moderate PD function, individuals with mild to moderate PD who per-
present with significantly lower respiratory muscle strength form a regular exercise routine have the potential to achieve
and respiratory abnormalities even at rest.150,151 In early and maintain a normal aerobic capacity.151 Exercise has
diagnosis bradykinesia and rigidity have been found to affect also proven beneficial and effective for the improvement of
gait, producing a decrease in stride length, impaired inter- physical functioning, health-related quality of life, strength,
limb coordination, and decreased cadence and velocity con- balance, and gait speed.157 Regardless of H&Y stage, there is
tributing to an increase in the energy cost of walking.152,153 a significant correlation between subjects who exercise and
Walking economy has been found to be worse in individuals their aerobic capacity. Sedentary individuals with PD pro-
with even mild to moderate PD demonstrated by impair- duce lower VO2 peak scores than those who exercise, further
ments in HR, minute ventilation, respiratory exchange supporting the need for a regular cardiovascular routine in
rate, and RPEs during ambulation at speeds greater than PD.151 Considering the progressive nature of PD, and the
1.0 mph.154 As the disease progresses individuals with PD relatively small window of effective medication management,
experience a decline in walking, balance, and ADL that con- participation in a well-designed exercise program is critical
tribute to a progressive decline in participation.144,145 Fatigue for minimizing disease-related and secondary impairments
is also noted in PD and can be related to central activation while maximizing quality of life. Under the direction of
failure from dopamine deficiency and abnormal levels of skilled a physical therapist, individuals with PD demonstrate
corticomotor excitability noted during exercise. Bradykinesia improvements in walking economy, motor features of PD
and rigidity may contribute to peripheral fatigue contribut- such as bradykinesia and rigidity, functional capacity, bal-
ing to further aerobic deconditioning. ance and flexibility.157-162
486 Chapter 12
Increased compliance and long-term participation in in aerobic capacity. Only the forced exercise group made
an exercise routine was demonstrated with prescriptions improvements in motor scores of the Unified Parkinson’s
that were based on current literature, were challenging and Disease Rating Scale (UPDRS) including components for
motivational, and provided a combination or variety of rigidity, bradykinesia, and tremors.175 The mechanism of the
activities.163 Since PD is a progressive disorder, lifelong par- motor improvements is not well understood, but the gains
ticipation is critical to maintaining the benefits. in aerobic fitness are further confirmed with moderate- to
Treadmill training has been demonstrated to improve high-intensity exercise.
gait speed and stride length in individuals with PD at H&Y The amount of VO2 obtained during exercise relies heav-
stages 1 through 3.164,165 Treadmill walking with and with- ily on the individuals level of fitness combined with the
out body weight support can produce a faster and more stable muscle mass involved in the activity. Arm crank ergometry
gait pattern, including symmetrical step and stride lengths. produces a VO2max value less than cycling or treadmill
These improvements were significantly more than just con- walking in healthy younger populations. When considering
ventional gait training alone, and continued during over- a typically more sedentary population, people with PD do
ground gait for hours to even weeks after the intervention not seem to be able to produce a high enough intensity to
ceased.166-168 Considering the decline in efficiency of walk- achieve a cardiovascular benefit with UE exercise such as
ing and decrease in motor initiation in individuals with PD, arm ergometer training.174 It has been demonstrated in other
conventional walking may be a less effective mode of exercise populations with motor control disorders that combining leg
when attempting to produce a cardiovascular benefit. and arm ergometry can produce a more effective cardiovas-
A more symmetrical gait pattern can improve the econ- cular benefit than cycling or arm bike alone.
omy of walking and allow individuals with PD to train Strength deficits are not often highlighted as a primary
within their age-predicted HR max and improve cardiovascu- problem for individuals with PD. However, those with
lar fitness. When subjects participated in a graded exercise reported bradykinesia demonstrate decreased rates of force
program on the treadmill up to 80% of the HR max, they generation, and time to reach peak velocity when perform-
showed improvements in oxygen uptake, HR, and respiratory ing tasks such as sit to stand.149,176 Individuals with mild to
frequency.169 Improvements in gait kinematics such as step moderate PD have the potential to increase muscle strength
length during and, for a period of time, after training on a and improve motor timing, similar to that of normal age-
treadmill are thought to be due to the proprioceptive infor- matched peers.153 The addition of high-intensity eccentric
mation provided by the treadmill belt.165 These improve- resistance training has shown improvements in bradykinesia
ments in step length also contribute to a more efficient gait and gait speed that significantly exceed those of gains made
pattern. Intensity of training has also been suggested to with basic resistance training.162 The primary muscle groups
produce a normalized corticomotor excitability level (CEL) that should be considered when prescribing a strengthening
in early PD when training is performed at a high intensity170 exercise program include the LE muscles that are key for
and has also shown to have an indirect benefit on measures improvement of gait parameters and efficiency. Both free
of quality of life, motor impairments, and postural control, weights and Nautilus equipment are safe and effective dur-
decreasing both fall risk and patient fear of falling.171,172 ing a recommended duration of strengthening 2 to 3 times
Repetition in practice and specificity of training combined per week. While effects can be seen in 8 to 12 weeks, the
with a high-intensity practice condition have been demon- long-term benefits are best achieved with a consistent weekly
strated to facilitate motor learning, especially in those indi- routine.
viduals with moderate to severe PD.173 When considering Physical exercise in the form of aerobic and resistance
that bradykinesia contributes to a slower gait velocity that training have several benefits for individuals with PD.
can further enhance the secondary effects of cardiovascular Improvements in motor performance, symptoms related to
deconditioning, high-intensity treadmill training may be the PD, tolerance for daily activities, aerobic capacity, quality
most task-specific and effective intervention for the improve- and longevity of life overwhelmingly supports the need for
ment of aerobic capacity in PD as well as the improvement in consistent exercise across the life span.146 Key principles
bradykinesia and gait speed. of exercise that also may promote neuroplasticity in PD
The estimate for maximum exercise capacity is lower for include 1) intense activity maximizing synaptic activity, 2)
stationary cycling, but may be a more practical option for complex activities promoting greater structural adaptations,
individuals with PD who have balance deficits and do not 3) rewarding and stimulating activities promoting increased
have access to a body weight-supported treadmill system.174 dopamine levels enhancing motor learning, 4) dopaminergic
There are initial data to suggest that forced exercise while neurons responding both in a positive way to exercise, and a
cycling improves motor function in people with PD. Ridgel negative way to inactivity, and 5) early introduction of exer-
et al studied a small group of people with PD performing cise, resulting in slowing of the disease process.146,177
tandem biking with a partner who pedaled at a rate 30%
Multiple Sclerosis
higher than the subjects preferred rate and compared them
to a group who pedaled alone at their preferred pedaling MS is a slow to moderately progressive degenerative
rate only. Subjects in both groups worked at 60% to 80% of disorder of the CNS. Prevalence is about 0.1% with about
their training HR max and made significant improvements 350,000 to 400,000 people currently living with MS in the
United States. Peak age of onset is between 20 to 40 years, this process so many individuals with MS feel even weaker
with a higher ratio of women to men affected.2 The disease when they are warm.2
process is characterized by acute relapses, remissions, and Weakness in the LE muscle groups can have a direct
chronic progression. Relapses are thought to occur with an impact on walking speed,189 which has shown to have an
acute inflammatory attack of T lymphocytes on oligoden- inverse correlation with EDSS level and deconditioning.190
droglial myelin, causing disruption of nerve conduction Respiratory muscle weakness, especially within the muscles
and a sudden change in clinical status. Discrete episodes of responsible for inspiration, are found even in the early stages
inflammatory response and demyelination occur insidiously, of MS. Weakness in these particular muscle groups can lead
followed by a period of remission with full or partial symp- to an ineffective cough an impaired ability to adequately
tom resolution thought to be due to remyelination.2,178,179 clear the airway, leading to a higher risk of respiratory com-
Periods of chronic progression can occur at clinical and sub- plications and further aerobic deconditioning.35,191
clinical levels throughout the disease process. This is thought Fatigue has a profound and global impact on individuals
to be the result of incomplete remyelination leading to per- with MS and is reportedly the most common symptom pres-
manent axonal loss that appear as lesion sites on magnetic ent in up to 80% of individuals with MS.18 Fatigue can be a
resonance imaging (MRI).178 Destruction of axons is thought primary impairment in people with MS because of dysfunc-
to be the essential cause of nonremitting disease progression tion along the pathways of neural activation. Fatigue in MS
and clinical disability in MS.180 Diagnosis is confirmed based can be related to hypometabolism in certain brain areas, or to
on the presence of clinical features, combined with white the amount of diffuse axonal damage and brain atrophy.14,192
matter lesions found on MRI, or the presence of oligoclonal This can be demonstrated by a compensatory increase in
bands in the cerebrospinal fluid (CSF).2 Immunomodulatory central motor drive exertion present during exercise, or
and immunosuppressant medications are used to partially delays in voluntary muscle activation. When activation of a
ameliorate symptoms, decrease the number and frequency muscle is incomplete, there is a greater perceived effort and
of relapses, and slow the progression of relapsing-remitting level of fatigue compared to their healthy peers when per-
MS.179 forming the same activity.18,193,194 Primary fatigue can also
Disease progression is routinely tracked in clinical prac- be associated with other side effects of MS including immune
tice using the Expanded Disability Status Scale (EDSS). This dysregulation, cortical hypofunction due to demyelination,
MS-specific scale rates the patient neurological status on an and abnormal thyroid function. Fatigue can be considered
ordinal scale ranging from 0.0 (normal) to 10.0 (death). The a secondary impairment in response to sleep dysfunction,
scale combines pyramidal and functional measures to rate pain, depression, medication side effects, and physical decon-
level of disability.181,182 ditioning from reduced muscle performance.18,192 Fatigue
Impairments Affecting Mobility can be present in very early or late stages of MS190 and is
not necessarily associated with motor function changes or
The clinical presentation of people with MS can be highly
impairments in ambulation.187 Fatigue can be directly cor-
variable. Weakness and fatigue are the 2 most common
related with a decline in respiratory muscle strength, endur-
deficits in body structure and function that have a negative
ance, depression, and a poor quality of life.18,191,192
impact on aerobic capacity, the ability to participate in exer-
cise and aerobic conditioning activities, and overall levels Deconditioning from the above factors can have a pro-
of physical activity.18,183 Autonomic dysfunction has been found impact on walking speed, walking endurance,190
inconsistently noted with MS, but when present can also have physical activity, participation,183 and overall quality of
detrimental effects.184-186 life.191 As the disease progresses deconditioning, cardio-
vascular, and pulmonary dysfunction tend to be more pro-
Weakness can be documented even in the early stages of
nounced.35,190,195 HR and BP responses appear to be blunted
the disease. The cortical demyelination that occurs during
in many individuals with MS during graded exercise test-
acute and chronic stages can lead to a decrease in motor
ing, possibly because of cardiovascular dysautonomia.196,197
unit firing rates, inadequate motor unit recruitment, and an
Autonomic dysfunction in MS is thought to be the result of a
increase in central motor conduction time.2 This decrease
dysfunction of the central parasympathetic nervous system’s
in central, or cortically driven, activation produces impair-
HR responses.195 This may impair perfusion to the brain and
ments in the force and rate of voluntary muscle contrac-
muscles causing early fatigue, HR response to exercise affect-
tion.187 There is also evidence of topographic changes in the
ing performance, and attenuate sweating responses, causing
cortical motor areas with deficits in conduction and excita-
increased susceptibility to heat stress.196 An increased num-
tion that correspond to changes in motor function. This
ber of lesions found on MRI throughout the progression of
suggests that there is also a process of neural plasticity that
MS, especially in the area of the midbrain, have been directly
occurs with axonal damage in MS.188 Peripheral weakness
correlated to a decrease in cardiovascular function.186,195
at the skeletal muscle and muscle fiber type appears to be
similar to age-matched sedentary individuals without MS.68 There is evidence that individuals with MS can safely
This indicates that changes in the quality of the muscle itself participate in physical activity in the form of strengthening
is most likely a response to deconditioning and immobility, exercise and aerobic conditioning at moderate to high inten-
and may potentially have a better response to strengthening. sities with reductions in MS symptoms, and improved func-
Increased body temperature has been shown to exacerbate tion and quality of life.55,191,193,198-202 Physical activity may
488 Chapter 12
also play an important role in modifying the progression of or cannot tolerate training on a treadmill, or who may have
disability in MS.199 While dose-response effects of exercise impairments in postural control.212 Walking and cycling
are variable in the current literature, both sub-maximal have similar locomotor patterns with reciprocal flexion and
aerobic and strengthening programs even at low intensities extension movements at the hips, knees, and ankles and
can be effective, and are safe and well tolerated by people alternating muscle activation patterns.55 Programs incor-
with MS.196,203 porating combined arm and leg ergometry have shown sig-
Strengthening in the form of progressive resistance exer- nificant increases in maximal aerobic capacity, physical work
cise (PRE) is a safe and effect training tool in individuals capacity, strength, and quality of life in MS.196 Petejan and
with mild to moderate MS that has shown to improve muscle White suggest parameters similar to those recommended
strength, decrease the perception of fatigue, and improve by the ACSM for healthy individuals. Aerobic exercise 2 to
ambulation.55,204-206 Despite the progressive nature of MS, 3 sessions per week for > 20 minutes at 65% to 75% age
PRE training has shown to induce improvements in force adjusted HR max, and resistance training starting at 2 sessions
production with muscle hypertrophy similar to responses per week.208
expected in subjects without MS.206,207 Key principles of PRE Fatigue in MS has demonstrated inconsistent responses
are to perform a small number of repetitions with a high load to medication management or exercise.192 The sources or
until peripheral muscle fatigue is reached, to allow sufficient sources of fatigue, whether peripherally or centrally driven
rest between exercise to allow for recovery, and to increase need to be clearly defined to design the most effective inter-
the load as the ability to generate force improves.205 As a vention. Treatment of comorbid conditions such as depres-
general guideline Petejan and White suggest selecting 1 to sion and sleep impairments can be necessary to alleviate
2 exercise per major muscle groups, and exercising at 60% to fatigue. Fatigue has been shown to improve by up to 22% in
80% of a maximum voluntary contraction,206,208 especially individuals with MS who participate in a regular, sustained
at the trunk and LEs. Exertion with temperature elevation exercise routine.15,212
may increase symptoms, so interval training and exercising Pulmonary muscle strengthening and endurance train-
in an air-conditioned environment may allow individuals ing has demonstrated improvements in forced vital capacity,
with MS to tolerate increased exercise intensity.196 among other measures of pulmonary function, in individuals
Strengthening can be performed using traditional free with mild to moderate MS.35
weights or Nautilus equipment. Cakt et al provided resis- Adherence to an exercise program can be a major obstacle.
tance using a cycle ergometer to target muscle groups and Since MS is a progressive disease, compliance and consisten-
movements patterns associated with gait. This study applied cy in a well-rounded program is imperative. Consideration
the principle of PRE training by applying resistance during of environmental and personal factors, along with exercise
the pedaling action, and demonstrated significant improve- preferences is considered key in the promotion of exercise in
ments in duration of exercise tolerance, max workload, individuals with MS.196
Timed Up & Go, Dynamic Gait Index, Functional Reach,
FSS, Falls Efficacy Scale, and the Beck Depression Inventory
Amyotrophic Lateral Sclerosis
compared to a home LE strengthening program and no exer- Pathology
cise.55 PRE has shown to significantly increase gait speed, ALS is a rare and rapidly progressive adult-onset degen-
endurance, and kinematics including increased step length, erative disease of motor neurons with an incidence of 1.5 to
improved toe clearance, and decreased double limb support 2.5 per 100,000.213 Approximately 90% of cases occur spo-
in individuals with moderate MD. Improvements in gait pat- radically while the remaining 10% may be from an inherited
tern allows for more efficient mobility and decreased levels of autosomal dysfunction.3 Initial symptoms most often include
fatigue as well.204,206,209 weakness in the distal extremities with the presence both of
In individuals with normal neuromuscular systems, high- UMN and LMN signs. “Amyotrophic” refers to symptoms of
resistance training through eccentric contractions produces muscle weakness, atrophy, and fasciculations that are associ-
an elevated muscle force at a low metabolic cost or level ated with LMN degeneration, while “lateral sclerosis” refers
of perceived exertion. It is thought of as a more effective to the process of gliosis and scarring that occurs with degen-
means of producing muscle hypertrophy and improvements eration of the lateral corticospinal tracts, brainstem, and
in strength.4,210 In individuals with MS, however, eccentric cortex causing UMN signs such as hyperreflexia, Hoffman
resistance exercise is less effective than standard concentric signs, Babinski, and clonus.3,214 Bulbar signs including dys-
training methods, and typically not recommended.211 arthria and dysphagia, can be present in 20% to 25% of cases
Mode of sub-maximal aerobic training for a person with at the initial presentation and are caused by degeneration of
MS needs to be individualized, taking into consideration corticobulbar fibers or the motor nuclei in the cranial nerves
underlying impairments or mobility restrictions that may of the medulla.2 Motor neurons of the oculomotor nuclei
affect the ability to participate at a high level. Program design are spared with preserved control of oculomotor function.3
needs to consider the individual person’s goals, body, struc- The resulting muscle atrophy and weakness causes profound
ture, and functional limitations secondary to MS, and level mobility limitations. Depending on initial clinical presenta-
of disability. Cycling has often been considered a relevant tion, mean survival is 3 to 5 years.215
training alternative for individuals who do not have access to
Disease progression through functional change is typical- The diagnosis and management of respiratory function
ly tracked using the ALS Functional Rating Scale (ALSFRS). in individuals with ALS is a vital component of care as most
This scale contains 10 functional items each rated on a deaths in ALS are due to respiratory failure.217 Forced vital
4-point ordinal scale from 0 (no movement or function) to capacity and nocturnal oximetry are often used as measures
4 (normal function). Items that are measured include speech, of respiratory function, predictors of survival, and as mark-
swallowing, salivation, handwriting, cutting food, and han- ers for the initiation of external ventilatory or nutritional
dling utensils, dressing and hygiene, turning in bed, walking, support.217,223 Impairments in respiratory function can con-
climbing stairs, and breathing.216 tribute to fatigue in individuals with ALS and are addressed
Drug management of ALS relies primarily on one medi- with noninvasive positive pressure ventilation that may ini-
cation. Riluzole is currently the only medication that is tially be introduced at night.21
approved for slowing the disease process of ALS and pro- Intervention
longing survival by anywhere from 2 to 24 months. The
The rapid progression of ALS and nature of the motor
max benefit can be found when Riluzole is initiated earlier
neuron loss have caused controversy in the past as to whether
in the disease process before the onset of respiratory com-
exercise is appropriate in this population. The low incidence
plications.217 Aggressive multidisciplinary care and symp-
of ALS poses a challenge to researchers, but a handful of
tom management to maximize function and independence
small but well-designed studies have shown that exercise
throughout the life span can support a longer life span and
can be physically and psychologically important for indi-
improved quality of life.218
viduals with ALS. This is especially true in the early stages
Impairments Affecting Movement and middle stages of the disease process before significant
Weakness is a primary symptom in ALS and stems not muscle atrophy and deconditioning, take place.222 Small-
only from the disease process itself, but also from disuse. randomized controlled trials have shown small to moderate,
Peripheral denervation caused by degeneration of anterior but not statistically significant, gains in function following
horn cells leads to structural damage of the muscle fiber, exercise.220 Considering the aggressive progression of this
affecting the ability of the muscle to produce a consistent disease, it can be important to note that even though the
and sustainable force. Axonal sprouting and reinnervation results did not show a significant gain, there also was not a
in the early stages of the disease allow partial innervation decline in function, or adverse effects reported.
of surviving motor units.219 Mitochondrial abnormalities Strengthening at low to moderate resistance in the early
in DNA impair the integrity of the muscle and further con- to middle stages of the disease with aerobic conditioning
tribute to weakness.220 Myelin loss appears in all areas of the at a sub-maximal level can be safe and effective.222,225 It is
spinal cord except in the posterior columns. This pattern of widely accepted that strength training is most safe and ben-
degeneration negatively affects force production capabili- eficial with muscles that are unaffected, or are able to move
ties, but allows the preservation of sensation.3 As the disease throughout full range against gravity.223 The implication
progresses individuals with ALS will lose weight through of a 3/5 muscle grade is that there are an adequate amount
the loss of lean muscle mass and a decrease in caloric intake, of motor neurons available to tolerate resistance training
which is often exacerbated by bulbar muscle weakness and without detrimental effects. Resistance training at a moder-
dysphagia.221 These factors contribute to a spiral of further ate intensity has been demonstrated to improve function as
muscle weakness due to insufficient activity and loss of con- measured by the ALSFRS and quality of life without adverse
tractile proteins, even in the early stages of the diagnosis. effects.226 Strengthening at a high intensity is not recom-
Cramping with volitional movement, motor fasciculations, mended as it may further damage mitochondria, increase
and complaints of stiffness are common. Other secondary extracellular and oxidative stress, and cause further damage
effects of immobility that individuals with ALS are highly to the muscle.220 In the later stages of the disease, structured
susceptible to are cardiovascular deconditioning contribut- strengthening exercise may not be beneficial and may even
ing further to fatigue and respiratory complications.222 be harmful as the performance of ADL alone may provide a
Deconditioning and a generalized feeling of fatigue are training effect to excessively denervated muscles.222 When
common complaints in individuals with ALS. Partially muscle grades fall below a 3/5 strength or in the presence
innervated motor units produce an inefficient muscle con- of spasticity, ROM exercises are an important addition to
traction with early fatigability.219 This loss of force-produc- maintain efficient mobility and prevent painful contractures.
ing capability in the PNS contributes to inefficient mobility Aerobic conditioning is another important component of
and complaints of physiological fatigue. Deconditioning may an exercise program in ALS at all stages because of the pro-
also be secondary to hypoventilation and respiratory found risk of respiratory complications that arise from the
insufficiency.223 combination of muscle weakness, deconditioning, and sec-
As a result of loss of UMN inhibition spasticity is a com- ondary complications of dysphagia. Aerobic exercise can be
mon and painful side effect. Combined with the progression performed safely also at submaximal levels at 50% to 60% of
of motor weakness, individuals with ALS are at risk for HR reserve, even in the presence of respiratory insufficiency
developing painful joint contractures.224 and with the use of supplemental oxygen or with bilevel
490 Chapter 12
positive airway pressure support.222,223 Intermittent breaks may show residual neurological deficits such as dysesthesia,
and rest periods are recommended to prevent overwork. foot drop, and intrinsic muscle wasting, and 7% to 15% of
Mode of exercise has not been well studied in ALS to these patients have enough residual deficits to present with a
determine which activity may provide the most benefit. A decrease in function. As many as 20% of patients who require
small pilot study by Sanjak demonstrated improvements in ventilator support remain nonambulatory at 6 months and
gait speed, fatigue, and levels of perceived exertion in indi- are considered the most severe.16,231 Total recovery time can
viduals with ALS following repetitive rhythmic treadmill take up to 2 years with less than a quarter of patients noting
walking with body weight support. Subjects were encouraged continued activity and participation deficits.232
to train at a moderate intensity measured by a 20-point Borg Impairments Affecting Mobility
scale, and were provided supplemental oxygen as needed to
The most common residual deficit in GBS affecting
maintain oxygen saturations about 90%. Rest breaks were
functional recovery is muscle weakness.233 Forsberg et
provided in between training period to avoid fatigue and
al reported that at 2 weeks 100% of patients present with
overwork. Treadmill training with body weight support was
submaximal muscle strength grades. At 1 year 62%, and at
a feasible method of aerobic conditioning, and measures of
2 years 55% of patients still present with submaximal muscle
perceived exertion using a self-monitored Borg scale were
grades.26 Adequate force production of a muscle depends on
reliable.227 Other options for consideration are stationary
effective depolarization of alpha motor neurons in the PNS.
bikes in the presence of balance impairments or trunk weak-
Demyelination in the PNS in GBS affects depolarization by
ness, and swimming.
disrupting the propagation of an action potential, slowing
Individuals with ALS should be educated to not exercise the conduction velocity. This can cause dyssynchrony of the
to the point of fatigue or exhaustion. Energy should be pre- conduction, conduction block or may even result in com-
served for patient safety and ADL. Symptoms of overwork plete axonal loss.229 This produces a decrease in the quality
should be monitored and avoided. These include muscle and quantity of motor units recruited to generate or sustain
cramps, pain, muscle fasciculations, or extreme fatigue with muscle forces adequate enough for ADL. Muscles that are
an inability to perform ADL after exercise. With careful con- only partially innervated have the potential for overwork and
sideration and monitoring of program intensity, therapeutic are easily fatigued.229,230
exercise can reduce the rate of muscle weakness progression,
A significant increase in muscle strength can be seen in
decrease fatigue, improve quality of life, and can be safely
the first 6 months, with up to 95% of strength expected to
initiated at most stages of the disease.222,228
be “fully recovered” by 18 months. This rapid rate of motor
Guillain-Barré Syndrome return makes accurate and consistent measurement of mus-
cle strength a critical element of the rehabilitation process
Pathology not only to determine a patient’s functional status, but to
Guillain-Barré syndrome (GBS) is a rapidly progressing monitor the progress of recovery, establish a prognosis, and
demyelinating disorder of the PNS that is typically preceded determine appropriate interventions.234 Accepted principles
by an infectious event such as upper respiratory or gastro- of strength training in GBS include 3 main parameters:
intestinal tract illness.16 There are several clinical variants, 1. Recognize and avoid overworking of a muscle. There is
but GBS usually refers to acute demyelinating inflammatory weak evidence in the polio literature that stress of a par-
polyneuropathy. The incidence of GBS in the United States tially innervated motor unit can cause further perma-
is approximately 1 to 3 per 100,000 and it typically affects nent damage to the motor unit with subsequent decline
otherwise healthy adults in their fifth to eighth decades.16 in strength.235 This theory remains controversial, but
Symptoms are caused by an autoimmune attack of the the basic concept remains in place for people with GBS.
PNS affecting Schwann cells, resulting in demyelination.229 Symptoms of overwork are a delayed onset of muscle
Primary clinical symptoms include a rapid progression of soreness 1 to 5 days after exercise with a reduction in the
symmetrical weakness in the arms and legs, and areflexia. maximum force a patient can produce. If a patient dem-
Other common features include paresthesias with or without onstrates signs of overwork, rest is advised until baseline
loss of sensation, pain, autonomic dysreflexia, cranial nerve strength levels return, and then strengthening can be
involvement, and a high concentration of protein found in resumed at a lower intensity.
the CSF > 1 week after onset of initial symptoms. Symptoms
2. Avoid eccentric contractions.
progress and then peak over a period of 1 to 4 weeks with as
many as 21% to 30% requiring mechanical ventilator support 3. Avoid strengthening until the muscle has achieved anti-
because of respiratory muscle weakness.16,26,230 This is fol- gravity strength.229
lowed by a plateau phase that can last for days to weeks. The Once the disease process has reached at least the plateau
longer it takes a patient to reach this plateau phase or “nadir,” phase and the patient has achieved anti-gravity strength,
the longer the acute stay and the poorer the functional out- strengthening recommendations are to perform short bouts
come.16 The process of remyelination and recovery can vary. of non-fatiguing exercise.236 Resistance and program inten-
Patients with less severe disease can gradually recover muscle sity can safely be increased if no adverse effects such as a
strength within 2 to 4 weeks after plateau and close to 80% decline in muscle weakness are noted.237
recover ambulation by 6 months. Of these patients, 50%
Fatigue remains the most persistent and disabling residual discussed may tolerate parameters outlines by the ACSM, a
symptom of GBS and can be found in 38% to 86% of patients thorough understanding of the pathology, implications for
well beyond the 18-month point in their recovery.15,16,234 mobility, exercise potential, and risk factors involved unique
Fatigue is often worse in older patients and females, and can to each person and diagnosis will promote the best perfor-
be independent of any residual neurological deficits.15 In mance and hopefully lifelong participation.
the acute stage of GBS, fatigue can be described as primar-
ily peripheral in origin. Demyelination disrupting nerve
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CASE STUDY 12-1 complications following stroke,16 are more likely to achieve
greater functional recovery5 and are more likely to be dis-
charged home.8,11,15 Sociological factors may play a role in
Laura Klassen, DipPT, BPT, MSc such findings.
EXAMINATION History of Current Complaint

Mr. Julep was admitted to an acute care hospital after
History developing rapid onset of a left lower facial droop, paresis of
left arm and leg, dysarthria, and dysphagia. He was inconti-
Current Condition/Chief Complaint nent at time of admission. He was treated with alteplase (ie,
Mr. Julep, a 70-year-old White male, was diagnosed with tissue plasminogen activator [tPA]).
a right side, lacunar stroke of thrombotic etiology, resulting Mr. Julep received physical therapy care (30 minutes/day
in hemiparesis. for 5 days) while in the acute care facility. He was transferred
from acute care to a rehabilitation facility 8 days after his
initial admission. He underwent a full interdisciplinary
Clinician Comment The most common cause rehabilitation assessment during his first days there. The
of ischemic stroke is thrombosis, which causes partial to results of the physical therapy portion of that assessment are
complete arterial stenosis.1 Lacunar cerebral vascular presented in the sections that follow.
accidents occur in small perforating branches of the middle
cerebral artery supplying blood to the diencephalon and
ventral pons.2 They typically result in localized lesions and Clinician Comment Incontinence had
a set of limited clinical signs and symptoms, as described by resolved in the acute post-stroke period, and dysarthria
Brown in Chapter 12. Although usually smaller in size than and dysphagia were resolving by time of admission to our
the lesions caused by cortical strokes, subcortical lesions rehabilitation facility. Therefore, these impairments were
can have substantial impact on motor control. Axons from not expected to detrimentally influence rehabilitation out-
the primary, secondary, and supplementary motor cortices comes or discharge destination.
all converge in the corona radiata, before passing through Those receiving tPA for acute treatment of stroke have been
the compact internal capsule.3 reported to have a 30% higher likelihood of minimal or no
Lacunar strokes are generally associated with better func- disability at 3 months’ postintervention.17 Although Mr.
tional outcomes4 and greater likelihood of discharge home5 Julep is unlikely to present with minimal disability as a
than other types of ischemic strokes. They are also generally final outcome of his stroke, having received optimal acute
associated with low rates of recurrence.6 However, there are treatment may have influenced the outcomes achieved.
a variety of other personal contextual factors influencing Earlier rehabilitation intervention is associated with bet-
rehabilitation outcomes and risks for recurrence. ter recovery of function.5 Shorter intervals between stroke
Mr. Julep’s age and gender are personal contextual factors onset and admission to a rehabilitation facility have been
influencing stroke outcomes.7 At 70 years of age, Mr. Julep reported to increase the likelihood of being discharged
is just slightly younger than the mean age for White males home; by a factor of 2, if the interval is 7 days or less.11 Mr.
at time of stroke.8 Increasing age has been associated with Julep was admitted to a rehabilitation facility a short 8 days
poorer functional recovery from stroke.9,10 It has also been after his stroke. In the interim, he received early physical
associated with decreased likelihood of return home.5,11 therapy intervention in the acute care facility, Therefore,
Poor outcomes are particularly true in the very old12 and the time between stroke onset and commencement of reha-
those with severe strokes.13 Increases in the number and bilitation intervention was minimal.
severity of comorbidities that occur with aging may play
a role in the association between age and rehabilitation
outcomes.5,11
When considered independently of other prognostic vari-
ables, age has been reported to have limited effect on func- Mr. Julep was a retired farmer, who lived with his wife
tional outcomes14 and discharge destination.15 Therefore, in a single-story house. His wife was in good health. He had
age should not, in isolation, influence decisions regarding 2 grown children. His daughter, son-in-law, and 2 grand-
access to rehabilitation or intervention planning. children lived in the basement suite of his home. The house
had 3 steps (no hand rail) at front entrance. Mr. Julep’s hob-
Mr. Julep’s gender weighs in his favor when considering
bies included fishing, gardening, and watching sports on
stroke outcomes. Men are less likely to have in-hospital
television.
498 Chapter 12
rehabilitation stay. As a result of diabetes, he presented with
Clinician Comment Mr. Julep’s wife attended mild retinopathy.
many of his physical therapy assessment and treatment ses- Mr. Julep was diagnosed and successfully treated for pros-
sions, demonstrating interest and support for her spouse. tate cancer in 1991.
His daughter and grandchildren also attended some treat-
ment sessions.
Patients with high levels of social support experience Clinician Comment Diabetes causes damage
to the linings of arteries, leading to development, over time,
more rapid and extensive recovery of function following
of cardiovascular disease and risk for stroke.27 Mortality
stroke.18,19 Those living with another individual are also
following stroke is higher in those with diabetes.28 Stroke
much more likely to be discharged home.5,11,15,20 In one
outcomes are similar in those survivors with and without
large epidemiological analysis, those living with a family
diabetes, but those with diabetes can be expected to take
member or friend were 4 times more likely to be discharged
longer to achieve the same level of function.28 As examina-
home than those who lived alone prior to the stroke.11 This
tion proceeds, further indications of arterial disease may
positive discharge outcome is likely associated with assis-
be revealed, and other signs and symptoms associated with
tance that another person is able to provide with activities
diabetes may be found.
of daily living (ADL) and instrumental ADL (IADL).
Social/Health Habits Medications

Mr. Julep was taking ticlopidine (250 mg, twice a day),
Mr. Julep smoked for 50 years, smoking 1 to 2 packs/day.
an antiplatelet aggregate. He was also taking insulin humu-
He quit 5 years ago.
lin daily (100u/mL-NDH vial, 100u/mL regular vial). He
He was physically active while farming, but has lived
required acetaminophen (325 mg, PRN) for back pain.
an inactive lifestyle since retiring. He had never followed a
regular exercise or fitness program and had not engaged in Relevant Clinical Tests
physically vigorous leisure activities since early adulthood. An initial computed tomography (CT) scan, performed
Mr. Julep reported that he typically walked approximately immediately after hospital admission, ruled out a hemor-
0.5 km/day prior to his stroke. rhagic stroke etiology. A follow-up CT scan, performed using
a contrast medium, demonstrated a localized ischemic lesion
Clinician Comment Regular physical exer- in the posterior limb of the internal capsule on the right side.
cise/activity is a health strategy known to reduce risk of A carotid Doppler ultrasound test conducted on the fourth
first stroke21,22 and recurrence of stroke.23 Conversely, day of his acute hospital stay found significant stenosis, with
infrequent physical activity prior to first stroke is a signifi- minimal plaque formation, in the region of the right carotid
cant prognostic factor for institutionalization at 5 years.24 bulb, just beyond the carotid bifurcation.
Assisting Mr. Julep to become more physically active during An initial electrocardiogram (EKG) demonstrated non-
his rehabilitation stay and to stay active in the long term specific ST and T wave changes. Repeat testing conducted
was a priority in intervention planning. just prior to transfer to the rehabilitation facility reported
the same results. An initial chest X-ray showed no lung
Mr. Julep’s inactivity for a number of years had, no doubt,
anomaly, but did make note of degenerative joint disease of
led to his physically deconditioned state and had likely
the thoracic spine. A barium swallow test, conducted on the
had a negative impact on his cardiovascular, pulmonary,
same day as the Doppler ultrasound, found a slight delay in
and musculoskeletal systems. Further deconditioning may
the swallowing mechanism, a normal cough reflex, and a
have occurred during his acute hospital stay. Although Mr.
tendency to aspirate when attempting to swallow thin fluids.
Julep’s deconditioned state was a modifiable health risk
A pureed diet was recommended at that time.
factor, it would be important to keep in mind that physi-
cal exercise had not been a regular part of Mr. Julep’s life.
Compliance with a regular exercise program, given limited Clinician Comment The corticospinal and
past experience, may be challenging.25 corticobulbar tracts travel from the primary motor cortex
It was fortunate that Mr. Julep had ceased smoking 5 years through the posterior limb of the internal capsule to lower
ago, as this might reduce the likelihood of recurrence of motor neurons innervating the trunk and extremities (corti-
stroke.26 cospinal) and the head and neck (corticobulbar). Secondary
motor efferent fibers from the premotor and supplementary
motor cortices pass through the genu and anterior limb
of the internal capsule, respectively, on their way to the
Medical/Surgical History reticulospinal, rubrospinal and vestibulospinal nuclei in
Mr. Julep presented with Type 2 diabetes mellitus. Blood the brainstem.3 Mr. Julep’s presentation of hemiparesis was
sugar levels had fluctuated during the acute care stay and indicative of corticospinal tract damage, and his initial
continued to do so until midway through his inpatient
presentation of dysphagia and dysarthria were indicative In summary, Mr. Julep presented with a lacunar, motor
of corticobulbar tract damage. In general, individuals stroke for which he received tPA as part of optimal, imme-
with small, incomplete lesions of the corticospinal tract are diate medical stroke management. He was slightly younger
expected to recover isolated movement of the arm and leg. than the average stroke patient and had a strong social sup-
Those with complete lesions of the corticospinal tract, but port system. However, he had lived an inactive lifestyle for
with preservation of supplementary and premotor efferents, the past 5 years and presented with the comorbid conditions
may only recover movement that is dependent on abnor- of Type 2 diabetes and carotid artery disease. EKG results
mal, stereotyped synergies.3 Assessment of extremity motor suggested possible initial signs of coronary artery disease,
control in Mr. Julep’s case would likely require evaluation of as well.
both isolated and synergistic movement. Mr. Julep’s admission to a rehabilitation facility meant that
Severe stenosis of the right carotid artery placed Mr. Julep he was considered a good candidate for rehabilitation inter-
at significant risk of stroke recurrence.29 vention. A systems review was required to guide selection of
EKG testing assists in determining presence of cardiac isch- most appropriate tests and measures for physical therapy
emia. The ST segment and T wave are produced by ventric- assessment purposes.
ular repolarization.30 Although the changes reported were
nonspecific, they may be representative of early coronary
artery disease. This possibility needed to be kept in mind Systems Review
when choosing tests and measures and planning physical
interventions. Cardiovascular/Pulmonary
Seated resting values for vital signs were as follows: heart
rate (HR) of 84 beats per minute (bpm), blood pressure (BP)
Reported Functional Status of 150/90 mm Hg, respiratory rate of 16, and arterial O2
Mr. Julep was right-hand dominant. Prior to the stroke, he saturation of 90%. Lower extremities were cool to touch and
was independent in all ADL and IADL activities. He assisted mottled in appearance, beginning below the knees bilater-
his wife in providing care to his grandchildren when his ally. Mild edema was noted in the left hand, foot, and ankle.
daughter and son-in-law were working and was the primary There were no signs or symptoms of deep vein thrombosis.
person responsible for finances, vehicle maintenance, and Mr. Julep demonstrated a strong and nonproductive
yard maintenance. He assisted his son-in-law during peak cough on request. Chest expansion felt slightly decreased on
farm seasons of crop seeding and harvesting. left (hemiplegic) side as compared to right to manual palpa-
During the initial examination, Mr. Julep reported that tion. He denied shortness of breath when completing physi-
since the stroke, he required some assistance and supervi- cal activities, despite finding most activities tiring.
sion to ensure safety with most activities, including walking.
He was observed to walk for short distances using a front-
wheeled walker. He was observed to use his right arm and
Clinical Comments Impaired circulatory sta-
tus in bilateral lower extremities was most likely related to
leg to maneuver the wheelchair. Mr. Julep reported dressing
the diagnosis of Type 2 diabetes. Edema was likely the result
independently if clothes were laid out for him, but he needed
of decreased voluntary movement and dependent position
assistance with bathing and toileting. He reported that most
of distal segments of the arm and leg. Impaired chest expan-
activities required more effort and time than they had before
sion on the left side may have been related to a combination
the stroke and that he tired easily.
of decreased trunk motor control on the affected side and
Mr. Julep reported that he now managed a regular diet,
sitting posture, which saw him side-flexed on the left, with
although he did choke occasionally when drinking fluids.
center of body mass (COM) displaced to the right.
Cardiorespiratory fitness can be defined as the ability to
Clinician Comment Mr. Julep reported that perform prolonged physical activity. It is dependent on the
he tired easily during physical activity. General physical capacity of circulatory, respiratory, and muscular systems
deconditioning, possible left ventricular dysfunction (EKG), to supply and use O2 during physical activity.31
diabetes, and decreased motor control may all have con- Cardiorespiratory fitness has been measured to be ~50% of
tributed to his complaint. that of age-matched controls in those with stroke32 and to
Those with stroke typically demonstrate substantially decrease quickly following stroke.33 When decreased fitness
decreased peak oxygen (O2) consumption during submaxi- is combined with very high rates of energy expenditure (as
mal exercise and as much as double the energy costs associ- previously discussed), it was not surprising that Mr. Julep
ated with walking, compared to age- and gender-matched was experiencing fatigue and an increased sense of effort
individuals without stroke.8 Decreased O2 availability and when performing functional mobility tasks. Post-stroke
increased energy costs of moving may both be contributing fatigue was found in 39% of participants in a 2001 Swedish
to his sense of increased effort in performing ADL. study.34
500 Chapter 12
Integumentary Balance
Mr. Julep presented with mild trophic skin changes in Mr. Julep was able to safely maintain quiet sitting over
both lower extremities below the knees and with thickened the edge of a hospital bed with feet dangling. However,
toenails. A scab, measuring 1 cm in diameter, was present on when reaching forward beyond arm span in this position, he
the left medial malleolus. The area surrounding it was red- required supervision.
dened. Mr. Julep reported that this abrasion had been present Mr. Julep was able to stand independently for short peri-
for some time. No other skin lesions were noted. ods, but required close supervision. He required verbal cues
to maintain left hip and knee extension. Ankle postural
motor strategy responses in response to postural sway were
Clinical Comments The skin and nail issues noted to be deficient on the left side.
identified were most likely related to Mr. Julep’s diagnosis
of Type 2 diabetes. Locomotion
Mr. Julep walked slowly with a front-wheeled walker for
short distances only, requiring supervision and minimal
Musculoskeletal assist to correct the path of the walker.
Mr. Julep was 69 inches in height; weighed 190 pounds
and had a body mass index (BMI) of 28.06, which placed him Clinical Comments Use of a walker promotes
in the overweight category.35 safety (Brown, Chapter 12) and symmetry. It also encour-
Mr. Julep reported intermittent low and mid back pain of ages upper extremity weightbearing, with elbow extension,
moderate intensity (6/10 on VAS numeric rating scale). He wrist extension, and palmar grasp, increasing functional
was observed to sit in a kyphotic posture with forward chin use of the upper extremity. However, a walker alters gait
poke. characteristics, and may not be the type of walking aide
Mr. Julep did not present with subluxation of the left best suited for long-term use in Mr. Julep’s case.
shoulder and did not complain of pain at rest or during
passive movement of the shoulder. He did, however, present
with some limitations in joint ranges of motion (ROMs) and Sensory and Perceptual Integrity
muscle flexibility for trunk and left extremities that were Mr. Julep wore glasses for decreased acuity both in far and
noted as needing additional assessment during the scan. near vision. He demonstrated no evidence of a visual field
defect or visual neglect. He denied any loss of normal sensa-
tion in his left arm, but did indicate that his feet felt numb
Clinician Comment Although Mr. Julep was and that it did not hurt when he accidentally banged his left
not obese, being overweight makes diabetes management foot and ankle against the wheelchair footrest.
more problematic.28
Absence of shoulder pain is a positive indicator as regards
potential use of the hemiplegic arm in daily activities.36 A Clinical Comments Although Mr. Julep
more detailed assessment of shoulder ROMs is important appeared to present with a motor stroke, tactile sensory
to determination of the risk for development of shoulder impairments due to involvement of thalamocortical sensory
pain.36 afferent fibers that travel in the posterior limb of the inter-
nal capsule3 or due to peripheral neuropathy in the lower
Given the presence of degenerative joint changes in the extremities were possibilities, making it important to assess
thoracic spine, it is likely that there are degenerative joint somatic sensation.
changes in the lumbar and cervical spines as well. More
detailed assessment of trunk mobility/ROM will be impor-
tant, as trunk and pelvic mobility are important to many
locomotor activities. Communication, Affect, Cognition,
Mr. Julep’s dysarthria had resolved sufficiently by the time
Neuromuscular of admission to the rehabilitation facility, so that his commu-
nication was no longer affected by it. However, communica-
Transfers
tion was hampered by a long-standing hearing impairment
General observation during performance of transfers and that required the use of a hearing aid in the left ear.
moving between sitting and lying confirmed that Mr. Julep
Mr. Julep was always pleasant and cooperative. However,
presented both with paresis and dependence on abnormal
he demonstrated little variation in emotional responses,
synergies for movement of the left arm and leg. The left leg
resulting in an affect that could be described as flattened.
was observed to bear Mr. Julep’s entire body weight very
He was alert and consistently oriented to person, place,
briefly without assistance during a full standing transfer. Mr.
and time. He demonstrated the ability to sustain attention,
Julep was observed to use the left leg to lift the left wheelchair
but had some difficulty in selectively attending when in a
pedal in preparation for transfers.
busy environment, especially if tired because of poor sleep

A mild impairment is not considered a major factor in pre-
the night before. His short-term memory appeared to be
dicting rehabilitation outcomes.5,9 It does, however, war-
impaired, as evidenced by incomplete recall of events in
rant consideration when choosing teaching methods used
physical therapy sessions from 1 day to the next. Mr. Julep
in the rehabilitation program.
did not spontaneously engage in problem solving regarding
performance of mobility activities, but would participate if
prompted and guided.
Posture
Mr. Julep’s posture was observed both in sitting and
Clinician Comment Mr. Julep’s hearing
standing. When observed in the sagittal plane, he presented
impairment was expected to make verbal instruction less
with a “slouched” sitting posture, demonstrating chin poke,
effective than demonstration during treatment sessions.
increased thoracic kyphosis, slightly reversed lumbar lordo-
Hinkle found that age, cognitive status, and initial function sis, and a posterior pelvic tilt. In the frontal plane, his trunk
accounted for 42% of the variance in functional recovery was noted to be slightly side flexed to the left and the left
at 3 months following motor strokes.9 Assessment of Mr. shoulder to be 1 inch lower than the right. Mr. Julep stood
Julep’s cognition was warranted. It should be noted that in a forward lean posture. Slight winging of left scapula was
cognitive dysfunction may not be due only to Mr. Julep’s observed. He stood more asymmetrically than he sat, with
recent stroke.15 his left hip and knee semi-flexed and with his COM shifted
During the systems review Mr. Julep showed deficits in diagonally to the right and forward over his base of support
ROM and sensory integrity. He was observed to demon- (BOS). His left shoulder was more than 1 inch lower than the
strate clinical signs of paresis/weakness, as well as depen- right and trunk side flexion on the left was increased. Mr.
dence on synergy for movement in the left arm and leg. Julep was able to correct both sitting and standing postural
Both his muscle performance and muscle function needed asymmetry with manual contact guidance and cueing. In
to be examined. sitting, he demonstrated limited correction of abnormalities
Mr. Julep’s aerobic capacity needed to be measured in addi- seen in sagittal plane, particularly at pelvis and lumbar spine
tion to his ability with self-care and home management despite cueing and manual contact assistance.
tasks. Examining his ADL and IADL status would also be
part of the occupational therapy assessment. Clinician Comment Observational assess-
The rate of depression following stroke is reported to range ment of posture provides a simple, but holistic, first picture
from 18% to 68%.37-39 Depression is one of a number of of the musculoskeletal system and the effects of neurologi-
factors that can contribute to the fatigue experienced by cal impairments. Postural asymmetry appears to be due to
individuals with neurologic disorders (Brown, Chapter 12). nonstructural limitations, as these could be corrected with
Depression has been linked to lower levels of independence effort and light manual cues. Abnormal thoracic kyphosis
following stroke.40 Upon reflection, assessment for depres- and lumbar lordosis may be structural in nature, thus
sion by clinical psychologist was likely warranted, but was limiting attempts at correction. However, tight hamstring
not completed. The Beck Depression Inventory would have muscles may be contributing to posterior pelvic tilt. A posi-
been an appropriate tool.7 tion of posterior pelvic tilt increases both lumbar lordosis
and thoracic kyphosis. Assessment of trunk mobility, hip
extension ROM, and hamstrings muscle extensibility will
assist in determining whether improvements in pelvic and
Tests and Measures trunk posture might be achieved through treatment. Poor
vertical alignment increases the energy expended to coun-
Cognitive Status teract the forces of gravity in upright postures.42
Concerns about cognitive status arose during the Systems
Review. Cognitive status was assessed using the Mini-Mental
State Examination (MMSE). This measure includes 11 ques- Range of Motion (Including Muscle
tions with a total score that can range from 0 to 30. Mr. Lengths)
Julep’s score was 25/30.
Limitations in joint ROMs and muscle lengths were
assessed using a combination of goniometry and visual com-
Clinician Comment The MMSETM is report- parison between left and right sides of the body. Mr. Julep
ed to have good reliability, the ability to differentiate among was found to have slight limitation in neck side flexion to the
diagnostic groups, and the ability to differentiate those with right, limited trunk side flexion ranges of 20 degrees to the
disorders from those without.41 Mr. Julep’s score is indica- left and 15 degrees to the right, combined neck and trunk
tive of mild cognitive impairment.4 rotation ranges of 75 degrees to the left and 65 degrees to
the right, and lumbar extension ROM to just slightly beyond
neutral.
502 Chapter 12
Passive hip extension ranges of motion were limited to half of the face or any extremities, although Mr. Julep did
5 degrees on the right and 0 degrees on the left. Passive describe light touch as feeling less distinct for his left arm
straight leg raise (SLR) was determined to be 45 degrees and leg. There was no tactile extinction for the left arm or
on the left and 60 degrees on the right. Ankle dorsiflexion, leg. The ability to distinguish between sharp and dull sensory
measured with knees flexed, were 5 degrees on the left and stimuli was intact for the upper extremities, but moderately
10 degrees on the right. With knees extended, dorsiflexion severe and patchy impairment was found for areas below the
ranges were 0 degrees on the left and 5 degrees on the right. knees bilaterally. There was no impairment in joint position
Left shoulder flexion was limited to 130 degrees, abduc- sense (ie, proprioception) for either the left arm or leg.
tion to 120 degrees, and external rotation to 60 degrees.
There was a capsular joint end feel at the limits of passive
ranges of motion. Left forearm supination was limited to
Clinician Comment Intact proprioception in
the left arm and leg may enhance possibilities for motor
75 degrees. Left thumb flexion, extension, abduction and
recovery. Individuals with lacunar strokes, presenting
opposition were all limited by 1/4 range.
without severe sensory deficits, have demonstrated a trend
Using the modified Ashworth Scale to evaluate resistance toward more frequent recovery of isolated upper extremity
to passive movement, Mr. Julep generally presented with movement.3
grade 1 to 1+ spasticity in the typical decorticate distribu-
tion for the left arm and leg, as well as left trunk side flexors. The patchy distribution of impairment in sharp/dull sensa-
However, left ankle plantar flexors were graded as 2, and tion for the distal lower extremities is more likely associated
unsustained clonus was elicited from the left ankle plantar with diabetic peripheral neuropathy than with the subcorti-
flexors. cal lesion. This impairment increases the risk of injury to
the shins, ankles, and feet caused by trauma, such as bang-
ing feet/ankles on wheelchair foot pedals.
Clinician Comment Limitations that could
potentially affect performance of mobility tasks and left
upper extremity function were targeted for assessment. Muscle Performance (Including Strength,
Limited spinal mobility may affect gait and bed mobility
activities.42 Limited hip extension ROM may contribute
to shortened step lengths, as a trailing limb position is The Motricity Index (MI) was used to evaluate extremity
not possible to achieve without excessive forward trunk strength. Mr. Julep’s summed arm and leg scores were 59/100
lean.42 Limited hamstrings muscle extensibility (as mea- and 69/100, respectively. Scores for individual test items were
sured using SLR) may contribute to posterior pelvic tilt as follows: pinch grip 26 (able to hold a 2.5 cm cube against
and slouched sitting posture.42 Limited ankle dorsiflexion a weak pull), elbow flexion 19 (movement through full range
ROM and plantar flexor muscle extensibility (as evidenced against gravity, but not against resistance), shoulder abduc-
by greater limitation in dorsiflexion ROM when tested tion 14 (movement present, but not full range/not against
with knee extended) will likely hinder performance of sit- gravity), ankle dorsiflexion 19 (movement full range against
to-stand43 and gait,42 as well as the ability to use ankle gravity, but not against resistance), knee extension 25 (move-
strategies effectively to control postural sway and balance ment full range against resistance, but weaker than other
in standing.42 side), and hip flexion 25 (movement against gravity, but
Mr. Julep may be developing a capsular pattern of restric- weaker than other side).
tion for the left shoulder that could lead to development of
shoulder pain in the future.36 Precautions in handling the
left upper extremity as well as encouraging functional range
Clinician Comment The Motricity Index was
developed specifically for use in evaluating hemiplegic arm
active-assisted movement at the shoulder are required to
and leg strength.45,46 Six test items, representative of move-
ensure that this does not occur. The modified Ashworth
ment at each limb segment, are evaluated, using a 5-level,
Scale demonstrates good interrater and intrarater reliabil-
weighted rating scale that is based on the Medical Research
ity in individuals with acute stroke.44
Council (MRC) manual muscle testing scale. All move-
Mr. Julep presented with mild spasticity that would be ments are tested in sitting, taking approximately 5 minutes
unlikely to limit performance of mobility tasks and ADL, to complete.
perhaps with the exception of the left ankle plantar flexors.
The Motricity Index is reported to have good interrater
reliability scores for arm and leg.45,47 The validity of this
tool has been determined through correlations with dyna-
Sensory and Perceptual Integrity mometer strength scores48 and with grip strength scores.49
Mr. Julep did not present with either homonymous hemi- Mr. Julep demonstrated greater recovery distally than
anopia or visual extinction on testing. There was no evidence proximally in the upper extremity. Having some ability to
of impairment in light touch sensation for the left lower grasp and release with the left hand suggests a reasonable
prognosis for left arm function.49 Ability to grasp and Clinician Comment The Chedoke-McMaster
release could be expected to increase the frequency with Stroke Assessment Impairment Inventory: Stage of Recovery
which Mr. Julep would attempt to use the arm for reaching, of Arm and Leg has good-excellent intrarater and interrater
thus forcing increased attempted movement at shoulder reliability (intraclass correlation coefficient [ICC] = 0.93 to
and elbow. A systematic review of motor recovery after 0.98; 0.85 to 0.97, respectively), and test-retest reliability
stroke found that patients with small lacunar strokes (ICC = 0.84 to 0.92).36 The inventory uses a 7-point scale,
showed relatively good motor recovery.50 corresponding to Brunnstrom’s stages of motor recovery fol-
lowing stroke to score motor performance.
Although an impairment tool that evaluates stage of recov-
5 Times Sit to Stand Test ery from dependence of abnormal synergies for limb move-
Lower extremity muscle endurance was evaluated using ment may not be as predictive of future functional outcomes
the 5 Times Sit to Stand Test described by Brown in Chapter as a measure of strength (see Chapter 12 for discussion), it
12. Mr. Julep completed the test in 20.6 seconds. does provide information important to the retraining of
extremity motor control by providing a progression frame-
work for increasing fractionation (ie, isolating movement
Clinician Comment The intrarater, interrater to 1 joint or limb segment) and recruiting muscles to more
and test-retest reliabilities of this measure, when used with
complex functional synergies including ability to recruit
a stroke population, were reported to be excellent if rat-
muscles from opposing flexion and extension synergies at
ers viewed video clips of test methods prior to use.51 Mr.
adjacent joints. For example, active ankle dorsiflexion from
Julep’s score was above the mean, but within the computed
the flexion synergy combined with knee extension from the
standard deviation for scores reported for individuals with
extension synergy are required to produce an effective ankle
stroke.51
postural motor strategy response to posterior displacement
of the COM in standing.42 Ability to recruit this more
complex muscle synergy would be represented by Stage 5
Motor Function (Motor Control and recovery of the foot, which Mr. Julep had not yet reached.
Learning)
Mr. Julep was observed to use his left arm to support
some body weight when rising from sitting to standing and Gait, Locomotion, Balance
when walking with the walker. The arm was also observed to Gait
perform assistive functions such as holding the wheelchair The following asymmetries in spatial and temporal gait
seat belt buckle, as well as simple grasp and manipulate func- characteristics and gait deviations were observed:
tions, such as applying the left wheelchair brake. However,
• Decreased step lengths bilaterally, right step length
Mr. Julep was not observed to use this arm effectively when
shorter than left
moving between side lying and sitting or for propelling his
wheelchair, instead demonstrating a weak associated reac- • Decreased single limb support time on left leg as com-
tion in the pattern of the abnormal flexion synergy during pared to right
performance of these tasks. • Excessive forward trunk lean during left stance phase
The Chedoke-McMaster Stroke Assessment: Impairment
• Excessive contralateral pelvic drop during left stance phase
Inventory: Stage of Recovery of Arm and Leg was used to
assess motor control as it pertained to the ability to isolate • Decreased hip extension during terminal stance, left
(ie, fractionate) movement and recruit muscles in a variety of more limited than right
combinations, as opposed to 2 stereotypical patterns.36 • Excessive left knee flexion during loading and rapid left
The left arm and hand presented with stages 3/7 and knee extension from mid-stance to terminal stance
4/7, respectively. The left leg and foot presented with stages • Decreased left knee extension with foot flat at initial
5/7 and 4/7, respectively. Stage 3/7 indicated that willed contact
movement in the patterns of the flexion and extension
synergies was possible. Stages 4 and 5 indicated progressive • Absence of left heel off in terminal stance
improvement in the ability to recruit muscles in more com-
plex movement patterns and to isolate movement. Although Clinician Comment Asymmetries in step
Mr. Julep was able to dorsiflex, then plantar flex, his foot lengths and single limb support times are common follow-
through full range with the knee flexed in sitting, he was not ing stroke.52 Asymmetries, as well as the gait deviations
able to dorsiflex the ankle through full available range with observed, can most likely be attributed to Mr. Julep’s pre-
the knee held in an extended position. sentation of muscle weakness, dependence on abnormal
synergies, and limitations in joint ROM and muscle exten-
sibility.42 Impaired balance also likely contributed to asym-
metry in single limb support time.
504 Chapter 12
Locomotion 15. Age appropriate walking distance for 2 minutes (2-point
Performance of locomotor and ambulatory activities was bonus if able to walk more than 84 m). Score = 0/2
evaluated using 3 standardized measures: the Chedoke- Mr. Julep’s total score was 54/100. All activities required
McMaster Stroke Assessment: Disability Inventory, the more time to complete than what would be considered
Modified Emory Ambulation Profile, and the 10 meter walk reasonable.
test. Sit to Stand
Chedoke-McMaster Stroke Assessment: Disability Although sit-to-stand is not an item on the Chedoke-
Inventory McMaster disability inventory, it was decided to assess this
This inventory includes a gross motor function index activity in more detail. Mr. Julep was able to perform sit-to-
composed of 10 items and a walking index composed of stand with supervision from a regular height surface using
5 items. Each item is rated using the same 1 to 7 point scale his arms to assist. In preparation for rising, Mr. Julep’s feet
that is used with the Functional Independence Measure were often asymmetrical with left positioned forward of the
(FIM).42 right. He demonstrated decreased and asymmetrical for-
Results of testing were as follows: ward displacement of COM during flexion momentum and
1. Bed mobility: Supine to side lying on strong side: momentum transfer, with diagonal displacement to the right.
5/7 (supervision required; cueing required for left arm He typically demonstrated incomplete extension of left hip
participation) and knee during the extension phase of rising to standing.
When rising from a lower than a standard height surface, he
2. Bed mobility: Supine to side lying on weaker side:
required minimal contact assistance.
6/7 (modified independence)
Car Transfers
3. Bed mobility: Side lying to long sitting through strong
Although transfer to/from a car is not an item on the dis-
side: 5/7 (supervision, cueing)
ability inventory, this task was assessed. Mr. Julep required
4. Bed mobility: Side lying to sitting on side of bed through moderate assistance with the task
strong side: 4/7 (minimal assistance at trunk and left
arm)
5. Bed mobility: Side lying to sitting on side of bed through Clinician Comment Interrater and test-retest
weaker side: 4/7 (minimal assistance at trunk and left reliability of the Chedoke-McMaster Stroke Assessment
arm) Disability Inventory, are reported to be excellent,42 and
the validity of the inventory has been extensively stud-
6. Remain standing for 30 seconds: 5/7 (supervision,
ied.42,53 The minimal clinically important difference
cueing)
(MCID) for the Disability Inventory has been reported as
7. Transfer to and from bed toward strong side: 5/7 (cueing 7 to 8 points.54
to achieve optimal starting position for sit to stand and
to complete turn before attempting to sit down)
8. Transfer to and from bed toward weaker side: 4/7 (mini- Modified Emory Ambulation Profile
mal assistance to maintain balance, cueing to achieve The Modified Emory Ambulation Profile Scale is used
optimal starting position for sit to stand, cueing for left to evaluate the ability to walk under varying task and envi-
arm participation and cueing to complete turn before ronmental conditions. The time required to complete each
sitting down) of 5 tasks is multiplied by an assistive device factor ranging
9. Transfer up and down from floor to chair: 3/7 (moderate from 1 (no assistance) to 6 (ankle-foot orthotics (AFO) and
assistance) walker or quad cane required). As Mr. Julep used a walker,
10. Transfer up and down from floor to standing: 3/7 his time scores were multiplied by a factor of 4.
11. Walk indoors, 25 meters (m): 4/7(minimal contact assis- Results of testing were as follows:
tance to correct path of front-wheeled walker, as walker 1. Walk on floor: 23.5 sec × 4 = 94
gradually deviates to the left) 2. Walk on carpet: 29 sec × 4 = 116
12. Walk outdoors, over rough ground, ramps, and curbs, 3. Timed Up & Go: 64.4 sec × 4 = 257.6
150 m: 1/7 (unable to walk 150 m, requires moderate 4. Obstacles: over a series of 2 bricks and around a trash
assistance to manage a ramp, curb, and a short distance bin: 75.5 sec × 4 = 302
over rough ground).
5. Stairs (4 steps): 65.7 × 4: (railing substituted for walker)
13. Walk outdoors several blocks, 900 m: 1/7 (unable to walk = 262.8
for this distance)
Summed score = 1032.4
14. Walk up and down stairs: 4/7 (railing on right, 2 feet/
step, leading with the right when ascending and with the
left when descending, minimal assistance).
Clinician Comment The modified Emory Excellent correlations with the Barthel Index, Functional
Ambulation Profile has excellent interrater55 and test- Independence Measure, and gait speed have been reported,
retest56 reliability for summed scores. Profile scores have and scores have been found to be predictive of disability
been found to correlate with those of timed walking level at 90 days post-stroke.61 Those stroke patients scor-
tests.56,57 ing > 20 on admission and > 40 on discharge have been
reported to be more likely to be discharged home.64
Mr. Julep walked slightly slower on carpet than on firm
flooring and demonstrated difficulty with foot clearance
on this semi-compliant surface. There is carpeting in most
rooms of his house. Managing obstacles and turns, as Sitting
would be required for safe household ambulation, were While sitting over the side of his hospital bed, Mr. Julep
substantial challenges. required minimal contact assistance to remain stable when
reaching down to his feet. Other sitting activities were per-
formed without risk to his safety. For this reason, dressing
Walking Velocity his lower body was performed sitting in the wheelchair.
Measured over the middle 5 meters of a 10-meter walk- Left upper extremity protective reactions were observed but
way. Mr. Julep’s walking velocity was 0.31 m/sec. appeared insufficient to prevent loss of balance in response
to large amplitude displacements of the COM. Equilibrium
reaction responses in sitting appeared decreased in ampli-
Clinician Comment Test-retest reliability of tude for trunk and left extremities.
walking velocity scores for individuals with stroke has been Mr. Julep was able to reach 6 to 8 inches beyond arm span
reported to be excellent for those requiring physical assis- safely in lateral and forward directions when feet were resting
tance to ambulate and to be good for those able to walk on the floor. When sitting on a hospital bed with feet dan-
without physical assistance.58 Minimal detectable change gling, Mr. Julep could reach forward a distance of 5 inches,
scores (90% confidence intervals) have been reported to but required supervision to ensure safety when doing so.
range from 0.05 to 0.08 m/sec.59
Standing
Based on his measured walking velocity, Mr. Julep would be
Postural motor strategies were observed during pos-
classified, at present, as a household ambulator. A velocity
tural sway in quiet standing and during completion of test
of 0.4 m/sec would be required to be classified as limited
items from the BBS. Ankle strategy responses demonstrated
community ambulator.31,60 Using a walker as an ambu-
decreased dorsiflexor and plantar flexor muscle activity on
latory aid is an impediment to improvement in walking
the left. Hip strategies demonstrated decreased excursions
velocity.
of forward/backward displacement of the pelvis. Left knee
wobble was observed intermittently, and the knee assumed a
position of semi-flexion frequently during testing. Stepping
Balance postural motor strategies were not evaluated during the ini-
The Berg Balance Scale (BBS) was used to evaluate Mr. tial assessment due to patient apprehension, but were identi-
Julep’s ability to maintain balance under a variety of task fied as items for future assessment.
conditions. His total score at admission to the rehabilitation
program was 34/56. Aerobic Capacity and Physical Endurance
Clinician Comment The internal consistency, Clinician Comment Independent sitting bal-
interrater reliability, intrarater reliability, and test-retest ance has been identified as an important predictor of dis-
reliability of the BBS have been reported as excellent when charge home,15 and of rehabilitative outcomes.65,66
used with stroke populations.61 Moderate to excellent sensi-
tivity of BBS scores have also reported, but with evidence of
floor and ceiling effects.61 The minimal detectable change
6-Minute Walk Test
(MDC) score for the BBS has been estimated to be 5.8 and
6.9 points, respectively, at 90% and 95% confidence inter- The 6-Minute Walk Test (6MWT) was used to evaluate
vals for individuals receiving rehabilitation following stroke aerobic capacity and physical endurance under submaximal
when assessed by 2 different raters.62 For those requiring test conditions. The distance walked with front-wheeled
an ambulation assistive device, an MDC of 7 points would walker in 6 minutes was 120.6 meters. Rate of perceived
be appropriate to be 90% confident that genuine change exertion (RPE), as measured using the Borg scale,67 was
had occurred.62 BBS scores should be used with caution 13/20 (somewhat hard). HR was 102 bpm and BP was
for predicting fall risk for individuals with chronic stroke, 165/100 mm Hg immediately following completion of the
particularly when a walking aid is being used.63 The same test.
caution would likely apply to those with more acute stroke.
506 Chapter 12
Clinician Comment Although maximal exer- consistency for the stroke group [C = 0.95] and good test-
cise testing is considered the gold standard for assessment retest reliability [rho = 0.88] within a normal subset of study
of aerobic capacity, this method was not feasible within the participants in a recent study.72 An MDC95 for FSS scores
rehabilitation facility for the reasons identified in Chapter in a stroke population has been reported to be 0.15.72
12. Mr. Julep was cleared for submaximal exercise testing Mr. Julep’s score was substantially higher than the aver-
by his physical medicine specialist. To reduce the possibility age of 3.9 ± 1.84 reported by Valko et al72 for individuals
of an adverse cardiac event during testing, a conservative with chronic stroke, and the cut-off score for normal-range
predetermined end point of 70% of predicted HR maxi- fatigue of 4 that was suggested by Van de Port et al.75
mum [(220 – age) × 0.7] = 105 bpm was chosen for testing.
Lighter intensity exercise has been suggested for those with
suspected coronary artery disease who have not undergone Self-Care and Home Management,
an exercise EKG.7 Including Activities of Daily Living and
The 6MWT test has demonstrated excellent test-retest reli- Instrumental Activities of Daily Living
ability as well as criterion validity and sensitivity to change
in a stroke population.68 Functional Independence Measure
Mr. Julep’s 6MWT distance score was substantially lower Overall functional status and care giver burden was quan-
than the established baseline value for subacute stroke indi- tified using the Functional Independence Measure (FIM). At
cated in Box 12-1 of Chapter 12 (215.8 ± 91.6 meters). This time of admission to our rehabilitation facility, Mr. Julep’s
comparatively poorer score may be related to Mr. Julep’s use total FIM score was 98/126, his motor sub-score was 70/91
of a walker in combination with his deconditioned state. An and his social-cognitive sub-score was 28/35. Scores for indi-
MDC of 54.1 meters has been reported for the 6MWT.68 vidual items were as follows: self-care: feeding (6), grooming
Given Mr. Julep’s low initial score, this value might not be a (6), bathing (5), dressing upper body (5), dressing lower body
realistic benchmark of true change if he continued to use a (5), toileting (5), bladder management (7), bowel manage-
walker for ambulation. ment (6), transfers to bed, chair, wheelchair (6), transfer
It is common for individuals with stroke who are undergoing to toilet (5), transfer to tub or shower (4), walking or using
rehabilitation to achieve lower workloads, lower HRs and wheelchair (4; can’t walk 150 feet), stairs (5), comprehension
lower BP responses than expected norms with sub-maximal (6), expression (6), social interaction (6), problem solving (5),
exercise testing.69 O2 uptake at submaximal workloads is memory (5).
greater than in healthy individuals, but peak O2 uptake is
lower.8 MacKay and Makrides70 found that peak O2 uptake Clinician Comment The FIM scores each
at 26 days following stroke was lower than that required to of 13 items on a 7-point ordinal scale ranging from inde-
meet the physiologic demands for daily living. pendent (7) to dependent (1).12,76 Test items are typically
grouped into 2 main sub-scores (motor, social-cognitive)
and 6 minor sub-scores (self-care, continence, transfers,
Fatigue Severity Scale locomotion, communication, and social cognition).16 The
Fatigue was measured using the Fatigue Severity Scale total maximum score that can be achieved is 126.
(FSS). Mr. Julep’s averaged FSS score was 5.4/7. FIM scores on admission have been found to be strongly
associated with functional recovery during inpatient reha-
bilitation,77 as well as with discharge destination.11,16 The
Clinician Comment Fatigue is a common Canadian Institute for Health Information11 has developed
complaint in individuals who have experienced stroke,71,72
a conceptual framework for modeling the likelihood of
is among the worst symptoms of stroke for approximately
being discharged home based on factors commonly refer-
40% of stroke clients,73,74 and has been found to persist as a
enced in the stroke literature. They reported that a high
complaint for at least 2 years post-stroke.72 Fatigue is also a
motor function score on the FIM (51 to 91) was the stron-
common symptom of diabetes. Although findings of fatigue
gest predictor of discharge home, increasing the likelihood
frequently overlap with findings of depression in those
of this discharge destination by a factor of 6. They also
with recent stroke, fatigue may be present in the absence
reported that those with high FIM social-cognitive subscale
of depression.72 Fatigue, independent of depression, has
scores (30 to 35) were 2.5 times more likely to be discharged
been found to be a significant factor associated with health-
home than those with low scores (5 to 20). The scores that
related quality of life.75
Mr. Julep obtained on the FIM strongly suggest that he will
The FSS, as discussed in Chapter 12, is a 9-item self-report be able to return home upon discharge.
questionnaire. This scale has been used to measure fatigue
in stroke populations,72,75 demonstrating excellent internal
comprehensive interdisciplinary intervention plan. As part of

EVALUATION this plan, the physical therapist was responsible for education
regarding the possible benefits of regular aerobic exercise.
Diagnosis Benefits that were discussed included improved physical
activity tolerance, possible reduction of fatigue, manage-
Practice Pattern ment of risk for stroke recurrence, as well as management of
weight and blood sugar levels. The physical therapist was also
Mr. Julep was classified into Pattern 5D: Impaired
responsible for counseling regarding ongoing participation
Motor Function and Sensory Integrity Associated with Non
in physical activity.
Progressive Disorders of the Central Nervous System—
Acquired in Adolescence or Adulthood.
Clinician Comment Exercise improves insu-
lin sensitivity and assists in normalizing plasma glucose
Disability and Health Model levels by increasing carbohydrate metabolism, thus reduc-
See ICF model on p 508. ing plasma glucose levels.
Prognosis
Intervention
Predictions about functional recovery and discharge des-
tination are influenced by stroke characteristics, medical Mr. Julep required an intensive program of task-specific
management of stroke, presentation of impairments and training in bed mobility, sit-to-stand, transfers, walking
activity limitations caused by the stroke, comorbidities, and under varying task and environmental conditions, as well as
personal and environmental contextual factors. All of these upper extremity support (ie, weightbearing), reach and grasp
variables, as they relate to Mr. Julep, have been discussed (see activities, ADL and IADL activities. Occupational therapy
Examination and Tests and Measures sections).To summa- (OT) team members were tasked with addressing ADL and
rize, factors with positive influences on functional outcomes IADL training and worked in conjunction with physical
and discharge destination include: lacunar stroke, early therapy on upper extremity function. Motor-learning princi-
intervention with tPA, male gender, strong social support, ples were employed during practice to enhance performance,
short interval between stroke onset and commencement of as well as retention and transfer of improved performance.
rehabilitation services, minimal cognitive impairment, early Because of hearing loss and mild cognitive impairment,
return of motor function, and good sitting balance. Factors frequent demonstration, repetitive teaching methods, writ-
with negative influences on outcomes include: comorbidities ten instructions, and diagrams were required for practice of
of Type 2 diabetes and carotid vascular disease, an inactive mobility tasks.
lifestyle prior to stroke, and high BMI. In addition to task-specific training, Mr. Julep required a
program of strengthening, stretching, and flexibility exercis-
es for trunk and left extremities, a standing balance retrain-
Clinician Comment Considering all of these ing program, and an aerobic exercise training program. In
variables enhances the clinician’s ability to determine this case description, strength training, gait training and
appropriate treatment goals and expectations, which are aerobic training were emphasized.
the foundations for intervention planning. It was predicted Precautions that were considered when planning and
that Mr. Julep would return to live with his wife and family, implementing physical therapy interventions included moni-
and would achieve independence in household ambulation toring HR and BP, as well as observing for signs of low blood
and ADL activities. It was also predicted that limited com- sugar levels. Individuals with Type 2 diabetes who take insu-
munity ambulation would be possible, with supervision. It lin may develop hypoglycemia during/following exercise,
was also predicted that Mr. Julep would be able to partici- but the risk of this occurring is much less than it is in those
pate in modified forms of his leisure activities of gardening with Type 1 diabetes. Symptoms of hypoglycemia may occur
and fishing. hours after completing exercise. Carbohydrates were made
available during and after exercise, and hydration during
exercise was encouraged.
Diabetic neuropathy affecting sensation in bilateral lower
Plan of Care extremities warranted education and diligent care during
exercise and task-specific training. Because of the presence
Prevention of back pain and degenerative joint changes, choice of body
Primary prevention of stroke recurrence and effective positioning for strengthening and stretching exercises had
management of Type 2 diabetes were considered criti- to be considered, and frequent feedback regarding comfort
cal to Mr. Julep’s future health and were addressed by a needed to be elicited.
508 Chapter 12
ICF Model of Disablement for Mr. Julep

Health Status
• Ischemic stroke causing subcortical lesion
• Hemiplegia
• Type 2 diabetes

Function
• Limited performance of bed • Limited ability with
• Decreased endurance mobility, transfers, sit to dressing, bathing and
• Paresis of left arm > leg stand, walking, stairs toileting
• Dependence on abnormal • Limited ability with LUE • Limited ability to care
synergies for left UE, LE to support body weight, for, and play with,
reach, grasp and manipulate grandchildren
• Abnormal gait
objects • Challenged resumption of
• Impaired standing and
gardening and fishing
walking balance
• Asymmetrical and slouched
posture in sitting and
standing
• Mild spasticity LUE, LLE
• Decreased ROM
• Intermittent thoracic and
LBP
• Trophic skin changes
• Mild cognitive impairment

• Age = 70 years • Stairs at entrance to home
• Male • Supportive family
• Inactive lifestyle • Small grand children posing risk to safety when
• Comorbidities ambulating
Proposed Frequency and Duration of Expected Outcomes

Physical Therapy Treatment Sessions 1. Walk independently using a single-point cane indoors
Two, 50-minute sessions/day, 5 days per week were planned (8 weeks).
for the remaining 4 weeks of inpatient physical therapy reha- 2. Walk with supervision using a single-point cane out-
bilitation. Inpatient programming was planned so Mr. Julep doors (8 weeks).
would spend approximately 50% of each treatment session 3. Walk for a distance of ≥ 500 meters before resting
on activities in standing by the beginning of week 2 of the (8 weeks).
remaining 4 weeks of inpatient program Strength training
4. Cast fishing rod with right arm when standing on a
occurred 3 times per wk. Stretching and mobility exercises,
semi-compliant surface with supervision (8 weeks).
balance training, and task-specific training were completed
daily. Physical endurance training was completed 2 times per 5. Hoe a 1-meter square patch of garden with supervision
week using overground walking initially, and progressing to (8 weeks).
include both overground walking and treadmill walking. Discharge Plan
Appropriate use of upper extremity for weightbearing, reach-
ing, grasping, and manipulating were encouraged during all Mr. Julep was to be discharged home to live with his wife
treatment sessions. and family, with a plan to attend outpatient programming,
2 times per week, for 1 month. He would have a predischarge
needs assessment 2 weeks prior to discharge, which would
Clinician Comment Current best practice rec- include a home visit attended by physical therapy and OT
ommendations for stroke care suggest a minimum of 1 hour rehabilitation team members. He was to spend a weekend at
of direct therapy from each relevant core therapy.78 home 1 week prior to being discharged.
Follow-up reviews with members of the rehabilitation
team were planned for 3 months, 6 months, and 12 months
Anticipated Goals following discharge from the outpatient service.
Mr. Julep and his wife participated in goal setting with
each team member. Involvement of individual and family in
goal setting and treatment planning increases the patient’s
adherence to therapy.79
INTERVENTION
Physical therapy goals agreed on were as follows:
1. Bed mobility: Independent supine to side lying to left/ Coordination, Communication, and
right in hospital bed (1 week). Documentation
2. Bed mobility: Independent lie-to-sit in hospital bed
(1 week). Coordination of the components of the rehabilitation
intervention program was achieved through weekly team
3. Independent sit-to-stand to/from hospital bed (1 week).
meetings of which Mr. Julep and his wife were part. The ini-
4. Independent sit-to-stand from standard height chair tial physical therapy assessment and plan of care were both
without arms (1 week). documented in the heath record. Communication regarding
5. Independent sit-to-stand from toilet (1 week). progress being made toward treatment goals occurred at
6. Independent transfers to/from wheel chair (1 week). team meetings and through weekly documented progress
reports. Reexamination occurred at discharge, and at the
7. Independent wheelchair propulsion using upper extrem-
completion of outpatient programming.
ities (1 week).
8. Independent sit-to-stand from sofa height, compliant
surface (2 weeks)
Patient-/Client-Related Instructions
9. Transfer to/from car with supervision (3 weeks). Mr. Julep and his family received information about the
proposed plan for inpatient care and the discharge plan. They
10. Independent ambulation with walker in rehabilitation
were provided information by various team members about
facility (3 weeks).
prevention of stroke recurrence and management of Type
11. Walk with single point cane and supervision (3 weeks). 2 diabetes. Team members discussed the information with
12. Walk for a continuous distance of ≥ 300 meters with Mr. Julep and his family and answered any questions arising
single-point cane (4 weeks). from discussions. Support was provided by the team for Mr.
13. Transfer up from floor to standing and/or sitting with Julep’s family.
minimal contact assistance of 1 (4 weeks). In collaboration with the physical therapist, the OT pro-
14. Ascend/descend a set of 5 stairs independently using vided Mr. Julep, his wife, and his daughter written instruc-
railing on right (4 weeks). tions and diagrams of upper extremity reach and grasp
510 Chapter 12
activities on a table-top surface that could be practiced • Trunk extension
outside of formal treatment sessions. Physical therapy was ◦ Position: Prone lying, elbows bent, palms down,
responsible for teaching the wife and daughter how to assist hands positioned just ahead of shoulders
with safe ambulation. The patient and his family were also
provided written instructions and diagrams for completion ◦ Activity: partial pushup with pelvis remaining on
of bed mobility tasks, sit to stand, transfers to/from wheel- treatment mat (part of task of moving from floor ↔
chair, and lower extremity stretching exercises that Mr. Julep sitting or standing).
was to perform independently at least once each day. ◦ Note: Discontinue if back pain worsens
Mr. Julep was encouraged by OT and physical therapy to • Trunk rotation
use his left arm for ADL and IADL such a brushing his hair,
turning on light switches, and holding a juice cup in his left ◦ Position: crook lying with arms outstretched in
hand while using the right hand to remove the lid. He was 90-degree horizontal abduction, palms turned up
also encouraged to use the left arm to assist with wheelchair ◦ Activity: shoulder horizontal adduction, neck and
propulsion. He was provided with a daily diary in which he trunk flexion with rotation to reach left outstretched
recorded use of the left arm. arm across body to touch palm to palm of out-
Mr. Julep, his wife and daughter received instruction in stretched right arm (similar to movement compo-
monitoring HR while walking. They also received instruc- nents of an upper body flexion strategy for rolling
tion in monitoring RPE. supine to side lying).
• Hip extension: both left and right legs
Clinician Comment Setting expectations ◦ Position 1: half kneeling with one foot forward, side
early in the rehabilitation process for some independent of body in contact with treatment mat, hand on treat-
practice and practice supervised by family was implement- ment mat for support/stability
ed to increases the total amount of intervention time per
week. Augmented task practice and exercise has been dem- ◦ Activity 1: forward weight shift with hip extension
onstrated to have a small, favorable effect on performance ◦ Position 2: forward lunge standing
of daily activities.80,81 ◦ Activity 2: forward weight shift with bilateral knee
Providing practical training to family care providers has semi-flexion
been found to decrease both burden and anxiety that these • Hamstrings stretch: both left and right legs
family members experience upon discharge to home.82
◦ Position: sitting with heel resting on foot stool; palms
Encouraging Mr. Julep to use both arms for wheelchair
stacked and resting on same knee
propulsion was intended to provide another opportunity for
Mr. Julep to use his left arm in a functional context. ◦ Activity: Hinge forward from hips to bring nose
forward over knees while keeping knee straight and
maintaining a straight trunk posture
• Calf stretch: both left and right legs
◦ Position: sitting with heel resting on foot stool; belt
Therapeutic Exercise positioned around forefoot, ends grasped in hands
Flexibility Exercises ◦ Activity: Draw toes toward knee by pulling on belt
while keeping knee straight.
Mode
Active movement, use of transition positions, passive ◦ Progress to calf stretch in forward lunge position with
stretching hands support on wall.
Duration Hamstrings and calf stretches in sitting position were
10 to 15 minutes designated for additional independent practice on a daily
Frequency basis.
Daily
Description of Intervention Clinician Comment A number of the treat-
• Trunk side flexion ment positions and exercises described above challenge
◦ Position: Elbow support side lying on each side (part muscle strength, muscle endurance and balance, in addi-
of the task of moving from side lying ↔ sitting) tion to addressing flexibility issues. Several positions used
were relevant to transitioning from one position to another,
◦ Activity: Active trunk shortening on uppermost side thus were set in a purposeful context. For example, half
causing lengthening on lowermost side by drawing kneeling is an important transition position used to move
uppermost side ear to shoulder and shoulder to hip from the floor to either sitting or standing. Forester and
while extending elbows to achieve side sitting. Young have reported that approximately 75% of individuals
in sitting, with progression to performance in standing in

with stroke fall in the 6-month period following discharge
conjunction with practice of backward postural sway.
from the hospital.83 Therefore, learning how to transition
from the floor to sitting and/or standing is an important
activity. Clinician Comment To the extent possible,
The hip flexor stretches performed in half kneeling and strengthening exercises were performed within functional
forward lunge standing both require the thigh to move contexts. To challenge standing balance and endurance,
posterior in relation to the pelvis, resulting in a trailing as well as to increase the weightbearing, support function
limb position. Achievement of a trailing limb position and of the left upper extremity, it was decided to conduct a
increased hip extension angle in terminal stance has been significant portion of the strengthening exercise program in
associated with higher walking velocity.59 standing with left hand positioned forward on a table top.
Wall support behind the patient was used initially to pro-
vide a tactile postural reference and to provide additional
Muscle Strength, Power and Endurance external support.
Training: Trunk and Lower Extremities From observation of gait characteristics and gait devia-
Mode tions, it appeared that Mr. Julep had difficulty supporting
his body weight and sustaining forward progression during
Gravity + body weight-resisted exercise, gravity + elastic-
left leg stance. Strengthening of hip and knee extensors was
resisted exercise.
targeted to assist in reducing the excessive knee flexion and
Duration
forward trunk lean observed during stance. Strengthening
~50 to 60 minutes of hip extensors as well as ankle plantar flexors was intend-
Frequency ed to increase the production of horizontal forces needed to
3 times per week propel the COM forward and create a trailing limb position
Intensity during left-leg stance.42 Strengthening of hip abductors was
The amount of resistance used and/or the number of exer- intended to enhance control of mediolateral stability and
cise repetitions were revisited at the beginning of each week. reduce contralateral pelvic drop during left leg stance.42
Progression There is evidence in the descriptive literature of associa-
The method of progression varied slightly for each exer- tions between strength of hemiparetic muscle groups and
cise. Most activities commenced with 2 sets of 8 repetitions, functional ambulation outcomes. Nadeau et al found a
progressing to 3 sets of 12. Exercises performed in standing significant relationship between hip flexor strength and
commenced with back to wall and with bilateral hand sup- natural (ie, customary) walking velocity.84 At maximal
port on table positioned in front, with progression to stand- walking velocity, significant relationships were found for
ing away from the wall with unilateral, left hand support. All both hip flexor and ankle plantar flexor strength. Kim and
strengthening exercises performed in standing commenced Eng found high correlations for plantar flexor strength with
with core abdominal muscle “setting.” both gait velocity and stair climbing.85 They found moder-
Description of Intervention ate correlations for hip flexor and knee flexor strength with
Abdominal strengthening commenced with trunk curls both gait velocity and stair climbing.
with rotation in crook lying, progressing to backward lean There is also evidence of associations between strength and
trunk curls with rotation in sitting. Hip and knee extensors the activity of sit-to-stand. Strength of knee flexors of both
were strengthened using a combination of wall squats and affected and unaffected legs has demonstrated moderate
task specific sit-to-stand practice. As a progression for both to good correlations with 5 rep sit-to-stand (STS) scores,51
wall squats and sit-to-stand, a staggered position with right and strength of knee extensors of both leg has demonstrated
foot ahead of left was used to increase required force output moderate correlations with independent performance of
from the left lower extremity. As a progression for sit-to- STS.86
stand practice, the height of the sitting surface was progres-
There is ample evidence supporting improvements in
sively lowered. Hip abductors were strengthened in standing
muscle strength with progressive resisted exercise train-
using lateral stepping to both left and right with elastic resis-
ing in individuals with stroke. However, the evidence for
tance. Strength and endurance of hip flexors was targeted
increases in strength translating to improved functional
using repetitive alternating stool step touches in standing.
outcomes is mixed.
Knee curls was performed against elastic resistance in sitting.
Mr. Julep was instructed to pull his foot back along the floor Two noncontrolled studies have suggested translation of
until the tips of the toes were directly under the knee (as per strength gains to functional outcomes. Weiss et al found
optimal foot starting position for sit-to-stand). Plantar flex- improvements in lower extremity strength, gait and bal-
ors were strengthened using bilateral heel raises in standing, ance following a high intensity lower extremity strength
progressing to unilateral, left heel raise with right leg posi- training program.87 Jorgensen et al reported improvements
tioned forward on a step stool and to practice of “push-off” in walking speed using a program that combined high inten-
in walk standing. Bilateral toe raises were initially performed sity, body weight-supported treadmill training, progressive
512 Chapter 12
Intensity
resistance strength training and aerobic exercise.88 As 3 dif-
Timely progressions in difficulty of balance requirements
ferent interventions were delivered simultaneously, it is not
possible to determine the extent to which each contributed Duration
to improved walking speed. 10 to 15 minutes of balance-specific training.
Frequency
A 2009 Cochrane review that included 4 trials of resistance
training and 9 trials using a mix of aerobic and resistance 4 to 5 times per week.
training found insufficient evidence for the beneficial
effects of strength training on walking speed or walking Clinician Comment Balance training was
tolerance.89 included as part of Mr. Julep’s intervention plan for the
A 2008 review including both randomized controlled trials purposes of reducing risk of falls, improving safety and
(RCTs) and noncontrolled studies, a mix of acute, subacute, performance of activities occurring in standing positions,
and chronic stroke populations, and interventions of either and facilitating progression to a single-point cane for
high-intensity resistance training alone or in combination ambulation.
with aerobic training, found that 9 of 11 studies reported an There is some evidence of a relationship between balance
improvement in gait speed.90 The average change in speed and functional outcomes. For example, balance has been
computed for all studies was 0.13 m/s. The average effect found to be significantly related to self-selected and maxi-
size for improved gait speed was 1.5, which is considered to mal walking velocities.84 There is also evidence of benefi-
be a substantial effect. Gains in lower extremity strength cial effects of balance training in acute stroke. Hammer et
were associated with improvements in activity limitations al found improvements in balance with physical therapy
(particularly ambulation, but also stair climb in one study interventions, reporting that interventions performed at
and chair rise in another study), and improved participa- least twice per week were required to achieve improve-
tion in 2 studies.90 ments.94 In a 2010 systematic review, Lubetzky-Vilnai and
Earlier RCTs found strong evidence for increased strength, Kartin reported moderate evidence for improved balance
but limited, inconclusive, or conflicting evidence for performance for individualized training programs in the
improved functional performance.91-93 acute stage (0 to 6 months) of stroke for those with moder-
In summary, although relationships between strength and ately severe stroke, with the results of 5 studies categorized
functional outcomes have been reported, the evidence from at level III evidence and 6 at level IV.95 The authors noted
RCTs and systematic reviews for increased strength trans- that most studies included other treatment methods in
lating to improved functional outcomes is limited. With this addition to balance training, making it difficult to deter-
in mind, careful consideration must be given to the amount mine the extent of the specific effects of balance training.
of treatment time spent performing strength training that Van de Port et al has suggested that specific balance train-
is not task specific or does not challenge other impairments ing interventions were required, noting that gait-specific
while achieving the purpose of strength training. training without balance training did not result in measur-
able improvements in balance in the study conducted.96
Balance, Coordination and Agility Training

Mode(s) Gait and Locomotion Training
Balance in quiet standing was challenged by: changing the Increasing both velocity and endurance were emphasized
size and/or shape of the BOS (eg, stand with feet together, in Mr. Julep’s gait training program.
tandem stand); changing/reducing sensory feedback (eg, eyes Modes
closed, stand on foam) and by combining these changes. Both treadmill and overground training were used.
Dynamic standing balance was challenged in a variety of Duration
ways: The amount of time spent walking progressed to an aver-
• Using standing positions for most strengthening exer- age of 30 minutes per day over the course of inpatient reha-
cises. bilitation. This average included aerobic training activities
• Practicing ankle, hip and stepping postural motor strate- 2 days per week.
gies using internally and externally generated displacing Frequency
forces of varying directions, amplitudes and velocities. Daily
Balance and agility were challenged using an obstacle Description of Intervention
course that required changing direction, turning, stepping Partial body weight support of 25% was used for the first
around and over obstacles, and stepping backward while week of treadmill training only. Intermittent verbal cues and
walking, as well as by walking in environments with mov- assistance were provided to increase ankle dorsiflexion in
ing obstacles. Balance was also challenged by progressing to swing and at initial contact, knee extension at initial contact,
dual task activities (eg, walking while carrying a grocery bag, as well as left hip extension and left ankle plantarflexion in
while holding a grandchild’s hand). terminal stance when walking on the treadmill. Treadmill
speed was progressively increased (see aerobic exercise train- Intensity

ing for more details). Warm-up and cool down were performed at an RPE of
Overground training included progression to single- 9 to 10/20.
point cane, use of a walking grid to enhance gait symmetry, Training commenced with an RPE of 11 to 12/20, pro-
obstacle course work, practice in avoiding moving obsta- gressing to an RPE of 13 over the course of inpatient reha-
cles, walking outdoors on uneven surfaces, and dual-task bilitation. Walking overground progressed to ≥ 1.5 km/
practice. hour. Walking on the treadmill commenced at a velocity of
~1.5 km/hr and progressed to ≥ 2 km/hour.
Clinician Comment The ability to walk is Duration
an important factor in determining discharge destination A duration of 16 minutes was used initially (6 min walk
after stroke97 and is typically identified by patients as the overground, rest/stretch, 5 min walk on treadmill, rest/
goal of highest priority. Walking performance is affected by review activity diary, 5 min walk on treadmill), progressing
motor control, cardiorespiratory fitness, dynamic balance to a total of 30 minutes at time to discharge to outpatient
and, possibly, muscle strength.98 All were addressed in the program.
development and delivery of Mr. Julep’s treatment plan. Frequency
The amount of gait training and the methods of training 2 times per week.
used addressed a number of the principles of experience-
dependent neural plasticity described by Kleim and Jones Clinician Comment As indicated in Chapter
(2008), including: use it and improve it, specificity, repeti- 12, fast walking over ground and treadmill walking are
tion matters, intensity matters, and salience matters.99 considered the most effective methods of aerobic training
One of the advantages of including treadmill training as post-stroke. Both are task specific and have been found
part of a gait training program is the ability to “ force” to also improve walking performance.89,102 The repeti-
increases in gait velocity in a safe environment. Although tive nature and task specificity inherent in the methods
partial body weight support increases safety, there are of endurance training chosen were expected to facilitate
concerns that it also reduces the work of treadmill walking. activity-dependent neural plasticity (see previous discus-
To ensure that work load was sufficient to increase aerobic sion about gait training).
fitness, partial body weight support was discontinued after The goal of endurance training is to improve aerobic fitness
the first week of treadmill training. in the hopes of reducing the energy cost of ADL,7 there-
In a recently published study, body-weight support tread- by increasing levels of activity and social participation.
mill training, whether instituted 2 or 6 months following Specific inclusion of endurance training in a rehabilitation
stroke, did not result in better walking outcomes at 1 year program is needed because other components of the reha-
post-stroke than a progressive home exercise program man- bilitation program may not be sufficiently intense to cause
aged by a physical therapist.100 At this point, it is not known an aerobic training effect.70
if earlier introduction of treadmill walking, as occurred in There is evidence of improved peak O2 consumption and
Mr. Julep’s case, using minimal body weight support, would peak workload with aerobic training regardless of stage
produce superior outcomes than other forms of gait training of stroke102 and regardless of significant comorbidity.103
in the longer term. There is also evidence of decreased submaximal energy
expenditure in chronic stroke populations with endurance
training.104 A Cochrane systematic review found sufficient
Aerobic Capacity/Endurance evidence to support the inclusion of cardio-respiratory
Conditioning or Reconditioning training involving walking in post-stroke rehabilitation.89
Mode Other benefits of endurance training that have been report-
Both fast overground walking and treadmill walking were ed in stroke populations include: reduced risk of future
used for aerobic training. A temporary dorsiflexion assist cardiovascular events,103,105 improved management of
device, fashioned using a tensor bandage,101 was used during diabetes by enhancing glucose regulation,106 reduced body
initial aerobic training sessions on the treadmill to prevent weight, and improved body composition.103
toe drag. Interval training was used initially. Walking veloci-
Maintaining a regular endurance training program after
ty and distance were recorded at each training session. Warm
discharge from rehabilitation care will be needed to achieve/
up and cool down for each training session involved walking
maintain optimal effects.7 As stated in Chapter 12, the
at customary (ie, natural) walking velocity.
greatest benefits are achieved with programs lasting longer
Safety: A training bout was to be discontinued if HR than 12 weeks. It will be important to encourage Mr. Julep
exceeded 110 bpm, systolic BP exceeded 220 mm Hg or dia- to maintain aerobic training using overground walking
stolic BP exceeded 115. HR, BP, and level of perceived exer- after discharge from rehabilitation programming.
tion were monitored during endurance training.
514 Chapter 12
part practice of flexion-momentum combined with momen-
Because Mr. Julep had not undergone a graded exercise
tum transfer, both of which were followed immediately by
test with EKG monitoring, and because he might have been
whole practice of the task.
at risk for exertion-related adverse cardiac complications
Practice of vertical transfers began with a floor ↔ sitting
related to coronary artery disease, it was decided to com-
transfer, using side sitting, 4-point kneeling, 2-point kneel-
mence with lighter-intensity exercise with gradual progres-
ing and half kneeling (with right leg forward) as transition
sion. Mr. Julep was educated as to symptoms of cardiac
positions. Practice was performed with Mr. Julep’s right side
distress and the need to stop if these occurred. A guideline of
next to chair/bed. Practice progressed to floor ↔ standing
~75% of predicted heart rate maximum [(220 – age) × 0.75]
transfers.
was chosen as the HR at which a training bout would be
discontinued. The upper limit for systolic BP was set below
the values of 250 mm Hg recommended for termination of Clinician Comment A force control strategy42
graded exercise testing in stroke populations.7 for lie-to-sit was used initially, as it was possible to com-
Choosing an initial target velocity for overground aerobic plete independently despite poor/fair abdominal muscle
training was based on Mr. Julep’s velocity score on the strength. Practice from both left and right side lying was
10-meter walk test. Goal velocities for both training meth- included. During practice, use of the left upper extremity to
ods were chosen based on functional gait classifications (see assist in supporting and moving the axial body, and trunk
Chapter 12). Sullivan et al suggest training at faster veloci- side flexion were facilitated as needed and were empha-
ties on a treadmill improves walking more than training at sized in instruction that proceeded practice. Performance
slower velocities.107 In that study, average training velocity was progressed to an asymmetrical momentum strategy101
was ~2 mph, which is approximately 3 km/hr. Overground in order to reduce the time required to complete the task of
walking velocity was expected to change substantially rising to sitting.
when Mr. Julep began using a single-point cane instead of
a walker. It was anticipated that he would be able to walk
faster on the treadmill than when walking over ground with Prescription, Application of Devices and
the walker or when walking with the cane. Equipment
Mr. Julep progressed from walking with a front-wheeled
walker to walking with a single-point cane.
Functional Training for Home, Community
and Leisure Reintegration Including
Instrumental Activities of Daily Living Clinician Comment A walker enhances safety
when walking, as it provides a substantial increase to the
Task-specific skill training in physical therapy sessions
size of the base of support. However, it increases metabolic
included practice of gait activities (already discussed), as
demands, interferes with postural motor stepping strategies
well as bed mobility, sit-to-stand, transfers (horizontal and
used to regain balance, decreases step lengths, and decreas-
vertical), and management of stairs. The objectives of task-
es walking velocity (Brown, Chapter 12). In addition, it is
specific skill training involving these mobility tasks were
cumbersome Using a cane allows for less limitation in com-
to improve both efficiency and independence. ADL were
munity ambulation activities.
addressed in OT treatment sessions.
Motor learning principles were applied, including ran-
dom order of task practice, delayed feedback, intermittent
feedback, and a focus on knowledge of results. Transfer of
learning was addressed with practice under environmental
REEXAMINATION (4 WEEKS)
conditions that would be encountered at home. For example,
Mr. Julep’s progress was monitored regularly and reported
STS was practiced from progressively lower height sitting
in health record progress notes. Full reexaminations occurred
surfaces and compliant sitting surfaces to simulate stand-up
at 4 weeks (discharge from inpatient programming), and
from a sofa. STS was also practiced while holding objects of
again at 8 weeks (discharge from outpatient programming).
various weights and sizes.
Reassessment reports were documented separately from
Practice of lying ↔ sitting commenced with a force
progress notes in the health record.
control strategy.42 Practice progressed to an asymmetrical
momentum strategy for rising to sitting, coming up over the
left side, as this is the side on which he would get out of bed Subjective
at home. Mr. Julep reported that he was using his left arm more
Initial practice of STS emphasized repositioning on sitting when dressing, grooming, and eating. He reported feeling
surface and foot positioning for optimal starting position. safe walking with the front-wheeled walker and that he was
It included part practice of the flexion-momentum phase, walking the distance from his room to the dining room by
(emphasizing symmetrical horizontal transfer of the COM), himself without stopping to rest. However, he did not yet
feel safe walking alone with a single-point cane. Mr. Julep

improved strength for all extremity segments tested, the
reported feeling less tired than when he was first admitted to
Motricity Index did not capture all of these. It may have
the rehabilitation program.
been beneficial to use a hand-held dynamometer (as
He was very excited about returning home to live. suggested by Brown, Chapter 12) for testing movements
included in the Motricity Index. A dynamometer would
Objective have generated ratio level data, which may have indicated
improvements in strength that were not captured by the
Cognitive Status Motricity Index. However, there would be some question as
Mr. Julep’s MMSE score was unchanged at time of reex- to whether small gains in force production would have been
amination (25/30). clinically significant.
Pain/Posture
Mr. Julep rated his back pain as 4 to 5/10 on the Visual Motor Function (Motor Control and Motor
Analog Scale (VAS). Less postural asymmetry was observed
Learning)
in sitting and standing. He was able to achieve a neutral
lumbar lordosis and pelvic tilt position in sitting with verbal Chedoke-McMaster Stroke Assessment Impairment
cueing. A very slight forward trunk lean was observed in Inventory: Stage of Recovery of Arm and Leg: On reassess-
standing, but Mr. Julep is now able to maintain hip and knee ment, the left arm and hand presented with stages 4 and 5 of
at 0 degrees when standing. recovery respectively, and the left leg and foot presented with
stages 6 and 5 respectively, all demonstrating improvement
Range of Motion (Including Muscle by 1 stage.
Lengths)
Gait, Locomotion and Balance
Trunk side flexion range of motion had increased to
25 degrees to the left and 20 degrees to the right. Combined Chedoke-McMaster Stroke
neck and trunk rotation had increased slightly to the right Assessment: Disability Inventory
and was 75 degrees to both left and right sides at time of Mr. Julep’s total score increased from 54/100 on initial
reexamination. assessment to 75/100, a change that was greater than the
Hip extension range of motion had increased to 5 degrees reported MCID for this measure (see Tests and Measures
on the left. SLR had increased to 60 degrees bilaterally. Ankle Section).
dorsiflexion on the left, with knee extended, had increased Modified Emory Ambulation Profile
to 0 degrees.
At time of discharge, Mr. Julep used a single-point cane,
Left shoulder ROM for external rotation had increased to
rather than a walker when completing the tasks included in
70 degrees, left forearm supination remained at 75 degrees,
the mEAP. Close supervision was required during perfor-
and left thumb range of motion had improved, although
mance of the obstacles task.
ranges were still slightly less than those for the right thumb.
1. Walk on floor: 20.2 × 2 = 40.4
Upon reexamination, spasticity was found to have gener-
ally decreased to grade 1, except for the left ankle plantar 2. Walk on carpet: 25.6 × 2 = 51.2
flexors, which remained at grade 2. Unsustained clonus at 3. Timed Up & Go: 46.6 × 2 = 93.2
left ankle continued to be demonstrated. 4. Obstacles: 65.5 × 2 = 131
Sensory and Perceptual Integrity 5. Stairs: 58.1 × 2 = 116.2
Mr. Julep now describes light touch as feeling the same on Summed score = 432. This score was substantially lower
left and right extremities. than the initial summed score of 1032.4. Much of the reduc-
tion could be attributed to the change in type of assistive
Muscle Performance
walking device.
Motricity Index scores had improved slightly: upper
Customary Walking Velocity
extremity 70/100, lower extremity 75/100. Individual items
scores that had changed included: elbow flexion of 25, shoul- Measured while walking with a single-point cane was
der abduction of 19, and ankle dorsiflexion of 25. 0.56 m/sec, a substantial improvement over his initial walk-
5 Timed STS: The time to complete the test improved to ing velocity with the walker of 0.31 m/sec.
16.9 sec from the initial time of 20.6 sec.
Clinician Comment Brown (Chapter 12) sug-
Clinician Comment In order to achieve a full gested that an increase of 0.16 m/sec likely produces
score for any item on the Motricity Index, normal power a meaningful improvement in participation. With this
(ie, equal to the strength of the nonhemiplegic extremity change in walking velocity, Mr. Julep is more likely to
segment) is required. Although there were indications of engage in walking in the community.
516 Chapter 12
BBG 4 weeks. Walking a continuous distance of ≥ 300 meters with
Mr. Julep’s score improved to 42/56 from the initial score a single-point cane was not achieved at 4 weeks, but ascend-
of 34/56. ing/descending stairs independently using a railing was.
Task-specific training, along with improvements in bal-
Postural Motor Stepping Strategies ance, motor control (particularly the lower extremity), and
When externally generated displacing forces (of sufficient flexibility contributed to accomplishing treatment goals that
amplitude to elicit stepping postural motor strategies) were were achieved.
applied in a controlled environment, Mr. Julep demonstrated
sufficient response time and amplitude of responses with the
right leg to regain balance. However, when forced to step with
Discharge
the left leg instead, responses were insufficient to regain bal- Mr. Julep was successfully discharged home to live with his
ance in lateral and posterior directions. wife and family. He attended 2, 60-minute outpatient treat-
Aerobic Capacity ment sessions for 4 weeks, missing only 1 session due to a cold.
Mr. Julep was provided with a 30- to 45-minute home
6MWT distance at time of discharge was 252 m, as com-
program of stretching and strengthening exercises. These
pared to 120.6 m at admission. The change in score exceeded
were reviewed with Mr. Julep and his wife. This program
the MDC of 54.1 m (see Tests and Measures Section).
was to be completed 3 times each week, on the weekdays on
Mr. Julep’s FSS score at time of discharge was 5.2, as which he was not attending outpatient programming. An
compared to 5.4 at time of admission which is greater than exercise diary was provided in which Mr. Julep could record
the MDC reported for this measure (reported in Tests and the number of times/week the exercises were completed and
Measures Section). the number of repetitions and sets completed. Mr. Julep was
instructed to walk indoors/outdoors for 20 to 30 minutes
Clinician Comment As training effects are 2 times each week. He was asked to record his RPE for each
believed to take 8 to 12 weeks to achieve maximum benefit, walk completed, along with the date, in the exercise diary. He
a good portion of the improvement in distance walked may was also encouraged to attend the stroke group exercise pro-
be attributed to the change from a walker to a cane and, gram that ran 2 days per week at a public recreation facility.
possibly, to improvements in motor control and balance. It was planned that Mr. Julep would walk on the treadmill
for 25 to 30 minutes during each outpatient visit. The remain-
der of his outpatient treatment time would be spent in review/
Self-Care and Home Management, revision of strength training and flexibility exercises as nec-
Including Activities of Daily Living and essary, progression of balance and gait training activities, as
Instrumental Activities of Daily Living well as continued practice of rising from the floor to standing.
Mr. Julep’s total FIM score at time of discharge was 106.
His motor sub-score had increased by 8 points to 78/91. His
social-cognitive sub-score had not changed. OUTCOME (END OF
Assessment OUTPATIENT PROGRAM, 8 WEEKS)
Improvements in primary and secondary impairments On reexamination at 8 weeks, Mr. Julep had improved
were achieved. In addition, gains were made in the perfor- his Motricity Index score for shoulder abduction to 25 and
mance of mobility tasks, including ambulation. Edema of his Chedoke-McMaster Inventory stage of recovery for the
left hand had resolved, but there was still mild edema of the arm to 5. His STS time decreased to 15.8 sec. His BBS score
left foot and ankle. There had been no change in the size increased to 45/56. When forced to step with the left leg in
of the abrasion on the left ankle. Blood sugar levels were response to large displacements of his COM, his postural
stable and well controlled at time of discharge from inpatient motor stepping strategy was sufficient to regain balance
rehabilitation. Mr. Julep lost 6 pounds during his inpatient in a lateral direction, but not in a posterior direction. His
rehabilitation stay. Chedoke-McMaster Stroke Assessment: Disability Inventory
Of the 7 goals anticipated to be met within 1 week, all score had increased to 80/100 and his customary walking
were met except for independent STS from toilet, which velocity (with single-point cane) had increased to .6 m/sec.
was met within 2 weeks. Independent STS from sofa was Mr. Julep met the goal of walking for a continuous dis-
achieved in 3 weeks, rather than in 2 weeks. Independent tance of 300 meters at 5 weeks and 500 meters at 8 weeks.
ambulation with the walker, supervised transfers to/from He was walking independently with a straight cane indoors
car, and supervised walking with a single-point cane were by 8 weeks, and outdoors with supervision by 8 weeks. He
achieved in the suggested 3-week time frame. Transfer up was able to maintain his balance when casting a fishing rod
from floor to sitting with minimal contact assistance was with the right arm and when hoeing a small garden patch at
achieved in 4 weeks, but transfer up to standing directly 8 weeks, but required supervision for both activities because
from the floor continued to require moderate assistance at of decreased balance confidence.
24. Hankey GJ, Jamrozik K, Broadhurst RJ, Forbes S, Anderson CS.
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Rehabil. 2004;18:27-39. ness is the cardinal impairment in ALS, the type and
94. Hammer A, Nilsagard Y, Wallquist M. Balance training in stroke
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a systematic review. Am J Phys Med Rehabil. 2007;86(11):935-951. and stage of the disease. Typically at disease onset, signs or
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Gait pattern in the early recovery period after stroke. J Bone Joint disease leads to increasing numbers and severity of impair-
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manner. This means signs and symptoms spread from
to promote optimization of walking recovery after stroke. Stroke
Res Treat. 2011;2011:601416. one focal region (eg, bulbar in the case of Mrs. Jelly) to an
99. Kleim JA, Jones TA. Principles of experience-dependent neu- anatomically adjacent area (eg, cervical in the case of Mrs.
ral plasticity: Implications for rehabilitation after brain damage. Jelly).
J Speech Lang Hear Res. 2008;51(1):S225-S239.
100. Duncan PW, Sullivan KJ, Behrman A, et al. Body-weight-supported
Bulbar-onset ALS is seen in 20% to 25% of cases. The term
treadmill rehabilitation after stroke. N Engl J Med. 2011;364:2026- bulbar-onset indicates involvement of motor nuclei of the
2036. cranial nerves IX, X, XI, XII or degeneration of the corti-
101. Davies PM. Steps to Follow: A Guide to the Treatment of Adult cobulbar tract, resulting in muscle weakness and wasting of
Hemiplegia. Berlin: Springer-Verlag; 1985. the tongue, pharynx, larynx, and soft palate. Bulbar-onset
102. Pang MYC, Eng JJ, Dawson AS, Gylfadóttir S. The use of aerobic
exercise training in improving aerobic capacity in individuals with
ALS occurs more frequently in middle-aged women, and
stroke: a meta-analysis. Clin Rehabil. 2006;20(2):97-111. initial symptoms include difficulty chewing, swallowing,
103. Rimmer JH, Rauworth AE, Wang EC, Nicola TL, Hill B. A and speaking.1,2
preliminary study to examine the effects of aerobic and thera-
peutic (nonaerobic) exercises on cardiorespiratory fitness and
coronary risk reduction in stroke survivors. Arch Phys Med Rehabil.
2009;90(3):407-412. History of Current Complaint
104. Macko RF, DeSouza CA, Tretter LD, et al. Treadmill aerobic exer- About 1 month prior to her initial physical therapy
cise training reduces the energy expenditure and cardiovascular
demands of hemiparetic gait in chronic stroke patients: a prelimi-
appointment, Mrs. Jelly noticed that the back of her neck and
nary report. Stroke. 1997;82:879-884. her upper shoulders were quite sore by the end of a work day.
105. Hambrecht R, Wolf A, Gielen S, et al. Effect of exercise on coronary Mrs. Jelly reported the pain was present throughout the day,
endothelial function in patients with coronary artery disease. N but she tried to ignore it. By the end of the day, however, the
Engl J Med. 2000;342(7):454-460. pain (“aching pain”) was quite severe. Mrs. Jelly also noticed
106. Franklin BA, Sanders W. Reducing the risk of heart disease and
stroke. Phys Sportsmed. 2000;28(10):19-26.
that her head “felt heavy” by the end of the day. Mrs. Jelly
107. Sullivan KJ, Brown DA, Klassen T, et al. Effects of task-specific often had difficulty finding a comfortable position for sleep-
locomotor and strength training in adults who were ambulatory ing. She reported that she woke frequently during the night,
after stroke: results of the STEPS randomized clinical trial. Phys and often woke up with a headache.
Ther. 2007;87(12):1580-1602.
Clinician Comment People with ALS typi-

CASE STUDY 12-2 cally develop cervical extensor muscle weakness, initially.
Early symptoms of cervical weakness includes neck stiff-
ness, heaviness, and fatigue with holding the head up or
Vanina Dal Bello-Haas, PT, PhD difficulties in keeping the head upright with unexpected
movements (eg, in an accelerating car).3,4
Although the poor sleep and early morning headaches
EXAMINATION may be related to neck pain, respiratory muscles may also
be weak. Early signs and symptoms of respiratory muscle
History weakness include fatigue, dyspnea on exertion, difficulty
sleeping in supine, frequent awakening at night, exces-
Current Condition/Chief Complaint sive daytime sleepiness, and morning headaches due to
hypoxia.5 People with ALS may not complain of respira-
Mrs. Jelly was a 59-year-old White woman with a diagno-
tory symptoms initially, because they tend to decrease their
sis of bulbar-onset amyotrophic lateral sclerosis (ALS). Mrs.
overall level of physical activity due to fatigue or increasing
Jelly was experiencing neck pain.
muscle weakness.
520 Chapter 12
Clinician Comment More than 90% of cases
Mrs. Jelly lived in a condominium with her husband of of ALS are classified as sporadic (ie, no clear family history),
30 years. Mr. Jelly had a stroke affecting his left side 5 years and the cause of sporadic ALS is unknown. The remaining
prior, was independent in activities of daily living (ADL) and 5% to 10% are classified as familial ALS (FALS), which is
instrumental ADL (IADL), but used a motorized wheelchair transmitted as an autosomal dominant disease.6,7 About
for mobility. Mr. Jelly did not work. The Jellys had 3 adult 15% to 20% of people with FALS (ie, about 1% of all patients
children: 2 who lived in a different state and a third who lived with ALS) have a mutation in the gene encoding an enzyme
in Asia. Mrs. Jelly reported that she had a strong support called copper-zinc superoxide dismutase.8
network of friends and coworkers.
Employment/Work (Job/School/Play)
Mrs. Jelly was an administrative assistant at a local uni- Medical/Surgical History
versity. Mrs. Jelly was very concerned about her ability to Mrs. Jelly was diagnosed with bulbar-onset ALS 11 months
continue to work because of increasing difficulty she was prior to the initial physical therapy appointment. About
experiencing with her speech. In particular, Mrs. Jelly was 6 months prior to her diagnosis, Mrs. Jelly noticed that she
concerned about losing her health benefits. was having difficulty pronouncing certain words. She also
noted that she began to choke when drinking coffee or water.
Clinician Comment The financial realities of This progressed to difficulty chewing and swallowing. On
living with ALS and trying to navigate the health care and physical exam, tongue fasciculations and a brisk jaw reflex
reimbursement systems can be daunting and overwhelm- were noted. Diagnostic tests ruled out any other conditions
ing. Individuals should be referred to a social worker as that may have accounted for signs and symptoms. An elec-
early as possible. The usual 24-month waiting period for tromyography (EMG) determined active denervation of the
Medicare was eliminated for Social Security Disability left hand and chronic denervation of the thorax. Mrs. Jelly
Insurance (SSDI) recipients disabled by ALS as a result was diagnosed with clinically probable ALS with laboratory
of extensive lobbying of Congress by The ALS Association support. Mrs. Jelly had no other medical problems. Past sur-
(ALSA). gical history included a tonsillectomy at age 10.
Clinician Comment ALS diagnosis is one of

Social/Health Habits exclusion, eg, neuroimaging and clinical laboratory studies
Mrs. Jelly was a nonsmoker and drank alcohol only on are performed and other all other diagnoses that might be
social occasions. Mrs. Jelly walked daily during her lunch the cause of signs and symptoms must be excluded. The El
hour with a colleague—she aimed to walk 30 to 45 minutes Escorial criteria, widely accepted criteria used for the diag-
per day, 5 days per week. Mrs. Jelly reported that she “greatly nosis of ALS for clinical practice, therapeutic trials, and
treasures the daily walks,” as this was an opportunity for her other research purposes, classifies ALS into “clinically defi-
to chat with her colleague about personal and work issues. nite,” “clinically probable,” “clinically probable with labora-
Mrs. Jelly was finding that on some days her walks were tory support,” and “ possible” categories.9 More information
taking her longer to complete and that sometimes she had to can be found online at http://www.alsa.org/assets/pdfs/fyi/
stop because of leg cramps. criteria_for_diagnosis.pdf.
A criticism of the El Escorial criteria is that they favor
clinical signs over electrodiagnostic findings, reducing sen-
Clinician Comment The etiology of muscle sitivity. Recently developed Awaji-shima criteria10 allow
cramping is not well understood. Muscle cramps are for electrophysiological evidence of LMN to be considered
thought to be related to hyperexcitability of motor axons, as equivalent to clinical signs. This makes the category of
and in people with ALS, cramps occur in uncommon sites “clinically probable ALS with laboratory-support” redun-
such as the tongue, jaw, neck, abdomen, as well as in more dant since all categories of the Awaji-shima criteria include
typical sites.3 evidence from electrodiagnostic findings.
The Awaji-shima criteria10 are as follows:
(i) Clinically definite ALS: clinical or electrophysiological
Family History
evidence of LMN and UMN signs in the bulbar region
Mrs. Jelly’s family history was negative for ALS. Her par- and at least 2 spinal regions, or the presence of LMN
ents both died of natural causes in their late 80s. Mrs. Jelly and UMN in 3 spinal regions.
had 2 younger brothers, one aged 38 and the other aged 45.
(ii) Clinically probable ALS: clinical or electrophysiologi-
She had a maternal cousin who was diagnosed with multiple
cal evidence of LMN and UMN in at least 2 regions,
sclerosis (MS) at the age of 45.
with some UMN signs necessarily rostral to the LMN the progression of her ALS. Based on the physical therapy
signs. interview, the other health care professionals who should
(iii) Clinically possible ALS: clinical or electrophysiological be involved with her care, in addition to her neurologist,
signs of LMN and UMN signs in 1 region; or UMN include: a speech-language pathologist, a registered dieti-
signs are found alone in 2 or more regions; or LMN cian, a social worker, an occupational therapist. The roles
signs are found rostral to UMN signs. for each of these practitioners will be presented in more
detail in the plan of care.

Prior to the diagnosis of ALS, Mrs. Jelly was very active. Systems Review
As noted previously, she walked daily. Mrs. Jelly had been
very active in several volunteer organizations, including par-
ticipating in overseas missions, but was no longer involved • Heart rate (HR) = 88
because she was embarrassed about her speech and fatigued • Blood pressure (BP) = 129/70
by the end of most work days. At the time of the initial
physical therapy appointment, Mrs. Jelly did not need any • Respiratory rate (RR)= 18
assistance for ADL or IADL. Depending on the day, however, • Oxygen saturation was 92% on room air
she noted that having to complete additional activities in • No accessory muscle use evident in sitting
the evening could be fatiguing. She also noted that she was
slower in completing tasks. Musculoskeletal
Medications Fasciculations were noted in the neck musculature, upper
chest, and left hand. Slight atrophy of the left anatomical
Mrs. Jelly was taking Rilutek (riluzole). In addition, she
snuff area was noted.
took calcium with vitamin D, vitamin E, vitamin C, and
coenzyme Q10(CoQ10). Mrs. Jelly reported no allergies.
Clinician Comment Fasciculations are com-
mon in individuals with ALS, although they are rarely an
Clinician Comment There is no cure for ALS, initial symptom. The etiology of fasciculations remains
and clinical trials of medications for reducing mortality unclear and is thought to be related to hyperexcitability of
and treating symptoms of ALS are ongoing. motor axons.3
Rilutek is the only Food and Drug Administration (FDA)-
approved medication to treat ALS. Riluzole is a glutamate
inhibitor. Studies have found that the drug delays disease Anthropometrics
progression modestly, extending survival for about 2 to
4 months. Although usually well tolerated, adverse effects • Height = 167.6 cm (5 feet, 6 inches)
include asthenia, nausea, vomiting, dizziness, liver toxicity, • Weight = 52.3 kg (115 pounds)
and neutropenia.11,12
• Body mass index (BMI) = 18.6
Medical management of ALS is symptomatic and there
are many medications and interventions that are used to
treat symptoms. Practice guidelines for the management Clinician Comment As nutrition status has
of ALS13,14 have been published and can be found online been identified as a prognostic factor for survival and
at http://www.neurology.org/content/73/15/1218.full.html. disease complications,16 careful attention to nutrition and
hydration is required.
As Mrs. Jelly is postmenopausal, calcium with vitamin D is
being taken to prevent bone loss. People with bulbar muscle weakness will have difficulty
chewing, swallowing, and manipulating food inside the
The oxidative stress/free-radical damage hypothesis con-
mouth or moving food into the esophagus. They may take
tributes to the theory that “high-dose” antioxidants may
in less than optimal fluid and caloric needs, which results
be beneficial for people with ALS. To date, there is no
in weight loss. Although, some weight loss can be expected
evidence of beneficial effects in humans. CoQ10 is a com-
due to loss of muscle mass as the disease progresses, exces-
ponent of the respiratory chain of mitochondria. Normally,
sive weight loss is more indicative of inadequate nutritional
CoQ10 acts both as an electron carrier and as a potent
intake. Laboratory blood counts and chemistries would
antioxidant.15
confirm signs of dehydration and undernourishment. BMI
Mrs. Jelly’s interview revealed that she had neck pain, pro- confirms a registered dietician should be involved in overall
gressive speech difficulties and muscle weakness, symptoms management of Mrs. Jelly.
of respiratory muscle weakness, fatigue, and concerns about
522 Chapter 12
Integumentary ALS disease spectrum. ALS-associated FTD signs include:
• Skin integrity = No integumentary abnormalities were cognitive decline, executive functioning impairments, dif-
noted. ficulties with planning, organization and concept abstrac-
tion, and personality and behavior changes. Individuals
Clinician Comment Skin integrity is usually with ALS, without FTD, can have difficulties with verbal
not compromised in people with ALS, even in the late stage fluency, language comprehension, memory, abstract rea-
of the disease, because sensation is normally preserved. soning, and generalized impairments in intellectual func-
However, skin inspection should be performed regularly, tion.17-19 People with bulbar-onset ALS are more likely to
especially when the patient becomes immobile. Pay particu- have cognitive impairments than patients with limb-onset
lar attention to contact points between the body and assis- disease.20 Clinicians should screen for cognitive impair-
tive, adaptive, orthotic, protective and supportive devices, ments. No ALS-specific cognitive test or measure exists. The
mobility devices, and resting and sleeping surfaces. Mini-Mental State Examination (MMSE)21 has been used
in clinical studies; however, it may not be sensitive enough to
identify frontotemporal function impairments. If dementia
or cognitive impairments are suspected, executive function,
Musculoskeletal language comprehension, memory, and abstract reasoning
• Gross symmetry/posture: Overall, Mrs. Jelly’s sitting should be examined and referrals to appropriate health care
posture was slumped throughout the interview. Mrs. professionals may be warranted (eg, neuropsychologist).22
Jelly occasionally rested her chin on her fist. When Living with ALS, a devastating disease with no cure, and
prompted, Mrs. Jelly was able to correct her posture. experiencing loss after loss as the disease progresses can
• Gross range of motion (ROM)/strength: Cervical spine result in psychological impairments, such as depression or
ROM was within normal limits (WNL). Mrs. Jelly lacked anxiety. Depression can interfere with sleep, cause fatigue,
some eccentric control when moving the head into full and greatly affect a person’s quality of life, as well as alter
flexion. one’s ability to cope with, and adapt to, the progressive
◦ Lower and upper extremity ROM and gross muscle changes and losses of the disease. Clinicians should screen
strength was WNL. Strength testing of quadriceps for depression and make the appropriate referral for further
muscles brought on muscle cramping bilaterally. assessment and management, eg, psychologist (psychologi-
cal counseling), psychiatrist or neurologist (medications).
◦ Mrs. Jelly was able to perform sit-to-stand with arms
Mrs. Jelly’s systems review indicated low BMI, which was
folded with no difficulty.
likely an indicator of progressive dysphagia. She reported
◦ Mrs. Jelly was able to walk a distance of 5 meters on cervical pain. Altered posture was observed throughout the
her tip-toes and on her heels. interview. Based on the findings from the systems review,
Neuromuscular screening for depression and further assessment of muscle
strength, especially hand strength, were warranted.
No impairments were noted in locomotion, transfers,
or transitions. No gait abnormalities were noted during
locomotion.
Tests and Measures
Language, and Learning Style: Pain
Mrs. Jelly slurred her words and occasionally had to repeat Mrs. Jelly rated her neck pain as 8 to 9/10 (at its worst)
herself to be understood. She had a flat affective. Mrs. Jelly using the 10-point visual analog scale (VAS), and described
answered questions appropriately and could follow 3-step it as “aching.” The pain is 4/10 in the morning upon waking
commands. She reported she preferred to have information and progresses to 8 to 9/10 by the end of the day.
presented to her in both written and verbal formats to ensure
Posture
she “doesn’t miss anything.”
Mrs. Jelly held her head forward, both the standing and
seated position. Bilateral shoulder girdles were held in a
Clinician Comment Mrs. Jelly presents with protracted position. She had a moderate increase in thoracic
a flat affect. It was not clear whether the flat affect was kyphosis. With verbal cues to correct her posture, Mrs. Jelly
due to cognitive changes or, perhaps, depression. She could, was able to hold herself more erect and could maintain this
however, answer questions appropriately and could follow position for short periods of time.
3-step commands.
Although once considered separate cognitive impairments, Clinician Comment The clinical assessment
symptoms ranging from mild deficits to severe fronto- of posture in people with ALS is largely subjective and
temporal dementia (FTD) are now considered part of the descriptive in nature.
Muscle Performance (Including Strength, Tone and Reflexes

Power and Endurance) Using the Modified Ashworth spasticity scores, Mrs. Jelly
showed 1+ for both upper extremities. She had a clonic jaw
MUSCLE GROUP GRADE reflex, hyperreflexia in both upper extremities, hyporeflexia
in both lower extremities, and a positive right Babinski reflex.
Cervical flexion 4/5
Cervical extension 3+/5
Clinician Comment The Modified Ashworth
Cervical right rotation 4+/5 Scale23 is used clinically to assess resistance to passive move-
Cervical left rotation 4+/5 ment and reflects only an aspect of spasticity. Psychometric
properties have not been tested in ALS populations. Limited
Cervical right side flexion 4+/5
reliability and lack of sensitivity exist with lower grades (eg,
Cervical left side flexion 4+/5 1, 1+, and 2).24,25 Deep tendon and pathological reflex test-
RANGE MEAN (SD)1 ing also assist in determining UMN and LMN involvement.
RIGHT* (POUNDS)
RIGHT (POUNDS)
LEFT (POUNDS)
LEFT (POUNDS)
AGE/GENDER
AGE/GENDER
MEAN (SD)23
Respiratory Function
Auscultation: normal breath sounds throughout; no
adventitious sounds
Cough: strong; effective for secretion clearance
Diaphragmatic excursion: 4 cm
Grip 55.5 33 to 86 32 31 to 76 Forced vital capacity (FVC) was assessed using a hand-
(Jamar dyna- 57.3 (12.5) 47.3 (11.9) held spirometer. Mrs. Jelly had slight difficulty maintaining
mometer) a tight lip seal on the apparatus due to orofacial weakness:
FVC = 95% predicted (sitting)
Tip pinch 11 9 to 16 7.5 8 to 13
FVC = 93% predicted (lying)
(pinch gauge) 11.7 (1.7) 10.4 (1.4)
Lateral (key) 14.5 11 to 21 10.5 12 to 19 Clinician Comment Supine FVC may be a
pinch better indicator of diaphragm weakness than erect FVC.
(pinch gauge) 15.7 (2.5) 14.7 (2.2) Monitoring of FVC or VC is important—although there is
Palmar pinch 15.5 11 to 26 10.5 11 to 21 no firm evidence, current practice guidelines suggest that
for optimal safety and efficacy the percutaneous endo-
(pinch gauge) 16.0 (3.1) 15.4 (3.0)
scopic gastrostomy (PEG) procedure should be offered to the
*Dominant side. patient and completed before the individual’s FVC/VC falls
below 50% of predicted.25
Clinician Comment Specific deficits in muscle Although Mrs. Jelly had difficulty finding a comfortable
strength can be measured with manual muscle testing position for sleeping, woke frequently during the night, and
(MMT), isokinetic muscle strength testing, or hand-held often woke with a headache, her FVC in sitting was WNL.
dynamometry. In clinical practice, MMT or hand-held Her FVC in lying did not vary much from her FVC in sitting.
dynamometry is preferred due to efficiency. As the disease
progresses, the physical therapist must weigh the emotional
and physical costs of repeated formal muscle testing against Fatigue
the benefits of what this information provides in the greater Mrs. Jelly rated her fatigue as 8/10 at its worst, which gen-
context of the individual’s overall evaluation and manage- erally occurred by the end of her work day.
ment plan. Specifically, it can be clearly evident muscles
when are wasted and limbs cannot be moved against gravity.
Clinician Comment Fatigue is very com-
Compared to a female aged 55 to 59, Mrs. Jelly’s left grip mon in individuals with ALS. As motor neurons die, the
and pinch strength was below the mean, or below, or close remaining neurons are overburdened. Weakened muscles
to, the lower end of the range. She was not complaining, must work at a higher percentage of their maximal strength
however, of activity limitations (eg, dressing) or participa- to perform the same activity, which also hastens muscle
tion restrictions (eg, work). Although premorbid grip and fatigue.26 Fatigue may also be related to sleep disturbances,
pinch values were not available, the wasting in the anatom- respiratory impairments, hypoxia, and depression. No
ic snuff and the EMG findings suggested that it was likely ALS-specific measures exist; the Fatigue Severity Scale27
that the findings in her left hand findings were due to ALS. has been used in clinical trials.
524 Chapter 12
Functional Status
AMYOTROPHIC LATERAL SCLEROSIS
Mrs. Jelly rated herself at 90% using the Schwab and
England Activities of Daily Living Scale; 90% corresponds FUNCTIONAL RATING SCALE-REVISED SCORES
to “completely independent; able to do all chores with some ITEM SCORE DESCRIPTOR
degree of slowness, difficulty, and impairment; may take
Dyspnea 4 Normal
twice as long as usual; beginning to be aware of difficulty.”
Orthopnea 4 Normal
Clinician Comment The Schwab and England Respiratory insuf- 4 Normal
Activities of Daily Living Scale28 is an 11-point global mea- ficiency
sure of functioning that asks the rater to report ADL func-
tion from 100% (normal) to 0% (vegetative functions only).
The scale has been used to examine function in individuals
with ALS, has been found to have excellent test-retest reli-
Clinician Comment The ALSFRS-R29 exam-
ines the functional status of patients with ALS. The patient
ability, to correlate well with qualitative and quantitative
is asked to rate his or her function using a scale from 4
changes in function, and to be sensitive to changes over
(normal function) to 0 (unable to attempt the task). The
time.
ALSFRS-R was expanded from the original 10-point scale
to include additional respiratory items, and has been found
to have internal consistency, construct validity, and to have
Disease-Specific Measures retained the properties of the original scale. Telephone
The ALS Functional Rating Scale-Revised was used to administration of the ALSFRS-R has also been found to be
assess Mrs. Jelly’s function and her scores appear next. reliable.30
Mrs. Jelly’s ALSFRS-R scores indicated she had bulbar func-
AMYOTROPHIC LATERAL SCLEROSIS tion and some ADL impairments, likely due to the left hand
weakness.
FUNCTIONAL RATING SCALE-REVISED SCORES
ITEM SCORE DESCRIPTOR
Psychosocial Function
Speech 3 Detectable speech
disturbance With the Beck’s Depression Inventory (BDI), Mrs. Jelly’s
score was 19, which was indicative of borderline clinical
Salivation 3 Slight but definite depression.
excess of saliva in
mouth; may have
nighttime drooling Clinician Comment The BDI31 consists of
21 items. Each item is a list of 4 statements arranged in
Swallowing 3 Early eating prob-
increasing severity about a particular symptom of depres-
lems̶occasional
sion. The BDI has been used in ALS clinical studies.
choking
Handwriting (pre- 4 Normal
ALS dominant hand)
Cutting food and 3 Somewhat slow and EVALUATION
handling utensils clumsy, but no help
(patients without needed Diagnosis
gastrostomy)
Dressing and 3 Independent and Practice Pattern
hygiene complete self- The Preferred Practice Pattern that best applied to Mrs.
care with effort or Jelly’s case was Neuromuscular Practice Pattern 5E: Impaired
decreased efficiency motor function and sensory integrity associated with pro-
Turning in bed; 3 Somewhat slow and gressive disorders of the central nervous system (CNS).
adjusting bed clumsy, but no help
clothes needed Clinician Comment Depending on the stage
Walking 4 Normal of the disease and the resultant impairments, activity
limitations and participation restrictions, several practice
Climbing stairs 4 Normal patterns may apply.
International Classification of Functioning, • Patient-/client-related instruction regarding energy con-

Disability and Health Model of Disability servation, sleep health and positioning, physical activity,
and exercise log.
See ICF model on p 526.
• A soft cervical collar to wear at work and during recre-
Prognosis ational walking.
With respect to neck pain, Mrs. Jelly’s prognosis was good. • A work environment assessment and recommendations.
It was expected that her neck pain could be relieved, at least
• A flexibility and strengthening exercise program.
in the shorter-term, with modifications to work environ-
ment, use of a cervical collar, and rest. • A revised recreational walking program.
• Referrals to other health care professionals (eg, Mrs.
Clinician Comment It is imperative that Jelly’s neurologist, a speech language pathologist, a
the physical therapist have a solid understanding of the registered dietician, a psychologist, and an occupational
nature and course of ALS in order make effective decisions therapist).
regarding the prognosis (eg, what impairments, limitations,
restrictions can be restored; what impairments, limitations, Clinician Comment Based on Mrs. Jelly’s
restrictions require compensatory strategies; and what history and presentation, the focus of physical therapy
impairments, limitations, restrictions cannot be affected by intervention for Mrs. Jelly was largely compensatory and
physical therapy interventions at all). preventive. Compensatory interventions were directed
With regard to the plan of care, management of people with toward modifying activities, tasks or the environment to
ALS is complex because of the progressive and devastat- minimize limitations and restrictions (eg, cervical col-
ing nature of the disease, and the progressive number and lar, energy conservation, work environment changes).
severity of impairments, activity limitations, participation Preventive intervention was directed toward minimizing
restrictions, and accompanying psychosocial issues that potential impairments (eg, secondary effects of immobility).
manifest. Future impairments, activity limitations, and
participation restrictions need to be considered and man-
agement needs to be planned for accordingly. Proposed Frequency and Duration of
Care requires a comprehensive and multidisciplinary Physical Therapy Visits
approach. It is clear that Mrs. Jelly would benefit from Mrs. Jelly would be scheduled for 4 physical therapy ses-
other health care professionals’ assessments and manage- sions initially with 3 sessions planned for interventions and
ment, even though she was in the earlier stages of ALS. education and 1 for reassessment. It was anticipated that as
Specialized centers or clinics that meet rigorous standards the disease progressed, Mrs. Jelly would benefit from addi-
set by the ALSA and the Muscular Dystrophy Association tional physical therapy visits.
(MDA) are considered to be the most advantageous for the
management of individuals with ALS. Research has found Anticipated Goals
that patients attending a multi-disciplinary clinic lived lon- 1. Mrs. Jelly would demonstrate understanding of, and
ger than those in the general neurology cohort.32 adhere to, use of the cervical collar (Visit #1).
The assessment a physical therapist would complete and 2. Mrs. Jelly would demonstrate understanding of, and
area of assessment foci would be determined by the physical adhere to, use of daily energy conservation techniques,
therapy setting, eg, whether the physical therapist is a mem- sleep health, and positioning (Visit #1).
ber of a multi-disciplinary clinic and what other health care 3. Mrs. Jelly would demonstrate understanding of, and
professionals are part of the team. ability to use, the Borg CR-10 Rate of Perceived Exertion
(RPE) scale33 and a physical activity and exercise log to
monitor exercise and activity effort (Visit #1).
Plan of Care 4. Mrs. Jelly would demonstrate understanding of the
rationale for and independence with a revised walking
Interventions program and flexibility and strengthening exercise pro-
Interventions identified for Mrs. Jelly included the gram (Visit #2).
following: 5. Mrs. Jelly would have a good understanding of, and
• Patient-/client-related instruction regarding her cur- adhere to, work environment modifications to decrease
rent impairments, activity limitations and participation muscle strain and fatigue (Visit #4).
restrictions, the plan of care (also provided in written 6. Mrs. Jelly’s cervical pain would decrease from 8/10 to
format), the discharge plan, and the reevaluation plan. 3/10 on the pain VAS (Visit #4).
526 Chapter 12
ICF Model of Disablement for Mrs. Jelly

Health Status
• ALS

Function
• Speech • Recreation
• Pain (neck) • Eating • Volunteering
• Fatigue • Feeding • Work
• Muscle cramps • Dressing
• Decreased strength (neck,
left hand, bulbar muscles)
• Depression

• Active individual; working • Lives in condominium
• Strong support network (friends, coworkers) • Supportive employment environment
• Lives with husband • Work benefits
• Depression
• Children not in area
• Husband living with stroke
Expected Outcomes (by Reassessment

Clinician Comment ALSA and MDA are
Visit 4 to Occur 2 Weeks After Visit 3) national voluntary organizations that provide many func-
1. Mrs. Jelly would report minimal (1 to 2/10) to no cervical tions and programs for people with ALS and their families
pain during work activities. and caregivers (eg, written and video educational materi-
2. Mrs. Jelly would demonstrate excellent understanding als, local education programs, patient and caregiver sup-
and 100% adherence with energy conservation tech- port groups, equipment loan programs, respite programs,
niques, sleep health, and positioning, use of cervical transportation programs, advocacy programs, and ALS
collar, revised recreational walking program, flexibility awareness programs).
and strengthening exercise program, use of RPE, and Printed educational materials can be downloaded and
completion of the physical activity and exercise log. given to Mrs. Jelly.
3. Mrs. Jelly would demonstrate excellent understand-
ing and 100% adherence with work environment
modifications. Procedural Interventions
Discharge Plan
Prescription, Application, and, as
It was anticipated that Mrs. Jelly would be ready for Appropriate, Fabrication of Devices and
discharge from physical therapy to her own care when she
achieved the established anticipated goals and expected out-
Equipment (Assistive, Adaptive, Orthotic,
comes. The plan of care, including the discharge plan, was Protective, Supportive, and Prosthetic)
discussed with Mrs. Jelly who reported she was in agreement. Supportive Device
Mrs. Jelly was provided with a soft foam collar and
instructed regarding use during work, prolonged sitting, and
INTERVENTION during recreational walking.
Coordination, Communication, and Clinician Comment For mild to moderate cer-

Documentation vical weakness, a soft foam collar is recommended. Soft col-
lars are comfortable and usually well tolerated by patients,
Coordinated and ongoing dialogue with members of the but wear-induced compressibility requires they be replaced
multi-disciplinary team regarding current status, care, and frequently. For moderate to severe weakness, a semi-rigid
plans for the future was essential. Ongoing communica- or rigid collar is prescribed. These collars provide very firm
tion with patient, family, referral sources, and other care- support, but can be very warm, may cause discomfort at
givers regarding progress toward goals would be pursued. points of body contact, and, may feel confining. Although a
Documentation would include all aspects of care, including soft collar is appropriate based on the assessment and has
initial examination/evaluation, daily treatment notes, tele- been prescribed, if Mrs. Jelly was agreeable, a semi-rigid
phone conversations, progress reports, reexaminations, and collar could also be prescribed for the longer term—as the
discharge summary. disease progresses, the cervical weakness will progress and
a semi-rigid collar will be needed.
Patient-/Client-Related Instructions
• Mrs. Jelly was informed about the plan of care, frequen-
cy of visits, and discharge plan. Functional Training in Work (Job/School/
• Mrs. Jelly received written and verbal information about Play), Community, and Leisure Integration
energy conservation, sleep health and positioning, use or Reintegration, Including Instrumental
of the cervical collar, use of the RPE, revised walking Activities of Daily Living, Work Hardening,
program, flexibility and strengthening exercise program and Work Conditioning
(with figures), and physical activity and exercise log.
• Mrs. Jelly received written and verbal information about
Work Environment Recommendations
work environment modifications. The following alterations to Mrs. Jelly’s work station were
recommended:
• Mrs. Jelly was provided the websites for ALSA and the
• Computer tabletop articulating forearm troughs to
MDA.
relieve muscle strain and weight of the limbs when work-
ing on the computer.
• Elevation of the computer screen to allow viewing at eye
level and to avoid cervical muscle fatigue
528 Chapter 12
• Full-back computer chair with head support.
• Ergonomic keyboard to reduce fatigue.
Clinician Comment An individualized flex-
ibility exercise program composed of ROM and stretching
Energy Conservation exercises and targeting major muscles and joints is con-
Mrs. Jelly was provided with written and verbal instruc- sidered standard care for people with ALS. This type of
tion about energy conservation, planning her daily and exercise program is appropriate for Mrs. Jelly and is imple-
weekly activities, pacing activities to avoid increased fatigue. mented for preventive purposes (eg, prevent contractures
and maintain ROM). In addition, Mrs. Jelly is experiencing
cramping with walking, so should be engaging in stretching
Clinician Comment Both the MDA and the exercises.
ALSA websites have resource materials related to energy
conservation—see http://www.als-mda.org/publications/
everydaylifeals/ch2/ or http://web.alsa.org/site/DocServer/ Strengthening Exercise
FYI_Minimizing_Fatigue.pdf?docID=29218. Program for Right Hand
Mode
Soft ball or Eggerciser
Physical Activity and Exercise Log Intensity
Mrs. Jelly was provided with a physical activity and exer- Not greater than moderate effort
cise log to use until her reassessment visit. Written and verbal Duration
instruction regarding use of the log was provided. 2 set of 8 repetitions of each exercise
Frequency
Clinician Comment A physical activity and 3 times per week
exercise log that the physical therapist can review is an
important component to include in the overall man- Clinician Comment How advisable was it for
agement plan for people with ALS, in particular when Mrs. Jelly to be engaged in strengthening exercises and, if so,
prescribing exercise. The patient should be educated in self- which muscles should be targeted?
monitoring. The log should collect data about the activity or
When designing a strengthening exercise program for a
exercise, the level of exertion, the level of fatigue during and
person with ALS, the physical therapist must take into
after, and “side effects” (eg, signs of overuse, which include:
consideration the stage of the disease, how quickly the
the inability to perform daily activities following exercise
disease is progressing (fast versus slow), the nature and
because of exhaustion or pain; a reduction in maximum
severity of impairments (eg, respiratory function, cog-
muscle force that gradually recovers; or increased or exces-
nitive impairments, fatigue), psychosocial and financial
sive muscle cramping, soreness, fatigue, or fasciculations).
issues, and patient goals. Prescribing exercise, in particu-
lar strengthening (or aerobic) modes, is not a simple and
straightforward process.
Therapeutic Exercise Prescription Reduced activity, particularly if prolonged, reduces function
Flexibility Exercise Program of the neuromuscular system, in addition to other systems.
Consisting of Stretching and Active Strength loss through inactivity and disuse can significantly
debilitate individuals with ALS, making them highly sus-
Range of Motion Exercises
ceptible to deconditioning, and muscle and joint tightness
Mode leading to contractures and pain. Thus, a balance between
Upper extremity (UE), lower extremity (L/E), hands— overuse fatigue and disuse atrophy needs to be struck when
Active ROM and stretching exercises prescribing strengthening (and aerobic) exercise.
Intensity
The effects of exercise programs have not been extensively
ROM exercises—no greater than moderate effort studied and are not well understood, despite the high inci-
Stretching exercises—maintain stretch below discomfort dence of muscle weakness in people with ALS. A Cochrane
point review of exercise for people with ALS identified only
Duration 2 studies that met the methodological quality inclusion
20-second hold for each stretching exercise criteria, indicating a dearth of randomized and well-
10 to 15 minutes total each session controlled research. The 2 included studies were too small
Frequency to determine to what extent exercise is of benefit for people
5 repetitions of each exercise; 2 sessions per day (eg, U/E with ALS. However, the mean difference in the primary
exercises [first session] and LE exercises [second session]). outcome, function as measured by the ALS Functional
Rating Scale, was statistically significant for the exercise
group, and adverse effects, such as increased muscle cramp- exercise program (eg, shorter sessions, RPE = 3, moderate).
ing, muscle soreness or fatigue, were not reported by the Signs and symptoms of overwork and fatigue could then be
investigators.34 monitored, and the plan and walking program reassessed.
Research indicates highly repetitive or heavy resistance For people with ALS, exercise program goals include: maxi-
exercise can cause prolonged loss of muscle strength in mizing functional capacity of the innervated muscle fibers;
weakened, denervated muscle.35 In individuals with other preventing or minimizing the effects of disuse atrophy;
neuromuscular diseases,36,37 research has found that over- preventing limitations in ROM and muscle length; and
use weakness does not occur in muscles with a Manual maximizing aerobic capacity, endurance, and functional
Muscle Test (MMT) grade of 3 or greater; moderate resis- level for as long as possible.
tance exercises can increase strength in muscles with a Both the physical therapist and Mrs. Jelly need to recognize
MMT grade of 3 or greater; strength gains are proportional and accept that people with ALS will become weaker and
to initial muscle strength; and heavy eccentric exercise more functionally limited despite any type or amount of
should be avoided. Exercise may produce functional ben- exercise. Although modest improvements may occur at the
efits; however, the extent of psychological benefits have yet onset of an exercise training program, the severity as well as
to be confirmed. the number of impairments will increase. Overall function
Mrs. Jelly had cervical extensor weakness and left hand will inevitably decrease over time.
weakness. Based on the findings and “complete picture,” People with ALS should be advised to exercise for several
compensatory versus restorative interventions were more brief periods throughout the day, with sufficient rest in
appropriate to address this weakness. Although a general between. If signs of overuse occur (see physical activity and
strengthening program could be prescribed to maximize exercise log), exercises should be stopped until symptoms
strength in nonaffected or mildly affected muscles in order resolve, and further evaluation is conducted.
to delay time to when function becomes impaired, because
In people with ALS, the safe range for therapeutic exercise
of fatigue, in Mrs. Jelly’s case, it was better to focus on a
narrows, and the degree to which the range narrows is
revised walking program and active ROM exercises rather
dependent on the extent of disease involvement and the
than specific UE and LE strengthening. Mrs. Jelly was
rate of disease progression. A weak or denervated muscle is
right-hand dominant. Since prescribing strengthening exer-
more susceptible to overwork damage because it is already
cises was an appropriate option to consider to increase or
functioning close to its maximal limits. ADL alone may
maintain her strength for functional purposes, this exercise
cause impaired muscles to act as though in training and
would not have been excessively fatiguing.
exercise that would improve normal muscles may actually
cause overwork damage in impaired muscles. The remain-
ing motor units will respond to training, and these motor
Aerobic Capacity/Endurance units must work harder to handle a given amount of exer-
Conditioning or Reconditioning cise stress.38
Mode Special attention must be paid to developing an exercise
Walking program program, in particular resistance or endurance, for people
Intensity with ALS. Exercise programs should be at moderate to low
Self-selected pace intensities and should be carefully monitored. Exercise pro-
RPE = 3 on Borg CR-10 RPE grams must be at a level that will minimize disuse atrophy,
Duration but be cautious enough to avoid fatigue and overwork, as
10 minutes per session both may be detrimental.39 Thus, the physical therapist
Frequency needs to continuously balance exercise “underwork” and
2 times per day: once at noon and once after work exercise “overwork” and adjust the program (eg, type of
exercise or activity, intensity) accordingly based on the
individual’s response to exercise, and other disease-specific
Clinician Comment In the case of Mrs. Jelly, factors (eg, respiratory impairments) in order to prevent
walking was an enjoyable and social activity and one of excessive fatigue and potential overwork damage. People
the few activities she had been continuing. Mrs. Jelly was with ALS should be advised not to carry out any activi-
also exhibiting signs and symptoms of depression. Thus, ties to the point of extreme fatigue, and should keep track
rather than completely eliminating walking as an activity, of symptoms of overuse (see physical activity and exercise
it was preferable to make the activity a safer one for her log). Once exercise becomes so tiring or is so difficult that it
status. Initial first steps included: decreasing the strain and prevents the individual from completing daily activities, it
cervical muscle fatigue in order to decrease overall fatigue; is no longer appropriate.
implementing energy conservation strategies so that energy
was conversed for the walking program; and, modifying the
530 Chapter 12
REEXAMINATION for patients with a VC greater than 50% predicted at the

time of the procedure.42,43 It is important for physical
The first reexamination of Mrs. Jelly took place as planned, therapists to be aware that a PEG does not prevent the risk
2 weeks after Visit #3. of aspiration.44,45
Subjective
Mrs. Jelly reported that she was wearing her cervical col-
Objective
lar as directed. She reported that she no longer had severe Pain
neck pain. She was utilizing her energy-conversation strate-
gies and was dividing up her exercise sessions throughout Mrs. Jelly reported her neck pain was 0 to 1/10 in the
the day. She was participating in her walking program and morning upon waking and 2/10 by the end of some work
reported no problems with her exercises or walking program. days (VAS).
She reported that she did not experience any signs or symp- Posture
toms of overwork postexercising.
No changes noted.
Mrs. Jelly had successfully negotiated with her supervisor
to have 2 20-minute rest periods during the work day, one
mid-morning and one mid-afternoon. Mrs. Jelly reported
Clinician Comment No changes expected.
that end-of-work-day fatigue was not as much of an issue
anymore. She was even considering resuming 1 volunteer Muscle Performance
activity per week.
Mrs. Jelly reported that her neurologist had prescribed Examination not completed.
Celexa (citalopram) for her depressive symptoms. She had
been taking the medication for a week at the time of the reas- Clinician Comment The reexamination visit
sessment. She reported she “hasn’t noticed much difference took place 2 weeks after the initial visits. Mrs. Jelly was not
yet.” Mrs. Jelly reported that she had appointments booked to complaining of any new signs or symptoms, nor was she
see a speech language pathologist and registered dietician in reported any signs or symptoms of overwork. Significant
the next 2 weeks. Her neurologist had provided information changes in muscle strength were not expected at this point
about a PEG and Mrs. Jelly was “thinking about this option.” in time. If Mrs. Jelly had new complaints of additional signs
and symptoms or limitations or restrictions, reassessment
of muscle strength would have been warranted.
Clinician Comment When pervasive,
depressive symptoms need to be treated aggressively with
psychopharmacological medications. If left untreated Functional Training in Work (Job/School/
psychosocial impairments can adversely affect an indi-
vidual’s ability to adapt, cope, and participate in the plan
Play), Community, and Leisure Integration
of care. Unfortunately, antidepressant medications usually or Reintegration, Including Instrumental
take several weeks (up to 6 weeks) to work, and some clients Activities of Daily Living, Work Hardening,
may need to trial different medications to find one that is and Work Conditioning
effective. Psychological well-being has been found to be an
Mrs. Jelly had implemented the work environment recom-
important prognostic factor. Individuals with psychological
mendations as well as the energy conservation instructions
well-being were found to have significantly longer sur-
identified for her. Mrs. Jelly’s physical activity and exercise
vival times compared to those with psychological distress.
log were reviewed. Her verbal report of the lack of signs and
Mortality rates were 6.8 times greater in those experiencing
symptoms of overwork was confirmed in her log entries.
psychological distress.40 These findings were confirmed in a
later study that found degree of physical disability, disease
progression, and survival could be predicted by the patient’s Assessment
psychological status.41 Mrs. Jelly implemented the recommendations and was
A PEG, a type of gastrostomy tube inserted via endoscopic managing well at the time of reassessment. As her disease
surgery that creates a permanent opening into the stomach progressed in the future, Mrs. Jelly would benefit from physi-
for the introduction of food, is useful for stabilizing body cal therapy to address any additional impairments, activity
weight/mass. Although there is no firm evidence, for opti- limitations, and participation restrictions that would appear.
mal safety and efficacy the PEG procedure should be offered
to the patient and completed before the individual’s FVC/
VC falls below 50% of predicted.25 Studies have found PEG
Plan
insertion may prolong survival and survival was greatest Mrs. Jelly will be reevaluated in 3 months.
9. Brooks BR, Miller RG, Swash M, et al. El Escorial revisited:
OUTCOMES revised criteria for the diagnosis of amyotrophic lateral sclerosis.
Amyotroph Lateral Scler Other Motor Neuron Disord. 2000;1(5):293-
293.
Discharge 10. de Carvalho M, Dengler R, Eisen A, et al. Electrodiagnosis criteria
for diagnosis of ALS. Consensus of an International Symposium
Mrs. Jelly planned to continue with her program indepen- sponsored by IFCN. December 3-5, 2006, Awiji-shima, Japan.
dently and would contact physical therapy before her next 11. Lacomblez L, Bensimon G, Leigh PN, Guillet P, Meininger V.
appointment, as needed. Dose-ranging study of riluzole in amyotrophic lateral sclerosis.
Amyotrophic Lateral Sclerosis/Riluzole Study Group II. Lancet.
1996;347(9013):1425-1431.
Clinician Comment Think about what might 12. Bensimon G, Lacomblez L, Meininger V. A controlled trial of rilu-
zole in amyotrophic lateral sclerosis. ALS/Riluzole Study Group.
be next for Mrs. Jelly. It was likely that in 3 months, bul- N Engl J Med. 1994;330(9):585-591.
bar impairments would have progressed, her FVC might 13. Mathiowetz V, Kashman N, Volland G, Weber K, Dowe M, Rogers
be decreased, L hand weakness would have progressed, S. Grip and pinch strength: normative data for adults. Arch Phys
and new impairments and activity limitations (UE > LE Med Rehabil. 1984;66(2):69-74.
because of the contiguous nature of ALS) might be present. 14. Pandyan AD, Johnson GR, Price CI, Curless RH, Barnes MP,
Rodgers H. A review of the properties and limitations of the
Additional compensatory interventions would likely need Ashworth and Modified Ashworth scales as measurements of spas-
to be implemented and eventually “exercise” would be com- ticity. Clin Rehabil. 1999;13(5):373‐383.
posed, more so, of functional performance activities. 15. Beal MF. Aging, energy, and oxidative stress in neurodegenerative
diseases. Ann Neurol. 1995;38:357.
In terms of overall prognosis for Mrs. Jelly, people with
16. Desport JC, Preux PM, Truong TC, Vallat JM, Sautereau D,
bulbar-onset ALS have a poorer prognosis than those with Couratier P. Nutritional status is a prognostic factor for survival in
limb-onset ALS. Five-year survival rates were reported ALS patients. Neurology. 1999;53(5):1059-1063.
to be 9% and 16% for those with bulbar-onset ALS, com- 17. Wilson CM, Grace GM, Munoz DG, He BP, Strong MJ. Cognitive
pared to 37% and 44% for limb-onset.46,47 Fifty percent impairment in sporadic ALS: a pathologic continuum underlying a
multisystem disorder. Neurology. 2001;57(4):651-657.
survival probability after initial symptom onset is slightly
18. Strong MJ, Grace GM, Orange JB, Leeper HA, Menon RS, Aere C.
greater than 3 years, unless mechanical ventilation is used A prospective study of cognitive impairment in ALS. Neurology.
to sustain breathing.1 In most individuals, death occurs 1999;53(8):1665-1670.
within 3 to 5 years after diagnosis and usually results from 19. Abrahams S, Leigh PN, Harvey A, Vythelingum GN, Grisé D,
respiratory failure.48 Goldstein LH. Verbal fluency and executive dysfunction in amyo-
trophic lateral sclerosis (ALS). Neuropsychologia. 2000;38(6):734-
Think about you, as the physical therapist involved in Mrs. 747.
Jelly’s care. Is there a role for you as a physical therapist as 20. Abrahams S, Goldstein LH, Al-Chalabi A, et al. Relation between
the disease progresses? What is the role? cognitive dysfunction and pseudobulbar palsy in amyotrophic
lateral sclerosis. J Neurol Neurosurg Psychiatry. 1997;62(5):464-472.
21. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A
practical method for grading the cognitive state of patients for the
REFERENCES 22.
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Miller RG, Jackson CE, Kasarskis EJ, et al. Practice Parameter
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lateral sclerosis in a database population: validation of a scoring behavioral impairment (an evidence-based review): report of the
system and a model for survival prediction. Brain. 1995;118:707. Quality Standards Subcommittee of the American Academy of
2. Brooks BR. The natural history of amyotrophic lateral sclerosis. In: Neurology. Neurology. 2009;73(15):1227-1233.
Williams AC, ed. Motor Neurone Disease. London: Chapman and 23. Bohannon RW, Smith MB. Interrater reliability of a modified
Hall; 1994:121. Ashworth scale of muscle spasticity. Phys Ther. 1987;67(2):206-207.
3. Swash M. Clinical features and diagnosis of amyotrophic lateral 24. Pandyan AD, Price CM, Barnes MP, Johnson GR. A biomechanical
sclerosis. In: Brown R Jr, Meininger V, Swash M, eds. Amyotrophic investigation into the validity of the Modified Ashworth scale as a
Lateral Sclerosis. London: Martin Dunitz Ltd; 2000:3. measure of elbow spasticity. Clin Rehabil. 2003;17(3):290-293.
4. Mitsumoto H, Chad DA, Pioro EK: Clinical features: signs and 25. 25. Miller RG, Jackson CE, Kasarskis EJ, et al. Practice Parameter
symptoms. In: Mitsumoto, H, Chad DA, Pioro EK, eds. Amyotrophic update: the care of the patient with amyotrophic lateral sclerosis:
Lateral Sclerosis. Philadelphia, PA: F.A. Davis; 1998:47. drug, nutritional, and respiratory therapies (an evidence-based
5. Rochester DF, Esau SA. Assessment of ventilatory func- review): report of the Quality Standards Subcommittee of the
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1994;15(4):751-763. 1226.
6. Norris F, Shepherd R, Denys E, et al. Onset, natural history and 26. Kilmer DD. The role of exercise in neuromuscular disease. Phys
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1993;118(1):48-55. 27. Krupp LB, LaRocca NG, Muir-Nash J, Steinberg AD. The fatigue
7. Strong MJ, Hudson AJ, Alvord WG. Familial amyotrophic lateral severity scale. Application to patients with multiple sclerosis and
sclerosis, 1850-1989: a statistical analysis of the world literature. systemic lupus erythematosus. Arch Neurol. 1989;46(10):1121-1123.
Can J Neurol Sci. 1991;18(1):45-58. 28. Schwab R, England A. Projection technique for evaluating sur-
8. Rosen DR. Mutations in Cu/Zn superoxide dismutase gene are gery in Parkinson’s disease. In: Gillingham J, Donaldson I, eds.
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29. Cedarbaum JM, Stambler N, Malta E, et al. The ALSFRS-R: a 39. Ribchester RR. Activity-dependent and independent synaptic inter-
revised ALS functional rating scale that incorporates assessments actions during reinnervation of partially denervated rat muscle.
of respiratory function. J Neurol Sci. 1999;169(1-2):13-21. J Physiol. 1988;401:53-75.
30. Kaufmann P, Levy G, Montes J, et al. Excellent inter-rater, intra- 40. McDonald ER, Wiedenfeld SA, Hillel A, Carpenter CL, Walter RA.
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31. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory 41. Johnston M, Earll A, Giles M, McClenahan R, Stevens D, Morrison
for measuring depression. Arch Gen Psych. 1961;4:561-571. V. Mood as a predictor of disability and survival in patients diag-
32. Traynor BJ, Alexander M, Corr B, Frost E, Hardiman O. Effect of a nosed with ALS/MND. Br J Health Psych. 1999;4(2):127-136.
multidisciplinary amyotrophic lateral sclerosis (ALS) clinic on ALS 42. Mathus-Vliegen LM, Louwerse LS, Merkus MP, Tytgat GN, Vianney
survival: a population based study, 1996-2000. J Neurol Neurosurg de Jong JM. Percutaneous endoscopic gastrostomy in patients with
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33. Borg G. Borg’s Perceived Exertion and Pain Scales. Champaign, IL: Gastrointest Endosc. 1994;40(4):463,-469.
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34. Dalbello-Haas V, Florence JM, Krivickas LS. Therapeutic exercise M. Percutaneous endoscopic gastrostomy and enteral nutrition in
for people with amyotrophic lateral sclerosis or motor neuron dis- amyotrophic lateral sclerosis. Neurology. 1995;242(10):695-698.
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36. Kilmer DD, McCrory MA, Wright NC, Aitkens SG, Bernauer gastrostomy or jejunostomy and the incidence of aspiration in 79
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37. Aitkens SG, McCrory MA, Kilmer DD, Bernauer EM. Moderate 47. Tysnes OB, Vollset SE, Larsen JP, Aarli JA. Prognostic factors
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38. Coble NO, Maloney FP. Effects of exercise in neuromuscular dis- 48. Ringel SP, Murphy JR, Alderson MK, et al. The natural history of
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Rehabilitation of Multiple Sclerosis and Neuromuscular Disorders.
New York: Lippincott; 1985:228.
Individuals With
13
Multi-System Disorders
• Describe complex regional pain syndrome (CRPS) and

CHAPTER OBJECTIVES distinguish between CRPS I and CRPS II.
• Identify the signs and symptoms of fat embolism
• List the most common risk factors for cancer and discuss
syndrome.
which could be prevented through behavioral changes.
• Identify the differences between benign neoplasms and
malignant neoplasms.
• Discuss cell differentiation and the difference between
CHAPTER OUTLINE
well-differentiated cells and cancer cells.
• Cancer
• Describe how radiation therapy, chemotherapy, and
◦ Epidemiology
immunotherapy work to treat cancer.
◦ Pathology/Pathophysiology
• Summarize the potential benefits of exercise in indi-
viduals with cancer. ◦ Physical Therapy Management
• Summarize exercise prescription and testing for indi- ▪ Exercise and Cancer
viduals with cancer. ▪ Exercise Testing and Prescription
• Name the 3 main types of diabetes and explain how they ▪ General Considerations
are similar and/or different.
• Diabetes Mellitus
• Identify and describe the 3 tests most commonly used to
◦ Prediabetes
diagnose diabetes.
◦ Diagnosis: Diabetes, Prediabetes, and Gestational
• List the risk factors for diabetes that can be modified and
Diabetes
those that cannot.
◦ Epidemiology
• Discuss abnormal insulin metabolism in individuals
with diabetes. ◦ Associated Morbidity/Mortality
• Identify exercise prescription guidelines for individuals ◦ Associated Costs
with diabetes. ◦ Pathology/Pathophysiology
• List the major characteristics of fracture blisters. ▪ Insulin Metabolism
• Contrast and compare acute compartment syndrome ▪ Type 1 Diabetes
and chronic compartment syndrome.
▪ Type 2 Diabetes
▪ Gestational Diabetes Mellitus

534 Chapter 13
◦ Complications this population is to provide the interventional support that
◦ Physical Therapy Management allows patients to achieve successful outcomes and remain
functional despite the existence of advanced chronic disease,
▪ Dietary Management severe trauma, and multi-system disorders. This chapter
▪ Managing Medications With Exercise will consider the physiology of abnormal cell development
▪ Physical Therapy/Exercise Testing and that affects normal structure and function in patients with
Prescription cancer, diabetes, and musculoskeletal trauma, some of the
more common multi-system disorders that occur in patients
▪ General Considerations who are referred to physical therapists for the management
• Musculoskeletal Trauma of their movement related impairments. Each section in
◦ Complications of Musculoskeletal Trauma this chapter initiates discussion with the epidemiology and
pathology/pathophysiology of these multi-system disorders
▪ Fracture Blisters and then examines how the patient/client management
▪ Compartment Syndrome model described in the Guide to Physical Therapist Practice
▪ Complex Regional Pain Syndrome can and should be applied to management of these patient
populations.
▪ Fat Embolism Syndrome
◦ Evaluation and Management of Musculoskeletal
Trauma CANCER
▪ History
▪ Systems Review The term cancer does not describe a single disease but
refers to more than 100 different diseases.1,2 This group of
▪ Tests and Measures diseases is characterized by uncontrolled growth and spread
• References of abnormal cells.2-4 Cancer can originate in almost any
part of the body and behaves differently depending on its
Advances in science, medicine, and rehabilitation in the organ of origin.1-3 When cancer cells spread and travel to
latter part of the 20th century have produced large numbers another part of the body, this is referred to as metastasis.
of citizens who survive into their 70s, 80s, and 90s. This Regardless of where a cancer may spread, it is always named
phenomenon is often referred to as the “graying of America.” for the body organ of origin and takes its characteristics with
Concurrently there have been aggressive advances in manag- it to the new site.2,3 For example, metastatic breast cancer in
ing both acute and chronic disease and the development of the lungs will continue to behave like breast cancer and if
life-sustaining technologies in critical care and trauma that viewed under a microscope will continue to look like a cancer
support the recovery and maintenance of life. The result is that originated in the breast.2
that many Americans are successfully living and functioning Just as cancer is not a single disease, there is more than
with multi-system disorders. Many, if not most of these indi- one cause of cancer. Causative agents are usually divided into
viduals, are unwilling to merely survive, but wish to thrive 2 categories, external or environmental (tobacco, chemicals,
in their remaining years. Physical therapists often manage radiation, and infectious organisms) and internal or genetic
the care of these individuals with multi-system disorders to (inherited mutations, hormones, immune conditions, and
address the functional limitations associated with the move- mutations that occur from metabolism).4,5 The American
ment-related impairments that compromise an individual’s Cancer Society (ACS) estimates that 5% of all cancers are
ability to participate and thrive. genetic while the rest are related to other factors, the result
Physical therapists who practice in acute or chronic of damage (mutations) to genes that occur over a lifetime.4 It
care settings, in a school system, in rehabilitation facilities, is thought that most cancers develop as a result of multiple
in home health or in the outpatient environment will all environmental, viral, and genetic agents working together or
receive referrals for patients and clients with multi-system repeated exposure to a single carcinogenic (cancer-produc-
disorders. Often they will elicit the history, signs, symptoms, ing) agent.1,5
and associated information that would identify these people According to the ACS all cancers caused by cigarette
when interviewing someone who has been referred for what smoking and heavy use of alcohol could be prevented com-
appears to be a “simple” musculoskeletal injury. It is not pletely.4 Research suggests that about one-third of the cancer
uncommon for a physical therapist to learn during a patient deaths that were expected to occur in 2009 were related
interview that the patient has a history of cancer, heart dis- to nutrition, physical inactivity, and overweight or obesity
ease, hypertension or diabetes in addition to the presenting and therefore could have been prevented (Box 13-1).6 Some
complaints from a sprain or strain. The possibility of new dis- cancers are related to infectious agents, such as hepatitis B
ease development, disease progression or disease recurrence virus, human papillomavirus, human immunodeficiency
exists with any patient. Physical therapists can recognize that virus, Helicobacter pylori, and others and could be prevented
possibility and address all such issues by attending to details through behavioral changes, vaccines or antibiotics. In 2009
during the examination. The challenge of rehabilitation in it was expected that more than 1 million skin cancers would
Individuals With Multi-System Disorders 535
be diagnosed. These cancers could have been prevented by
appropriate protection from sun exposure. BOX 13-1. MOST COMMON
RISK FACTORS FOR CANCER
Epidemiology ● Age
Cancer is second only to heart disease as a cause of death ● Certain hormones
in the United States.7 In fact, 1 in every 4 deaths in the United
● Tobacco
States is due to cancer.4,8 However, when deaths are aggre-
gated by age, starting in 1999 statistics demonstrated that ● Heredity
cancer surpassed heart disease as the leading cause of death ● Sunlight
for people under the age of 85.8,9 In 2009, the ACS estimated
that there would be a total of 1,479,350 new cancer cases and ● Alcohol
an expected 562,340 deaths from cancer in the United States. ● Ionizing radiation
This translates to more than 1500 deaths each day from can-
cer (Table 13-1).4,8
● Nutrition
Anyone can develop cancer. The risk of developing can- ● Certain chemicals and other substances
cer increases as we age. Approximately 77% of all cancers ● Physical inactivity
are diagnosed at age 55 and older.4 In the United States, the
lifetime risk for men of all races developing cancer is a little ● Some viruses and bacteria
less than 1 in 2 while for women of all races the risk is a little ● Overweight
more than 1 in 3.4,8,10 The National Cancer Institute (NCI)
Adapted from National Cancer Institute. October 4, 2006. www.
estimates that as of January 2005, there were ~11.1 million cancer.gov/cancertopics/wyntk/overview/page4. Accessed May
Americans alive who had a history of cancer.4 Some of these 14, 2010.
individuals were cancer free while others had continued
evidence of their disease and may have been undergoing
treatment. death rates for the first time since national record keeping
In early stages, most cancers are asymptomatic. Cancer is was begun in the 1930s.12 Since then, subsequent reports
most often detected or diagnosed after a tumor can be felt or have confirmed this finding and provided updates. In their
when other symptoms develop. These symptoms may devel- report published in 2010, death rates declined for the 3 most
op because the cancer has grown large enough to impinge common cancers in men (lung, prostate, and colorectal can-
on nearby organs, blood vessels, and nerves. Unexplained cers) and for 2 of the 3 leading cancers in women (breast and
weight loss, fever, fatigue, pain, and changes in the skin colorectal cancer; Box 13-2).13 The 2009 statistics further
are some of the nonspecific signs and symptoms of cancer. delineated the decline in death rates by 2.0% per year from
However, there are many other conditions that may cause 2001 and 2005 in men and by 1.6% per year in women from
these symptoms as well. Other signs and symptoms may be 2002 and 2005.8 (This compares with declines of 1.5% in
more indicative of cancer. These include changes in bowel men from 1993 to 2001 and 0.8% per year in women from
habits or bladder function, sores that do not heal, unusual 1994 to 2002.)
bleeding or discharge, thickening or a lump in the breast or The 5-year relative survival rate for all cases of cancers
other body part, indigestion or difficulty swallowing, change diagnosed between 1996 and 2004 is 66%.4 Survival rates
in a wart or mole, a nagging cough or hoarseness. Other vary greatly depending on the type of cancer and stage at
cancers, however, develop in places where there may be no diagnosis. The 5-year relative survival rate represents the
symptoms until the cancer has grown quite large. Pancreatic percentage of cancer patients who are living 5 years after
cancer is an example of this type of cancer. By the time there diagnosis relative to persons without cancer regardless of
are signs and symptoms, the cancer has usually reached whether they are disease free, have relapsed or are currently
an advanced stage.11 The earlier a cancer is diagnosed, the undergoing treatment. It is important to remember that
more likely it is that treatment will be successful and that the 5-year relative survival rates are most useful for monitoring
cancer can be cured. When a physical therapist is interview- progress in the early detection and treatment of cancer and
ing an individual over the age of 50 who presents with the they do not represent the proportion of people who are cured
nonspecific signs and symptoms of cancer, or, those signs permanently since cancer deaths can occur beyond 5 years
and symptoms that are more indicative of cancer, they should after diagnosis.
consider the possibility of cancer. The overall costs for cancer are considerable. The National
The ACS, the Centers for Disease Control and Prevention Institutes of Health (NIH) estimates that in the year 2008, a
(CDC), the NCI, and the North American Association of total of $228.1 billion was spent on cancer; $93.2 billion went
Central Cancer Registries (NAACCR) collaborated to pro- to direct medical costs (total of all health expenditures), $18.8
duce an annual report to the nation on the current status of billion for indirect morbidity costs (lost productivity due to
cancer in the United States, issuing their first report in 1998. illness) and $116.1 billion for indirect mortality costs (lost
That first report documented a sustained decline in cancer productivity due to premature death).4
536 Chapter 13
TABLE 13-1. NEW CANCER CASES AND DEATHS BY SELECT CANCER SITES AND SEX:
2014 UNITED STATES ESTIMATES
ESTIMATED NEW CASES ESTIMATED DEATHS
Male Female Male Female
Prostate Breast Lung and bronchus Lung and bronchus
233,000 (27%) 232,670 (29%) 86,930 (28%) 72,330 (26%)
Lung and bronchus Lung and bronchus Prostate Breast
116,000 (14%) 108,210 (13%) 29,480 (10%) 40,000 (15%)
Colon and rectum Colon and rectum Colon and rectum Colon and rectum
71,830 (8%) 65,000 (8%) 26,270 (8%) 24,040 (9%)
Urinary bladder Uterine corpus Pancreas Pancreas
56,390 (7%) 52,630 (6%) 20,170 (7%) 19,420 (7%)
Melanoma of the skin Thyroid Liver and intrahepatic Ovary
43,890 (5%) 47,790 (6%) bile duct 14,270 (5%)
15,870 (5%)
Kidney and renal pelvis Non-Hodgkin s lymphoma Leukemia Leukemia
39,140 (5%) 32,530 (4%) 14,040 (5%) 10,050 (4%)
Non-Hodgkin s lymphoma Melanoma of the skin Esophagus Uterine corpus
38,270 (4%) 32,210 (4%) 12,450 (4%) 8,590 (3%)
Leukemia Kidney and renal pelvis Urinary bladder Non-Hodgkin s lymphoma
30,100 (4%) 24,780 (3%) 11,170 (4%) 8,590 (3%)
Oral cavity and pharynx Ovary Non-Hodgkin s Liver and intrahepatic bile
30,220 (4%) 21,980 (3%) lymphoma duct
10,470 (3%) 7,130 (3%)
Pancreas Pancreas Kidney and renal pelvis Brain and other nervous
23,530 (3%) 22,890 (3%) 8,900 (3%) system
6,230 (2%)
All other sites 167,850 All other sites 169,630 All other sites 83,160 All other sites 65,130
All sites 855,220 (100%) All sites 810,320 (100%) All sites 310,010 (100%) All sites 275,710 (100%)
*Excludes basal and squamous cell skin cancers and in situ carcinoma except urinary bladder.
Percentages may not total 100% due to rounding
Reprinted with permission from the American Cancer Society. Cancer Facts & Figures 2014. Atlanta, GA: American Cancer Society; 2014.
Pathology/Pathophysiology vital functions.1,14 Alternatively, malignant neoplasms have

the tendency to grow rapidly and spread widely. Malignant
Normal, healthy cells grow, divide, and die in an orderly neoplasms extensively infiltrate and invade the surrounding
fashion. Cancer cells continue to grow and divide to form tissue.1 With their rapid rate of growth, malignant neoplasms
new abnormal cells.3 A neoplasm (often referred to as a tend to compress blood vessels and outgrow their blood sup-
tumor) is the abnormal mass of tissue that results from the ply with resultant tissue ischemia and necrosis.
failure of cells to divide normally and die within the expected Cells divide and bear offspring during a process called
time frame. Neoplasms can be benign or malignant. Benign cell proliferation. Cell proliferation is normally regulated
neoplasms have the same cell type as the parent cell, but grow so that the number of cells that are actively dividing equals
at an abnormal rate.14 They do not metastasize nor do they the number of cells dying or being shed. Cell differentiation
invade the surrounding tissue.14,15 They are usually encap- is defined as the process whereby cells are transformed into
sulated.1 Benign neoplasms cause problems when they grow different and more specialized cell types. Cell differentiation
large enough to compress other organs and interfere with determines the structure, function, and life span of a cell.
BOX 13-2. TOP 15 CANCER SITES IN MEN AND WOMEN

MALE FEMALE
● Prostate ● Breast
● Lung and fronchus ● Lung and bronchus
● Colon and rectum ● Colon and rectum
● Urinary bladder ● Corpus and uterus, not otherwise specified (NOS)
● Melanoma of the skin ● Melanoma of the skin
● Non-Hodgkin s lymphoma ● Non-Hodgkin s lymphoma
● Kidney and renal pelvis ● Thyroid
● Leukemia ● Ovary
● Oral cavity and pharynx ● Pancreas
● Pancreas ● Leukemia
● Stomach ● Kidney and renal pelvis
● Liver and intrahepatic bile duct ● Urinary bladder
● Esophagus ● Cervix uteri
● Brain and other nervous system ● Oral cavity and pharynx
● Myeloma ● Brain and other nervous system
Adapted from Edwards BK, Ward E, Kohler BA, et al. Annual report to the nation on the status of cancer, 1975-2006, featuring colorectal
cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer. 2010,116(3):544-573.
Well-differentiated cells are no longer able to divide and bear are symptoms, the type and frequency of the symptoms
offspring. Cancer cells fail to undergo normal cell prolifera- depend on the size and location of the metastasis.15 For
tion and differentiation processes. Because cancer cells lack example, cancer that has metastasized to the bone frequently
cell differentiation, they do not function properly nor do they causes pain and may result in bone fractures, while cancer
die in the same time frame as normal cells. Altered cell dif- that metastasizes to the brain may cause a variety of symp-
ferentiation also results in changes in cell characteristics and toms that include seizures, headaches, and dizziness.
cell function that distinguishes cancer cells from fully differ- According to the ACS, there are 3 major types of treat-
entiated normal cells. The inability of cancer cells to differ- ment for cancer: surgery, radiation therapy (RT), and chemo-
entiate prevents cancer cells from performing their normal therapy.16 Surgery is the oldest form of cancer treatment and
functions and results in a variety of tissue changes including can be used in combination with other treatments. Surgery
pain, cachexia, decreased immunity, anemia, leukopenia, and radiation are used to treat localized cancers while che-
and thrombocytopenia.14 Because tumor cells take the place motherapy is particularly helpful when used to treat cancer
of normally functioning parenchymal tissue, the initial that is widespread or has metastasized. Another form of
symptoms of cancer usually reflect the site of involvement. cancer treatment is immunotherapy. It is relatively new com-
Lung cancer, for example, usually presents with impaired pared to the 3 main forms of cancer treatment and still plays
respiratory function.1 a fairly small role in treating most cancers.17
Metastasis is the term used to describe the development RT is the use of ionizing radiation to kill cancer cells and
of a secondary cancer in a location distant from the location to shrink tumors. Radiation may come from an external
of the primary cancer. With metastasis, cancer cells travel source (external-beam RT) or it can be delivered by radio-
to other areas of the body via the blood or lymphatic systems. active material placed in the body, near the cancer cells
The most common sites for cancer metastases are the lungs, (internal RT, implant therapy or brachytherapy). RT works
bone, liver, and brain.15 With spread via the circulatory sys- by injuring or destroying cells in the area being treated by
tem, the blood-borne cancer cells typically follow the venous damaging their genetic material. This makes it impossible
flow that drains the site of the neoplasm.1 The lymphatic for cancer cells to continue to grow and divide.18 RT dam-
channels empty into the venous system as well, so even with ages both cancer cells and healthy cells though most normal,
spread via the lymphatic channels, cancer cells that survive healthy cells recover from the effects of radiation and resume
may eventually gain access to the circulatory system. Not all normal function.
people with metastatic cancer have symptoms. When there
538 Chapter 13
It is well known that RT, especially external-beam RT, Comprehensive Cancer Center (NCCN) Fatigue Guidelines
causes significant long-term or chronic changes to the con- Committee developed the most commonly used definition
nective tissue.5 Though changes such as fibrosis, atrophy, of CRF. They defined CRF as “an unusual, persistent, subjec-
and contraction of tissue can occur to any irradiated area, tive sense of tiredness related to cancer or cancer treatment
this is especially true of collagen. Edema, decreased range that interferes with usual functioning.”23 The etiology of
of motion (ROM), and impaired function are some of the CRF is poorly understood and the relative contributions of
impairments associated with fibrosis of connective tissue. the disease itself, the treatment modalities, and comorbid
Radiation also has a fibrotic effect on the circulatory and conditions remain unclear.24 The current thinking is that the
lymphatic systems. This is typically seen as a loss of elastic- etiology of CRF likely involves the dysregulation of a number
ity and contractility of the irradiated vessels that transport of interrelated physiological, biochemical, and psychological
the blood, lymph, and waste products from the area being systems.23,24 CRF is different from the fatigue experienced
treated. This may result in lymphedema or decreased vascu- after the flu, exercise or other exertion. It has both subjec-
larity of some of the tissues. tive and objective components and may include symptoms
Chemotherapy uses drugs to destroy cancer cells. A such as physical weakness or tiredness, depression, impaired
combination of drugs has been found to be more effective cognitive function, and impaired ability to sustain social
than treatment with one drug alone. These drugs destroy relationships.23 A recently published review in the Cochrane
cancer cells by preventing them from growing or multiply- Database of Systematic Reviews evaluated the effect of exer-
ing. Chemotherapy can also harm normal, healthy cells, cise on CRF.25 Twenty-eight studies were included in this
especially those that divide quickly.19 The side effects from review. The results of the review suggest that exercise can
chemotherapy are a result of this damage to healthy cells. be helpful in reducing fatigue both during and after treat-
Fortunately, healthy cells usually repair themselves after ment for cancer. However, there was insufficient evidence to
chemotherapy. determine the best type or intensity of exercise for reducing
Chemotherapy drugs can be classified as either cell cycle the fatigue associated with cancer. This clearly presents an
specific or cell cycle nonspecific.1 Drugs are classified as opportunity for management by physical therapists as well as
cell cycle specific when they exert their action during a spe- for further research to determine the most effective exercise
cific phase of the cell cycle. Methotrexate, an antimetabolite parameters (best type of exercise [aerobic versus resistance],
agent, works by interfering with DNA synthesis thus inter- mode, frequency, intensity, and duration of exercise) to assist
rupting the S phase of the cell cycle. In contrast, cell cycle- in the management of CRF. Other impairments that are com-
nonspecific agents exert their effect during all phases of the mon in cancer patients and managed by physical therapists
cell cycle. Cytoxan (cyclophosphamide), an alkylating agent,5 include impaired cardiorespiratory endurance, lymphedema,
acts by disrupting DNA when cells are in their resting state pain, muscle weakness, and neuropathy.
and when they are dividing.1 Cell cycle-specific and cell
cycle-nonspecific chemotherapy drugs are often combined to Physical Therapy Management
treat cancer since they differ in their mechanisms of action.
Immunotherapy, also referred to as biologic therapy or Exercise and Cancer
biotherapy, uses the body’s immune system to fight dis- There has been an abundance of research on the benefits
eases, including cancer.17 It may be used alone but is most of exercise in the general population. In comparison, research
often used as an adjuvant to enhance the effects of the on the benefits of exercise in individuals with cancer is still in
primary therapy. The 2 main types of immunotherapy are its infancy. The traditional recommendations for individu-
active immunotherapies and passive immunotherapies.20 als with cancer included rest and limiting physical activity.
Active immunotherapies act by stimulating the body’s own Though that still may be the case if movement causes severe
immune system to fight the disease. Passive immunothera- pain, rapid heart rate or shortness of breath, beginning in
pies use components of the immune system (such as anti- the late 1980s research demonstrated that moderate intensity
bodies) made in the lab to start the attack on the disease. aerobic exercise training was of benefit to individuals with
At present, monoclonal antibodies (passive immunothera- cancer throughout the various stages of treatment, recovery,
pies) are the most widely used form of cancer immuno- remission, and palliative care.14,26 This research concluded
therapy.20,21 Two commonly used monoclonal antibodies that not only did exercise improve physiological performance
are Herceptin (trastuzumab) and Rituxan (rituximab).5,21 measures, but there were also psychological benefits includ-
Herceptin is used to treat metastatic breast cancer in patients ing enhanced quality of life (QOL). Some of the possible
whose tumors produce excess amounts of human epidermal benefits of exercise may include27:
growth factor receptor 2 (HER-2) protein. Rituxan is used in
• Improved balance, lower risk of falls and fractures
the treatment of non-Hodgkin’s lymphoma.
Fatigue is the most common side effect reported by • Prevention of muscle atrophy due to inactivity
patients undergoing cancer treatments and can be a side • Reduced risk of heart disease
effect of surgery, RT, and chemotherapy. It has been reported • Reduced risk of osteoporosis
that ~90% of cancer patients experience cancer-related
fatigue (CRF) during RT or chemotherapy.22 The National • Improved blood flow to the legs and decreased risk of
blood clots
• Decreased nausea • Known cardiac, pulmonary or metabolic disease
• Fewer symptoms of fatigue • Two or more of the risk factors for cardiac disease such
• Improved flexibility and strength as elevated cholesterol levels, smoking, hypertension or
diabetes mellitus
• Improved self-esteem
• One or more of the following signs/symptoms of cardiac
• Enhanced self-confidence and independence disease such as dizziness, chest pain, irregular heart
• Lower risk of anxiety and depression rates or rhythms, or shortness of breath
• Better weight control • Chemotherapy agents that are toxic to the heart or lung
Though the ideal level of exercise for individuals with such as doxorubicin hydrochloride (Adriamycin) or
cancer has not yet been determined, an effective exercise bleomycin sulfate (Blenoxane)
program should be customized for the individual’s current • RT that may have caused pulmonary fibrosis, pneumo-
level of fitness/functioning and include activities directed nitis or pericarditis
at improving aerobic conditioning, muscular strength, and As discussed earlier in this section, research has found
flexibility. that moderate-intensity aerobic exercise training was benefi-
Exercise Testing and Prescription cial to individuals with cancer. Moderate exercise is defined
as activity that takes as much effort as a brisk walk.28 Two
For individuals with cancer, whether they are currently
of the methods for determining training heart rate (HR) for
undergoing active treatment or have had cancer in the past, it
aerobic exercise training are the heart rate reserve (HRR)
is absolutely essential that a complete history, systems review,
also known as the Karvonen method and the maximum
and examination (including functional exercise testing) be
heart rate (HR max). These methods can be difficult to use
performed prior to beginning any exercise program. When
in this population since individuals with cancer may have
managing individuals with cancer the focus is on identify-
inappropriate HR responses to exercise and large physiologic
ing signs and symptoms that would indicate the cancer itself
changes on a day-to-day basis from the disease, their treat-
and/or the cancer treatments have had an impact on cardio-
ments or changes in medications.14 Alternative methods for
respiratory function, muscular performance, the integumen-
determining exercise intensity in this population include HR
tary system, sensory integrity, and functional abilities.
response based on O2 consumption or metabolic equivalent
Exercise testing prior to beginning an exercise program
(MET) levels and Borg’s Rating of Perceived Exertion Scale
is essential in this population. An exercise test will assess
(RPE). Drouin and Pfalzer14 have suggested 3 intensities of
whether it is safe for an individual with cancer to begin an
exercise training for individuals with cancer (Table 13-2).
exercise program and provide the data that will allow for the
The high- and moderate-intensity aerobic exercise training
design of an individualized exercise prescription.14 The exer-
should be preceded by a 5- to 10-minute warm-up period27
cise test performed in this population is typically a submaxi-
and followed by a 5- to 10-minute cool-down period.14,27
mal test. These submaximal exercise tests can be field tests,
The generalized weakness and deconditioning associated
clinical tests or the more formal graded exercise test. Field
with cancer treatments can be more debilitating than the
tests provide information on a subject’s fitness category and
disease itself and not every person with cancer will be able
include the 6- and 12-Minute Walk Tests, the Cooper 1.5 Mile
to participate in moderate intensity aerobic exercise training.
Walk Test, the Rockport Fitness Test, and the 12-Minute Run
Though 30 minutes per day of exercise training is optimal,
Test. Clinical exercise tests such as the Timed Up & Go Test,
this may not be possible for severely deconditioned indi-
the Modified Shuttle Walk, and the Bag and Carry Test pro-
viduals. Research has demonstrated that cardiorespiratory
vide additional information on coordination, balance, and
fitness gains are similar when physical activity is divided
motor planning. Submaximal graded exercise tests appropri-
into 3 10-minute sessions and would be an option for get-
ate for individuals with cancer include the Modified Bruce
ting these individuals started on an aerobic exercise training
Treadmill Test, the Astrand-Rhyming Cycle Ergometer Test
program.28 Individuals who are confined to bed or who are
as well as the Single Stage Submaximal Walking Test. Graded
ambulating less than 50% of the time5 and those who fatigue
exercise testing provides good predictive information on the
with mild exertion may benefit from low levels of physical
individual’s maximal oxygen (O2) consumption and level of
activity such as ROM exercises and gentle resistance exercises
fitness. As always, the history and systems review will direct
until their tolerance for activity improves.5,14
the selection of the appropriate exercise test for each indi-
vidual. Graded exercise tests are appropriate for individu- The goal of exercise in individuals recovering from cancer
als with a complex medical history or when there is a need treatments or in remission is to return them to their prior
to assess potential risk factors associated with performing level of function both physically and psychologically. For this
exercise. The American College of Sports Medicine (ACSM) population participation in aerobic exercise training can lead
recommends examination of the cardiovascular system with to improved fitness, physical work capacity, and cardiovascu-
a graded exercise test with 12-lead electrocardiogram (EKG) lar response to exercise. They typically begin with moderate
in individuals with any of the following: intensity exercise training and then progress to increased
levels of training.14
540 Chapter 13
TABLE 13-2. SUGGESTED INTENSITIES OF EXERCISE TRAINING FOR INDIVIDUALS WITH CANCER
EXERCISE PRESCRIPTION
High-intensity training (to promote fitness) 30 to 45 minutes, 3 to 5 days per week RPE 14 to 16
70 to 90% of HRmax (60% to 85% HRR)
Moderate-intensity training (to promote Accumulate 30 minutes most days per week RPE 11 to 13
health) 50% to 70% HRmax (40% to 60% HRR)
Low-intensity training (activity to maintain 3 to 5 minutes of activity that is well tolerated Gradually increase
function and prevent deconditioning) several times per day or below 50% of HRmax exercise duration
and intensity
RPE: rate of perceived exertion; HRR: heart rate reserve; HRmax: maximum heart rate.
Adapted from Drouin J, Pfalzer, L. Cancer and Exercise. National Center on Physical Activity and Disability (NCPAD). March 5, 2009.
http://www.ncpad.org/disability/fact_sheet.php?sheet=195. Accessed May 14, 2010.
General Considerations should have their electrolytes checked prior to initiating

exercise.
There are certain precautions and contra-indications spe-
cific to cancer patients14,27: • If patients still have a catheter in place, resistance train-
• Monitoring vital signs during exercise is essential in ing that use muscles in the area of the catheter should
the immunosuppressed population. Cancer patients be avoided.
should be watched closely for signs of cardiopulmonary • Patients should be advised to contact their physician if
compromise including dyspnea, pallor, diaphoresis, and they experience any of the following abnormal responses
fatigue during exercise. Patients should be instructed to including fever; extreme or unusual fatigue; unusual
monitor their pulse rate, respiratory rate, and BP when muscular weakness; irregular heartbeat; palpitations;
exercising on their own. chest pain; leg pain or cramps; unusual joint pain;
• The RPE should not exceed 11 (light) to 13 (somewhat unusual bruising or nosebleeds; sudden onset of nausea
hard) for moderate-intensity training or submaximal during exercise; rapid weight loss; severe diarrhea or
testing. vomiting; disorientation; confusion; dizziness; light-
headedness; blurred vision; fainting; pallor; night pain
• Patients should be advised not to exercise within 2 hours or pain not associated with any injury.
of chemotherapy or RT. Increased circulatory response
Finally, it is important to remember that in this popula-
resulting from exercise may have a potentially negative
tion exercise is something that individuals can do to exert
impact on the patient.
some control over their care and their body. It’s something
• In the presence of anemia, adjustments may need to they can do for themselves, not something that is done to or
be made in exercise intensity and duration because of for them.
increases in pulse and respiratory rates from hypoxia, Management by physical therapists of this population is
which may lead to fatigue with minimal exertion. directed toward identifying the multi-system impact of can-
Interval exercise with frequent, short sessions through- cer as it affects the musculoskeletal, neuromuscular, cardio-
out the day may be more appropriate in the presence of vascular, and pulmonary systems to produce impairments
anemia. that affect movement and functional performance. Physical
• Hematological values (hematocrit, hemoglobin, white therapy interventions are directed toward prescribing treat-
blood cells, and platelets) must be monitored in patients ment programs and interventions to reduce or alleviate
undergoing active treatment to determine if exercise impairments and functional limitations.
may be initiated.
• In patients with compromised skeletal integrity, non-
weightbearing activities such as cycling, rowing, and DIABETES MELLITUS
swimming may be a better choice. However, water
activities may not always be appropriate for the immu- Diabetes mellitus (DM) is a group of metabolic diseases
nosuppressed population. In the presence of impaired marked by hyperglycemia (high levels of blood glucose) and
sensation, a stationary bicycle would be a better choice the development of long-term macrovascular, microvascular,
to lessen the risk of falls. and neuropathic complications. It is a disorder of carbo-
• In patients who have had severe bouts of vomiting or hydrate, protein, and fat metabolism that results from an
diarrhea, there may be an electrolyte imbalance and they imbalance of insulin availability and insulin need.1 There
are 3 main types of diabetes, Type 1 diabetes, Type 2 diabetes
TABLE 13-3. PLASMA GLUCOSE LEVELS

TEST NORMAL PREDIABETES (IMPAIRED DIABETES
GLUCOSE TOLERANCE)
Fasting Plasma < 100 mg/dl (5.6 mmol/l) 100 to 125 mg/dl (5.6 to 6.9 ≥ 126 mg/dl (7.0 mmol/l)*
Glucose Test (FPG) mmol/l)
Oral Glucose < 140 mg/dl (7.8 mmol/l) 140 to 199 mg/dl (7.8 to 11.0 ≥ 200 mg/dl (11.1 mmol/l)*
Tolerance Test (OGTT) mmol/l)
*Positive test results on any of these 3 tests should be confirmed with a second test on a different day.
Adapted from Porth CM. Essentials of Pathophysiology: Concepts of Altered Health States. 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2007; American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2010;33:S62-S69.
and gestational diabetes mellitus (GDM). In addition, there diagnosing prediabetes, but it is less convenient to administer.
are other types of diabetes that result from specific genetic It measures blood glucose levels after at least 8 hours with-
conditions, surgery, medications, infections, pancreatic dis- out eating and 2 hours after drinking a beverage containing
ease, and other illnesses. These types of diabetes account for 75 grams of glucose dissolved in water.29,33 Both the FPG
1% to 5% of all cases diagnosed.29 and OGTT are used to detect diabetes and prediabetes, but
the Random Plasma Glucose Test, also known as the casual
Prediabetes plasma glucose test, in combination with symptom assess-
ment (increased urination, increased thirst, unexplained
Prediabetes is a condition in which blood glucose levels weight loss) is used solely to diagnose diabetes.33 It measures
are elevated, but are not high enough to be classified as dia- blood glucose levels without regard to when an individual
betes. Please refer to Table 13-3 Plasma Glucose Levels.1,30 last ate. Positive tests results on any of these 3 tests should be
Individuals with prediabetes have impaired fasting glucose confirmed by repeating either the FPG or OGTT on a differ-
(IFG) or impaired glucose tolerance (IGT) or sometimes both ent day (Table 13-4). Gestational diabetes is diagnosed using
and are at increased risk for developing Type 2 diabetes, heart the OGTT and based on plasma glucose values. When testing
disease, and stroke.29 IFG and IGT are associated with meta- for gestational diabetes, it is preferable to use 100 grams of
bolic syndrome. Metabolic syndrome is defined as a collec- glucose in liquid for the test. Blood glucose levels are checked
tion of risk factors that include obesity (especially abdominal 4 times during the test. Blood glucose levels that are above
or visceral obesity), dyslipidemia of the high-triglyceride and/ normal on at least 2 of these tests indicate that the woman
or low-high-density lipoprotein (HDL) type and hyperten- has gestational diabetes. It is also important to note that in
sion in addition to insulin resistance or glucose intolerance. 2009 an international expert committee recommended the
Elevated levels of insulin and glucose are linked to damage to use of the hemoglobin A1C assay for the diagnosis of diabe-
the lining of coronary and other arteries, which is a key step tes.34 The committee determined that an A1C value of 6.5%
in the development of heart disease, stroke, and peripheral or greater should be used for the diagnosis of diabetes. The
vascular disease (macrovascular complications).30-32 Having committee’s findings were referred to practice groups for
prediabetes does not have to mean that the development of review of the implications and for further recommendations.
Type 2 diabetes is inevitable. Studies have shown that indi-
viduals with prediabetes who lose weight and increase their
physical activity can prevent or delay diabetes29,33 and even
Epidemiology
return their blood glucose levels back to normal.29 In 2008 United States Statistic reports, ~1.6 million new
cases of diabetes were diagnosed in people aged 20 years and
Diagnosis: Diabetes, Prediabetes, and older in 2007.29 It is estimated that 23.6 million people or
7.8% of the United States population, have diabetes. Of those
Gestational Diabetes 23.6 million people, 17.9 million have been diagnosed with
diabetes and 5.7 million have yet to be diagnosed. There are
The Fasting Plasma Glucose Test (FPG), the Oral Glucose
approximately 186,300 people aged 20 and younger who have
Tolerance Test (OGTT), and the Random Plasma Glucose
diabetes (Type 1 or Type 2). This corresponds to 0.2% of all
Test are the 3 tests most commonly used to diagnose diabe-
people in this age group. Although Type 2 diabetes is still
tes.33 The FPG is the preferred test to diagnose diabetes. It is
rare in this age group, it is being diagnosed more frequently
convenient and is most reliable when done in the morning. It
in children and adolescents of American Indian, African
measures blood glucose levels after at least 8 hours without
American, Hispanic/Latino American, and Asian/Pacific
eating. It will, however, miss some diabetes or prediabetes
Islander descent. For Americans living in the United States
that can be found with the OGTT. Studies have demon-
who are age 20 years and older, 23.5 million or 10.7% of all
strated that the OGTT is more sensitive than the FPG test for
people in this age group have diabetes. For Americans age
542 Chapter 13
TABLE 13-4. HOW DIABETES AND PREDIABETES ARE DIAGNOSED

TEST TEST DESCRIPTION DIAGNOSIS
Fasting Plasma The FPG is the preferred test to diagnose diabetes. It is convenient and is Diabetes or pre-
Glucose Test most reliable when done in the morning. It measures blood glucose levels diabetes
(FPG) after at least 8 hours without eating.*
Oral Glucose The OGTT is more sensitive than the FPG test for diagnosing prediabetes, Diabetes or pre-
Tolerance Test but it is less convenient to administer. It measures blood glucose levels diabetes
(OGTT) after at least 8 hours without eating and 2 hours after drinking a beverage
containing glucose.*
Random Plasma This test along with an assessment of symptoms is used only to diagnose Diabetes
Glucose Test diabetes. It measures blood glucose levels without regard to when an
individual last ate.*
*Positive test results on any of these 3 tests should be confirmed with a second test on a different day.
Adapted from National Institute for Diabetes and Digestive and Kidney Diseases. Diagnosis of diabetes. NIH Publication No. 09-4642,
October 2008.
60 years or older, 12.2 million or 23.1% of all people in this to transport glucose into either fat or muscle cells and glu-
age group have diabetes. cose continues to accumulate in the blood.1,5 The result is
fuel deprivation and essential starvation of the body’s cells
Associated Morbidity/Mortality and an increase in the breakdown of fat and protein.1 The
kidneys attempt to compensate for the imbalance in blood
Diabetes is the sixth leading cause of death in the United glucose accumulation and restore normal levels by excreting
States and the fifth leading cause of death by disease.7 the excess glucose in the urine. Excess glucose in the urine
Diabetes, however, is likely to be underreported as a cause of acts as an osmotic diuretic, which causes the excretion of an
death. Studies have reported that only 35% to 40% of those increased amount of water as well.5
individuals with a history of diabetes had diabetes listed When glucose is not available to serve as fuel for the cell,
anywhere on their death certificate and only 10% to 15% had the body relies on fat stores for energy.5 Fat cell breakdown
it listed on their death certificate as the underlying cause of and mobilization results in the formation of breakdown
death.29 For example, coronary heart disease, stroke, and products known as ketones. Ketones accumulate in the
end-stage renal disease are all complications of diabetes that blood and are excreted via the kidneys and lungs. Ketones
may be listed as the cause of death while the diagnosis of produce hydrogen ions. The production of hydrogen ions
diabetes goes unlisted. It is estimated that the overall risk by the ketones increases the acidity of blood and interferes
for death among individuals with diabetes is approximately with acid-base balance. Accumulation of hydrogen ions
twice that of individuals without diabetes of a similar age. can cause the blood pH to fall and can result in metabolic
acidosis. When the renal threshold for ketone metabolism
Associated Costs is exceeded, the overflow ketones appear in the urine as
acetone (ketonuria). Excretion of a large amount of glucose
The overall costs for diabetes are substantial. In 2007, the and ketones increases osmotic diuresis, resulting in fluid and
total cost (direct and indirect) for diabetes was estimated at electrolyte loss via the kidneys. Critical electrolyte loss that
$174 billion; $116 billion went to direct medical costs and occurs when potassium and sodium are excreted in the urine
$58 billion for indirect costs (disability, work loss, premature can produce severe dehydration, electrolyte deficiency, and
mortality).29,35 worsening acidosis. Additionally, when fats are metabolized
as the primary source of energy, there may be an increase in
Pathology/Pathophysiology the circulating lipid level to 5 times the normal amount. This
significant elevation of blood lipids can contribute to the
Insulin Metabolism development of atherosclerosis and its resultant cardiovascu-
The body uses glucose, fatty acids, and other substrates lar complications.
as the source of fuel to provide for the body’s energy needs.1 Insulin is also required for the transport of amino acids
Insulin and glucagon control the body’s energy metabolism. (the building blocks of proteins) into cells.5 Under normal
It is insulin, however, that has the effect of lowering the blood circumstances, proteins are continually being broken down
glucose level. It lowers blood glucose levels by increasing the and rebuilt. In the absence of insulin to transport amino
transport of glucose into body cells and by decreasing the acids into the cells, the balance between building and break-
production and release of glucose into the bloodstream by down is altered and there is an increase in protein catabo-
the liver. An individual with uncontrolled diabetes is unable lism. The loss of protein that results from protein catabolism
interferes with the inflammatory response process and the is used to describe those cases of beta cell destruction where
tissue’s ability to repair itself. no evidence of autoimmunity is present. What differentiates
Another metabolic role for insulin relates to its effect on Type 1a from Type 1b is the presence of islet autoantibod-
the smooth muscle tone in arterial walls. Insulin is a directly ies.38 Only a very small percentage of individuals with Type
acting arterial vasodilator.36 It relaxes arterial wall muscles 1 diabetes have Type 1b and most are usually of African or
thus increasing blood flow. In the absence of adequate insu- Asian descent.1.
lin, blood flow, especially in the microvascular system, is It is estimated that Type 1 diabetes accounts for 5% to 10%
reduced because of contraction of the arterial wall muscles. of all diagnosed cases of diabetes29 and of those, 95% have
During exercise there can be as much as a 20-fold increase Type 1a diabetes.1 Type 1 diabetes is usually diagnosed in
in whole body O2 consumption depending on the inten- children and young adults, although onset can occur at any
sity and duration of activity. It is thought that even greater age (Table 13-5). The onset of Type 1 diabetes is often sudden.
increases may occur in the working muscles.37 To meet the In addition to the common symptoms, nausea, vomiting or
energy requirement of increased O2 consumption, skeletal stomach pains often accompany the abrupt onset of Type 1
muscles increase the utilization of glycogen and triglyceride diabetes.39 The risk factors for Type 1 diabetes are less clear
fuel stores as well as relying on free fatty acids resulting from than those for Type 2 or GDM, but autoimmune, genetic,
the breakdown of triglycerides in adipose tissue and glucose and environmental factors are involved in developing Type 1
released from the liver. Blood glucose levels are remark- diabetes (Table 13-6).29
ably well maintained during exercise with hypoglycemia Type 2 Diabetes
rarely occurring in nondiabetic individuals. This is possible
because of hormonally mediated metabolic adjustments that Type 2 diabetes was previously known as noninsulin-
occur during exercise.5,37 Hepatic glucose production is dependent DM or adult-onset diabetes, though it can occur
triggered by a decrease in plasma insulin and the presence at any age, even during childhood. Ninety percent to 95%
of glucagon during exercise.37 During periods of prolonged of all diagnosed cases of diabetes are Type 2.29,30 This type
exercise, increases in plasma glucagon and catecholamines of diabetes usually begins as insulin resistance. In insulin
provide the necessary glucose for use by muscles and other resistance, the muscle, liver, and fat cells do not utilize insu-
body tissues.5,37 lin properly. Initially the pancreas is able to keep up with
Insulin-deficient patients with Type 1 diabetes aren’t able the additional demand by producing more insulin. In time,
to make these hormonal adjustments during exercise.5,37 however, the pancreas gradually loses the ability to produce
Because insulin-deficient individuals routinely have a low sufficient insulin in response to the demand placed on it by
circulating insulin level, the active cells essentially sense meals. Development of Type 2 diabetes is associated with
impending starvation or lack of fuel, which triggers the advancing age, obesity, family history of diabetes, history
release of an excessive amount of glucagon and catechol- of GDM, impaired glucose metabolism, physical inactiv-
amines. Release of these hormones stimulates a further ity, and race/ethnicity. The risk factors for Type 2 diabetes
increase in glucose mobilization, which significantly increas- that cannot be modified are age, previous history of GDM,
es the already high circulating levels of glucose and ketones, family history, and race/ethnicity. Type 2 diabetes usually
compounding the problem. This may precipitate ketoacidosis develops more insidiously than Type 1 diabetes, and many
if the hyperglycemia and ketosis are at a sufficiently high individuals with Type 2 diabetes have no signs or symp-
level and/or if the individual is dehydrated. When high levels toms. Or, symptoms may be so mild that they are ignored.
of insulin are present in these same individuals as a result The symptoms of Type 2 diabetes (see Table 13-5) include
of insulin administration, this can ease or even prevent the increased urination, increased thirst, fatigue, blurred vision,
increased mobilization of glucose and other substrates that and frequent infections and sores that are slow to heal. At
are induced by exercise, and hypoglycemia may result.37 times the diagnosis of diabetes is not made until someone
Though this is possible in individuals with Type 2 diabetes seeks treatment for a complication of diabetes such as blurred
who take insulin or sulfonylurea therapy, it tends to be less vision (microvascular complication) or heart disease (macro-
of a problem in this group. In this population, exercise is vascular complication).
thought to improve insulin sensitivity and assist in bringing Gestational Diabetes Mellitus
elevated plasma glucose levels into the normal range.5,37 GDM is a form of glucose intolerance that is first diag-
Type 1 Diabetes nosed during pregnancy. It is thought to be caused by the
Type 1 diabetes was previously known as insulin-depen- hormones of pregnancy that block the action of the mother’s
dent DM or juvenile-onset diabetes. In Type 1 diabetes, the insulin, making it difficult for insulin to do its job of con-
beta cells of the pancreas have been destroyed by the body’s trolling blood sugar or by insufficient production of insulin
immune system. The beta cells are the only cells that produce to meet the demands of pregnancy. GDM develops when
insulin, the hormone that regulates blood glucose. Type 1 the pancreas is unable to produce sufficient insulin to keep
has been further subdivided into Type 1a and Type 1b.1 Type blood glucose levels within an acceptable range. GDM occurs
1a, immune-mediated diabetes, is characterized by autoim- more frequently among African Americans, Hispanic/Latino
mune destruction of beta cells. Type 1b, idiopathic diabetes, Americans, and American Indians.29 Asian Americans and
544 Chapter 13
TABLE 13-5. SIGNS AND SYMPTOMS OF DIABETES

SIGN/SYMPTOM TYPE 1 TYPE 2 GESTATIONAL DIABETES
MELLITUS (GDM)
Polyuria (excessive Yes Yes Yes, though most pregnant
urination) women have to urinate
more frequently.
Polydipsia (excessive Yes Yes Yes
thirst)
Polyphagia (excessive Yes Is usually not present in people with Type 2 Yes, though most pregnant
hunger) diabetes. women feel hungrier.
Unexpected weight Yes Yes, but more common in Type 1. Many people
loss with Type 2 have problems with obesity.
Blurred vision Yes Yes. This is frequently a symptom that prompts Yes
an individual to seek medical treatment.
Numbness or tingling Yes Yes. This is frequently a symptom that prompts
in hands or feet an individual to seek medical treatment.
Fatigue Yes Yes. This is frequently a symptom that prompts
Very dry skin Yes Yes
Sores that are slow to Yes Yes
heal
Frequent infections Yes Yes. This is frequently a symptom that prompts
Often asymptomatic Yes Yes. Many women are sur-
prised to learn that they
have GDM since they fre-
quently have no symptoms.
Adapted from Porth CM. Essentials of Pathophysiology: Concepts of Altered Health States. 2nd ed. Philadelphia, PA: Lippincott Williams
& Wilkins; 2007; Goodman CC, Boissonnault WG, Fuller KS. Pathology: Implications for the Physical Therapist. 2nd ed. Philadelphia, PA:
Saunders; 2003; Centers for Disease Control and Prevention. Basics about diabetes. March 12, 2010. http://www.cdc.gov/diabetes/consum-
er/learn.htm#. Accessed May 29, 2010; BC HealthGuide. Gestational diabetes. February 10, 2010. http://www.bchealthguide.org/kbase/
topic/special/hw197466/sec5.htm. Accessed May 29, 2010.
Pacific Islanders are also at greater risk for developing Complications

GDM.40 Obese women and women with a family history of
diabetes are also at greater risk for developing GDM29 as are Diabetes is associated with significant complications.
women who have had GDM during an earlier pregnancy or These complications can be divided into acute and chronic
who have given birth to at least one baby weighing more than complications. The acute complications of diabetes include
9 pounds.40 Frequently, there are no symptoms and women diabetic ketoacidosis and hyperosmolar (nonketotic) coma.
are surprised to learn that they have GDM. When they do Uncontrolled diabetes often leads to biochemical imbalances
have symptoms they may include increased thirst, increased that can cause these life-threatening events. In addition to
urination, increased hunger, and blurred vision.41 GDM the acute complications listed above, the CDC in its 2007
requires treatment to normalize maternal blood glucose National Diabetes Fact Sheet29 reported specific complica-
levels to avoid complications in the unborn child. Five per- tions of diabetes in the United States (Table 13-7).
cent to 10% of women with GDM are found to have Type 2
diabetes after pregnancy.29 In addition, women who have had Physical Therapy Management
GDM have a 40% to 60% chance of developing diabetes in the
next 5 to 10 years. At present, there is no known cure for diabetes.
Management is directed at regulation of blood glucose levels
and usually includes a combination of dietary management,
TABLE 13-6. RISK FACTORS FOR TYPE 1, TYPE 2, AND GESTATIONAL DIABETES MELLITUS
Type 1 diabetes ● The risk factors for Type 1 DM are less clear than those for Type 2 DM or GDM, but
mellitus risk factors autoimmune, genetic, and environmental factors are involved in developing Type 1
diabetes.
Type 2 diabetes ● Family history of diabetes (parent, brother, or sister)
mellitus risk factors ● Physical inactivity
● Race/ethnicity: African American, Alaska Native, American Indian, Asian American,
Hispanic/Latino American, or Pacific Islander
● Overweight or obese
● Older age (45 years or older)
● History of GDM or delivery of at least one baby weighing more than 9 pounds
● Hypertension (greater than or equal to 140/90 mm Hg in adults) or being treated for
high blood pressure
● HDL cholesterol < 35 mg/dL and/or triglyceride level > 250 mg/dL
● Previous history of impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)
● Polycystic ovary syndrome (PCOS)
● Acanthosis nigricans, a condition characterized by a dark, velvety rash around the
neck or armpits
● History of cardiovascular disease
Gestational dia- ● Family history of diabetes (parent, brother, or sister)
betes mellitus risk ● Race/ethnicity: African American, Hispanic/Latino American, American Indian, Asian
factors American, or Pacific Islander
● Age (25 or older)
● Obesity
● History of GDM or delivery of at least one baby weighing more than 9 pounds
● Diagnosis of prediabetes
DM: diabetes mellitus; HDL: high-density lipoprotein.
Adapted from Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates
on diabetes in the United States, 2007. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and
Prevention, 2008. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf; National Institute for Diabetes and Digestive and Kidney
Diseases. Diagnosis of diabetes. NIH Publication No. 09-4642, October 2008; National Institute of Diabetes and Digestive and Kidney
Diseases. What I need to know about gestational diabetes. NIH Publication No. 06-5129, April 2006.
exercise, and antidiabetic drugs with the goal of keeping test. Results of this test reflect average blood glucose over a
blood glucose, lipid, and BP at normal levels. Education 2- to 3-month period.
is an essential component in the management of diabetes. Type 2 diabetes is most frequently managed with proper
Individuals with diabetes must understand the relationship nutrition and exercise, sometimes in conjunction with oral
among food intake, exercise, medication, and blood glucose. medication. Insulin may be required when adequate control
Dietary Management of blood glucose levels cannot be achieved with oral medica-
tions. Weight loss, if indicated, is also an important manage-
Individuals with Type 1 diabetes require insulin supplement tool.
mentation. The amount of insulin required to maintain
blood sugar is variable and is determined by food intake Managing Medications With Exercise
and physical activity. Patients with Type 1 diabetes are The benefits of exercise are well known. For individuals
encouraged to eat consistent amounts and types of food at with Type 2 diabetes, the benefits of a regular exercise pro-
specific and routine times. Blood glucose levels are closely gram include an increase in carbohydrate metabolism, which
monitored. This is performed daily with home monitoring results in lower plasma glucose levels,5 better weight control,
devices and several times per year with the A1C laboratory decreased body fat, increased HDL,5 decreased triglycerides,5
546 Chapter 13
TABLE 13-7. COMPLICATIONS OF DIABETES

Heart disease In 2004, heart disease was listed on 68% of diabetes-related death certificates and stroke was
and stroke listed on 16% of diabetes-related death certificates in individuals aged 65 years and older.
Adults with diabetes die of heart disease 2 to 4 times more frequently than adults without
heart disease, and their risk for stroke is 2 to 4 times higher.
Hypertension In 2003 to 2004, 75% of adults with self-reported diabetes had blood pressure readings great-
er than or equal to 130/80 mm Hg or took prescription medications to control hypertension.
Blindness Among adults aged 20 to 74 years of age, diabetes is the leading cause of new cases of
blindness. Diabetic retinopathy results in 12,000 to 24,000 new cases of blindness each year.
Kidney disease Diabetes is the leading cause of kidney failure. In 2005, diabetes accounted for 44% of the
new cases of kidney failure.
Nervous It is estimated that 60% to 70% of individuals with diabetes have mild to severe forms of ner-
system disease vous system involvement including impaired sensation or pain in the hands or feet, slowed
digestion of food in the stomach, carpal tunnel syndrome and erectile dysfunction. Close to
30% of individuals with diabetes aged 40 years or older have impaired sensation in their feet.
Severe diabetic neuropathy is a major contributing factor to lower extremity amputations.
Amputations More than 60% of nontraumatic lower limb amputations occur in individuals with diabetes.
In 2004, 71,000 nontraumatic lower-limb amputations were performed in individuals with
diabetes.
Dental disease Periodontal disease is more common in people with diabetes than in the general population
with almost one-third having severe periodontal disease. Young adults with diabetes have
approximately twice the risk of periodontal disease compared to those without diabetes.
Complications When diabetes is poorly controlled before conception and during the first trimester of preg-
of pregnancy nancy there is the risk of major birth defects in 5% to 10% of these pregnancies as well as the
possibility of spontaneous abortions in 15% to 20% of these pregnancies.
Other compli- Individuals with diabetes have also been found to be more susceptible to other illnesses and
cations once they become ill, frequently have poorer prognoses.
Individuals with diabetes aged 60 years or older are 2 to 3 times more likely to report an
inability to walk one-quarter mile, climb stairs, do housework or use a mobility aid when
compared with individuals in their same age group without diabetes.
Adapted from Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates
on diabetes in the Unites States, 2007. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and
Prevention, 2008. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf.
and an improvement in insulin sensitivity.5,37 It has also exercise testing), be performed prior to beginning any exer-
been found to be beneficial in preventing the complications cise program. The history should focus on eliciting any
associated with Type 2 diabetes. In individuals with insulin- signs or symptoms that indicate that the DM has had an
dependent diabetes, the benefits of exercise must be weighed impact on the cardiovascular system, eyes, kidneys, feet,
with the increased risk of hypoglycemia.1,5,37 In some indi- and/or nervous system. Impairment of any of these could
viduals, the symptoms of hypoglycemia may occur hours have a deleterious effect on movement-related functions.
after completing their exercise. They need to be aware that The examination should screen for the presence of macro-
this is a possibility and that they may need to adjust their dia- vascular, microvascular or neuropathic complications of DM
betes medication dose, their carbohydrate intake, or both.1,5 that could significantly affect and alter the performance of
This is something the physical therapist must consider when exercise such as heart disease, peripheral vascular disease,
prescribing and administering exercise programs in indi- retinopathy, nephropathy, peripheral neuropathy, and auto-
viduals with altered insulin metabolism. nomic neuropathy. Examination of the cardiovascular sys-
tem with a graded exercise test with EKG may be indicated if
Physical Therapy/Exercise Testing and
the individual is at risk for underlying cardiovascular disease
Prescription (CVD) based on any of the following criteria37,42:
For an individual with the pathologic diagnosis of either • Initiating exercise > 60% HR max or > brisk walking
Type 1 or Type 2 diabetes, it is essential that a complete his-
• Age > 35
tory, systems review, and examination, (including functional
• Age > 25 years and In individuals with Type 1 diabetes, vigorous activity is
◦ Type 2 diabetes of > 10 years’ duration avoided in the presence of hyperglycemia and ketosis.43 In
individuals with Type 2 diabetes, it has not been deemed nec-
◦ Type 1 diabetes of > 15 years’ duration essary to postpone exercise solely based on blood glucose lev-
• Additional risk factors for coronary artery disease els > 300 mg/dl, particularly in a postprandial state provided
(CAD), eg, BP > 140/90, smoking, dyslipidemia or family the individual feels well, is adequately hydrated, and there is
history of premature CAD no evidence of ketosis. As previously discussed, hypoglyce-
• Presence of any complications of diabetes (eg, retinopa- mia is a possibility in individuals with Type 1 diabetes.1,5,37
thy, nephropathy, peripheral neuropathy) Consequently, there is a need to adjust diabetes medication
dosing and potentially carbohydrate intake to balance the
• Peripheral vascular disease metabolic response to exercise.1,5 Postexercise hypoglycemia
• Autonomic neuropathy is also a possibility in individuals with Type 2 diabetes who
Individuals with known CAD require a diagnostic evalu- take insulin or sulfonylurea therapy, though it tends to be less
ation to assess for an ischemic response to exercise, identify of a problem in this group.37
the ischemic threshold, and to test for the predisposition In 1996 the United States Surgeon General’s report recom-
to arrhythmia during exercise.37 This diagnostic evalua- mended that all people participate in aerobic activity of mod-
tion specifically focuses on evaluation of left ventricular erate intensity for at least 30 minutes on most, if not all, days
function at rest and during exercise. Resting tachycardia of the week.28,43 Currently, the recommended frequency of
(HR > 100 beats per minute), orthostasis, failure of the heart aerobic training for this population is 4 to 7 days per week,
rate to increase during exercise or undesirable exercise- or every other day.42,43 General recommendations of this
induced elevation of blood pressure may be indicative of type assume a lack of movement-related impairment and
autonomic neuropathy.37,42 are generally prescribed using a generic formula intended to
Caution must be taken before proceeding with an exercise address the general population. For example, exercise inten-
program in individuals with some specific complications of sity for an aerobic training program can be calculated using
diabetes including retinopathy, peripheral neuropathy, auto- Karvonen’s formula (HR reserve): [(HRpeak – HR rest) × (40%
nomic neuropathy, and nephropathy.43 In individuals with to 70%)] + HRrest,42 which assumes that an exercise test has
proliferative or severe nonproliferative diabetic retinopathy, been performed that documented the resting and peak exer-
vigorous aerobic or resistance exercise may be contraindi- cise HR and that there were no untoward responses in HR,
cated because of the risk of triggering vitreous hemorrhage BP, or other signs and symptoms of a pathologic response.
or retinal detachment. In the presence of impaired pain The duration and frequency of this aerobic training pre-
sensation of the extremities there is obviously increased risk scription can then be set at 20 to 30 minutes, preceded by
of skin breakdown and infection as well as Charcot joint a 5- to 10-minute warm-up period, and followed by a 5- to
destruction. Therefore, it may be prudent to encourage activi- 10-minute cool-down period, and performed 3 to 5 times
ties that do not involve weightbearing such as swimming or per week.37,42,43 These general guidelines are a reasonable
bicycling. In individuals with autonomic neuropathy there starting point for patients with a history of diabetes; how-
can be an increased risk of exercise-induced injury as a result ever, the essential individual changes in prescription will be
of decreased cardiac responsiveness to exercise (blunting of made as a result of the actual exercise test findings. Exercise
BP and HR response to exercise),42,43 postural hypotension, testing, (as described in Chapter 6 and discussed in Chapter
impaired thermoregulation resulting from impaired skin 7), is appropriate and necessary in this population. Given the
blood flow and sweating, impaired night vision, and impaired abnormalities associated with glucose mobilization and cel-
thirst with an increased risk of dehydration and gastroparesis lular uptake, careful monitoring of blood sugar and insulin
with unpredictable food delivery.37,43 There is a strong asso- levels is essential to prescribing a safe and effective level of
ciation between autonomic neuropathy and CVD in individu- exercise for these patients.
als with diabetes.43 It is recommended that individuals with To improve glycemic control, assist with weight mainte-
diabetic autonomic neuropathy undergo cardiac investiga- nance, and reduce the risk of CVD, the American Diabetes
tion prior to increasing their physical activity beyond their Association (ADA) recommends at least 150 min/week of
usual level of activity. In addition, these individuals are also moderate intensity aerobic training (40% to 60% of maxi-
at risk for silent ischemia (dyspnea, diaphoresis, orthostasis) mum O2 consumption (VO2max) or 50% to 70% of HR max)
and must be closely monitored during exercise.42 There can and/or at least 90 min/week of vigorous aerobic exercise
also be an increase in urinary protein excretion with physical (> 60% of VO2max or > 70% of HR max.43 The duration of
activity.43 This increase is in proportion to the acute increase aerobic training should be 20 to 30 minutes with an addi-
in BP. Microalbuminuria and proteinuria are associated with tional 5- to 10-minute warm-up and cool down.42 Blood
an increased risk of CVD in individuals with a history of these glucose monitoring is an essential part of the aerobic train-
conditions. In previously sedentary individuals with diabetic ing program for the individual with diabetes (Table 13-8).42
nephropathy, it is important to perform an exercise EKG stress Though hypoglycemia is the most common problem for
test before they begin an exercise program that will be signifi- diabetics who exercise, hyperglycemia is also a risk, espe-
cantly more demanding than their usual level of activity. cially for those individuals with Type 1 diabetes who are not
548 Chapter 13
TABLE 13-8. MONITORING AND MANAGING

BLOOD GLUCOSE LEVELS BEFORE AND DURING EXERCISE
BLOOD GLUCOSE WHAT TO DO COMMENTS
< 70 mg/dL Hypoglycemia. Do not exercise. Ingest carbohydrates
70 to 100 mg/dL Snack 15 g of carbohydrates every hour of
moderately intense activity
100 to 300 mg/dL Proceed with exercise program
> 300 mg/dL and on oral meds Try 10 to 15 minutes of activity If BG rises: stop
If BG drops: continue, rechecking every
10 to 15 minutes
> 300 mg/dL and on insulin Should be checked for ketones If (+) ketones: avoid activity
(via urine dip stick or Precision If (‒) ketones: participate with close
Xtra® glucose meter) blood glucose monitoring
Adapted from American Physical Therapy Association. Physical fitness and type 2 diabetes. September 13, 2007. http://www.apta.org/
AM/Template.cfm?Section=PFSP_Pocket_Guides&Template=/MembersOnly.cfm&ContentID=44367. Accessed May 29, 2010.
in glycemic control.44 Carbohydrate intake and or insulin taught to closely monitor their feet for blisters, redness or
injections/infusion should be adjusted prior to beginning to other signs potential injury.37 It is essential that they be well
exercise based on blood glucose levels and exercise intensity hydrated since dehydration can affect blood glucose levels.
to prevent hypoglycemia. In order to avoid the risk of hypo- They should be encouraged to consume adequate fluids (eg,
glycemia associated with exercise, injecting insulin into exer- 17 ounces of fluid 2 hours before exercise) and to continue to
cising limbs should be avoided. Abdominal site injections are drink during exercise. Adequate precautions should be taken
recommended. Increased consumption of carbohydrates may when exercising in extremely hot or cold environments.
be necessary when exercising late in the evening to minimize Management by physical therapists of this population
the risk of nocturnal hypoglycemia. In addition, carbohy- is directed toward identifying the multi-system impact of
drates should be readily available during and after exercise.37 diabetes as it affects the musculoskeletal, neuromuscular,
Studies have also shown resistance training to have cardiovascular, and pulmonary systems to produce impair-
beneficial effects in individuals with Type 2 diabetes.43 ments that affect movement and functional performance.
The strength training prescription for these individuals is Physical therapy interventions are directed toward prescrib-
prescribed in response to examination and exercise testing ing treatment programs and interventions to reduce or alle-
that documents deficiencies that are either generalized or viate impairments and functional limitations.
specific. Functional exercise testing such as a timed stair
climb or the Timed Up & Go assessment can be extremely
useful to elicit deficits and establish a baseline level of per- MUSCULOSKELETAL TRAUMA
formance. Exercise prescription can be made using the over-
load principle and having the subject train at 50% to 60% of The musculoskeletal system accounts for nearly 70%
maximum, or, in severely limited patients, an intermittent of body mass and is subject to a wide array of injuries.1
training program performing the limited task has also been Musculoskeletal injuries result from a variety of physical and
shown to be beneficial. The current recommendations for mechanical forces and include blunt tissue trauma (hemato-
specific resistance training of muscle groups or activities that mas, lacerations, and contusions), disruption of tendons and
are limited are use of an 8 to 10 repetition max beginning ligaments (sprains, strains, and dislocations) and fractures
with one set and progressing to 3 sets.42,43 Exercises should of the bony structures. Factors such as age, environment or
include 8 to 10 of the major muscle groups involved and be activity also play a role and can place an individual at greater
performed 2 to 3 days per week. risk for injury. For example, high-speed motor vehicle acci-
General Considerations dents (MVA) are a common cause of musculoskeletal trauma
in adults younger than 45 years of age with the greatest risk
There are several other important considerations in indi-
in the 16- to 19-year-old age range.1,45 Childhood injuries
viduals with diabetes. The proper footwear and socks are
are most often the result of falls, bicycle-related injuries,
essential to minimize trauma to the feet. The footwear
and sports injuries.1 The most frequent cause of injuries in
should fit properly and have adequate cushioning and sup-
individuals 65 years of age and older is falls.46 Falls are also
port to prevent blisters. The socks should be made of an
the most frequent cause of injury and death and the most
absorbent material to keep the feet dry. Individuals must be
common cause of nonfatal injuries and hospital admissions
for trauma in this population.46,47 Each year approximately Compartment syndrome can occur when there is an
35% to 40% of adults 65 and older experience at least one increase in the compartment’s volume due to trauma, swell-
fall.46 Falls are also the most common cause of fractures and ing, vascular injury, and bleeding or venous obstruction, a
traumatic brain injuries in this age group.47 decrease in the size of the compartment that is associated
with constrictive dressings, casts, closure of fascial defects
Complications of Musculoskeletal or burns, or, a combination of the 2.1,49,50 One of the most
significant causes of CS is the bleeding and edema associated
Trauma with fractures and bone surgery.1 Contusions and soft tissues
are also frequently associated with CS.
The complications associated with musculoskeletal trau-
ma include impaired bone healing (malunion or nonunion), There are 2 types of CS, acute and chronic. Acute CS is
fracture blisters, compartment syndrome, complex regional usually associated with a traumatic event such as a fracture
pain syndrome, and fat embolism syndrome. Please refer to or crush injury. The hallmark symptom of acute CS is severe
Chapter X for information on impaired bone healing. pain that is out of proportion to the injury or physical find-
ings, and does not respond to traditional control methods
Fracture Blisters such as elevation and pain medication.1,51,52 Sensory changes
Fracture blisters are defined as skin bullae and blisters such as numbness, tingling and loss of sensation, diminished
that represent areas of epidermal necrosis with separation reflexes, and motor impairment are indications of nerve
of the epidermis from the underlying dermis by edema compression. Symptoms usually begin within hours of the
fluid.1 The blisters can be either filled with clear fluid or injury, but can be delayed up to 64 hours after injury.1,51
blood.48 They are most frequently associated with severe Muscle necrosis can occur in as little as 4 to 8 hours, mak-
injuries such as those resulting from an MVA or a fall from ing it extremely important that individuals at risk for CS are
a significant height, but can also occur after excessive joint identified and appropriate treatment is initiated.1,52
manipulation, dependent positioning, heat application or Conservative management consists of decreasing the
from peripheral vascular disease.1 Fracture blisters most compartmental pressures and may include splitting a cast
frequently occur at the tibia, ankle, and elbow or areas where or removal of restrictive dressings.1,52 These measures are
there is little soft tissue between the skin and the bone. It is frequently sufficient to reduce much of the underlying
thought that a major factor in the development of fracture pressure and relieve many of the symptoms. Elevation of
blisters is injury to the dermal-epidermal junction caused the extremity to the level of the heart will often reduce the
by excessive shearing of the skin during the mechanism edema. Elevation beyond this is contraindicated because it
of fracture.48 Fracture blisters are associated with a higher will decrease arterial blood flow and narrow the arteriove-
incidence of complications, they delay surgical management, nous pressure gradient, which will worsen the ischemia.52
and there is an increased risk of infection, particularly in When conservative measures fail, a fasciotomy is indicated
individuals with DM. to decompress the compartment, normalize compartment
pressures, and restore blood flow to the affected tissues.
Compartment Syndrome Rhabdomyolysis and subsequent renal failure are the most
Compartment syndrome (CS) occurs when the tissue severe life-threatening complications of CS.51,52
pressure (interstitial pressure) within an enclosed space (eg, Chronic CS also known as chronic exertional compart-
abdominal and limb compartments) is greater than the per- ment syndrome is an overuse injury of the lower extremity.
fusion pressure,1,49 resulting in compromised blood flow and It is typically seen in athletes such as long-distance runners,
muscle and nerve damage. In this chapter, the discussion will basketball players, skiers, and soccer players.52 It most fre-
be limited to a discussion of limb compartment syndrome as quently involves the anterior and lateral compartments.51
an illustration of how this pathology can produce significant Usually an individual is pain free at rest. Chronic CS typi-
impairment issues that need to be addressed by physical cally presents as exercise-induced pain that dissipates quickly
therapy management. when the exercise is stopped. The exact mechanism of injury
Fascia is the inelastic membrane that surrounds and is not fully understood. It is thought that the stress of hard-
separates groups of muscles from one another in the upper surface exercise leads to edema, increasing the compartment
and lower extremities. The area inside this enclosed space is volume with a resultant increase in intramuscular pressure
referred to as a compartment. Each compartment includes that then leads to tissue ischemia and pain.1,51 It is not the
muscle tissue, nerves, and blood vessels. CS can occur when- medical emergency that acute CS is and usually responds
ever increased tissue pressure in a compartment restricts the to conservative management consisting of rest from the
blood flow to the muscles and nerves within that compart- aggravating activity. As in the management of any overuse
ment. If left untreated, the outcome will be tissue ischemia syndrome, ice and elevation may assist with the recovery as
with subsequent necrosis and nerve damage with resultant well as the use of nonsteroidal anti-inflammatory medica-
functional impairment. Data suggest that the ischemic tions. For obvious reasons, compression would be contra-
threshold for normal muscle is reached when pressure within indicated. If conservative management fails, a fasciotomy
the compartment increases to 20 mm Hg below the diastolic may be indicated.
pressure or 30 mm Hg below the mean arterial pressure.50
550 Chapter 13
TABLE 13-9. SYMPTOMS OF COMPLEX REGIONAL PAIN SYNDROME

In addition to the cardinal symptom of CRPS, pain that is out of proportion to the severity of the injury, which worsens
rather than improves over time, may spread to the entire extremity, and may be exacerbated by emotional stress. Other
symptoms of CRPS include:
SENSORY Hyperesthesia̶Increased sensitivity

Allodynia̶Perception of pain resulting from a stimulus that would not ordinarily cause pain
VASOMOTOR Temperature asymmetry and/or skin color changes and/or skin color asymmetry
SUDOMOTOR Sweating changes and/or sweating asymmetry
EDEMA Swelling and stiffness in affected joints
MOTOR Impaired range of motion and/or motor dysfunction (weakness, tremor, dystonia)
TROPHIC Changes in hair, nail and skin growth patterns and nutritional status
Adapted from National Institute of Neurological Disorders and Stroke. Complex regional pain syndrome fact sheet. May 19, 2010. Parrillo
SJ. Complex regional pain syndrome. March 23, 2010. http://www.emedicine.com/emerg/topic497.htm#section clinical Accessed May
29, 2010; Harden RN, Stanton-Hicks M, Wilson PR. Proposed new diagnostic criteria for complex regional pain syndrome. Pain Med.
2007;8:326-331.
Complex Regional Pain Syndrome The cause of CRPS remains poorly understood. Most
researchers agree that CRPS is a neurologic disorder affect-
Complex Regional Pain Syndrome (CRPS) is a chronic
ing the central and peripheral nervous systems.53 One of
pain condition. CRPS presents as pain that is out of propor-
the most recent hypotheses suggests that pain receptors in
tion to the severity of the injury that gets worse rather than
the involved extremity become responsive to the group of
better over time. It is thought to be the result of dysfunc-
nervous system messengers collectively known as catechol-
tion in the central or peripheral nervous systems.53 CRPS
amines. In animal studies, norepinephrine (a catecholamine
has been further divided into CRPS I and CRPS II. CRPS I
released by sympathetic nerves) acquires the ability to acti-
(previously known as reflex sympathetic dystrophy) is most
vate pain pathways following tissue or nerve injury. Another
frequently triggered by tissue trauma or immobilization,54
hypothesis suggests that the immune response is triggered in
while CRPS II (also known as causalgia) is associated with
postinjury CRPS (CRPS II), which then leads to the typical
a nerve injury.5,53,54 In the United States, the incidence of
inflammatory symptoms of warmth, redness, and edema in
CRPS after fractures and contusions is 10% to 30% while the
the involved extremity. Thus CRPS may result from a disrup-
incidence after peripheral nerve injuries is 1% to 15%.54 It
tion in the healing process. It is most likely that CRPS is the
affects persons of all ages though most experts agree that it is
result of multiple causes that produce similar symptoms.
most commonly seen in women.
There is no known cure for CRPS. Treatment is directed
The cardinal symptom of CRPS is intense, burning pain
at relief of the painful symptoms associated with CRPS.
that is out of proportion to the severity of the injury. In addi-
Treatment interventions include physical therapy, psycho-
tion, other symptoms can include the presence of edema,
therapy, sympathetic nerve blocks, medication, surgical
abnormal sensory, motor, sudomotor, vasomotor, and/or
sympathectomy, spinal cord stimulation, and intrathecal
trophic findings.55 These include increased skin sensitiv-
drug pumps.53 It has been suggested that early diagnosis
ity, changes in nail and hair growth patterns, changes in
and treatment may help in limiting the disorder, but there
skin temperature, color and texture, swelling and stiffness
has been insufficient evidence to date from clinical studies
in affected joints, and motor impairment (Table 13-9).53-55
to support this.
Though the symptoms of CRPS vary in severity and dura-
tion, they may all contribute to movement-related impair- Fat Embolism Syndrome
ments and functional limitations. Since there is no specific Fat Embolism Syndrome (FES) is a collection of clinical
diagnostic test for CRPS, it is diagnosed primarily based on signs and symptoms that result when fat droplets are released
the history and clinical examination.5 Consequently, physical into the small blood vessels of the lungs and other organs
therapists are well positioned to identify the development of after long-bone1,56-58 or pelvic58,59 fractures. It is thought
these signs and symptoms and can be instrumental in ensur- that the fat emboli are released from the bone marrow or
ing that these issues are accurately diagnosed early in the adipose tissue at the fracture site into the venous system
course of development. Diagnostic testing is used to either through torn veins.1 FES is also associated with trauma other
rule out other diagnoses53 or may be used to evaluate second- than fractures as well as nontraumatic surgical conditions
ary changes that may assist in establishing a diagnosis.5 (eg, liposuction, cardiopulmonary bypass, joint replacement)
and medical conditions (eg, acute pancreatitis, DM, sickle Evaluation and Management of
cell crisis).1,57-59
It is important to note that fat embolization and FES are Musculoskeletal Trauma
not synonymous. Fat embolization involves the presence
of fat droplets in the systemic circulation.1,55 Fat emboliza- History
tion after long-bone trauma is a common occurrence yet Issues to focus on while interviewing and taking a history
the actual incidence of the clinical syndrome known as FES from patients who have sustained musculoskeletal trauma
is low.56- 59 The incidence of FES has been estimated at 3% would include the mechanism of injury, date of onset and
to 4% with 90% of all cases linked to blunt trauma.58 Fat course of events, recent hospitalization, any surgical proce-
embolization is usually asymptomatic and nonlife-threat- dures as a result of the injury, preexisting medical conditions
ening whereas FES can be fatal. The main signs and symp- as well as any other health-related conditions that might
toms of FES are respiratory distress, cerebral dysfunction, affect the current injury. If during this phase of the examina-
and petechial rash.58 The petechial rash typically develops tion the patient reports he or she had surgery to “relieve the
within 24 to 36 hours while respiratory distress is usually pressure” in one or more limbs, this may indicate that the
seen anywhere from 12 to 72 hours after injury. Respiratory patient developed CS as a complication of the injury. This
dysfunction varies in severity from mild (dyspnea, tachy- would then direct the clinician to inspect the skin for fas-
pnea) to severe, where the signs and symptoms may appear ciotomy scars during the systems review. Another example
indistinguishable from adult respiratory distress syndrome would be the geriatric patient who sustained a femur fracture
(ARDS).58,59 Cerebral dysfunction initially manifests as and reports that he or she spent time in the intensive care
subtle changes in behavior and signs of disorientation,1 unit (ICU) on a ventilator. This might lead the clinician to
develops after the onset of respiratory system dysfunction59 suspect that the patient had developed ARDS as a complica-
and is thought to result from emboli in the cerebral circulation of FES.
tion as well as respiratory depression.1 This may progress to
agitated delirium, seizures or focal defects.1,59 The diagnosis Systems Review
of FES is made based on clinical signs and symptoms since During the systems review the physical therapist should
laboratory and radiographic findings are nonspecific and can pay particular attention to the presence of edema, the skin
be inconsistent.56,59,60 integrity, the skin color, presence of scar formation, gross
Medical management is prophylactic or supportive, symmetry of the limbs, gross ROM, gross strength, bal-
directed at management to ensure adequate oxygenation and ance, locomotion and transfers, and transitions. In a patient
ventilation, hemodynamic stability, hydration, prophylaxis who has sustained a fracture, the presence of skin bullae or
of deep vein thrombosis, and stress-related gastrointestinal blisters may indicate that the patient had developed fracture
bleeding, as well as nutrition.58,60 Studies suggest that early blisters as a complication of their fracture. Another example
stabilization of long-bone fractures reduce recurrent fat of a finding during the systems review is the presence of
embolism and FES,58,60 and reduce the incidence of ARDS shiny, glossy skin over the area of injury with excessive rubor,
5-fold.58 The mortality rate for FES is 10% to 20%, with older warmth to the touch, and the inability of the patient to toler-
individuals with comorbidities and/or decreased physiologic ate even light touch. This may indicate the presence of CRPS.
reserves having worse outcomes. This would then direct the clinician to select appropriate
At present the underlying pathophysiology for FES is tests in the integumentary integrity, pain, and sensory integ-
unclear.1,56 There are currently 2 theories (the mechanical rity categories to provide them with additional information.
theory and the biochemical theory) that explain how fat It might also direct the clinician to refer the patient back to
emboli result in FES.55,58 The mechanical theory hypoth- their physician for further evaluation of the possibility of
esizes that when fat droplets are released into the venous CRPS and, if confirmed, the medical management of this
circulation, the larger particles become lodged in and block complication of musculoskeletal trauma.
pulmonary capillaries while the smaller particles are able Tests and Measures
to pass through the lung capillaries and enter the systemic
circulation.1,58 The droplets deposited in the pulmonary As always, the findings from the history and systems
capillaries then travel through the arteriovenous shunts to review will direct the selection of tests and measures for each
the brain. Microvascular lodging of these droplets produce individual. The following categories of tests and measures
local ischemia and inflammation that result in the release of would most likely be considered in patients who have sus-
inflammatory mediators, platelet aggregation, and vasoac- tained musculoskeletal trauma:
tive amines.58 The biochemical theory proposes that hor- Aerobic capacity and endurance; anthropometric charac-
monal changes resulting from trauma and/or sepsis trigger teristics; assistive and adaptive devices; cranial and peripheral
a systemic release of free fatty acids as chylomicrons. Acute- nerve integrity; gait, locomotion and balance; integumentary
phase reactants, such as C-reactive proteins, then cause integrity; joint integrity and mobility; motor function (motor
chylomicrons to coalesce and create the physiologic reactions control and motor learning); muscle performance (including
described in the mechanical theory. This second theory helps strength, power and endurance); orthotic; protective and
to explain the presence of FES in nontraumatic situations. supportive devices; pain; posture; ROM including muscle
552 Chapter 13
length; self-care and home management (including activities 18. National Cancer Institute. August 25, 2004. http://www.cancer.gov/
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Physical therapists are in the forefront of providing 20. American Cancer Society. August 25, 2009. http://www.cancer.
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org/docroot/ETO/content/ETO_1_4X_Monoclonal_Antibody_
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43. Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C, White difficulty with locomotion and hip movements secondary
RD. Physical activity/exercise and type 2 diabetes: a consensus to the pain in his groin. He hoped to return to being able to
statement from the American Diabetes Association. Diabetes Care.
2006;29(6):1433-1438.
walk without pain.
44. Whaley MH, Brubaker PH, Otto RM, eds. ACSM’s Guidelines History of Current Complaint
for Exercise Testing and Prescription. 7th ed. Philadephia, PA:
Lippincott Williams & Wilkins; 2006. Dr. Lacrosse was a medical school graduate whose pri-
45. Centers for Disease Control and Prevention. Teen drivers: Fact mary language was English. He fell while chasing a mouse
sheet. April 26, 2010. http://www.cdc.gov/MotorVehicleSafety/ in his living room. He remembered turning quickly and then
Teen_Drivers/teendrivers_factsheet.html. Accessed May 29, 2010.
falling. Dr. Lacrosse landed on his left side and hit his head.
46. Centers for Disease Control and Prevention. Injury among older
adults. October 9, 2007. http://www.cdc.gov/ncipc/olderadults.htm. There was no loss of consciousness, but he was unable to
Accessed May 29, 2010. get up. His wife called 911 and he was taken by ambulance
47. Centers for Disease Control and Prevention. Falls among older to the emergency department (ED) with chief complaint of
adults: an overview. October 6, 2009. http://www.cdc.gov/ncipc/ left hip and groin pain. Plain films in the ED were negative
factsheets/adultfalls.htm. Accessed May 29, 2010.
for a hip or pelvic fracture. Dr. Lacrosse was admitted for
48. Strauss EJ, Petrucelli G, Bong M, Koval KJ, Egol KA. Blisters asso-
ciated with lower-extremity fracture: results of a prospective treat- further workup. A subsequent computed tomography (CT)
ment protocol. J Orthop Trauma. 2006;20(9):618-622. scan revealed a left pubic ramus fracture. He was discharged
49. Weinmann M. Compartment syndrome. Emerg Med Serv. to home 3 days after his admission and referred to a certified
2003;32:36. home health agency (CHHA) for home health care services
50. Olson SA, Glasgow RR. Acute compartment syndrome in lower
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2005;13:436-444. Social History/Environment
51. Swain R, Ross D. Lower extremity compartment syndrome.
Postgrad Med. 1999;3:159-162,165,168. Dr. Lacrosse was a retired psychiatrist who had worked in
52. Wallace S, Goodman S, Smith DG: Compartment syndrome, lower both an academic medical center and as a consultant to the
extremity. February 9, 2009. http://www.emedicine.com/orthoped/ New York Police Department (NYPD). He was married and
topic596.htm. Accessed May 29, 2010.
lived with his wife, who was ~20 years younger, in a high-rise
53. National Institute of Neurological Disorders and Stroke. Complex
regional pain syndrome fact sheet. May 19, 2010. http://www.ninds. apartment building with a doorman at the entrance. Mrs.
nih.gov/disorders/ref lex_sympathetic_dystrophy/detail_ref lex_ Lacrosse was currently undergoing radiation therapy (RT)
sympathetic_dystrophy.htm. Accessed May 29, 2010. status post (s/p) lumpectomy for breast cancer. Mrs. Lacrosse
54. Parrillo SJ. Complex regional pain syndrome. March 23, 2010. was very supportive and would be able to assist her husband
http://www.emedicine.com/emerg/topic497.htm#section~clinical.
with activities of daily living (ADL) and manage all instru-
Accessed May 29, 2010.
55. Harden RN, Stanton-Hicks M, Wilson PR. Proposed new diag- mental ADL (IADL) during his recovery period. There were
nostic criteria for complex regional pain syndrome. Pain Med. no steps to enter the building, but there were 2 steps without
2007;8:326-331. railings to access the apartment’s terrace. Dr. Lacrosse had
56. Parisi DM, Koval K, Egol K. Fat embolism syndrome. Am J Orthop. bilateral hearing aids and wore glasses to read. He was dis-
2002;31:507-512.
charged to home with a raised toilet seat and standard fold-
57. Mellor A, Soni N. Fat embolism. Anaethesia. 2001;56:145-154.
58. Kirkland L. Fat embolism. August 4, 2009. http://www.emedicine. ing walker.
com/med/topic652.htm. Accessed May 29, 2010. Social/Health Habits
59. Georgopoulos D, Bouros D: Fat embolism syndrome: clinical
examination is still the preferable diagnostic method. Chest. Dr. Lacrosse never smoked and he denied alcohol use. He
2003;123:982-983. spent his leisure time reading and enjoyed sculpting in the
60. Habashi NM, Andrews PL, Scalea TM. Therapeutic aspects of fat “studio” he had in his apartment. He did not participate in
embolism syndrome. Injury. 2006;37(Suppl 4): S68-S73.
any regular exercise other than walking.
CASE STUDY 13-1 Dr. Lacrosse’s past medical history was as follows: hyper-
tension (20 years prior), cardiac arrhythmia (24 years prior),
Melanie A. Gillar, PT, DPT, MA prostate cancer (20 prior, in remission), s/p bilateral hernia
repairs and osteoarthritis (OA) in both feet. His hyperten-
sion and cardiac arrhythmia were well managed on a medi-
EXAMINATION cation regimen of digoxin, Cozaar (losartan potassium), and
amiloride hydrochloride.
History
Prior to hospitalization, Dr. Lacrosse was completely inde-
Current Condition/Chief Complaint pendent with all ADL and participated in IADL, but shared
responsibility for them with his wife who was primarily
Dr. Lacrosse was a 92-year-old White male referred to
responsible for household chores. He was able to ambulate
home physical therapy after he sustained a left pubic ramus
independently indoors and outdoors without an assistive
fracture from a fall in his home. Dr. Lacrosse was having
554 Chapter 13
device. At the time of the physical therapy evaluation, Dr.
Fractures of the pubic rami occur commonly in the elder-
Lacrosse required assistance with locomotion and self-care.
ly,4,5 and there is evidence that their incidence is increas-
He was not able to participate in IADL.
ing.4 In a study by Hill et al,4 the overall incidence of a
Medications fracture of a pubic ramus in the general population during
Cozaar (losartan potassium) 25 mg daily (QD), digoxin the study period was 6.9/100,000/year while the incidence
0.125 mg QD, amiloride hydrochloride 5 mg twice a day in patients over 60 years of age was 25.6/100,000/year. Alost
(BID), Colace (docusate) 100 mg 3 times per day (TID). The and Waldrop5 in their study found that 56% of the pelvic
patient refused pain medications because he did not want to fractures in the patients studied were pubic rami fractures.
take a chance that they would cause some gastrointestinal There is evidence in the available literature that the major-
(GI) disturbance. Medications prior to hospitalization were ity of the pelvic fractures seen in the elderly are caused by
the same except for the addition of the Colace. low-energy/moderate trauma, usually in the form of a fall
from standing height.1,3 In a study by Hill et al,4 87.4%
of the fractures was a result of a simple fall with 55.7% a
During the previous year, Dr. Lacrosse had blood tests and result of a fall at home. Since Dr. Lacrosse’s fall was from
an electrocardiogram (EKG). a standing height and occurred at home, it would fit into
this category.
A study by Alost and Waldrop5 suggests that though the
Clinician Comment The interview provides mechanism of injury in most geriatric patients is usually
the clinician with the opportunity to gather a wealth of
a fall, a less severe mechanism of injury than that seen in
information about patients beyond the presenting com-
younger patients who most often sustain pelvic fractures as
plaint. It allows the clinician to listen to how they present
a result of a motor vehicle accident, there is a significantly
and express themselves and what their concerns are and to
greater mortality associated with pelvic fractures in geriat-
observe their thought processes. How they listen and inter-
ric patients. Exacerbation of preexisting cardiovascular dis-
pret information may give important information about
ease was thought to be the cause of the increased mortality
their hearing and cognition. If there appears to be impaired
seen in this population. Dr. Lacrosse had a history of both
memory, do they acknowledge it when they are asked about
hypertension and cardiac arrhythmia, but fortunately for
it or do they seem to be unaware of the problem? Asking
him, there was no evidence of an exacerbation of his under-
them specific questions during the past medical history
lying cardiovascular disease during his hospital course, at
(PMH), eg, such as “Do you have a history of heart disease,
the time of my initial visit or during the course of his home
diabetes, cancer, etc”? may trigger the sharing of a diagno-
care services.
sis they have failed to mention that may have a bearing on
how their case is managed. What is their perception of their There are surprisingly few articles available on stable or
limitations and what are their goals? A patient’s answer closed pelvic fractures and several studies noted this. The
to this question provides the clinician with important vast majority of the available literature on all aspects of
information that will be useful later when developing and pelvic fractures and their management deal with those
implementing the plan of care. If the patient understands fractures that are a result of high-energy or blunt trauma,
that the plan of care recommended will address his or her most frequently motor vehicle accidents. These fractures
concerns (as well as additional concerns identified by the and their management are very different because they are
clinician), this can often be the key to compliance with the associated with many potentially life-threatening injuries.5
prescribed regimen. In the home, having a family member There was, however, a study by Koval et al6 published in
or caregiver present during the interview can be extremely 1997 that evaluated the outcome of elderly patients who
helpful. In this case, having the patient’s wife present during sustain pubic rami fractures. Of note was that the demo-
the interview provided verification of the accuracy of the graphics reported in their study was similar to that reported
patient’s report as to both the events preceding the fall and for elderly patients who sustain femoral neck fractures or
his prior functional status. intertrochanteric hip fractures. In addition, prefracture
Pelvic fractures are rare injuries when compared to frac- dependency, general health status, and ambulatory sta-
tures in other body regions. They comprise 3% to 8% of all tus were also found to be similar between those groups
skeletal injuries.1 The pelvic ring is defined as the continu- of patients. Of particular interest for this case study was
ous osseous cage formed by the paired innominate bones, that Dr. Lacrosse fit the patient profile for the patients in
which are composed of the ilium, ischium, and pubis, and their study. He too was community dwelling and ambula-
the sacrum, including the relatively rigid articulations at tory prior to sustaining a pubic ramus fracture. Ninety-five
the sacroiliac joints and the symphysis pubis. Stable pelvic percent of the patients who sustained an acute pubic ramus
fractures are ones that do not disrupt any joint articula- fracture required hospitalization for pain control and
tions.2 Dr. Lacrosse sustained a pubic ramus fracture, physical therapy. In Dr. Lacrosse’s case he was admitted
which is considered a stable fracture and one that is treated for further work-up because of his severe pain and nega-
symptomatically.3 tive radiographs. Once he had further imaging studies (CT
scan) and the diagnosis of pubic ramus fracture was made, Musculoskeletal
Dr. Lacrosse was referred for physical therapy that con- Gross range of motion (ROM) was intact. Gross muscle
sisted primarily of gait training and then he was discharged strength of both upper extremities and of both ankles and
to home for further management. Seventeen percent of the knees was intact. All hip motions elicited pain and there-
patients studied had additional imaging studies before the fore gross muscle strength of the hips was not assessed. Dr.
diagnosis of pubic ramus fracture was made. There was, Lacrosse exhibited a forward head, kyphotic posture. Height:
however, a significant difference between Dr. Lacrosse’s 5 feet, 7 inches; weight: 135 pounds; body mass index (BMI):
length of stay and the average length of stay (LOS) of the 21.1.
patients in the study. His LOS was 4 days, which was con-
Neuromuscular
siderably less than their average length of stay of 14 days.
Several studies have suggested that underlying osteoporosis Gait
may be a risk factor for pelvic fractures,3 though there has Impaired. Patient required supervision and verbal cueing
been little direct evidence to support that fractures of the for sequencing of the walker and his lower extremities. The
pelvis sustained in low-energy trauma are associated with patient was weightbearing as tolerated (WBAT) left lower
osteoporosis.2 This is an area for further study. There is, extremity (LE) and was able to ambulate ~40 feet with a
however, available literature describing the risk factors standard walker.
for falls in the elderly. An article by Palmer7 provides a Locomotion
comprehensive summary of these risk factors. According to
Impaired ability to transition sit to supine secondary to
Palmer, accidental falls such as the one Dr. Lacrosse experi-
pain and impaired ability to perform bathtub transfers for
enced are not random occurrences, but they are predictable
showering.
and preventable. Falls occur in 50% of community-dwelling
persons over the age of 80. After every fall, an elderly Balance
patient is at increased risk of hospitalization, nursing home No impairment noted.
placement, and death. Risk factors that have been identi- Motor Function
fied as predictive of falls in the elderly include the following:
Intact.
• Sedative use
• Cognitive impairment
• Abnormalities of gait and balance
• Disability of the lower extremities Dr. Lacrosse was alert and oriented to person, place, and
time. He was an accurate historian and his communica-
• Difficulty performing tandem gait
tion was appropriate. Even with his bilateral hearing aids,
• Small calf circumference his hearing was impaired. It was important to speak clearly
• Impaired vision and slowly to him in order for him to hear what was said
• Low body mass index without repetition. As a result, he learned best through
• Incontinence demonstration.
• Depression Dr. Lacrosse would benefit from education regarding
Based on the information gathered during the history, Dr. safety, use of appropriate assistive device(s), ADL, and an
Lacrosse’s only risk factor was impaired vision. However, exercise program.
chasing a mouse and turning quickly were clearly not usual
activities for Dr. Lacrosse and had to have been a major Clinician Comment The Guide to Physical
contributing factor for his fall. Therapist Practice (Guide)8 describes the systems review
as a brief or limited examination of the cardiovascular/pul-
monary, integumentary, musculoskeletal, and neuromus-
Systems Review cular systems as well as the communication ability, affect,
cognition, language, and learning style of the patient. The
Cardiovascular/Pulmonary systems review consists of a minimum mandatory set of
tests that have been selected for each of the systems based on
Seated resting values: heart rate (HR): 66 irregular; blood
their reliability and validity as screens for potential pathol-
pressure (BP): 150/93 (According to patient and his wife this
ogy, impairment, functional limitation, and disability
was within his normal range.) Respiratory rate (RR): 14;
related to the movement system. The information gathered
Edema: None present
during the systems review in combination with the history
Integumentary helps to identify patient/client needs and to generate diag-
There was a healing scab at the crown of patient’s head nostic hypotheses that need to be further investigated with
and ecchymotic areas at the left hip and elbow. No other additional tests and measures. The systems review also
areas of skin breakdown were noted.
556 Chapter 13
assists the physical therapist to identify potential problems Tests and Measures
that may require consultation with or referral to another
provider.
Clinician Comment The tests and measures
Though Dr. Lacrosse was already at home, this was still utilized were incorporated into the required initial physical
the acute phase of his recovery and rehabilitation (Injury therapy visit form utilized by the CHHA.
occurred December 28 and initial home physical therapy
visit was January 3). The acuteness of his injury was an
important consideration when performing the systems
review as well as later when choosing the procedural inter- Environmental, Home and Work (Job/
ventions. In the case of pelvic fractures, the limiting factor School/Play) Barriers
during “physical” testing was pain since pain is the hall- Home safety assessment performed to evaluate home
mark of pelvic fractures. This was the reasoning behind the safety and identify any current barriers that required reme-
decision to perform only gross ROM and muscle strength diation. None were identified.
tests.
The information gathered during Dr. Lacrosse’s systems Clinician Comment This can be accom-
review, in combination with the information from his his- plished with checklists or questionnaires of current and
tory, identified needs that would direct the physical therapy potential barriers. A “Home Safety Assessment” checklist
interventions to address his impairments (pain with func- that is answered, “Yes,” “No” or “Not Applicable” was used
tional movements and activities) and functional limita- to identify any safety issues in Dr. Lacrosse’s apartment.
tions (inability to transition sit to supine without assistance There was also an area to identify what action(s) was taken
for his lower extremities, his inability to ambulate without if anything was found to be unsafe or inadequate. The
an assistive device and his inability to perform self-care in checklist included the following items:
the usual manner). It also identified the need for additional
tests and measures in the following categories: • Are the rooms cluttered?
• Is the lighting adequate?
• Environmental, Home, and Work (Job/School/Play)
Barriers • If throw rugs are present, are they properly secured?
• Pain • Are there skid-resistant mats in risk areas of the bath-
room?
• Self-Care and Home Management (Including ADL and
IADL) • If there are stairs, are they unobstructed and do they
In addition, it identified an elevated BP despite an existing have nonslip surfaces and handrails?
medication regimen. According to the guidelines published • Is there any durable medical equipment (DME) safety
in The Seventh Report of the Joint National Committee equipment such as tub seat or grab bars present?
on Prevention, Detection, Evaluation and Treatment of • Does the patient have adequate sensory capabilities
High Blood Pressure,9 most patients with hypertension will regarding water temperature?
require 2 or more antihypertensive medications to achieve a • Are electrical appliances away from the tub/shower?
BP < 140/90. Dr. Lacrosse had a history of hypertension and
was taking Cozaar, an angiotensin receptor blocker that is • Are the electrical and telephone cords safely positioned?
used in the treatment of hypertension (causes relaxation of • If there is DME equipment, is it appropriate, in good
the smooth vascular muscle) at the recommended dosage condition, and is the patient using it appropriately?
and amiloride hydrochloride, which is a potassium-sparing • Are there any obstructions near the stove or oven?
diuretic, also at the recommended dosage.10 • Is the patient able to access emergency assistance?
At the time of initial visit his BP was 150/93 and on sub- There was also an area to identify if anything unsafe or
sequent visits his BP remained within this range (140 to unusual was found in the home. If anything unsafe or
150 for systolic and 85 to 95 for his diastolic). According to unusual was identified there was an area to describe what
both the patient and his wife, this was a normal BP reading was found and when other members of the health care team
for him. Dr. Lacrosse reported that he and his physician were informed. The home safety assessment performed in
feel that his current medication regimen was keeping his Dr. Lacrosse’s apartment did not identify any safety issues
BP under good control and there was no need to modify or barriers that required remediation.
his medication regimen. Follow-up with his physician con-
firmed this.
Pain shower/tub transfers, how the patient toilets, whether he is
The pain assessment performed included the use of a able to feed, dress, bathe or groom himself as well as IADL
numeric rating scale, which revealed that Dr. Lacrosse’s pain information, including managing in the kitchen, shopping,
was 8/10. The pain was localized to his groin. The pain was and housework. One of the advantage of working with a
triggered by any hip movement and when getting in and out patient in the home is that if through interview or report a
of bed. deficit is identified in any of the aforementioned areas, it is
easy to ask for a demonstration and then to figure out how
best to remediate the problem. In the case of Dr. Lacrosse,
Clinician Comment The pain assessment the data were gathered for this category through interview
used included not only a numeric rating scale (NRS), but and observation. It was able to be determined that Dr.
questions regarding the frequency of pain, type of pain, Lacrosse had been independent with all ADL prior to hos-
location of pain, precipitating factors, signs/symptoms of pitalization and participated in IADL but shared responsi-
pain, as well as any control measures. There was also an bility for them with his wife, who was primarily responsible
area to include any recommendations. The numeric rating for household chores. At the time of the initial visit Dr.
scale is a 0 to 10 intensity scale where zero indicates that Lacrosse required assistance for LE dressing and to sponge
there is no pain and 10 is the worst pain imaginable. The bathe. A raised toilet seat allowed him to be independent
pain assessment performed revealed that Dr. Lacrosse’s performing toilet transfers.
pain was 8/10, was localized to his groin, and was triggered
by any hip movement and when getting in and out of bed. It’s important to complete the interview portion of the
This pain report was consistent with the pain patterns initial visit prior to beginning the systems review and tests
reported by patients with pelvic fractures. Further research and measures because if a patient states that he or she is
supports the use of an NRS both in cognitively impaired and unable to perform a specific task or activity, the therapist
cognitively intact older adults.11,12 The NRS, when com- can test the ability to perform that task and ask for a dem-
bined with additional questions about frequency of pain, onstration during the exam. A common example is when
type of pain, etc, allows the clinician to gather the necessary the patient reports that he or she is unable to perform LE
information to choose appropriate procedural interventions dressing activities such as donning and doffing pants. More
to manage a patient’s pain and/or make appropriate recom- often than not these same patients have adequate ROM
mendations about pain control to a patient’s physician. In and muscle performance to be able to perform the activity.
addition, this combination scale can be used to monitor a When asked to demonstrate why they are unable to put on
patient’s response to physical therapy interventions and/or their pants, it is frequently observed that they are used to
pain medication. doing this activity standing and have never considered that
it could be done in sitting or even supine. In the case of Dr.
Lacrosse, his pain with all hip motions would explain his
report that he required assistance with LE dressing and to
Self-Care and Home Management sponge bathe. In addition, his pain with all hip motions,
(Including Activities of Daily Living and coupled with his need for a walker to ambulate, would cor-
Instrumental Activities of Daily Living) relate with his difficulty transferring into and out of his tub
Information gained through interview and observation for showering thus necessitating the need to sponge bathe.
identified that Dr. Lacrosse required assistance for lower
extremity dressing and to sponge bathe. A raised toilet seat
allowed him to be independent performing toilet transfers. EVALUATION
Clinician Comment The Guide8 defines self- Diagnosis
care management as the ability to perform ADL such as
bed mobility, transfers, dressing, grooming, bathing, eating, Practice Pattern
and toileting. Home management is defined as the ability
to perform the more complex IADL such as maintaining a Based on the above history, systems review, and tests
home, shopping, and performing household chores. and measures, this patient is classified into Musculoskeletal
Pattern 4G: Impaired Joint Mobility, Muscle Performance,
There are many ways to gather the data for this category.
and Range of Motion Associated with Fracture
As previously indicated, the initial physical therapy visit
used a form required by the CHHA. This was a very com- International Classification of Functioning,
prehensive form. An entire area of the form was devoted Disability and Health Model
to “Functional Assessment,” which included the patient’s
See ICF model on p 558.
prior level of function, all aspects of bed mobility, transfers,
558 Chapter 13
ICF Model of Disablement for Dr. Lacrosse

Health Status
• Left pubic ramus fracture
• Hypertension
• Cardiac arrhythmia
• Prostate cancer—in remission
• S/p hernia repair, bilaterally
• OA, both feet

Function
• Needed assistance to • Unable to complete usual
• Healing pelvic fracture manage lower extremities in IADL
• Pain transitions and transfers • Unable to pursue sculpting
• Healing integument from • Unable to walk without a hobby
his fall walker • Difficulty leaving home
• Symptom limited hip • Pain limited ambulation for social or recreational
movement, bilaterally and transfers outings.
• Kyphotic posture • Required verbal cues and
supervision for safe gait
with the walker
• Assistance required for LE
dressing and sponge baths
• Unable to transfer into tub
for a shower

• Age = 92 years • Two steps without rails to the terrace of his
• Refusing pain medications to avoid any apartment
associated gastric disturbance • Spouse able to assist Dr. Lacrosse with ADL and
• Impaired hearing even with hearing aids IADL
• Knowledgeable as an MD, psychiatrist • Has a raised toilet seat
• No structural safety issues or barriers within his
apartment
Prognosis so that he is able to negotiate the 2 steps to his terrace
(4 weeks).
This 92-year-old male was in good health and indepen- 3. Patient’s endurance capacity will increase to allow for
dent prior to his fall. His hospitalization course was brief independent mobility (with straight cane), within the
and at the time of initial visit, 6 days after his fall, he was apartment (3 weeks), and able to walk outside of his liv-
already able to ambulate 40 feet in his apartment with a ing area to the front of his building and access curb side
walker with supervision and verbal cueing for sequencing of transportation (4 weeks).
the walker and his LEs. Though he was unwilling to take any
pain medications, he was willing to do whatever was asked of Expected Outcomes
him despite the pain. It was anticipated that over the course Over the 3 to 6 months following the completion of physi-
of 3 to 6 months, beyond the 4 weeks of anticipated physical cal therapy, it could be anticipated that the patient would
therapy, Dr. Lacrosse would make a complete or near com- resume participation in IADL and he will be able to ambu-
plete recovery. late outdoors with a straight cane on all surfaces, weather
permitting.
Plan of Care
Discharge Plan
Interventions
Patient will be ready for discharge from home health
• Patient-/client-related instruction regarding his current
physical therapy to his own care when he has achieved the
condition, the plan of care, and the discharge plan.
anticipated goals listed above. The plan of care including the
• Endurance reconditioning program will consist of an in- discharge plan was discussed with the patient, who was in
home, timed walking prescription based on his current agreement.
functional walk test (maximum of 40 feet with assistive
device).
• Patient will be instructed in his prescribed home exer- INTERVENTIONS
cise program (HEP) that had been written out (his pre-
ferred learning style). Frequency of performance equals
2 to 3 times daily for a 15- to 20-minute session equaling Patient-/Client-Related Instruction
a total duration of ~40 minutes. Dr. Lacrosse received instruction about his plan of care
• Gait training will progress from use of a walker to use of and discharge plan as previously discussed. In addition, he
a straight cane on level surfaces and stairs. was educated about his current condition, what to expect in
terms of pain, progression to a cane, etc, as well as explana-
• Patient education will include instruction regarding
tions for the procedural interventions chosen and why they
safety with an assistive device.
would benefit him. He received instructions about safety
• Bed mobility training will incorporate the use of issues when ambulating with an assistive device, including
upper extremities and sliding movement techniques to placement of the device, how to make sure the walker was
strengthen arms/trunk and minimize hip pain. “locked” in the open position, etc. Dr. Lacrosse was also
• As pain with hip movements decreases, will begin LE instructed in a HEP and provided with a written copy of his
dressing instruction and initiate tub transfer training HEP.
for showering.
Proposed Frequency and Duration of Procedural Interventions
Physical Therapy Visits Therapeutic Exercise Prescription
Over the course of 4 weeks, Dr. Lacrosse will be seen for
10 visits; 3 times per week for 2 weeks and then 2 times per
week for 2 weeks. Conditioning or Reconditioning:
Mode
Anticipated Goals Walking program
1. Patient to have sufficient decrease in pain with hip Intensity
movements so that he is independent transitioning from RPE < 11, symptoms < 3 to 4/10
sit to supine (2 to 3 weeks), independent performing LE Duration
dressing (2 to 3 weeks), and independent with tub trans-
One to 5 minutes to cover 5 to 50 feet
fers for showering (4 weeks).
Frequency
2. Patient to be able to ambulate independently indoors One time every waking hour until total feet walked for the
with a straight cane on all level surfaces in his apartment day is 300 to 500 feet
(3 weeks) and independent with a straight cane on stairs
560 Chapter 13
Dr. Lacrosse was instructed in a walking program that Gait and Locomotion Training
consisted of ambulating short distances, (5- to 10-foot seg- Gait training—Progress from walker to straight cane
ment minimums) for a minimum of 30 feet for every hour (including stair climbing).
that he was awake. He was instructed that the distance he
walked each time could be short with rests in between, but it Functional Training in Self-Care
was essential that he walked every hour for a total of 300 to and Home Management
500 feet per day. Activities of Daily Living Training
Bed mobility and transfer training; LE dressing
Clinician Comment An hourly ambulation Prescription, Application, and, as
schedule can be prescribed for patients with instructions Appropriate, Fabrication of Devices and
to total their distance walked over the course of the day. Equipment (Assistive, Adaptive, Orthotic,
This is an effective tool for reconditioning patients after Protective, Supportive, and Prosthetic)
hospitalization as the duration and frequency of walking is
Assistive Device
within their control and they can easily add the distances
and track their progress. The frequency and intensity of Prescribe an adjustable straight cane when the patient was
walking prescriptions are not as important as the total ready to progress to gait training with a cane.
duration of walking in cases of severe impairment (ability
to walk less than 500 feet in 6 minutes). Once the patient is Clinician Comment There is next to noth-
able to complete a total of 500 feet without pain or loss of ing published in the literature about physical therapy
balance, it is possible to add in the component of “intensity” interventions after pelvic fracture. Koval et al6 in their
to the exercise prescription by combining the distance to article discuss that “physical therapy was started when
be walked with a specific time frame. There is research to symptoms allowed and consisted of unrestricted weight-
support the efficacy of intermittent training in improving bearing ambulation using a walker. Patients progressed to
aerobic conditioning,13 and there are studies to support the using a cane as tolerated.” That’s true, but what about the
efficacy of a walking program in improving walk endurance other interventions? The demographics reported in their
capacity.14 study were similar to those reported for elderly patients
who sustain femoral neck fractures or intertrochanteric
hip fractures. In addition, prefracture dependency, general
Strength, Power, and Endurance Training health status and ambulatory status were also found to be
Mode similar between these 2 groups of patients. Dr. Lacrosse fit
Isometric and against gravity, strengthening exercises. the patient profile for the patients in their study. A search of
Intensity the literature was then completed to identify recommended
Slow movements through entire ROM, as able, and avoid physical therapy interventions after hip fracture.
undue fatigue. Many studies discussed patients receiving “physical therapy”
Duration and there was general agreement that physical therapy inter-
Fifteen to 20 minutes (for entire routine of identified ventions are indicated after hip fracture, but few discussed
exercises). exactly what specific physical therapy interventions were
Frequency utilized. Naglie et al15 studied elderly patients (at least 70
years old) status postsurgical repair of a hip fracture that
10 repetitions, 2 to 3 times per day.
were randomly assigned to receive either postoperative inter-
An HEP was developed for Dr. Lacrosse consisting of
disciplinary care or usual care during their hospitalization.
active exercise in supine and sitting as well as isometric exer-
Interdisciplinary care included routine assessment and care
cises in supine.
by an internist-geriatrician, physical therapist, occupational
• Gluteal sets in supine with 5-second hold both LEs. therapist, social worker, and clinical nurse specialist. In
• Quad sets in supine with 5-second hold both LEs. addition, interdisciplinary rounds were held twice weekly
• Ankle pumps in supine to be performed simultaneously to set goals for the patients and monitor their progress. The
with both ankles. Dr. Lacrosse was instructed to per- physical therapy interventions included early mobilization
form each repetition slowly to achieve maximal ROM. full weightbearing on the operative leg and twice-daily physi-
cal therapy sessions. This is an example of physical therapy
• Heel slides in supine alternating legs. Dr. Lacrosse was interventions that were provided but specific details about
instructed to perform each repetition slowly to maxi- what those interventions were are not indicated. However,
mize ROM and minimize pain on affected side. the study looked at outcomes at 3 and 6 months and whether
• Marching in place sitting in a straight back chair to be there was a decline from baseline in terms of ambulation,
performed slowly to achieve maximal ROM. chair or bed transfers, and place of residence. It could be
• Knee extension in sitting in straight back chair to be per- postulated from this that interventions included gait and
formed slowly and with 5-second hold, alternating legs. transfer training as well as functional training in self-care.
Kauffman et al16 in their 1987 article were a bit more spe- Intuitively it makes sense to provide physical therapy inter-
cific in discussing the physical therapy interventions after ventions to address the limited ROM and pain with func-
hip fracture. They acknowledged that the physical therapy tional movements and activities that are 2 of the common
was individualized to the patient and fracture type. In impairments associated with hip and pelvic fractures. It is
addition, they described the standard physical therapy also fairly clear from the limited available literature that
interventions after hip fracture as ROM, strengthening transfers and gait training are appropriate physical therapy
exercises, and gait training. interventions for this population. It is less clear from the
Tinetti et al17 in their study looked at whether a home- literature that functional training in self-care is a routine
based systematic multicomponent rehabilitation strategy part of physical therapy interventions. In Dr. Lacrosse’s
(SMR) resulted in better outcomes relative to usual care geographic area and in the home health setting, LE dress-
(UC). They discussed that the usual components of home ing instruction, recommendations for bathing/showering
care physical therapy after hip fracture included various options, etc, are a routine part of the physical therapy
combinations of muscle strength conditioning, ambula- interventions provided to patients who have sustained
tion, transfer, and balance training. They also contend that pelvic and hip fractures. What is not clear from the review
though home health aides may provide some assistance of the literature is which exercises are most appropriate in
with ADL, most patients after hip fracture receive limited the weeks immediately following a fracture. It makes good
retraining in self-care either from an occupational thera- sense to instruct patients in exercises such as ankle pumps
pist or rehabilitation nurse. For the purpose of their study, and circles as well as other active ROM exercises to improve
the physical therapy component of the SMR strategy was circulation, to prevent blood clots and maintain available
designed to identify and remediate impairments in upper ROM. Starting patients on mild strengthening exercises
extremity and LE strength, balance, transfers, gait, and such as gluteal sets and quad sets would also seem to make
bed mobility. The interventions for gait, transfers, and bed good sense. However, the question that remains unan-
mobility included instruction in safer, more effective tech- swered is the specificity of exercise that is most effective in
niques, the provision of and training in the use of assistive facilitating return to function after hip or pelvic fractures,
devices, as well as environmental modifications. Patients particularly in the elderly.
were also instructed in individualized HEPs that they were
to do daily on their own.
The UC physical therapy interventions consisted of gait REEXAMINATION
training and transfer training, as well as strengthening and
ROM exercises. The specific interventions and duration of
the physical therapy were left up to the discretion of the
Objective
physical therapist. Their conclusion was that the SMR pro- Observation of gait and assessment of pain was ongoing
gram was no more effective in promoting recovery than the and permitted patient to be progressed to gait training with
usual home-based rehabilitation. They conclude by saying: straight cane, including stair climbing, LE dressing instruc-
“The challenge that remains is to determine the composition, bed mobility, and tub transfer training at the appropri-
tion and duration of rehabilitation and home services that ate time. Observed the patient’s response to exercise every
ensures optimal functional recovery most efficiently in visit and modified his HEP accordingly.
older persons who fracture a hip.”
More recently Mangione and Palombaro18 in their case
report noted that exercise is the least-examined factor OUTCOMES
affecting outcome in patients’ status post-hip fracture.
They listed the general categories of physical therapy inter-
ventions provided in this population as including active- Discharge
assistive, active, and resistance exercises as well as transfer Dr. Lacrosse was seen for a total of 10 physical therapy vis-
and gait training, instructions on weightbearing limitations its over the course of 4 weeks. At that point he had achieved
and precautions, and moist heat. They too pointed out the his anticipated goals and was discharged from home health
lack of complete exercise prescriptions that include the physical therapy to his own care. No further physical therapy
frequency, intensity, and duration for patients after hip intervention was indicated. At the time of discharge, he no
fracture. They designed a program based on the overload longer had pain with hip movements and was independent
and specificity principles for the subject with good results. transitioning sit to supine, performing LE dressing, and
It would be difficult to generalize the results of this type of transferring into and out of the tub for showering. In addi-
exercise prescription for Dr. Lacrosse because he was seen tion, he was independent ambulating with a straight cane
in the period immediately postfracture. His fracture had indoors on all level surfaces in his apartment and was able
not fully healed whereas their subject was seen 1 year after to negotiate the 2 steps to his terrace. He was instructed to
surgery for repair of her hip fracture. continue performing his HEP once daily and encouraged to
do as much walking as possible.
562 Chapter 13
16. Kauffman TL, Albright L. Wagner C. Rehabilitation outcomes after
Clinician Comment In their study, Koval hip fracture in persons 90 years and older. Arch Phys Med Rehabil.
et al6 found that there were 38 patients for whom 1-year 1987;68:369-371.
17. Tinetti ME, Baker DI, Gottschalk M, et al. Home-based mulitcom-
minimum follow-up was available (range 12 to 70 months).
ponent rehabilitation program for older persons after hip fracture:
At this follow-up, 35 of the 38 patients (92%) were living at a randomized trial. Arch Phys Med Rehabil. 1999;80(8):916-922.
home and 32 of the 38 patients (84%) had no or only mild 18. Mangione KK, Palombaro KM. Exercise prescription for a patient 3
complaints of hip/groin pain. Thirty-five patients (92%) had months after hip fracture. Phys Ther. 2005;85:676-687.
returned to their prefracture ambulatory status and 36 of
38 patients (95%) had returned to their prefracture ability
in performing ADL. Their conclusion was that patients
with pubic ramus fractures have a good prognosis with
CASE STUDY 13-2
regard to long-term pain relief and functional outcome. Melanie A. Gillar, PT, DPT, MA
At 4-year follow-up, Dr. Lacrosse was still living at home and Nancy Gage, PT, DPT
with his wife, had no complaints of hip or groin pain,
was independent performing his ADL, had resumed par-
ticipation in IADL, and was back to sculpting. The only
significant difference was in his ambulation status. He now
EXAMINATION
required a cane to ambulate on all surfaces indoors and did
not go outdoors unless accompanied by his wife. History
REFERENCES Ms. Ledger was a 66-year-old White woman who was
referred to physical therapy to assist with right upper extrem-
1. Morris RO, Sonibare A, Green DJ, Masad T. Closed pelvic fractures: ity mobility. Three weeks prior to the initial physical therapy
characteristics and outcomes in older patients admitted to medical appointment she had undergone a right modified mastec-
and geriatric wards. Postgrad Med J. 2000;76:646-650. tomy and axillary lymph node dissection. Ms. Ledger was
2. McKinnis LN. Fundamentals of Orthopedic Radiology. Philadelphia,
PA: F. A. Davis Company, 1997.
scheduled to begin radiation therapy (RT) in 3 weeks.
3. Melton LJ 3rd, Sampson JM, Borrey BF, Ilstrup DM: Epidemiologic Ms. Ledger reported pain associated with her recovery
features of pelvic fractures. Clin Orthop. 1981;155:43-47. from her recent surgery that resulted in significant limita-
4. Hill RMF, Robinson CM, Keating JF. Fractures of the pubic rami: tions in her mobility and function. She reported difficulty
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finding a comfortable position for sleeping. In addition,
B:1141-1144.
5. Alost T, Waldrop RD. Profile of geriatric pelvic fractures presenting she needed to be able to comfortably maintain a position of
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6. Koval KJ, Aharonoff GB, Schwartz MC, et al. Pubic rami fracture: a initial mapping for RT and subsequent treatments.
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Clin J Med. 2001;68(4):303-306.
Ms. Ledger was diagnosed with breast cancer 9 months
8. American Physical Therapy Association. Guide to Physical Therapist
Practice. 2nd ed. 2001;81:9-744. prior to the initial physical therapy appointment, A routine
9. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the mammogram showed an area of increased density in her
Joint National Committee on Prevention, Detection, Evaluation, and right medial breast. A follow-up mammogram and ultra-
Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206- sound performed 1 week later showed a suggestion of a
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spiculated density measuring 2.0 to 2.5 cm. She underwent
10. Holland N, Adams MP. Core Concepts in Pharmacology. Upper
Saddle River, NJ: Prentice Hall; 2003. an ultrasound-guided core biopsy 10 days after the follow-up
11. Ware LJ, Epps CD, Herr K, Packard A. Evaluation of the Revised mammogram and ultrasound. The biopsies were positive for
Faces Pain Scale, Verbal Descriptor Scale, Numeric Rating Scale a Stage 2/3 infiltrating carcinoma in all cores. The tumor was
and Iowa Pain Thermometer in older minority adults. Pain Manag Estrogen Receptor/Progesterone Receptor (ER/PR) positive
Nurs. 2006;7(3):117-125.
and HER-2 negative. She began a course of neoadjuvant che-
12. Bergh I, Sjöström B, Odén A, Steen B. An application of pain rat-
ing scales in geriatric patients. Aging (Milano). 2000;12(5):380-387. motherapy, Femara (letrozole), prior to her surgery.
13. Christensen EH, Hedman R, Saltin B: Intermittent and continuous
running. Acta Physiol Scand. 1960;50:269-286.
14. MacRae PG, Asplund LA, Schnell JF, Ouslander JG, Abrahamse A,
Clinician Comment Breast cancers can vary
Morris C. A walking program for nursing home residents: effects on tremendously in terms of severity and long-term prognosis.
walk endurance, physical activity, mobility, and quality of life. J Am It is the staging of the disease that determines the serious-
Geriatr Soc. 1996;44(2):175-180. ness. The American Joint Committee on Cancer uses the
15. Naglie G, Tansey C, Kirkland JL, et al. Interdisciplinary inpatient TNM classification system.1,2 Staging is the system used
care for elderly people with hip fracture: a randomized controlled
trial. CMAJ. 2002;167(1):25-32.
to identify the extent of the tumor (T), spread to lymph
nodes (N), and metastases (M) when first diagnosed. These
categories are further broken down with a suffix indicating performed to see whether estrogen receptors are present.
the degree of involvement. Is the tumor estrogen receptor positive (ER+), and likely
to respond to hormonal therapy? Or is the tumor estrogen
T (Primary (x, 0, is, 1 to 4) size or direct extent receptor negative (ER–), and therefore unlikely to respond
tumor) of primary tumor to hormone therapy? Another common test is the HER2/
neu genetic test. Cancers that have this gene tend to be
Tx Primary tumor cannot be evaluated very aggressive and may respond to Herceptin as part of an
T0 No evidence of primary tumor adjuvant chemotherapy treatment plan.3
T is Carcinoma in situ (LCIS, DCIS or Neoadjuvant chemotherapy is administered prior to sur-
Paget s disease of the nipple gery with the intent of reducing tumor size to make surgery
more manageable and less extensive. A major benefit to
T1, T2, Size and/or extent of the primary neoadjuvant chemotherapy is the potential to increase
T3, T4 tumor breast conservation and possibly eliminate the need for a
N (Lymph (x, 0, 1 to 3) amount of spread to mastectomy. Preoperative chemotherapy allows for an in
nodes) regional lymph nodes situ assessment of the tumor behavior during chemotherapy
and to determine effectiveness of different cytotoxic drugs
Nx Regional nodes cannot be evaluated avoiding the unnecessary administration of medications to
N0 No regional lymph node involve- which the cancer is resistant.4
ment
N1, N2, Number and/or extent of spread to
N3 regional lymph nodes Social History/Environment
Ms. Ledger was an active 66-year-old woman. She was
M (x, 0, 1) presence or absence of
divorced and lived alone in a single-family 2-story home with
(Metastasis) metastasis
her 3 dogs. She had 4 grown children, 2 of whom lived out of
Mx No distant metastasis can be evalu- state. All were very supportive. She also had a strong support
ated network of friends and coworkers.
M0 No distant metastasis present Employment/Work (Job/School/Play)
M1 Metastasis is present Ms. Ledger was a third-grade teacher. She had taken the
LCIS: lobular carcinoma in situ; DCIS: ductal carcinoma in situ. school year off to accommodate medical appointments and
treatments. She hoped to return in the fall for at least 1 more
year of teaching prior to her retirement. She expressed con-
These criteria may be then translated into a more simple cern about her ability to perform at her previous work level.
classification of staging.
Social/Health Habits
Ms. Ledger was a nonsmoker and she reported only rare
Stage Definition
use of alcohol.
Stage 0 Carcinoma in situ (present only in the
layer of cells in which it began).
Family History
Ms. Ledger’s family history was significant for 2 maternal
Stage The higher the number, the more exten-
aunts with breast cancer; one diagnosed at the age of 40 and
1, 2, 3 sive the disease: larger tumor size, and/
the other at the age of 90. Her mother died of dementia and
or spread to nearby lymph nodes and/or
her father died of chronic obstructive pulmonary disease
organs adjacent to the primary tumor.
(COPD). She had one sister who was alive and well.
Stage 4 The cancer has spread to another organ.
Data from American Cancer Society. Breast Cancer Facts and
Figures 2007-2008. Atlanta: American Cancer Society Inc.; Ms. Ledger’s past medical history was significant for
and National Cancer Institute. September 25, 2008. http:// hypercholesterolemia, endometriosis, asthma, and degenera-
www.cancer.gov/cancertopics/pdq/treatment/breast/ tive disc disease. There was a question of a recent episode of
HealthProfessional/page1. Accessed October 28, 2008. pneumonia. She reported that she had taken estrogen for
20 years. Past surgical history included a hysterectomy, bilat-
Breast cancer can be treated in a variety of ways including eral salpingo-oophorectomy secondary to endometriosis, an
surgery, (RT), chemotherapy, and hormonal therapy. The appendectomy, tonsillectomy, right ankle reconstruction,
first step in treatment is the removal of the cancer. Also and a caesarean section. As mentioned earlier, Ms. Ledger
important in the initial treatment planning is testing of had surgery 3 weeks prior to the initial physical therapy
the tumor itself. The estrogen receptor assay is a lab test appointment.
564 Chapter 13
Clinician Comment Ms. Ledger underwent Flovent is a corticosteroid that is used in the maintenance
a modified radical mastectomy as well as axillary lymph treatment of asthma.5 When used regularly, it prevents the
node dissection (ALND). A modified radical mastectomy wheezing and shortness of breath seen in asthma, bronchi-
removes the breast, skin, nipple areola, and some axillary tis, and some types of emphysema. It works directly in the
lymph nodes but spares the pectoralis muscles. An ALND is lungs to make breathing easier by reducing the swelling and
the surgical resection and histological examination of the inflammation of the airways. It is not indicated for an acute
first 2 layers of lymph nodes in the axilla. Level 3 nodes may asthma attack.
also be removed. Albuterol is taken as needed for the treatment of acute epi-
sodes of bronchospasm or the prevention of the symptoms
of asthma.5
Reported Functional Status Klonopin is indicated for the treatment of panic disorders,
Prior to the diagnosis of breast cancer, Ms. Ledger was characterized by the occurrence of unexpected panic attacks
very active. She walked her 3 dogs a distance of ~1 mile each and the associated concern of experiencing additional
day and gardened in the spring and summer. She reported attacks.5 It is in a class of drugs known as benzodiazepines.
a decline in her energy level that she believed was related
to both her chemotherapy as well as her recent surgery. She
needed assistance for all but light housework and activities of Other Clinical Tests
daily living (ADL). She was unable to perform any yard work
A chest computed tomography (CT) scan, brain magnetic
and she was not able to handle her dogs on a leash. Her goal
resonance imaging (MRI) scan, thoracic spine MRI, positron
was to return to work as a third-grade teacher at the begin-
emission tomography (PET) staging, and bone density exam
ning of the next school year, 5 months away. She wanted to
were performed within the month following the breast core
work in her garden.
biopsies. The test results appear below.
Medications Computed Tomography Scan
Ms. Ledger was taking Femara, Zometa (zoledronic acid), • No significant mediastinal adenopathy identified.
calcium with vitamin D, Lipitor (atorvastatin), Flovent (fluti- Previously identified structure appeared simply to rep-
casone), albuterol, and Klonopin (clonazepam). She was aller- resent a pericardial recess.
gic to penicillin, sulfa drugs, tetracycline, and bees.
• Persistent small bilateral pleural effusions similar to
exam 6 months earlier.
Clinician Comment Femara, an aromatase • Multifocal small sclerotic lesions had developed in the
inhibitor, is an anti-estrogen drug that is Food and Drug thoracic spine consistent with sclerotic metastatic dis-
Administration (FDA) approved and typically used for the ease. In addition, there appeared to be small lytic lesions
adjuvant treatment of postmenopausal women with hor- on the anterior aspect of T7 and T8.
mone receptor-positive, early-stage breast cancer.
Femara is also approved for the extended adjuvant treat-
Brain Magnetic Resonance Imaging
ment of early-stage breast cancer in postmenopausal • No evidence of intracranial metastatic disease.
women who are within 3 months of completing 5 years of Questionable metastatic disease involving skull and
tamoxifen therapy. And finally, as in the case of Ms. Ledger, proximal cervical spine.
Femara is approved for the treatment of estrogen receptor- • No evidence of acute infarction or acute or chronic
positive or unknown breast cancer that has metastasized.5 intracranial hemorrhage or significant atrophy. Minimal
Zometa is a member of the group of medications known periventricular signal white matter abnormality was
as bisphosphonates that are used to treat hypercalcemia nonspecific.
in the blood associated with a malignancy. The primary Magnetic Resonance Imaging
pharmacologic action of zoledronic acid is the inhibition of
Thoracic Spine
bone resorption.5
• Innumerable sclerotic foci scattered throughout the
Calcium with vitamin D is a dietary supplement taken to
cervical, thoracic, and the proximal lumbar spine and
prevent bone loss.5
the margin of this study. These findings were thought
Lipitor is a cholesterol-lowering medication that blocks to be consistent with metastatic disease. There was no
the production of cholesterol in the body.5 Atorvastatin evidence of a pathological fracture or a bony expansion.
reduces low-density lipoprotein (LDL) cholesterol and total There was no evidence of central canal or foraminal
cholesterol in the blood. Atorvastatin is used to treat high narrowing.
cholesterol and to lower the risk of stroke, heart attack, or
other heart complications. • There were chronic-appearing degenerative and/or post-
traumatic changes in the cervical spine and the cord
may be contacted at multiple levels. There was little or
progressing to full blown swelling. Lymphedema onset is
no impingement associated with this. This might be bet-
usually within the first 2 or 3 years following treatment, but
ter evaluated with a dedicated cervical MRI if clinically
may occur as many as 30 years later.
indicated.
• There were disc osteophyte complexes and/or small disc
protrusions as described above, but no cord contact or Integumentary
impingement is identified.
• Skin integrity: The skin was dry and flaky with some
• Bilateral pleural effusions.
peeling skin in the area around the mastectomy scar.
Positron Emission Tomography Staging • Presence of scar formation: Mastectomy scar was a
• Diffuse metastatic disease in the spine and pelvis. healed 8-inch incision, extending from the lateral chest
• Moderate pleural effusions and left renal calcifications. wall in line with the axilla at the level of the fifth and
sixth ribs to the sternum. Axillary lymph node dissec-
Bone Density Exam tion scar was well healed but with adhesions throughout.
“All regions are much, much better than average for
age, with no sign of evolving osteoporosis or osteopenia. Musculoskeletal
Excellent bone mineral density (BMD).” • Gross symmetry/posture—Overall, Ms. Ledger’s posture
was slumped and asymmetric throughout the interview.
When prompted, she attempted to correct her spine and
Clinician Comment The results of the MRI shoulder girdle posture but was only partially successful.
of the thoracic spine and the PET staging revealed that Ms.
Ledger had metastatic disease, which would indicate that • Gross ROM/ strength—Both lower extremities, left upper
she had Stage 4 breast cancer (cancer that had spread to extremity, and cervical spine were without impairments
another organ) and not Stage 2/3 as originally thought. in gross mobility and strength. The entire right upper
extremity was limited and painful with movement. The
Nothing appeared in the interview that would contrain-
patient was reluctant to perform any right shoulder
dicate Ms. Ledger’s participation in physical therapy. The
motions secondary to fear and pain.
system review would further evaluate her status as well as
assist in the selection of indicated tests and measurements. • Height = 5 feet, 4 inches
• Weight = 166 pounds
• Body mass index (BMI) = 28.5
Systems Review Neuromuscular
Cardiovascular/Pulmonary No impairments noted in balance, locomotion, transfers
or transitions.
• Heart rate (HR) = 82
• Blood pressure (BP) = 149/89
Language, and Learning Style:
• Respiratory rate (RR) = 14
Ms. Ledger was a pleasant, cooperative woman. She
• Oxygen saturation was 99% on room air was alert, oriented, and eager to “get moving.” She and her
• Edema: There was no edema noted in the distal extremi- daughter asked many very appropriate questions specific
ties including Ms. Ledger’s right arm, forearm, and to physical therapy as well as her overall plan of care. She
hand. was appropriately concerned with moving her right upper
extremity and fearful of increasing her pain.
She stated that “as a teacher she preferred to understand
Clinician Comment Lymphedema is an what was being done and why.” She also reported doing best
accumulation of the protein-rich lymphatic fluid in the
with slow, clear explanations in “layman’s” terms. Ms. Ledger
interstitial tissue that causes swelling, most often in the
had no barriers to learning. All educational needs would be
arm(s) and/or leg(s) and occasionally in other parts of
addressed verbally in the clinic and she would be given writ-
the body.6 Lymphedema can develop when lymphatic ves-
ten instructions as well.
sels are missing or impaired (primary), or when lymph
vessels are damaged or lymph nodes removed or damaged
(secondary), as in the case of surgical or radiotherapeutic Clinician Comment Ms. Ledger’s interview
interventions. It has been reported that approximately revealed that she had pain, restrictions in self-care and
25% of patients will develop lymphedema after breast home management tasks and concerns about whether
cancer surgery and that can increase to 38% if the patient she had adequate right upper extremity mobility for the
receives RT.7 Onset of lymphedema is often slow and subtle, planned RT sessions. The systems review confirmed the lim-
beginning with a heavy or full sensation in the limb before itations in right upper extremity ROM and strength as well
566 Chapter 13
as noted impaired posture and integument characteristics, Integument

namely, decreased scar mobility. Because of her extensive Pliability—The scar was thick and restricted laterally with
axillary surgery and planned RT, Ms. Ledger was at high decreased mobility and adhesions throughout.
risk for developing lymphedema. Anthropometric measures Axillary web syndrome/lymphatic cording—There was
of baseline girth and volume were indicated to be taken of significant and diffuse cording present throughout the right
her upper extremities, as well, in the tests and measures upper arm, axilla, lateral chest wall, and abdomen.
portion of the examination.
Clinician Comment A formal or standardized
scar-rating tool was not used to assess Ms. Ledger’s soft tis-
Tests and Measures sue changes but there are several scar rating tools available
that are both valid and reliable. The Vancouver Scar Scale
Pain was developed to assess burn scars and is the most widely
Ms. Ledger rated her pain as 8/10 using the 10-point used scar-rating scale.10 It has been shown to be a valid,
Numeric Rating Scale. reliable, and feasible tool to objectively evaluate scars after
breast cancer surgery. It looks at 4 parameters related to
wound maturation, appearance, and function of healed
Clinician Comment There are numerous, skin. It also assesses pliability, pigmentation, vascularity,
well documented ways to assess pain. Three that have been
and scar height independently. The scar is assigned points
found to be valid and reliable are:
for each of these categories and the sum is tallied for the
• The Visual Analog Scale (VAS), which is a 10-cm line final score. The maximum score is 13 and the lower the
on which the patient marks the spot he or she feels cor- score, the “better” the scar. Inter-rater reliability was sig-
responds to the level of pain. One endpoint on the line nificant with Spearman’s correlation coefficient of 0.66 for
is labeled “no pain” and the other endpoint is labeled the overall score (all p values < 0.001).
“worst pain possible.” It is estimated that 90% of patients treated with RT for
• The Numeric Rating Scale (NRS) uses a 0 to 10 inten- breast cancer will develop some degree of radiation-induced
sity scale, where zero indicates that there is no pain dermatitis.11 Early effects are those that occur within
and 10 is the worst pain imaginable. 90 days of initiation of radiation and include: dryness, epi-
• The Verbal Rating Scale (VRS) asks patients to choose lation, pigment changes, and erythema. Dry and moist des-
a word that best describes their pain.8 quamation may also develop. Late effects, occurring more
than 90 days after completion of RT, may include: atrophy,
fibrosis characterized by progressive induration, edema,
Self-Care and Home Management and thickening of the dermis. Pigmentation changes, tel-
(Including Activities of Daily Living and angiectasias, and dermal necrosis can also occur several
months after RT has been completed. Physical therapy is
Instrumental Activities of Daily Living) crucial during this phase to educate the patient in skin
Ms. Ledger was not able to sleep on her right side because care, prevent postural changes, and maintain joint integ-
of pain. She reported difficulty dressing. She had not been rity. Measurement of these changes has tended to be very
able to resume driving. The Shoulder Pain and Disability subjective.
Index (SPADI) was used to establish Ms. Ledger’s baseline. One tool that has been preliminarily investigated for reli-
Her initial score was 97.8. ability and validity is the Skin Toxicity Assessment Tool
(STAT).12 This tool looks at not only the physical description
Clinician Comment The SPADI is a 13-item, of the skin, but also asks for patient subjective comments. In
2-part questionnaire in which the patient rates his or her addition, there is a section for treatment recommendation.
pain and level of difficulty with basic daily activities.9 A The STAT has been found to have an inter-observer level
higher score is associated with a higher degree of func- of agreement for eliciting subjective complaints of 72% to
tional limitations. The score is calculated by adding the 92% (95% confidence interval (CI) = 63% to 96%; k = 0.33 to
scores from both parts of the questionnaire, dividing that 0.68). The inter-observer agreement when scoring skin reac-
number by the highest score possible, and then multiplying tions ranged from 65% to 97.5% (k = 0.46 to 0.81). There is
by 100. The highest score possible is 130 if all the ques- a significant correlation between objective and subjective
tions are answered. If an item is deemed not applicable, toxicity scores (p < 0.05).
no score is calculated for that item. The SPADI has been
Lymphatic cording is thought to occur from lymphatic dis-
found to be reliable and valid in measuring disability in
ruption following breast or axillary surgery.13 Lymphatic
community based patients reporting shoulder pain due
cording in the upper quarter is characterized by axil-
to musculoskeletal pathology. The SPADI is available at
lary pain radiating down the upper extremity/chest wall,
http://www.workcover.com/worker/reference-library/forms
decreased shoulder ROM, and a palpable or visible web
under Documents A – Z.
of subcutaneous tissues, especially with upper extremity MOTION RIGHT LEFT LEFT
abduction.14 Previously named axillary web syndrome (Passive Only) (Active) (Passive)
because it was first described in the axilla, lymphatic cord-
ing more accurately describes the condition as symptoms Shoulder exter- 60 degrees 85 90
can extend beyond the axilla, including the chest wall nal rotation degrees degrees
and abdomen. The condition is thought to be a result of *Painful/
lymphovenous injury secondary to positioning in surgery, apprehensive
lymphovenous stasis, or hypercoagulability caused by Shoulder 25 degrees 50 60
surgery.13,14 Another theory suggests that cording may extension degrees degrees
be a result of thrombosed lymphatics and a variant of
Mondor’s disease.14 The severity of cording is described Elbow ‒10 degrees 0 0
as mild, mild-moderate, moderate, moderate to severe, extension degrees degrees
or severe.14,15 Review of the literature yielded limited Elbow flexion 135 degrees 135 135
information and no studies related to the reliability of this degrees degrees
classification system.
CERVICAL RANGE OF MOTION
Forward bend Full
Posture Backward bend Full
Ms. Ledger held her right upper extremity in a guarded
Side bend right ¾
“sling” position in both the standing and seated position.
Her right shoulder was elevated and internally rotated. Her Side bend left ½
scapula was protracted and there was a moderate increase in Rotation right ¾
thoracic kyphosis with an increased flattening of her cervical
lordosis. With verbal cues to correct her posture, Ms. Ledger Rotation left ½
sat a little more erect but did not change her shoulder girdle
position.
Clinician Comment Goniometric shoulder
measurements have high intrarater reliability when taken
Clinician Comment The clinical assessment either in sitting or in supine.18,19 There is a decreased reli-
of posture is largely subjective and descriptive in nature.
ability when taken in one position and then another.18 It is
The plumb line is inexpensive and commonly used for
therefore important to remain consistent in the positioning
clinical assessment of posture. It establishes a line of refer-
and in the documentation of the positioning.
ence that coincides with the midline of the body in anterior,
posterior, and lateral views.16 Kendall and McCreary16 use Chen et al20 identify visual estimation (VE) as a quick and
this plumb line to describe a “standard posture.” The visual easy way to measure cervical range of motion, but report
assessment of posture may have only fair intrarater reliabil- errors have been estimated to be as great as differences of
ity and poor interrater reliability.17 5 degrees and 45 degrees. They go on to state that it is too
unreliable and its use should be discouraged. They recom-
mend single inclinometry as it has been proven reliable
Range of Motion (Including Muscle for all active motions but clarify it is most reliable when
performed by the same therapist using the same procedure.
Length) Youdas et al21 have also discouraged the use of VE, citing
With Ms. Ledger positioned in supine, ROM measures the use of a goniometer or a cervical ROM instrument
were recorded for her bilateral upper extremities. Cervical that was found to have good to high intrarater reliability.
spine measures were subjectively assessed with Ms. Ledger Although VE is used as a means for measuring spinal ROM,
seated. it may not be the better choice.
MOTION RIGHT LEFT LEFT

(Passive Only) (Active) (Passive)
Shoulder 150 degrees 175 180
flexion degrees degrees
Shoulder 141 degrees 170 180
Shoulder flexion 2-/5 4+/5
abduction degrees degrees
Shoulder abduction 2-/5 4+/5
Shoulder inter- 70 degrees 70 70
nal rotation degrees degrees Shoulder internal rotation 3/5 5/5
568 Chapter 13
MUSCLE GROUP RIGHT LEFT Clinician Comment Lymphedema limb

Shoulder external rotation 2/5 4+/5 assessment can be performed a number of ways: water
displacement, tape measure, Perometer (Pero-System), or
Shoulder extension 3+/5 5/5 bioimpedence.25-28
Elbow extension 3+/5 5/5 With the factors of cost and convenience considered, a tape
Elbow flexion 3+/5 5/5 measure, with circumferential measurements at 5 cm inter-
vals and subsequent volume calculations, was used.
Middle trapezius 2/5 3+/5
The volume of a truncated cone is calculated as follows:
Middle deltoid 2/5 3+/5 V = h (C1² + C1C2 + C²)/12π
Rhomboids 2/5 3/5 V is the volume of the segment and C (1) and C (2) are the
circumferences at the end of each segment, and h is the dis-
tance between them (segment length).
Clinician Comment A literature review per- Circumferential girth measurements are a reliable, valid,
formed by Cuthbert and Goodheart22 found the Manual
and fairly easy way to measure for presence of limb edema.25
Muscle Test (MMT) to be a useful clinical tool, but because
Water displacement, although messy and time consum-
of the many factors contributing to decreased muscle per-
ing, is an effective and reliable measurement tool for limb
formance, additional research is required to establish its
volume.25,26 Because of the relative ease, convenience and
validity. Other studies, however, have shown the MMT
no cost, circumferential girth measurements were used to
to highly correlate to the hand-held dynamometer, whose
establish baseline limb volume. The results of these mea-
reliability has been established.23 In a study conducted
surements, a 0.07% difference in the right upper extremity in
by Bohannon,24 he concluded that his results “cast doubt
a right-handed individual, indicated that at baseline there
in the suitability of MMT as a screening tool for muscle
is no significant difference between the 2 upper extremities.
impairment.” Though MMT is a commonly used and
convenient test, additional research is needed. Hand-held
dynamometry might have been the better choice.
EVALUATION
Anthropometric Measures
Diagnosis
Upper Limb Volume for Baseline
Lymphedema Assessment Practice Pattern
Circumferential measurements: Ms. Ledger fit into several of the Preferred Practice
Patterns.
RIGHT UPPER LEFT UPPER Musculoskeletal Practice Patterns
EXTREMITY* EXTREMITY 4B Impaired Posture
MCP 16.6 cm 17 cm 4D Impaired Joint Mobility, Motor Function, Muscle
Performance, and Range of Motion Associated With
Ulna styloid (US) 15.1 15.2 Connective Tissue Dysfunction
5 cm above US 17.1 18.4 Integumentary Practice Pattern
10 cm 20.7 21.0 7A Primary Prevention/Risk Reduction for Integumentary
Disorders
15 cm 24.3 24.2
20 cm 25.5 26.2 International Classification of Functioning,
25 cm 25.4 25.8
See ICF Model on p 569.
30 cm 29.5 29.5
35 cm 31.5 31.0 Prognosis
40 cm 32.8 30.8 Ms. Ledger had an excellent physical therapy prognosis. It
Total volume 1837.6 ml 1823.3 ml was expected that she would achieve and maintain the ROM
required for RT. It was anticipated that she would return
Difference 0.07% (patient is to all ADL and light household activities upon completion
right (R) handed) of RT. Her goal of returning to work as a school teacher in
MCP: metacarpophalangeal joints. 5 months depended on her response to the medical treatment
of her cancer.
ICF Model of Disablement for Ms. Ledger

Health Status
• S/p Modified radical mastectomy, right, with
axillary lymph node dissection
• Metastatic breast cancer—stage 4
• Endometriosis
• Asthma
• Degenerative disc disease
• S/p pneumonia?

Function
• Inability to assume the • Inability to pursue her usual
• Pain position required for recreational activities (ie,
• Healing incisions with radiation therapy gardening, walking her
adhesions forming • Unable to position herself dogs)
• Lymphatic cording for comfortable rest or sleep • Inability to work (teach
• Difficulty with dressing and third grade)
• Asymmetrical and slumped
posture personal care
• Decreased ROM, especially • Inability to perform
in right UE housework
• SPADI = 97.8

• Age = 66 years • Lives alone
• Interrupted sleep • Needs to be able to drive to commute to her job
• Motivated to return to work
• Misses gardening and walking her dogs
• Knowledge deficit regarding radiation therapy
effects and management strategies
570 Chapter 13
Plan of Care 7. Ms. Ledger’s right shoulder ROM would be her optimum
and tolerant of overpressure at end ranges (10 weeks).
Interventions 8. All upper extremity MMT show greater than 3+/5
strength, at least (12 weeks).
Interventions planned for Ms. Ledger included:
• Patient-/client-related instruction regarding her current 9. She would be independent in a full home program of
condition, the plan of care, and the discharge plan. mobility, strengthening, and postural correction exer-
cises in addition to a walking program (16 weeks).
• Patient education on skin care and lymphedema-preven-
tion guidelines. She would also be instructed to include Expected Outcomes (16 weeks)
use of Aquaphor (Eucerin) and daily moisturizing to 1. Ms. Ledger would resume her previous level of ADL and
minimize skin changes before and during RT. IADL tasks.
• Manual therapy techniques consisting of: soft tissue 2. She will have an excellent understanding and 100%
mobilization to normalize tissue density of the cervical, compliance with lymphedema guidelines/precautions to
shoulder and scapular muscles, scar mobilization and allow safe return to all previous activities.
skin tractioning for cording release.
3. She would estimate that she would be able to return to,
• Scapula and glenohumeral joint mobilization to allow at least, 85% to 90% of her work tasks.
for RT positioning.
Discharge Plan
• Wand exercises for shoulder flexion, abduction, and
extension beginning in supine and progressing to stand- The patient would be ready for discharge from physical
ing. Later the exercises would progress to strengthening therapy to her own care when she achieved the anticipated
with 1- to 2-pound cuff weight or TheraBand. goals and expected outcomes listed above. The plan of care,
including the discharge plan, has been discussed with the
• An endurance reconditioning program would begin patient, who was in agreement.
once other interventions were underway and she showed
that she could meet a functional walk standard of 500
feet. It was anticipated that she would have a program
with timed walking prescription. INTERVENTION
• Patient would be instructed in her prescribed home
exercise program (HEP), which would be provided in a Coordination, Communication, and
written form also.
Documentation
Proposed Frequency and Duration of Coordinated dialogue with both medical and radiation
Physical Therapy Visits oncologists, as well as her surgeon, to clarify the required
Ms. Ledger would be scheduled for 3 physical therapy ses- movement for radiation field mapping and treatment would
sions per week for 3 weeks in preparation for RT. It was also be undertaken, and thereafter as needed. Ongoing commu-
anticipated that she will need an additional 6 to 8 visits over nication with patient, family, referral sources, and other care-
the course of her RT. givers regarding progress toward goals would be pursued.
Documentation would include all aspects of care, including
Anticipated Goals initial examination/evaluation, daily treatment notes, tele-
1. Ms. Ledger would have a good understanding of, and phone conversations, progress reports, reexaminations, and
comply with, lymphedema precautions and skin care discharge summary.
(1 week).
2. Ms. Ledger would tolerate mobilization techniques Patient-/Client-Related Instructions
to mobilize her scar and decrease lymphatic cording
(2 to 3 weeks). The patient and her family were informed regarding the
plan of care, frequency of visits, and discharge plan as previ-
3. She would demonstrate independence with an initial
ously discussed.
HEP (2 to 3 weeks).
Ms. Ledger received written and verbal information
4. Her right shoulder flexion would increase to 165 degrees pertaining to lymphedema prevention guidelines. She was
and abduction to 150 degrees to allow for positioning also given information on how to access the National
during RT (3 weeks). Lymphedema Network (NLN). Lymphedema guidelines are
5. Ms. Ledger’s pain would decrease from 8/10 to 4/10 on published on the website (http://www.lymphnet.org). Side
the NRS (6 weeks). effects and adverse effects that may occur during and after
6. The mobility of her mastectomy scar would normalize the delivery of RT, such as fatigue, skin changes, sensation
and lymphatic cording would be eliminated or, at least, changes, and breast swelling will also be covered through-
reduced (8 weeks). out the course of therapy. Additional information was also
provided on current conservative treatment options, should Ms. Ledger would be shown and given an opportunity
she develop lymphedema.6,7 to practice the exercise program. As her proficiency with
Skin care, precautions, and preparation for radiation the exercises improves, the program will become a HEP to
therapy would be reviewed. An integumentary protection address postural corrections and right shoulder and scapular
technique consisting of skin preparation with Aquaphor mobility.
daily before RT begins and then continued following the • Cervical side bend and rotation stretching—In sit-
delivery of RT would be reviewed with Ms. Ledger. ting, the patient would be instructed to perform gentle
A written postural HEP would be initiated along with stretches to the point of moderate tension only, with a
general activity guidelines, including an endurance recondi- 20-second hold.
tioning program. • Postural corrections—In sitting, the patient would be
instructed in scapula retraction and depression along
Clinician Comment The lymphedema guide- with gentle chin tuck to restore normal postural align-
lines from the NLN focus on 5 key areas: skin care, activ- ment, with a 10-second hold.
ity/lifestyle, avoidance of limb constriction, compression • Wall walking for shoulder flexion to be performed bilat-
garments, and temperature extremes. Printed educational erally to maintain symmetry and prevent substitution,
materials adapted from the NLN guidelines were available with a 20-second hold.
to give to Ms. Ledger. Ms. Ledger would be instructed to perform each repeti-
tion slowly to achieve maximal benefit.
Procedural Interventions Clinician Comment In people with cancer,

exercise and physical activity have been shown to improve
Manual Therapy Techniques (Including fitness, reduce fatigue, and modestly reduce weight and
Mobilization/Manipulation) body fat. There is also a strong correlation between strenu-
Ms. Ledger would be seen for scar management and ous exercise and quality of life.30
release of lymphatic cording. The manual therapy techniques
utilized would include: soft tissue mobilization to normalize
tissue density of the cervical, shoulder and scapular muscles, Aerobic Capacity/Endurance
scar mobilization, and skin tractioning for cording release.
Mode
Clinician Comment Although Moskovitz et Walking program.
al29 suggest that lymphatic cording is self-resolving in a Intensity
3-month period, Wyrick et al13 found a much shorter reso- RPE < 11.
lution time with physical therapy intervention. A 3.6-week Duration
time frame was the average for acute-onset and only the 3 to 5 minutes to cover 250 feet.
“late-onset” cases required longer interventions of up to 10 Frequency
weeks.
Once every waking hour until total feet walked for the day
is 2000 to 2500 feet.
Ms. Ledger would be instructed in a walking program that
Therapeutic Exercise Prescription would consist of ambulating a minimum of 250 feet for every
hour that she was awake. She would be instructed that the
Body Mechanics and Postural
distance she walked each time could be short with rests in
Stabilization; Flexibility Exercises between, but that it was essential that she walked every hour
Mode for a total distance each day of 2000 to 2500 feet.
Active and against gravity, flexibility, and postural
exercises.
Intensity Clinician Comment An hourly ambulation
schedule with instructions for the patient to total their
Slow movements through entire ROM, as able, and avoid
distance walked over the course of the day is an effective
undue fatigue.
tool for reconditioning patients after hospitalization as the
Duration
duration and frequency of walking is within their control
10 to 15 minutes (for entire routine of identified exercises). and they can easily add the distances and track their prog-
Frequency ress. The frequency and intensity of walking prescriptions
10 repetitions, 2 to 3 times per day. are not as important as the total duration of walking when
the patient is severely impaired (ability to walk less than
572 Chapter 13
500 feet in 6 minutes). Once the patient is able to complete Objective

a total of 500 feet without shortness of breath or significant
fatigue, it is possible to add in the component of “intensity” Pain
to the exercise prescription by combining the distance to be Ms. Ledger reported her pain had improved from 8/10 to
walked within a specific time frame. There is research to a 2/10 on VAS.
support the efficacy of intermittent training in improving
aerobic conditioning31 and there are studies to support the Self-Care and Home Management
efficacy of a walking program in improving walk endurance Ms. Ledger reported she was able to sleep on her right side.
capacity.32 She was performing light household chores and she was able
to reach overhead with very little pain (eg, she could empty
the dishwasher and reach to put plates on the second shelf).
Functional Training in Self-Care and Home Her SPADI score had improved to 11.6.
Management Integumentary System
Energy Conservation Techniques Scar/skin integrity—The skin in the area of mastectomy
Ms. Ledger would receive assistance, as needed, to help scar was smooth and well moisturized. The scar was well
her plan her daily and weekly activities but also guidelines healed and pink. There was good mobility of the scar medi-
for pacing the activities to avoid increased fatigue. ally; adhesions persisted at the lateral end of the scar.
The lymphatic cording was reduced from severe to mod-
Instrumental Activities of erate with elimination of the cording in the abdomen inferior
Daily Living Training to the mastectomy scar. Cording was also reduced in the
Ms. Ledger would have the opportunity to seek advice on antecubital area, but persisted in the upper arm, lateral chest
how to organize her kitchen to make meal preparation easier. wall, and the axilla.
Injury Prevention or Reduction Posture
Ms. Ledger would have the opportunity to practice simu- Ms. Ledger self-corrected her posture during treatment
lated IADL tasks—including those requiring forward bend- sessions. Her posture was symmetrical with only trace pro-
ing, squatting or lifting—to ensure she was using correct traction in right shoulder girdle.
body mechanics.
Range of Motion
Prescription, Application, and, as
Appropriate, Fabrication of Devices and
MOTION RIGHT (ACTIVE) LEFT (ACTIVE)
Equipment (Assistive, Adaptive, Orthotic,
Protective, Supportive, and Prosthetic) Shoulder 165 degrees (was 175 degrees
flexion 150 degrees)
Supportive/Prosthetic Device
Shoulder 165 degrees (was 170 degrees
Ms. Ledger would be referred to a qualified vendor for abduction 141 degrees)
prosthetic devices and mastectomy bras. If she began to show
lymphedema signs in her right upper extremity, her physi- Shoulder inter- 90 degrees 90 degrees
cian would be notified and assistance provided to acquire nal rotation
appropriate compression garments as appropriate. Shoulder exter- 90 degrees (was 85 degrees
nal rotation 60 degrees and
extremely pain-
REEXAMINATION ful/apprehensive)
Shoulder 25 degrees 50 degrees
The first reexamination took place 3 weeks after the initial extension
physical therapy appointment and on the day of anticipated
radiation field mapping. Results were as follows: Elbow exten- 0 degrees (was 0 degrees
sion ‒10 degrees)
Subjective Elbow flexion 135 degrees 135 degrees
“I feel so much better. I’m anxious to begin radiation.”

She was also able to achieve and maintain the overhead
position of shoulder flexion/abduction required for RT with-
out pain.
Muscle Performance OUTCOMES
Discharge
Shoulder flexion 3/5 (was 2/5) 4+/5
Ms. Ledger continued to receive physical therapy through-
Shoulder abduction 3/5 (was 2/5) 4+/5
out her course of RT. She received a total of 21 physical thera-
Shoulder internal rotation 4/5 (was 3/5) 5/5 py treatments. She had achieved all the anticipated goals and
Shoulder external rotation 4/5 (was 2/5) 4+/5 reached the desired functional outcomes listed below:
• Her skin had healed, and she was fit for and received a
Shoulder extension 4+/5 (was 3+/5) 5/5 breast prosthesis.
Elbow extension 4+/5 (was 3+/5) 5/5 • She was compliant with skin care and prevention guide-
Elbow flexion 4+/5 (was 3+/5) 5/5 lines for lymphedema.
Middle trapezius 3/5 (was 2/5) 3+/5 • She was dressing without assistance, performing all
ADL, self-care activities, and sleeping well.
Middle deltoid 3/5 (was 2/5) 3+/5
• She was independent in her HEP and had an excellent
Rhomboids 3-/5 (was 2/5) 3/5 understanding of activity progression.
• She was in the process of organizing her classroom
and decorating her bulletin boards without limitations
Work, Community, and Leisure in preparation to begin her final year as a third-grade
Reintegration teacher.
Ms. Ledger had not returned to work and would remain Her only stated restriction was with reaching in extreme
at home the rest of the summer. She had not yet returned to overhead positions with her right upper extremity.
her leisure activities secondary to fatigue as well as a busy
schedule of medical appointments. Her surgeon had not yet
cleared her to walk her dogs. Clinician Comment Other self-report shoul-
der assessment tools include the Disabilities of the Arm,
Shoulder and Hand (DASH), the American Shoulder and
Assessment Elbow Surgeons standardized shoulder form (ASES), the
Ms. Ledger made excellent progress with her program. Simple Shoulder Test (SST) and the University of California
She increased the passive and active ROM of her shoulder at Los Angeles (UCLA) Shoulder Score. These have all been
and reported decreased pain. She was starting to resume found to have good reliability, validity, and responsiveness
self-care and home management activities. She was able to and while there is a high correlation among the scores, the
achieve and maintain the overhead position required for RT. tools are not equivalent in their assessment of function.33
She would continue to benefit from physical therapy to fur- Because the diagnosis of breast cancer and its subsequent
ther increase her ROM. treatment, including surgery, chemotherapy, and RT is
more complex than a simple shoulder disability, in retro-
Plan spect, the SPADI is most appropriate for the short-term
measurement of functional outcome.
The frequency of treatment sessions was reduced to A long-term quality of life survey such as the Quality of
2 times per week for 3 weeks and then 1 time per week for Life in Adult Cancer Survivors (QLACS) may also have
3 weeks to span the projected course of her RT. It was antici- been useful in this case.34 The QLACS has 47 items and
pated that she may then need 2 to 4 visits over the remaining 12 domains: 7 generic and 5 cancer specific. The generic
4 to 6 weeks to complete the treatment plan. Treatment ses- domains are physical pain, negative feelings, positive feel-
sions would continue to work on glenohumeral and scapula ings, cognitive problems, sexual problems, social avoidance,
mobilization and progress to shoulder and scapula stabilizer and fatigue. The cancer-specific domains are financial
strengthening. Continue to provide education and support problems resulting from cancer, distress about the fam-
regarding skin care changes with RT. Continued monitoring ily, distress about reoccurrence, appearance concerns, and
and education regarding skin care would also be indicated benefits of cancer. In a study by Avis et al,34 the QLACS
as she progressed toward returning to her previous level of was evaluated for test-retest reliability, concurrent and ret-
activity. rospective validity, and responsiveness. The results of that
study showed good test-retest reliability and high internal
574 Chapter 13
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consistency. The generic domain summary showed consis- of common postural abnormalities in the cervical, shoulder, and
tency with other health-related quality of life (HRQL) tools. thoracic regions and their association with pain in two age groups
The cancer-specific domains exhibited divergent validity of healthy subjects. Phys Ther. 1992;72(6):425-431.
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visual assessment of cervical and lumbar lordosis: how good are we?
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outcome status for Ms. Ledger. ing in supine and sitting positions. Arch Phys Med Rehabil.
1998;79(6):647-651.
19. Riddle DL, Rothstein JM, Lamb RL. Goniometric reliability in the
clinical setting: shoulder measurements. Phys Ther. 1987;67:668-
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Financial Disclosures
Dr. Joanell A. Bohmert has no financial or proprietary interest in the materials presented herein.
Dr. Lisa Brown has no financial or proprietary interest in the materials presented herein.
Cheryl L. Brunelle has no financial or proprietary interest in the materials presented herein.
Dr. LeeAnne Carrothers has no financial or proprietary interest in the materials presented herein.
Dr. David Chapman has no financial or proprietary interest in the materials presented herein.
Dr. Cynthia Coffin-Zadai has not disclosed any relevant financial information.
Dr. Debra Coglianese has no financial or proprietary interest in the materials presented herein.
Kathleen Coultes has no financial or proprietary interest in the materials presented herein.
Dr. Vanina Dal Bello-Haas has no financial or proprietary interest in the materials presented herein.
Dr. Skye Donovan has no financial or proprietary interest in the materials presented herein.
Dr. Susan L. Edmond has no financial or proprietary interest in the materials presented herein.
Dr. Nancy Gage has no financial or proprietary interest in the materials presented herein.
Dr. Paul D. Gaspar has no financial or proprietary interest in the materials presented herein.
Dr. Melanie A. Gillar has no financial or proprietary interest in the materials presented herein.
Laura Klassen has no financial or proprietary interest in the materials presented herein.
Dr. Kerri Lang has no financial or proprietary interest in the materials presented herein.
Dr. Daniel Malone receives royalties from SLACK Incorporated for his work, Physical Therapy in Acute Care.
Dr. Mary Jane Myslinski has no financial or proprietary interest in the materials presented herein.
Dr. Lola Sicard Rosenbaum has no financial or proprietary interest in the materials presented herein.
Dr. Brian D. Roy has no financial or proprietary interest in the materials presented herein.
Dr. Robert M. Snow has no financial or proprietary interest in the materials presented herein.
Dr. Alison L. Squadrito has no financial or proprietary interest in the materials presented herein.
Dr. Jane L. Wetzel has no financial or proprietary interest in the materials presented herein.
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Clinical Exercise Pathophysiology For: Physical Therapy

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Coglianese

Clinical Exercise Pathophysiology

Clinical Exercise Pathophysiology for Physical Therapy

Debra Coglianese SLACK Incorporated

Debra Coglianese, PT, DPT, OCS, ATC

Copyright © 2015 by SLACK Incorporated

Published by: SLACK Incorporated

Library of Congress Cataloging-in-Publication Data

Section I Foundations of Physiological Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Section II Pathophysiology of Deconditioning and Physiology of Training . . . . . . . . . . . . 135

Section III Pathophysiological Considerations and Clinical Practice . . . . . . . . . . . . . . . . . . 209

Financial Disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .575

For teachers and mentors who lit the way,

Cynthia Coffin-Zadai, DPT, MS, FAPTA

Debra Coglianese, PT, DPT, OCS, ATC

Coglianese D, ed. Clinical Exercise Pathophysiology for

physiologic responses and fully appreciate the pathophysi-

A TABLE 1-1. ABSOLUTE AND PERCENTAGE

Although each ventricle contracts and propels an equal

Figure 1-12. Sinus node and the Purkinje system of the

TABLE 1-2. AUTONOMIC NERVOUS SYSTEM INFLUENCES ON CARDIOVASCULAR SYSTEM

The Cardiac Cycle ultimately CO are influenced by multiple factors, including

cardiovascular system is a closed pressure and closed volume

TABLE 1-3. VASOACTIVE INFLUENCES ON

the contraction or relaxation of the smooth muscle within

TABLE 1-4. ACTIVITIES OF DAILY LIVING AND METABOLIC EQUIVALENTS

Normal Response to Increasing Loads

Coglianese D, ed. Clinical Exercise Pathophysiology for

since the mother’s LNMP began approximately 14 days prior

Intramembranous Ossification development that is typically observed in the skull, man-

Figure 2-5. (A) A microphotograph of a

play key roles in the development of aerobic capacity, while

age. Further changes occur with growth spurts through bone

AND ADOLESCENCE Development of Bony Tissue

Developmental Changes in Muscle

Other Clinical Tests

Clinician Comment Jill demonstrated vital

Clinician Comment Observation of move- Tests and Measures

Clinician Comment In adolescents, manual Posture

Clinician Comment Individuals with CP

ICF Model of Disablement for Jill

Body Structure/ Activity Participation

Personal Factors Environmental Factors

Body fat handheld analyzer 23.4%

Social History/Environment Medical/Surgical History

Reported Functional Status

Tests and Measures Pain

AROM AROM PROM Ankle inversion 4+/5 3-/5

ICF Model of Disablement for Jack

Body Structure/ Activity Participation

Personal Factors Environmental Factors

sphygmomanometer and placing the inflated cuff behind REEXAMINATION

Plan Gastrocnemius -10 degrees

Plan Ankle dorsiflexion 15 degrees

Anticipated Goals Heel cord 5 degrees

• Discuss how the age-related changes to the 3 compo-

Coglianese D, ed. Clinical Exercise Pathophysiology for

review of the literature provides evidence of an age-related

Figure 3-1. Maximum transdiaphragmatic pressures in young and elderly