Lawrence P. Cahalin

Short‐term changes in pulmonary function and respiratory movements after cardiac surgery via median sternotomy

Objective—To study the changes in bilateral respiratory motion and pulmonary function following sternotomy and the relationships between the changes in respiratory movements, spirometry, radiographic analyses, and several intra‐operative surgical characteristics. Design—Respiratory motion during deep breathing and lung volumes were measured in 20 patients (mean age 65 years, SD 16) before and after median sternotomy. Chest x‐rays were analyzed pre‐ and postoperatively and a variety of perioperative variables were measured. Results—Average abdominal motion decreased to 57% of preoperative values bilaterally 1 week postoperatively, the average lower thoracic motion decreased to 72%, and the average upper thoracic motion decreased to 87%, whereas the right upper thoracic motion increased 3% compared with preoperative values. Lung volumes decreased to around 60% of preoperative values (p < 0.05). Significant correlations were found between the decrease in pulmonary function and the mean respiratory movements. Abnormal chest radiographs were found in all patients. Conclusion—The breathing pattern before sternotomy is predominantly abdominal but moves to a thoracic and upper thoracic pattern postoperatively and is associated with reduced pulmonary function. Therapeutic interventions aimed at correcting the less effective upper thoracic breathing pattern should likely be implemented.

Effect of exercise training on respiratory muscle oxygenation in children with congenital heart disease

Background Diminished aerobic capacity and weakness of both respiratory and peripheral muscles have been observed in cardiac patients and may contribute to exercise limitation. The aim of this study was to evaluate the effects of a home-based training programme on aerobic fitness and oxygenation of the respiratory muscles in children with congenital heart disease (CHD). Methods and results Eighteen patients with CHD aged 12–15 years participated in this study. Ten patients (training group, TG) underwent a training programme for 12 weeks and eight patients served as a non-training control group (CG). All subjects performed a cardiopulmonary exercise test before and after the study period. Oxygenation of the respiratory muscles was assessed using near-infrared spectroscopy. No significant differences were observed, at baseline and after the completion of the study, between the CG and TG in peak exercise workload, oxygen uptake (VO2), carbon dioxide output (VCO2), pulmonary ventilation (V E), and heart rate (HR). However, a significant improvement in exercise performance was found in the TG versus the CG when results were compared at the ventilatory threshold (V th): workload (45.2 ± L 8.0 versus 58.5 ± 7.4%; P<0.05), VO2 (62.3 ± L 7.5 versus 69.8 ± 5.1%; P<0.05), VCO2 (49.8 ± L 5.7 versus 60.0 ± 5.8%; P<0.05), V E (42.8 ± L9.9 versus 50.1 ± 9.5%; P<0.05), and HR (69.5 ± 6.1 versus 76.0 ± 3.5%; P<0.05). After training, an improvement in oxygenation of the respiratory muscles was found in the TG from 60% of VO2max until the end of exercise. At the V th, the TG showed greater oxygenation after training (55.1 ± 6.6 versus 43.0 ± 6.9%, P<0.01, respectively). Furthermore, we showed a significant correlation of the change in respiratory muscle oxygenation and VO2 in the TG (r = 0.90, P<0.01). Conclusion It is concluded that general physical training at submaximal intensity induces better aerobic fitness and improves respiratory muscle oxygenation in children with CHD.

Inspiratory muscle endurance testing: Pulmonary ventilation and electromyographic analysis

This study analyzed regional pulmonary ventilation and electromyographic (EMG) activity of the respiratory muscles during an inspiratory muscle endurance (IME) test in 10 young women. Radioaerosol (99mTc-DTPA) was generated using a jet nebulizer connected to a linear inspiratory loading system. The lung scintigraphic analysis showed an increase in the radioaerosol deposition using loads of 20 and 30 cmH(2)O (p<0.01). The vertical gradient showed a larger radioaerosol deposition in the medium third of the lungs during the control period (p<0.001). There were larger amounts of radioaerosol deposition in the medium third when compared with the upper and lower third at 30 cmH(2)O (p<0.001). The horizontal gradient showed a larger deposition in the intermediate and central segments during all phases (p<0.00). Electromyographic activity from the muscles of the lower rib cage increased with loads of 20 and 30 cmH(2)O (p<0.03). There was an increase in deposition of radioaerosol when the load increased (r=0.584, p=0.000 for the left lung and r=0.609, p=0.000 for right lung). These findings suggest that during the IME test, EMG activity in the muscles of the lower rib cage increase during progressive respiratory workloads is associated with a greater radioaerosol deposition in the medium third and intermediate and central segments of the lungs.

Managing gait disorders in older persons residing in nursing homes: a review of literature.

Managing gait disorders in the nursing home setting is a challenge. Nursing home residents can present with a variety of factors that may contribute to the presentation of gait abnormalities. The development of an individualized intervention program can be effective in improving a residents ability to ambulate. This article reviews the research pertaining to the management of gait disorders including deconditioning, therapeutic exercise intervention, dementia, and cardiovascular and cardiopulmonary systems. The review provides the reader with strategies to help improve and understand gait performance in older persons residing in nursing homes.

Suspected Statin-Induced Respiratory Muscle Myopathy During Long-Term Inspiratory Muscle Training in a Patient With Diaphragmatic Paralysis

Background and Purpose: Abnormal lipids are associated with the development of coronary heart disease; for this reason, lipid-lowering agents have become a standard of care. The purposes of this case report are: (1) to highlight the association of impaired inspiratory muscle performance (IMP) with statin therapy and (2) to describe potentially useful methods of examining and treating people with known or suspected statin-induced skeletal myopathies (SISMs). Case Description: The patient had breathlessness on exertion and a restrictive lung disorder from a right hemidiaphragmatic paralysis, for which he was prescribed high-intensity inspiratory muscle training (IMT). He had a secondary diagnosis of hyperlipidemia, which was treated with 40 mg of simvastatin after 5½ months of IMT. Outcomes: The improvements in IMP, symptoms, and functional status obtained from almost 6 months of high-intensity IMT were lost after the commencement of simvastatin. However, 3 weeks after termination of simvastatin combined with high-intensity IMT, the patients IMP, symptoms, and functional status exceeded pre-statin levels. Discussion: This case report suggests that high-intensity IMT can be used effectively in a patient with impaired diaphragmatic function and during recovery from a respiratory SISM. The marked reduction in IMP and inability to perform IMT resolved with the cessation of statin therapy. The case report also highlights the potential effects of SISMs in all skeletal muscle groups. The clinical implications of this case report include the potential role of physical therapy in monitoring and possibly facilitating the spontaneous recovery of an SISM, as well as the need to investigate the IMP of a person with dyspnea and fatigue who is taking a statin.

Educational and professional issues in physical therapy--an international study.

Very little information exists regarding physical therapy educational and professional issues in various regions of the world. A better understanding may facilitate physical therapy (PT) practice, education, and research around the globe. The purpose of this study was to gain a worldwide perspective of physical therapy educational and professional issues in 40 separate countries. Forty countries known to provide PT were chosen from a World Confederation for Physical Therapy (WCPT) list of affiliates based on language, geography, and presumed PT practice. An English survey consisting of 22 items and four primary areas (accreditation of PT educational programs, licensure, specialization, and earning potential) was translated into five different languages (Spanish, French, Portuguese, Japanese, and Korean). The survey was administered electronically to key WCPT contacts in the 40 countries. The response rate was 42.5% and revealed modest diversity in physical therapy educational and professional issues among countries with the exception that 1) all but one country had an accreditation process for PT educational programs; 2) all but one country had licensure for PTs; and 3) all but five countries had a specialization process that included a written examination. Modest diversity in physical therapy educational and professional issues appears to exist among countries except for accreditation, licensure, and specialization.

Job strain and older workers: Can a reduction in job strain help to eliminate the Social Security drain?

Job strain is the psychological and physiological response to a lack of control or support in the work environment. It appears to be an important risk factor for continued employment throughout the lifespan. Reducing job strain earlier in a workers life has the potential to have substantial beneficial health effects throughout a workers life. Early screening for job strain should be implemented in known high risk or high strain jobs. This is particularly important since there a fewer younger workers entering the labor force and there will be a growing need for older workers to remain in the workforce. Furthermore, healthier workers will require less medical care and are likely to work longer if they are willing and able. Healthier older workers who are willing and able to work longer will defer receipt of retirement benefits while continuing to pay into the Social Security System. Further investigation of older individuals (1) willingness and motivation to work past the normal retirement age, (2) career and employment security, skills development, and reconciliation of working and non-working life, and (3) job strain and effects of reducing job strain is needed. The current job strain literature has been expanded to the Social Security System arena and suggests that reducing job strain has the potential to help eliminate the Social Security drain by increasing older worker labor force retention.

Integrated physical therapy intervention for a person with pectus excavatum and bilateral shoulder pain: a single-case study.

OBJECTIVE To examine the effects of an individualized physical therapy (PT) program for a subject with pectus excavatum and bilateral shoulder pain. DESIGN Single-case study of a man diagnosed with moderate-to-severe pectus excavatum and constant bilateral shoulder pain. Exercise tolerance was measured through the Bruce protocol and home exercise log, pulmonary function, ventilatory muscle strength, echocardiography, chest wall and abdominal excursion, self-perception of pectus excavatum, and a variety of anthropometric and volumetric tests before and after PT. SETTING University laboratory. PARTICIPANT A 22-year-old man. INTERVENTION A 3-month PT program including breathing exercises and therapeutic exercises. MAIN OUTCOME MEASURES Exercise tolerance, ventilatory muscle strength, chest wall and abdominal excursion, self-perception of the pectus excavatum, and other anthropometric and volumetric tests. RESULTS The most striking anthropometric and volumetric test change was the pectus severity index (in H2O), which decreased from 50 to 20 mL H2O (60% change). The subject reported no shoulder pain at rest and with recreational activity after 8 weeks of intervention. CONCLUSION An individualized PT program provided minimal-to-moderate improvements on many characteristics of pectus excavatum. Bilateral shoulder pain was eliminated. An individualized PT program integrating cardiopulmonary and musculoskeletal interventions that is provided to other patients with pectus excavatum may provide similar results. However, PT provided to younger patients with the pectus excavatum may be of even greater benefit because of a less mature skeleton. Further investigation of the effects of PT intervention provided to younger and older persons with the pectus excavatum is needed.