Chronic Disease Part 1: Heart Failure

Ya’ll know how much I love freeing the yoke! Chronic disease is a huge burden to the general population. This post is the first in a series of posts addressing some of the major chronic diseases placing a yoke around the necks of our patients. We will discuss what these diseases are, what causes them, and what we can do about it! I’ll help you with what you need to know before you go. Let’s talk about one of the major culprits: Heart Failure.

In 2012-2013, new terminology was adopted for the description of heart failure types. Even though it is not widely used, the new language has increased awareness of and research on diastolic dysfunction and opened our eyes to the two major types of heart failure. We used to just think “left” or “right” or “both”, and that wasn’t exactly wrong, but heart failure is more complicated than that, so the terminology needed to be a better descriptor of what was actually going on.

Heart Failure reduced Ejection Fraction (HFrEF)

Also classically known as systolic heart failure, Heart Failure with Reduced Ejection Fraction indicated that the patient has an Ejection Fraction of <40%. In patients with this diagnosis, EKG abnormalities are more common, indicating that heart rhythm issues are present. HFrEF is clearly associated with coronary heart disease (CHD). HFrEF is typically caused by:

  • Myocardial Infarction
  • Viral myocarditis
  • Physical damage to the heart tissue

Damage to the actual cardiac muscle, electrical, valvular, or vascular tissue is what reduces the ejection fraction in these patients. Either the pump can’t pump as hard (left ventricle), the electrical function is interrupted which results in incoordination and decreased strength of contraction (left ventricle), the valve can’t close and open properly so blood slips out when it isn’t supposed to, or the coronary vasculature can’t supply the oxygen and nutrients to the musculature that it requires. In some of the more long-term causes, blood pools up in the left ventricle, stretching the muscle beyond it’s optimal length and reduces the strength of contraction.

This heart failure is typically more of sudden onset which can result in patients having increased difficulty coping and managing the symptoms. Thankfully, because it typically has a sudden onset, the heart musculature doesn’t have enough time to atrophy before rehab professionals are able to intervene. So, although the patients with this type of heart failure may struggle emotionally or mentally with their new diagnosis, their physical function is less limited after initial diagnosis. This is, of course, dependent on the degree of infarction or physical damage.

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There are some in the category who do have significant physical damage or require longer term treatment, such as with viral infections. They may be significantly debilitated due to PICS. Sometimes, this condition is caused by long term disease which results in a larger level of damage, especially if the diseases are left uncontrolled for a longer period of time. Causes of this kind of damage can include:

  • Hypertension
  • Coronary Artery Disease (CAD)
  • Mitral Regurgitation
  • Aortic Stenosis

This is a great population for us to jump in with. These are the folks that are still feeling pretty ok. They know they are going to be facing difficulties, but they typically are ready to go on the rehab to prevent HFrEF from affecting them for as long as possible. They can also undergo procedures to correct for some of these issues (like TAVR procedures for valve repairs). But for hypertension and CAD, prevention is key. One of my patients with HFrEF diagnosis had to be discharged early from home care services because he had reached his only self-selected goal which was to go kayaking with his grandsons. All the warm and fuzzies. We still transitioned him to outpatient cardiac rehab for long term management, though.

Heart Failure preserved Ejection Fraction (HFpEF)

In Heart Failure with preserved Ejection Fraction, the left ventricle of the heart cannot properly fill with blood. Overall, less blood than “normal” still leaves the heart, but 55% or more of the blood in the left ventricle still leaves the chamber. Therefore, the ejection fraction is maintained, but the cardiac output is still less. The ventricle can still pump well but the ventricle walls may be very stiff, so cannot relax enough to fill properly during diastole. This can also happen is the heart wall muscle becomes too thick and the chamber no longer holds as much blood. HFpEF can be diagnosed if the ejection fraction is anything greater than 40%. HFpEF is more likely in females and renal failure a more common comorbidity. Causes include:

  • Long term hypertension
  • Complication of uncontrolled diabetes or long term diabetes (severely stiffened arteries systemically including coronary arteries)
  • Failure/Sarcopenia due to debility and/or obesity
  • Hypertrophic Cardiomyopathy
  • Aortic Stenosis
  • Pericardial Disease (abnormalities of the sac surrounding the heart)

As you can see, many of the causes are the same as HFrEF. That is because the development of these conditions depends on the systemic condition of the person, comorbidities, overall physical level, and many other factors. However, the difference here is that HFpEF is typically caused by long term chronic diseases, which means that I’ve seen a lot of these patients.

The difficulty with treating HFpEF is that these patients ride the long slow train down the very slight decline. There can definitely be a triggering event that starts the train ride, but it is all down hill. The burden of chronic disease takes its toll on their body and the recovery process involves riding that long slow train back up the hill. This takes a lot of time and a lot of effort on the part of the patient and the therapist. The other hard piece to the puzzle is that we don’t usually get to intervene here until much later in the disease process which means there has been systemic muscle atrophy, multiple system failure, and ongoing difficulty with chronic disease management. These patients require a good deal of monitoring at all times when participating in activity because they tend to have a very low overall tolerance.

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The medication burden to the patient with HFpEF is also much higher and more difficult to sustain. They are typically treated with mineralocorticoid receptor antagonists (spironolactone or eplerenone) which cause hyperkalemia, as well as other medications that elevate potassium, so potassium level and intake must be monitored regularly. Have you ever heard of Milrinone? Nasty business… And then add in that they may also require hemodialysis three days per week due to the associated renal failure, and the physical, mental, and emotional toll of that… I have tons of research on that but we will address ESRD in another post.

This all means that, as the physical therapist, exercise may not be the best or only intervention you are providing. This also means that you have some serious considerations for whole-patient management that go far beyond your assessments and interventions. Let’s talk about some of those things…

The treatment is still exercise!

Regardless of the type of heart failure, the treatment is the same: MOVE! Where you start is definitely going to differ based on acuity and type. More acute HFrEF may need phase 1 cardiac rehab interventions, but may progress to stage 3 quickly and be on their merry way. However, patient with HFpEF will be in phase 2 for a very long time and may meander across stages and settings of care. They typically endure a relapsing/remitting disease course that places a large burden on themselves and their caregivers. Baseline functional assessments and outcome measures are critical for patients with HFpEF because progress is long and labored so maintaining skilled care can be more difficult.

Straight from the Clinical Practice Guideline, here is the exercise prescription patients with heart failure need. Please observe those RPE levels… that’s right… 90-95% peak workload is your target.

Physical therapists must prescribe aerobic exercise training for patients with stable, NYHA Class II-III HFrEF using the following parameters: Time: 20–60 min; Intensity: 50%–90% of peak VO2 or peak work; Frequency: 3–5/wk; Duration: at least 8–12 wks; Mode: treadmill or cycle ergometer or dancing (Evidence Quality I; Recommendation Strength: A—Strong) 
Physical therapists should prescribe high-intensity interval exercise training in selected patients for patients with stable, NYHA Class II-III HFrEF using the following parameters: Time: >35 min; Intensity: >90%–95% of peak VO2 or peak work; Frequency: 2–3/wk; Duration: at least 8–12 wks; Mode: treadmill or cycle ergometer. HIIT total weekly exercise doses should be at least 460 kcal, 114 mins, or 5.4 MET-hrs. (Evidence Quality I; Recommendation Strength: A—Strong) 
Shoemaker, M. J., et al. (2020)

There is also plenty of information on the strengthening of the muscles of respiration using IMT training and proper prescription of resistance training. Dr. Shoemaker and his crew even provide the guidance for combining all the different types of training so you can get it all in. We will get in to more details of High-Intensity Interval Training in another post. I’m super excited about that!

Other than exercise…

Keep in mind all the things we talked about in the post about the Rule of 2s! All of these things still come in to play for every one of these patients. Many patients with HFrEF don’t receive the education on how to manage their heart failure using the Rule of 2 because they tend to go quickly in and out of treatment, but that doesn’t mean they don’t need it! If they want to get back to their normal life and live it the best they can for as long as possible, they need to manage themselves properly to prevent decompensation and be healthy enough to participate in exercise or activity-based interventions.

Yes, that means you need to take your patient’s weight. You need to check their weight log. You need to listen to their lungs at every visit and know what you are listening for. You need to check their heart rate (manually, because they have rhythm issues, remember?), blood pressure, and pulse oximetry before, during, and after activity. And if you are in the outpatient setting, you definitely need to do this. Just because someone walked in to your clinic today doesn’t mean they are healthy. That 72-year-old man here for a basic knee evaluation may have knee pain from joint effusion resulting from lower extremity edema secondary to fluid overload. I’ve seen it. This is chronic disease management. Within our scope, within our ability = our responsibility.

For more specifics on treating patients with heart failure, please take a read on the BRAND SPANKING NEW Clinical Practice Guideline for Physical Therapists Managing Heart Failure!

What baseline functional outcome measure is your “go-to” for patients with heart failure? Tell me in the comments!

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Black, H. R. & Pitt, B. (2015). HFpEF: The ‘New’ Heart Failure. Commentary for MedScape. Retrieved from /838790#vp_3

Ho, J. E., Gona, P., Pencina, M. J., Tu, J. V., Austin, P. C., Vasan, R. S., Kannel, W. B., D’Agostino, R. B., Lee, D. S., Levy, D. (2012). Discriminating clinical features of heart failure with preserved vs. reduced ejection fraction in the community. European Heart Journal. 33(14):1734–1741.

Oktay, A. A., Rich, J. D., & Shah, S. J. (2013). The emerging epidemic of heart failure with preserved ejection fraction. Current heart failure reports10(4), 401–410.

Pai, R. K., Thompson, E. G., Gabica, M. J., Husney, A. (2019). Heart Failure With Reduced Ejection Fraction (Systolic Heart Failure). HealthWise. Retrieved from,less%20than%20the%20body%20needs.

Pai, R. K., Thompson, E. G., Gabica, M. J., Husney, A. (2019). Heart Failure With Reduced Ejection Fraction (Systolic Heart Failure). HealthWise. Retrieved from

Shoemaker, M. J., Dias, K. J., Lefebvre, K. M., Heick, J. D., & Collins, S. M. (2020). Physical Therapist Clinical Practice Guideline for the Management of Individuals With Heart Failure. Physical therapy100(1), 14–43.

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Treating Long-COVID: Part 1

I’m sure you have been hearing a lot lately about Long COVID. You may have heard it called many different things: Long-COVID, Post-COVID Syndrome, Myalgic Encephalomyelitis, Post-Viral Fatigue Syndrome, Chronic Fatigue Syndrome, ME/CFS, long-haul COVID, or post-exertional malaise (really a symptom, or PESE – post-exertional symptom exacerbation). These terms are not interchangeable, but in the conversations on these conditions, they are all frequently mentioned. I’m going to give you a brief overview of what you need to know about Long-COVID and what role PTs play in managing this condition.

First, new evidence suggests that around 55% of all people who have had COVID-19 will develop at least one of the following symptoms. MORE THAN HALF of all people who have had COVID-19. Yes, You read that correctly and you can go read the article yourself (citation below: Taquet, 2021). Long-COVID has been associated with a host of symptoms that result from the initial viral illness regardless of how impaired or sick the individual became because of it. What that means is that someone could develop Long-COVID after an asymptomatic bout of COVID-19. Some sources estimate that Long-COVID affects about one-quarter to one-third of people who have had COVID-19. Nearly one-third of all people who experience long-COVID had no symptoms of active COVID-19 infection.

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Most people who experience Long-COVID show symptoms of fatigue and shortness of breath but, according to the Mayo Clinic, many other symptoms have also been associated with Long-COVID:

  • Cough
  • Joint pain
  • Chest pain
  • Memory, concentration or sleep problems
  • Muscle pain or headache
  • Fast or pounding heartbeat
  • Loss of smell or taste
  • Abdominal discomfort
  • Depression or anxiety
  • Fever
  • Dizziness when you stand
  • Worsened symptoms after physical or mental activities

That last one is where we are going to spend some time. Worsened symptoms after physical or mental exertion is what has been termed “post-exertional malaise, (PEM)” or “post-exertional symptom exacerbation, (PESE)” and is a symptom that can and should significantly impact your rehabilitation plan and exercise prescription for patients with long-COVID.

Long-COVID with PEM

Rehabilitation for patients with Long-COVID has been a troublesome and confusing concept, as these patients do not and cannot progress like the typical respiratory failure patients do in therapy. The reason for this (we think, as evidence is frequently developing) is the diffuse endothelial damage of the vascular system throughout the entire body secondary to COVID-19 infection. The vasculature in the lungs can be significantly damaged producing impaired ventilation/perfusion ratios. The endothelium cannot produce or release the chemicals necessary for efficient or effective vasodilation to increase blood supply to the tissues. This produces impaired vascular return to the heart. The brain cannot get enough oxygen because of these other faults. In addition, there are many effects of this diffuse vascular damage that we can’t completely account for, but that seriously impact overall physiological function, such as the increased presence and reduced ability to clear inflammatory substances. These issues, among others, contribute to the increased incidence of clotting.

But the endothelium is a two-way street. Things don’t just pass into the bloodstream, but also pass out of it through this single-cell layer. And when it isn’t functioning properly, all those things that need to get out just can’t. This results in a build-up of inflammatory substances like cytokines and interleukin-6. Inability to clear these inflammatory factors contribute to ongoing damage to the endothelium, creating an iterative process.

And, let’s not forget that some treatments for COVID-19 can actually produce Long-COVID symptoms. Yep, that’s right. Some of the treatments for COVID can cause Long-COVID-type symptoms. Specifically, monoclonal antibody treatment, which has been around for a while, is known to be cardiotoxic. You can read more about how to monitor patients who have received this treatment HERE.

If your patient is experiencing post-exertional malaise or symptom exacerbation secondary to Long-COVID, you should not be pushing them to the point of developing this malaise, as it can take days or weeks to recover from a single bout of the activity or mental exertion, if they are able to recover at all. Your PT evaluation could be all the exertion it takes to put these folks out for a week. But that doesn’t mean there is nothing we can do. Physical Therapists can hold many important roles when managing patients with post-exertional malaise. Let’s talk about some of those roles.

Managing Patients with Post-Exertional Malaise
  1. Do No Harm: Our first job, as Decrary and colleagues (2021) so eloquently stated, is to do no harm. But, how do we go about our job and not do harm to these patients? Take some steps to educate yourself, first. There are several continuing education courses to help you out that revolve around treating patients with post-viral fatigue syndromes and chronic fatigue syndrome. We need to see this as similar to trauma-informed care. Many of these patients have experienced trauma in some form, whether that be within the experience of severe COVID and being hospitalized for a long period of time, or because they feel they have been dismissed by other healthcare providers. Either way, approaching management through a trauma-informed lens can be helpful.
  2. Validate and Advocate: Physical Therapists hold the tools to validate and advocate for our patients. We can assess their physiological responses to activity, because that is what we are trained to do, and report them to the medical team to validate concerns and help guide treatment. We can be the evidence-supported voice for our patients, improving their care and their experience.
  3. Stop. Rest. Pace. BUT Do It Right!: Decrary and colleagues (2021) released the Stop. Rest. Pace. Guidelines for treating patients with Long-COVID (and other post-viral illnesses). Implementing these guidelines into our practice is critical. But it’s really not that simple. If you’ve ever visited the ME/CFS Twitter or Facebook groups or spoken to people who have ME/CFS, they will often tell you that they’ve tried Physical Therapy, and gotten worse. They know we exist and they are told we can help, but we just aren’t doing it to the best of our ability. In speaking with these folks, that is really because we aren’t teaching ALL of the Stop. Rest. Pace. concepts that we could be teaching.

    The biggest gap in the education we provide seems to be education on activity pacing. This is an area where we should be the experts. We should know how to pace out activity to help a patient safely complete a 6-minute walk test or safely finish a marathon, but we aren’t translating those concepts to patients with Long-COVID. Pacing applies to the total amount of activity a person has the ability to perform over the course of a day, not just for exercise, but for every single thing they have to do, from showering to dressing to meal prep to driving. If that amount of energy (both physical AND cognitive) significantly decreases, we need to help them pace out their day. These are the basics of energy conservation.

All of this doesn’t mean that you can’t make progress. The goal of Stop. Rest. Pace. is to allow for healing time. These patients have some major healing to do for their entire vascular system and you have to keep them active to facilitate that healing. Encourage them, support mental health and faith-based healing, and educate them on a diet that supports tissue healing and reduces inflammation. As they heal, introduce them to low-level activities like beginner yoga, walking, or stretching, and consider injury prevention techniques. Remember that learning novel activities increases the mental load as well as the physical load, so may produce fatigue faster than familiar activities. Therefore, if they used to enjoy a particular activity, try that one, or an adapted version of it first.

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Energy Charts

Adding a visual can help your patient see this concept. Let your patients lead by having them rank activities they have to perform by how much energy it takes to do each one. Maybe brushing their teeth takes 3 energy units compared to driving to work which takes 6 energy units. Make a chart with these values and ask them how many they can do before they are exhausted or before they know they will experience fatigue symptoms. Use that total number to help them build their day with activities that add up to less than that total number so they aren’t pushing their limits.
Allow them to make choices about what activities they put in their day.

Here’s the shock-value statement: There may be no room for your exercise program. You’ll have to adapt.

These energy charts are a concept I’ve often used for patients who experience chemo or cancer-related fatigue. The visual representation of activities helps to picture an entire day, build in rest breaks, and prevent fatigue.

Patients will make value choices that surprise you, so be prepared.
Use this to establish your plan of care and write goals for these patients.

Finally, you need to reconsider what YOU think of as rest. This may not be what your patients view as rest. They may not live in a place where they can even achieve physical and mental rest. They may hold a job where they feel they cannot achieve rest or cannot take the time off to get the rest they need. They may have used all their PTO and sick time in the hospital. Ask your patients what they consider rest and help them problem solve how they can achieve that.

You can all tell from previous posts that I’m a pusher. I’m usually the one pushing people further, physically and mentally, than they are otherwise willing to go. Even if I can achieve a fraction more today than I did yesterday, I’ll push for it.
BUT NOT HERE. I’ve drawn my line in the sand. This is where we have to think differently. Until that vascular system properly heals, we have to think about the acute phases of tissue healing, protection, providing building blocks, and ensuring the basic levels of function are maintained.

In the next post, I will go into the details on how and why to provide exercise and activity-based interventions for your patients who are post-COVID but without post-exertional malaise. This one might get me some hate mail, so stay tuned!

Do you see patients with Long-COVID? What is the most common symptom they report? Tell me in the comments!

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Taquet, M., Dercon, Q., Luciano, S., Geddes, J. R., Husain, M., & Harrison, P. J. (2021). Incidence, co-occurrence, and evolution of long-COVID features: A 6-month retrospective cohort study of 273,618 survivors of COVID-19. PLoS medicine18(9), e1003773.

Décary, S., Gaboury, I., Poirier, S., Garcia, C., Simpson, S., Bull, M., … & Daigle, F. (2021). Humility and acceptance: working within our limits with long covid and myalgic encephalomyelitis/chronic fatigue syndrome. journal of orthopaedic & sports physical therapy51(5), 197-200.

Mayo Clinic Staff. (2021, Oct 21). COVID-19: Long-term effects. Mayo Clinic.

(No Author). (2021, March 30). Studies show long-haul COVID afflicts 1 in 4 COVID-19 patients, regardless of severity. UC Davis Health.

Centers for Disease Control and Prevention (CDC). (2021, January 27). What is ME/CFS? Myalgic encephalomyelitis/chronic fatigue syndrome.

World Physiotherapy. World Physiotherapy Response to COVID-19 Briefing Paper 9. Safe rehabilitation approaches for people living with Long COVID: physical activity and exercise. London, UK: World Physiotherapy; 2021

The contents of this blog and all associated pages reflect the opinions of the author and should not be construed as medical advice. Please consult your doctor for medical advice.

Treating Long-COVID: Part 2

So, like I mentioned in Part 1 of this post, I might get some hate mail for this. Keep in mind that research is constantly changing around Long-COVID and that I’m just trying to stick with what the research tells us. I know some or many may not agree, but these aren’t my opinions, they are evidence-based statements and I’m going to keep them that way. I’ll update this information as the evidence changes so keep checking back!

Post-COVID without PEM

It is important to remember that, although ANY case of COVID-19 can eventually develop into Long-COVID, not all of them do. Not everyone experiences diffuse vascular damage. We don’t know what makes the difference between who does and who does not get Long-COVID. We do know that it is important to monitor all post-COVID patients for symptoms of Long-COVID.

“Before recommending physical activity (including exercise or sport) as rehabilitation interventions for people living with Long COVID, individuals should be screened for post-exertional symptom exacerbation through careful monitoring of signs and symptoms both during and in the days following increased physical activity, with continued monitoring in response to any physical activity interventions.”

World Physiotherapy, 2021

So how do you screen for Long-COVID or PEM, then? According to World Physiotherapy, here’s what to look for:

  • Patient-specific symptom exacerbation 12-48 hours after exercise or cognitive strain that lasts days or longer
  • Objective, measurable decline in aerobic capacity and anaerobic threshold on serial cardiopulmonary exercise testing due to neuroimmmune and metabolic dysregulation
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That means you have to know what baseline symptoms are and what symptoms are the most often exacerbated. This is likely to be different for each patient, but the most likely ones are generalized fatigue and decreased cognitive function/fogginess. You can read more about that in Part 1.

This also means you need to have a baseline test of some kind to demonstrate this “objective, measurable decline.” But that’s problematic, isn’t it? Patients with Long-COVID can’t often tolerate an official cardiopulmonary exercise test. So, you’ll have to talk to them about how much activity they can tolerate and if there is a significant change in that level of activity.

Post-COVID Exercise Prescription

Here is where I’m going to get hate mail.

But what about the exercise? Isn’t well-prescribed exercise the best possible intervention to expedite the healing of damaged vasculature? Yes. Yes it is. We know that from hundreds, if not thousands, of studies on vascular diseases and diseases that cause vascular damage. So, can a patient who is post-COVID without post-exertional malaise exercise to the extent of their ability? According to the evidence, the answer is YES! Here’s the breakdown.

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Remember, not ALL cases of Long-COVID come with PEM, PEM is just one symptom. So, if your patient doesn’t have PEM, exercise may be very helpful for them. It might be a slow start, and that’s ok. Remember that COVID-19 is a systemic vasculitis. You have miles of vasculature in your body, and that’s miles of potential damage. That damage takes time to heal and the greater the extent of the damage, the longer it may take. That systemic vasculitis comes along with the potential for post-exertional symptom exacerbation which you DO NOT want happening because of the exercise you prescribed. You can prescribe activity and you can prescribe exercise, but you have to make sure that is within the patient’s ability and goals.

Well, that’s great! But what kind of exercise is the best exercise for people after they have COVID-19? The answer may shock you…

High-Intensity Interval Training

Yep, I know, I know. But it’s true. High-intensity interval training has some of the strongest evidence for people with vascular disease. It also has very strong evidence for people with vascular disease who has a host of comorbidities. However, this high-intensity interval training isn’t the same thing you see in infomercials, fitness classes, or gyms. The design and framework are the same but it is used differently, with skilled precision and constant monitoring.

Some evidence translated from pre-COVID vascular diseases indicates that using an inverse design to high-intensity interval training is a great place to start. This is because high-intensity interval training has the strongest evidence for providing anti-inflammatory effects by decreasing the production of inflammatory factors and increasing the clearance of inflammatory substances already in the body. High-intensity interval training does this better than moderate-intensity continuous exercise. High-intensity interval training is also more effective at promoting the healing of vascular and cardiac tissues and can even induce left ventricular remodeling.

Patients with systemic vasculitis secondary to COVID-19 have A LOT of inflammatory junk in their systems. Their entire vascular system is damaged meaning that there are byproducts of the cellular damage, cellular metabolism, and apoptosis circulating everywhere and the load has exceeded the body’s natural ability to clear it. High-intensity interval training can give your patient the extra assistance they need, but only if you design their programs properly. Designing programs that have longer rest intervals and shorter work intervals, at least to start with, has shown to be more effective for patients post-COVID. These programs should include functional and meaningful movements and activities so that the daily workload can be built into the exercise program to prevent over-taxing the system. I’ve heard recent patient stories that report heart rates over 200 beats per minute simply vacuuming, or walking up a single flight of stairs! Don’t be afraid to progress, but let the patient’s symptoms and tolerance lead you.

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We learned in Part 1 of this post that you cannot calculate max heart rate the same way for patients post-COVID as you do for patients who haven’t had COVID. People who have the cardiac effects of long-COVID (elevated heart rate at rest and exaggerated heart rate response to minimal activity) may be on medications, like beta-blockers, to control their heart rate. That means that determining what “high” intensity is for that specific patient includes hitting a specific heart rate window. It also means that the “low” intensity target is also a very specific window. And there is no way to know you hit those windows unless you are constantly monitoring vitals before, during, and after exercise, and also with recovery. Make sure to go back to Part 1 and read the specifics on calculating max heart rate in patients with long-COVID!

Don’t forget about the other vitals, either. Many patients post-COVID have excessive respiratory rates, but normal heart rates, with activity. This should be equally concerning and should tell you they need a different exertion scale! Keep your eyes on the blood pressures and pulse oximeter readings, also. You have to keep the big picture in front of you at all times!

Take-Home Points:

Calculate heart rate max and target heart rate zones properly.
Design HIIT programs to match those heart rate zones.
Monitor vitals to ensure you are reaching, but not exceeding the heart rate zones.
Use the right exertional scales for your patient.
Always be assessing symptoms!

Evidence for ME/CFS

PLEASE… Do NOT throw the tomatoes at the messenger. The evidence for post-viral fatigue / myalgic encephalomyelitis / chronic fatigue syndrome even prior to COVID-19 supported the use of high-intensity interval training with this population IF they do not have post-exertional malaise. Remember, post-exertional malaise is just one of many symptoms of these post-viral conditions and DOES NOT happen to every patient who contracts them.

Photo by Jonathan Borba on

Specifically, there is evidence to support high-intensity interval training as a more tolerable method of exercise in patients with chronic fatigue syndrome because it does not exacerbate fatigue like moderate-intensity continuous exercise. It is thought that the shorter bursts of activity, followed by either complete rest or active rest are more tolerable than longer bouts of exercise because this design allows the body to have intermittent recovery periods while working. This evidence goes on to report that high-intensity interval training can actually help patients who experience other symptoms of chronic fatigue syndrome, such as insomnia and decreased physical function.

Take-home points:

Not every case of ME/CFS or post-viral syndrome or long-COVID will have the same presentation and/or symptoms.
Not every person who has ME/CFS has post-exertional malaise.
Not every person will be intolerant of physical activity.
Let the symptoms (and the patient) be your guide.
Refer to Part 1 for more info on other options besides exercise.

Can you take this back to the clinic tomorrow? Will you take this back to the clinic tomorrow? Let me know in the comments.

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Sandler, C. X., Lloyd, A. R., & Barry, B. K. (2016). Fatigue Exacerbation by Interval or Continuous Exercise in Chronic Fatigue Syndrome. Medicine and science in sports and exercise48(10), 1875-1885.

Foged, F., Rasmussen, I. E., Budde, J. B., Rasmussen, R. S., Rasmussen, V., Lyngbæk, M., … & Christensen, R. H. (2021). Fidelity, tolerability and safety of acute high-intensity interval training after hospitalisation for COVID-19: a randomised cross-over trial. BMJ open sport & exercise medicine7(3), e001156.

Larun, L., Brurberg, K. G., Odgaard-Jensen, J., & Price, J. R. (2017). Exercise therapy for chronic fatigue syndrome. The Cochrane database of systematic reviews4(4), CD003200.

Keech, A., Way, K., Holgate, K., Fildes, J., Indraratna, P., & Yu, J. (2021). HIIT for post-COVID patients within cardiac rehabilitation: Response to letter to the editor. International journal of cardiology322, 291–292.

Nelson, M. J., Bahl, J. S., Buckley, J. D., Thomson, R. L., & Davison, K. (2019). Evidence of altered cardiac autonomic regulation in myalgic encephalomyelitis/chronic fatigue syndrome: A systematic review and meta-analysis. Medicine98(43), e17600.

Décary, S., Gaboury, I., Poirier, S., Garcia, C., Simpson, S., Bull, M., … & Daigle, F. (2021). Humility and acceptance: working within our limits with long covid and myalgic encephalomyelitis/chronic fatigue syndrome. journal of orthopaedic & sports physical therapy51(5), 197-200.

Christensen RH and Berg RMG (2021) Vascular Inflammation as a Therapeutic Target in COVID-19 “Long Haulers”: HIITing the Spot? Front. Cardiovasc. Med. 8:643626. doi: 10.3389/fcvm.2021.643626

Brockway, K., Ayers, L., Shoemaker, M. (2022). HIIT-ing Your Target: Applying High-Intensity Interval Training in Special Populations. APTA Cardiovascular and Pulmonary Academy. Presentation at APTA Combined Sections Meeting, San Antonio, TX.

The contents of this blog and all associated pages reflect the opinions of the author and should not be construed as medical advice. Please consult your doctor for medical advice.

Can I Touch Your Face? – Screening the Cranial Nerves

Most providers start the cranial nerve screen with CNII, but that has been changing since COVID-19 entered the scene. The primary presenting symptoms of loss of taste and smell have re-anchored the sensory systems in the neurological screening and the cranial nerve exam. Both smell and taste are transmitted via cranial nerves so this screening is becoming all the more important in identifying patients with mild cases of COVID-19 in outpatient settings.

Remember the story I told about the patient with a shearing injury to her brain? In clinical practice, the cranial nerve screen is a standard part of my Neuro Screen, which you can check out HERE! In every patient I see who has a complex disease presentation or any risk factors for underlying neurological conditions, (let’s be real, that’s everyone I see) I do this screening and include a cranial nerve screen as well.

Specifically for patients with advanced diabetes, several balance issues can be related to visual disturbances resulting from calcified arterial supply to the cranial nerves. You’ll find these when you do a good cranial nerve exam. And for patients with BPPV, a vestibular condition happening at increased frequency in patients with COVID-19, checking those cranial nerves is a necessary portion of your evaluation.

Here is the quick screening version:

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CN I: Smell – have them smell something… your choice here… Probably one of the more important tests these days, so don’t skip it like we used to. As people age, their sense of smell can severely decrease, leading to changes in their ability to enjoy or crave food. Smell is a primary factor in nutrition. See the whole patient.

CN II: Optic – have them give you the color of something or read your name badge or count your fingers (you’ll have to accommodate those who are color blind, who cannot read, or who have aphasias). You can also test peripheral vision here.

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CN III: Oculomotor – have them follow your finger with only their eyes, draw a capital “X” with a strike-through horizontal line (X). Then make sure to move your finger in a circle in both directions. Look for saccadic or abnormal eye movements, nystagmus, or strabismus. These can be a sign of decompensated or mismanaged chronic health conditions like diabetes.
My little trick for this one: LR6(SO4)3 . I was a chemistry minor in college so this worked for me, but it basically means that the Lateral Rectus is innervated by CN VI, Superior Oblique is innervated by CN IV, and all the other oculomotor nerves are CN III. So you get three tests in one here.

CN IV: Trochlear – see CN III, tested together. The downward part of drawing the letter X. Drawing the circle gives you Superior Oblique.

CN V: Trigeminal – supplies sensory to the face and comes in three branches (ophthalmic, maxillary, and mandibular). Make sure to check all three regions. The trigeminal nerve also supplies motor input to the pterygoids, so you can have the patient clench their jaw and palpate contraction.

CN VI: Abducens – see CN III, tested together. The horizontal bar across the letter X.

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CN VII: Facial – supplies motor input to the face and comes in five branches (temporal, zygomatic, buccal, mandibular, and cervical). Make sure to assess all five branches of motor control using facial expression. Typical facial expressions are eyebrow elevation/forehead wrinkle, puff out cheeks, big smile, purse lips, and close eyes tightly. You can also test taste on the anterior 2/3 of the tongue, especially if screening for COVID-19.

CN VIII: Vestibulocochlear – In the absence of a tuning fork, this is typically tested by gently rubbing fingers together near the patient’s ears and asking if they hear anything, however, this is highly subjective.

CN IX and X: Glossopharyngeal and Vagus – have the patient open their mouth a say “ah”, observe for uvula deviation. Ensure the palate is rising symmetrically and that air is not escaping through the nose. You can also observe your patient swallowing if you know what you’re looking for, or you can test taste on the posterior 1/3 of the tongue (maybe the test of choice if screening for COVID-19). Vagus nerve damage at any point along the nerve including the root within the brain can also result in blood pressure fluctuations (see the case I mentioned above).

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CN XI: Accessory – controls the motor to the spinal accessory muscles. Have the patient elevate both shoulders and hold against resistance.

CN XII: Hypoglossal – have the patient stick their tongue out and observe for midline positioning.

So, there are the easy ways to do the screen, making it easier for you to quickly fit it in amongst all the other things you need to do. Setting that baseline is so important so that, when things change, because they will, you have something to compare it to!

How often do you do a cranial nerve screen? Drop a number in the comments!

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The contents of this blog and all associated pages reflect the opinions of the author and should not be construed as medical advice. Please consult your doctor for medical advice.

Did Anyone Else See That?

The Basics on Neurological Baselines

Do you ever wonder, “did anyone else see that?” We find those red flags sometimes, don’t we? We see something odd in a physical exam and it completely changes our perspective on the patient. The key to seeing it, though, is to look for it.

You may be thinking, “another thing I need to add to my very limited time with the patient… great.” But I have great news for you! This can be done quickly and easily. You don’t have to do in-depth coverage of every single neurological deficit, but you can cover a lot of bases and get a baseline without dedicating a huge amount of time. This can lead you to go a little deeper later if you need to. But, this big piece here is that you’ll never know it’s an issue if you never look for it.

We now know that COVID-19 presents with any number of strange symptoms depending on which entry point the virus utilizes. This may include neurological symptoms such as loss of taste or smell, headaches, or other neurological signs that we discuss at length in this post. But, this screen isn’t just relevant for COVID-19 patients. Like I said before, I started educating on this years ago, way before COVID-19 was even a thing. If you have patients you see for any reason and they have a history of neurological events or conditions (old CVA, TIAs, old TBI, old CHI, peripheral nerve injury, seizure disorders), or even some neurocardiological-endocrine conditions like diabetes, you’ll want to get a neurological baseline in place. You can look back at this to see if they have made progress or are showing new symptoms for some reason!

The big tagline here is: You don’t know where the patient is at if you don’t know where they started. You can’t be calling in the physician to report neurological findings if you have no basis for comparison. Even strokes leave residual deficits that magnify under odd conditions. This doesn’t mean the person is having a stroke, as you’ll see later.

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From Neck Pain to TIA in a the Twitch of a Finger

For example, I saw a patient at home with severe neck pain. Her cervical spine assessment showed that she could not rotate her head in either direction while seated, so I did a neurological screen. She was mildly confused, her blood pressure was high, and she was living alone. Some minor coordination tests didn’t look right and she had a (+) Hoffman’s sign. ***my eyes widen*** I dug a little deeper and found that she was completely unable to dissociate her upper body from her lower body. She was having TIAs and quickly losing neuromotor coordination. Her neck pain was a result of high blood pressure (instead of a headache) and her inability to dissociate her movements.

She wasn’t the only (+) Hoffman’s sign I’ve seen, either. I spent a long time learning about neurocardiological function from a patient who had sustained a brain injury in a car accident. Her midbrain shearing injury resulted in disruption of her ability to control her blood pressure which was leading to falls and emergency visits for excessive hypertension. My first clue that her hypertension wasn’t typical was that (+) Hoffman’s sign, which lead to an in-depth discussion of her medical history and revealed the TBI. She had moved and no longer had the same medical team, so no one was aware of this, and she hadn’t even told her home care nurse who was struggling to get her enough fast-acting medication to control her hypertension. But I never would have found that Hoffman’s sign if I hadn’t been screening for it.


Tone, Strength, Sensation, Synergies, Coordination, Posture, and Balance all need to be assessed as part of the neurological screening. And to top it all off, let’s throw in a cranial nerve exam. The only way I remembered all the things I needed to do for a neurological baseline assessment was to create an acronym. This is really generic, but it allows me to cover each of the important items and directs me toward where I need to dig a little deeper. Some of these things can also be observed simultaneously if you are looking for them. So, I came up with T.S.S.S.C.P.B. (“T, Triple S, CPB”) Just the first letter of each of these items. This helps keep me on track and ensures I don’t miss something I need to do. It may not work for you. I realize it’s a bit odd but it got me an A on my practical in school and I’ve been using it ever since! Yes, I do this at EVERY evaluation. Why not? It takes five minutes and it clears so many red flags.

Tone: Assessed with strength as in any typical MMT assessment using the bicep and tricep and/or hamstring and quad in seated. Remember, tone is resistance of a muscle to a passive stretch. Like I said, this is only a screen, so if there is a less common tonal presentation or it only presents in a different position, I won’t find it here.

Strength: Assessed as typical MMT as with any orthopedic examination. I also do reflexes here since I tend to already have them seated for quad and can easily assess brachioradialis, tricep, and plantarflexors. Since I already have their hands and feet, I also check UMN signs here. I focus on the big ones: Hoffman’s, Clonus, Babinski…

Here is a great video of how to quickly assess some upper motor neuron signs, like that Hoffman’s sign I talked about:

Sensation: Screened with light touch and deep pressure during positioning for MMT and other tests, but also screened using proprioceptive testing of the hallux. For screening purposes, if the most distal segment is intact, I assume that all above segments are intact (except in the case of diabetes or other stocking/glove disturbances).

Synergy: Observed during normal movements or assessed when needed, like in the case I mentioned above where the patient could not rotate her cervical spine bilaterally.

Coordination: Assessed using finger opposition, visual targeting, AND in the lower extremity using the heel to shin slide, usually just before MMT.

Posture: Assessed in seated and standing as part of any normal evaluation, but intensive attention paid to symmetry and posture during active movements. (Looking specifically for things like associated movements or signs of Pusher)

Balance: Gotta have that standardized test in there. Remember to choose something challenging. I always tell my patients, “If I’m not challenging you, I’m not going to change you.” Some of my favorites include the Function in Sitting Test (FIST), the Dynamic Gait Index (DGI), and the Balance Evaluations Systems Test (BESTest). Take your pick from what works best in your setting and for your population.

After doing this neurological screen, I tend to get a lot of comments like, “No one has ever done any of those things before. What do they mean?” Which gives me a great opportunity for patient education. Sometimes I get comments like, “My neurologist does those things, too,” from a patient’s family member, which strengthens my patient-provider relationship because they know that I know what I’m doing.

Once you get the hang of it and do it a few times, this comes really fast. Keep in mind that this is a SCREEN, so no, it’s not perfect, and it’s probably not what the neurologist does, and it won’t answer every single diagnostic question. But that’s not the point of a screen.

And once you get the flow, don’t forget to add in that Cranial Nerve Screen! Learn more about that HERE.

I cannot even put a number to the neurological signs I have picked up with this screen that warranted further investigation. Have you ever found neurological signs that completely altered the course of treatment for your patient? Tell me your story in the comments!

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Follow @DoctorBthePT on Twitter for regular updates!

The contents of this blog and all associated pages reflect the opinions of the author and should not be construed as medical advice. Please consult your doctor for medical advice.

More Than Just A Respiratory Disease: The COVID-19 Toolbox

Isn’t COVID-19 just a respiratory disease? If only that was true. We are good at treating respiratory infections. We have lots of drugs for viral, bacterial, parasitic, and fungal infections of the lungs. Most of them work really well! We also have several backup treatments, inhaled medications, and adjuvant therapies (like rehab!) that make primary treatments even more effective. We are pretty darn good at treating respiratory infections. So, if COVID-19 was a respiratory disease only, we would have been all over that. We’ve been battling influenza in varying forms for over a century. We’ve stopped pneumonia in its tracks in even the most fragile patients. So, why haven’t we been able to put a cork in COVID-19? The answer is NO, it isn’t just a respiratory disease.

Yes, influenza can give you muscle aches. Yes, pneumonia, if left untreated, can lead to sepsis. But, COVID-19 causes severe physical damage to multiple organs and systems in your body. Particularly susceptible are the kidneys, heart, vasculature, and brain. It is thought that their susceptibility is due to their expression of ACE-2 receptors, something this coronavirus is eager to find. Even the blood-brain barrier can’t keep it out, because this coronavirus destroys the barrier. The pancreas, skin, and blood vessels are also at particular risk.

We’ve talked about these topics quite a bit in several previous posts. What do I have to offer that is new? I’m going to tell you how to start assessing and treating COVID-19 like a multi-system disease. Just like we treat diabetes, just like we treat heart failure, just like we treat most other chronic diseases.

Notice how I mention “chronic” disease? That’s intentional. Many people who didn’t require any medical intervention are several months out now on their infections and are still experiencing symptoms such as shortness of breath with little to no activity, and other symptoms that just keep lingering. Many experts feel that the damage this coronavirus causes to the endothelium (the lining of the vessels) will cause a long-term increased risk for blood clots and strokes. As rehab providers, we need to know if someone has had COVID-19 because we will want to keep this in the back of our minds when performing our differential diagnosis.

Inflammatory markers, including C-reactive protein and interleukin-6, are found in increasing numbers in patients with and after COVID-19 infection. These are the same inflammatory markers we blame for so many long-term inflammatory conditions. Down to the sub-cellular level, this disease changes our physiological function, interfering with the renin-angiotensin-aldosterone system (RAAS). This hormone-based system also helps regulate inflammation, fluid levels, and blood pressure. People who have heart failure depend on regulated fluid levels in their bodies, so upsetting this already debilitated system would cause them serious harm.

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Sure, we can treat the inflammation with dexamethosone. We can pump you full of antibiotics to prevent opportunistic infections. We can give you antivirals to slow the damage. We can thin your blood down to water and hope it still carries oxygen. We can treat the breathing problems. Heck, we just can breathe for you. We can put you out so you don’t feel a thing. We can filter your blood for you. We can circulate your blood for you. We can flip you over so you breathe better. We can even wake you up just a little bit and walk you around the room attached to 30 different machines with a team of 8 or more highly skilled medical providers… But my goodness, we’ve never really had to do all of that at one time for one single person… And now we are doing it for thousands of people at hundreds of facilities all over the world.

Even if we come up with the perfect treatment, perfect engineering controls, or preventative tomorrow (fingers crossed!), we still have people currently experiencing COVID-19 and its sequelae that need quality treatment. We can actually predict with greater than 90% accuracy what someone’s clinical disease course will be, what levels of care they will need, and what treatments will be the best for them at each phase. We know that COVID-19 isn’t overall that deadly, but we do know that it is very damaging, and either one isn’t good. Polio was pretty damaging, too. We have many studies confirming airborne transmission, especially in close confines and indoor environments.

All this to say that there is a lot the medical community can do for patients at risk for and with COVID-19. But what can WE, the rehab professionals, do?

Evaluating a Multi-System Disease

If we have a patient with diabetes, we don’t just treat their blood sugar. Even as rehab providers, we look at their circulation, their peripheral sensation, their central and peripheral balance, their cardiac function, their vision, their skin, their shoes, and many other things because we know that diabetes causes impairments in all of these domains. If we have a patient with heart failure, we never just look at their heart, do we? We know they have changes in their kidneys, their lungs, their vasculature, and their muscles… So we use tests and measures to address all of these components. This is exactly How we need to be looking at survivors of COVID-19.

In the rehab world, what can we do to address COVID-19 as a multi-system disease? How does this change the way we screen, evaluate, and treat? You will need to look at the whole patient. Even in the outpatient setting, they are not just knee pain who had COVID-19 two months ago. If you are seeing patients in any setting who have had COVID-19, even tested positive but remained asymptomatic, you need to be looking at a number of things and the APTA has summed it up in 5 easy measures:

  1. Physical Function. Can we start out with, “Duh?”. The best way to do that is to use the Short Physical Performance Battery (otherwise known as the SPPB). This is a combination of three already standardized tests (timed chair rise, gait speed, and static balance) that give you raw scores and a sum score that is highly predictive of function. This is a great tool across functional levels and gives you a good amount of functional information to inform and direct your treatments. You can get all the deets here:

2. Strength. COVID-19 is known for causing weakness in the small muscle groups and the core. You may have a patient who can stand, but they can’t write their name. They may do a squat, but can’t walk 10 feet. Anyone who you meet that has had an ICU stay for COVID-19 is at risk for ICU acquired weakness (ICUAW). In that case, the Medical Research Council Sum Score (MRC-SS) is recommend for assessing strength. There are several articles listen in the references for the MRC-SS, but generally it is a combination of manual muscle tests of certain muscle groups.
Here is the source for this file: ResearchGate.

You can also learn more about scoring this was from this video:

3. Endurance. You’ve probably heard by now of someone who had COVID-19 and needed months of rehab. Or who didn’t go to the hospital but still gets short of breath walking short distances. Whether it’s due to long term immobility in the hospital or actual parenchymal damage to the lung tissue (or other body systems), endurance becomes significantly affected. The recommended test for endurance in people who have had COVID-19 is the 2 minute step test. This is a favorite of mine for people of all ages! I’ve used this for my ESRD patients, VAD patients, young athletes, and middle-aged adults. You can download the one-page here:

4. Cognition. We have talked several times about the effects COVID-19 can have on the brain. In this case, you should probably have a tool in your pocket to assess cognition. There are some specific cases of COVID-19 that are associated with delirium lasting longer than 72 hours. In the absence of other serious symptoms, you may find this patient in your clinic for any number of reasons or you may find that one of your current patients starts to develop some strange symptoms. The SLUMs (the Saint Louis University Mental Status Exam) is the recommended assessment to use in this case. You can access it for free here:

5. Quality of Life. Isn’t this what we should always be focused on? What can we do as rehab providers to improve someone’s quality of life? Unfortunately, we so often do not assess or quantify it, so it can be difficult to demonstrate improvement other than subjective reports. The ED-5Q-5L is a simple questionnaire that can reliably quantify the quality of life for patients who have had COVID-19. Unfortunately, I can’t give you this one. However, you may be able to get it for free when you register with the company that created it. You can do that here:

Keep Reading HERE for more on Assessments and Interventions for COVID-19!

There is your toolbox! You’ve got something for every major system. Obviously, you can insert other objective measures you may need specific to your patient. Hopefully, soon, we won’t need to worry so much about all of this, but until that day comes, we will continue to be the frontline against community spread, and the treatment for those with long-term medical complications regardless of their setting.

Keep in mind that patients with Long-COVID may not be up for doing some or all of these assessments in one visit, especially if they have post-exertional malaise. Also, you may want to include a few other screenings… More on those topics next week!

Have you used any of these tools for assessing patients with COVID-19 or patients experiencing Long-COVID? Did they paint an accurate picture? Tell me in the comments.

More Reads…

COVID and Clotting: How to Identify, Assess, and Treat Clotting Disorders in COVID-19 Survivors

Treating patients with acute and chronic clotting conditions is not new to rehabilitation professionals. We even have clinical practice guidelines around how to do so safely. However, what is new is the increased risk of newly acquired clotting conditions among post-COVID-19 patients. Those of us practicing in acute, subacute, emergency, and outpatient settings are uniquely tasked withContinue reading “COVID and Clotting: How to Identify, Assess, and Treat Clotting Disorders in COVID-19 Survivors”


American Physical Therapy Association. (2020). APTA Academies and Sections Consensus Statement: COVID-19 Core Outcome Measures. Retrieved from

Arshad, S., Kilgore, P., Chaudhry, Z. S., Jacobsen, G., Wang, D. D., Huitsing, K., Brar, I., Alangaden, G. J., Ramesh, M. S., McKinnon, J. E., O’Neill, W., Zervos, M., & Henry Ford COVID-19 Task Force (2020). Treatment with hydroxychloroquine, azithromycin, and combination in patients hospitalized with COVID-19. International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases97, 396–403.

Azimi, P., Keshavarz, Z., Laurent, J. G. C., Stephens, B. R., Allen, J. G. (2020). Mechanistic Transmission Modeling of COVID-19 on the Diamond Princess Cruise Ship Demonstrates the Importance of Aerosol Transmission. medRxiv 2020.07.13.20153049. Retrieved from doi:

Bonn, D., Smith, S. H., Somsen, A., van Rijn, C., Kooij, S., van der Hoek, L., Bem, R A. (2020). Probability of aerosol transmission of SARS-CoV-2. medRxiv 2020.07.16.20155572. Retrieved from doi:

Connolly, B., Thompson, A., Moxham, J., Hart, N. (2020). Relationship Of Medical Research Council Sum-Score With Physical Function In Patients Post Critical Illness. American Journal of Respiratory and Critical Care Medicine. 201:A3075. Retrieved from

Connolly, B. A., Jones, G. D., Curtis, A. A., Murphy, P. B., Douiri, A., Hopkinson, N. S., Polkey, M. I., Moxham, J., & Hart, N. (2013). Clinical predictive value of manual muscle strength testing during critical illness: an observational cohort study. Critical care (London, England)17(5), R229.

Kingsland, J. & Sanfins, A. (2020). COVID-19: Doctors round up evidence of damage outside the lungs. Medical News Today. Retrieved from

Rikli, R.E., Jones, C.J. (1999). Functional fitness normative scores for community residing older adults ages 60-94. Journal of Aging and Physical Activity. 7:160-179.

Santarpia, J. L., Herrera, V. L., Rivera, D. N., Ratnesar-Shumate, S., Reid, S., Denton, P. W., Martens, J. W. S., Fang, Y., Conoan, N., Callahan, M. V., Lawler, J. V., Brett-Major, D M., Lowe, J. J. (2020). The Infectious Nature of Patient-Generated SARS-CoV-2 Aerosol. medRxiv 2020.07.13.20041632. Retrieved from doi:

Tsui, E. L. H., Lui, C., Woo, P. P. S., Cheung, A. T. L., Lam, K. W., Tang, T. W. , Yiu, C. F., Wan. C. H., Lee, L. H. Y. (2020). Development of a data-driven COVID-19 prognostication tool to inform triage and step-down care for hospitalised patients in Hong Kong: A population based cohort study. medRxiv. 2020.07.13.20152348 Retrieved from doi:

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The Donut Hole in Primary Care PT

The occurrence of federal legislation that heavily impacts the practice of Physical Therapy typically comes from changes to the Medicare and Medicaid system. These laws don’t normally change how we practice, but moreso change how we document and bill for things. However, several bills recently introduced to Congress could significantly impact how Physical Therapists provide services.

One of these bills, HR 5365 – Primary Health Services Enhancement Act, has the potential to expand our ability to provide care for patients under Medicare and Medicaid by cementing the Physical Therapist as a primary care provider1. This bill gives Physical Therapists the ability to provide services to Medicare and Medicaid beneficiaries and independently bill for that care in rural health clinics and federally qualified health centers. The bill was introduced to Congress (where it still sits) in September 2021. So, why is this important? I’ll use Texas as an example, but most states have low-access rural areas that will benefit from this.

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The State of Texas has 35 counties that have no primary care physician and ranks 41st in the country for physician-to-population ratio2. If you do the math, that means every available physician (not just primary care) has 1913 patients who require their care. This is a problem that is expected to grow by another 47% by 2032. Unfortunately, only 47% of primary care offices in Texas utilize mid-level providers to expand access and those in single-provider offices, which are more likely to provide care for rural areas, are least likely to utilize mid-level providers3. Many organizations are looking at solutions including increasing physician reimbursement, increasing funding and scholarships for physician education, and medical student debt relief programs, but to no avail4. It’s time we look outside the box by increasing access to other qualified providers to offload the current workforce, which would create overall better working environments for physicians.

“Instead of relying on old models and assumptions of how things have always been done, teams develop new solutions that are matched to the details of the problem.”

Dr. Jason Silvernail, a U.S. Army PT, in reference to how the military solved a physician shortage in the 1960s5

Where do Physical Therapists come in? The utilization data from 2013 shows that almost 105 million of the 1.25 billion physician visits in the United States were for musculoskeletal or soft tissue-related conditions6. According to this data, the most frequently reported musculoskeletal condition was knee pain and the most costly was non-specific low back pain, both conditions that are effectively and efficiently treated by Physical Therapists7. This means that Physical Therapists could offload nearly 10% of visits from primary care providers across the country. But you may be asking, “Is this safe?”

Decades of research answer this question with a resounding, “Yes.” Not only is it safe, but it is also less costly, more time-efficient, and results in better patient outcomes (Frogner, et al., 2018; Fritz, et al., 2012 & 2017; Arnold, et al., 2019; Bornhöft, et al., 2019; Demont, et al., 2020, Garrity, et al., 2020). The military has been practicing in this manner for decades and they have produced a large amount of research to show that Physical Therapists are significantly better diagnosticians of musculoskeletal conditions than primary care physicians and are equally as accurate in diagnosis and referral as orthopedic surgeons (Plack, 2000; Moore, et al., 2005).

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This is all only in reference to musculoskeletal conditions, but the evidence for use of prescribed guided exercise for the treatment of multi-system health conditions such as obesity, diabetes, heart failure, hypertension, chronic obstructive pulmonary disease, depression, cancer, and many others has been well established for decades (ACSM, 2021). Quoting Dr. Silvernail, a PT in the US army, “There may be barriers to translating such a [military] model to civilian care, such as high copays and Medicare not recognizing PTs as primary care practitioners, but such barriers are based on health policy, not on medical necessity or appropriateness5.”

“…barriers are based on health policy, not on medical necessity or appropriateness.”

Dr. Jason Silvernail, PT, US Army

As the law currently stands, veterans, active-duty military and their families, and people with private third-party payers can access a Physical Therapist directly in all states and the Physical Therapist can independently bill for their services. This creates yet another donut around Medicare and Medicaid recipients, as they do not currently have this access. The passage of HR 5365 has the potential to fill this donut hole for this large group of people1. This solves more than one problem, as access to primary musculoskeletal (and hopefully chronic disease) care will increase for a population that utilizes these services at a higher rate than the general population (Liu, et al., 2016; Fritz, et al., 2011), offloading other providers who are already stretched too thin.

Overall, this bill does not change our profession or our services at all, as the military has been utilizing primary care Physical Therapists since the Vietnam War5. In an interview with the American Physical Therapy Association, Dr. SIlvernail stated, “No single provider can do it all—that’s why you need a team. PTs are ready now to take on this team role if we are willing to confront the policy obstacles that stand between Americans and the quality care provided by doctors of physical therapy as part of primary health care teams.” The Primary Health Services Enhancement Act is the policy change Medicare and Medicaid beneficiaries need to increase access to quality care, especially in rural settings.

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Don’t just take my word for it. Former APTA President Sharon Dunn had this to say “Community health centers provide health care services to over 29 million people in over 12,000 rural and urban communities. Increased access to physical therapist services in these communities is essential for those recovering from Long COVID, and provides a non-pharmacological treatment option for those with chronic pain… this important legislation … will expand patient access to essential physical therapy services, and provide flexibility to community health centers in how they deliver care.”

So, what’s the ask? A Call to Action. Contact your Representatives and Congresspeople and tell them HR 5365 – Primary Health Services Enhancement Act needs their vote. When you do, let me know by commenting below!

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Read more here!

More Than Just A Respiratory Disease: The COVID-19 Toolbox

Isn’t COVID-19 just a respiratory disease? If only that was true. We are good at treating respiratory infections. We have lots of drugs for viral, bacterial, parasitic, and fungal infections of the lungs. Most of them work really well! We also have several backup treatments, inhaled medications, and adjuvant therapies (like rehab!) that make primaryContinue reading “More Than Just A Respiratory Disease: The COVID-19 Toolbox”


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  1. Primary Health Services Enhancement Act, H.R. 5365, 117th Cong. (2021).
  2. Cross, R. (2021). Access to care: Addressing Texas’ physician-to-population ratio. Texas Hospitals Association.
  3. Center for Disease Control and Prevention (CDC). (2014). State variability in supply of office-based primary care providers: United States. National Center for Health Statistics.
  4. Graham Center. (n.d.) Texas: Projecting primary care physician workforce.
  5. Silvernail, J. (2018). Primary care and the Physical Therapist: Lessons from the military.
  6. American Academy of Orthopaedic Surgeons (AAOS): Department of Research & Scientific Affairs. (2013) Physician Visits for Musculoskeletal Symptoms and Complaints. 
  7. Arnold, E., La Barrie, J., DaSilva, L., Patti, M., Goode, A., & Clewley, D. (2019). The effect of timing of physical therapy for acute low back pain on health services utilization: A systematic review.  Archives of Physical Medicine and Rehabilitation, 100(7), 1324–1338.
  8. Frogner, B.K., Harwood, K., Andrilla, C.H.A., Schwartz, M. and Pines, J.M. (2018). Physical Therapy as the first point of care to treat low back pain: An instrumental variables approach to estimate impact on opioid prescription, health care utilization, and costs. Health Serv Res, 53: 4629-4646.
  9. Fritz, J., Childs, J., Wainner, R., Flynn, T. (2012) Primary care referral of patients with low back pain to physical therapy. Spine, 37(25), 2114-2121 doi: 10.1097/BRS.0b013e31825d32f5
  10. Fritz, J. M., Kim, M., Magel, J. S., & Asche, C. V. (2017). Cost-effectiveness of Primary Care management with or without early physical therapy for acute low back pain: Economic evaluation of a randomized clinical trial. Spine (03622436), 42(5), 285–290.
  11. Bornhöft, L., Thorn, J., Svensson, M., Nordeman, L., Eggertsen, R., Larsson, M. (2019). More cost-effective management of patients with musculoskeletal disorders in primary care after direct triaging to physiotherapists for initial assessment compared to initial general practitioner assessment. BMC Musculoskeletal Disorder. 20(1). doi: 10.1186/s12891-019-2553-9.
  12. Demont, A., Quentin, J., Bourmaud, A. (2020). Impact of care models integrating direct access to physiotherapy in a primary or emergency care context for patients with musculoskeletal disease: a review of the literature. Journal of Epidemiology and Public Health [French]. 68(5), 306-313.
  13. Garrity, B. M., McDonough, C. M., Ameli, O., Rothendler, J. A., Carey, K. M., Cabral, H. J., Stein, M. D., Saper, R. B., & Kazis, L. E. (2020). Unrestricted Direct Access to Physical Therapist Services Is Associated With Lower Health Care Utilization and Costs in Patients With New-Onset Low Back Pain. Physical Therapy, 100(1), 107–115.
  14. Plack, M. (2000). The Evolution of the Doctorate of Physical Therapy: Moving beyond the controversy. Journal of Physical Therapy Education.
  15. Moore, J. H., Goss, D. L., Baxter, R. E., DeBerardino, T. M., Mansfield, L. T., Fellows, D. W., Taylor, D. C. (2005). Clinical diagnostic accuracy and magnetic resonance imaging of patients referred by physical therapists, orthopedic surgeons, and non-orthopedic providers. Journal of Orthopedic & Sports Physical Therapy. 35(2), 67-71.
  16. American College of Sports Medicine, Riebe, D., Ehrman, J. K., Liguori, G., & Magal, M. (2018).  ACSM’s guidelines for exercise testing and prescription (Tenth edition.). Philadelphia: Wolters Kluwer.
  17. Liu, X., Hanney, W., Masaracchio, M., Kolber, M. (2016). Utilization and payments of office-based physical rehabilitation services among individuals with commercial insurance in New York state. Physical Therapy, 96(2):202–211,
  18. Fritz, J., Hunter, S., Tracy, D., Brennan, G. (2011). Utilization and clinical outcomes of outpatient physical therapy for Medicare beneficiaries with musculoskeletal conditions. Physical Therapy, 91,(3):330–345,

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The contents of this blog and all associated pages reflect the opinions of the author and should not be construed as medical advice. Please consult your doctor for medical advice.

COVID and Clotting: How to Identify, Assess, and Treat Clotting Disorders in COVID-19 Survivors

Treating patients with acute and chronic clotting conditions is not new to rehabilitation professionals. We even have clinical practice guidelines around how to do so safely. However, what is new is the increased risk of newly acquired clotting conditions among post-COVID-19 patients. Those of us practicing in acute, subacute, emergency, and outpatient settings are uniquely tasked with identifying these patients in their facilities, possibly upon presentation for unrelated conditions or for rehabilitation due to long-COVID.

A Clotting Case Study…

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Sternal Precautions

“Patients exchanging habits of activity for complete rest are likely to become rapidly worse.” This quote fuels my everyday. These words have informed nonsurgical and surgical rehabilitation and its evolution from handing out bed rest like Oprah hands out cars to getting people moving early and keeping them moving often. Here’s the crazy thing: ThisContinue reading “Sternal Precautions”

Diaphragmatic Breathing

Let’s talk about this super simple technique that can change everything. Diaphragmatic breathing is really just how we are all supposed to be breathing most of the time. The purpose of the diaphragm is to facilitate breathing. Diaphragmatic breathing improves gas exchange and increases lung volumes. These are all really good things if we need toContinue reading “Diaphragmatic Breathing”


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The contents of this blog and all associated pages reflect the opinions of the author and should not be construed as medical advice. Please consult your doctor for medical advice.

Monoclonal Antibodies: A Designer COVID-19 Treatment Requires Designer Rehabilitation

This article can be read for free on MedBridge! Click the link below!

Could the cardiotoxic effects of monocloncal antibody treatment be contributing to the ongoing effects experienced by those with long COVID? Let me know what you think in the comments!

More Reads…

The Donut Hole in Primary Care PT

The occurrence of federal legislation that heavily impacts the practice of Physical Therapy typically comes from changes to the Medicare and Medicaid system. These laws don’t normally change how we practice, but moreso change how we document and bill for things. However, several bills recently introduced to Congress could significantly impact how Physical Therapists provideContinue reading “The Donut Hole in Primary Care PT”

Blow Out the Candles…

If there is any treatment that I feel like gets used in a cookie-cutter fashion, it’s pursed-lip breathing. As much as I hate seeing this technique used for every single patient that has shortness of breath, it does have clinical usefulness. So let’s talk about how to implement pursed-lip breathing properly based on patient presentationContinue reading “Blow Out the Candles…”

Postural Drainage

We’ve all seen that dreaded picture in our textbooks… All the human figures laying in so many different positions with pillows and tables tilted all over… and I very clearly remember thinking, “How on earth am I supposed to remember all of those?” Well, good news. You really don’t have to. It’s great if youContinue reading “Postural Drainage”


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Altitude Medicine: Rehab at the Peak

I took a trip to Denver recently and, right around the same time, was consulted regarding the use of a pulse oximeter at high altitudes. It all got me thinking: how different could it really be to practice at 9,000ft? So, I did some work on this and I have to tell you, finding this information was nowhere as easy as I thought it’d be. Apparently there is a very specialized branch of medicine known as “mountain medicine” or “altitude medicine” that is the established group of experts on the changes altitude can have on human physiology. The primary article I’m referring to for this post was written by Luks and Swensen, the same two who wrote the guidelines on using pulse oximetry for monitoring COVID patients for the American Thoracic Society. I’m excited to tell you all about what I’ve learned!

First off, we all know that as we go higher, there is less usable oxygen in the air. That is, the fraction of inspired oxygen (FiO2) remains about the same at 20.9% but the pressure of the oxygen (PiO2) decreases. Anyone remember Boyle’s law from junior high? That’s what we are talking about here: the inverse relationship between pressure and volume. Essentially, increased pressure results in decreased volume and, therefore, increased concentration of a given component. The volume of air we have under our atmosphere doesn’t change (the space stays the same), but as we ascend to higher altitudes, the pressure of gravity lessens, so the concentration of oxygen also lessens.

You may have heard this referred to as “thinner air” which is far more accurate than saying there is less oxygen. This change influences our body’s ability to diffuse the oxygen into our lungs and perfuse it into our tissues, impacts the oxygen-hemoglobin dissociation curve, and begins the process of significant physiological change. This graphic gives a percent of oxygen pressure at varying altitudes.

Based on this table, you may think that patients (or people in general) would become breathless pretty easily around 5280 ft (1 mile), but that’s not the case. Most people don’t feel any effects of altitude in regular daily activity until at least 4000ft, with the greatest majority of people experiencing effects around 7500ft. Of course, because our patients tend to be patients for a reason (they are more sick than the average person), they may start experiencing effects somewhat below those elevations.

At VERY high altitudes (above 11,500ft) the maximum amount of oxygen your blood can carry decreases to about 90% or less (your maximum blood oxygen saturation – SaO2 – is 90%), which will then result in significant breathlessness with activity. And above 20,000ft, we don’t expect to see long term human habitats due to severe physiological impairment. The presence of cardiovascular or pulmonary disease will result in symptom onset at lower altitudes than expected.

Training and Rehabilitation At High Elevations

The biggest challenge in practicing at higher elevations comes with seeing patients who are not regular residents in these areas. If your patient has been in the mountains for two weeks, their body has had time to accommodate. They will produce more red blood cells, hemoglobin molecules, and become more efficient at perfusing tissues (their oxygen-hemoglobin dissociation curve shifts to the right). This may take a bit longer if your patient has underlying medical conditions. Some people actually use this physiological adaptation to their advantage. Let’s look at that.

You may have heard of blood doping? That is where people (usually athletes) go to higher elevations to train for their sport because the altitude will cause them to develop this hemoglobin-rich blood that is so much more efficient at carrying oxygen, especially when they go back down to a lower elevation, which results in better aerobic performance. Although clever and a fully drug-free way to enhance performance, (which can also be achieved through transfusions, drugs that modify the oxygen-hemoglobin dissociation curve, and erythropoietin injections) the practice was outlawed in professional sports in 1986. This was due to a huge scandal at the 1980 Olympics that resulted in 17 medals being relinquished because of blood doping. However, if you are just looking to enhance your own sport performance outside the roles of professional sports, head up to 6,000ft!

When prescribing and performing activity at higher elevations, you should see a fairly quick rebound in healthy people once they start to rest (less than 5 minutes). However, you’ll eventually run in to trouble because even healthy people don’t have enough Hemoglobin to carry O2 for longer bouts of activity if they aren’t accommodated to the altitude. You may have to use shorter bouts and regulate the intensities to maximize oxygen supply (high-intensity interval training would be great for this!).

So how does altitude impact pulse oximetry?

Thankfully, it doesn’t, at least not significantly. As you move toward higher elevations, the “normal” O2 saturation as measured via a pulse oximeter just becomes a bigger range due to a larger standard deviation in the tool. And, the lower the saturation measurement (like in a symptomatic patient), the larger the standard deviation in the readings. Around 4000ft, the first standard deviation found in pulse oximetry readings encompasses a range of 5-7% difference when compared to SaO2 (the oxygen saturation of arterial blood – not the same thing as SpO2). You also may find more symptoms in patients on Sulfonomide antibiotics (Bactrim, Augmentin, etc) as these drugs shift the oxygen-hemoglobin dissociation curve and can cause a decrease in useful hemoglobin. As we discussed HERE, this wont show up on your pulse oximeter but will show in the patient’s symptoms. The best thing you can do is make sure you are optimizing your use of the pulse oximeter by following the tips I provide HERE. Basically, you need to keep in mind that the more desaturated your patient becomes, the less you can trust your pulse oximeter to give you accurate readings.

Pulse oximetry should not be any different if your patients are residents or have lived in these elevations for a long time. If they are travelers, you may have a problem because they haven’t acclimatized. In this case, you will definitely see a drop in pulse oximetry readings with activity because these people will burn up their smaller supply of oxygen pretty quick and they can’t pull enough oxygen from the air to replace the deficit. This is a problem with V/Q matching.

Is this what causes altitude sickness?

Odds of experiencing altitude sickness increase as your elevation increases, but typically doesn’t occur until 7500ft in healthy people. Some sources estimate between 20-40% of people who travel to this altitude will experience symptoms. Your fitness and activity level has no impact on whether or not you experience altitude sickness. What does matter is how quickly you ascended to the destination altitude!

Altitude sickness results from the body having difficulty responding to the lower partial pressure of oxygen in the air. Oxygen diffuses into the lungs based on a gradient from areas of higher pressure (the atmosphere at 760 mmHg) to areas of lower pressure (our lungs at 756 mmHg). That’s only a 4 mmHg difference in pressure that drives inspiration. Therefore, small changes in the partial pressure of oxygen in air can significantly impact this pressure gradient. As the pressure of air decreases to become closer to the pressure in our lungs, the gradient that drives inspiration becomes smaller and breathing becomes more effortful. We can actually predict the symptom onset based on altitude as seen in this graphic form the Mountain Medicine Association.

When we aren’t able to consciously alter our breathing to adjust to this, like when we are sleeping, our body experiences the effects of this pressure change which can make some people sick. Symptoms will usually occur within the first three days of arrival to a higher elevation, and as quickly as 6 hours after arrival. Symptoms of altitude sickness include:

  • Headache
  • Fatigue
  • Lightheadedness or dizziness
  • Lack of appetite
  • Difficulty staying asleep (waking frequently)
  • Nausea, sometimes with vomiting

Altitude sickness is common and not an emergency unless it does not stop after the initial three days. In our travel party to Denver of six adults and two children, one child experienced altitude sickness but made a quick recovery. That’s right, children are also susceptible, especially if they have underlying medical conditions. The Mountain Medicine Association provides extensive guidance for traveling to altitudes with children, as well as instructions on how to assess if a child has altitude sickness. The scale seen here is often used for vocal children. Our party member had a score of 7 on this scale. It is important to note that all symptoms must be present in the experience of a significant change in altitude.


Ongoing symptoms can lead to dehydration from the vomiting, but also because our body loses more water vapor through breathing at higher elevations. The most critical progression of symptoms can lead to cerebral edema with symptoms of confusion and significant lethargy (a condition know as High Altitude Cerebral Edema – HACE) or pulmonary edema with symptoms of tachycardia, shortness of breath at rest, and a nonproductive cough (a condition known as High Altitude Pulmonary Edema – HAPE). These two progressions can also afflict an acclimatized mountain-dweller who descend rapidly to lower altitudes. These more serious form of altitude sickness are less likely to occur below 7500ft, and the overall incidence even in expeditioners is less than 4%. However, they are life-threatening and require emergency medical intervention.

Avoiding Altitude Sickness

The only real way to completely avoid altitude sickness when traveling to higher altitudes is to ascend and descend slowly, and spend about a day in each 1000ft ascent after 3000ft before ascending further. People considered “low-landers” (aka those of us who live below 3000ft) and have a range of specific health conditions, should take caution when traveling to higher altitudes, or not travel to them at all. The Mountain Medicine Association provides this list for guidance:

Caution with travel to high altitudes:
Moderate chronic obstructive pulmonary disease (COPD)
Compensated congestive heart failure (CHF)
Sleep apnea syndromes
Troublesome arrhythmias
Stable angina/coronary artery disease
Sickle cell trait
Cerebrovascular diseases
Any cause for restricted pulmonary circulation
Seizure disorder (not on medication)
Young children

Avoid high altitude:
Sickle cell anemia (with history of crises)
Severe COPD
Pulmonary hypertension
Uncompensated CHF

A chest radiograph demonstrating the right middle lobe and left lingular segment infiltrates characteristic of HAPE. Source

However, we know very well that Physical Therapists and other Rehabilitation Professionals that live and work in the altitude see people who have lived in these places for long periods of time who have these conditions. They have acclimatized, so we need to know how best to use our tools to keep them safe, monitor and treat them, and most importantly, make them better. I hope this article was helpful you in providing those skills for your patients!

For more really cool stuff on altitude medicine, check out the “High Altitude Medicine and Biology” Journal. And I’m sending a big shoutout to my friend Nicole for requesting this topic!

Are you planning on traveling to a region of high altitude during the COVID-19 pandemic? Check out this guidance from the Mountain Medicine Association!

Vibration & Percussion

If you read my post on airway clearance techniques, you probably saw vibration and percussion down at the bottom of the force progression. Although I have covered several other pieces of the force progression (Active Cycle of Breathing, PEP Devices, etc) in subsequent posts, I haven’t touched on these topics yet because they haven’t beenContinue reading “Vibration & Percussion”

Open Heart, Open Mind… Learning About Amio-Loading

I’m always learning something new. I called the cardiologist after an evaluation to report some severe orthostatic hypotension and the nurse and I got to talking. She was going back through the patient’s history and looking for why this may be happening. I had just finished assessing the patient in their home and they wereContinue reading “Open Heart, Open Mind… Learning About Amio-Loading”


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Center for Wilderness Safety. (2021). Oxygen at High Altitude.

Gallagher, S.A., & Hackett, P. (2021, July 14). Acute mountain sickness and high altitude cerebral edema. UpToDate.

The International Mountaineering And Climbing Federation (Union Internationale Des Associations D’Alpinisme). (2021). Advice and Recommendations Library.

Luks, A. M., & Swensen, E. R. (2011). Pulse Oximetry at High Altitude. High Altitude Medicine & Biology, 12(2).

Meijer, H.J. & Jean, D. (2008). Consensus statement of the UIAA Medical Commission (Vol 9): Children at Altitude. The International Mountaineering And Climbing Federation (Union Internationale Des Associations D’Alpinisme).

Napier, P. J., & West, J.P. (1996). MMA Memo No 162: Medical and physiological considerations for high altitude. National Radio Astronomy Observatory.

Paralikar S. J. (2012). High altitude pulmonary edema-clinical features, pathophysiology, prevention and treatment. Indian journal of occupational and environmental medicine16(2), 59–62.

Yesalis, C. E., & Bahrke, M. S. (2002). “History of Doping in Sport” (PDF). International Sports Studies, Vol 24, Issue 1. 2002. Archived from the original (PDF) on November 23, 2017.

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