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:
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.
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.
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 IXand 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).
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!
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.
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.
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!
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 bloodvessels 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.
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:
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: https://euroqol.org/support/how-to-obtain-eq-5d/
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.
WHILE WE WAIT FOR THE NECT CHAPTER OF DIABETES MANAGEMENT, LET’S KEEP TALKING ABOUT INCONTINENCE
Chronic management of urinary incontinence can lead to many issues like infection and hospitalization if it doesn’t account for fluid balance! Let’s talk I’s and O’s!
#physicaltherapy #incontinence #chronicdisease
Dr. Rebekah Griffith, other wise known as The ED PT, interviewed Dr. B on all things patient care management and how PTs in the ED and Home Health PTs can work together to provide the best possible care for patients. We talked about the struggles we each face in managing complex patients and the rolesContinue reading “Home (Health) is Where the Heart Is”
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 Diseases, 97, 396–403. https://doi.org/10.1016/j.ijid.2020.06.099
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: https://doi.org/10.1101/2020.07.13.20153049
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: https://doi.org/10.1101/2020.07.16.20155572
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. https://doi.org/10.1186/cc13052
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: https://doi.org/10.1101/2020.07.13.20041632
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: https://doi.org/10.1101/2020.07.13.20152348
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.
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).
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.”
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.
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!
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 addContinue reading “Did Anyone Else See That?”
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”
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. https://doi.org/10.1016/j.apmr.2018.11.025
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. https://doi.org/10.1111/1475-6773.12984
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
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. https://doi.org/10.1097/BRS.0000000000001729
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.
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. https://doi.org/10.1093/ptj/pzz152
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. https://www.jospt.org/doi/abs/10.2519/jospt.2005.35.2.67
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.
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, https://doi.org/10.2522/ptj.20150060
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, https://doi.org/10.2522/ptj.20090290
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.
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!
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 thisContinue reading “Altitude Medicine: Rehab at the Peak”
I hope, at this point, you’ve all heard of the FAST acronym for identifying signs of a cerebrovascular accident (aka stroke). My in-laws even have a magnet on their fridge with a great comic strip describing the FAST acronym. I have run in to a couple different versions of it in the last few years,Continue reading “Emergency Response Screening”
Let’s start with a story… Man on a Train I was exiting a train on the platform at Reagan Airport when suddenly I see a man falling back onto the train as it was pulling away. His eyes were rolled back and he looked limp. My husband and I pulled him off the moving trainContinue reading “Chronic Disease Part 4: Type 2 Diabetes – Part 1”
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:
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 Pregnancy 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
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!
So, who’s up for some bloodwork? Venipuncture, anyone? Finger prick, maybe? No..? Oh… Well, ok then. I’ll carry on. I know it may sound a bit crazy, but as a PT, I actually do some (very) minor blood work. I’m not trained as a nurse or phlebotomist or anything like that. Nope. Just some on-the-job-trainingContinue reading “PT/INRs: Helping Patients Manage their Anticoagulation”
How many times have you had your temperature taken lately? I think I’ve had my temperature taken thousands of times in the last few months. We are seeing the increased use of forehead scanning thermometers and temporal scanners, all the non-contact forms of temperature assessment, to screen folks for COVID-19 symptoms upon entry to anyContinue reading “It’s Getting Hot in Here: Body Temperature”
Paralikar S. J. (2012). High altitude pulmonary edema-clinical features, pathophysiology, prevention and treatment. Indian journal of occupational and environmental medicine, 16(2), 59–62. https://doi.org/10.4103/0019-5278.107066
Alright, so I left you with a pretty serious cliffhanger on that last post. Here is the big ending! This is going to go pretty deep into the BASICS of management techniques for urinary incontinence. Like I keep saying, I’m not a pelvic floor therapist, but I do know enough about the basics that I can help you out and get you started. In Part 1 of this post, we discussed MANY of the lifestyle changes that need to happen to reduce or resolve urinary incontinence, but in this post, we are going to talk about the exercises! Remember, these posts are discussing management of urinary incontinence in all populations, but specifically in the presence of other chronic diseases. You can read much more about that in Part 1. Here is a little review…
I was speaking with a colleague of mine who also does a fair amount of chronic disease management and critical care work as a Physical Therapist. We were discussing heart failure management, the incidence of incontinence and urinary tract infection, and the effects these things have on our patients. We came up with this saying, “If you drink too much water, you’ll die. If you don’t drink enough water, you’ll die.” As morbid as that sounds, it’s all about finding the healthy balance.
In the case of heart failure, you’ll tend to find that less water is better (due to fluid limitations) but that patients still need to meet a minimum amount in order to function. Many of these patients ALSO develop urinary incontinence, either as a secondary effect of their heart failure medications and pathophysiology, or as a diagnosis due to many other possible causes. Finding their individual healthy balance can be really tough, but they definitely can’t do it alone. They need your education in the importance of water for the proper function of the cardiopulmonovasculorenourinary system. Ha!
Patients who have COPD also have a very high incidence of urinary incontinence which is thought to be linked to chronic coughing and structural changes in their chest which lead to changes in the length-tension relationship of the diaphragm and altered breathing patterns. If you read the post on Intra-Abdominal Pressure and Part 1 of Urinary Incontinence Management, you’ll understand that these relationships play a large role in pelvic floor function, bladder contractility, and incontinence management. Feel free to check out all the other linked posts to put that one together for yourself.
Pelvic Floor Strengthening and Managing Bladder Contractility
I’ll start off by just clearly stating a reminder here: NOT ALL PATIENTS NEED KEGELS. I know, we hear about Kegels all the time. They are huge part of incontinence management because stress incontinence or mixed incontinence which is at least partially stress incontinence is a large proportion of cases. If your patient is reporting symptoms of overflow incontinence, you may not want to use Kegels for management because they don’t need more tightening! I continue to not claim to be an expert, so when in doubt, consult your local pelvic floor therapist.
Time for an Anatomy Lesson: Two Types of Kegels
The Quick Flick and the Long Hold are the two main types of Kegels exercises I use with my patients. I use them both and for different reasons, so I’ll take you through the specifics. Quick Flicks are also referred to as “knacks”, so you will see both terms used here. It’s important to remember that several different muscle fiber types exist in the muscles of the pelvic floor and all must be addressed to adequately increase strength. Anatomy lesson: We are talking about the levator ani muscle, which provides the “sling” support for the pelvic organs. This muscle, in addition to several smaller hip and pelvis muscles, makes up the pelvic floor. Coccygeous is the small band of muscle just posterior in this image, and also helps to support the pelvic organs.
The Levator Ani, which has three parts with different functions, is going to be the focus of the morphological information I provide. Going back to your basics, you have type 1 (slow-twitch) and type 2 (fast-twitch) fibers present in the muscles of the pelvic floor. These fiber types both decrease in number and size with age. Research shows us that more than 50% of women CANNOT voluntarily contract their pelvic floor muscles, and personal experience is that a far greater a number of men also cannot. People NEED to be trained.
The Tiny Pebble
Here goes my crazy. I get some serious looks for this one, but it WORKS!!! The way the levator ani contracts is similar to the diaphragm. When it contracts, it pulls upward in to the body. When you teach someone how to activate and contract this muscle, you need to ensure they are performing the correct motion. A very effective way to do this is to use the “Tiny Pebble” explanation. You ask your patient to pretend that there is a tiny pebble at the opening of their anus. To perform a pelvic floor contraction, they want to grab the tiny pebble with their anus and then attempt to pull it up inside. How long they do this for will be determined by the type of exercise you are asking them to do. Here is what I mean:
The Quick Flick: How-To and Why
Quick flicks are fast contractions of the pelvic floor. These address the type 2 muscle fibers. Increasing the presence and function of type 2 muscles fibers BY ITSELF can significantly reduce the presence and risk of stress incontinence.
You will ask your patient to grab the pebble 5 times in a row, and put it back down between each one. These should be somewhat fast but that will depend on your patient’s skill level.
Quick flicks, or knacks, are really useful for two things:
Performing a quick flick just prior to an increase in intra-abdominal pressure, like a cough or sneeze, can give the pelvic floor a bit more support to prevent leakage. This is the primary usage of knacks.
The other function of quick flicks is neurological. Say you are walking home and are about 5 minutes from your door. You know you have to go to the bathroom pretty bad because your bladder is sending you all kinds of signals telling you so. If you perform a few sets of quick flicks, you can silence those alarms temporarily until you can get home to use the bathroom, essentially preventing function incontinence.
That second one can be really useful for our patients who need to get up out of bed in the middle of the night to use the bathroom, but have a long walk, move slowly, or need to make several adjustments and preparations before going. You can just buy a little bit of time to reduce the rushing, make the trip safer, and reduce the fall risk.
The Long Holds: How-To and Why
Long Holds address type 1 muscle fibers (the slow-twitch fibers). Increasing the size and number of these muscle fibers can significantly improve pelvic organ support and be helpful for different types of overflow incontinence that may be due to organ prolapse. However, it can also be really useful for long-term strengthening programs and endurance training. Sometimes we are further than 5 minutes from home and still have to wait.
To instruct your patient in long holds, ask them to grab the tiny pebble, pull it up inside, and hold it there. I typically start with 5 second holds and build from there. I have them do one 5-second hold at a time.
The “why” of this one I feel like is pretty obvious but it’s basically endurance. You need to be able to support your pelvic organs all day and you need to control your urine flow all day. This may take some time to achieve and there are all different ways to go about this training. I like to have people in the hospital or at home perform their pelvic floor exercises every time a commercial comes on the TV. That gets a lot of sets and reps in!
The Bigger Picture
Planning out your sets and reps shouldn’t be any different than when you are training any other muscle group. If you are using the Oddvar-Holten curve to prescribe your sets and reps, and you want to focus on strengthening, you may want to do fewer reps per set than if you were working on endurance training with longer sets of more reps. You can’t really calculate a 1-Rep Max other than the weight of the internal organs, so using body weight is about the closest you’re going to get. Just a different way to apply the basics of what you already know, right?
But that’s not the whole thing. I talked a lot about intra-abdominal pressure regulation in relationship to the pelvic floor and my instruction in pelvic floor exercises is not complete without including instructions on how to properly BREATHE during these exercises. I will want you now, when your patients perform these, they will hold their breath, just like every other type of exercise we have patients do. They may also stick their tongue out or raise their shoulders or eyebrows with the muscle contractions. I typically end up doing the eyebrow thing, too, when I’m teaching it… It makes it a bit more entertaining. But you have to correct the breathing part! When you put it all together, your instructions to your patient go like this:
Breathe IN, Breathe OUT As you breathe out, reach out and grab the pebble and let it go Count out loud for each time, “1, 2, 3, 4, 5” Relax & Repeat
Breathe IN, Breathe OUT As you breathe out, reach out, grab the pebble, and pull it up inside… and HOLD! Count out loud for a five-second hold, “1, 2, 3, 4, 5” Relax & Repeat
The counting out loud part of this is crucial. If they aren’t counting out loud, they are probably holding their breath. If they are counting out loud, you know they are breathing out! Like I mentioned earlier, you will inevitably get many people who hold their breath during these exercises. I like to remind them that these particular muscles are NOT breathing muscles. I know that is a bit simplistic, but it makes them laugh a bit and then I know they are breathing.
BONUS: Internal Exam NOT Required
When you are instructing patients in these techniques, research has shown that verbal instruction alone is more than sufficient to produce the ability to contract the pelvic floor musculature.
Protecting the Pelvic Floor
You may work with a population of patients who are young, highly athletic, healthy, and deny any urinary incontinence or other pelvic floor issues. That is so great! But, let’s keep it that way, shall we? The BEST way to treat a chronic disease is to prevent it from happening in the first place! It is important to remember that the pelvic floor is a set of muscles, tissues, bones, and joints that need to be cared for, well used, and protected, just like any other body system. You need to take in to consideration patients who do high-impact activity and/or high-load lifting. Their intra-abdominal pressure regulation is CRUCIAL to protecting that pelvic floor. Read more about that in the post specific to intra-abdominal pressure. But pregnant women also need to know some tips on protecting their pelvic floor before, during, and after birth so that they can have minimal issues throughout. Obviously, there is a tiny-space occupying person that is GOING to cause some strain, so we have to work on how to manage that strain.
High Impact & High Load Athletes
High impact athletes, like runners, gymnasts, and cheerleaders, can find some pretty interesting ways to force their body to achieve the high level tasks the want to achieve. That doesn’t necessarily mean they are using their body the right way to achieve them. Runners may need help with regulating their breathing and maintaining the strength of their pelvic floor muscles to prevent leakage on the initial contact phase of their running gait. Gymnasts and cheerleaders may find that they can stabilize their body in many crazy ways, but can also be fully capable of stabilizing with your shoulder complexes or their glutes and still have minimal core activation. This combination CAN lead to reduced pelvic floor muscle activation and result in stress urinary incontinence. If that is the case, you may find you have to reprogram their trunk stability techniques to include pelvic floor and core.
For high-load athletes, like power lifters and functional fitness participants (F45, Crossfit, etc), you are really going to have to work with them on proper form, training certain muscle groups, and regulating intra-abdominal pressures. They will probably need to do some specific pelvic floor training to know how to regulate the pressures when they need to without increasing strain on the pelvic floor musculature.
You may also work with a different kind of athlete: The manual laborer. These workers may have to lift heavy loads with or without assistance. They may be utilizing all types of strategies to achieve these work loads, but you may also find that many of them are presenting with impairments to their pelvic floor. These may or may not be related to incontinence. You may see a higher rate of abdominal or inguinal hernias, piriformis syndrome, glute atrophy, or any number of other conditions that impact the pelvic floor due to altered length-tension relationships or unregulated intra-abdominal pressure. These may also include prolapses, as intra-abdominal pressure can result in all different types of this condition. Prevention is the key. Strengthen the pelvic floor, train better body mechanics, teach lifting safety, and regulate intra-abdominal pressure.
Pregnancy, Labor, and Post-Partum
This section could be a whole other post, but, like I keep saying, I’m no expert here. What I can tell you is that pregnant women have to pee, a lot. It’s a function of a growing baby taking up space and physically placing pressure on the bladder and other organs within the intra-abdominal space. Not all women will experience incontinence with pregnancy, but many will. We can’t resolve that for the most part, but we can improve it. Lots of water and lots of bathroom breaks are crucial for incontinence management for pregnant women, but this isn’t always achievable due to work and life demands. So, do the best you can with the schedule.
Strengthening that pelvic floor and training knacks will not only help patients manage incontinence, but prepare them for birth. Think about a patient who needs a total knee replacement but has weak quads… You wouldn’t expect them to have a stellar rehab from that knee replacement unless they did some pre-habilitation first to increase quad strength and activation. The same goes for birth. Strengthening the pelvic floor prior to birth can shorten and ease the recovery afterward. Good pelvic floor activation and control can help post-partum women regain control of their incontinence before it becomes a bigger issue. Remember how we talked about the importance of length-tension relationships and breathing with pelvic floor functoin? In the case of cesarean section (C-section) managing intra-abdominal pressure and reducing the work of the pelvic floor can be crucial. Again, not an expert here, so get them to a pelvic floor therapist ASAP!
Most of all, if you have incontinence, if your friend does, or your mom does, or your neighbor does, or your gym buddy does, tell them there is help that doesn’t involve surgery or medication. Tell them about pelvic floor PT. Network with the pelvic floor PT’s in your area. These PT’s are amazing! Give out their cards. Make it a normal thing to talk about. Your friends, family, and patients will thank you.
Do you have a favorite Pelvic Floor PT in your area? We can all use a bigger network! Give them a shout out in the comments!
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More about how Physical Therapists Manage Chronic Disease…
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 screeningContinue reading “Can I Touch Your Face? – Screening the Cranial Nerves”
Ayeleke, R. O., Hay-Smith, E. J., & Omar, M. I. (2015). Pelvic floor muscle training added to another active treatment versus the same active treatment alone for urinary incontinence in women. The Cochrane database of systematic reviews, 2015(11), CD010551. https://doi.org/10.1002/14651858.CD010551.pub3
Bush, H. M., Pagorek, S., Kuperstein, J., Guo, J., Ballert, K. N., & Crofford, L. J. (2013). The Association of Chronic Back Pain and Stress Urinary Incontinence: A Cross-Sectional Study. Journal of women’s health physical therapy, 37(1), 11–18. https://doi.org/10.1097/JWH.0b013e31828c1ab3
Carvalho, N., Fustinoni, S., Abolhassani, N. et al. Impact of urine and mixed incontinence on long-term care preference: a vignette-survey study of community-dwelling older adults. BMC Geriatr20, 69 (2020). https://doi.org/10.1186/s12877-020-1439-x
Fitz, F. F., Paladini, L. M., Ferreira, L. A., Gimenez, M. M., Bortolini, M., & Castro, R. A. (2020). Ability to contract the pelvic floor muscles and association with muscle function in incontinent women. International urogynecology journal, 31(11), 2337–2344. https://doi.org/10.1007/s00192-020-04469-0
Koelbl, H., Strassegger, H., Riss, P. A., & Gruber, H. (1989). Morphologic and functional aspects of pelvic floor muscles in patients with pelvic relaxation and genuine stress incontinence. Obstetrics and gynecology, 74(5), 789–795.
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Simmering, J. E., Tang, F., Cavanaugh, J. E., Polgreen, L. A., & Polgreen, P. M. (2017). The Increase in Hospitalizations for Urinary Tract Infections and the Associated Costs in the United States, 1998-2011. Open forum infectious diseases, 4(1), ofw281. https://doi.org/10.1093/ofid/ofw281
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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 presentation and medical history so that you can use this most effectively and appropriately. This is going to take up down some roads, both general and specific, to help you understand what pursed-lip breathing does and how it should be used. But, first, let’s watch a pretty decent video on pursed-lip breathing. This video incorporates several different techniques along with pursed-lip breathing, but doesn’t give a whole lot of clinical specifics which makes it GREAT for patient education. You’ll need to clarify the specifics for your patient based on their needs.
Let’s start at the beginning: What is Pursed Lip Breathing? Pursed-lip breathing is a respiratory technique with many uses depending on how it is implemented. The general purpose of pursed lip breathing is to prolong exhalation, slow respiration, and provide positive pressure to breathing. Overall, this technique can improve vital capacity and tidal volume.
Sounds simple enough right? We hear the same cues used all the time: “Smell the roses, blow out the candles,” but I have to tell you… If you think you know, you have no idea. This is so much more complex than we give it credit for. Let’s break this down by diagnosis…
Restrictive lung diseases: Lung resection, sarcoidosis, chronic atelectasis, pulmonary fibrosis including interstitial lung diseases, COVID-19 and other viral/bacterial pneumonias, pleural effusion
There is no amount of deep, diaphragmatic, or pursed lip breathing you can do that will change the fact that these patients have restricted lung volume. You can’t get air in if there is nowhere to put it, you cannot use what just isn’t there. Pursed lip breathing can still be used for these patients, but the use is NOT to improve vital capacity, because that won’t happen. When people with restrictive lung conditions become short of breath, it is typically associated with a high level of stress and anxiety because they literally can’t breathe. Their lungs are closing down or scarring up or any other mechanism that reduces viable lung tissue amount or function.
Pursed-lip breathing can help these folks, for sure, but it is through mechanisms that are emotionally and autonomically linked to breathing. Mindfulness of breathing has been shown by numerous studies (thank you, yoga and tai chi!) to change a person’s emotional state and physiological function. This mechanism is well studied but very complex and involves chemical transmitters as well as stretch-response mechanisms in the musculoskeletal, vascular, cardiac, olfactory, and limbic systems (and probably several others). It is important to note that the slowedrate of breathing is the emphasis of the research, not necessarily the “pursed-lip” portion of the technique.
That all being said, please use pursed lip breathing in this individuals for the purpose of decreasing anxiety and respiratory rate. Keep in mind that this may only be a band-aid and that medications, increased oxygen titration, and other medical interventions may be necessary to recover shortness of breath. Pursed lip and diaphragmatic breathing can be used together to stimulate the autonomic nervous system (chemo-, baro-, and stretch-receptors) to reduce respiratory rate and chemically alter emotional state to reduce stress and anxiety and lessen symptoms of shortness of breath. This is based in parasympathetic activation which slows heart rate and relaxes smooth muscles throughout the body. This means arteries relax and are able to carry more oxygen rich blood to needed organ systems, blood pressure lowers, and cardiac effort is reduced due to reduced peripheral resistance. All good things for someone who is experiencing shortness of breath 🙂
Unfortunately, research shows us that pursed lip breathing may also increase the overall metabolic workload of breathing in patients with restrictive lung diseases, which may outweigh the benefits if you are attempting to increase oxygen saturation with activity. It has also been found that pursed lip breathing is not effective to reduce shortness of breath during activity in patients with restrictive lung diseases. So, although it may seem pretty simple, this intervention does need to be used with caution and for the right reasons.
This one is the big red flag for me. The video does a pretty decent job of showing how to accommodate pursed-lip breathing to obstructive conditions, but doesn’t exactly explain the reasoning. The big problem with obstructive lung disease is that you can’t get enough air OUT of the lungs. Therefore, telling someone to breathe in deeply through their nose is NOT going to improve their symptoms! In fact, it will actually make things worse because you are just attempting to pack more air in to a space that is already full of dead air. This does not improve ventilation, and significantly reduces ventilation/perfusion matching requirements of activity. In essence, the more you have them breathe deeply, the less oxygen they have left in their blood supply to actually perform the mechanical work of breathing!
To perform pursed lip breathing properly in a patient who has obstructive lung disease, you have to have them focus on the breathing OUT portion of pursed lip breathing. And this activity is two-fold in benefits! Here’s why:
The video instructs pretty well on the importance of breathing out and incorporates a great tool I teach to my patients all the time: Counting! Patients with obstructive lung conditions need to get more air out than they take in. This helps remove the dead air from their lungs and replaces it with new air. The more air they breathe out, the more room they have to put new air in. Make sense? So having your patient count, “1, 2” for their breath IN and “1, 2, 3, 4” for their breath OUT helps them focus on getting the air out. Sometimes I add in a PEP device to help shift to focus to getting air OUT for patients with obstructive conditions.
The second bonus to focusing on exhalation is the actual performance of the “pursed-lip” portion of pursed-lip breathing. This maneuver, when done properly, causes some of the air coming out of the lungs to bounce off the inside of the lips and cheeks and rebound into the airway and lungs. This is similar to PEEP (positive end-expiratory pressure). We provide PEEP when patients are mechanically ventilated with the exact same purpose it fulfills with pursed lip breathing: to provide back pressure that splints open smaller or collapsed airways, allowing for exhalation of greater volumes of carbon dioxide, therefore improving vital capacity. That means that the little bit of back pressure holds the airways open longer to allow for more dead air to escape, making room for more good air to get back in.
And when I say “done properly,” I don’t mean that you try to force air out through whistle-tight lips. That just doesn’t allow for that back pressure to build up correctly. Just like in mechanical ventilation, too much PEEP can be a problem. Lips should still be open somewhat and the cheeks should be loose and allowed to flare so that air can gather and build pressure. Here’s a terrible up-close video of me pursed-lip breathing so you can get the idea.
There have been some recent studies that have shown that a simulated pursed-lip breathing during non-invasive ventilation (NIV) can actually be more effective than NIV alone for patients with COPD who are in hypercapnic respiratory failure! This intervention even held up under activity demands of a functional maximal exercise capacity test (the 6 minute walk test).
Did you know there was that much to it? I know I was shocked to find out something that seemed so simple was actually so complex and that it could be used in such varying ways if it was used correctly. I hope that you are able to repurpose this old stand-by technique with better clinical application for your patients.
I’ve gotta tell you all something… I love this stuff. I love getting down to the absolute basics, figuring out the “why” of it all, applying it in the best possible way for my patients, and then telling all of you about it! Now, pucker those lips and get to breathing!
Do you find that pursed-lip breathing recovers shortness of breath better for your restrictive or obstructive patients? Let me know in the comments!
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”
The long awaited clarification on aerosol generating procedures for physical therapists and physical therapist assistants has finally dropped! The APTA just released its professional guidelines for what portions of physical therapist and physical therapist assistant care equates to an aerosol generating procedures, therefore requiring increased PPE for procedure performance to ensure clinician safety. On AprilContinue reading “Aerosol Generating Procedures”
Have you seen an Acapella Duet before? This is another one of those things I wish I could hand out to maybe half of my patients. A Duet device is a special kind of Positive Expiratory Pressure (PEP) that provides resistive oscillatory pressure to exhalation which promotes increased lung volumes due to re-inflation of collapsedContinue reading “The Duet Device”
Bellissimo, G., Leslie, E., Maestas, V., & Zuhl, M. (2020). The Effects of Fast and Slow Yoga Breathing on Cerebral and Central Hemodynamics. International journal of yoga, 13(3), 207–212. https://doi.org/10.4103/ijoy.IJOY_98_19
Jünger, C., Gaede, K. I., Herzmann, C., Lange, C., Reimann, M., Rüller, S. (2020). Pursed-lip breathing ventilation for the treatment of hypercapnic respiratory failure in COPD. ERJ Open Research. 6: 41; DOI: 10.1183/23120541.RFMVC-2020.41
Jünger, C., Rüller, S., Reimann, M., Krabbe, L., Gaede, K., Lange, C., Herzman, C. (2019). Mechanical non-invasive pursed-lip breathing ventilation for hypercapnic patients with COPD. European Respiratory Journal. 54: PA4237; DOI: 10.1183/13993003.congress-2019.PA4237
Parisien-La Salle, S., Rivest-Abel, E., Boucher, V. G., Lalande-Gauthier, M., Poirier, C., Dube, B. P., Manganas, H., Morisset, J., Comtois, A. S. (2017). Effect of pursed lip breathing on dyspnea and walking distance in interstitial lung disease: a randomized crossover study. European Respiratory Journal 50: PA2246; DOI: 10.1183/1393003.congress-2017.PA2246
Russo, M. A., Santarelli, D. M., & O’Rourke, D. (2017). The physiological effects of slow breathing in the healthy human. Breathe (Sheffield, England), 13(4), 298–309. https://doi.org/10.1183/20734735.009817
Zaccaro, A., Piarulli, A., Laurino, M., Garbella, E., Menicucci, D., Neri, B., & Gemignani, A. (2018). How Breath-Control Can Change Your Life: A Systematic Review on Psycho-Physiological Correlates of Slow Breathing. Frontiers in human neuroscience, 12, 353. https://doi.org/10.3389/fnhum.2018.00353
I hope, at this point, you’ve all heard of the FAST acronym for identifying signs of a cerebrovascular accident (aka stroke). My in-laws even have a magnet on their fridge with a great comic strip describing the FAST acronym. I have run in to a couple different versions of it in the last few years, but I’ll give you the basic one so you know what I’m talking about. But, we will also go over some other tools you can have in your arsenal for emergency response screening and I’ll tell you where you can go find even more!
I’m not sure if calling 911 is a skill or not, but I’ve certainly done it enough times that I have the process pretty much figured out. We skip the pleasantries and get straight to the point: Where are you, what’s the situation, who is the caller. DON’T WASTE TIME saying “Hi.” Wait your turn to talk. Use speakerphone so you can follow whatever instructions they give you. And always prioritize symptoms: breathing is always MOST important! You are given a priority number (0 is highest priority – that’s for the not breathing folks). And you NEVER hang up until you are told to do so or EMS arrives. It’s fast. It’s nerve-racking the first few times, but you get used to it (that’s a bit weird to say). If you are in doubt, you have two options: Call the physician and request next steps OR
Emergency response is a basic skill for rehabilitation clinicians and Physical Therapists are skilled to provide first line triage in the case of an emergency. Our specialty is movement: to move someone or not to move someone, and how that movement should be done is a critical part of not only our interventions but also emergency response. Large scale emergencies or single patient emergencies both require this level of clinical decision-making. Thankfully, if you don’t feel like you’re ready to provide that knowledge or skill, there are lots of tools to help you in both small and large scale emergencies.
My best advice: Stay calm, trust your training, and trust your gut. If something feels wrong, it probably is.
Let’s look at the FAST tool we mentioned. This is what really got me started down this rabbit hole of exploring emergency response screening processes. What is fast, easy, and gives me the most information to make the determination of what my next step is? The FAST tool is easy and, well… fast. I don’t have to do much other than look at someone and I know they need emergency help. I also know I need to get that help as fast as I can.
Pretty self-explanatory. I’ve had a few significant events in my practice (and outside of my practice!) where I have had to utilize this tool and other tools to assess my patients. I’ll tell you a little about these events so you know when and how to use these tools. I hope you can’t implement them quickly and easily so that, no matter what setting you are in, you can determine the best course of action for your patients, family, friends, or random strangers at your friend’s wedding…
The Stroke Diagnostic Tool
One of my patients in an AFC had a history of middle cerebral artery stroke which is what landed him in an AFC to begin with. One day, I showed up for his visit and he had fallen in the bathroom. The door was locked so couldn’t let me in to help him. His staff was unaware this had happened. As I was talking to him through the door, he told me he was uninjured but couldn’t seem to get up. He was confused and his speech was slurring harder than normal. I knew this because I had established a neurological baseline at my first visit with him.
After the AFC staff assisted me in opening the bathroom door, his symptoms persisted, so I took a set of vitals while calling 911. Although his heart rate was a bit high (he did just fall in the bathroom, after all…), his blood pressure was normal and he did have a slight fever. Upon answering and receiving the required information, the Emergency Dispatcher had me preform a stroke screening. In case you’ve never done this or heard of it, it’s three simple questions:
Can he smile? (this checks for facial droop)
Can he raise both arms equally overhead? (this checks for unilateral paresis/paralysis)
Can he say, “The early bird gets the worm?” (this checks for slurring or other speech deficits)
This is called the Medical Priority Dispatch System (MPDS) Stroke Diagnostic Tool (SDxT), and it is based on research of the FAST acronym for stroke screening. The SDxT has a high specificity (0.96) and a not so impressive sensitivity (0.41). Therefore, this tool is great for ruling in a NEW stroke, but, because my patient already had a stroke with residual deficits, it gave false results. I had to repeatedly interpret the results in comparison to his baseline. I’m sure the dispatcher was really annoyed with me saying, “No more than his baseline,” as an answer to her first two questions. Thankfully, it was only a new UTI and he turned out fine after some antibiotics and inpatient rehab. Because this tool has a specificity of 0.96, though, it is great for ruling in new stroke if your patient presents with these clinical symptoms in any setting.
PT Clinical Decision-Making: Is this an emergency? Yes, single-patient – needs evaluation s/p fall and for neurological changes, FAST criteria met, SDxT inconclusive Does this patient need to move? Yes How should this patient move? Lift assist team from the floor, track-chair up the stairs and out of the house (a chair on tracks that can climb stairs), and by ambulance to hospital
Other Clinical Tools
Another piece of the puzzle needs to be blood pressure. However, like I’ve mentioned many times before, taking a single blood pressure measurement (although better than doing nothing) doesn’t give you much information. You need to have a baseline measurement. The rate of noncompliance with hypertension medication can be anywhere from 40-60% depending on the article you read. So, even if you KNOW your patient has hypertension, that doesn’t mean they’ve been managing it properly. Those medications can have some side effects that people just don’t like (like going to the bathroom too often or symptoms of orthostasis), so people tend to not take them for different reasons. And that’s just the people you KNOW about! We’ve talked about exercise induced hypertension which may be present in just about anyone, and we don’t even really know how best to manage that yet. And then there is the basic fact that you can’t just look at someone and know they have hypertension. Clinical symptoms don’t always present in people who are young and healthy otherwise, and they often are missed. Please take a read in the article about blood pressure basics and dig in to some of the items regarding blood pressure management. We, as Physical Therapists, should be playing a crucial role in this arena. This is my soapbox and I will die on it. Vitals are vital.
Blood pressure screening isn’t just useful to identify cerebrovascular accidents! If you take that baseline blood pressure and you know they typically run high, maybe 160/94, you may not be as concerned when you see a 166/94 pop up at your visit today. However, if you have established a baseline 160/94 blood pressure and you see 200/106 show up, now you can make a clinical decision regarding what you need to do next: do some further assessment because you know they run high, call the physician to determine next steps if they are exhibiting no symptoms, or call 911 if they are are in a hypertensive crisis with symptoms.
Unfortunately, if you see 164/90 show up, but you have no baseline to compare to, you may not know what to do. One of my very first patients as a PT student presented with a 164/100 blood pressure one day, but was having many symptoms of something else going on. She did not meet FAST criteria and I had no comparison blood pressure to go off of. I had clinical presentation of something so I called 911. She had a seizure in the Emergency Department shortly after arriving, but turns out she had a history of seizures. Hypertension was kind of like an aura for her. You just never know. If I had taken a baseline blood pressure, I may have had a better idea of what to do with her and not struggled to figure it out until the end of our visit.
PT Clinical Decision-Making Is this an emergency? I didn’t know because I had no baseline to determine if this was a hypertensive crisis for her and I didn’t know her history of seizures. But, No, it was not an emergency due to her history. Does patient need to move? Yes, but… How does this patient need to move? …only to the floor if I would have known her seizure history. I would have called the physician for persistent symptoms and notified them of a seizure if it happened. She could have transferred to the hospital via private car with a driver if necessary depending on the outcome and length of the seizure.
To be very clear: DO NOT DELAY CALLING 911 to take a patient’s blood pressure. If they’ve met the FAST criteria, SDxT criteria, both, or ANY other emergency response criteria, and you haven’t taken their blood pressure yet, call for emergency medical assistance first! Time is literally brain cells. Don’t waste even a second. Like my patient above, even if it isn’t a stroke, they may still need medical attention for some reason. You can take their blood pressure while you wait for EMS to arrive or when the Dispatcher asks you to do it.
And then there is my friend’s wedding…
There I am in a gown at the head table during the reception and down goes someone in the crowd. The medical expertise at the reception included me, an NP student, and an ortho nurse. Not your best emergency response team, but better than nothing, right? I rush over to this mildly responsive man who cannot move and is slurring something and I’m immediately informed by a family member that he has a history of stroke somewhat recently. I observed pretty quickly that he met the FAST criteria so, I call for someone to call 911 because time is brain cells here.
Having no equipment other than my brain, I immediately started the SDxT assessment to save time, but again, because he has a history of CVA, lots of positives show up: heavily slurred speech, inability to raise the left arm, and obvious facial droop (I didn’t have to ask him to smile…). I started a detailed neuro assessment (think acute care-style) with his family member assisting for comparison to baseline and sure enough… exacerbation of symptoms. EMS arrived, I handed off the neuro evaluation outcomes, and off he went.
PT Clinical Decision-Making Is this an emergency? Yes, single patient – needs evaluation of acute neurological changes, FAST criteria met, SDxT positive Does patient need to move? Yes, immediately How does this patient need to move? Yes, lift team transfer to stretcher from floor and by ambulance to hospital
Although these tools are specific to screening for cerebrovascular accidents, the Medical Priority Dispatch System utilizes an algorithm to screen for several emergency medical events. You can take a look at more tools here:
They have emergency protocols for tourniquet use, emergency child delivery, and even active shooter response! There is a section on nurse triage, fire, and many others!
Your clinical knowledge as a Physical Therapist (or other Rehab Clinician) goes a long way, even when other tools can’t give you clear answers. Overall, even though both of these patients were assessed with the same tools, both of them had history of strokes, and both of them gave confounding outcomes, they BOTH required urgent medical care for one reason or another. Having both tools in your pocket gives a higher percentage shot of remembering how to identify the need for emergency response and having a baseline comparison was key for both patients to identify the level of need. Eventually, it was clinical knowledge that determined the cause (not mine, but some very smart provider at a hospital), but it was the initial tools that got the patients the care they needed in time.
Have you used the SDxT or the FAST tool? I’d love to hear your story in the comments!
Abegaz, T. M., Shehab, A., Gebreyohannes, E. A., Bhagavathula, A. S., & Elnour, A. A. (2017). Nonadherence to antihypertensive drugs: A systematic review and meta-analysis. Medicine, 96(4), e5641. https://doi.org/10.1097/MD.0000000000005641
Buck, B. H., Starkman, S., Eckstein, M., Kidwell, C. S., Haines, J., Huang, R., Colby, D., & Saver, J. L. (2009). Dispatcher recognition of stroke using the National Academy Medical Priority Dispatch System. Stroke, 40(6), 2027–2030. https://doi.org/10.1161/STROKEAHA.108.545574
Clawson, J. J., Scott, G., Gardett, I., Youngquist, S., Taillac, P., Fivaz, C., & Olola, C. (2016). Predictive Ability of an Emergency Medical Dispatch Stroke Diagnostic Tool in Identifying Hospital-Confirmed Strokes. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association, 25(8), 2031–2042. https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.04.021