Self-reported measurement of heart rate and blood pressure in patients by physical therapy clinical instructors. (Research Report).

We believe the need for physical therapists to measure heart rate (HR) and blood pressure (BP) has increased for several reasons. First, high BP is a serious health concern in the United States. One in 4 adults has high BP, almost one third (31.6%) of people with high BP are not aware they have the condition, and 26.2% of people taking BP medications do not have their high BP under control. (1) A recent study of adults living in a socio-economically prosperous community showed that 39% of the participants were unaware that they had high BP. (2) Second, high BP is associated with other cardiovascular disorders. The Department of Veterans Affairs, in its high BP treatment and screening algorithms, recommends that BP be measured in any patient aged 18 years or older in primary care settings. (3) A study of 68 people referred for outpatient orthopedic physical therapy showed that 42 (62%) had secondary cardiovascular disease. (4) Third, in a growing number of states, physical therapists are practicing in primary care roles and can examine and treat patients without a medical referral. (5) Thus, a physical therapist may be the first health care professional an individual sees for a medical concern or wellness intervention.

The American Physical Therapy Association (APTA) has recognized the need to describe the practice of the physical therapy profession. The APTA Board of Directors, in response to a call from legislative bodies for descriptions of practice parameters of health care professions, appointed a task force to develop a document describing physical therapist practice. This effort resulted in the publication of the Guide to Physical Therapist Practice, Volume I: A Description of Patient Management, which was approved by the APTA Board of Directors in 1995. Development of Volume II began by using an expert consensus method, and this volume included preferred practice patterns in 4 categories: cardiopulmonary, integumentary, musculoskeletal, and neuromuscular. In 1997, Volumes I and II were combined to become Part One and Part Two of a single document, which was published as the first edition of the Guide to Physical Therapist Practice (Guide). Revisions to the first edition, based on input from the general membership of APTA and changes in House of Delegates policies, were made in 1998 and 1999. The second edition of the Guide, which includes templates of forms for inpatient and outpatient settings, was published in 2001. (6) The Guide does not mandate practice behavior, but rather provides guidelines for individual decision making on the part of the physical therapist. According to Harris (7) and Duncan, (8) such clinical decision making should be based on the best available evidence in the literature.

In the Guide, (6) examination is 1 of the 5 elements of patient/client management and should occur prior to the initial intervention for all patients and clients. The Guide (6) recommends that patient examination should begin with a history and a systems review that includes examination of the "anatomical and physiological status of the cardiovascular/pulmonary [emphasis added], integumentary, musculoskeletal, and neuromuscular systems...." (6) (pS34) Heart rate and BP are measured to assess aerobic function and circulation, and these measurements can assist the physical therapist in identifying cardiovascular or pulmonary problems that might affect prognosis and intervention or require referral to another health care provider. This information also can aid in the selection of additional tests and measures to identify the patient's impairments and functional limitations.

Measurement of HR and BP provides the physical therapist with information about the patient's physiological status and response to activity (9,10) and can help the physical therapist decide whether there is an abnormal HR response to activity, which can be a predictor of ischemic heart disease. (11) A hypertensive BP response to exercise in people without known pathology can be an early marker of high BP, (12) and delayed recovery of BP after exercise also can indicate high BP. (12) High BP in elderly people is a predisposing factor for postural hypotension, (13) which can increase the risk for falls. Winslow et al (14) recommended measuring HR and BP when first getting a patient out of bed due to the increased incidence of orthostatic hypotension. Many older patients referred for physical therapy have secondary cardiovascular comorbidities and are taking cardiovascular medications. These medications often alter HR and BP responses to activity. (15)

Information obtained about HR and BP relating to the patient's activities can be used by the physical therapist to choose the most appropriate interventions. (16-18) For example, diastolic BP and HR can be useful measures for determining differences in energy expenditure among modes of transfer. (19) Heart rate and BP can be used to determine the efficiency and energy cost of ambulation, with and without assistive devices, and this information can assist the physical therapist in choosing the most appropriate device for a patient. (9) Monitoring HR and BP also provides information about the patient's response during a physical therapy intervention and the possible need to modify the intervention. (18,20)

For example, if a patient has an abnormal HR or BP response, the therapist may need to decrease the intensity of the intervention. Balogun et al (21) found small drops in systolic and diastolic BP during continuous cervical traction in young subjects. They recommended that physical therapists monitor the BP response of patients at high risk for cardiovascular disease before, during, and after cervical traction. Patients at high risk for cardiovascular disease were described as elderly patients, those with increased sensitivity of baroreceptors, and those with carotid artery plaques or a history of hypotension or hypertension. Several authors (22-24) recommended that HR and BP should be monitored in patients undergoing isokinetic orthopedic rehabilitation protocols. This is especially true for patients with risk factors for cardiovascular disease, patients with coronary artery disease, and older individuals. (22-24) Negus et al (22) reported that maximum systolic BP during an isokinetic orthopedic rehabilitation protocol was higher than that achieved during a maximum cycle ergometry test, especially at higher isokinetic velocities. Furthermore, rate-pressure product (HR x systolic BP) reached 90% of the value obtained during the maximum cycle ergometry test. Thus, measurement of HR and BP is an important part of the systems review of new patients, and it can provide information for decisions about intervention and can be used to monitor a patient's response to activity.

Currently, there is no information about the extent to which physical therapists routinely measure HR and BP or the way in which they use this information in clinical practice. Therefore, we surveyed physical therapy clinical instructors to determine the frequency of HR and BP measurement in new patients and in patients already on the therapists' caseload. We also examined the use of information obtained from HR and BP measurement in decision making for patient care and the effects of practice setting and academic preparation on the measurement of HR and BP and use of these measurements in physical therapy practice.

Method

Subjects

The subjects for this study were selected from a list of 2,663 clinical instructors at the clinical education sites of the Department of Physical Therapy, Saint Louis University, and the Program in Physical Therapy, Washington University. We chose to survey clinical instructors because we had access to an existing list. We decided not to send packets of survey questionnaires to the institutions for individual clinicians to complete for 2 reasons. First, we believed that this would make following up on nonrespondents more difficult. Second, the clinicians may have perceived this approach as less personal, leading to a decrease in the return rate.

Although both programs are located in St Louis, Mo, their clinical education sites are located throughout the continental United States. We used 2 decision rules when selecting our sample. First, to avoid a preponderance of clinical instructors working in the Midwest, at least one clinical instructor was selected from each of the states where clinical education sites are located. Using this method, we selected 597 clinical instructors (roughly half from each university) working in 35 states and the District of Columbia. Second, we included clinical instructors from sites representing major practice areas such as rehabilitation, acute care, pediatrics, skilled nursing, outpatient care, and home health. Because we surveyed only clinical instructors, there may have been a systematic bias in our respondents. We do not know whether clinical instructors are similar to other therapists in the way they practice. In an effort to reduce the risk of bias in subject selection, the investigator (EMF) who chose names from the list was not a member of the clinical education team at either university.

Survey Questionnaire

The 26-item survey questionnaire was in 2 parts. The first part had questions about HR and BP measurement in clinical practice, and the second part asked for demographic data. Questions in part 1 asked about access to equipment needed to measure HR and BP, the frequency with which HR and BP measurements were taken, and the effects of vital sign measurements on the choice of interventions. To assess the frequency of HR and BP measurement, we used a 6-point Likert-like rating scale (1=never, 2=seldom, 3=less than half the time, 4=about half the time, 5=more than half the time, and 6=always). We also asked respondents about the importance of measuring vital signs, their potential use as screening measures, and reasons why they did not measure HR and BP. The final questions in the first part of the survey instrument asked about educational preparation for measuring HR and BP. Part 2 of the survey questionnaire asked respondents about the types of patients seen, the type of facility where the clinical instructors worked, the type of cardiopulmonary comorbidities reported as present in patients seen by the clinical instructors, the number of years the clinical instructors had been engaged in practice, and their sex. To give respondents a frame of reference, we asked them to limit their responses on the frequency of HR and BP measurement, use of these measures, and the presence of comorbidities to patients they had seen within the week before the survey. Five physical therapy faculty members, 2 of whom were involved in clinical practice, reviewed the survey questionnaire. After the reviewers critiqued the survey questionnaire, their suggestions were incorporated into the final version of the survey instrument. We did not evaluate the reliability or validity of data obtained by use of the survey.

Procedure

In July 2000, survey instruments were mailed to the 597 individuals selected from the list of 2,663 clinical instructors. We followed several of the procedures recommended by Dillman (25) in designing and implementing the survey. In an accompanying letter, we explained the purposes of the study and defined vital signs as HR and BP. We also explained that return of the survey questionnaire implied informed consent. A business reply envelope was included with the questionnaire. We requested that the questionnaires be returned within 3 weeks. A postcard reminder was mailed to nonrespondents 2 weeks following the initial mailing, and a second mailing was sent to nonrespondents in mid August 2000 with a letter requesting participation and another copy of the survey instrument. We used a code on the return envelope to track the survey instrument. Return envelopes were separated from the survey questionnaires when they were received.

Data Analysis

Data analysis was performed using SPSS, Release 10.0.7 (2000). * Frequencies, means, and medians were used to describe the data. The median was used to better describe the data when an extreme datum may have influenced the mean. To compare the responses of subgroups within the sample, we used contingency tables, the Fisher exact test, and chi-square analysis. (26) A Bonferroni correction was used to maintain an overall alpha of .05.

Results

Return Rate and Respondent Characteristics

We received 388 completed survey questionnaires from July 2000 to September 2000. Eighteen questionnaires were returned as undeliverable, and 1 questionnaire was eliminated from the analysis because the clinical instructor had based her responses on experiences prior to her maternity leave. Therefore, our final response rate was 64.8% (387). The number of respondents by state ranged from 1 (5 states) to 101 (1 state), with a mean of 11.1 respondents per state and a median of 5 respondents per state. Some respondents did not answer all questions; therefore, the reported percentages and analyses are based on different sample sizes (range=350-387). When we compared subsamples, the smallest sample size was 162. The majority of the respondents were female (82.8%), and almost two thirds reported practicing as a physical therapist from 1 to 10 years. Although respondents worked in a variety of settings, most (43.4%) worked in outpatient facilities. A complete description of the respondent demographics is presented in Table 1. Although our respondents were clinical instructors who worked at facilities that were affiliated with our universities, the demographic information from our respondents regarding sex and type of facility was similar, in our view, to the membership profile of APTA. (27) Like the APTA membership, most of the survey respondents were female, and the percentages of people working in outpatient facilities were similar (APTA=43.8% versus our survey=43.4%). More of our respondents reported practicing as a physical therapist from 1 to 10 years (62.1%) than the APTA membership profile (44.2%). (27) Therefore, it appears that our respondents had fewer years of experience than the APTA membership profile.

Measurement and Use of HR and BP

When asked to consider their actual clinical practice, the majority of respondents strongly agreed or agreed (59.5%) that measuring vital signs should be included in physical therapy screening. When asked if routinely taking vital signs during clinical practice was essential, opinions were nearly split (strongly agree or agree=45.0%, strongly disagree or disagree=43.7%, no opinion=11.3%). More than a third (38.0%) of the respondents reported never taking HR measurements as part of their examination of new patients during the week before completing the survey, and a slightly larger percentage (43.0%) reported never taking BP measurements of new patients. Only 6.0% and 4.4% of the respondents reported that they had always measured HR and BP, respectively, of new patients (Tab. 2). There was no difference between respondents practicing 5 years or less and those practicing more than 5 years for frequency of measuring HR and BP in new patients (Fisher exact test, P=.582 for HR and P=.653 for BP). When asked how often they had measured the HR of individuals already on their caseload during the previous week, 33.0% said never, and only 2.9% said always. Finally, 34.0% of the respondents reported that vital sign information had not been used during the previous week to make decisions about the progression of

an intervention, and only 2.3% reported that vital sign information was always used to make such decisions.

Reasons Given for Not Measuring HR and BP

Lack of equipment did not appear to be a reason for not measuring BP. More than half (60.6%) of the respondents who reported that they never measured the BP of new patients also reported that they always had access to a BP cuff. When given a list of reasons (Tab. 3) why HR and BP were not routinely measured in clinical practice, respondents most frequently chose "not important for my patient population" (52.3%). A relatively large percentage of respondents (19.8%) chose "other." Among the written reasons under "other," 2 of the most frequent were: nurses monitor vital signs (23.2%) and HR and BP were measured only when respondents believed these measures were necessary (48.8%).

When given a list of possible cardiopulmonary comorbidities in patients seen in the previous week, respondents most frequently chose hypertension (83.4%) (Tab. 4). We did not ask respondents whether they measured HR and BP in patients with cardiopulmonary comorbidities, because we were concerned about social desirability influencing the responses. (28) When we examined the subsample of respondents who reported that routine measurement of HR and BP was not important for their patient population, we found that 85.2% reported seeing patients with at least one cardiopulmonary comorbidity within the week before the survey. The comorbidities reported by this subsample are listed in Table 4.

Relationship Between Practice Setting and Measurement of HR and BP

Relationships were found between practice setting and frequency of HR ([chi square]=49.59, P<.001) and BP ([chi square]=45.25, P<.001) measurement in new patients (Tab. 5). We examined the standardized residuals for these chi-square analyses to determine which cells contributed to the significant chi-square results. (29) Standardized residuals close to or greater than 2.0 were considered important. (29) More respondents working in home health settings reported taking HR measurements "about half the time," "more than half the time," or "always" than would be expected by chance. Fewer respondents working in outpatient settings reported taking HR measurements "about half the time," "more than half the time," or "always" than would be expected by chance (Tab. 5). We found similar results for BP.

Relationship Between Academic Preparation and Measurement of HR and BP

We asked respondents how well their physical therapy education prepared them to measure HR and BP. The 5 response options were anchored with "my preparation was very good" to "my preparation was inadequate." Almost all respondents (96.3%) reported that they were at least adequately prepared to measure HR and BP. We used the Fisher exact test to compare academic preparation and frequency of measurement of HR and BP. We created 2 educational preparation categories by combining "adequate preparation," "good preparation," and "very good preparation" into the first category and "marginal preparation" and "inadequate preparation" into the second category. Two categories also were created from frequency of measurement of HR and BP: "less than half the time," "seldom," and "never" versus "half the time," "more than half the time," and "always." There was no association between preparation and frequency of measurement of HR (Fisher exact test, P=.730) and BP (Fisher exact test, P=1.00).

Discussion

We believe that we are the first authors to report on routine physical therapist practice with regard to measurement of HR and BP. Our data indicate that HR and BP are infrequently measured in new patients as well as in patients already on clinical instructors' caseloads even though the majority of physical therapists across all study settings generally agree that HR and BP should be measured in new patients. For example, 40.9% of those respondents who had not measured HR of new patients during the last week and 46.0% of the respondents who had not measured BP strongly agreed or agreed with the statement that measuring vital signs should be included in a physical therapy screening. We did not have a random sample, and our survey was limited to clinical instructors. These 2 factors limit our ability to generalize the results; however, our respondents' demographics closely matched those of the APTA membership. It is possible that physical therapists who are not clinical instructors might practice in a different manner from those we surveyed. Nevertheless, the findings are strikingly different from recommended practice. (6,22-24,30) Very few clinical instructors reported always measuring HR and BP when examining a new patient, and a large percentage reported never taking HR and BP measurements in new patients. These results differ from recommendations found in the systems review portion of the Guide (6) and with the view expressed by the respondents: the majority (59.5%) strongly agreed or agreed that vital signs should be included in a physical therapy screening. The respondents also infrequently measured HR in patients already on their caseload.

We believe that HR and BP measures should be included in the examination of all new physical therapy patients. Three factors led us to this conclusion. First, the prevalence of risk factors for cardiovascular disease in the United States is on the rise; 1 in 4 adults has high BP, (1) and 56% of adults are overweight or obese. (31) Approximately 5 million children aged 6 to 17 years are considered overweight. (1) In addition, other risk factors for cardiovascular disease, such as smoking and high cholesterol, are prevalent. (1) Second, common physical therapy interventions such as orthopedic rehabilitation can affect HR and BP. (20,22-24) Third, it is the responsibility of a primary care provider to screen the cardiovascular system. (3,32)

Routine measurement of HR and BP after an initial examination may not be warranted for every patient and all activities. However, routine measurement of HR and BP is important for patients with cardiopulmonary comorbidities regardless of the practice setting in which patients are seen. (4,13,14,24) In this study, more respondents working in home health settings reported measuring HR and BP more frequently than would have been expected by chance. A possible explanation may be that physical therapy examination forms used in home health settings frequently include OASIS (US Department of Health and Human Services Outcome and Assessment Information Set) items that require HR and BP measurements to be documented for Medicare reimbursement. (32,33) Fewer respondents working in outpatient settings reported measuring HR and BP than would have been expected by chance. Given the high incidence of cardiovascular disease, (1) we are concerned that HR and BP are infrequently measured in outpatient settings, as demonstrated by our data. If HR and BP are not measured, physical therapists may not recognize normal or abnormal physiological changes occurring when a patient performs activities during examination and intervention. Thus, the physical therapist could ere in decisions regarding choice or progression of an intervention. (21-23)

Nearly a fourth of the respondents (22%) did not routinely measure HR and BP because they stated the information could be obtained from a patient's chart. Nearly a quarter (23.2%) of the respondents who did not routinely measure HR and BP and chose "other" wrote that nurses monitored vital signs. Our concern is that the physical therapist may not see the patient for several hours after a nurse has measured vital signs and the patient's physiological status may have changed in that period. In addition, nurses usually measure vital signs at rest in a sitting or supine position, whereas physical therapists require patients to be active and move into various positions. Basing decisions on resting HR and BP measured well before physical therapy could lead to an inappropriate clinical decision, especially in acute care settings, where patient status is often labile.

Another reason respondents gave for not routinely measuring HR and BP was that physical therapists take HR and BP measurements only when indicated. It is unclear, however, what signs and symptoms or comorbidities therapists look for in patients to determine the need to take HR and BP measurements, and how consistent their judgments are. Given current demands for increased productivity in physical therapy, (34,35) we were surprized that lack of time was not given by more respondents as a reason for not measuring HR and BP (15.7%). Perhaps lack of time is seen as a socially unacceptable reason for not measuring HR and BP. Making the judgment that measuring HR and BP is not important for a particular patient could be seen as an acceptable reason for omitting these measurements. Physical therapists also may not view HR and BP measurement as part of their patient care responsibility; thus, they may believe that omitting HR and BP measurement in the examination and management of patients is not problematic.

Lack of skill in measuring HR and BP was not frequently reported as a reason for not taking these measurements (0.8%). Therefore, it appears that physical therapists are being taught to measure HR and BP. In a survey of physical therapy department chairs or program directors, Brooks (36) found that 97.1% of respondents believed that performance of vital sign assessment is an essential component of the cardiopulmonary portion of the curriculum.

Our results suggest that information obtained from HR and BP measurement may have minimal influence on clinical decision making about progression of an intervention in a general population of patients (Tab. 2). This is not surprising, because few physical therapists reported measuring HR and BP as part of an examination of new patients. Not using HR and BP measures in clinical decision making for appropriate patients may compromise the physical therapist's ability to formulate an optimal exercise prescription for a patient. (11,12,20) Thus, the physical therapist could overestimate or underestimate the appropriate exercise intensity for a patient or fail to modify an intervention as needed. (9,17,36) Heart rate and BP measurement also can provide information for documenting outcomes of physical therapy intervention. (18,37) For example, measures of HR and BP can provide information regarding improvement in response to activity due to physical therapy intervention.

We believe the current level of practice, especially in the area of examination, may not be sufficient for a profession that seeks to provide primary care. Physical therapists may need to implement standard operating procedures to encourage routine measurement of HR and BP.

The results of our study indicate the need for future research in several areas. First, a random sample of physical therapists working in a variety of settings would enhance the generalizability of the findings. Second, a study of education programs and physical therapist students would indicate whether students are taught to make clinical decisions based on HR and BP measurements. Third, a study of practicing physical therapists could determine if and how HR and BP measurements are used in clinical decision making. Fourth, a study is needed to determine whether clinical practice patterns can be modified by efforts to encourage physical therapists to measure and use HR and BP measurements during clinical practice.

Conclusion

The Guide (6) recommends that HR and BP measurement be included in the examination of new patients. Practices related to HR and BP measurement reported by this sample of clinical instructors do not meet the recommendations for physical therapy care described in the Guide. If the suggestions of the Guide are considered correct, physical therapists should change their practice. Such a change is warranted for a profession seeking practice without physician referral.

Table 1.
Respondent Characteristics

                                          Percentage of
                                          Respondents

Sex (n=383)
  Female                                  82.8
  Male                                    17.2

Practice setting (n=380)
  Outpatient                              43.4
  Acute care with rehabilitation          16.1
  Rehabilitation                          14.5
  Acute care                              13.4
  Pediatric hospital or facility           5.0
  Extended care facility/long-term care    2.4
  Home health agency                       2.4
  School system                            1.6
  Nursing home                             1.3

Years practicing as a physical therapist
  (n=383)
  1-5                                     30.8
  6-10                                    31.3
  11-15                                   14.4
  >15                                     23.5

Table 2.
Extent of the Measurement of Heart Rate (HR) and Blood Pressure (BP)

                                          Percentage

During the Previous Week,
How Often Did You:                   n     Never   Seldom

Measure HR as part of your
  examination of new patients?       384   38.0    25.0
Measure the BP of new patients?      384   43.0    27.3
Measure the HR of patients already
  on your caseload?                  382   33.0    25.1
Use vital sign information to make
  decisions about the progress of
  an intervention?                   385   34.0    27.8

                                             Percentage

During the Previous Week,            Less Than       About Half
How Often Did You:                   Half the Time   the Time

Measure HR as part of your
  examination of new patients?       16.9            7.8
Measure the BP of new patients?      13.5            6.0
Measure the HR of patients already
  on your caseload?                  23.0            8.6
Use vital sign information to make
  decisions about the progress of
  an intervention?                   19.5            9.1

                                          Percentage

During the Previous Week,            More Than
How Often Did You:                   Half the Time   Always

Measure HR as part of your
  examination of new patients?       6.3             6.0
Measure the BP of new patients?      5.7             4.4
Measure the HR of patients already
  on your caseload?                  7.3             2.9
Use vital sign information to make
  decisions about the progress of
  an intervention?                   7.3             2.3

Table 3.
Why Respondents Do Not Routinely Measure Heart Rate and Blood
Pressure in Their Clinical Practice (n=363)

                                              Percentage of
Item                                          Respondents (a)

Not important for my patient population       52.3
Information obtained from patient's chart     22.0
Monitored in intensive care unit              16.5
Lack of time                                  15.7
Equipment not available                        3.3
Lack of skill in taking these measurements     0.8
Other                                         19.8

(a) Respondents could choose more than one item.

Table 4.
Cardiopulmonary Comorbidities That Respondents Reported as Present in
Patients Seen in the Previous Week (a)

                                Percentage of Respondents Reporting a
                                Comorbidity as Present

                                              By Respondents Who Also
                                              Indicated That Routine
                                              Measurement of Heart Rate
                                              and Blood Pressure Was
                                Across All    Not Important for Their
Cardiopulmonary                 Respondents   Patient Population
Comorbidity                     (n=350)       (n= 162)

Hypertension                    83.4          76.5
Diabetes                        80.0          72.2
Cerebrovascular accident        55.4          40.7
Coronary artery disease         55.1          34.0
Congestive heart failure        44.9          24.7
Chronic obstructive pulmonary
  disease                       41.7          22.8
Myocardial infarction           35.4          22.8
Asthma                          32.9          35.2
Renal failure                   28.6          14.2
Other                           11.7           8.0

(a) Respondents could choose more than one item.

Table 5.
Relationship Between Type of Setting and Frequency of Measurement of
Heart Rate (HR) and Blood Pressure (BP) in New Patients

                          During the Last Week, How Often Did You Take
                          HR or BP Measurements as Part of Your
                          Examination of New Patients?

                          HR (b)

                          Never, Seldom, or    About Half the Time,
                          Less Than Half the   More Than Half the
Type of Facility (a)      Time (%)             Time, Always (%)

Acute care                76.8                 23.2
Rehabilitation            70.9                 29.1
Extended care facility/
long-term care            53.8                 46.2
Home health agency        11.1                 88.9
Outpatient facility       91.5                  8.5

                          During the Last Week, How Often Did You Take
                          HR or BP Measurements as Part of Your
                          Examination of New Patients?

                          BP (c)

                          Never, Seldom, or    About Half the Time,
                          Less Than Half the   More Than Half the
Type of Facility (a)      Time (%)             Time, Always (%)

Acute care                83.9                 16.1
Rehabilitation            69.1                 30.9
Extended care facility/
long-term care            61.5                 38.5
Home health agency        22.2                 77.8
Outpatient facility       92.1                  7.9

(a) For this analysis, we collapsed the following facility response
options: acute care with rehabilitation and acute care, because we
believe that practice in acute care and in acute care with
rehabilitation facilities is similar. We used the same rationale when
combining the facility response options nursing home and extended
care facility/long-term care. We omitted pediatric hospital or
facility and school system response options because the focus in this
study was on adult patients.

(b) [chi square]=49.59, P(.001. The chi-square statistic was
calculated using the observed frequencies.

(c) [chi square]=45.25, P(.001. The chi-square statistic was
calculated using the observed frequencies.

* SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

References

(1) 2002 Heart and Stroke Statistical Update. Dallas, Tex: American Heart Association; 2001.

(2) Meissner I, Whisnant JP, Sheps SG, et al. Detection and control of high blood pressure in the community: Do we need a wake-up call? Hypertension. 1999;34:466-471.

(3) Diagnosis and Management of Hypertension in the Primary Care Setting. Washington, DC: Department of Veterans Affairs; 1999.

(4) Billek-Sawhney B, Sawhney R. Cardiovascular considerations in outpatient orthopedic physical therapy [abstract]. J Orthop Sports Phys Ther. 1998;27:57.

(5) Moore J. Vision in action: direct access. PT Magazine. 2001;9(2): 76 -79.

(6) Guide to Physical Therapist Practice. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001.

(7) Harris SR. How should treatments be critiqued for scientific merit? Phys Ther. 1996;76:175-181.

(8) Duncan PW. Evidenced-based practice: a new model for physical therapy. PT Magazine. 1996;4(12):44-48.

(9) Holder CG, Haskvitz EM, Weltman A. The effects of assistive devices on the oxygen cost, cardiovascular stress, and perception of nonweight-bearing ambulation. J Orthop Sports Phys Ther. 1993;18:537-542.

(10) Kispert CP. Clinical measurements to assess cardiopulmonary function. Phys Ther. 1987;67:1886-1890.

(11) Marcelino J, Harms MC. Heart rate monitoring: reliability of the Tunturi pulse meter. Physiotherapy. 1992;78:571-574.

(12) Iyriboz Y, Hearon CM. Blood pressure measurement at rest and during exercise. J Cardiopulm Rehabil. 1992;12:277-287.

(13) Raiha I, Luutonen S, Piha J, et al. Prevalence, predisposing factors, and prognostic importance of postural hypotension. Arch Intern Med. 1995;155:930-935.

(14) Winslow EH, Lane LD, Woods RJ. Dangling: a review of relevant physiology, research, and practice. Heart Lung. 1995;24:263-272.

(15) Peel C, Mossberg KA. Effects of cardiovascular medications on exercise responses. Phys Ther. 1995;75:387-396.

(16) Dean E. Preferred practice patterns in cardiopulmonary physical therapy: a guide to physiologic measures. Journal of Cardiopulmonary Physical Therapy. 1999;10:124-134.

(17) Dean E, Ross J, Bartz J, Purves S. Improving the validity of clinical exercise testing: the relationship between practice and performance. Arch Phys Med Rehabil. 1989;70:599-604.

(18) Eason JM. Cardiopulmonary assessment. Journal of Cardiopulmonary Physical Therapy. 1999;10:135-142.

(19) Jackson BS, Kinney MR. Energy expenditure, heart rate, rhythm, and blood pressure in female subjects engaged in common hospitalized patient positions and modes of patient transfer. Int J Nurs Stud. 1978;15:115-128.

(20) Al-Obaidi S, Anthony J, Dean E, Al-Shuwia N. Cardiovascular responses to repetitive McKenzie lumbar spine exercises. Phys Ther. 2001;81:1524-1533.

(21) Balogun JA, Abereoje OK, Olagun MO, et al. Cardiovascular responses of healthy subjects during cervical traction. Physiotherapy Canada. 1990;42:16-22.

(22) Negus RA, Rippe JM, Freedson P, Michaels J. Heart rate, blood pressure, and oxygen consumption during orthopaedic rehabilitation exercise. J Orthop Sports Phys Ther. 1987;8:346-350.

(23) Douris PC. Cardiovascular response to velocity-specific isokinetic exercise. J Orthop Sports Phys Ther. 1991;13:28-32.

(24) Thompson E, Versteegh TH, Overend TJ, et al. Cardiovascular responses to submaximal concentric and eccentric exercise in older adults. Journal of Aging and Physical Activity. 1999;7:20-31.

(25) Dillman DA. Mail and Telephone Surveys: The Total Design Method. New York, NY: John Wiley & Sons Inc; 1978.

(26) Siegel S, Castellan NJ. Nonparametric Statistics for the Behavioral Sciences. 2nd ed. New York, NY: McGraw-Hill Inc; 1988.

(27) PT Demographics as of February 2000. Available at: https://www. apta.org/Research/survey_stat/pt_demo. Accessed: March 7, 2002.

(28) Sudman S, Bradburn NM. Asking Questions: A Practical Guide to Questionnaire Design. San Francisco, Calif: Jossey-Bass Publishers Inc; 1982.

(29) Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice. 2nd ed. Upper Saddle River, NJ: Prentice Hall Health; 2000.

(30) American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. 6th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000.

(31) Mokdad AH, Bowman BA, Ford ES. The continuing epidemics of obesity and diabetes in the United States. JAMA. 2001;286:1195-1200.

(32) Guidelines and Exhibits Regarding Regulatory Requirements for Comprehensive Assessment and Use of the Outcome and Assessment Information Set (OASIS). Washington, DC: Health Care Financing Administration, US Dept of Health and Human Services; 1999:1-50. Transmittal No. 99-2.

(33) Outcome and ASsessment Information Set Implementation Manual: Implementing OASIS at a Home Health Agency to Improve Patient outcomes. Washington, DC: Center for Health Services and Policy Research, Health Care Financing Administration, US Dept of Health and Human Services; revised April 2001. Transmittal No. 99-2.

(34) Wynn K. The pearls and perils of managed care. PT Magazine. 1999;7(1):34-44.

(35) Kovacek P. The productive PT. PT Magazine. 1996;4(4):33-35.

(36) Brooks G. A survey of entry level cardiopulmonary physical therapy education. Journal of Cardiopulmonary Physical Therapy. 1996;7:9-14.

(37) Clinical Research Agenda for Physical Therapy. Phys Ther. 2000;80: 499-513.

EM Frese, PT, MHS, CCS, is Associate Professor, Department of Physical Therapy, Edward and Margaret Doisy School of Allied Health Professions, Saint Louis University, 3437 Caroline St, St Louis, MO 63104 (USA) ([e-mail]). Address all correspondence to Ms Frese.

RR Richter, PT, PhD, is Associate Professor, Department of Physical Therapy, Edward and Margaret Doisy School of Allied Health Professions, Saint Louis University.

TV Burlis, PT, MHS, CCS, is Instructor, Program in Physical Therapy, Washington University School of Medicine, St Louis, Mo.

All authors provided concept/idea/research design, writing, and data analysis. Ms Frese provided data collection and project management. The authors acknowledge Matthew B Thomas for providing clerical support.

Portions of this study were presented as a poster at the Combined Sections Meeting of the American Physical Therapy Association; February 20-24, 2002; Boston, Mass.

This study was approved by the institutional review boards of the Department of Physical Therapy, Saint Louis University, and the Program in Physical Therapy, Washington University.

This article was submitted October 18, 2001, and was accepted June 17, 2002.