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Self-Reported Measurement of Heart Rate and Blood Pressure in Patients by Physical Therapy Clinical Instructors

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) (freseem{at}slu.edu). 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

Submitted October 18, 2001; Accepted June 17, 2002

	Abstract

 
Background and Purpose. The Guide to Physical Therapist Practice (Guide) recommends that heart rate (HR) and blood pressure (BP) measurement be included in the examination of new patients. The purpose of this study was to survey physical therapy clinical instructors to determine the frequency of HR and BP measurement in new patients and in patients already on the physical therapists' caseload. The use of information obtained from HR and BP measures in decision making for patient care and the effects of practice setting and academic preparation on the measurement and use of HR and BP also were examined. Subjects and Methods. A sample of 597 subjects was selected from a list of 2,663 clinical instructors at the clinical education sites of the 2 participating universities. Clinical instructors from a variety of practice settings were surveyed. A 26-item survey questionnaire was mailed to the clinical instructors. Results. Usable survey questionnaires were received from 387 respondents (64.8%); 43.4% reported working in an outpatient facility. The majority of the respondents strongly agreed or agreed (59.5%) that measurement of HR and BP should be included in physical therapy screening. When asked if routinely measuring HR and BP during clinical practice is essential, opinions were nearly split (strongly agree or agree=45.0%, strongly disagree or disagree=43.7%, no opinion=11.3%). More than one third (38.0%) of the respondents reported never measuring HR in the week before the survey as part of their examination of new patients. A slightly larger percentage (43.0%) reported never measuring BP of new patients in the week before the survey. Conversely, 6.0% and 4.4% of the respondents reported always measuring HR and BP, respectively, of new patients in the week before the survey. When given a list of reasons why HR and BP were not routinely measured in their clinical practice, respondents most frequently chose "not important for my patient population" (52.3%). Relationships were found between practice setting and frequency of HR and BP measurement in new patients. Discussion and Conclusion. 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.

Key Words: Blood pressure • Clinical instructor • Heart rate • Measurement • Survey

	Introduction

Top Abstract Introduction Method Results Discussion Conclusion References

 
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 socioeconomically 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 Harris⁷ 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 Guide⁶ 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 al¹⁴ 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 al²¹ 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 al²² 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

Top Abstract Introduction Method Results Discussion Conclusion References

 
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 Dillman²⁵ 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

Top Abstract Introduction Method Results Discussion Conclusion References

 
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.

	Discussion

Top Abstract Introduction Method Results Discussion Conclusion References

 
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 Guide⁶ 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, Brooks³⁶ 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

Top Abstract Introduction Method Results Discussion Conclusion References

 
The Guide⁶ 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.

	Footnotes

 
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.

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

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This Article Abstract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when Rapid Responses are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Frese, E. M Articles by Burlis, T. V Search for Related Content PubMed PubMed Citation Articles by Frese, E. M Articles by Burlis, T. V