Role of physiotherapists in intensive care units of India: A multicenter survey

Perspectives of healthcare professionals in Nigeria about physiotherapists’ scope of practice and skills in ICU patients’ management: a cross-sectional study

Background

There is growing evidence for physiotherapy in the intensive care unit (ICU), but physiotherapy in the ICU and patients’ referral rate remains low in Nigeria. This study assessed the healthcare professionals’ perception of the physiotherapists’ scope of practice and skills in managing patients in the ICU of selected teaching hospitals in Southern Nigeria. The study was a cross-sectional survey that involved seventy healthcare professionals working in the ICU who completed an adapted and validated questionnaire. The data obtained from the cross-sectional study were presented using descriptive statistics of mean, standard deviation, frequency distribution, and percentage.

Results

The mean age of the participants was 39.74 ± 7.08 years. The majority of the participants had a bachelor’s degree and had worked for a minimum of 5 years in the ICU, with all the participants working in a mixed ICU and 46.7% work in ICUs with four to six beds. Physiotherapists (PTs) are not posted exclusively to the ICUs, and PTs were reported to be on call in most of the ICUs during the weekdays and weekends. Patients were referred for physiotherapy by the physicians. Healthcare professionals had negative perceptions about PTs’ scope in airway suctioning, nebulization, weaning, and adjustment of mechanical ventilators, intubation, extubation, and changing tracheostomy tubes for ICU patients. Participants had a positive perception about PTs’ assessment skills in the ICU except for hypoxemia calculation, readiness for weaning, and the need for humidification.

Conclusion

Healthcare professionals working in the ICU in the selected hospitals had both negative and positive perceptions regarding certain areas about the scope of practice and skills of PTs in managing patients in the ICU.

Feasibility of establishing a rehabilitation programme in a Vietnamese intensive care unit

Increasing numbers of people are surviving critical illness throughout the world, but survivorship is associated with long-term disability. In high-income settings physical rehabilitation is commonly employed to counter this and improve outcomes. These utilize highly-trained multidisciplinary teams and are unavailable and unaffordable in most low and middle income countries (LMICs). We aimed to design a sustainable intensive care unit (ICU) rehabilitation program and to evaluate its feasibility in a LMIC setting. In this project patients, care-givers and experts co-designed an innovative rehabilitation programme that can be delivered by non-expert ICU staff and family care-givers in a LMIC. We implemented this programme in adult patient with patients with tetanus at the Hospital for Tropical Diseases, Ho Chi Minh City over a 5-month period, evaluating the programme's acceptability, enablers and barriers. A 6-phase programme was designed, supported by written and video material. The programme was piloted in total of 30 patients. Rehabilitation was commenced a median 14 (inter quartile range (IQR) 10-18) days after admission. Each patient received a median of 25.5 (IQR 22.8-34.8) rehabilitation sessions out of a median 27 (22.8-35) intended (prescribed) sessions. There were no associated adverse events. Patients and staff found rehabilitation to be beneficial, enhanced relationships between carers, patients and staff and was deemed to be a positive step towards recovery and return to work. The main barrier was staff time. The programme was feasible for patients with tetanus and viewed positively by staff and participants. Staff time was identified as the major barrier to ongoing implementation.

Knowledge, Attitudes, and Perceived Barriers of Healthcare Providers toward Early Mobilization of Adult Critically Ill Patients in Intensive Care Unit

Background

Early mobilization (EM) of critically ill adult patients in intensive care units (ICUs) is a newer concept. It is known to improve overall outcomes, but little is known regarding the attitude and knowledge of healthcare providers (HCPs) and multidisciplinary barriers to its use in the Indian scenario.

Aims and objectives

To study the knowledge and attitude of HCPs in ICU about the EM of adult patients who are critically ill and identify perceived barriers to the application of EM.

Materials and methods

In a cross-sectional survey conducted in a tertiary care academic institute, the HCPs, namely, physicians, anesthetists, surgeons, nursing staff, and physiotherapists working in ICU were interviewed using a self-structured questionnaire. The data were presented as descriptive statistics.

Results

There was 80% response rate. The benefits of EM as shortened length of mechanical ventilation (MV) were acknowledged by 78% respondents and 54% believed that it maintains muscle strength. It was considered crucial by 44% respondents, who opined that it should be started as the patient's cardiorespiratory status stabilizes. The favorable attitudes observed were recognition of benefits for patients under MV exceeded the risks and readiness by physicians to reduce sedation levels and change the parameters of MV. The main barriers identified were the absence of written guidelines or protocols for EM, limited staff to mobilize patients, inadequate training of HCP to facilitate EM, excessive sedation, and medical instability.

Conclusion

There exists an awareness of the benefits of EM and favorable attitudes to its application. However, the actual performance of EM was perceived as a challenge due to barriers identified in the study.

How to cite this article

Akhtar PM, Deshmukh PK. Knowledge, Attitudes, and Perceived Barriers of Healthcare Providers toward Early Mobilization of Adult Critically Ill Patients in Intensive Care Unit. Indian J Crit Care Med 2021;25(5):512–518.

What Interventions Do Physical Therapists Provide for Patients With Cardiorespiratory Conditions, Neurological Conditions, and Conditions Requiring Acute Hospital Care? A Systematic Review

OBJECTIVE

The aim of this systematic review was to determine what percentages of physical therapists provide interventions that are of high value, low value, or unknown value for cardiorespiratory conditions, neurological conditions, or conditions requiring acute hospital care. Whether an intervention was considered high or low value was determined by reference to guidelines or systematic reviews.

METHODS

Searches of numerous databases were performed by combining terms synonymous with "practice patterns" and "physical therapy" until April 2018. Studies that investigated what interventions physical therapists provide for any cardiorespiratory condition, neurological condition, or condition requiring acute hospital care through surveys and audits of clinical notes were included. Through the use of medians and interquartile ranges, the percentages of physical therapists who provided interventions that were of high value, low value, or unknown value were summarized.

RESULTS

Twenty-six studies were included. The median percentages of physical therapists who provided interventions of high, low, and unknown value for chronic obstructive pulmonary disease ranged from 78% to 96%, 67% to 100%, and 56% to 91%, respectively. These percentages ranged from 61% to 97%, 87% to 98%, and 83% to 98% for adults who were critically ill in intensive care units; 70% to 93%, 38% to 50%, and 8% to 95% before or after cardiac/thoracic surgery; 25% to 96%, 23% to 84%, and 96% for acute stroke; and 11% (high value) and 13% (unknown value) for Parkinson disease, respectively.

CONCLUSIONS

This review found patterns of physical therapist practice for cardiorespiratory conditions, neurological conditions, and conditions requiring acute hospital care that were both evidence based and not evidence based. A concern is that a substantial percentage of physical therapists provided interventions that were of low or unknown value despite the availability of high-value interventions.

IMPACT

This systematic review is the first, to our knowledge, to summarize the percentage of physical therapist treatment choices that were high versus low value for cardiorespiratory conditions, neurological conditions, and conditions requiring acute hospital care. The findings highlight areas of practice where low-value care could be replaced with high-value care-such as in the management of patients who have chronic obstructive pulmonary disease or who are in intensive care-and identify an urgent need to develop and test strategies to ensure that patients with these conditions receive the interventions most likely to improve their outcomes.

The scope of physiotherapy services provided in public ICUs in Greece: A pilot study

The aim of the present study was to determine the scope of physiotherapy services provided in Greek ICUs in Athens. A cross-sectional study was conducted with two postal questionnaires administered separately, one for ICU directors and one for ICU physiotherapists. Responses were received from 19 ICU directors and 103 physiotherapists employed in all the adult public mixed medical and surgical ICUs across Athens. The response rate for the survey completion was 100% for ICU directors and 68.7% for physiotherapists. The results showed a 1:50 to 1:12 range in the ratio of physiotherapists to ICU beds. Among the 19 ICUs, 15 (78.9%) employed physiotherapists on a rotational basis, while four (21.0%) retained them exclusively. On weekdays, all surveyed ICUs were covered by physiotherapists in the morning and 10/19 (52.6%) during the afternoon. On weekends, 12/19 (63.2%) of the surveyed ICUs reported physiotherapy care during the morning and 4/19 (21.0%) during both morning and afternoon. All 103 physiotherapists conducted airway clearance techniques and progressive mobilization, 92/103 (89.3%) were involved in extubating patients, 102/103 (99.0%) in passive and active range of motion exercises, and 61/103 (59.2%) in walking. In conclusion, all Greek ICUs in Athens surveyed had physiotherapy cover. The physiotherapists working in these ICUs in Athens were involved in respiratory care and mobilization.

Experiences of Physical Therapists Working in the Acute Hospital Setting: Systematic Review

BACKGROUND

Physical therapists working in acute care hospitals require unique skills to adapt to the challenging environment and short patient length of stay. Previous literature has reported burnout of clinicians and difficulty with staff retention; however, no systematic reviews have investigated qualitative literature in the area.

PURPOSE

The purpose of this study was to investigate the experiences of physical therapists working in acute hospitals.

DATA SOURCES

Six databases (MEDLINE, CINAHL Plus, EMBASE, AMED, PsycINFO, and Sociological Abstracts) were searched up to and including September 30, 2015, using relevant terms.

STUDY SELECTION

Studies in English were selected if they included physical therapists working in an acute hospital setting, used qualitative methods, and contained themes or descriptive data relating to physical therapists' experiences.

DATA EXTRACTION AND DATA SYNTHESIS

Data extraction included the study authors and year, settings, participant characteristics, aims, and methods. Key themes, explanatory models/theories, and implications for policy and practice were extracted, and quality assessment was conducted. Thematic analysis was used to conduct qualitative synthesis.

RESULTS

Eight articles were included. Overall, study quality was high. Four main themes were identified describing factors that influence physical therapists' experience and clinical decision making: environmental/contextual factors, communication/relationships, the physical therapist as a person, and professional identity/role.

LIMITATIONS

Qualitative synthesis may be difficult to replicate. The majority of articles were from North America and Australia, limiting transferability of the findings.

CONCLUSIONS

The identified factors, which interact to influence the experiences of acute care physical therapists, should be considered by therapists and their managers to optimize the physical therapy role in acute care. Potential strategies include promotion of interprofessional and collegial relationships, clear delineation of the physical therapy role, multidisciplinary team member education, additional support staff, and innovative models of care to address funding and staff shortages.

Mobilization of patients in neurological Intensive Care Units of India: A survey

Context:

The rehabilitation needs of the patients in neurological Intensive Care Units (ICUs) vary from that of a medical ICU patient. Early mobilization is known to improve the various neurological outcomes in patients admitted to neurological ICUs, although little is known about the practice pattern among physiotherapists. The mobilization practice pattern may vary significantly than that of developed countries due to the reasons of differences in training of professionals, availability of equipment, and financial assistance by health insurance.

Aim of the Study:

To study the current mobilization practices by the physiotherapists in neurological ICUs of India.

Subjects and Methods:

A cross-sectional survey was conducted with a content validated questionnaire about the mobilization practices. Online questionnaire was distributed to physiotherapists working in neurological ICUs of India. Descriptive statistics were used.

Results:

Out of 185 e-mails sent, 82 physiotherapists completed the survey (survey response rate = 44%). Eighty participants (97.6%) mentioned that the patients received some form of mobilization during the day. The majority of the physiotherapists (58.5%), “always” provided bed mobility exercises to their patients when it was found appropriate for the patients. Many physiotherapists (41.5%) used tilt table “sometimes” to introduce orthostatism for their patients.

Conclusion:

Mobilization in various forms is being practiced in the neurological ICUs of India. However, fewer mobilization sessions are conducted on weekends and night hours in Indian Neurological ICUs.

National Profile of Physical Therapists in Critical Care Units of Sri Lanka: Lower Middle-Income Country

BACKGROUND

The availability and role of physical therapists in critical care is variable in resource-poor settings, including lower middle-income countries.

OBJECTIVE

The aim of this study was to determine: (1) the availability of critical care physical therapist services, (2) the equipment and techniques used and needed, and (3) the training and continuous professional development of physical therapists.

METHODS

All physical therapists working in critical care units (CCUs) of state hospitals in Sri Lanka were contacted. The study tool used was an interviewer-administered telephone questionnaire.

RESULTS

The response rate was 100% (N=213). Sixty-one percent of the physical therapists were men. Ninety-four percent of the respondents were at least diploma holders in physical therapy, and 6% had non-physical therapy degrees. Most (n=145, 68%) had engaged in some continuous professional development in the past year. The majority (n=119, 56%) attended to patients after referral from medical staff. Seventy-seven percent, 98%, and 96% worked at nights, on weekends, and on public holidays, respectively. Physical therapists commonly perform manual hyperinflation, breathing exercises, manual airway clearance techniques, limb exercises, mobilization, positioning, and postural drainage in the CCUs. Lack of specialist training, lack of adequate physical therapy staff numbers, a heavy workload, and perceived lack of infection control in CCUs were the main difficulties they identified.

LIMITATIONS

Details on the proportions of time spent by the physical therapists in the CCUs, wards, or medical departments were not collected.

CONCLUSIONS

The availability of physical therapist services in CCUs in Sri Lanka, a lower middle-income country, was comparable to that in high-income countries, as per available literature, in terms of service availability and staffing, although the density of physical therapists remained very low, critical care training was limited, and resource limitations to physical therapy practices were evident.

Early mobilization of critically ill adults: a survey of knowledge, perceptions and practices of Canadian physicians and physiotherapists

BACKGROUND

The promotion of early mobilization following critical illness is tempered by national reports of patient and institutional barriers to this approach. We carried out a survey to assess current knowledge, perceptions and practices of Canadian physicians and physiotherapists with respect to acquired weakness and early mobilization in adults in the intensive care unit (ICU).

METHODS

We conducted a cross-sectional, self-administered postal survey among critical care physicians and physiotherapists in all 46 academic ICUs in Canada in 2011-2012. To identify all physicians and physiotherapists working in the ICUs, we contacted division heads and senior physiotherapists by telephone or email. We designed, tested and administered a questionnaire with the following domains: knowledge of ICU-acquired weakness and early mobilization; personal views of, perceived barriers to and adequacy of technical skills for early mobilization; assessments for initiation of early mobilization and permissible activity levels by patient physiologic characteristics, diagnoses and therapies; staffing issues; and sedation practices.

RESULTS

The overall response rate was 71.3% (311/436); it was 64.2% (194/302) among physicians and 87.3% (117/134) among physiotherapists. A total of 214 respondents (68.8%) underestimated the incidence of ICU-acquired weakness in the general medical-surgical ICU population, and 186 (59.8%) stated they had insufficient knowledge or skills to mobilize patients receiving mechanical ventilation. Excessive sedation, medical instability, limited staffing, safety concerns, insufficient guidelines and insufficient equipment were common perceived barriers to early mobilization.

INTERPRETATION

Physicians and physiotherapists in the ICU underestimated the incidence of ICU-acquired weakness and felt inadequately trained to mobilize patients receiving mechanical ventilation. We identified multiple modifiable barriers to early mobilization at the institutional, health care provider and patient levels that need to be addressed when designing mobilization programs for critically ill adults.

Physiotherapy practice patterns in Intensive Care Units of Nepal: A multicenter survey

Context:

As physiotherapy (PT) is a young profession in Nepal, there is a dearth of insight into the common practices of physiotherapists in critical care.

Aims:

To identify the availability of PT services in Intensive Care Units (ICUs) and articulate the common practices by physiotherapists in ICUs of Nepal.

Settings and Design:

All tertiary care hospitals across Nepal with ICU facility via an exploratory cross-sectional survey.

Subjects and Methods:

An existing questionnaire was distributed to all the physiotherapists currently working in ICUs of Nepal with 2 years of experience. The survey was sent via E-mail or given in person to 86 physiotherapists.

Statistical Analysis Used:

Descriptive and inferential statistics according to nature of data.

Results:

The response rate was 60% (n = 52). In the majority of hospitals (68%), PT service was provided only after a physician consultation, and few hospitals (13%) had established hospital criteria for PT in ICUs. Private hospitals (57.1%) were providing PT service in weekends compared to government hospitals (32.1%) (P = 0.17). The likelihood of routine PT involvement varied significantly with the clinical scenarios (highest 71.2% status cerebrovascular accident, lowest 3.8% myocardial infarction, P < 0.001). The most preferred PT treatment was chest PT (53.8%) and positioning (21.2%) while least preferred was therapeutic exercise (3.8%) irrespective of clinical scenarios.

Conclusions:

There is a lack of regular PT service during weekends in ICUs of Nepal. Most of the cases are treated by physiotherapists only after physician's referral. The preferred intervention seems to be limited only to chest PT and physiotherapists are not practicing therapeutic exercise and functional mobility training to a great extent.

Physiotherapy practices in Intensive Care Units across Maharashtra

Purpose:

To find out the current physiotherapy practices in Intensive Care Unit (ICU) across Maharashtra.

Materials and Methods:

Study design was exploratory cross-sectional survey. Questionnaires were sent to the physiotherapists working in hospitals across Maharashtra state, India. Four weeks for completion of questionnaire was given in an attempt to ensure good response rates.

Result:

Of 200, 73 questionnaires were received representing a 36% response rate. The study revealed that 76% of the respondents were bachelors qualified, 15% were masters in physiotherapy with only 4% specialized in cardio-respiratory physiotherapy; 82% had <5 years experience in ICU. Almost 19% had not at all attended any seminars/workshops related to ICU management while 61% attended up to three within last 2 years. The availability of a physiotherapist during the night was affirmed by 63%, 58% responded initiation of physiotherapy to be “always physician referred” and 39% mentioned “physiotherapist initiated.” Almost 80% performed chest wall techniques, 86% positioning, 27% postural drainage, 5% manual hyperinflation, 12% application of nebulizer, and 56% bedsores management. Only 5% reported involvement in ventilator setting, 11% had their opinion sought before weaning from ventilator, 29% practiced noninvasive ventilation, 11% were involved in decision-making for extubation and 44% reported involvement in patient family education.

Conclusion:

The study showed that physiotherapists among the responding ICUs surveyed lack in experience and updated knowledge. Physician reference is necessary to initiate physiotherapy and there exists no established criteria for physiotherapy treatment in ICU. All physiotherapists were routinely involved in chest physiotherapy, mobilization, and positioning.

Profile of patients and physiotherapy patterns in intensive care units in public hospitals in Zimbabwe: a descriptive cross-sectional study

Background

Physiotherapy is integral to patient management in the Intensive Care Unit. The precise role that physiotherapists play in the critical care differs significantly worldwide. The aim of the study was to describe the profile of patients and the current patterns of physiotherapy services delivered for patients admitted in the five public hospital intensive care units in Zimbabwe.

Methods

A prospective record review was performed and records of all consecutive patients admitted into the five units during a two months period were included in the analysis. The data was collected using a checklist and the following were recorded for each patient: 1) demographic information, 2) admission diagnoses, 3) surgery classification, 4) method and time of mechanical ventilation 5) physiotherapy techniques and frequency and 6) the length of stay.

Results

A total of 137 patients were admitted to five units during the study. The mean age of patients in the study was 36.0 years (SD = 16.6). A mortality rate of 17.5 % was observed with most of the patients being below the age of 45 years. The majority of the patients, 61(45 %) had undergone emergency surgery and were in the ICU for postoperative treatment, whilst only 19(14 %) were in the units for clinical treatment (non-surgical). On admission, 72(52.6 %) of the patients were on mechanical ventilation. The mean duration on mechanical ventilation for patients was 4.0 days (SD =2.7) and a length of stay in the unit of 4.5 days (SD = 3.0).

Of the patients who were admitted into the ICU 120 (87.6 %) had at least one session of physiotherapy treatment during their stay. The mean number of days physiotherapy treatment was received was 3.71 (SD = 3.14) days. The most commonly used physiotherapy techniques were active assisted limb movements (66.4 %), deep breathing exercises (65.0 %) and forced expiratory techniques (65.0 %).

Conclusion

A young population admitted in the ICU for post-surgical treatment was observed across all hospital ICUs. The techniques which were executed in Zimbabwean ICUs showed that the goal of the physiotherapy treatment was mainly to prevent and treat respiratory complications and a culture of promoting bed rest still existed.

Trial registration

PACTR201408000829202

Chest physiotherapy techniques in neurological intensive care units of India: A survey

CONTEXT

Neurological intensive care units (ICUs) are a rapidly developing sub-specialty of neurosciences. Chest physiotherapy techniques are of great value in neurological ICUs in preventing, halting, or reversing the impairments caused due to neurological disorder and ICU stay. However, chest physiotherapy techniques should be modified to a greater extent in the neurological ICU as compared with general ICUs.

AIM

The aim of this study is to obtain data on current chest physiotherapy practices in neurological ICUs of India.

SETTINGS AND DESIGN

A tertiary care hospital in Karnataka, India, and cross-sectional survey.

SUBJECTS AND METHODS

A questionnaire was formulated and content validated to assess the current chest physiotherapy practices in neurological ICUs of India. The questionnaire was constructed online and a link was distributed via E-mail to 185 physiotherapists working in neurological ICUs across India.

STATISTICAL ANALYSIS USED

Descriptive statistics.

RESULTS

The response rate was 44.3% (n = 82); 31% of the physiotherapists were specialized in cardiorespiratory physiotherapy and 30% were specialized in neurological physiotherapy. Clapping, vibration, postural drainage, aerosol therapy, humidification, and suctioning were used commonly used airway clearance (AC) techniques by the majority of physiotherapists. However, devices for AC techniques such as Flutter, Acapella, and standard positive expiratory pressure devices were used less frequently for AC. Techniques such as autogenic drainage and active cycle of breathing technique are also frequently used when appropriate for the patients. Lung expansion therapy techniques such as breathing exercises, incentive spirometry exercises, and positioning, proprioceptive neuromuscular facilitation of breathing are used by majority of physiotherapists.

CONCLUSIONS

Physiotherapists in this study were using conventional chest physiotherapy techniques more frequently in comparison to the devices available for AC.

Practice patterns of physiotherapists in neonatal intensive care units: A national survey

OBJECTIVE

To determine practice pattern of physiotherapists in the neonatal intensive care units (ICUs) in India with regards to cardiopulmonary and neuromuscular physiotherapy.

MATERIALS AND METHODS

A cross-sectional survey was conducted across India, in which 285 questionnaires were sent via e-mail to physiotherapists working in neonatal intensive care units.

RESULTS

A total of 139 completed questionnaires were returned with a response rate of 48.7%, with a majority of responses from Karnataka, Maharashtra and Gujarat. More than 90% of physiotherapists performed chest physiotherapy in neonatal ICUs. Chest physiotherapy assessment predominantly focused on vital parameter assessment (86%) and in treatment predominantly focused on percussion (74.1%), vibration (75.5%), chest manipulation (73.3%), postural drainage (67.6%) and suction (65.4%). In neuromuscular physiotherapy more than 60% of physiotherapists used positioning, and parent education, whereas more than 45% focused on passive range of motion exercise and therapeutic handling.

CONCLUSION

The practice pattern of physiotherapists for neonates in neonatal intensive care units involves both chest physiotherapy as well neuromuscular physiotherapy. Chest physiotherapy assessment focused mainly on vital parameter assessment (heart rate, respiratory rate and partial pressure of oxygen saturation SpO2). Treatment focused on airway clearance techniques including percussion, vibration, postural drainage and airway suction. In neuromuscular physiotherapy most physiotherapists focused on parent education and passive range of motion exercise, therapeutic handling, as well as positioning.

The effects of ‘on-call/out of hours’ physical therapy in acute exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial

Objective: To assess the effectiveness of an on-call physical therapy programme in the management of acute exacerbations of chronic obstructive pulmonary diseases.

Design: Randomized controlled trial.

Setting: Secondary care level, rural hospital.

Subjects: Thirty-eight patients with acute exacerbations of chronic obstructive pulmonary disease.

Interventions: Regular physical therapy and on-call physical therapy was given to two groups of patients with 19 in each arm. On-call physical therapy included providing respiratory physical therapy as required by the patient out of business hours.

Main measures: Peak expiratory flow rate, sustained maximal inspiration, six-minute walk distance and rating of perceived exertion post six-minute walk test.

Results: In the group receiving on-call physical therapy, peak expiratory flow rate and six-minute walk test showed a significant difference (52.1 L/min and 98.16 m, respectively) when compared with the control group (211.57 ± 51.12 L/min and 159.47 ± 67.78 L/min; P =0.01 and 387.89 ± 110.1 m and 289.73 ± 103.2 m; P=0.004 respectively). The difference in peak expiratory flow rate (Δ peak expiratory flow rate) was seen to be more in the on-call group (120 L/min) when compared to the control group (50 L/min), P =0.002. Improvements in sustained maximal inspiration and Borg’s rating of perceived exertion after the six-minute walk test were also observed (P>0.05).

Conclusion: On-call physical therapy brings about a significant increase in peak expiratory flow rates, six-minute walk distance and sustained maximal inspiration.