Physiotherapy Research International Vol 28 Issue 1

Physiotherapy
VOLUME 28, ISSUE 1 January 2023

ISSN 1471-2865
Research
International
14712865, 2023, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pri.1953 by Nat Prov Indonesia, Wiley Online Library on [09/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
EDITOR
PHYSIOTHERAPY Geert Verheyden, University of Leuven, Belgium
RESEARCH DEPUTY EDITORS
INTERNATIONAL Karen Grimmer, University of South Australia, Australia
Gail Jensen, Creighton University, Omaha, USA
Gill Arbane, St. George’s University of London, UK
Lotte Janssens, Hasselt University, Belgium
Peter Malliaras, Monash University, Australia
Seng Kwee Wee, Singapore Institute of Technology, Singapore
EDITORIAL ADVISORY BOARD

Christine Bithell, St George’s Jennifer Jelsma, University of Kathryn Refshauge, University of
Hospital Medical School, Cape Town, South Africa Sydney, Australia
Kingston University, UK Alice Jones, Hong Kong Fiona Reid, King’s College,
Sandra Brauer, University of Polytechnic University, Kowloon, London, UK
Queensland, Brisbane, Australia Hong Kong Karin Harms Ringdahl,
Andrew Butler, Emory University Lester Jones, La Trobe Karolinska Hospital, Stockholm,
School of Medicine, USA University, Victoria, Australia Sweden
Linda Denehy, University of Gwendolen Jull, University of Katherine Shepard, Temple
Melbourne, Australia Queensland, Brisbane, Australia University, Philadelphia, USA
Lorraine de Souza, Brunel Sheila Kitchen, King’s College,
Margot Skinner, Dunedin,
University, UK London, UK
New Zealand
Janine Dizon, University Bart Koes, Institute for Research in
Tori Smedal, Haukeland
of South Australia, Australia Extramural Studies, Amsterdam,
University Hospital, Norway
Brian Durward, Glasgow The Netherlands
Caledonian University, City Brad Stockert, California State
Stanislav Korobov, Odessa, Ukraine
Campus, Glasgow Gert Kwakkel, VU University University, Sacramento, California,
Jennifer Freeman, University of Medical Centre, Amsterdam, USA
Plymouth, UK The Netherlands André Thevenon, Hôpital
Rachel Garrod, Kings College Sheila Lennon, Flinders University, Gériatrique ‘Les Batliers’, Lille, France
Hospital, London, UK Adelaide, South Australia, Australia Sarah Tyson, University of
Leigh Hale, University of Otago, Alice Nieuwboer, Katholieke Manchester, UK
Dunedin, New Zealand Universiteit, Belgium Steven Wolf, Research Center for
Paul Hodges, University of Gita Ramdharry, St George’s Rehabilitation Medicine, Atlanta,
Queensland, Brisbane, Australia University of London, UK USA
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Cover Image © Monkey Business Images/Shutterstock.
Received: 5 January 2022
DOI: 10.1002/pri.1972
RESEARCH ARTICLE
- -
Revised: 24 May 2022 Accepted: 28 August 2022
Effects of continuous aerobic training associated with

resistance training on maximal and submaximal exercise
tolerance, fatigue, and quality of life of patients post‐
COVID‐19
Bruna T. S. Araújo1 | Ana Eugênia V. R. Barros1 | Daiara T. X. Nunes1 |

2 1
Maria Inês Remígio de Aguiar | Viviane W. Mastroianni |
1 3
Juliana A. F. de Souza | Juliana Fernades | Shirley Lima Campos1 |
Daniella Cunha Brandão1 | Armele Dornelas de Andrade1
1
Department of Physiotherapy, Federal
University of Pernambuco, Recife, Brazil Abstract
2
Department of Clinical Semiology of the Background and Purpose: Dyspnea, fatigue, and reduced exercise tolerance are
Medicine Faculty, Federal University of
common in post‐COVID‐19 patients. In these patients, rehabilitation can improve
Pernambuco, Recife, Brazil
3
Laboratory of Physiotherapy and Public
functional capacity, reduce deconditioning after a prolonged stay in the intensive
Health, Department of Physiotherapy, Federal care unit, and facilitate the return to work. Thus, the present study verified the
University of Pernambuco, Recife, Brazil
effects of cardiopulmonary rehabilitation consisting of continuous aerobic and
Correspondence resistance training of moderate‐intensity on pulmonary function, respiratory muscle
Armele Dornelas de Andrade, Department of strength, maximum and submaximal tolerance to exercise, fatigue, and quality of life
Physical Therapy, Federal University of
Pernambuco, Avenida Jornalista Aníbal in post‐COVID‐19 patients.
Fernandes, s/n–Cidade Universitária, Recife Methods: Quasi‐experimental study with a protocol of 12 sessions of an outpatient
CEP: 50740‐560, Pernambuco, Brazil.
Email: armele.andrade@ufpe.br intervention. Adults over 18 years of age (N = 26) with a diagnosis of COVID‐19 and
hospital discharge at least 15 days before the first evaluation were included. Par-
Funding information
ticipants performed moderate‐intensity continuous aerobic and resistance training
Conselho Nacional de Desenvolvimento
Científico e Tecnológico; Coordenação de twice a week. Maximal and submaximal exercise tolerance, lung function, respira-
Aperfeiçoamento de Pessoal de Nível
tory muscle strength, fatigue and quality of life were evaluated before and after the
Superior; Fundação de Amparo a Ciência e
Tecnologia; Initiative “Fazer o Bem Faz Bem”; intervention protocol.
Observatório COVID PROPG/PROPESQI
Results: Cardiopulmonary rehabilitation improved maximal exercise tolerance, with
UFPE 2020
18.62% increase in peak oxygen consumption (VO2peak) and 29.05% in time to
reach VO2peak. VE/VCO2slope reduced 5.21% after intervention. We also observed
increased submaximal exercise tolerance (increase of 70.57 m in the 6‐min walk
test, p = 0.001), improved quality of life, and reduced perceived fatigue after
intervention.
Discussion: Patients recovered from COVID‐19 can develop persistent dysfunc-
tions in almost all organ systems and present different signs and symptoms. The
complexity and variability of the damage caused by this disease can make it difficult
to target rehabilitation programs, making it necessary to establish specific protocols.
In this work, cardiopulmonary rehabilitation improved lung function, respiratory
Physiother Res Int. 2023;28:e1972. wileyonlinelibrary.com/journal/pri © 2022 John Wiley & Sons Ltd. 1 of 9
https://doi.org/10.1002/pri.1972
2 of 9
- ARAÚJO ET AL.
muscle strength, maximal and submaximal exercise tolerance, fatigue and quality of
life. Continuous aerobic and resistance training of moderate intensity proved to be
effective in the recovery of post‐COVID‐19 patients.
KEYWORDS
COVID‐19, exercise tolerance, fatigue, long‐COVID‐19, quality of life, rehabilitation
1 | INTRODUCTION Laboratory of Cardiopulmonary Physiotherapy of the Federal Uni-

versity of Pernambuco. Interventions took place at Physical Therapy
Severe COVID‐19 impairs lung, physical, and mental functions Outpatient Clinic (Post‐ICU Rehabilitation) of Hospital das Clínicas in
(Goërtz et al., 2020). Dyspnea, fatigue, and reduced exercise toler- Pernambuco. The study was approved by the human research ethics
ance are also common in patients post‐COVID‐19 (Cortés‐Telles committee of the Federal University of Pernambuco (number
et al., 2021). The long‐term effects of these symptoms in patients 4.598.136) and registered at clinicaltrials.gov (ID: NCT04767477). All
with acute respiratory syndrome after hospital discharge are called participants signed the informed consent form following resolution
long‐COVID (Iqbal et al., 2021). The National Institute for Health and 466/12 of the Brazilian National Health Council and Declaration of
Care Excellence guideline defines long‐COVID as signs and symp- Helsinki. The study followed CONSORT and Standard Protocol Items:
toms that continue or develop after acute COVID‐19. Includes both Recommendations for Interventional Trials Extension for RCTs
ongoing symptomatic COVID‐19 (4–12 weeks) and post‐COVID‐19 Revised in Extenuating Circumstances (CONSERVE) guidelines
Syndrome (>12 weeks) (Excellence National Institute for Health (Orkin et al., 2021).
and Clinical Excellence, 2022). Adults aged over 18 years, diagnosed with COVID‐19 using
Decreased lung function is associated with damage caused by reverse transcription polymerase chain reaction test and without
both mechanical ventilation and pathophysiology of virus response mental disorders. Patients were admitted with limiting sequelae from
(Cortés‐Telles et al., 2021). Also, prolonged immobility and use of 15 days after hospital discharge or ongoing symptomatic COVID‐19
sedatives are associated with respiratory and peripheral muscle up to 8 weeks of symptom permanence. Those with orthopedic lim-
weakness. All these factors reduce functional capacity and quality of itations and unable to perform cardiopulmonary exercise tests were
life of patients post‐COVID‐19 (Torres‐Castro et al., 2021). excluded.
In this context, rehabilitation is important for treating patients
post‐COVID‐19, especially in those who have been hospitalized. The
benefits of physical exercise in dependence and community reinte- 2.1 | Instruments for data collection
gration of patients are well documented in other populations
(Anderson et al., 2016; Araújo et al., 2019; Rugbjerg et al., 2015). In 2.1.1 | Manovacuometry
patients post‐COVID‐19, rehabilitation may improve functional ca-
pacity, reduce deconditioning after prolonged stay in the Intensive A digital manometer MVD‐300 (Globalmed) assessed respiratory
care unit (ICU), facilitate return to work, and improve quality of life muscle strength. Patients used a nose clip and were instructed to sit
(Wasilewski et al., 2021). with feet flat on floor, erect spine, and no upper limb support.
However, few studies addressed intensity, duration, and effects Maximum inspiratory pressure (MIP) was assessed by performing a
of aerobic and resistance training in patients post‐COVID‐19 (Day- maximal and sustained inspiration from residual volume, whereas
nes et al., 2021; Liu et al., 2020; Mayer et al., 2021). Thus, the present maximal expiration from total lung capacity was performed to assess
study verified the effects of a cardiopulmonary rehabilitation pro- maximum expiratory pressure (MEP). Predicted values for MIP and
gram consisting of continuous moderate‐intensity aerobic and MEP were calculated according to Simões et al. (2010). Patients with
resistance training on lung function, respiratory muscle strength, MIP and MEP values of <70% of predicted were considered with
maximal and submaximal exercise tolerance, fatigue, and quality of inspiratory and expiratory muscle weakness, respectively (Dall’Ago
life of patients post‐COVID‐19. et al., 2006).
2 | METHODS 2.1.2 | Spirometry
This is a quasi‐experimental study performed between March and Lung function was assessed using a portable spirometer (Micro
September 2021 and conducted with a convenience sample of pa- Medical Microloop MK8, England). At least three forced vital capacity
tients post‐COVID‐19. Assessments and data collection, such as (FVC) maneuvers were performed with a two‐minute interval in
clinical history and associated comorbidities, were performed at the between, according to reproducibility and acceptability criteria of the
ARAÚJO ET AL.
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American Thoracic Society (Graham et al., 2019). Forced vital ca- 2.1.7 | Patient global impression of change
pacity, forced expiratory volume in the first second (FEV1) and, FEV1/
FVC were expressed as percentage of predicted for the Brazilian The Patient Global Impression of Change (PGIC) was used to assess
population (De Castro Pereira et al., 2007), while classification of the degree of perceived satisfaction and importance of changes in
ventilatory disorders followed Pereira (2002). health status. Patients can rate improvements associated with the
intervention on a 7‐item scale ranging from 1 (no change) to 7 (a
great deal better and a considerable improvement that has made all
2.1.3 | Cardiopulmonary exercise test the difference) (Dominges & Cruz, 2012).
Maximal functional capacity was assessed using a symptom‐limited

cardiopulmonary exercise test (CPET). Patients performed a ramp 2.1.8 | Intervention protocol
protocol (Weisman et al., 2003) on a treadmill (Centurium 300,
Micromed, Brazil) associated with a 12‐channel electrocardiogram Aerobic training was prescribed between 60% and 80% of VO2peak,
(Micromed, Brazil). The following respiratory variables were assessed assessed using CPET. Exercise was performed on a treadmill for
breath‐by‐breath using a gas analyzer (Cortex—Metalyzer II, Ger- 40 min: 5 min of warm‐up, 30 min of conditioning, and 5 min of cool‐
many) under standard temperature, pressure, and humidity condi- down (Barker‐Davies et al., 2020; Carvalho & Mezzani, 2011).
tions: peak oxygen consumption (VO2peak), VO2 at first ventilatory Resistance training consisted of exercises for upper (triceps, bi-
threshold (VO2AT), ventilatory equivalent of carbon dioxide (VE/ ceps, and shoulder abductors) and lower limb muscles (quadriceps,
VCO2), slope of increase of ventilation relative to carbon dioxide hip abductors, and sural triceps). Exercise load was 60% of one‐
production (VE/VCO2 slope), time to reach the first ventilatory repetition maximum, with load progression every six sessions. Exer-
threshold (TVO2 AT), time to reach VO2peak (TVO2 peak), and recovery cises were performed twice a week in three sets of 8–12 repetitions,
time of 50% of VO2peak (T1/2). and patients were reassessed after 12 sessions.
2.1.4 | Six‐minute walk test 2.1.9 | Statistical analysis
The six‐minute walk test (6MWT) was performed according to the Data analysis was performed using SPSS® software (IBM Corp.,
American Thoracic Society (Crapo et al., 2002). Patients walked as USA), version 20. Shapiro‐Wilk test verified data distribution. Paired
fast as possible in a 30 m corridor, without running, for 6 minutes. t‐test was used to analyze intragroup variables before and after
The test was interrupted if the patient reported dizziness, cramps, intervention. McNemar's test analyzed categorical variables in both
chest pain, severe dyspnea, sweating, or pallor. moments of the study. Cohen's d effect size was calculated and
interpreted as very small (0.1), small (0.2), medium (0.5), and large
(0.8) (Fritz et al., 2012). p‐value < 0.05 (two‐tailed) was considered
2.1.5 | Fatigue Pictogram significant.
Fatigue intensity and its impact after COVID‐19 were assessed

using the Fatigue Pictogram. This is an ordinal scale composed of 3 | RESULTS
two questions with five illustrations to assess fatigue intensity (I can
do everything I usually do; I can do almost everything I usually do; A total of 41 patients started the intervention protocol, however 26
I can do some of the things I normally do; I do what I have to do; patients completed the cardiopulmonary rehabilitation program
I can do very little). Cutoff points for diagnosis or classification (Figure 1). Mean age was 51.73 � 10.41 years, and 46.20% of pa-
of fatigue intensity are not available in the literature (Mota tients were hospitalized in the ICU. Sample characterization is pre-
et al., 2009). sented in Table 1.
Table 2 presents lung function and respiratory muscle strength
data. The percentage of patients with ventilatory disorders and res-
2.1.6 | Short‐form—36 piratory muscle weakness reduced after cardiopulmonary rehabili-
tation program.
The Short‐form—36 was used to assess quality of life. It consists of Maximal exercise tolerance improved with a significant increase
36 items divided into eight subscales: physical functioning, role of 18.62% in VO2peak (19.11 � 4.61 ml·kg−1·min−1 vs. 22.67 �
physical, bodily pain, general health, vitality, social functioning, role 4.81 ml·kg−1·min−1; Cohen's d = 0.76, p < 0.001) and 29.05% in
emotional, and mental health. Final score ranges from 0 to 100, and TVO2peak (397.38 � 165.60s vs. 512.85 � 75.82s; Cohen's d = 0.96,
high scores correspond to better general health status (Ciconelli p = 0.001). VE/VCO2slope also reduced 5.21% (34.90 � 5.13 L/min vs.
et al., 1999). 33.08 � 4.44 L/min; Cohen's d = 0.38, p = 0.011) (Table 2), while
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- ARAÚJO ET AL.
FIGURE 1 Flowchart of study sample
submaximal exercise tolerance increased 70.57 m (419.47 � 119.72 improvement in VO2peak, TVO2peak, and quality of life and reduc-
vs. 490.04 � 7 1.66; Cohen's d = 0.74, p = 0.001) (Figure 2). tion in VE/VCO2slope and fatigue after the intervention.
Quality of life increased in all subscale scores. Physical func- In this study, 39.10% of patients had restrictive and 21.70%
tioning increased 59.37%, role emotional improved 69.49%, and total obstructive ventilatory disorder in the initial evaluation. After
SF‐36 score increased 49.53% (Table 3). intervention, this percentage was reduced due to improvements in
Regarding fatigue after COVID‐19, 36% of patients reported be- FVC and predicted percentage of FEV1. Respiratory muscle weakness
ing “A little bit tired” and 32% “Moderately tired”, whereas only 12% was also reduced, with significant increase in MEP. Lung function
reported “I can do everything I normally do”. After cardiopulmonary improved after 6 weeks of respiratory rehabilitation in a clinical trial
rehabilitation program, 36% of patients reported being “Not at all conducted with older adults post‐COVID‐19 (Liu et al., 2020).
tired” and 28% reported “I can do everything I normally do” (Figure 3). Moreover, similar effects have been reported in patients with chronic
According to PGIC, 65.4% of patients reported “Better, and a obstructive pulmonary disease, indicating aerobic and resistance
definitive improvement that has made a real and worthwhile training improve respiratory muscles strength (Chiu et al., 2020;
difference“. Lee & Kim, 2019). Therefore, increased ventilation provided by
physical training may affect respiratory muscles, increasing oxidative
fibers and oxidative enzyme activity (Decramer, 2009).
4 | DISCUSSION Regarding maximal exercise tolerance, VO2peak, TVO2peak, and
VE/VCO2slope increased after rehabilitation. These are considered
This is the first study investigating the effects of a cardiopulmonary significant predictors of mortality and hospitalization related to heart
rehabilitation program consisting of continuous moderate‐intensity disease (Arena et al., 2004). Clavario et al. (2021) highlighted the
aerobic and resistance training in patients post‐COVID‐19. This importance of evaluating VO2peak and TVO2peak in a study that
program improved respiratory muscle strength, lung function, exer- assessed patients with COVID‐19 3 months after hospital discharge.
cise tolerance, fatigue, and quality of life. We highlight the significant Authors observed that VO2peak was below 85% of predicted (mean
ARAÚJO ET AL.
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TABLE 1 Clinical variables of patients post‐COVID‐19 T A B L E 2 Lung function, respiratory muscle strength, and
cardiopulmonary exercise test (CPET) before and after
Variablesa n = 26
cardiopulmonary rehabilitation
Age (years) 51.73 � 10.41
Pre‐ Post‐
Sex (% males) 53.80 rehabilitation rehabilitation
Variablesa (n = 26) (n = 26) p
Weight (kg) 86.51 � 20.18
Pulmonary function
Height (m) 1.64 � 0.07
FEV1 (%) 68.50 � 15.18 84.32 � 19.17 0.008
BMI (kg/m2) 31.72 � 6.51
FVC (%) 81.27 � 18.64 84.73 � 17.09 0.249
Comorbidities
FEV1/FVC (%) 88.86 � 21.84 99.32 � 18.00 0.090
Hypertension (%) 61.50
Ventilatory disorder
Diabetes (%) 23.10
Obstructive (%) 21.70 4.50 0.102
Obesity (%) 53.80
Restrictive (%) 39.10 36.40 0.102
Lung diseases (%) 26.90
Respiratory muscle strength
CKD (%) 7.70
MIP (cmH2O) 78.20 � 25.14 85.36 � 27.29 0.111
Hospitalized
Inspiratory muscle 26.90 4.00 0.070
Nursery (%) 23.10
weakness (% of
ICU (%) 46.20 patients)
Not hospitalized (%) 30.80 MEP (cmH2O) 87.56 � 34.09 102.28 � 43.65 0.009
Abbreviations: BMI, Body mass index; CKD, Chronic kidney disease; Expiratory muscle 3.80 0 *
ICU, Intensive care unit. weakness (% of
a
Variables presented as mean � standard deviation. patients)
Cardiopulmonary exercise test
VO2peak 19.11 � 4.61 22.67 � 4.81 <0.001

of 17.7 ml·kg−1·min−1) in almost one‐third of patients and increased
(ml·kg−1·min−1)
significantly in approximately half of survivors (Clavario et al., 2021).
VO2AT (ml·kg−1·min−1) 13.96 � 3.35 15.13 � 3.57 0.850
Patients in our study also presented mean VO2peak below
20 ml·kg−1·min−1 in the initial assessment, which increased VE/VCO2 (L/min) 31.18 � 3.98 29.08 � 5.45 0.650
−1 −1
3.56 ml·kg ·min (18.62%) after intervention. In adult males, an VE/VCO2 slope (L/min) 34.90 � 5.13 33.08 � 4.44 0.011
increase of 3.5 ml·kg−1·min−1 (1 Metabolic Equivalent) may corre-
TVO2 peak (s) 397.38 � 165.60 512.85 � 75.82 0.001
spond to a 12% improvement in survival (Arena et al., 2004; Myers
TVO2 AT (s) 228.50 � 120.12 269.44 � 71.50 0.061
et al., 2002; Trevizan et al., 2021).
On the other hand, high VE/VCO2slope values, especially ≥34, T1/2 (s) 135.95 � 45.50 139.77 � 28.18 0.626
may indicate worse prognosis (Arena et al., 2004; Arena et al., 2003). Note: * Computed only for a PxP table, where p must be greater than 1.
In our study, mean VE/VCO2slope was 34.90 before intervention and Abbreviations: AT, anaerobic threshold; CPET, cardiopulmonary
reduced 5.21% after 12 training sessions. A decrease in these vari- exercise test; FEV1, forced expiratory volume in the first second; FVC,
forced vital capacity; MEP, maximal expiratory pressure; MIP, Maximal
ables was also observed in patients with heart failure after 4 weeks
inspiratory pressure; T1/2, time for a 50% drop in VO2 measured at
of physical training (Gademan et al., 2008) and after 12 weeks of peak exercise; time, to oxygen consumption at anaerobic threshold;
aerobic training (Fu et al., 2013). TVO2, AT; TVO2peak, time to peak oxygen consumption; VE/VCO2,
A change of 14–30.5 m in the 6MWT is considered clinically ventilation to carbon dioxide production; VE/VCO2slope, ventilation to
carbon dioxide production slope; VO2, oxygen consumption.
important in patients with cardiopulmonary diseases (Bohannon &
a
Variables presented as mean � standard deviation.
Crouch, 2017). In our study, patients increased 70.57 m in the dis-
tance walked after 12 sessions of aerobic and resistance training. A
6‐week pulmonary rehabilitation program also improved distance and depression are common after COVID‐19 and may persist for
walked in older adults with post‐COVID‐19 (Liu et al., 2020). A case 6 months after COVID‐19 infection (Huang et al., 2021). In our study,
study with one patient post‐COVID‐19 showed an increase of 199 m most patients reported slight or moderate tiredness before rehabil-
in the distance walked in the 6MWT after 15 rehabilitation sessions itation. A total of 36% of patients also answered “I can do some of the
(Mayer et al., 2021). These results demonstrate the benefits of aer- things that I usually do”. After intervention, a higher percentage of
obic training, which improves skeletal muscle properties and increase patients reported feeling “not tired at all” and “I can do almost
physical fitness (Nambi et al., 2021). everything that I usually do”. Similarly, a 6‐week supervised reha-
Adaptations caused by exercise may impact fatigue and activities bilitation program improved fatigue symptoms (Daynes et al., 2021).
of daily living of patients post‐COVID‐19. Fatigue, insomnia, anxiety, The same was observed in a case series with patients post‐COVID‐
6 of 9
- ARAÚJO ET AL.
19, in which most did not report fatigue or only reported very light daily activities, may impact quality of life (Halpin et al., 2021). All SF‐
exertion after the exercise program (Ferraro et al., 2021). 36 domains improved after rehabilitation, indicating better quality of
Manifestations presented by patients post‐COVID‐19, such as life. Similar results were observed after a 6‐week pulmonary reha-
reduced lung function, exercise intolerance, fatigue, and difficulties in bilitation program in patients post‐COVID‐19 (Liu et al., 2020) and an
8‐week aerobic training program in elderly adults with sarcopenia
after COVID‐19 infection (Nambi et al., 2021).
Regarding perception of clinical change, a higher percentage of
patients chose an answer to number six on the scale, which considers
“Better, and a definite improvement that has made a real and
worthwhile difference”. Another study found an association between
clinical improvement and reduced risk of future clinical events in
patients with heart failure (Luo et al., 2019). The findings on clinical
perception reinforce the benefits of physical training for patients
included in rehabilitation programs.
4.1 | Limitations
Strenuous circumstances changed the study design during the

COVID‐19 pandemic. Functional impairments of many patients dur-
ing initial screening, reduced number of patients, and insecurity of
F I G U R E 2 Distance walked before and after cardiopulmonary patients in attending to or using public transport to reach the hos-
rehabilitation pital affected sample size and limited randomization and recruitment
T A B L E 3 Quality of life before and

Variablesa Pre‐rehabilitation (n = 26) Post‐rehabilitation (n = 26) p
after cardiopulmonary rehabilitation
Physical functioning 40.00 � 24.58 63.75 � 24.14 <0.001
Role physical 10.42 � 19.38 39.58 � 39.64 0.004
Bodily pain 47.50 � 29.99 61.96 � 24.22 0.006
General health 44.50 � 24.83 65.25 � 23.94 <0.001
Vitality 46.88 � 27.21 65.63 � 20.17 <0.001
Social functioning 48.88 � 31.05 71.25 � 27.79 0.001
Role emotional 31.96 � 42.28 54.17 � 40.36 0.015
Mental health 63.00 � 25.76 76.67 � 21.02 <0.001
Total score 333.13 � 182.10 498.13 � 159.21 <0.001

a
Variables presented as mean � standard deviation.
FIGURE 3 Comparison between feeling of fatigue (a) and impact of fatigue (b) before and after intervention
ARAÚJO ET AL.
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of a control group. Therefore, we extended the data collection period, P E R M I S S I O N T O R E P R O DU C E M A T E R I A L F R O M OT H E R

provided financial assistance for patients to reach the outpatient SOURCES
clinic, and modified the data analysis plan. Furthermore, length of Not applicable.
hospital stay could not be stratified.
Although we know that COVID‐19 can have repercussions on STUDY REGISTRATION
lung function, the sample of the present study showed a percentage The study was registered at clinicaltrials.gov (ID: NCT04767477).
of obese individuals and individuals with lung diseases. These data
may be a limitation to determine the real impacts of COVID‐19 on OR CI D
the initial characterization of the sample. Bruna T. S. Araújo https://orcid.org/0000-0001-7754-4397
Several issues regarding COVID‐19, including symptoms and Ana Eugênia V. R. Barros https://orcid.org/0000-0001-8495-9865
post‐COVID‐19 repercussions, are still poorly understood and need Daiara T. X. Nunes https://orcid.org/0000-0002-8806-8151
further studies for better clarification. The exercise program per- Maria Inês Remígio de Aguiar https://orcid.org/0000-0001-8497-
formed in the present study probably contributed to the improve- 0415
ment of the patients, but other factors should also be taken into Viviane W. Mastroianni https://orcid.org/0000-0003-3723-2166
account, such as the functional adaptations and the natural evolution Juliana A. F. de Souza https://orcid.org/0000-0002-1236-0340
of the condition presented by the patients. Juliana Fernades https://orcid.org/0000-0002-7509-8853
Shirley Lima Campos https://orcid.org/0000-0003-3079-8300
Daniella Cunha Brandão https://orcid.org/0000-0001-8805-6815
5 | CONCLUSION Armele Dornelas de Andrade https://orcid.org/0000-0001-9430-
4395
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moderate‐intensity aerobic and resistance training is effective for R E F E R E NC E S
patients post‐COVID‐19. Rehabilitation improved lung function, Anderson, L., Oldridge, N., Thompson, D. R., Zwisler, A. D., Rees, K.,
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A C K N O WL ED GM E N T S
uous training on functional capacity in individuals with heart failure.
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English revision and editing. This study was financed in part by CNPQ 293–298. https://doi.org/10.1097/hcr.0000000000000424
(421756/2021‐7, 40334/2020‐5, 428841/2018‐0) and Coordenação Arena, R., Humphrey, R., & Peberdy, M. A. (2003). Prognostic ability of VE/
VCO2 slope calculations using different exercise test time intervals
de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) Finance
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2020 and FACEPE APQ 0801–4.08/21and APQ 0249–4.08/20. We 74402.5b
also acknowledge the JBS S.A. initiative “Fazer o Bem Faz Bem” for Arena, R., Myers, J., Aslam, S. S., Varughese, E. B., & Peberdy, M. A. (2004).
Peak VO2 and VE/VCO2 slope in patients with heart failure: A
the financial support.
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Received: 9 September 2021
DOI: 10.1002/pri.1976
RESEARCH ARTICLE
- -
Revised: 30 March 2022 Accepted: 9 October 2022
People with mild Parkinson's disease have impaired force

production in upper limb muscles: A cross‐sectional study
Renee Salmon1 | Elisabeth Preston1 | Niruthikha Mahendran1 | Louise Ada2 |

1
Allyson Flynn
1
Faculty of Health, University of Canberra,
Canberra, Australia Abstract
2
Faculty of Health Sciences, University of Background: There has been little examination of force production of the upper
Sydney, Lidcombe, Australia
limb in people with Parkinson's disease (PD), despite its impact on activities of daily
Correspondence living and clear evidence that force production is significantly reduced in lower limb
Elisabeth Preston, Faculty of Health, muscle groups. The aim of this study was to determine the force production of the
University of Canberra, Canberra, Australia.
Email: Elisabeth.preston@canberra.edu.au major muscle groups of the upper limb in people with PD during the “on” phase after
medication, compared with aged‐matched neurologically‐normal controls.
Present address
Method: A cross‐sectional study was carried out.
Niruthikha Mahendran, University of
Queensland, Queensland, Australia. Participants: Thirty people with mild PD (Hoehn Yahr mean 1.1) and 24 age‐
matched neurologically‐normal controls.
Funding information
Open access publishing facilitated by Outcome measures: Maximum isometric force production of the shoulder flexors,
University of Canberra, as part of the Wiley ‐ extensors, abductors, adductors, internal rotators and external rotators, elbow
University of Canberra agreement via the
Council of Australian University Librarians. flexors and extensors, wrist flexors and extensors and hand grip using dynamometry.
Results: There was a significant impairment in force production in all upper limb
muscle groups, compared with control participants, except in the wrist flexors. On
average the deficit in force production was 22%, despite people with PD having mild
disease, being physically active and being measured during the “on” phase of medi-
cation. The most severely affected muscle groups were the upper limb extensors.
Conclusion: People with PD have a significant deficit in force production of the
upper limb muscle groups compared with age‐matched neurologically normal
controls.
Clinical Implications: Regular assessment of strength of the upper limb should be
considered by clinicians and strengthening interventions could be implemented if a
deficit is identified.
KEYWORDS
muscle strength, Parkinson disease, rehabilitation, upper extremity
This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.
© 2022 The Authors. Physiotherapy Research International published by John Wiley & Sons Ltd.
Physiother Res Int. 2023;28:e1976. wileyonlinelibrary.com/journal/pri 1 of 6

2 of 6
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1 | INTRODUCTION 2 | METHOD
Parkinson's disease (PD) affects approximately 7 million people 2.1 | Design

worldwide and is the second most common neurodegenerative dis-
ease, after Alzheimer's disease (De Lau & Breteler, 2006; Pring- A cross‐sectional study was carried out. People with PD recruited
sheim & Frolkis, 2014). The common motor impairments associated from a physiotherapy clinic in Canberra, Australia, were compared
with PD include bradykinesia, balance impairment, tremor and ri- with neurologically‐normal age matched control participants
gidity. However, it has become clear that a significant impairment in recruited from the community. Force production of upper limb
force production of muscle groups in the lower limb is also evident, muscle groups was measured during one session at a university
even in people with mild PD (Salmon et al., 2021; Skinner laboratory. Participants with PD were measured during their “on”
et al., 2019). Force production is important because of its contribu- phase of medication. Ethical approval was obtained from the Uni-
tion to power, which is required to effectively complete many daily versity Human Ethics Committee (16‐220) and all participants pro-
activities, for example, walking, house work and gardening (Lundg- vided written informed consent prior to measurement.
ren‐Lindquist, 1983).
All the major muscle groups of the lower limb have been exam-
ined in relation to force production (Salmon et al., 2021; Skinner 2.2 | Participants
et al., 2019), with an average deficit of 22% evident across 12 major
lower limb muscle groups in people with mild PD compared with People with PD were eligible to participate if they were over
healthy controls (Salmon et al., 2021). However, only three muscle 40 years old, could walk 10 m with or without a walking aid, and had
groups in the upper limb have been tested (Jones et al., 2017; Pang & not changed levodopa medication in the previous 6 weeks. Control
Mak, 2009; Robichaud et al., 2004; Roland et al., 2013). Grip force participants were eligible to participate if they were over 40 years
has been investigated in three studies of people with PD (H&Y = 2.2 old and could walk 10 m at as speed of at least 1.2 m/s with or
out of 5) and compared with age‐matched healthy controls, and an without an aid. Participants (PD and control) were excluded if they
average deficit in force production of 16% (i.e. 84% of healthy con- had significant cognitive impairment (<24 on the Mini Mental State
trols) was found (Jones et al., 2017; Pang & Mak, 2009; Roland Examination), or if they had any co‐morbidities that could influence
et al., 2013). The force production of the elbow flexors and elbow force production of the upper limb muscle groups (e.g., previous
extensors have only been examined in one study, and an average stroke, shoulder injuries). Demographic information was recorded for
deficit in force production of 25% (i.e. 75% of healthy controls) was all participants, including age, sex, height, weight, and hand domi-
found in the flexors and 31% (i.e. 69% of healthy controls) was found nance. Time since diagnosis, Hoehn & Yahr stage of disease, medi-
in the extensors (Robichaud et al., 2004). cations, time since last dose and walking speed were also recorded to
Given that only three of the major upper limb muscle groups describe participants with PD.
have been examined, and that other muscle groups, including the
shoulder flexors and abductors, and wrist flexors, have been found to
be correlated with effective upper limb use in other populations 2.3 | Outcome measures
(Harris & Eng, 2007; Mercier & Bourbonnais, 2004), the aim of this
study was to investigate the isometric force production of all major Maximum isometric force production of the upper limb muscle
upper limb muscle groups in people with PD using hand‐held dyna- groups was measured in Newtons using hand‐held dynamometry.
mometry. Isometric strength testing is needed to examine force Hand‐held dynamometry can be easily implemented in a clinical
production without the influence of bradykinesia. Measuring context, and is a valid and reliable measure of force production in
strength throughout movement (i.e. isokinetic testing) in people with people with neurological conditions (Bohannon, 1986; Kolber &
PD may be confounded by bradykinesia, and therefore can result in Cleland, 2005). Eleven upper limb muscle groups were measured:
an underestimate of force production (Allen et al., 2009; Cano‐De‐ shoulder flexors, extensors, abductors, adductors, internal rotators
La‐Cuerda et al., 2010; Nogaki et al., 2001; Yanagawa et al., 1990). and external rotators, elbow flexors and extensors, wrist flexors and
Maximal isometric strength testing on the other hand, does not extensors and whole hand grip. For all muscle groups, except grip,
involve limb movement, and when performed with enough time, al- force production was measured with participants in supine, with the
lows for measurement of force production that is not influenced by upper limb stabilized on the plinth and the shoulder at 45 degrees of
bradykinesia in people with PD. The research question, therefore, abduction. The testing protocol was based on standardized posi-
was: what is the force production of the major muscle groups tioning for hand‐held dynamometry (Andrews et al., 1996). Force
(shoulder flexors, extensors, abductors, adductors, internal rotators production was measured using a “make” test, where participants
and external rotators, elbow flexors and extensors, wrist flexors and exerted maximum force against the tester for 4–5 s or until a plateau
extensors and grip) of the upper limb in ambulatory people with PD in force was reached (Bohannon, 1986). Grip force was measured
during the “on” phase after medication, compared with aged‐matched using a Saehan grip dynamometer with participants in a seated po-
neurologically‐normal controls? sition. The best of two attempts was recorded for statistical analysis
SALMON ET AL.
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for each muscle group. All measures were completed by one 3.2 | Difference in force production between
researcher (RS). groups
Table 2 presents between group differences, 95% CIs and the force
2.4 | Data analysis production of people with PD as a percentage of healthy controls.
There was a significant impairment in force production in participants
Descriptive statistics were used to examine the characteristics of with PD in all muscle groups, except the wrist flexors when compared
participants with PD and healthy controls. The average force pro- with control participants. The force production of participants with
duction of the left and right sides was used to create a single value PD was, on average, 78% (SD 8%) of control participants. The most
of force production for each muscle group, to take into account both severely affected muscle groups were the upper limb extensors:
dominance and asymmetry. A univariate general linear model anal- shoulder extensors (68%), wrist extensors (71%) and elbow extensors
ysis was used to compare force production between participants (73%).
with PD and control participants. Sex and group were entered as
fixed effects and body weight and age were entered as covariates.
The adjusted means (SD) for each muscle group are reported. The 4 | DISCUSSION
mean difference between groups and 95% confidence interval (CI)
were calculated using the adjusted means. Furthermore, the force This study examined maximum isometric force production of 11
production of each muscle group in participants with PD was upper limb muscle groups in people with PD compared with
calculated as a percentage of the force production in control par- neurologically‐normal age‐matched controls. There was a significant
ticipants. The sample size of 24 for each group was determined to loss of strength in all upper limb muscle groups, except the wrist
detect a 20 N difference in force production between participants flexors, in people with PD when compared with neurologically‐
with PD and control participants at a significance level of 0.05% and normal older adults. The average impairment in force production of
80% power. participants with PD was 22% (SD 8%) of that of control participants,
with the shoulder, elbow and wrist extensors being the most severely
affected. This impairment in force production was evident despite
3 | RESULTS participants with PD having mild disease severity and a relatively
short time since diagnosis.
3.1 | Flow of participants through the study Our findings are consistent with the findings from the few other
muscles (i.e., grip, elbow flexors and elbow extensors) examined in
Thirty people with PD and 24 control participants were included other studies of the upper limb in people with PD (Jones et al., 2017;
(Table 1). The two groups were similar for age, sex, height, weight and Pang & Mak, 2009; Robichaud et al., 2004; Roland et al., 2013). We
hand dominance. Participants with PD had mild disease, as evidenced found a 20% deficit in grip strength, which is slightly higher than the
by their Hoehn and Yahr score of 1.1 out of 5, their walking speed of deficit found by Roland et al. (2013) (15%) and Pang and Mak (2009)
1.4 m/s and stride length of 1.4 m. (13%), and consistent with Jones et al. (2017) (21%). In terms of the
TABLE 1 Participant characteristics

Characteristic PD (n = 30) Control (n = 24)
Age (yr), mean (SD) 69 (8) 69 (6)
Sex, n male (%) 20 (66) 15 (63)
Height (cm), mean (SD) 170 (9) 173 (9)
Weight (kg), mean (SD) 75 (13) 77 (12)
Hand dominance, n right (%) 30 (100) 22 (92)
Walking speed (m/s), mean (SD) 1.4 (0.2) N/A
Stride length (m), mean (SD) 1.4 (0.2) N/A
Affected side, n right (%), n = 21 15 (75) N/A
Time since diagnosis (yr), mean (SD) 4.0 (3.2) N/A
Levodopa medication, n taking (%) 29 (97) N/A
Time since last medication (hr), mean (SD) 3.0 (2.8) N/A
Hoehn and Yahr stage (1–5), mean (SD) 1.1 (0.7) N/A
Abbreviations: N/A, not applicable; PD, Parkinson's disease; SD, standard deviation.
4 of 6
- SALMON ET AL.
T A B L E 2 Mean (SD) maximum

PD Control Between‐group difference PD as a percentage of
isometric force production (N) of each
Muscle group (n = 30) (n = 24) PD minus control the control group
muscle for both groupsa and mean (95%
Shoulder flexors 89 (27) 109 (25) −20 (−34 to −5), p = 0.008 82 CI) difference between groups
Shoulder extensors 104 (35) 153 (33) −49 (−68 to −31), p ≤ 0.001 68
Shoulder abductors 94 (26) 109 (123) −15 (−28 to −1), p = 0.04 86
Shoulder adductors 97 (32) 129 (30) −32 (−49 to −16), p ≤ 0.001 75
Shoulder internal 108 (33) 136 (32) −28 (−45 to −10), p = 0.003 79
rotators
Shoulder external 78 (25) 104 (23) −26 (−39 to −13), p ≤ 0.001 75

rotators
Elbow flexors 150 (41) 189 (39) −39 (−60 to −17), p = 0.001 79
Elbow extensors 96 (35) 132 (33) −35 (−54 to −17), p ≤ 0.001 73
Wrist flexors 76 (17) 80 (17) −3 (−13 to 6), p = 0.48 95
Wrist extensors 65 (19) 91 (18) −26 (−36 to −16), p ≤ 0.001 71
Grip 286 (69) 359 (66) −73 (−110 to −37), p ≤ 0.001 80
Abbreviations: CI, confidence interval; N, Newtons; PD, Parkinson's disease; SD, standard deviation.
a
Adjusted for age, sex and weight.
force production of the elbow flexors and extensors, the participants average deficit we found in lower limb muscle groups (22%, SD
in our sample had a deficit of 21% and 27% respectively, compared 6%) (Salmon et al., 2021). This is unlike other neurological condi-
with 25% and 31% found by Robichaud et al. (2004). The slightly tions, such as stroke, where the prevalence and extent of impair-
smaller deficit in our sample may be accounted for by our partici- ment in force production are greater for the upper limb than the
pants having mild disease severity, rather than moderate disease lower limb (Tyson et al., 2006). This suggests that force production
severity. of both the upper limb and lower limb require assessment in
Impaired strength is generally considered a secondary impair- people with PD.
ment of PD, that occurs as a result of physical inactivity and If left to develop, a deficit in force production may become large
muscular disuse (Canning et al., 2006; Morris, 2000; Nimwegen enough to impact on performance of activities, especially those ac-
et al., 2011; Pedersen et al., 1991; Rossi et al., 1996). However, the tivities requiring power, such as housework and gardening (Lundg-
participants in our study were relatively young, had a short time ren‐Lindquist, 1983). As such, force production of the upper limb
since diagnosis and had mild disease severity suggesting that the muscles should be monitored, and strength training could be imple-
weakness in this population is not necessarily due to disuse. Central mented to delay the development of a clinically significant impair-
mechanisms related to the pathophysiology of PD (such as an ment in force production. Several systematic reviews have found that
inability to activate agonist muscles and control antagonist muscles strength training is effective in improving both force production and
appropriately as a result of basal ganglia dysfunction) have been performance of activities in people with PD (Lima et al., 2013; Roeder
hypothesized to contribute impaired strength (Kakinuma et al., 2015).
et al., 1998; Moreno Catala et al., 2013; Pääsuke et al., 2004; This study has some limitations. Participants did not complete a
Yanagawa et al., 1990). We found weakness during the “on” phase familiarization test prior to measurement, which may have resulted in
of medication, so it is possible that a malfunction in another area of submaximal force production in some. However, all participants had
the central nervous system, rather than the basal ganglia, may also two attempts at producing a maximum contraction, and force pro-
be contributing to this strength deficit. duction on the second attempt was not consistently higher than the
All participants with PD were measured during the “on” phase first, suggesting that this was not the case. People with PD and
of medication. They had mild PD, reflected in their low Hoehn and control participants were matched for age, sex and physical measures
Yahr score and normal walking speed. They were attending phys- such as height and weight, but not for socio‐economic status. Socio‐
iotherapy at least once per week and undertook regular physical economic status is a potential confounder because it is strongly
activity outside of these sessions. Despite this, people with PD had correlated with health outcomes in Australia (Turrell & Math-
a 22% impairment in force production relative to their counter- ers, 2000). However, all participants were recruited from a city with a
parts. The most severely affected muscle groups were the exten- high socioeconomic index with little variability (Pink, 2013). People
sors at each joint, which all had deficits of over 25%. The average with PD were measured during the “on” phase of medication to
deficit in force production in the upper limb is the same as the minimize the impact of other motor impairments during testing, and
SALMON ET AL.
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Received: 4 January 2022
DOI: 10.1002/pri.1977
RESEARCH ARTICLE
- -
Revised: 20 July 2022 Accepted: 9 October 2022
From passenger to citizen—portraits of learning to be a

physiotherapist
Sarah Barradell1,2
1
Department of Nursing and Allied Health,
Swinburne University, Hawthorn, Victoria, Abstract
Australia
Background and Purpose: Understanding the experiences of learners—and future
2
Sydney School of Education and Social Work,
graduates—is integral to their professional development and to the development of
University of Sydney, Sydney, New South
Wales, Australia the profession. This paper adds to understanding of physiotherapy student expe-
riences by exploring the ways students and recent graduates approach, learn about,
Correspondence
Sarah Barradell, Department of Nursing and connect with and form a relationship with their chosen profession of physiotherapy.
Allied Health, Swinburne University, Methods: Heuristic inquiry, a form of phenomenology, was used. Thirteen partici-
Hawthorn, VIC 3122, Australia.
Email: sbarradell@swin.edu.au pants (11 students and 2 new graduates) were interviewed.
Results: The findings are presented as four portraits: passenger, tourist, resident and
Funding information
citizen. These represent four particular and prominent ways that the participants
Open access publishing facilitated by
Swinburne University of Technology, as part of connected with specific situations and/or to the profession as a whole, the sense
the Wiley ‐ Swinburne University of
they made of those situations (or the broader profession) and the identity formed.
Technology agreement via the Council of
Australian University Librarians. Discussion: The portraits help educators to think about how students are navigating
the process of becoming a physiotherapist and might act as a tool to help foster
students' professional development. Educators who understand students' motiva-
tions and struggles are better prepared to help students to see themselves and the
profession in sophisticated ways.
KEYWORDS
becoming, experiences, professional development, student
1 | INTRODUCTION that its main purpose is learner preparation and competency, despite
a range of researchers highlighting the limitations (i.e. lacking clear
While physiotherapy education has evolved in terms of adopting meaning and shared understanding, narrow focus) of both (Atkin-
new educational strategies, different degree structures and addi- son & McIlroy, 2016; Barradell, 2017; Burford & Vance, 2014;
tional learning environments, the purpose of physiotherapy educa- Chesterton et al., 2021; Ottrey et al., 2021; Reeves et al., 2009; Zou
tion has been slower to change. The World Confederation for et al., 2021). While the COVID‐19 pandemic was a catalyst to teach
Physical Therapy (WCPT) (2019) states that the goal of physio- and work differently, especially with more use of technology through
therapy education is to ‘facilitate the continuing intellectual, pro- necessity, very few physiotherapy initiatives strayed from traditional
fessional and personal development of students….’, yet the profession‐bound experiences (Maric & Nicholls, 2020). A key aim of
curriculum the WCPT describes is very much centred around physiotherapy education remains the graduation of safe, profes-
traditional knowledge and skills. Physiotherapy education, and sionally capable practitioners ready for their first day of clinical
indeed health professional education generally, has often advanced work.
This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.
© 2022 The Authors. Physiotherapy Research International published by John Wiley & Sons Ltd.
Physiother Res Int. 2023;28:e1977. wileyonlinelibrary.com/journal/pri 1 of 9

2 of 9
- BARRADELL
Physiotherapy education involves supporting students to learn satisfaction with new educational activities or their perspectives of
the implicit and explicit practices of their chosen profession. These areas of practice such as resilience, ethical dilemmas and clinical
practices reflect the ways of knowing and doing that the profession reasoning. Research directed at understanding students' overall
holds in esteem (Barradell et al., 2018, 2021). Professional identity is educational experience of becoming a physiotherapist is less com-
formed along the way but there are different theories as to how that mon, yet this work is critical for physiotherapy education because it is
might happen (Leedham‐Green et al., 2020). One is through social- better able to gauge its outcomes and impact, and to most effectively
isation. As students interact with others and learn about their place meet contemporary demands. It is a complex space of inquiry; there
within the profession, they become enculturated to the norms and is no single definition about physiotherapy formation and it includes
values of the social surroundings. Through this lens, learning to concepts such as professionalism, professional values, identity, roles
become a physiotherapist is a social practice, and physiotherapy ed- and development pathways (Rappazzo et al., 2022) yet these are not
ucators and researchers are increasingly embracing sociocultural homogenous constructs (Trede, 2012; Trede et al., 2012). The body
theories of learning, such as communities of practice, to engage of work that focuses on students' overall educational experiences
students in experiences that enable them to join the professional within physiotherapy is small and diverse. Previous studies have
community (O'Brien & Battista, 2020) but also to advocate and lead it provided insights on how physiotherapy students' university learning
(Barradell, 2021; Trede & McEwen, 2016; Tshoepe & Goulet, 2017). experiences impact their engagement with their study (Hamshire &
However, another school of thought is that learning fundamentally Wibberley, 2014), new students' expectations of being a physio-
changes people and who they are. More and more, engaging students therapist (Richardson et al., 2002), the focus of physiotherapy stu-
in educational experiences that form and transform are necessary to dents' learning experiences (Lindquist et al., 2006a; Lindquist
develop the capabilities that graduates require in an increasingly et al., 2010), professional identity (Lindquist et al., 2006b) and
complex, ambiguous world. In this view, graduates become contrib- development pathways (Korpi et al., 2014; Kurunsaari et al., 2018,
uting members of society and the best versions of themselves they 2021).
can be (e.g. Barnett, 2004; Barradell, 2017; Biesta & Braak, ; Dal- This study adds to the understanding of physiotherapy student
l’Alba, 2009; Halman et al., 2017; Higgs, 2013; Horton, 2010; Trede & experiences by exploring the ways a selection of students and recent
McEwen, 2016; Tshoepe & Goulet, 2017). The emphasis has shifted graduates approach, learn about and connect with learning to
towards learning to be a physiotherapist in society, rather than become a physiotherapist. The study reflects contemporary un-
learning to be ‘like one’. derstandings of the intersubjectivities of practice (Dall’Alba &
For accrediting bodies, institutions and educators (academics and Sandberg, 2006) as it focuses on the students themselves, but at the
clinically based supervisors), substantial effort goes into the ‘why’— same time the curriculum and practice (i.e. context) comes in and out of
questions of the purpose (i.e. meeting the healthcare demands of the foreground. It also highlights the kinds of relationships students
individuals and communities, addressing practice standards); the are forming with their chosen profession of physiotherapy, through
‘what’—matters of content (i.e. theoretical knowledge, practical skills, physiotherapy education. The insights from this research are inten-
clinical reasoning) and 'the how’ (i.e. teaching and pedagogical prac- ded to support physiotherapy bodies and educators rethink the
tices) of physiotherapy education. There has arguably been less shape of the curriculum, and to shift the intersection between stu-
consistent attention on ‘the who’ (i.e. learners), yet learners—who dents, universities and clinical experiences for future generations of
they become—are the real outcome of physiotherapy education. practitioners.
Understanding the experiences of learners—and future graduates—is
therefore critical to helping students develop both professionally and
personally and also to shaping the future of the profession. To work 2 | METHODS
in a complex, ambiguous world requires that graduates learn how to
be emotionally intelligent, socially responsible, agentic, imaginative, 2.1 | Design
courageous, empowered and reflective. These skills and dispositions
require graduates to know themselves as much as they know pro- This study is part of a larger heuristic phenomenologically oriented
fessional theory and skills and to develop a feel for their contribution inquiry (Moustakas, 1990, 1995) that explored how physiother-
to practice and the profession. Physiotherapy educators who have a apy practice was experienced through physiotherapy education
rich and nuanced understanding of the development and growth of (Barradell, 2020). Heuristic inquiry focuses on: experiences of a
their learners are better prepared to support learners to achieve phenomenon; the meaning and significance attributed to those
these educational goals and transition to professional life. Contem- experiences by those experiencing it; and prolonged periods of
porary higher education approaches (i.e. Blackie et al., 2010; Healey reflection and analysis from the researcher (Finlay, 2012). Heuristic
et al., 2014) position students and educators alongside each other inquiry presents experiences of the phenomenon and/or participants
but this can only begin to happen when staff take steps to understand in four sequential but different ways (Table 1) to develop a layered
learners, their concerns, struggles, hopes and beliefs. understanding of the phenomenon. Each way of presenting these
Physiotherapy students are increasingly approached to offer experiences is a move away from the original raw data and has a
feedback and act as data sources, especially to gauge their particular analytical intention. Individual depictions are ‘closest’ to
BARRADELL
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TABLE 1 Heuristic inquiry's forms of data representation and their analytical intention (Moustakas, 1990)
1. Individual depiction 2. Composite depiction 3. Exemplary portraits 4. Creative synthesis
� focuses on an individual's story/ � represents the totality of partic- � focuses on select individuals as � an original and integrative re‐
experience without extrapolation ipants' experiences as themes exemplars (examples) of experi- presentation that includes the
(i.e. participant focus) (i.e. phenomenon focus) ence considered characteristic of most explicit interpretations of
the whole group (i.e person and the researcher's own knowledge
phenomenon focus) and personal experience
T A B L E 2 Summary characteristics of Males: Females 3:8

participant sample
Year of study Year 1 = 2 participants
Year 2 = 3
Year 3 = 3
Year 4 = 3
Graduates = 2
International students None
Previous tertiary study Yes = 4 (whole degree completed)

Yes = 2 (1 year of study only)
No = 5
Previous allied health assistant work Yes = 4

No = 7
the original data, with each subsequent stage involving more researcher field notes. Face‐to‐face semi‐structured interviews last-
researcher interpretation while remaining grounded in the data. ing between 50 and 90 min were conducted individually with each
Describing these four forms of data representation as ‘stages’ belies participant. Interviews were audio‐recorded and transcribed
the complexity of both the analysis and findings, but it is useful verbatim. Field notes served as supplementary data. Further detail
practically. This paper reports on the third ‘stage’, the exemplary about the raw data is described elsewhere (Barradell et al., 2018).
portraits, and aims to illustrate experiences of learning to become a The researcher's interpretive insights from the previous stages of
physiotherapist via typical characteristics of the whole sample. data representation (i.e. through developing the individual and
Ethics approval was obtained from the Human Research Ethics composite depictions respectively) also informed the development of
Committees of the University of Sydney (2014/138) and La Trobe the exemplary portraits. These interpretive insights helped to guide
University (FHEC14/083). the specific analytical process needed to develop the exemplary
portraits.
The aim of exemplary portraits is to bring the person and the
2.2 | Participants experience to life. In the context of this research, exemplary
portraits are thus portraits of two connected things: the individual
Participants were recruited from an entry‐level physiotherapy de- students and their experience of physiotherapy. It was clear from
gree of a large metropolitan Australian university using purposeful earlier analysis stages (i.e. interpretive insights when developing
sampling. Students enrolled at the time of the research, or who had the individual and composite depictions) that participants had
graduated within the previous 18–24 months (recent graduates) described experiences relating to their learning journey from
were invited to participate. Students across all year levels were student to graduate practitioner; that is the development of
eligible. It was anticipated that this sampling strategy would assist in knowledge, skills and values when learning to become a physio-
achieving both a breadth of experiences and saturation. A staff therapist. The relationship between the student and what they
member independent to the study informed students of the oppor- were learning about their profession (including the capacity to
tunity to participate; those who expressed an interest were sent exercise agency along the way) seemed to be different among the
further information. Eleven students (spanning all levels of the participants. The various forms of data—most particularly the raw
course) and two recent graduates consented to participate (Table 2). data—were returned to afresh to analyse them in terms of the
way participants made sense of or approached learning to be a
physiotherapist. This analysis aimed to connect the individuals and
2.3 | Procedure (data collection and analysis) their experience of learning physiotherapy as described above. The
analysis was inductive and emergent (i.e. coding occurred without
The data to develop the exemplary portraits came from multiple any pre‐conceptions about the experiences), and as it progressed,
sources. There was raw data in the form of interview transcripts and it also became deductive (i.e. coding was informed by the reading
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and analysis of other transcripts) (Patton, 2002). The analysis bigger picture and alternative perspectives. Each participant's expe-
included coding words and statements that seemed meaningful to rience of learning to become a physiotherapist is reflected in one of
the participants. This involved exploring statements used by par- the portraits.
ticipants and how their responses shed light on what might have A brief general description of each portrait follows; a supporting
informed and shaped their perspectives of professional life. The description of participants who exemplified each portrait can be
learning of knowledge, skills and values (or the knowing, doing and found in the Supplementary Material S1. The features of each
being associated with learning to become a physiotherapist) was portrait, with respect to knowledge, skills and values, are summarised
also an analytical lens, drawn from higher education curriculum, in Table 4. The table's function is to illustrate the prominent differ-
teaching and learning literature generally and health professional ences across and between portraits rather than to suggest distinct
formation literature more specifically. Table 3 shows an example boundaries. Transitioning from one portrait to another (i.e. a shift in
of moving from transcript to coding to portrait. For example, some experiences and approach to learning) appears to be unsettling and
students talked about valuable sources of knowledge (i.e. journal problematic. It is at these ‘crossings’ that learners engaged with
articles but not books) based on what they had been told by needing to know, do and behave differently to cope with new situ-
others but at no point had those students questioned this. Such ations ahead (Kilminster et al., 2011). Reading the Supplemen-
statements were interpreted as ‘rule following’ with students tary Material S1 along with Table 4 provides a full sense of the
acting with little agency. meaning of the experience.
2.4 | Researcher‐researched relationship and 3.1 | The passenger

reflexivity
The passenger is embarking on a pre‐determined path to professional
The researcher‐researched relationship is essential to heuristic in- entry, with choices based on certain likes and interests. These se-
quiry (Moustakas, 1986, 1995). Being an ‘insider’ is a strength of this lections and perspectives are strongly influenced by prominently
research but it is also not without its challenges, as is true of research displayed ideas, such as those portrayed in the media, from hearing
conducted with similar researcher positioning (Toy‐Cronin, 2019). stories or from limited prior experiences. As a result, passengers have
Some of those challenges relate to the conduct of the research itself ‘knowledge about’ based on a subjective form of reality (Scan-
and included managing potential conflicts of interest (i.e. recruiting lon, 2011). Passengers are sheltered from the real world, bound by
and interviewing current students) and ensuring interpretive dis- rules, and are not in control, nor authentically contributing to the
tance. Strategies to enhance methodological and interpretive rigour passage. Their chosen degree is seen as similar to an itinerary
included: prolonged immersion; critical friends to prod at assump- comprising an overall course structure, enrolment, subject codes,
tions and push for clarity and explanation; the complementary use of topics and skills. Passengers focus on getting to the chosen ‘place’
reflexive field notes as a data source; and member checking. Then and what they see themselves doing in the future, and so may be
there were challenges of a more ethical nature. It is likely that par- oriented towards tasks and stages.
ticipants were willing to share their experiences due to their famil-
iarity with me. Some students told me more about their experiences
than anticipated: for example, sharing personal likes and dislikes 3.2 | The tourist
about subjects in the course. It was as though they appreciated ac-
cess to someone who would listen to their concerns, perhaps seeing The tourist is very much outside of his/her customary environment
me as someone who could make change happen. It was a privilege to but is experiencing aspects of the culture and community and
have heard their stories and it was a deliberate decision to focus on therefore starting to create ‘knowledge of’ (Scanlon, 2011). In this
perspectives typically under‐represented in physiotherapy education sense, a tourist is an outsider‐in, being located within an environment
literature. but not fully a part of it. His/her horizons are broadening and a sense
of purpose is beginning to develop, as well as an understanding of the
culture and surrounds. However, this understanding is more as a
3 | RESULTS series of isolated parts rather than the whole. The tourist is exposed
to new discourses and experiences, and the contrast between the
Four exemplary portraits were developed: passenger, tourist, resident familiar and the different is never more obvious, which can be both
and citizen. The portraits differ in terms of an individual's disposition disconcerting and exhilarating. There are similarities with the
and capacity for independence around knowledge, skills and values, passenger—certain things are of prominence—but the tourist starts
and thus their development towards physiotherapy graduate. Each to see beyond what is on show, to make their own choices (albeit
portrait demonstrates variation in, for example,: learner expecta- with limitations) and looks for meaning behind what might be
tions, awareness of structural influences (i.e. power, organisations), considered traditional. Plans and routines help the tourist to join in
personal values, emotional capital and the ability to see both the and navigate the unaccustomed.
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TABLE 3 Example of moving from transcript to coding to portrait
Transcript Coding Knowledge, skills and values Portrait
‘Credible sources of information. Obviously I'm not going to Knowledge sources Knowledge ‐ being told by others, Passenger
put Wikipedia in my references or Google or anything like What's credible knowledge? accepting this on face value, conventions,
that by scholarly articles from experts in that field but Who decides that? right and wrong
even then some of them are a bit dodgy….. Skills ‐ not questioning
Basically at uni we've been told to not use those. Anyone can ‘Proper’
go on Wikipedia and write anything but for a journal to
get published in a magazine, especially if it's peer
reviewed, it's got to be accepted by other experts in the
field. So you know that it’s written by people who are
doing proper research not some person who's just pub-
lishing on some public blog about why the sky's blue or
something. It's from people who have spent their whole
careers in that field so surely they've got to know what
they're talking about.
TABLE 4 Summary of the four portraits
Development of and learning approach to
Portrait Knowledge Skills Values
Passenger Be told Choices, job, tasks, like doing Time concerns

Exact knowledge Safety Self‐serving
Being ‘trained’ Fun and satisfying Getting further along (in life)
Studies required topics, skills, subjects Follow rules (without question or Very underdeveloped
Being correct, right, know nuance) Responsibility lies outside of self
Based on what is visible and of prominence Sheltered
(‘knowledge about’)
Preconceptions, assumptions
Tourist Things to cover, see and move onto need to be Work orientated Learning intentions centred on self
exposed to it to learn it Structured parts Follows
Developing but limited (due to learner and The good parts Struggles and insecurities abound as assumptions,
learning expectations) Opening up in the right now pre‐conceptions and identity are challenged
Experiences start to be important but focus on Developing some awareness but not the capacity
what without why to deal with what arises
Outsider looking in, expanding but in specific
separate contexts
Resident Mix of professional and personal shows through Occupation Independence

integration of the multiple layered parts Expanding but situated within Focus shifts beyond self
particular confines
Degree of authenticity and
ownership
Aware to a point but not
challenging
Citizen Seeks Profession, career Flexible, mature, self aware in a range of situa-
Asking questions in limited scopes Layered, nuanced, complex tions both familiar and not
Boundaries expanding but still in similar area Aware of alternative perspectives Degree of humility
and experiences Starting to think can have a limited influence as
Greatest sense of the inherent change agent
tensions but still in
development
3.3 | The resident self and others (who are like minded), and one that is quite different
to his/her initial naïve views. The non‐ordinary has begun to become
The resident has a greater level of professional competency, and with the familiar, even taken for granted, and residents possess a sense of
it, more confidence than the tourist. Another key difference is the security. Residents are comfortable and for the first time demon-
resident has an awareness of the bigger picture having developed an strate a sense of belonging; the resident ‘belongs’ by having reached
understanding of how things are connected—one that includes both a certain level of know‐how and ability to actively make their own
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choices. This allows residents to have established their own place development (at least in terms of skill acquisition) is earlier than
within a community but also act somewhat independently within the graduation. The research described in this study lends further sup-
‘neighbourhood’. They have an understanding of the local in- port to the idea of professional development starting during pre‐
frastructures and are comfortable with their own role within the registration learning experiences. Each of the four portraits
scope of these infrastructures which act more as boundaries (at least describe experiences around particular skills and how they were
until residents have belonged for a while). Becoming a resident marks perceived and valued. However, the portraits do more than describe
the point at which most students achieve entry‐level competency. skills (or doing); they also reflect experiences relating to knowledge
and values. For each portrait, the three elements (knowledge, skills
and values) together come to represent a particular approach—an
3.4 | The citizen ontological and epistemological representation—towards becoming a
physiotherapist.
The citizen shares some similarities with the resident but is more Moreover, there are parallels between the four portraits and
curious and more capable. The citizen is beginning to show signs that other research about students' overall educational experiences
they are not afraid of uncertainty and is comfortable with venturing within physiotherapy (Korpi et al., 2014; Kurunsaari et al., 2021;
into situations they have not previously encountered. This signals Lindquist et al., 2006a; Lindquist et al., 2010). For example, there are
greater agency. In some ways, citizens set their own course through a similarities between the portraits and the three learning patterns
greater willingness to adapt and while the scope of their capabilities (‘Learning to cure body structure’, ‘Learning to educate about movement
are expanding, they are still confined within the distinct boundaries problems’ and ‘Learning to manage peoples’ health) described by Lind-
of their chosen field. Nonetheless citizens enjoy the challenge and quist et al. (2010). In that work, the learning patterns reflect different
stimulation that comes with forging ahead. categorical views about knowledge and learning, and they vary in
terms of what, how, and with whom, students learned. Some features
about what students learn are represented across the portraits
4 | DISCUSSION AND IMPLICATIONS presented in this study: for example, Lindquist et al.’s ‘learning to cure
body structure’ pattern and the passenger portrait both tend to focus
The portraits resulted from a novel interpretative methodology that on exact knowledge and facts, while the learning to educate about
sought an original and integrative representation of physiotherapy movement and problems pattern and resident portrait both represent
student participant experiences. These empirically derived portraits a shift beyond one's self. Another similarity lies with the stages
remind us that a critical objective of higher education is to pay (e.g., previous studies, new ways, understanding physiotherapy and
attention to learners as they navigate becoming health professionals, turning professional) described by Korpi et al. (2014) and the
as educators are in a better position to facilitate student learning expansion of understanding that comes with embracing new ways of
when they understand where students are coming from and what learning, seeing the profession differently and more holistically and
they are wrestling with. The portraits also remind us that student adopting a professional mindset; similar transitions are reflected
cohorts are not homogenous. While systemic issues in higher edu- across the four portraits. There are also differences between the
cation such as resourcing and infrastructure challenge tailored indi- portraits and existing literature that explores the structural factors
vidual approaches, key learner‐centred strategies with high impact impacting achievement and sense of belonging (Hamshire & Wib-
are a good investment. Paying attention to the development paths of berley, 2014), ways of thinking and practising in the form of skills or
students should be an imperative in health professional courses competencies (Kurunsaari et al., 2018; Lindquist et al., 2006b;
because if students remain as passengers, or even tourists, it hinders Richardson et al., 2002). The differences across this body of work and
their professional development resulting in a form of ‘mimicry’ of the the study presented here are perhaps indicative of the different
ways of thinking and practising of the practitioner (Meyer & understandings and inherent complexity of professional formation.
Land, 2005); they graduate ‘like a physiotherapist’, rather than being While there is undoubtedly value and meaning in these studies
a physiotherapist. collectively, the portraits presented here make their own unique
The professional development literature, particularly within contribution to the professional formation landscape and offer
medicine and nursing, draws strongly on the seminal work of Dreyfus another layer to our understanding of becoming a physiotherapist.
and Dreyfus (2004) and Benner (2004), despite more recent critique Their power lies in the accompanying descriptions of each exemplar
(e.g. Dall’Alba & Sandberg, 2006; Peña, 2010). That seminal research participant. Stories or cases are valuable pedagogical tools in
focuses on skill acquisition and knowledge utilization and describes healthcare education because individuals are memorably brought to
development for qualified practitioners as a series of sequential life as a way of making sense of complex human situations
stages from novice through to expert. Research within physiotherapy (Gray, 2009; Talley, 2016). Educators can use the portraits to think
seems to support the existence of these stages within certain phys- about their teaching and the conditions that usefully shape the en-
iotherapy practice contexts, although one difference is that ‘novice’ culturation and development of their students. It might likewise be
was found to map to final year students and new graduates beneficial to ask learners to self‐identify with a portrait, to critically
(Brooks, 2011), suggesting physiotherapy's view of professional reflect on related strengths and weaknesses and develop a learning
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contract towards becoming a citizen. In both these applications, the as the main determinant, with respect to sampling, is that partici-
portraits act as a narrative that can develop reflective practitioners pants have experience of the phenomenon (i.e. studying physio-
(Greenfield et al., 2015). It is also important to recognise that these therapy). Although the sample is small, the number of participants
portraits are exemplary for the sample of study and the methodolog- was sufficient for heuristic inquiry (Moustakas, 1990) where the aim
ical approach used. They are best used by both teachers and students is not generalisability but rather a process of ‘being informed, a way
in partnership; they prompt thinking rather than narrowly categorise. of knowing’ (p. 10). Furthermore, the exemplary portrait phase of
Indeed, students within the sample, such as Freya and Beth (see heuristic inquiry is a way of vividly profiling unique stories that still
Supplementary Material S1) described experiences that showed they have relevance to all individual participants. The portraits are
were straddling features of both tourist and resident. Teachers may informed by what each participant chose to talk about and it is
be able to design learning activities around the portraits that shift acknowledged that they might not represent the totality of physio-
and reward student behaviours and consider if their own teaching therapy students' stories. Additionally, the physiotherapy profession
was conducive to students' developing a more educationally nuanced and physiotherapy education have particular ways of thinking and
view. Students might also become more equipped to evaluate their practising that provide context to the student experiences. It is
professional development, seek out and ask for specific help, and take acknowledged that the experiences represented here may not
steps to more fully engage with the process of becoming. translate to contexts in other institutions and/or countries. More
If we accept that the purpose of higher education, and therefore broadly, physiotherapy shares commonalities with other health pro-
physiotherapy education, is to transform not to train (Bram- fessions but also important differences. Features of the portraits may
ming, 2007; Wenger, 1998), then physiotherapy educators need to resonate with other contexts (including other health disciplines) and
foster learning for becoming and being. As Shulman (2002) offers ‘an they offer a useful framework for shifting students beyond the
educator can teach with integrity only if an effort is made to examine learning of knowledge and skills.
the impact of his or her work on the students’ (p. vii)—the impact of In focusing on the student experience, this research focuses on
educational work should be judged by whether ‘transformation is an one element of physiotherapy education. If it is accepted that cur-
ontological condition of learning’ (Bramming, 2007, p. 48). Learning riculum, teaching and learning should be considered in broad,
for becoming and being therefore demands that educators know expansive ways, then understanding the student experience is just
their students. And it demands that students know themselves, their one means of thinking more deeply about professional formation.
capabilities and capacities, and to develop skills to shape their future Professional identity is influenced by a myriad of things including the
and that of the profession. In an educational climate still focused on nature of the profession being studied, pedagogic experiences and
work‐readiness while simultaneously wrestling with how to manage participation, conceptions and expectations of teaching and learning
the 21st century limitations of an historical focus on disciplinary and workplace or learning culture (Reid et al., 2008; Strand
specific clinical skills, agency can be an overlooked even though it is et al., 2015). This research did not aim to critique the nature of
an important capability of education (Su, 2011). The development of physiotherapy, its underpinning philosophies or how and where these
agency contributes to a shift in thinking from knowing about or doing might be represented within the formal curriculum the students were
to towards knowing oneself (within the profession). The four portraits exposed to. The degree structure, pre‐requisites and descriptions of
differ in terms of agentic capability; the passenger is more a passive intended learning outcomes however indicate the intended curricu-
recipient, the tourist a naïve learner, the resident an experiential lum is highly structured and biomedically oriented. Additionally, this
learner and the citizen a more active learner. For physiotherapy to research did not set out to explore the delivery of curriculum or
remain relevant and respond to the challenges facing society, the teaching practices and it is acknowledged that intended and enacted
profession needs ‘citizens’ to come out of its physiotherapy programs. curricula are determining factors in students' experiences.
Learners who are self aware, ask questions, embrace different ways
of seeing the world and are comfortable with not knowing are most
capable of being the kinds of physiotherapists that the world needs 5 | CONCLUSION
right now (Barradell, 2021). The portraits can help program directors
and educators to think about curriculum, teaching, learning and This research offers a new understanding about physiotherapy
assessment—from cohort selection to graduation—in ways that learners and how they approach, learn about, connect with and form
maximise personal and professional transformation. a relationship with their chosen profession. Presented as four por-
traits and a summary of associated characteristics, the findings offer
educators additional insight about the development of students and
4.1 | Limitations provide an avenue for educators to think about the conditions of
teaching and learning that might help move and transform learners
None of the students identified as international students although from passengers to citizens. While derived from a particular phys-
there was some ethnic diversity amongst the participants. Sociocul- iotherapy sample, the summary descriptions may resonate with and/
tural characteristics were not a determining factor for inclusion or a or provoke conversation in other health professional contexts. This
lens for analysis. This does not detract from heuristic inquiry's rigour, research also offers an example of how valuable it is to listen to and
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involve students in how we make sense of the profession, its prac- cross‐sectional survey. European Journal of Physiotherapy, 1–10.
tices and educational programs. https://doi.org/10.1080/21679169.2021.1958007
Dall’Alba, G. (2009). Learning to be professionals. Springer.
Dall’Alba, G., & Sandberg, J. (2006). Unveiling professional development:
A CK N O WL ED GE M EN T S A critical review of stage models. Review of Educational Research,
I thank Tai Peseta and Simon Barrie for the many conversations that 76(3), 383–412. https://doi.org/10.3102/00346543076003383
greatly helped the development of this paper. And thank you also to Dreyfus, S. (2004). The five‐stage model of adult skill acquisition. Bulletin
of Science, Technology & Society, 24(3), 177–181. https://doi.org/10.
#thesisthinkers for their encouragement.
1177/0270467604264992
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Technology, as part of the Wiley ‐ Swinburne University of Tech- Iterative stages of "seeing afresh". Journal of Humanistic Psychology,
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Research data are not shared.
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Physiotherapy

VOLUME 28, ISSUE 1 January 2023

EDITORIAL ADVISORY BOARD

AIMS AND SCOPE

Effects of continuous aerobic training associated with

Bruna T. S. Araújo1 | Ana Eugênia V. R. Barros1 | Daiara T. X. Nunes1 |

1 | INTRODUCTION Laboratory of Cardiopulmonary Physiotherapy of the Federal Uni-

2 | METHODS 2.1.2 | Spirometry

Maximal functional capacity was assessed using a symptom‐limited

2.1.4 | Six‐minute walk test 2.1.9 | Statistical analysis

Fatigue intensity and its impact after COVID‐19 were assessed

FIGURE 1 Flowchart of study sample

Cardiopulmonary exercise test

VO2peak 19.11 � 4.61 22.67 � 4.81 <0.001

Strenuous circumstances changed the study design during the

T A B L E 3 Quality of life before and

Role physical 10.42 � 19.38 39.58 � 39.64 0.004

Bodily pain 47.50 � 29.99 61.96 � 24.22 0.006

General health 44.50 � 24.83 65.25 � 23.94 <0.001

Vitality 46.88 � 27.21 65.63 � 20.17 <0.001

Social functioning 48.88 � 31.05 71.25 � 27.79 0.001

Role emotional 31.96 � 42.28 54.17 � 40.36 0.015

Mental health 63.00 � 25.76 76.67 � 21.02 <0.001

Total score 333.13 � 182.10 498.13 � 159.21 <0.001

of a control group. Therefore, we extended the data collection period, P E R M I S S I O N T O R E P R O DU C E M A T E R I A L F R O M OT H E R

People with mild Parkinson's disease have impaired force

Renee Salmon1 | Elisabeth Preston1 | Niruthikha Mahendran1 | Louise Ada2 |

Physiother Res Int. 2023;28:e1976. wileyonlinelibrary.com/journal/pri 1 of 6

Parkinson's disease (PD) affects approximately 7 million people 2.1 | Design

TABLE 1 Participant characteristics

Age (yr), mean (SD) 69 (8) 69 (6)

Sex, n male (%) 20 (66) 15 (63)

Height (cm), mean (SD) 170 (9) 173 (9)

Weight (kg), mean (SD) 75 (13) 77 (12)

Hand dominance, n right (%) 30 (100) 22 (92)

Walking speed (m/s), mean (SD) 1.4 (0.2) N/A

Stride length (m), mean (SD) 1.4 (0.2) N/A

Affected side, n right (%), n = 21 15 (75) N/A

Time since diagnosis (yr), mean (SD) 4.0 (3.2) N/A

Levodopa medication, n taking (%) 29 (97) N/A

T A B L E 2 Mean (SD) maximum

Shoulder abductors 94 (26) 109 (123) −15 (−28 to −1), p = 0.04 86

Shoulder adductors 97 (32) 129 (30) −32 (−49 to −16), p ≤ 0.001 75

Shoulder external 78 (25) 104 (23) −26 (−39 to −13), p ≤ 0.001 75

Elbow extensors 96 (35) 132 (33) −35 (−54 to −17), p ≤ 0.001 73

Wrist flexors 76 (17) 80 (17) −3 (−13 to 6), p = 0.48 95

Wrist extensors 65 (19) 91 (18) −26 (−36 to −16), p ≤ 0.001 71

Grip 286 (69) 359 (66) −73 (−110 to −37), p ≤ 0.001 80

From passenger to citizen—portraits of learning to be a

Physiother Res Int. 2023;28:e1977. wileyonlinelibrary.com/journal/pri 1 of 9

1. Individual depiction 2. Composite depiction 3. Exemplary portraits 4. Creative synthesis

T A B L E 2 Summary characteristics of Males: Females 3:8

International students None

Previous tertiary study Yes = 4 (whole degree completed)

Previous allied health assistant work Yes = 4

2.4 | Researcher‐researched relationship and 3.1 | The passenger

TABLE 3 Example of moving from transcript to coding to portrait

Transcript Coding Knowledge, skills and values Portrait

TABLE 4 Summary of the four portraits

Development of and learning approach to

Portrait Knowledge Skills Values

Passenger Be told Choices, job, tasks, like doing Time concerns

Resident Mix of professional and personal shows through Occupation Independence

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