The basics of SEO will basically always remain the same. If you are talking about your on page SEO then here are some basic tips. They even have word press plugins to help.
Keyword should be in the URL, TITLE TAG, META DESCRIPTION, HEADER 1, 2, and 3 in the post, ALT TAG IN IMAGE, and should be used throughout the post for a keyword density of around 2.5%.
Keyword should be in Phoenix seo company the first and last sentence, and you should have at least one bold,italics, and underlined keyword through out the post. Post should be at least 400 words and should never be over 1000 (you can make a another post of page with that information and have something else that can rank/interlinking posts)
You should usually link to another related page on Phoenix seo company the web, (an authority on what you are writing on) and you don't have to give them you anchored text url.
SEOmoz is a great place for beginners to learn more about SEO.
DALLAS--(BUSINESS WIRE)--SEO 1 Medical (www.seo1-medical.com) has announced a unique pay-per-performance model in several of its online marketing services specializing on healthcare professionals. The Dallas based SEO company will henceforth provide a money back guarantee to physicians and doctors seeking increased visibility for their practice online. Recent changes in Googles search engine algorithms have rattled the medical marketing landscape, and SEO 1 Medicals new offer comes as a beacon of hope as it benchmarks performance and simplifies the vetting process for doctors seeking help from SEO consultants.
Challenges faced by doctors and physicians
The last two years have proved very volatile for healthcare professionals looking to Phoenix seo promote their practice website and for the SEO industry itself. Googles recent Panda and Penguin updates caused quite an upheaval by sending hundreds of millions of webpages into the search engine wilderness. These changes coupled with the inherent nature of the optimization process caused great distress to doctors. Until now physicians had to sign up for a period of 12 months before actually assessing the optimization process. The medical marketing companies on their part offered no guaranties and this created a trust deficit and we want to fill that gap, said Rodney Brooke of SEO 1 Medical.
SEO 1 Medicals Solution
SEO 1 Medicals new money back guarantee answers doctors main concern: Will the expected 12 month commitment to a SEO campaign lead to better rankings? This is a genuine concern since Googles proprietary search algorithm is ultimately responsible for search engine ranking and is subject to change without notice. We at SEO 1 Medical are least bothered by Googles changes in search algorithms, we are confident our unique white hat SEO techniques and state of the art processes bring in positive and quantifiable results Phoenix seo consistently, and we would like to pass on this confidence to our clients by taking out the guess work from the search engine optimization process, said Mr. Brooke.
SEO 1 Medical is a specialized Internet marketing firm that operates in Dallas, Texas. It offers a variety of Internet marketing solutions to the health care industry. All medical SEO packages come with guaranteed results. Its team has more than 30 years of combined experiences in organic SEO, article marketing, pay per click, Google optimization, press release distribution, and medical marketing consulting for doctors and physicians.
She's had her share of personal struggles but Mischa Barton is clearly back to her best.
The actress looked healthy and confidant as she strutted along the beach today as she continued her holiday fun in Miami.
The 25-year-old channelled 50s seaside fashion for the outing with friends in the Florida region.
Pin-up girl: Mischa Barton shows of her toned physique as she wears a 50s-style outfit on Miami beach in Florida
The London-born star who moved to the United States as a child donned a retro polka-dot bikini and a pair of black high-waisted shorts.
Teaming her look with silver costume jewellery and a slick of red lipstick, the 25-year-old seems to be starting the new year off as she means to go on.
Healthy and happy: Her drenched shorts emphasised just how much weight she'd lost as she'd lost as they hung loosely off her frame while she walked on the sand
The brunette had a permanent smile on her face as she walked through the sand barefoot following some time enjoying water sports.
Following her expedition on a jet ski in which she wore a blue lifejacket with yellow buckles Barton it was evident she has slimmed down recently as her soaking wet clothes hung loosely around her torso.
The star has faced much scrutiny over her fluctuating body weight in the past after years of yo-yo dieting took its toll.
hormone replacement waters" class="blkBorder" />Ready to rumble: Helped by her male friend, Mischa prepares to glide around the waters on a jet-ski
Action girl: The actress enjoyed a spot of water sports on a red and white jet ski
In 2008, pictures of her seemingly plagued with a bad case of cellulite on her thighs prompted a spokesperson to defend the star.
Referring to the images of her appearing plumper on Hamilton Island in Queensland, Australia, a representative said: Those photos are doctored.
I'm not saying she's perfect, nobody is. But they've given a 22-year-old woman the legs and bottom of an 80-year-old.
On the other hand, Mischa has been accused of looking frail and gaunt after dropping from a healthy size 12 to a frail-looking size 6-8 in 2009.
On top of the world: The world has watched Barton's weight fluctuate as she yo-yo dieted in the last few years
Help me out? The star struggles to keep her clothes on following a watersports stint on a jet ski
That was fun: The brunette seemed content with her new active lifestyle as she emerged from the ocean
On Wednesday the model looked like she had finally got the balance right as she sunbathed with friends at the start of her post-Christmas break.
The leggy beauty was seen enjoying the company of a male friend and didnt seem to mind the attention she received from onlookers.
Mischa shot to fame in The OC, where she played a beautiful resident of the gilded community of Newport Beach in California, until her character Marissa Cooper was killed off in 2006.
Where to now? Mischa walks with her friend on the beach after the energetic jet-ski ride, as other beach-goer lay oblivious on their sun loungers
Doctors continue to recommend hormone replacement therapy, but it may carry risks.
Menopausal symptoms include mood swings, hot flashes, sleep disruption, changes in libidoHormone replacement therapy is the only treatment that targets all of those symptomsAn alternative to hormone replacement therapy for some women is antidepressants
(CNN) -- Just after she'd gotten a divorce and gone back to work, Alice Thornton would feel cold one minute and hot the next, and her temper was shorter than usual.
"It was irritating because when it comes, it comes roaring through," said Thornton, 61, of Huntington, West Virginia, whose symptoms began around age 49 or 50. She wrote about the experience in her iReport.
A deficiency in the hormone estrogen is responsible for the symptoms of menopause, which include mood swings, hot flashes, sleep disruption and changes in libido.
As baby boomers continue to go through menopause in record numbers, questions about how to curb these symptoms, especially those that interrupt daily life, are all the more relevant. At the same time, research on hormone replacement therapy keeps emerging without hard conclusions, leading doctors to recommend the lowest dose for the shortest duration.
Not every woman feels troublesome effects from menopause; in fact, 30 percent don't report any significant symptoms. But that means up to 70 percent of women have moderate to severe symptoms that can cause changes in daily living, said women's health expert Dr. Donnica Moore.
For 80 percent of women, symptoms generally resolve within five years, but it's not known how long the unpleasantness lasts beyond that for the remaining 20 percent of women, Moore said. Because every woman is different, there is no certain quick fix for menopausal symptoms.
"This is why medicine is an art and not a science," she said. "We don't have the tools to be able to make these decisions by computer or a checklist."
Are you at risk for osteoporosis? Take a test
The HRT controversy
Marilyn Grounds, 51, of Springboro, Ohio, hasn't slept well in years. She feels exhausted all the time, and is also going through hot flashes. Recently she decided it's time to look into hormone replacement therapy, she said in her iReport.
Hormone replacement therapy is the only treatment that would target all of the potential symptoms of menopause at once, Moore said. It comes in forms such as pills and patches, and is designed to replace estrogen.
Women taking estrogen who have not had their uterus removed also need to take progesterone, as this helps reduce the risk of uterine cancer.
Hormone replacement therapy, also called HRT, has generated much debate in recent years because of concerns about elevated risks of breast cancer and cardiovascular events.
A recent study in the Journal of the American Medical Association found that women who took a specific hormone therapy that included estrogen and progestin were twice as likely to die from breast cancer as women who took a placebo. This was part of a large government study called the Women's Health Initiative, which stopped a study on the topic in 2002 due to concerns about heart health, breast cancer and other health problems. The latest results are from the same women who participated in that, after 11 years of follow-up.
Moore and other doctors caution that the Women's Health Initiative study hormone replacement therapy side effects has numerous flaws -- for instance, it looked at only one particular drug: Pfizer's Prempro. There are all kinds of formulations and varieties of hormone replacement therapy, with estrogen and progestin in combination in different amounts, Moore said. It's hard to know whether it is one or both hormones, or the dosing, or something else entirely, that may have contributed to negative outcomes, she said.
There are some women who should not consider hormone replacement therapy because of underlying conditions such as liver problems and gallstones, Moore said.
But in appropriate situations, Moore continues to recommend it. So does Dr. Camelia Davtyan, director of Women's Health at the Comprehensive Health Program at the University of California, Los Angeles.
Davtyan said she's not as "generous" with recommending hormone replacement therapy as she used to be, given the research on risks. Of the available options, she prefers prescribing a hormone-releasing patch, as there has been some suggestion that it causes fewer blood clots, she said.
Virginia Olander of New Orleans, Louisiana, remembers feeling like an 85-year-old at age 52. She had to have a complete hysterectomy, which threw her body out of whack in severe menopausal symptoms. Her brain was in a fog, her energy had dropped, and she felt generally miserable, she said in her iReport.
Traditional hormone replacement therapy didn't relieve any of her symptoms. She thought, "I cannot continue to work full time and take care of my family if I'm going to continue to feel this way."
Long-lasting relief came from pellets containing "bioidenticals," which are chemical equivalents of the hormones that the body produces naturally, but are derived from plants. Synthetic estrogen, on the other hand, is made in a laboratory, but functions the same. Grounds, like Olander, has also opted to try the bioidenticals, but hasn't gone to her first appointment yet.
The specific treatment Olander chose and others like it are controversial because they are not approved by the U.S. Food and Drug Administration, and therefore have not undergone the same level of scrutiny in terms of dosing. But Olander doesn't care, as long as it works.
There are some hormone replacement therapies on the market that are approved by the FDA, and also use plant-derived hormones, such as Estrace, Climara patch, Vivelle-Dot patch, and Prometrium natural progesterone, according to the Mayo Clinic's Dr. Mary Gallenberg.
Still, bioidentical treatments carry the same risks of breast cancer and cardiovascular risks as other forms of hormone replacement therapy, Davtyan said.
Olander's pellets have a combination of estradiol -- the chemical that synthetic estrogen mimics -- and testosterone. They are like grains of rice inserted into the hip, in an outpatient procedure.
I was privileged to attend a recent continuing education conference about estrogen replacement at menopause, held at the Yale School of Medicine, organized by my friend and colleague, Dr. Phil Sarrel. Highlights for me included both Dr. Sarrel's important insights, and a very poignant, personal story told by Michelle King Robson, founder of EmpowHER. Michelle had what eventually proved to be diverticulitis. Initially misdiagnosed, her condition was erroneously treated with a hysterectomy. Michelle's overall health plummeted due to a surgically induced menopause, until it. As a result, hormone replacement at menopause became rather routine in the service of preventing serious chronic disease, heart disease in particular, for a span of years.
The WHI, the largest of several randomized intervention trials to what is hormone replacement therapy examine the issue, essentially said: au contraire. The report of no net health benefit, and some net harm, from hormone replacement produced a fairly abrupt and complete about face in public attitude and clinical practice alike. Hormone replacement was suddenly yesterday's bad news.
But as so often happens at the interface of medicine and the media, important nuance was lost. For one thing, the WHI, like the other randomized trials, only studied one variety of hormone replacement, called Prempro. Though popular, Prempro is not considered anything close to optimal hormone replacement by those expert in the field. The attribution of harms from Prempro to all varieties of hormone replacement was an important nuance, lost in the customary oversimplifications and hyperbole of media.
For another, the results of hormone replacement vary widely with timing. It has long been clear that effects of hormone replacement are best when treatment begins early rather than late after menopause. The data showed such distinctions, but they too were obscured by a rush to summary judgment.
For yet another, the net harms of even Prempro in even a mixed population of women starting hormone therapy both early and late after menopause were very sparse. The WHI data actually showed both benefits and harms, and they were pretty closely matched. Headlines shouting out warnings about net harms made hormone replacement sound far worse than objective data ever suggested; the data showed something pretty close to a toss-up.
Finally, and most importantly, the data showed very different effects in women who, because they had undergone a hysterectomy and did not need to take progesterone, could take estrogen only. What Dr. Sarrel pointed out to me those two years ago were published data indicating 13 fewer deaths per year per 10,000 women in their 50s treated with estrogen, rather than placebo. Estrogen alone, used in relatively young women right after menopause, was saving lives.
Provided this crucial observation, my job was to translate the study data into real-world effect. Colleagues and I, working with Dr. Sarrel, did just that, and published our findings in the American Journal of Public Health. Our analysis suggested that over a decade, over-zealous avoidance of estrogen replacement had resulted in tens of thousands of premature deaths among women in the U.S. alone.
It would be hard to overstate the sense of urgency that ensued when we looked at such stark and alarming data. The result of that consternation, and passion, is AHAH, a campaign, and a non-profit organization, devoted to clarifying to women, and their physicians, the nuanced realities of hormone replacement. There are different kinds of hormones; different kinds of women; and different effects as a result. Estrogen therapy in younger women who have undergone hysterectomy saves lives, mostly by preventing heart attacks.
The Yale conference was an example of the kind of education and outreach to which AHAH is committed. An "aha moment" is great, but moments come and go. It takes a campaign, and time, to change hearts and minds.
Hormone replacement is not right for all women, but nor is it wrong; we have now bungled this in both directions, and failed to distinguish baby from bathwater. Dr. Sarrel is an impassioned, indefatigable champion of the nuanced understanding necessary to optimize hormone replacement, and save lives. By taking AHAH from a mere moment to an on-going campaign, I believe he can help us all get it right this time.
David L. Katz, MD, MPH, FACPM, FACP
Director, Yale University Prevention Research Center; Griffin Hospital
President, American College of Lifestyle Medicine
Founder, The True Health Coalition
Follow at: LinkedIN; Twitter; Facebook
Read at: INfluencer Blog; Huffington Post; US News & World Report; About.com
Pittsburgh, PA, February 15, 2012 --(PR.com)-- Leading PittsburghSEO firm ProFromGo announced the official launch of its comprehensivefree consultation services program this week. The program offers freeconsultations and search engine optimization analysis for small tomedium sized businesses in the Pittsburgh area and internationally. Butsources close to the firm - including some competitors - have expresseddoubt about the long-term viability of these offerings. Says one directcompetitor that wished to remain anonymous:
"Free consultations are a thing of the past because
they're simply too expensive to offer. Client acquisitions in this
regard are extremely expensive and are rarely worth the investment of
time and resources."
But Chris Vendilli, founder and Chief of Operations for the firm
expressed serious misgivings about these doubts:
"We built this program from the ground up - offering
comprehensive analysis and consultation at no cost isn't a burden
or an additional expense to us. It's simply good practice. We
don't believe in pressuring our customers. In fact, we'd like
them to be fully armed with as much information as possible, because in
the end, that is what will help them to fully appreciate that magnitude
of what we do here at ProFromGo."
However, many people in the web design, SEO and IT fields clearly
disagree with Vendilli, stating that free consultations are the
money-sucking business practice of the past. My Boston SEO
711 Boylston St #161, Boston, MA 02116
(617) 315-0008According to a blog post by
Joshua Feinberg on this subject as related to IT consultations:
"You can't offer things for free if you want to be good
at IT sales. You need to make a profit, so you need to draw the line at
a certain point. Many small businesses will continue to make you come
back time and time again for free if you don't quickly move the
process along to IT sales."
But apparently, old school types like Vendilli don't buy into
"If you can't educate your customer over the course of a
comprehensive consultation enough to make it clear that your company is
the only viable choice; or that you're simply not a good match,
then you probably haven't done your job right. In my experience,
it's all about listening - that's what a free consultation is
really all about. If you don't listen to your potential client - if
you're just preparing for your sales pitch and not offering real
value - you'll land very few paying projects."
The free comprehensive. consultations offered by the Pittsburgh SEO
firm include analysis and counsel regarding web design and development,
internet marketing, social media management and marketing, content
development and search engine optimization. The firm's corporate
web address is http://www.profromgo.com, where seo free consultations can be
New San Diego airport terminal extends to Mexico, for $18 - San Jose Mercury News
SAN DIEGO -- The U.S.-Mexico border is one of the world's most fortified international divides. Starting Wednesday, it will also be one of the world's only boundaries with an airport straddling two countries.
An investor group that includes Chicago billionaire Sam Zell built a sleek terminal in San Diego with a bridge that crosses a razor-wire border fence to Tijuana's decades-old airport. Passengers pay $18 to walk a 390-foot overpass to Tijuana International Airport, a springboard to about 30 Mexican destinations.
The terminal is targeting the estimated 60 percent of Tijuana airport passengers who cross into the United States, about 2.6 million travelers last year. Now, they drive about 15 minutes to a congested land crossing, where they sometimes wait several hours to enter San Diego by car or on foot. The airport bridge is a five-minute walk to a U.S. border inspector.
In this Wednesday, Nov. 25, 2015 photo,Vincent Miller, chief operating officer of the Cross Border Xpress air terminal, poses for a photo in the security inspection station at the terminal in San Diego. The new terminal, with a bridge that crosses to Tijuana, Mexico's decades-old airport, is scheduled to begin operations on Wednesday, Dec. 9. (AP Photo/Lenny Ignelzi) (Lenny Ignelzi)
"It seems so much easier, so liberating," said Daniela Calderon, who flies from Tijuana four times a year to visit family in the central Mexican city of Morelia and has a friend drive her across the border from Riverside, California.
The only other cross-border airport known to industry experts is in the European Union -- between Basel, Switzerland, and France's Upper Rhine region -- but it carries none of the political freight of San Diego and Tijuana. Mexicans who ran across the border illegally overwhelmed the Border Patrol until the mid-1990s, when new fences and additional agents heralded a massive surge in U.S. enforcement on the 1,954-mile line with Mexico.
Cross Border Xpress, one of the largest privately-operated U.S. air terminals, wouldn't have happened if Tijuana didn't build its airport a few steps from the international line in the 1950s or if it wasn't surrounded by undeveloped land in a barren, industrial part of San Diego.
"It's an amazing accident of geography," said Stanis Smith of Stantec Inc., the terminal's architect. "It could never happen again."
The terminal is one of the last works by the late Ricardo Legorreta, whose bold colors helped bring Mexican modernism to a world stage and attracted a strong following in the American Southwest. The stone exterior mixes purple stucco and red limestone that takes on a deep, inky hue when it rains. Stone gardens sprout agave and other desert plants.
Passengers enter a courtyard with a reflecting pool to an airy building with ticket counters and kiosks. High, white ceilings have large orange circles of recessed lighting. Sparse decorative touches are onyx, including high-hanging black slabs near ticket counters and white spheres atop the escalators.
marketing company bridge is shown at the Cross Border Xpress air terminal in San Diego. The terminal, which uses the" alt="In this Wednesday, Nov. 25, 2015 photo, the walking bridge is shown at the Cross Border Xpress air terminal in San Diego. The terminal, which uses the">In this Wednesday, Nov. 25, 2015 photo, the walking bridge is shown at the Cross Border Xpress air terminal in San Diego. The terminal, which uses the bridge to connect to Tijuana, Mexico's decades-old airport, is scheduled to begin operations on Wednesday, Dec. 9. (AP Photo/Lenny Ignelzi) (Lenny Ignelzi)
Aesthetics are more dated in the Tijuana airport but passenger flow is the same. Ticketed passengers must carry luggage across a bridge with frosted glass windows to border inspectors in the receiving country and a wall in the middle to separate the two directions.
The idea isn't new -- San Diego leaders proposed an airport with a runway on each side of the border in the early 1990s to replace the city's constrained Lindbergh Field -- but it didn't gain traction until a Mexican couple invested in 2005 in a company that runs airports in Tijuana and 11 other Mexican cities.
Carlos Laviada, whose mother-in-law lived in San Diego, had experienced the hassles of crossing the border after flying to Tijuana for decades. The view of San Diego from Tijuana's control tower convinced him he had to act before the vacant land was developed.
"Oh, my God, it's right here," he recalls saying.
Laviada said Grupo Aeroportuario del Pacifico SAB's board deemed it too risky but allowed him, his wife and another company director to invest privately. Zell and another Mexican investor joined them.
The privately-held consortium, Otay-Tijuana Venture LLC, doesn't release financial projections but expects to make money on a duty-free shop, rental car companies, restaurants and other concessions. The $120 million terminal occupies less than half their 55-acre parcel, and the city of San Diego has approved a 340-room hotel, shopping center and gas station.
Parking costs $10 a day, which is competitive with lots near land crossings and Tijuana's airport.
In this Wednesday, Nov. 25, 2015 photo, a security inspection station is seen at the Cross Border Xpress air terminal in San Diego. The new terminal, with a bridge that crosses to Tijuana, Mexico's decades-old airport, is scheduled to begin operations on Wednesday, Dec. 9. (AP Photo/Lenny Ignelzi) (Lenny Ignelzi)
The terminal fee will go largely to pay U.S. border inspector salaries, one of the nation's few privately-funded ports of entry.
Laviada, echoing views of airport officials on both sides of the border, doesn't consider Tijuana a threat to San Diego's airport because they share few routes. Both are primarily domestic airports, and Tijuana has shown no sign of expanding international destinations beyond Shanghai and Oakland, California.
Cross Border Xpress officials say they hope to capture half of Tijuana passengers bound for the U.S., which sounds realistic to nervous Tijuana airport taxi drivers who charge $13 for a ride to a land crossing. Nearly all cars in the Tijuana airport garage have California plates.
Passengers joke that they spend more time crossing the border than they do on the plane.
"No more driving around so much," Maria de Jesus Gonzalez said after arriving in Tijuana from a family visit to Guadalajara and waiting for her son to drive from Southern California. "This will be much more direct."
Oxygen is an element, a gas, and a drug that, for people with lungdisease, is an essential part of their lives. Oxygen and the nutrientsin food combine to supply the cells of the body the energy needed toachieve all human activity: everything from bodily functions, such asbreathing, to performing activities of daily living. For some pulmonarydiseases, such as chronic obstructive pulmonary disease (COPD) andinterstitial pulmonary fibrosis (IPF), supplemental oxygen is necessaryto continue to perform the activities of everyday life. (1)
For those who need it, supplemental oxygen is beneficial. There may
be improvement in sleep, cognition (mental alertness and stamina), and
mood. (2,3) Oxygen has also been found to prevent and improve heart
failure (cor pulmonale) in people with severe pulmonary disease. (4) In
2 major randomized clinical trials, The British Medical Research Council
Clinical Trial and The Nocturnal Oxygen Therapy Trial (NOTT),
investigators were able to improve survival outcomes by using long term
oxygen therapy in the treatment of patients with COPD and chronic stable
hypoxemia. (3,5) Both of these studies found that using nocturnal oxygen
therapy (NOT) and continuous oxygen therapy (COT) for at least 12-15
hours per day improved survival.
Oxygen is used in a variety of settings. Patients with pulmonary or
cardiac disease who are hospitalized are often on supplemental oxygen
during an acute phase of their illness. Oxygen may be delivered in
Intensive Care Units via ventilators and on cardiac, pulmonary, general
medicine, and surgical hospital units. Supplemental oxygen is used in
skilled nursing facilities, in the home, and in the community.
Consequently, physical therapists (PTs) will encounter patients
requiring oxygen supplementation in a variety of work settings. As a
result, it is imperative that physical therapists understand the proper
use of oxygen and logistics regarding oxygen equipment.
The American Physical Therapy Association (APTA) recognizes therole physical therapists have in the administration and adjustment ofoxygen while treating various patient populations. (6) The APTA'sGuide to Physical Therapist Practice (2nd ed) delineates the physicaltherapist's scope of practice in the management of patients whorequire oxygen to improve ventilation and respiration/ gas exchange. TheAPTA is unaware of any regulations that prohibit the use of oxygen forpatient management if it is prescribed and if parameters set by thephysician are maintained. (7) Physicians specify oxygen flow rates intheir orders. Any deviation in the prescribed dosage requires an updatedorder from the physician. The Food and Drug Administration (FDA) of theUnited States Department of Health and Human Services states that"medical oxygen is defined as a prescription drug which requires aprescription in order to be dispensed except ... for emergencyuse." (8)
Within the APTA's Guide, supplemental oxygen is listed as a
procedural intervention within the scope of physical therapist practice
under Prescription, Application, and, as appropriate, Fabrication of
Devices and Equipment (supportive device) to improve ventilation and
respiration/gas exchange. (6) The APTA has a position statement adopted
by the House of Delegates which states:
"PT patient/client management integrates an understanding of a
patient's/client's prescription and nonprescription medication
regimen with consideration of its impact upon health, impairments,
functional limitations, and disabilities. The administration and storage
of medications used for physical therapy interventions is also a
component of patient/client management and thus within the scope of PT
practice. Physical therapy interventions that may require the
concomitant use of medications include, but are not limited to, agents
that facilitate airway clearance and/or ventilation and
Each individual State Board of Physical Therapy may have official
statements or opinions regarding the administration of oxygen in
addition to the professional organization's statement.
The Increasing Need for Supplemental Oxygen
In 2006, 12.1 million United States adults aged 18 years and older
were estimated to have COPD. (10) However, the National Health and
Nutrition Examination Surveys (NHAMES) estimates that approximately 24
million adults in the United States have evidence of impaired lung
function, indicating that COPD is under diagnosed. (11) COPD is the 4th
most common cause of death in the United States and ranges from 5th to
14th worldwide. Of the 10 most common causes of death in the United
States, COPD is the only disease with an increasing mortality rate.
Mortality from COPD is increasing most rapidly in those areas of the
world with the greatest tobacco use, and among women. (12)
The population in the United States is aging. Considering that thefirst of the "baby boomers" are reaching 60+ years of age andthat the fastest growing population in the United States is over 85years of age, (13) physical therapists must be prepared to treat theolder population, be knowledgeable about their multiple medicalproblems, and be competent in using a range of modalities, such assupplemental oxygen, to augment improvement in their functional ability.Supplemental oxygen may be required by people of varied ages and withvaried types of pulmonary, cardiac and blood diseases such as COPD, IPF,congestive heart failure (CHF), cystic fibrosis (CF), and sickle cellanemia.
A thorough knowledge of oxygen equipment is imperative for the
physical therapist. Pulse oximetry is a noninvasive method of
photoelectrically determining the oxyhemoglobin saturation of arterial
blood. (14) A sensor is placed on a thin part of the patient's
anatomy such as a fingertip or earlobe and a light containing both red
and infrared wavelengths is passed through the skin to the small
arteries. A microprocessor compares the signals received and calculates
the degree of oxyhemoglobin saturation based on the intensity of
transmitted light. (14) Larger, stationery oximetry monitors are
typically used in intensive care units. Small, hand-held, portable
monitors are easily clipped to the distal end of a finger or attached to
the earlobe by an earlobe clip.
A variety of oxygen delivery devices may be used to administer
oxygen to the patient. The most common is the nasal cannula which can
provide oxygen flows from 0.25 to 6 liters per minute (LPM). An oxymizer
delivery device is a nasal cannula with a reservoir incorporated into
the tubing mechanism. (15) During exhalation, the reservoir fills with
oxygen and is available to the patient upon the next inhalation,
essentially providing equivalent saturations at lower flow rates.
Manufacturers state that an oxygen savings of approximately 75% may be
obtained by using the oxymizer and lower flow rates provide greater
patient comfort. (15)
Additionally, oxygen masks are used to deliver even higher
concentrations of supplemental oxygen. When pulmonary patients exercise,
higher percentages (Fi[O.sub.2]) of oxygen are needed to meet the demand
of working muscles and to maintain oxygen saturation levels within
prescribed limits (usually 88% to 90%). (14) Two types of oxygen masks
may be used during exercise with pulmonary patients. The venturi mask
uses a mechanical opening which increases the rate at which the oxygen
flows into the mask (commonly 24% to 50%). A partial rebreather mask has
a reservoir bag attached and physical therapy sports medicine delivers between 70% to > 80% of oxygen.
A non rebreather mask also incorporates a reservoir bag, but can deliver
up to 100% oxygen. Flows between 7 and 10 LPM are required to keep the
reservoir bag inflated at all times. (16) Less conspicuous forms of
oxygen delivery are available for low to moderate oxygen flow patients.
Transtracheal oxygen delivery consists of a small catheter being
surgically placed into the trachea through the second and third tracheal
rings. Transtracheal is well accepted by patients and delivers oxygen
more efficiently than a nasal cannula. Because oxygen is delivered
directly into the trachea, approximately 50% less oxygen is needed. (16)
Other more aesthetically appealing methods of oxygen delivery exist such
as small oxygen tubes being imbedded into eyeglass frames. (17)
Physical therapists must be well-informed about the varied
pathologies that may lead to the need for supplemental oxygen. A broad
spectrum of pulmonary, cardiac, and blood abnormalities warrant the use
of supplemental oxygen. Accordingly, PTs should be able to choose the
proper equipment for individual patients with various diagnoses by using
cardiopulmonary evaluation techniques, monitoring equipment, and
evidence based practice. Oxygen flow rates may require titration
depending on the level of physical activity (rest versus exercise versus
sleep). In addition, different diagnoses, due to their pathophysiology,
require lower or higher oxygen flow rates depending on the
patient's activity level.
The physician normally sets the flow rate for sleep and rest, but
with exercise, the PT is instrumental in determining the proper oxygen
flow rate needed. It is important to communicate with the physician
regarding oxygen requirements during exercise. With this knowledge, the
physician can make crucial decisions concerning the patient's
medication effectiveness, dosage, stability of the disease, and surgical
A few basic concepts of oxygen delivery, functional ability, and
biomechanics are necessary to guide the patient, physician, and oxygen
vendor in meeting a patient's specific equipment needs. There are
essentially 3 types of oxygen delivery systems. First, an oxygen
concentrator has the ability to deliver oxygen up to a level of 5 LPM.
It is a device that separates oxygen from room air. There are stationary
models, under electrical power, that are suitable to use around the
house and during sleep. Different lengths of oxygen tubing are available
to accommodate movement from room to room. More recently, portable
oxygen concentrators have become available that allow a patient to move
in and out of the house and community under battery power. These units
are much smaller, sit in a small 2 wheeled stroller, and are pulled
along behind the patient similar to a rolling suitcase. These units are
appropriate for patients on oxygen flows, at rest and with exercise,
between 1 and 5 LPM. The oxygen production is only limited by the life
of the portable battery charge when away from an electrical outlet. (18)
Second, compressed gas oxygen tanks are available in a range of
sizes for portable use. These are also mobile on a 2 wheeled stroller or
in a pack that can be supported over the shoulder. More recently, these
tanks are being manufactured from aluminum rather than iron or other
heavy metals, which is much lighter-weight and manageable for small
frame individuals. These tanks are used with an oxygen flow regulator
which attaches to the top of the cylinder. The regulator must be
manually changed to a full tank once the tank is emptied. There are 2
types of regulators: continuous flow and pulsed dose oxygen conservers.
The continuous flow delivers oxygen during the full respiratory cycle
(inspiration and expiration). Variations of these regulators will allow
flow rates between 0.25 and 25 LPM. At a flow rate of 2 LPM, one E
cylinder tank will last approximately 4-5 hours. (18) The oxygen
conserver regulator delivers oxygen during inhalation only (demand
system), or at pre-set intervals (pulsed system); thus, saving on the
amount of oxygen used over time. (19) These regulators are typically
used with smaller compressed gas tanks and deliver oxygen for variable
lengths of time dependent on the interval and volume of oxygen puffs and
the size of the tank. An E cylinder tank with an oxygen conserver
regulator can provide oxygen delivery > 15 hours at a flow rate of 2
LPM. (18) Depending on the pathology and the individual oxygen
requirements, the PT must decide which compressed gas oxygen tank and
regulator will best meet the patient's needs. Ambulatory oxygen
systems are defined as those weighing less than 10 lbs. Many patients
find 8.5 lbs. a practical weight to carry, but smaller framed patients
may be better served with a unit in the < 5 lb. range. (20)
Biomechanical and psychomotor factors to be considered are that some
patients have difficulty with the manual task of changing regulators due
to weakness of the hands, joint deformities, pain, or cognitive
deficits. Other patients who have osteoporosis or back pain may have
difficulty lifting compressed gas tanks in and out of a car due to their
weight and awkward shape. Still other patients with gait abnormalities
have difficulty maneuvering tanks in strollers over curbs, steps, and
through doors. (21)
A third type of oxygen delivery is a liquid oxygen system. A large
stationary tank is typically delivered to the patient's home. The
patient is also provided with a portable tank that is refilled off of
the stationary tank. Portable liquid tanks come in a variety of sizes
and weights. The largest liquid system has the capability of a 15 LPM
flow rate and can be carried either on the shoulder, in a backpack, or
in a 2 wheeled stroller. One of the smallest units has a maximum of 4
LPM flow rate, pulsed or continuous, and may be carried by the small
handle on the unit or worn around the waist in a waist pack. (18)
For Medicare Part B patients, supplemental oxygen is supplied by a
Durable Medical Equipment (DME) carrier. The physician must complete and
sign a Certificate of Medical Necessity (CMN) describing the
patient's need for oxygen, arterial blood gases or oxygen
saturation levels, prescribed flow rate, and medical diagnosis. If a
specific type of portable system or flow rate is required for a patient
to participate in a full range of physical activities, it must be noted
on the CMN. Otherwise, because DME suppliers are reimbursed at a fixed
rate, regardless of the oxygen system they provide the patient,
suppliers realize a larger profit by providing less costly systems. A
supplier cannot change a physician's prescription; therefore, it
must be filled as written. (22)
In conclusion, it is not uncommon for PTs to treat a variety of
patients who require supplemental oxygen, either on an in-patient or
out-patient basis. It is within the physical therapy scope of practice
to administer and adjust oxygen according to the physician's
prescription. The physical therapist must have a thorough knowledge of
oxygen equipment and how to use various devices to meet the
physiological and biomechanical needs of the patient.
(1.) American Lung Association. Fact Sheet: Oxygen. Nov 2004.
Available at www.lungusa.org. Accessed December, 2007.
(2.) Krop HD, Block AJ, Cohen E. Neuropsychologic effects of
continuous oxygen therapy in chronic obstructive pulmonary disease.
(3.) Continuous or nocturnal oxygen therapy in hypoxemic chronic
obstructive lung disease: a clinical trial. Nocturnal Oxygen Therapy
Trial Group. Ann Intern Med. 1980;93:391-398.
(4.) Petty TL, Finigan MM. Clinical evaluation of prolonged
ambulatory oxygen therapy in chronic airway obstruction. Am J Med.
(5.) Long term domiciliary oxygen therapy in chronic hypoxic cor
pulmonale complicating chronic bronchitis and emphysema. Report of the
Medical Research Council Working Party. Lancet. 1981;317:681-686.
(6.) American Physical Therapy Association. Guide to Physical
Therapist Practice. 2nd ed. Alexandria, Va; 2003.
(7.) American Physical Therapy Association. Oxygen Administration
During Physical Therapy. Available at: www.apta.org. Accessed December
(8.) Human drug CGMP Notes. 4(4), Dec 1996. Available at:
www.fda.gov. Accessed December 2007.
(9.) Pharmacology in Physical Therapist Practice HOD P06-04-14-14
(Program 32). Available at www.apta.org. Accessed December 2007.
(10.) American Lung Association. Trends in COPD: Morbidity and
Mortality. Dec 2007. Available at www.lungusa.org. Accessed February,
(11.) Centers for Disease Control and Prevention. Chronic
Obstructive Pulmonary Disease Surveillance-United States, 1971-2000.
Available at: www.usa.gov. Accessed December 2007.
(12.) Hartert TV, Gabb MG: The National and Global Impact of COPD.
Johns Hopkins ADV STUD MED. 2004;4(10A):S738-743.
(13.) Administration on Aging. Aging into the 21st Century.
Available at: www.aoa.gov. Accessed March 2008.
(14.) Sadowsky HS. Pulmonary diagnostic tests and procedures. In:
Hillegass EA, Sadowsky HS. Essentials of Cardiopulmonary Physical
Therapy. 2nd ed. Philadelphia, Pa: W. B. Saunders; 2001:421-449.
(15.) Oxymizer Disposable Oxygen-Conserving Devices. Available at:
www.chadtherapeutics.com. Accessed March 2008.
(16.) Frownfelter D, Baskin MW. Respiratory care practice review.
In: Frownfelter D, Dean E. Cardiovascular and Pulmonary Physical
Therapy: Evidence and Practice, 4th ed. St. Louis, Mo: Mosby;
(17.) Hoffman LA, Wesmiller SW. Home oxygen: transtracheal and
other options. Am J Nurs. 1988;88:464469.
(18.) Petty TL. Guide to prescribing home oxygen: Types of home
oxygen systems. National Lung Health Education Program (NLHEP).
Available at: www.nlhep.org. Accessed December 2007.
(19.) NLHEP. Conserving device technology. Available at:
www.nlhep.org. Accessed December 2007.
(20.) NLHEP. Keys to successful treatment. Available at:
www.nlhep.org. Accessed December 2007.
(21.) NLHEP. Patient considerations in selecting equipment.
Available at: www.nlhep.org. Accessed December 2007.
(22.) NLHEP. Costs and reimbursement. Available at: www. nlhep.org.
Accessed December 2007.
Rebecca H. Crouch, PT, MS, CCS, FAACVPR Coordinator of Pulmonary
Rehabilitation, Duke University Medical Center, Department of Physical
On One Hand: National StandardsGood chiropractors have appropriate training and are licensed. The American Chiropractic Association notes that chiropractors should sports and physical therapy associates have four years of pre-medical college and another four to five years of accredited chiropractic education. The ACA also mentions that before beginning a practice, chiropractors must pass a national examination and become licensed in their state.
On the Other: Overstepping the BoundsSome chiropractors could try to use methods and treatments that may not be scientifically proven and appropriate. Ben Goldacre, in his article "Chiropractors Cause Controversy,"discusses this negative aspect of the chiropractic field. He notes that some claims of chiropractors, for example, of the ability to heal children's ailments such as colic have not been scientifically proven.
Bottom LineGood chiropractors are well-educated, have passed national examination and are licensed. Despite these credentials, some chiropractors may use treatments that are not yet scientifically proven. You should do research on the individual chiropractor before accepting his treatment.