OBJECTIVE: To analyse the timing of Return to Sports (RTS) as a potential risk factor for a second anterior cruciate ligament (ACL) injury after ACL reconstruction. DESIGN: Systematic review with ...meta-analysis. LITERATURE SEARCH: The Cochrane Library, EMbase, MEDLINE, AMED and PEDro databases were searched in August 2021 and November 2022. STUDY SELECTION CRITERIA: Clinical studies published in English in peer-reviewed journals, that reported time to RTS after ACL reconstruction and occurrence of second ACL injury were eligible. DATA SYNTHESIS: We pooled continuous data with random-effects meta-analyses, and pooled estimates were summarised in forest plots. A qualitative data synthesis was performed for data not included in meta-analysis. RESULTS: Twenty-one studies were included in the meta-analysis and 33 were included in the qualitative synthesis. Pooled incidence of a second ACL injury was 16.9% (95% Confidence Interval CI 12.8-21.6). Patients who suffered a second ACL injury returned to sport significantly earlier (0.77 months 95% CI 0.26-1.28). CONCLUSION: Time to RTS was a risk factor for a second ACL injury, where patients who suffered a second ACL injury returned to sport almost one month earlier compared with patients who did not suffer a second ACL injury: 9.1 compared with 8.7 months. There was no difference in time to RTS between professional athletes who suffered a second ACL injury and athletes who did not. The certainty of evidence in the results was graded as "very low".
Background: Underlying factors contributing to increased risk of graft rupture after anterior cruciate ligament reconstruction (ACLR) are not well described.
Objective: To systematically review ...intrinsic risk factors for sustaining a graft rupture.
Design: A systematic review with meta-analysis according to the PRISMA guidelines. Four databases (MEDLINE, CINAHL, EMBASE, Sport Discus) were searched from inception to January 2020. Meta-analyses (random effect model) were performed and expressed as odds ratios (OR).
Setting: The included studies describe a variety of sport settings and activity levels.
Participants: The review comprises studies including males and/or females of any age who have had ACLR.
Assessment of Risk Factors: All longitudinal studies investigating any intrinsic risk factor for future graft rupture were included.
Main Outcome Measurements: Graft rupture.
Results: Seventy-seven studies were eligible for meta-analysis. The following factors all independently increased the odds of sustaining a graft rupture after ACLR: Age ≤ 18 years (OR: 3.87, 95% CI: 2.32–6.46), higher pre-primary injury activity level (OR: 2.43, 95% CI: 1.56–3.82), family history of ACL injury (OR: 1.98, 95% CI: 1.50–2.62), returning to a high activity level (OR: 1.87, 95% CI: 1.11–3.15), and increased lateral tibial slope (OR: 1.64, 95% CI: 1.13–2,38). None of the following factors were found to be associated with future graft rupture; sex, smoking status, generalized joint laxity, timing of surgery or return to sport (RTS), playing soccer compared to other sports, hop performance at time of RTS or concomitant meniscal or collateral ligament injuries.
Conclusions: Young age, family history of ACL injury, high tibial slope and previous and current high activity level should be considered when screening for increased risk of graft rupture following ACLR. Future studies on the possible role of sensorimotor factors, e.g., muscle activation and/or strength and proprioception for future graft ruptures are warranted.
Background: There is limited knowledge about which risk factors that contribute to the high numbers of contra-lateral anterior cruciate ligament (C-ACL) injury after primary ACL injury.
Objective: ...To systematically review intrinsic risk factors for sustaining a C-ACL injury.
Design: A systematic review with meta-analysis according to the PRISMA guidelines. Four databases (MEDLINE, CINAHL, EMBASE, Sport Discus) were searched from inception to January 2020. Meta-analyses were performed and expressed as odds ratios (OR).
Setting: The included studies describe a variety of sport settings and activity levels.
Participants: The review comprises studies including males and/or females of any age with ACL injury.
Assessment of Risk Factors: The review comprises longitudinal studies investigating any intrinsic risk factor for future C-ACL injury.
Main Outcome Measurements: C-ACL injury
Results: Thirty-five moderate-to-high quality studies were eligible for meta-analysis, including up to ~59 000 individuals. The following factors all independently increased the odds of sustaining a C-ACL: Returning to a high activity level (OR: 3.26, 95% CI: 2.10–5.06), BMI < 25 (OR: 2.73, 95% CI: 1.73–4.36), Age ≤ 18 years (OR: 2.42, 95% CI: 1.51–3.88), Family history of ACL injury (OR: 2.07, 95% CI: 1.54–2.80), Primary ACL reconstruction performed ≤ 3 months post injury (OR: 1.65, 95% CI: 1.32–2.06), Female sex (OR: 1.35, 95% CI: 1.14–1.61) and Concomitant meniscal injury (OR 1.21, 95% CI: 1.03–1.42). There were no associations between the odds of sustaining a C-ACL injury and Smoking status, Pre-injury activity level, Playing soccer compared to other sports or Timing of return to sport.
Conclusions: Demographic factors such as female sex, young age and family history of ACL injury, as well as early reconstruction and returning to a high activity level all contribute to the risk of sustaining a C-ACL injury. Studies on modifiable sensorimotor risk factors are warranted.
Introduction : Hospital-acquired pneumonia may affect hospitalized patients and results in increased morbidity and mortality. Preventive actions to reduce the incidence are required, especially in ...patients at a higher risk of postoperative complications, such as the elderly.
Purpose : To explore whether an intensified physiotherapy regimen can prevent hospital-acquired pneumonia and reduce hospital length of stay in patients aged 80 and older who have undergone hip fracture surgery.
Method : Inclusion criteria were patients aged 80 or older who had undergone hip fracture surgery at a University Hospital in Sweden (n=69). The study has a quasi-experimental design with a historical comparison group (n=64) receiving routine physiotherapy treatment. The intervention group received intensified physiotherapy which included breathing exercises with positive expiratory pressure (PEP) valve. The patients were instructed to take a deep breath, hold their breath for two seconds and then exhale through the valve three sessions of 10 deep breaths, with 30–60 seconds of rest, at least four times daily. Early mobilization to a seated position and walking was advised as soon as possible after surgery.
Results : There was a significant difference in number of hospital-acquired pneumonia between the intervention group; 2 patients (3%) and the comparison group; 13 patients (20%) (p=0.002). Patients in the intervention group had a significantly shorter length of stay than those in the comparison group (10.6 ± 4 vs 13.4 ± 9 days, p=0.022).
Conclusion : Intensified physiotherapy treatment after hip fracture surgery may be of benefit to reduce the number of hospital-acquired pneumonia in patients over 80 years.
Background
Cystic fibrosis is a life‐limiting genetic condition in which thick mucus builds up in the lungs, leading to infections, inflammation, and eventually, deterioration in lung function. To ...clear their lungs of mucus, people with cystic fibrosis perform airway clearance techniques daily. There are various airway clearance techniques, which differ in terms of the need for assistance or equipment, and cost.
Objectives
To summarise the evidence from Cochrane Reviews on the effectiveness and safety of various airway clearance techniques in people with cystic fibrosis.
Methods
For this overview, we included Cochrane Reviews of randomised or quasi‐randomised controlled trials (including cross‐over trials) that evaluated an airway clearance technique (conventional chest physiotherapy, positive expiratory pressure (PEP) therapy, high‐pressure PEP therapy, active cycle of breathing techniques, autogenic drainage, airway oscillating devices, external high frequency chest compression devices and exercise) in people with cystic fibrosis.
We searched the Cochrane Database of Systematic Reviews on 29 November 2018.
Two review authors independently evaluated reviews for eligibility. One review author extracted data from included reviews and a second author checked the data for accuracy. Two review authors independently graded the quality of reviews using the ROBIS tool. We used the GRADE approach for assessing the overall strength of the evidence for each primary outcome (forced expiratory volume in one second (FEV1), individual preference and quality of life).
Main results
We included six Cochrane Reviews, one of which compared any type of chest physiotherapy with no chest physiotherapy or coughing alone and the remaining five reviews included head‐to‐head comparisons of different airway clearance techniques. All the reviews were considered to have a low risk of bias. However, the individual trials included in the reviews often did not report sufficient information to adequately assess risk of bias. Many trials did not sufficiently report on outcome measures and had a high risk of reporting bias.
We are unable to draw definitive conclusions for comparisons of airway clearance techniques in terms of FEV1, except for reporting no difference between PEP therapy and oscillating devices after six months of treatment, mean difference ‐1.43% predicted (95% confidence interval ‐5.72 to 2.87); the quality of the body of evidence was graded as moderate. The quality of the body of evidence comparing different airway clearance techniques for other outcomes was either low or very low.
Authors' conclusions
There is little evidence to support the use of one airway clearance technique over another. People with cystic fibrosis should choose the airway clearance technique that best meets their needs, after considering comfort, convenience, flexibility, practicality, cost, or some other factor. More long‐term, high‐quality randomised controlled trials comparing airway clearance techniques among people with cystic fibrosis are needed.
Background
Cystic fibrosis (CF) is an inherited life‐limiting disorder. Over time persistent infection and inflammation within the lungs contribute to severe airway damage and loss of respiratory ...function. Chest physiotherapy, or airway clearance techniques (ACTs), are integral in removing airway secretions and initiated shortly after CF diagnosis. Conventional chest physiotherapy (CCPT) generally requires assistance, while alternative ACTs can be self‐administered, facilitating independence and flexibility. This is an updated review.
Objectives
To evaluate the effectiveness (in terms of respiratory function, respiratory exacerbations, exercise capacity) and acceptability (in terms of individual preference, adherence, quality of life) of CCPT for people with CF compared to alternative ACTs.
Search methods
We used standard, extensive Cochrane search methods. The latest search was 26 June 2022.
Selection criteria
We included randomised or quasi‐randomised controlled trials (including cross‐over design) lasting at least seven days and comparing CCPT with alternative ACTs in people with CF.
Data collection and analysis
We used standard Cochrane methods. Our primary outcomes were 1. pulmonary function tests and 2. number of respiratory exacerbations per year. Our secondary outcomes were 3. quality of life, 4. adherence to therapy, 5. cost–benefit analysis, 6. objective change in exercise capacity, 7. additional lung function tests, 8. ventilation scanning, 9. blood oxygen levels, 10. nutritional status, 11. mortality, 12. mucus transport rate and 13. mucus wet or dry weight.
We reported outcomes as short‐term (seven to 20 days), medium‐term (more than 20 days to up to one year) and long‐term (over one year).
Main results
We included 21 studies (778 participants) comprising seven short‐term, eight medium‐term and six long‐term studies. Studies were conducted in the USA (10), Canada (five), Australia (two), the UK (two), Denmark (one) and Italy (one) with a median of 23 participants per study (range 13 to 166). Participant ages ranged from newborns to 45 years; most studies only recruited children and young people. Sixteen studies reported the sex of participants (375 males; 296 females).
Most studies compared modifications of CCPT with a single comparator, but two studies compared three interventions and another compared four interventions. The interventions varied in the duration of treatments, times per day and periods of comparison making meta‐analysis challenging. All evidence was very low certainty.
Nineteen studies reported the primary outcomes forced expiratory volume in one second (FEV1)and forced vital capacity (FVC), and found no difference in change from baseline in FEV1 % predicted or rate of decline between groups for either measure. Most studies suggested equivalence between CCPT and alternative ACTs, including positive expiratory pressure (PEP), extrapulmonary mechanical percussion, active cycle of breathing technique (ACBT), oscillating PEP devices (O‐PEP), autogenic drainage (AD) and exercise. Where single studies suggested superiority of one ACT, these findings were not corroborated in similar studies; pooled data generally concluded that effects of CCPT were comparable to those of alternative ACTs.
CCPT versus PEP
We are uncertain whether CCPT improves lung function or has an impact on the number of respiratory exacerbations per year compared with PEP (both very low‐certainty evidence). There were no analysable data for our secondary outcomes, but many studies provided favourable narrative reports on the independence achieved with PEP mask therapy.
CCPT versus extrapulmonary mechanical percussion
We are uncertain whether CCPT improves lung function compared with extrapulmonary mechanical percussions (very low‐certainty evidence). The annual rate of decline in average forced expiratory flow between 25% and 75% of FVC (FEF25–75) was greater with high‐frequency chest compression compared to CCPT in medium‐ to long‐term studies, but there was no difference in any other outcome.
CCPT versus ACBT
We are uncertain whether CCPT improves lung function compared to ACBT (very low‐certainty evidence). Annual decline in FEF25–75 was worse in participants using the FET component of ACBT only (mean difference (MD) 6.00, 95% confidence interval (CI) 0.55 to 11.45; 1 study, 63 participants; very low‐certainty evidence). One short‐term study reported that directed coughing was as effective as CCPT for all lung function outcomes, but with no analysable data. One study found no difference in hospital admissions and days in hospital for exacerbations.
CCPT versus O‐PEP
We are uncertain whether CCPT improves lung function compared to O‐PEP devices (Flutter device and intrapulmonary percussive ventilation); however, only one study provided analysable data (very low‐certainty evidence). No study reported data for number of exacerbations. There was no difference in results for number of days in hospital for an exacerbation, number of hospital admissions and number of days of intravenous antibiotics; this was also true for other secondary outcomes.
CCPT versus AD
We are uncertain whether CCPT improves lung function compared to AD (very low‐certainty evidence). No studies reported the number of exacerbations per year; however, one study reported more hospital admissions for exacerbations in the CCPT group (MD 0.24, 95% CI 0.06 to 0.42; 33 participants). One study provided a narrative report of a preference for AD.
CCPT versus exercise
We are uncertain whether CCPT improves lung function compared to exercise (very low‐certainty evidence). Analysis of original data from one study demonstrated a higher FEV1 % predicted (MD 7.05, 95% CI 3.15 to 10.95; P = 0.0004), FVC (MD 7.83, 95% CI 2.48 to 13.18; P = 0.004) and FEF25–75 (MD 7.05, 95% CI 3.15 to 10.95; P = 0.0004) in the CCPT group; however, the study reported no difference between groups (likely because the original analysis accounted for baseline differences).
Authors' conclusions
We are uncertain whether CCPT has a more positive impact on respiratory function, respiratory exacerbations, individual preference, adherence, quality of life, exercise capacity and other outcomes when compared to alternative ACTs as the certainty of the evidence is very low.
There was no advantage in respiratory function of CCPT over alternative ACTs, but this may reflect insufficient evidence rather than real equivalence. Narrative reports indicated that participants prefer self‐administered ACTs. This review is limited by a paucity of well‐designed, adequately powered, long‐term studies. This review cannot yet recommend any single ACT above others; physiotherapists and people with CF may wish to try different ACTs until they find an ACT that suits them best.
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