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".
Since the concept of evidence-based medicine was introduced into medical practice, a paradigm shift from conventional empirical-based physical therapy to evidence-based physical therapy has been ...promoted. In order to practice evidence-based physical therapy, the elements of "using evidence," "creating evidence," and "communicating evidence" are essential. However, these practical methods still need wide dissemination. As such, this book provides a comprehensive overview of evidence-based physical therapy. Chapters are organized into three sections: "Physical Therapy Theory", "Physical Therapy Assessment", and "Physical Therapy Practice". This book will help healthcare professionals establish evidence-based physical therapy and deliver optimal physical therapy to their patients.
Background
Autogenic drainage is an airway clearance technique that was developed by Jean Chevaillier in 1967. The technique is characterised by breathing control using expiratory airflow to mobilise ...secretions from smaller to larger airways. Secretions are cleared independently by adjusting the depth and speed of respiration in a sequence of controlled breathing techniques during exhalation. The technique requires training, concentration and effort from the individual but it has previously been shown to be an effective treatment option for those who are seeking techniques to support and promote independence. However, at a time where the trajectory and demographics of the disease are changing, it is important to systematically review the evidence demonstrating that autogenic drainage is an effective intervention for people with cystic fibrosis.
Objectives
To compare the clinical effectiveness of autogenic drainage in people with cystic fibrosis with other physiotherapy airway clearance techniques.
Search methods
We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference books. We also searched the reference lists of relevant articles and reviews, as well as two ongoing trials registers (02 February 2021).
Date of most recent search of the Cochrane Cystic Fibrosis Trials Register: 06 July 2021.
Selection criteria
We identified randomised and quasi‐randomised controlled studies comparing autogenic drainage to another airway clearance technique or no therapy in people with cystic fibrosis for at least two treatment sessions.
Data collection and analysis
Data extraction and assessments of risk of bias were independently performed by three authors. The authors assessed the quality of the evidence using the GRADE system. The authors contacted seven teams of investigators for further information pertinent to their published studies.
Main results
Searches retrieved 64 references to 37 individual studies, of which eight (n = 212) were eligible for inclusion. One study was of parallel design with the remaining seven being cross‐over in design; participant numbers ranged from 4 to 75. The total study duration varied between four days and two years. The age of participants ranged between seven and 63 years with a wide range of disease severity reported. Six studies enrolled participants who were clinically stable, whilst participants in two studies received treatment whilst hospitalised with an infective exacerbation. All studies compared autogenic drainage to one (or more) other recognised airway clearance technique. Exercise is commonly used as an alternative therapy by people with cystic fibrosis; however, there were no studies identified comparing exercise with autogenic drainage.
The certainty of the evidence was generally low or very low. The main reasons for downgrading the level of evidence were the frequent use of a cross‐over design, outcome reporting bias and the inability to blind participants.
The review's primary outcome, forced expiratory volume in one second, was the most common outcome measured and was reported by all eight studies; only three studies reported on quality of life (also a primary outcome of the review). One study reported on adverse events and described a decrease in oxygen saturation levels whilst performing active cycle of breathing techniques, but not with autogenic drainage. Seven of the eight included studies measured forced vital capacity and three of the studies used mid peak expiratory flow (per cent predicted) as an outcome. Six studies reported sputum weight. Less commonly used outcomes included oxygen saturation levels, personal preference, hospital admissions, intravenous antibiotics and pseudomonas gene expression. There were no statistically significant differences found between any of the techniques used with respect to the outcomes measured except when autogenic drainage was described as being the preferred technique of the participants in one study over postural drainage and percussion.
Authors' conclusions
Autogenic drainage is a challenging technique that requires commitment from the individual. As such, this intervention merits systematic review to ensure its effectiveness for people with cystic fibrosis, particularly in an era where treatment options are changing rapidly. From the studies assessed, autogenic drainage was not found to be superior to any other form of airway clearance technique. Larger studies are required to better evaluate autogenic drainage in comparison to other airway clearance techniques in view of the relatively small number of participants in this review and the complex study designs. The studies recruited a range of participants and were not powered to assess non‐inferiority. The varied length and design of the studies made the analysis of pooled data challenging.
Background
Chest physiotherapy is widely prescribed to assist the clearance of airway secretions in people with cystic fibrosis (CF). Positive expiratory pressure (PEP) devices provide back pressure ...to the airways during expiration. This may improve clearance by building up gas behind mucus via collateral ventilation and by temporarily increasing functional residual capacity. The developers of the PEP technique recommend using PEP with a mask in order to avoid air leaks via the upper airways and mouth. In addition, increasing forced residual capacity (FRC) has not been demonstrated using mouthpiece PEP. Given the widespread use of PEP devices, there is a need to determine the evidence for their effect. This is an update of a previously published review.
Objectives
To determine the effectiveness and acceptability of PEP devices compared to other forms of physiotherapy as a means of improving mucus clearance and other outcomes in people with CF.
Search methods
We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising of references identified from comprehensive electronic database searches and handsearches of relevant journals and books of conference proceedings. The electronic database CINAHL was also searched from 1982 to 2017.
Most recent search of the Group's CF Trials Register: 20 February 2019.
Selection criteria
Randomised controlled studies in which PEP was compared with any other form of physiotherapy in people with CF. This included, postural drainage and percussion (PDPV), active cycle of breathing techniques (ACBT), oscillating PEP devices, thoracic oscillating devices, bilevel positive airway pressure (BiPaP) and exercise.
Data collection and analysis
Three authors independently applied the inclusion and exclusion criteria to publications, assessed the risk of bias of the included studies and assessed the quality of the evidence using the GRADE recommendations.
Main results
A total of 28 studies (involving 788 children and adults) were included in the review; 18 studies involving 296 participants were cross‐over in design. Data were not published in sufficient detail in most of these studies to perform any meta‐analysis. In 22 of the 28 studies the PEP technique was performed using a mask, in three of the studies a mouthpiece was used with nose clips and in three studies it was unclear whether a mask or mouthpiece was used. These studies compared PEP to ACBT, autogenic drainage (AD), oral oscillating PEP devices, high‐frequency chest wall oscillation (HFCWO) and BiPaP and exercise.
Forced expiratory volume in one second was the review's primary outcome and the most frequently reported outcome in the studies (24 studies, 716 participants). Single interventions or series of treatments that continued for up to three months demonstrated little or no difference in effect between PEP and other methods of airway clearance on this outcome (low‐ to moderate‐quality evidence). However, long‐term studies had equivocal or conflicting results regarding the effect on this outcome (low‐ to moderate‐quality evidence).
A second primary outcome was the number of respiratory exacerbations. There was a lower exacerbation rate in participants using PEP compared to other techniques when used with a mask for at least one year (five studies, 232 participants; moderate‐ to high‐quality evidence). In one of the included studies which used PEP with a mouthpiece, it was reported (personal communication) that there was no difference in the number of respiratory exacerbations (66 participants, low‐quality evidence).
Participant preference was reported in 10 studies; and in all studies with an intervention period of at least one month, this was in favour of PEP. The results for the remaining outcome measures (including our third primary outcome of mucus clearance) were not examined or reported in sufficient detail to provide any high‐quality evidence; only very low‐ to moderate‐quality evidence was available for other outcomes. There was limited evidence reported on adverse events; these were measured in five studies, two of which found no events. In a study where infants performing either PEP or PDPV experienced some gastro‐oesophageal reflux , this was more severe in the PDPV group (26 infants, low‐quality evidence). In PEP versus oscillating PEP, adverse events were only reported in the flutter group (five participants complained of dizziness, which improved after further instructions on device use was provided) (22 participants, low‐quality evidence). In PEP versus HFCWO, from one long‐term high‐quality study (107 participants) there was little or no difference in terms of number of adverse events; however, those in the PEP group had fewer adverse events related to the lower airways when compared to HFCWO (high‐certainty evidence).
Many studies had a risk of bias as they did not report how the randomisation sequence was either generated or concealed. Most studies reported the number of dropouts and also reported on all planned outcome measures.
Authors' conclusions
The evidence provided by this review is of variable quality, but suggests that all techniques and devices described may have a place in the clinical treatment of people with CF.
Following meta‐analyses of the effects of PEP versus other airway clearance techniques on lung function and patient preference, this Cochrane Review demonstrated that there was high‐quality evidence that showed a significant reduction in pulmonary exacerbations when PEP using a mask was compared with HFCWO. It is important to note that airway clearance techniques should be individualised throughout life according to developmental stages, patient preferences, pulmonary symptoms and lung function. This also applies as conditions vary between baseline function and pulmonary exacerbations.
STUDY DESIGN:Human volunteers were exposed experimentally to single-sidedmechanical shocks (SSMS) and double-sided mechanical shocks (DSMS) while seated.
OBJECTIVE:To describe and contrast seated ...postural reactions due to SSMSor DSMS in healthy male adults.
SUMMARY OF BACKGROUND DATA:Mechanical shocks to the body, caused when driving on irregular terrain,are suggested to be hazardous to the spine and may be associated with the reported musculoskeletal pain of the back and neck among professional drivers. However, very little is known about the characteristics of seated postural reactions and the biomechanical effects caused by mechanical shocks.
METHODS:Twenty healthy male subjects (18-43 years old) were exposed while seated to 5 SSMS and 15 DSMS in lateral directions. The second acceleration in the DSMSwas in the opposite direction to the first acceleration and was eitherfast, medium or slow depending on the speed of direction change. Surface electromyography (EMG) was recorded in muscles of the upper neck, trapezius, erector spinae and external oblique while kinematics were recorded with inertial sensors placed at the neck, trunk and pelvis. Muscle activity was normalized to maximum voluntary contractions (MVC).
RESULTS:The EMG amplitudes were significantly higher (0.6-1%; p<0.001) for the fast DSMS compared to all other shocks. Range of motion (ROM)of the neck and trunk was greater during the DSMS compared to the SSMS. Evoked muscle activity was less than 2% MVC in the trapezius, less than 10% MVC in the erector spinae and upper neck while the activity exceeded 10% MVC in the external oblique muscles.
CONCLUSION:Fast DSMS in lateral directions appear more demanding compared to SSMS,demonstrating augmentedseated postural reactions. However, the present mechanical shocks employed did not seem to induce postural reactions with regard to ROM or muscle activity of a magnitude likely to cause musculoskeletal overload.Level of Evidence4
Physiotherapy in a specialized rehabilitation center (CER) has an important role in the care of Persons with Disabilities (PwD), it can be a fundamental part of adopting the biopsychosocial approach ...that is sought in these centers, provided that the organization of work is also aligned providing comprehensive care to PwD.
to know facilitators and obstacles related to the organization of the physiotherapist's work in the Center specialized in rehabilitation and its relationship with the care practices provided to Persons with Disabilities.
This is a qualitative and descriptive study, taking the case study as a guiding model, developed from ethnographic analysis resources. The study was developed with the association of three data collection strategies: document analysis, direct observation with conversational approaches and interviews with CER physiotherapists in the state of Paraíba-PB, data analysis was performed through the reconstruction of scenes, articulating the elements captured in the data production process.
The study reveals that there are weaknesses in the organization of the work of physiotherapists in the CER in question, and that these have an impact on the way work is conducted and provided to people with disabilities, noting that improvements and adjustments are needed in the organization of work in issues such as: promoting strategies that bring the physiotherapist closer to practices such as welcoming, favoring moments between the physiotherapist and the multidisciplinary team for assessments in an integrated manner and articulation with other points of the care network for people with disabilities, stimulating and organizing strategies to strengthen and include shared care in the sector, and implement strategies such as team meetings and the execution of the Singular Therapeutic Project.
Knowledge of the facilitators and obstacles in the organization of the physiotherapists' work allowed identifying the weaknesses present in the service, which distances these professionals from providing assistance from the perspective of the biopsychosocial approach to CER users, and verifying the aspects that contribute to the distance between work prescribed by the Rehabilitation Instruction, and how the work is performed at the study site.
Understanding the organization of the work of physiotherapists in health services is still a scarce task in the field of research, so this work raises this debate in the field of physiotherapy. In addition, its results can become important elements for a better understanding of the management of the work of these professionals in the centers and perhaps produce changes in the organization and work process of physiotherapists in the CER.
The 6-Minute Step Test (6MST) has been used to evaluate exercise capacity and physiological responses during the test in different populations, to assess physical performance for the activity of ...stepping up and down a step, as well as check for possible symptoms that the individual may present during the test. The use of 6MST to evaluate the exercise capacity of individuals who were hospitalized for COVID-19 can identify the persistence of symptoms and exercise intolerance.
To compare the exercise capacity and physiological responses of individuals hospitalized for COVID-19 using the 6MST, at 30 days and 12 months after hospital discharge.
A longitudinal study was conducted with individuals hospitalized for COVID-19 and evaluated at two-time points: 30 days after hospital discharge and 12 months after hospital discharge. The 6MST was applied with monitoring of vital signs (blood pressure - BP, heart rate - HR, and peripheral oxygen saturation - SpO2) and recording of perceived pain/fatigue in the lower limbs and respiratory fatigue. At the end of the test, the number of steps executed was recorded to establish the individual's exercise capacity and to identify the percentage of the number of steps achieved according to predicted values for sex, age, height, and weight.
Twenty-three individuals were evaluated, and a significant difference was found in the 6MST performance (p≤0.05), with a higher number of steps recorded in the evaluation after 12 months of hospital discharge in 82.6% of individuals. Regarding vital signs, there was a statistically significant difference (p≤0.05) in SpO2 at the peak of the 6MST, with better saturation in the evaluation performed after 12 months of hospital discharge. There was a moderate positive correlation (R=0.420, p≤0.046) between a worse 6MST performance (evaluated by the number of steps) in individuals who required intensive care. There was no statistically significant difference (p≤0.05) in HR and SpO2 at the peak of the test and in the first minute of recovery.
The exercise capacity verified by the 6MST performance in individuals who were hospitalized and received intensive care due to COVID-19 is significantly lower in the first days after hospital discharge, compared to a period of 12 months after discharge. The 6MST performance was better after 12 months of hospital discharge, indicating improvement in exercise tolerance in 82.6% of individuals. The mean SpO2 measured at the peak of the 6MST was lower in the evaluation at 30 days compared to the assessment at 12 months after hospital discharge. It may be related to lower exercise capacity in individuals affected by COVID-19.
It is necessary to monitor these individuals affected by COVID-19, and when indicated, they should be included in a pulmonary rehabilitation program with individualized physical training prescription, promoting improvement in exercise capacity and reduction of persistent symptoms.
COPD is described as a progressive and persistent airflow limitation, with the presence of pulmonary and extrapulmonary manifestations such as dyspnea, reduced exercise capacity and muscle weakness, ...which impairs functional performance and physical activity as the disease worsens. The functional performance can be assessed by the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) questionnaire, as it is an instrument that encompasses biopsychosocial principles according to the International Classification of Functioning, Disability and Health, however there is no knowledge whether this instrument can track physical inactivity in this population.
To verify the correlation between WHODAS questionnaire score and physical activity levels in people with COPD.
This is a cross-sectional study, which assessed 35 patients with COPD, aged over 50 years (21 males, 69±8 years, FEV1/FVC 56 ±13%, FEV1 post-Bronchodilator 50 ± 13%). This study was approved by the Research Ethics Committee of the Federal University of São Carlos (UFSCar), under number 85901318.0.0000.55.04. To evaluate functionality, the WHODAS 2.0 questionnaire, with 36 items was applied in the interview format. The level of physical activity was assessed by the actigraph activPAL3TM (Pal Technologies Ltd., Glasgow, United Kingdom), for 7 consecutive days, by time spent sitting, standing and walking; number of steps and time spent at certain exercise intensities (sedentary, if MET <1.5 and low intensity exercise, if MET >1.5, but < 3). Participants who could not perform the proposed tests and/or had difficulty understanding the questionnaire were excluded. For data analysis and correlation, the statistical software SPSS version 21 (2012) was used, with significance established at a p value <0.05.
Significant correlation were found only between the mobility domain of WHODAS 2.0 and number of steps (r= -0.490; p=0.003), sitting time (r=0.472; p=0.004), standing time (r= -0.366; p= 0.031), walking time (r= -0.510; p= 0.002), time during MET < 1.5 (r= 0.426; p= 0.011) and time during MET >1.5, but < 3 (r= -0.428; p=0.010).
The WHODAS 2.0 mobility domain showed association with the variables that reflect the level of physical activity and sedentary time in COPD patients, thus the instrument may be effective to track physical inactivity in this population.
This study shows that the WHODAS 2.0 questionnaire is an effective tool for tracking the level of physical activity in COPD patients and can be used as a clinical outcome before and after physical therapy intervention.
Osteoarthritis (OA) is a slow and progressive musculoskeletal disorder that primarily affects the hip and knee joints. As a result, it leads to loss of flexibility, pain, reduced range of motion, and ...affects gait and body balance, resulting in functional dependence and reduced quality of life for individuals. Physical therapy based on exercises is considered the best treatment option due to its favorable cost-benefit ratio, helping to reduce pain and improve physical function, gait, and body balance. Additionally, studies suggest that group physical therapy has proven beneficial as it utilizes fewer resources, thereby reducing costs, offering greater interaction among patients, and achieving similar results to individual treatment.
This study aimed to evaluate the effects of a group exercise protocol on static and dynamic body balance in individuals with knee and hip osteoarthritis.
A clinical trial was conducted with patients diagnosed with knee and/or hip OA, who were able to walk independently and scored above 25 on the Lower Extremity Functional Scale (LEFS). The assessment instruments included the LEFS functionality questionnaire, Visual Analogue Scale (VAS) for pain assessment, Agility and Dynamic Balance Test (ÁGIL), and Stabilometry using an electronic baropodometer (FootWalk Pro®, AM CUBE, France), where participants maintained a bipedal position without support for 30 seconds. The intervention protocol consisted of 10 group kinesiotherapy sessions, conducted twice a week, with progressive exercises. The first week focused on mobility exercises involving active movements of the lower limbs, ballistic stretching, oscillations, and adopting different positions. The second week they emphasized mobility and resistance, incorporating shin pads and active lower limb exercises. In the third week, the focus was on resistance with higher intensity compared to the previous week. The fourth week they included resistance and functional exercises simulating musculoskeletal strain during daily activities. The fifth week involved functional exercises with increased intensity and additional balance training. Data were presented as means and standard deviations, and comparisons were made using dependent sample tests determined by the Kolmogorov-Smirnov test with the assistance of SPSS software (version 19.0) at a significance level of 5%.
The sample comprised 27 participants, 20 women (74%) and seven men (26%), and a mean age of 64.19±8.33 years. After accounting for sample loss between the first and second evaluation moments (after intervention), there were 18 participants available for comparison tests. The results showed a significant 17% improvement in functional capacity and a 44% reduction in pain during movement.
The five-week group exercise protocol improved pain and functionality in this sample; however, it did not lead to significant changes in static and dynamic body balance parameters.
This study demonstrates the clinical applicability of group exercises, which can improve pain and function in patients with knee and/or hip osteoarthritis, thereby reducing costs and enhancing the efficiency of care in clinics.
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