Background
International clinical practice guidelines routinely recommend that cardiac patients participate in rehabilitation programmes for comprehensive secondary prevention. However, data show ...that only a small proportion of these patients utilise rehabilitation.
Objectives
First, to assess interventions provided to increase patient enrolment in, adherence to, and completion of cardiac rehabilitation. Second, to assess intervention costs and associated harms, as well as interventions intended to promote equitable CR utilisation in vulnerable patient subpopulations.
Search methods
Review authors performed a search on 10 July 2018, to identify studies published since publication of the previous systematic review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL); the National Health Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of s of Reviews of Effects (DARE)), in the Cochrane Library (Wiley); MEDLINE (Ovid); Embase (Elsevier); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost); and Conference Proceedings Citation Index ‐ Science (CPCI‐S) on Web of Science (Clarivate Analytics). We checked the reference lists of relevant systematic reviews for additional studies and also searched two clinical trial registers. We applied no language restrictions.
Selection criteria
We included randomised controlled trials (RCTs) in adults with myocardial infarction, with angina, undergoing coronary artery bypass graft surgery or percutaneous coronary intervention, or with heart failure who were eligible for cardiac rehabilitation. Interventions had to aim to increase utilisation of comprehensive phase II cardiac rehabilitation. We included only studies that measured one or more of our primary outcomes. Secondary outcomes were harms and costs, and we focused on equity.
Data collection and analysis
Two review authors independently screened the titles and s of all identified references for eligibility, and we obtained full papers of potentially relevant trials. Two review authors independently considered these trials for inclusion, assessed included studies for risk of bias, and extracted trial data independently. We resolved disagreements through consultation with a third review author. We performed random‐effects meta‐regression for each outcome and explored prespecified study characteristics.
Main results
Overall, we included 26 studies with 5299 participants (29 comparisons). Participants were primarily male (64.2%). Ten (38.5%) studies included patients with heart failure. We assessed most studies as having low or unclear risk of bias. Sixteen studies (3164 participants) reported interventions to improve enrolment in cardiac rehabilitation, 11 studies (2319 participants) reported interventions to improve adherence to cardiac rehabilitation, and seven studies (1567 participants) reported interventions to increase programme completion. Researchers tested a variety of interventions to increase utilisation of cardiac rehabilitation. In many studies, this consisted of contacts made by a healthcare provider during or shortly after an acute care hospitalisation.
Low‐quality evidence shows an effect of interventions on increasing programme enrolment (19 comparisons; risk ratio (RR) 1.27, 95% confidence interval (CI) 1.13 to 1.42). Meta‐regression revealed that the intervention deliverer (nurse or allied healthcare provider; P = 0.02) and the delivery format (face‐to‐face; P = 0.01) were influential in increasing enrolment. Low‐quality evidence shows interventions to increase adherence were effective (nine comparisons; standardised mean difference (SMD) 0.38, 95% CI 0.20 to 0.55), particularly when they were delivered remotely, such as in home‐based programs (SMD 0.56, 95% CI 0.37 to 0.76). Moderate‐quality evidence shows interventions to increase programme completion were also effective (eight comparisons; RR 1.13, 95% CI 1.02 to 1.25), but those applied in multi‐centre studies were less effective than those given in single‐centre studies, leading to questions regarding generalisability. A moderate level of statistical heterogeneity across intervention studies reflects heterogeneity in intervention approaches. There was no evidence of small‐study bias for enrolment (insufficient studies to test for this in the other outcomes).
With regard to secondary outcomes, no studies reported on harms associated with the interventions. Only two studies reported costs. In terms of equity, trialists tested interventions designed to improve utilisation among women and older patients. Evidence is insufficient for quantitative assessment of whether women‐tailored programmes were associated with increased utilisation, and studies that assess motivating women are needed. For older participants, again while quantitative assessment could not be undertaken, peer navigation may improve enrolment.
Authors' conclusions
Interventions may increase cardiac rehabilitation enrolment, adherence and completion; however the quality of evidence was low to moderate due to heterogeneity of the interventions used, among other factors. Effects on enrolment were larger in studies targeting healthcare providers, training nurses, or allied healthcare providers to intervene face‐to‐face; effects on adherence were larger in studies that tested remote interventions. More research is needed, particularly to discover the best ways to increase programme completion.
Breathing exercises for adults with asthma Santino, Thayla A; Chaves, Gabriela SS; Freitas, Diana A ...
Cochrane database of systematic reviews,
03/2020, Letnik:
2020, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Background
Breathing exercises have been widely used worldwide as a non‐pharmacological therapy to treat people with asthma. Breathing exercises aim to control the symptoms of asthma and can be ...performed as the Papworth Method, the Buteyko breathing technique, yogic breathing, deep diaphragmatic breathing or any other similar intervention that manipulates the breathing pattern. The training of breathing usually focuses on tidal and minute volume and encourages relaxation, exercise at home, the modification of breathing pattern, nasal breathing, holding of breath, lower rib cage and abdominal breathing.
Objectives
To evaluate the evidence for the efficacy of breathing exercises in the management of people with asthma.
Search methods
To identify relevant studies we searched The Cochrane Library, MEDLINE, Embase, PsycINFO, CINAHL and AMED and performed handsearching of respiratory journals and meeting s. We also consulted trials registers and reference lists of included articles.
The most recent literature search was on 4 April 2019.
Selection criteria
We included randomised controlled trials of breathing exercises in adults with asthma compared with a control group receiving asthma education or, alternatively, with no active control group.
Data collection and analysis
Two review authors independently assessed study quality and extracted data. We used Review Manager 5 software for data analysis based on the random‐effects model. We expressed continuous outcomes as mean differences (MDs) with confidence intervals (CIs) of 95%. We assessed heterogeneity by inspecting the forest plots. We applied the Chi2 test, with a P value of 0.10 indicating statistical significance, and the I2 statistic, with a value greater than 50% representing a substantial level of heterogeneity. The primary outcome was quality of life.
Main results
We included nine new studies (1910 participants) in this update, resulting in a total of 22 studies involving 2880 participants in the review. Fourteen studies used Yoga as the intervention, four studies involved breathing retraining, one the Buteyko method, one the Buteyko method and pranayama, one the Papworth method and one deep diaphragmatic breathing. The studies were different from one another in terms of type of breathing exercise performed, number of participants enrolled, number of sessions completed, period of follow‐up, outcomes reported and statistical presentation of data. Asthma severity in participants from the included studies ranged from mild to moderate, and the samples consisted solely of outpatients. Twenty studies compared breathing exercise with inactive control, and two with asthma education control groups. Meta‐analysis was possible for the primary outcome quality of life and the secondary outcomes asthma symptoms, hyperventilation symptoms, and some lung function variables. Assessment of risk of bias was impaired by incomplete reporting of methodological aspects of most of the included studies. We did not include adverse effects as an outcome in the review.
Breathing exercises versus inactive control
For quality of life, measured by the Asthma Quality of Life Questionnaire (AQLQ), meta‐analysis showed improvement favouring the breathing exercises group at three months (MD 0.42, 95% CI 0.17 to 0.68; 4 studies, 974 participants; moderate‐certainty evidence), and at six months the OR was 1.34 for the proportion of people with at least 0.5 unit improvement in AQLQ, (95% CI 0.97 to 1.86; 1 study, 655 participants). For asthma symptoms, measured by the Asthma Control Questionnaire (ACQ), meta‐analysis at up to three months was inconclusive, MD of ‐0.15 units (95% CI −2.32 to 2.02; 1 study, 115 participants; low‐certainty evidence), and was similar over six months (MD −0.08 units, 95% CI −0.22 to 0.07; 1 study, 449 participants). For hyperventilation symptoms, measured by the Nijmegen Questionnaire (from four to six months), meta‐analysis showed less symptoms with breathing exercises (MD −3.22, 95% CI −6.31 to −0.13; 2 studies, 118 participants; moderate‐certainty evidence), but this was not shown at six months (MD 0.63, 95% CI −0.90 to 2.17; 2 studies, 521 participants). Meta‐analyses for forced expiratory volume in 1 second (FEV1) measured at up to three months was inconclusive, MD −0.10 L, (95% CI −0.32 to 0.12; 4 studies, 252 participants; very low‐certainty evidence). However, for FEV1 % of predicted, an improvement was observed in favour of the breathing exercise group (MD 6.88%, 95% CI 5.03 to 8.73; five studies, 618 participants).
Breathing exercises versus asthma education
For quality of life, one study measuring AQLQ was inconclusive up to three months (MD 0.04, 95% CI ‐0.26 to 0.34; 1 study, 183 participants). When assessed from four to six months, the results favoured breathing exercises (MD 0.38, 95% CI 0.08 to 0.68; 1 study, 183 participants). Hyperventilation symptoms measured by the Nijmegen Questionnaire were inconclusive up to three months (MD −1.24, 95% CI −3.23 to 0.75; 1 study, 183 participants), but favoured breathing exercises from four to six months (MD −3.16, 95% CI −5.35 to −0.97; 1 study, 183 participants).
Authors' conclusions
Breathing exercises may have some positive effects on quality of life, hyperventilation symptoms, and lung function. Due to some methodological differences among included studies and studies with poor methodology, the quality of evidence for the measured outcomes ranged from moderate to very low certainty according to GRADE criteria. In addition, further studies including full descriptions of treatment methods and outcome measurements are required.
Purpose The aim of this study was to investigate the associations between self-reported and valid performance-based measures of functional capacity in individuals with chronic stroke. Subjects and ...Methods Self-reported measures of functional capacity of 31 individuals with chronic stroke were assessed by the Duke Activity Status Index scores, whereas performance-based measures were assessed by the distance covered (in meters) and oxygen consumption (relative oxygen consumption, in ml·kg−1·min−1) during the six-minute walking test. Results The subjects had a mean age of 58.6±13 years and a mean time since the onset of stroke of 28.3±15.1 months. They had a mean Duke Activity Status Index of 27.3±14.4, mean distance covered of 325.2±140.2 m, and mean relative oxygen consumption of 9.6±2.3 ml·kg−1·min−1. Significant, positive, and moderate to good correlation coefficients were found between the Duke Activity Status Index scores and the distance covered during the six-minute walking test (r=0.68). Significant, positive, and fair associations were also found between the Duke Activity Status Index scores and relative oxygen consumption values obtained during the six-minute walking test (r=0.45). Conclusion The findings of the present study support the clinical use of the Duke Activity Status Index as a tool to assist in clinical evaluations of functional capacity of individuals with chronic stroke.
Chest physiotherapy for pneumonia in children Chaves, Gabriela SS; Freitas, Diana A; Santino, Thayla A ...
Cochrane database of systematic reviews,
01/2019, Letnik:
2019, Številka:
9
Journal Article
Recenzirano
Odprti dostop
Background
Pneumonia is a lung infection that causes more deaths in children aged under five years than any other single cause. Chest physiotherapy is widely used as adjuvant treatment for pneumonia. ...Physiotherapy is thought to help remove inflammatory exudates, tracheobronchial secretions, and airway obstructions, and reduce airway resistance to improve breathing and enhance gas exchange. This is an update of a review published in 2013.
Objectives
To assess the effectiveness of chest physiotherapy with regard to time until clinical resolution in children (from birth to 18 years) of either gender with any type of pneumonia.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1), which includes the Cochrane Acute Respiratory Infections Group Specialised Register, MEDLINE (22 February 2018), Embase (22 February 2018), CINAHL (22 February 2018), LILACS (22 February 2018), Web of Science (22 February 2018), and PEDro (22 February 2018). We also searched clinical trials registers (ClinicalTrials.gov and WHO ICTRP) to identify planned, ongoing, and unpublished trials.
Selection criteria
We included randomised controlled trials (RCTs) that compared any type of chest physiotherapy with no chest physiotherapy for children with pneumonia.
Data collection and analysis
We used standard Cochrane methodological procedures. The primary outcomes of interest were mortality, duration of hospital stay, and time to clinical resolution. We used Review Manager 5 software to analyse data and GRADE to assess the quality of the evidence for each outcome.
Main results
We included three new RCTs for this update, for a total of six included RCTs involving 559 children aged from 29 days to 12 years with pneumonia who were treated as inpatients. Pneumonia severity was described as moderate in one trial, severe in two trials, and was not stated in three trials. The studies assessed five different interventions: effects of conventional chest physiotherapy (3 studies, 211 children), positive expiratory pressure (1 study, 72 children), continuous positive airway pressure (CPAP) (1 study, 94 children), bubble CPAP (bCPAP) (1 study, 225 children), and assisted autogenic drainage (1 studies, 29 children). The included studies were conducted in Bangladesh, Brazil, China, Egypt, and South Africa. The studies were overall at low risk of bias. Blinding of participants was not possible in most studies, but we considered that the outcomes were unlikely to be influenced by the lack of blinding.
One study of bCPAP reported that three deaths occurred in children in the physiotherapy group (N = 79), and 20 deaths in the control group (N = 146) (risk ratio (RR) 0.28, 95% confidence interval (CI) 0.08 to 0.90; 225 children; low‐quality evidence). One study of assisted autogenic drainage (N = 29), and one study of conventional chest physiotherapy (N = 72) reported no deaths occurred. It is uncertain whether chest physiotherapy techniques (bCPAP, assisted autogenic drainage, and conventional chest physiotherapy) reduced hospital stay duration (days) (mean difference (MD) 0.10, 95% CI ‐0.56 to 0.76; 4 studies; low‐quality evidence).
There was variation among clinical parameters used to define clinical resolution. Two small studies found no difference in resolution of fever between children in the physiotherapy (conventional chest physiotherapy and assisted autogenic drainage) and control groups. Of five studies that considered peripheral oxygen saturation levels, only two reported that use of chest physiotherapy (CPAP and conventional chest physiotherapy) showed a greater improvement in peripheral oxygen saturation levels. However, it was unclear whether respiratory rate (breaths/min) improved after conventional chest physiotherapy (MD ‐2.25, 95% CI ‐5.17 to 0.68; 2 studies, 122 children; low‐quality evidence). Two studies assessed adverse events (number of events), but only one study reported any events (RR 1.28, 95% CI 0.98 to 1.67; 2 studies, 254 children; low‐quality evidence).
Authors' conclusions
We could draw no reliable conclusions concerning the use of chest physiotherapy for children with pneumonia due to the small number of included trials with differing study characteristics and statistical presentation of data. Future studies should consider the following key points: appropriate sample size with adequate power to detect expected differences, standardisation of chest physiotherapy techniques, appropriate outcomes (such as duration of leukocytosis, and airway clearance), and adverse effects.
Breathing exercises for adults with asthma Freitas, Diana A; Holloway, Elizabeth A; Bruno, Selma S ...
Cochrane database of systematic reviews,
10/2013, Letnik:
2013, Številka:
10
Journal Article
Recenzirano
Odprti dostop
Background
Breathing exercises have been widely used worldwide as a complementary therapy to the pharmacological treatment of people with asthma.
Objectives
To evaluate the evidence for the efficacy ...of breathing exercises in the management of patients with asthma.
Search methods
The search for trials led review authors to review the literature available in The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and AMED and to perform handsearching of respiratory journals and meeting s. Trial registers and reference lists of included articles were also consulted.
The literature search has been updated to January 2013.
Selection criteria
We included randomised controlled trials of breathing exercises in adults with asthma compared with a control group receiving asthma education or, alternatively, with no active control group.
Data collection and analysis
Two review authors independently assessed trial quality and extracted data. RevMan software was used for data analysis based on the fixed‐effect model. Continuous outcomes were expressed as mean differences (MDs) with confidence intervals (CIs) of 95%. Heterogeneity was assessed by inspecting the forest plots. The Chi2 test was applied, with a P value of 0.10 indicating statistical significance. The I2 statistic was implemented, with a value greater than 50% representing a substantial level of heterogeneity.
Main results
A total of 13 studies involving 906 participants are included in the review. The trials were different from one another in terms of type of breathing exercise performed, number of participants enrolled, number and duration of sessions completed, outcomes reported and statistical presentation of data. Asthma severity in participants from the included studies ranged from mild to moderate, and the samples consisted solely of outpatients. The following outcomes were measured: quality of life, asthma symptoms, number of acute exacerbations and lung function. Eleven studies compared breathing exercise with inactive control, and two with asthma education control groups. All eight studies that assessed quality of life reported an improvement in this outcome. An improvement in the number of acute exacerbations was observed by the only study that assessed this outcome. Six of seven included studies showed significant differences favouring breathing exercises for asthma symptoms. Effects on lung function were more variable, with no difference reported in five of the eleven studies that assessed this outcome, while the other six showed a significant difference for this outcome, which favoured breathing exercises. As a result of substantial heterogeneity among the studies, meta‐analysis was possible only for asthma symptoms and changes in the Asthma Quality of Life Questionnaire (AQLQ). Each meta‐analysis included only two studies and showed a significant difference favouring breathing exercises (MD ‐3.22, 95% CI ‐6.31 to ‐0.13 for asthma symptoms; MD 0.79, 95% CI 0.50 to 1.08 for change in AQLQ). Assessment of risk of bias was impaired by incomplete reporting of methodological aspects of most of the included trials.
Authors' conclusions
Even though individual trials reported positive effects of breathing exercises, no reliable conclusions could be drawn concerning the use of breathing exercises for asthma in clinical practice. This was a result of methodological differences among the included studies and poor reporting of methodological aspects in most of the included studies. However, trends for improvement are encouraging, and further studies including full descriptions of treatment methods and outcome measurements are required.
Abstract. Purpose The aim of this study was to investigate the associations between self-reported and valid performance-based measures of functional capacity in individuals with chronic stroke. ...Subjects and Methods Self-reported measures of functional capacity of 31 individuals with chronic stroke were assessed by the Duke Activity Status Index scores, whereas performance-based measures were assessed by the distance covered (in meters) and oxygen consumption (relative oxygen consumption, in ml・kg-1・min-1) during the six-minute walking test. Results The subjects had a mean age of 58.6+-13 years and a mean time since the onset of stroke of 28.3+-15.1 months. They had a mean Duke Activity Status Index of 27.3+-14.4, mean distance covered of 325.2+-140.2 m, and mean relative oxygen consumption of 9.6+-2.3 ml・kg-1・min-1. Significant, positive, and moderate to good correlation coefficients were found between the Duke Activity Status Index scores and the distance covered during the six-minute walking test (r=0.68). Significant, positive, and fair associations were also found between the Duke Activity Status Index scores and relative oxygen consumption values obtained during the six-minute walking test (r=0.45). Conclusion The findings of the present study support the clinical use of the Duke Activity Status Index as a tool to assist in clinical evaluations of functional capacity of individuals with chronic stroke.
Chest physiotherapy for pneumonia in children Chaves, Gabriela S S; Fregonezi, Guilherme A F; Dias, Fernando A L ...
Cochrane database of systematic reviews,
09/2013
9
Journal Article
Recenzirano
Pneumonia is an inflammatory lung disease and it is the greatest cause of deaths in children younger than five years of age worldwide. Chest physiotherapy is widely used in the treatment of pneumonia ...because it can help to eliminate inflammatory exudates and tracheobronchial secretions, remove airway obstructions, reduce airway resistance, enhance gas exchange and reduce the work of breathing. Thus, chest physiotherapy may contribute to patient recovery as an adjuvant treatment even though its indication remains controversial.
To assess the effectiveness of chest physiotherapy in relation to time until clinical resolution in children (from birth up to 18 years old) of either gender with any type of pneumonia.
We searched CENTRAL 2013, Issue 4; MEDLINE (1946 to May week 4, 2013); EMBASE (1974 to May 2013); CINAHL (1981 to May 2013); LILACS (1982 to May 2013); Web of Science (1950 to May 2013); and PEDro (1950 to May 2013).We consulted the ClinicalTrials.gov and the WHO ICTRP registers to identify planned, ongoing and unpublished trials. We consulted the reference lists of relevant articles found by the electronic searches for additional studies.
We included randomised controlled trials (RCTs) that compared chest physiotherapy of any type with no chest physiotherapy in children with pneumonia.
Two review authors independently selected the studies to be included in the review, assessed trial quality and extracted data.
Three RCTs involving 255 inpatient children are included in the review. They addressed conventional chest physiotherapy, positive expiratory pressure and continuous positive airway pressure. The following outcomes were measured: duration of hospital stay, time to clinical resolution (observing the following parameters: fever, chest indrawing, nasal flaring, tachypnoea and peripheral oxygen saturation levels), change in adventitious sounds, change in chest X-ray and duration of cough in days. Two of the included studies found a significant improvement in respiratory rate and oxygen saturation whereas the other included study failed to show that standardised respiratory physiotherapy and positive expiratory pressure decrease the time to clinical resolution and the duration of hospital stay. No adverse effects related to the interventions were described. Due to the different characteristics of the trials, such as the duration of treatment, levels of severity, types of pneumonia and the techniques used in children with pneumonia, as well as differences in their statistical presentation, we were not able to pool data. Two included studies had an overall low risk of bias whereas one included study had an overall unclear risk of bias.
Our review does not provide conclusive evidence to justify the use of chest physiotherapy in children with pneumonia due to a lack of data. The number of included studies is small and they differed in their statistical presentation.
Background
Postural drainage is used primarily in infants with cystic fibrosis from diagnosis up to the moment when they are mature enough to actively participate in self‐administered treatments. ...However, there is a risk of gastroesophageal reflux associated with this technique.
This is an update of a review published in 2015.
Objectives
To compare the effects of standard postural drainage (15º to 45º head‐down tilt) with modified postural drainage (15º to 30º head‐up tilt) with regard to gastroesophageal reflux in infants and young children up to six years old with cystic fibrosis in terms of safety and efficacy.
Search methods
We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register. We also searched the reference lists of relevant articles and reviews. Additional searches were conducted on ClinicalTrials.gov and on the WHO International Clinical Trials Registry Platform for any planned, ongoing and unpublished studies.
The date of the most recent literature searches: 19 June 2017.
Selection criteria
We included randomised controlled studies that compared two postural drainage regimens (standard and modified postural drainage) with regard to gastroesophageal reflux in infants and young children (up to and including six years old) with cystic fibrosis.
Data collection and analysis
We used standard methodological procedures expected by Cochrane. Two review authors independently identified studies for inclusion, extracted outcome data and assessed risk of bias. We resolved disagreements by consensus or by involving a third review author. We contacted study authors to obtain missing or additional information. The quality of the evidence was assessed using GRADE.
Main results
Two studies, involving a total of 40 participants, were eligible for inclusion in the review. We included no new studies in the 2018 update. The included studies were different in terms of the age of participants, the angle of tilt, the reported outcomes, the number of sessions and the study duration. The following outcomes were measured: appearance or exacerbation of gastroesophageal reflux episodes; percentage of peripheral oxygen saturation; number of exacerbations of upper respiratory tract symptoms; number of days on antibiotics for acute exacerbations; chest X‐ray scores; and pulmonary function tests. One study reported that postural drainage with a 20° head‐down position did not appear to exacerbate gastroesophageal reflux. However, the majority of the reflux episodes in this study reached the upper oesophagus (moderate‐quality evidence). The second included study reported that modified postural drainage (30° head‐up tilt) was associated with fewer number of gastroesophageal reflux episodes and fewer respiratory complications than standard postural drainage (30° head‐down tilt) (moderate‐quality evidence). The included studies had an overall low risk of bias. One included study was funded by the Sydney Children’s Hospital Foundation and the other by the Royal Children’s Hospital Research Foundation and Physiotherapy Research Foundation of Australia. Data were not able to be pooled by meta‐analysis due to differences in the statistical presentation of the data.
Authors' conclusions
The limited evidence regarding the comparison between the two regimens of postural drainage is still weak due to the small number of included studies, the small number of participants assessed, the inability to perform any meta‐analyses and some methodological issues with the studies. However, it may be inferred that the use of a postural regimen with a 30° head‐up tilt is associated with a lower number of gastroesophageal reflux episodes and fewer respiratory complications in the long term. The 20° head‐down postural drainage position was not found to be significantly different from the 20° head‐up tilt modified position. Nevertheless, the fact that the majority of reflux episodes reached the upper oesophagus should make physiotherapists carefully consider their treatment strategy. We do not envisage that there will be any new trials undertaken that will affect the conclusions of this review; therefore, we do not plan to update this review.
Postural drainage is used primarily in infants with cystic fibrosis from diagnosis up to the moment when they are mature enough to actively participate in self-administered treatments. However, there ...is a risk of gastroesophageal reflux associated with this technique.
To compare the effects of standard postural drainage (greater (30° to 45° head-down tilt) and lesser (15° to 20° head-down tilt)) with modified postural drainage (greater (30º head-up tilt) or lesser (15º to 20º head-up tilt)) with regard to gastroesophageal reflux in infants and young children up to six years old with cystic fibrosis in terms of safety and efficacy.
We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register. We also searched the reference lists of relevant articles and reviews. Additional searches were conducted on ClinicalTrials.gov and on the WHO International Clinical Trials Registry Platform for any planned, ongoing and unpublished studies.The date of the most recent literature searches: 20 January 2015.
We included randomised controlled studies that compared two postural drainage regimens (standard and modified postural drainage) with regard to gastroesophageal reflux in infants and young children (up to and including six years old) with cystic fibrosis.
Two review authors independently selected the studies to be included in the review, assessed their risk of bias and extracted data.
Two studies, including 40 participants, were eligible for inclusion in the review. The studies were different in terms of the age of participants, the angle of tilt, the reported outcomes, the number of sessions and the study duration. The following outcomes were measured: appearance or exacerbation of gastroesophageal reflux episodes; percentage of peripheral oxygen saturation; number of exacerbations of upper respiratory tract symptoms; number of days on antibiotics for acute exacerbations; chest X-ray scores; and pulmonary function tests. One study reported that postural drainage with a 20° head-down position did not appear to exacerbate gastroesophageal reflux. However, the majority of the reflux episodes reached the upper oesophagus. The second included study reported that modified postural drainage (30º head-up tilt) was associated with fewer number of gastroesophageal reflux episodes and fewer respiratory complications than standard postural drainage (30º head-down tilt). The included studies had an overall low risk of bias. Data were not able to be pooled by meta-analysis due to differences in the statistical presentation of the data.
The available evidence regarding the comparison between the two regimens of postural drainage is still weak due to the small number of included studies, the small number of participants assessed, the inability to perform any meta-analyses and some methodological issues with the studies. However, it may be inferred that the use of a postural regimen with a 30° head-up tilt is associated with a lower number of gastroesophageal reflux episodes and fewer respiratory complications in the long term. The 20º head-down postural drainage position was not found to be significantly different from the 20º head-up tilt modified position. Nevertheless, the fact that the majority of reflux episodes reached the upper oesophagus should make physiotherapists carefully consider their treatment strategy.
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