An individual with schizophrenia, and her therapist of 30 years, came to feel strongly that it is important for professionals to hear a patient's view of the therapy experience and for them to have ...the opportunity to question both patient and therapist. This article is based on their panel at the American Psychological Association Division of Psychoanalysis meeting in New York, April 25, 2014, which included a discussion facilitated by Diana Diamond, which follows this article. The patient described how her relationship with her therapist and her own understanding of transference have grown and how these have affected her life, including the development of more complex images of herself and others and her relationships with internal and external figures and a stronger sense of self. The therapist describes and discusses her approach to the therapy, and Dr. Diamond comments on changes in object representations over time and on the process of change in psychotherapy.
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.
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.
We used standard, extensive Cochrane search methods. The latest search was 26 June 2022.
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.
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).
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 (FEV
)and forced vital capacity (FVC), and found no difference in change from baseline in FEV
% 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 (FEF
) 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 FEF
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 FEV
% 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 FEF
(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).
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.
BackgroundYoung-people with Cerebral Palsy (CP) have been shown to have reduced physical fitness estimated at 15–28% less than healthy age matched children. As a result, they are at an increased risk ...of developing secondary health consequences due to a reduction in physical activity levels, lower cardiorespiratory capacity, and a decrease in muscle strength. There is limited research investigating the impact of a targeted exercise-programme for these young-people. The aim of this project was to conduct a service evaluation to explore the effects of a community-based, exercise-programme, for young people (age 9–13 years) with CP (GMFCS Levels-I-III).ObjectivesTo design and implement a community-based exercise-programme for young-people with CP.To investigate the impact on physical activity levels using daily step-count data and Physical Activity Questionnaire for Older Children (PAQ-C) scores.To investigate the impact on functional-mobility using Timed-Up-and-Go (TUG) times.To investigate participation scores using the Child and Adolescent Scale of Participation (CASP) scores.MethodsYoung people with CP were identified using inclusion and exclusion criteria from a single centre. Approvals were granted and consent was obtained from all participants and their parents/carers. A weekly, individualised, physiotherapy-led, exercise-programme was completed at a large public leisure centre for six consecutive weeks. Outcome measures were completed to measure changes in physical activity, functional-mobility, and participation at pre-intervention, post-intervention and three-month follow-up.ResultsEight young-people with CP consented and four participants completed the intervention and outcomes. The mean daily step-count increased from post-intervention for three-participants (range -1914.06–2096.86 steps) and was higher on weekdays (range 6410 (SD=±58.35) to 664.49 steps (SD=±1367.92)) than weekend-days (range 461.35 (SD=±67.84) to 5586.64 steps (SD=±539.17)).The PAQ-C-scores increased for all participants post-intervention (within-participant-difference range (WPDR) 0.21 (SD=±0.38) to 0.58 (SD=±0.70)) and varied at follow-up (WPDR -0.46 (SD=±0.72) to 0.69 (SD=±0.80)). The TUG-times improved for two-participants post-intervention (WPDR -24.29 (SD=±6.13) to 1.28 seconds (SD=±0.57)) and was maintained at follow-up (WPDR -23.70 (SD=±6.22) to 1.17 seconds (SD=±0.42)). The CASP-scores improved for three-participants (range 2 to 11) and was maintained at follow-up (2 to 12).ConclusionsThe aim of this project was to explore the feasibility and effects of a community-based exercise-group for young-people with CP. Overall the implementation and integration of the programme into the gym-environment was very successful. Attendance levels were 90% and all participants reported excellent subjective levels of enjoyment. The results of this project demonstrate preliminary, positive evidence for the effectiveness of the intervention on physical activity, functional-mobility, and participation measures in this small sample. The sample size and data collection were unfortunately affected by the Covid-19 pandemic. Therefore, additional data collection will be conducted in the future to further investigate the impact of the programme. It is clear that further studies are required to investigate outcome measures, to record the effects of interventions on physical activity, functional-mobility, and participation in young-people with CP. This preliminary study shows promise for the positive impact of community-based, exercise-programmes and should be considered as an additional option to facilitate young-people with CP to increase their participation, and to incorporate physical activity into their daily lives.
Cystic fibrosis (CF) is a genetically inherited, life-limiting condition, affecting ~90,000 people globally. Physical activity (PA) and exercise form an integral component of CF management, and have ...been highlighted by the CF community as an area of interest for future research. Previous reviews have solely focused on PA or structured exercise regimens independent of one another, and thus a comprehensive assessment of the physical health benefits of all PA, including exercise, interventions, is subsequently warranted. Therefore, the purpose of this review is to evaluate the effects of both PA and exercise upon outcomes of physical health and healthcare utilisation in people with CF.
A systematic review has been registered and reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analysis-P guidelines. This will include randomised control trials on the effects of PA and exercise, relative to usual treatment, upon people with CF. Primary outcomes will include variables associated with fitness, PA, lung health, inflammation, body composition, glycaemic control and patient-reported outcomes. Secondary outcomes will include adverse events and healthcare utilisation. Searches will be undertaken in Ovid MEDLINE, OVID EMBASE, PsychINFO, ERIC, SPORTDiscus, ASSIA, CCTR, CINHAL and Web of Science databases, and will be searched from date of inception onwards. Two reviewers will independently screen citations and abstracts, and full-texts, for inclusion and data extraction, respectively. Methodological quality will be assessed using the Cochrane Risk of Bias-2 tool. If feasible, random-effects meta-analyses will be conducted where appropriate. Additional analyses will explore potential sources of heterogeneity, such as age, sex, and disease severity.
This systematic review will build on previous research, by comprehensively assessing the impact of both PA and exercise upon physical health and healthcare utilisation in people with CF. Results of this review will be utilised to inform discussions that will ultimately result in a consensus document on the impact of physical activity and exercise for people with CF.
PROSPERO CRD42020184411.
There is a lack of functional performance measures for children and young people with haemophilia (CYPwH) with associated control data from typically developing boys (TDB). The literature advocates ...development of a core set of outcome measures for different chronic conditions. As medical treatment improves, CYPwH are experiencing better outcomes; therefore, more challenging measures are required to monitor physical performance. Such testing is not performed routinely, due to practical and safety concerns.
Evaluate the feasibility, safety and acceptability of select outcome measures as part of a study protocol testing CYPwH; including myometry, 10 metre incremental shuttle walk test (10-m ISWT), iSTEP (an incremental step test, with data from TDB), and 1 week of accelerometry-wear at home.
Sixty-six boys aged 6-15 years with mild, moderate or severe haemophilia A or B (including inhibitors) attending routine clinics at Great Ormond Street Hospital were approached to participate. Descriptive statistics and content analysis were used to assess outcomes of feasibility, safety and acceptability, which included recruitment/retention rates, protocol completion within routine appointment timeframes, performance testing without serious adverse events/reactions (SAE/SARs), and acceptability to CYPwH of high-level performance measures.
Outcomes were met: 43 boys completed testing at clinic review (Jan-Nov 2018) within a 10-month timeframe, retention was 95% at completion of protocol and no SAE/SARs were reported throughout testing.
Feasibility, safety and acceptability of the study protocol have been established in this population. Both high-level performance tests, iSTEP and 10-m ISWT, were an acceptable addition to boys' routine clinic appointments and could be safe, acceptable choices of outcome measure as part of a core set of tests for CYPwH. Further investigation of the psychometric properties for the iSTEP is now justified, in order for it to be used as a standardised, validated, reliable outcome measure in clinical or research settings.
Retrospectively registered on September 3, 2019, on ClinicalTrials.gov (ID: NCT04076306 ).
The purpose of this study was to create an educative guidebook for teachers based on the principles of Cognitively Guided Instruction (CGI), a constructivist approach to teaching mathematics through ...contextual word problems. The guidebook is designed to be used as a First- Grade mathematics supplemental curriculum resource with complete, daily lessons. The development of the guidebook began by identifying the problem of lack of support and professional development for teachers to enact the instructional strategies aligned with CGI.CGI is an impactful instructional method as it allows a teacher the opportunity to enact all of the National Council of Teachers of Mathematics’ “Effective Teaching Practices.” A Qualitative Content Analysis of seven of the most widely used elementary mathematics curriculum resources was conducted using a coding framework that included 11 key elements of a CGI lesson. The findings showed a strong lack of these 11 features of CGI. In some cases, they were entirely or nearly entirely absent. This data was used to inform the development of the CGI Guidebook. A first draft of five lessons was implemented by two First-Grade teachers. Revisions were made based on feedback from the teachers. The final guidebook provided First-grade teachers with a module of CGI lessons that is designed for both student and teacher learning, making it an “educative curriculum for teachers”. The “5 Practices for Orchestrating Productive Mathematics Discussions” (Smith & Stein, 2018) were also used to inform the guidebook and all 5 practices are embedded through each lesson. The guidebook provides a contextual word problem for each daily lesson, a rationale for the problem type and numbers in the problem, directions for selecting and sequencing student strategies and facilitating a discussion about the student strategies. The guidebook shows where standards are embedded in the lessons and provides, in every lesson, drawn example student strategies, rationales for the selection and sequencing ofstrategies as well as discussion guidance that will support the teacher to make connections between student strategies and to illuminate mathematical connections for students. The guidebook fulfills a need for access to Cognitively Guided Instruction professional development through a medium that is not currently available.
Purpose
Exercise training is the central component in Cardiac Rehabilitation (CR). A baseline assessment of aerobic capacity is paramount for exercise prescription and safety. The Two‐Minute Step ...Test (2MST) has been used to measure aerobic capacity in healthy older adults. However, the reliability and validity of the 2MST in older adults post‐coronary revascularisation (CRV) is unknown.
Methods
A prospective observational study was conducted in a single CR centre. Two 2MSTs and one six‐minute walk test (6MWT) were completed in a single session. The 2MST measurements were recorded by two raters for each individual. The six‐minute walk distance (6MWD) and 2MST steps recorded by both raters were analysed to determine the relationship and agreement between measurements.
Results
Thirty one participants with a median (IQR) age of 66 (62,73) years old were included in the study post CRV. Strong positive correlations were found between steps achieved during the 2MSTs and the 6MWD (r = 0.87, 95% CI 0.82–0.91, p < 0.0001). Excellent inter‐rater reliability was demonstrated between raters during the 2MSTs (ICC = 0.999–1.000, p = 0.000). Excellent relative test‐retest reliability was demonstrated in both 2MSTs recorded by both raters (ICC = 0.927–0.934, p = 0.000). However, absolute test‐retest reliability may have been limited by a learning effect between repeated 2MSTs.
Conclusions
The results of this study indicate that the 2MST may be used as an alternative to the 6MWT as an outcome measure for aerobic capacity in older adults post‐CRV. However, a practice trial is recommended at baseline to account for a learning effect.
Objective
The primary aim of the study was to explore the prevalence of generalized joint hypermobility (GJH) and generalized hypermobility spectrum disorder (gHSD) using the new classification ...system in a community paediatric physiotherapy service in Ireland. The second aim was to explore the relationship between GJH, gHSD and physical activity level, while considering the association of probable developmental coordination disorder (pDCD).
Methods
A case‐controlled cross‐sectional study of children aged 6–12 years, recruited from the community paediatric physiotherapy department (n = 32) and a local school (n = 41), was carried out. A Beighton score of ≥6/9 distinguished GJH. The new framework for hypermobility spectrum disorder (HSD) was used. Self‐reported physical activity level was measured using the Physical Activity Questionnaire—Older Children. A parent‐reported validated questionnaire screened for pDCD.
Results
The prevalence of GJH was 21.9% of children attending physiotherapy. One child in the physiotherapy group was identified as having gHSD, with a prevalence of 3.1%. There was no significant difference in physical activity level between children with and without GJH attending physiotherapy (independent samples t‐test, p = 0.28). Probable developmental coordination disorder (pDCD) was observed in 71.9% of children attending physiotherapy. There was no significant difference in the number of children with pDCD in those with and without GJH (Fisher's exact test, p = 0.370).
Conclusions
This study was the first to explore the prevalence of GJH and gHSD in the paediatric physiotherapy population in Ireland. The presence of GJH did not affect self‐reported physical activity level or motor coordination in children attending physiotherapy.
The prognostic value of cardiopulmonary exercise testing (CPET) for survival in cystic fibrosis (CF) in the context of current clinical management, when controlling for other known prognostic ...factors, is unclear.
To determine the prognostic value of CPET-derived measures beyond peak oxygen uptake (
o
peak) following rigorous adjustment for other predictors.
Data from 10 CF centers in Australia, Europe, and North America were collected retrospectively. A total of 510 patients completed a cycle CPET between January 2000 and December 2007, of which 433 fulfilled the criteria for a maximal effort. Time to death/lung transplantation was analyzed using Cox proportional hazards regression. In addition, phenotyping using hierarchical Ward clustering was performed to characterize high-risk subgroups.
Cox regression showed, even after adjustment for sex, FEV
% predicted, body mass index (z-score), age at CPET, Pseudomonas aeruginosa status, and CF-related diabetes as covariates in the model, that
o
peak in % predicted (hazard ratio HR, 0.964; 95% confidence interval CI, 0.944-0.986), peak work rate (% predicted; HR, 0.969; 95% CI, 0.951-0.988), ventilatory equivalent for oxygen (HR, 1.085; 95% CI, 1.041-1.132), and carbon dioxide (HR, 1.060; 95% CI, 1.007-1.115) (all P < 0.05) were significant predictors of death or lung transplantation at 10-year follow-up. Phenotyping revealed that CPET-derived measures were important for clustering. We identified a high-risk cluster characterized by poor lung function, nutritional status, and exercise capacity.
CPET provides additional prognostic information to established predictors of death/lung transplantation in CF. High-risk patients may especially benefit from regular monitoring of exercise capacity and exercise counseling.
Many patients with cystic fibrosis (CF) and non-CF bronchiectasis present with common symptoms in clinical domains that appear to benefit from airway clearance strategies. These symptoms include ...chronic productive cough, retention of excessive, purulent mucus in dilated airways, impairment of normal mucociliary clearance (MCC), atelectasis, breathlessness, fatigue, respiratory inflammation, fever, infection, and airflow obstruction. Airway clearance strategies may involve singular and focused interventions for the purpose of removing secretions and improving lung recruitment and gas exchange in patients with atelectasis. Strategies may also involve indirect or adjunctive interventions that facilitate or enhance effective airway clearance at different ages or stages of the disease process, for example, inhalation therapy, exercise, oxygen therapy, or noninvasive ventilation. The aim is to optimize care by selecting any one or combination of these in responding intelligently and sensitively to individual and changing patient requirements during their lifetime. Currently, a solid evidence base does not exist for airway clearance strategies in CF and non-CF bronchiectasis, and much of airway clearance clinical practice remains in the domain of clinical expertise. The paucity of evidence is partly explained by the relatively immature research machinery in allied health care internationally but is also partly to do with inadequate or inappropriate research designs. This article aims to provide an overview of the nature of, and physiological basis for, the direct and indirect airway clearance strategies in CF and non-CF bronchiectasis with reference to the best available evidence.
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