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.
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.
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 abstract 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.
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.
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.
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.
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.
: In 2018, the American Physical Therapy Association (APTA) published a clinical guideline for adults with neurological conditions, which included recommendations for the Five-Repetition Sit-to-Stand ...test (5STSt). According to the APTA, a standard-height chair should be used, but there is no recommendation regarding seat depth. In addition, the APTA recommended the use of one trial of the test, based on expert opinion.
: (1) Compare the 5STSt scores of patients post-stroke and healthy-matched controls using two types of chairs (one standardized and one adjusted to the individual's anthropometric characteristics); and (2) Verify whether different numbers of trial affect the 5STSt scores.
: Eighteen patients post-stroke and 18 healthy-matched controls performed three trials of the 5STSt for each type of chair. ANOVA was used for analysis (α = 0.05).
: No significant interaction between groups and chairs was found. Patients post-stroke showed worsened performances in 5STSt when using both chairs compared to the healthy controls (
= .001). In both groups, the 5STSt scores were lower when using a standardized chair than an adjusted chair (
< .003) and different numbers of trials provided similar 5STSt scores (0.44 ≤
≤ 0.98).
: The 5STSt scores were affected by the physical characteristics of the chair, and an adjusted chair should be used. The APTA recommendation for one trial of the 5STSt is supported by the present results.
Pulmonary rehabilitation (PR) programs play a key role in reducing the sensation of dyspnea, improving exercise capacity, physical activity level and quality of life in patients with different ...severity of COPD. However, it is still uncertain whether there is an association between dyspnea and the level of physical activity in these individuals, as patients with different pre-RP baseline dyspnea scores may have different responses in the level of physical activity after PR.
to verify whether there is an association between the sensation of dyspnea and the level of physical activity in response to a PR program in patients with COPD.
This is a retrospective observational study, which evaluated 22 patients diagnosed with COPD, who participated in a PR program for 8 weeks, and had an FEV1/FVC ratio <70%, both genders, mean age of 67 ±SD years, post-bronchodilator FEV1 (48±12%). For pre- and post-PR evaluation of dyspnea sensation, the mMRC scale (Medical Research Council), distance covered by the 6-minute walk test (DPTC6) and the level of physical activity through the activPAL3TM actigraph (Pal technologies Ltd. United Kingdom), for 7 consecutive days. The physical activity level variables analyzed were time in lying/sitting, standing, and walking positions; number of steps, and time spent at certain exercise intensities (sedentary, when METS<1.5 and light exercise, when MET <1.5 but <3). Those patients who could not perform the proposed tests and/or had difficulty understanding the scale were excluded. For correlation analysis and linear regression of the data, the statistical software SPSS v21(2012) was used, with significance of p<0.05.
A high negative correlation was found between mMRCpre and DPTC6 (r=-0.769; p=0.000), as well as a moderate negative correlation with the number of steps (r= -0.678; p =0.001), walking time (r= - 663 ; p= 0.001) and METS(> 1.5 to 3.0). Regarding mMRC and sitting/lying time, there was a moderate positive correlation (r=0.546; p= 0.009). It was found in the simple linear regression analysis between mMRC with 6MWT (r² =0.529), with the number of steps (r² =0.451), with walking time (r²=0.463) and with MET > 1.5 to 3.0 (r²= 0.519).
it is concluded that the pre-intervention mMRC can explain the exercise capacity and the level of physical activity after PR, and more symptomatic patients reached lower exercise capacity and less time in light and moderate physical activity intensities.
This study has the clinical implications that when prescribing a PR program for patients with more symptomatic COPD, greater attention is given to these patients so that there is an improvement in exercise capacity and physical activity level.
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.
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.
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.
Temporomandibular disorders (TMDs) are the second most common form of orofacial pain after an odontogenic source. Despite their complex aetiopathology they are considered a musculoskeletal disorder. ...They can have a significant impact on the quality of life of those suffering from TMDs, but can be treated and managed through a mixture of conservative and surgical approaches. Physiotherapists specialising in musculoskeletal therapy and pain management can offer a variety of techniques to help in the treatment and management of TMDs. In this narrative review the evolution of physiotherapy practice in the United Kingdom will be outlined, along with a discussion about physiotherapeutic theoretical frameworks in the management of musculoskeletal disorders and idiopathic TMDs. Finally, a narrative review will be presented, outlining the literature exploring the use of physiotherapy post TMJ surgery, underpinned by a systematic literature search on the topic. After screening for inclusion in the narrative review, eight articles were included for narrative synthesis. The main findings were that there is a relative paucity of studies looking at the value of physiotherapy post TMJ surgery compared with the treatment of idiopathic TMDs, and there is heterogeneity in the physiotherapy programmes described in the literature, but the addition of physiotherapy post TMJ surgery seems to augment the patient's response to surgery. The article concludes by describing the domestic challenges and opportunities of integrating physiotherapy into TMD management pathways.
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