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Conventional chest physiotherapy compared to other forms of chest physiotherapy for cystic fibrosis
... Nevertheless, these changes returned to baseline on the second study day [10]. In two recent reviews where conventional physiotherapy [11] and the active cycle of breathing techniques (ACBT) [12] were compared with other airway clearance techniques, no significant differences were observed between the techniques in terms of pulmonary function measured with spirometry [11]. Nevertheless, when oscillating devices for airway clearance were used, significant results were observed in pulmonary function, the FEV 1 being the primary outcome measure more frequently reported [13]. ...
... Nevertheless, these changes returned to baseline on the second study day [10]. In two recent reviews where conventional physiotherapy [11] and the active cycle of breathing techniques (ACBT) [12] were compared with other airway clearance techniques, no significant differences were observed between the techniques in terms of pulmonary function measured with spirometry [11]. Nevertheless, when oscillating devices for airway clearance were used, significant results were observed in pulmonary function, the FEV 1 being the primary outcome measure more frequently reported [13]. ...
... However, no significant differences were shown between interventions [46, 47]. In the most recent Cochrane reviews [11, 12] about physiotherapy in CF, chest radiography is no longer reported as an outcome measure in the included studies. It therefore, seems that chest radiography is ideal for contributing to diagnosis and providing a measure of improvement or deterioration over time but might not be the most appropriate to be used as an outcome measure for respiratory physiotherapy. ...
Respiratory physiotherapy is part of the routine management of patients with cystic fibrosis. It normally consists of airway clearance techniques and exercise training. The evidence of such interventions has been questioned. Nevertheless, the lack of evidence should not be interpreted as lack of benefit. Instead, attention to methodological issues, such as the selection of the outcome measures, is needed, as they may hamper the establishment of the effectiveness of respiratory physiotherapy techniques. Hence, this chapter presents and discusses the strengths and weaknesses of conventional and emerging outcome measures possibly to be used (i) in clinical practice before, during and after each session of respiratory physiotherapy to monitor its effectiveness; (ii) before and after the respiratory physiotherapy treatment (i.e., normally characterised by weeks of intervention) and (iii) in applied research in respiratory physiotherapy used in the management for cystic fibrosis. A comprehensive overview of the available outcome measures is provided, with particular emphasis on their strengths and limitations that should be recognised when interpreting the results.
... The technique may also include postural drainage (PD) or percussion/shaking. 21 Similarly, the technique of FET was required to contain relaxation or breathing control, and huffing, and may include PD and percussion/shaking. ...
... Conventional physiotherapy (CPT): any combination of PD, percussion, shaking, vibrations, huffing and directed coughing. 21 Devices which provided resistive inspiratory manoeuvres (RIM): adjunctive equipment which provided resistance of approximately 80 per cent of the maximal sustained inspiratory pressure. ...
... 6,35 Sensitivity analyses were performed to assess the impact of the assumed correlation on the meta-analysis by repeating the analysis assuming zero correlation. 21,22 As to be expected by assuming such a conservative correlation, there was a general widening of the confidence intervals. In studies where the intervention and comparator group standard deviations were unavailable, the assumed correlation was used to calculate the SMD as well as the SE (SMD) , therefore there was an obvious effect on the overall effect estimate (Table 7). ...
What is the best available research evidence (volume, quality, consistency, generalisability) for the active cycle of breathing technique (ACBT)?
Systematic review with meta-analysis.
Participants with respiratory conditions characterised by chronic sputum production.
The active cycle of breathing or forced expiratory technique. COMPARATOR: All comparators including control conditions.
All outcomes providing continuous data.
Twenty-four studies were included. Ten comparators were identified with the most common being conventional chest physiotherapy, positive expiratory pressure and a control. The outcomes most frequently assessed were sputum wet weight (n = 17), forced vital capacity (n = 12) and forced expiratory volume in 1 s (n = 12). Meta-analysis was completed on the primary outcome of sputum wet weight. The standardised mean difference (SMD, random effects) showed an increase in sputum wet weight during and up to 1 h post ACBT compared to conventional physiotherapy (SMD 0.32, 95%CI 0.05-0.59), external oscillatory devices (0.75, 0.48-1.02), and control (0.24, 0.02-0.46).
The overall body of evidence was classified as good (good volume, quality and consistency, excellent generalisability). High level, variable risk of bias research evidence favours ACBT over most alternatives for short-term improvements in secretion clearance.
... Whilst anecdotally and clinically there is a strong belief that chest physiotherapy is vital, there is as yet insufficient research evidence to prove efficacy of these traditional methods (van der Schans, Prasad, and Main, 2000). Another person is required to perform such treatments; they are time consuming and often uncomfortable (Main, Prasad, and van der Schans, 2005 ). To overcome these drawbacks, alternative methods have been developed, which foster greater independence and are also quicker and easier to perform. ...
... Two studies have also shown that there may be significant long-term benefit of PEP mask therapy over postural drainage and manual percussion for maintaining, or even improving, lung function (McIlwaine, Wong, Peacock, and Davidson, 1997; Tonneson and Stovring, 1984). These results should be interpreted with caution because two recent Cochrane reviews concluded that the evidence for PEP therapy was, in general, of poor quality and insufficiently powered to be able to prove the efficacy of these techniques (Elkins, Jones, and van der Schans, 2006; Main, Prasad, and van der Schans, 2005 ). Despite this there is some evidence that individuals with CF prefer to use PEP devices over traditional methods. ...
... In this study both groups of participants reported very high satisfaction with the devices they used. A number of studies have also reported such a preference in favour of treatments that allow greater independence (Elkins, Jones, and van der Schans, 2006; Main, Prasad, and van der Schans, 2005). It is important that the effectiveness of the Acapella for home physiotherapy is evaluated, especially given the home-based IV intervention programs now available. ...
The Acapella is a positive pressure device designed to assist mucociliary clearance. This study investigated the effectiveness of the Acapella in comparison to PEP mask therapy. Twenty-three participants with cystic fibrosis (CF) with a median age of 12 years (range 7-18 years), who were admitted to hospital for a respiratory exacerbation were randomised to either the PEP mask or Acapella treatment group. Both groups completed two treatment sessions each day (10 sets of 10 breaths in sitting) over a 10-day period. Outcome measures were change in lung function (FEV1, FVC, FEF(25-75), and PEF) and exercise performance (modified 10-metre shuttle). In addition, total sputum production during treatment (wet weight) and patient satisfaction were assessed over the 10-day period. At the end of 10 days there were no statistically significant differences between the groups for any of the outcome measures. Participants were highly satisfied with both devices. The results suggest that there is no statistically significant difference between the Acapella device and the PEP mask for use in CF during an acute exacerbation. Larger studies are required to determine whether differences between PEP mask and Acapella noted in this trial are clinically worthwhile.
... autogenic drainage (AD), slow expiration with glottis opened in lateral posture (ELTGOL), and positive expiratory pressure devices] are currently attracting more interest than conventional chest physiotherapy techniques (i.e. postural drainage, percussion and vibration) due to higher patient adherence and preference [11,12]. The main mechanism to improve mucus clearance is the generation of expiratory flow exceeding inspiratory flow [13], thereby making slow expiratory ACTs (flow-assisted/active drainage) an option to increase mucus transportation. ...
... To facilitate daily expectoration, the use of different ACTs has increased recently in the management of patients with bronchiectasis. Self-management techniques are recommended to improve the level of treatment adherence [8,11], but no one technique to date has demonstrated greater efficacy than other techniques [22,293031. However, to the best of our knowledge, this is the first study to compare three slow expiratory ACTs with different levels of autonomy (total autonomy, requiring physiotherapist assistance and device-dependent). ...
Objective:
To compare the efficacy of three slow expiratory airway clearance techniques (ACTs).
Design:
Randomised crossover trial.
Setting:
Tertiary hospital.
Participants:
Thirty-one outpatients with bronchiectasis and chronic sputum expectoration.
Interventions:
Autogenic drainage (AD), slow expiration with glottis opened in lateral posture (ELTGOL), and temporary positive expiratory pressure (TPEP).
Main outcomes:
Sputum expectoration during each session (primary endpoint) and in the 24-hour period after each session. Leicester Cough Questionnaire (LCQ) score and spirometry results were recorded at the beginning and after each week of treatment. Data were summarised as median difference [95% confidence interval (CI)].
Results:
Median (interquartile range) daily expectoration at baseline was 21.1 (15.3 to 35.6)g. During physiotherapy sessions, AD and ELTGOL expectorated more sputum than TPEP [AD vs TPEP 3.1g (95% CI 1.5 to 4.8); ELTGOL vs TPEP 3.6g (95% CI 2.8 to 7.1)], while overall expectoration in the 24-hour period after each session was similar for all techniques (P=0.8). Sputum clearance at 24hours post-intervention was lower than baseline assessment for all techniques [AD vs baseline -10.0g (95% CI -15.0 to -6.8); ELTGOL vs baseline -9.2g (95% CI -14.2 to -7.9); TPEP vs baseline -6.0g (95% CI -12.0 to -6.1)]. The LCQ score increased with all techniques (AD 0.5, 95% CI 0.1 to 0.5; ELTGOL 0.9, 95% CI 0.5 to 2.1; TPEP 0.4, 95% CI 0.1 to 1.2), being similar for all ACTs (P=0.6). No changes in lung function were observed.
Conclusions:
Slow expiratory ACTs enhance mucus clearance during treatment sessions, and reduce expectoration for the rest of the day in patients with bronchiectasis.
Clinical trial registration number:
NCT01854788.
... Many reviews of airway clearance techniques have been performed over the last 20 years. Some of the more recent include a meta-analysis by Thomas et al. [26], Cochrane reviews by Main et al. [27] and Van der Schans et al. [28], and review papers by Hess [29], Pryor [30] and Lapin [31]. All found a lack of high-level evidence for the use of any airway clearance technique, and reached different conclusions and recommendations due to the inclusion of studies demonstrating varying methodological rigor. ...
... Main et al. [27] found that there was no advantage of conventional chest physiotherapy over other airway clearance techniques. Van der Schans et al. [28] found that airway clearance techniques have short-term benefits. Hess [29] found that there is not enough high-quality evidence to support any airway clearance technique; a conclusion with which Pryor [30] agreed, stating that choice of treatment should be based upon preference. ...
Described by Jean Chevaillier in 1967, autogenic drainage is an airway clearance technique that is widely used throughout Europe. The technique is characterised by breathing control, where the individual adjusts the rate, depth and location of respiration in order to clear the chest of secretions independently. This paper describes the technique, based on the work of Chevaillier, offering a physiological explanation for how the technique works. This paper will also review the evidence supporting the use of autogenic drainage.
... Forty-one meta-analyses, 353 trials and 42,342 patients contributed to the analysis.Table 1 and S2 Table detail the characteristics of the reviews. Briefly, the reviews were published between 2008 and 2011 and included meta-analyses of the effectiveness of physical therapy interventions for musculoskeletal (22 reviews)323334353637383940 cardiorespiratory (8 reviews)4142434445464748, neurological (6 reviews)49505152535455, and other areas of physical therapy (5 reviews)5556575859 . A median number of 6 trials were included in each meta-analysis (interquartile range 5–8). ...
There is debate on how the methodological quality of clinical trials should be assessed. We compared trials of physical therapy (PT) judged to be of adequate quality based on summary scores from the Physiotherapy Evidence Database (PEDro) scale with trials judged to be of adequate quality by Cochrane Risk of Bias criteria.
Meta-epidemiological study within Cochrane Database of Systematic Reviews.
Meta-analyses of PT trials were identified in the Cochrane Database of Systematic Reviews. For each trial PeDro and Cochrane assessments were extracted from the PeDro and Cochrane databases. Adequate quality was defined as adequate generation of random sequence, concealment of allocation, and blinding of outcome assessors (Cochrane criteria) or as trials with a PEDro summary score ≥5 or ≥6 points. We combined trials of adequate quality using random-effects meta-analysis.
Forty-one Cochrane reviews and 353 PT trials were included. All meta-analyses included trials with PEDro scores ≥5, 37 (90.2%) included trials with PEDro scores ≥6 and only 22 (53.7%) meta-analyses included trials of adequate quality according to the Cochrane criteria. Agreement between PeDro and Cochrane was poor for PeDro scores of ≥5 points (kappa = 0.12; 95% CI 0.07 to 0.16) and slight for ≥6 points (kappa 0.24; 95% CI 0.16-0.32). When combining effect sizes of trials deemed to be of adequate quality according to PEDro or Cochrane criteria, we found that a substantial difference in the combined effect size (≥0.15) was evident in 9 (22%) out of the 41 meta-analyses for PEDro cutoff ≥5 and 10 (24%) for cutoff ≥6.
The PeDro and Cochrane approaches lead to different sets of trials of adequate quality, and different combined treatment estimates from meta-analyses of these trials. A consistent approach to assessing RoB in trials of physical therapy should be adopted.
... Many chest physiotherapy techniques exist, and their definition and whether they should be used or not are decided during country wide consensus meetings. Consequently, the available pool of maneuvers can differ from one country to the other, mostly because their efficiency are difficult to compare [18, 28]. Historically, most of the maneuvers were based on applying relatively strong pressures on the chest, bringing discomfort and, if ill performed, to risks to the patient, most particularly to baby and children. ...
Chest physiotherapy is an empirical technique used to help secretions to get out of the lung whenever stagnation occurs. Although commonly used, little is known about the inner mechanisms of chest physiotherapy and controversies about its use are coming out regularly. Thus, a scientific validation of chest physiotherapy is needed to evaluate its effects on secretions. We setup a quasi-static numerical model of chest physiotherapy based on thorax and lung physiology and on their respective biophysics. We modeled the lung with an idealized deformable symmetric bifurcating tree. Bronchi and their inner fluids mechanics are assumed axisymmetric. Static data from the literature is used to build a model for the lung's mechanics. Secretions motion is the consequence of the shear constraints apply by the air flow. The input of the model is the pressure on the chest wall at each time, and the output is the bronchi geometry and air and secretions properties. In the limit of our model, we mimicked manual and mechanical chest physiotherapy techniques. We show that for secretions to move, air flow has to be high enough to overcome secretion resistance to motion. Moreover, the higher the pressure or the quicker it is applied, the higher is the air flow and thus the mobilization of secretions. However, pressures too high are efficient up to a point where airways compressions prevents air flow to increase any further. Generally, the first effects of manipulations is a decrease of the airway tree hydrodynamic resistance, thus improving ventilation even if secretions do not get out of the lungs. Also, some secretions might be pushed deeper into the lungs; this effect is stronger for high pressures and for mechanical chest physiotherapy. Finally, we propose and tested two a dimensional numbers that depend on lung properties and that allow to measure the efficiency and comfort of a manipulation.
... In our study we compared two devices commonly used during RPT. It has been hypothesised that their effect on mucus clearance is caused by stabilising the airways and by enhancing gravitational effects on ventilation distribution [1,6,29] If it is accepted by the patient and if there are no unwanted side effects, gravity assisted positioning (without any device) as a possibility to enhance mucus clearance is recommended in patients with cystic fibrosis or noncystic fibrosis-related bronchiectasis [30]. We demonstrated that the investigated devices had a different influence on ventilation distribution in the lateral position, with CPAP enhancing the effect of gravity on spatial distribution whereas PEP appeared to counteract it. ...
Background and objectives
We investigated the effect of different breathing aids on ventilation distribution in healthy adults and subjects with cystic fibrosis (CF).
Methods
In 11 healthy adults and 9 adults with CF electrical impedance tomography measurements were performed during spontaneous breathing, continuous positive airway pressure (CPAP) and positive expiratory pressure (PEP) therapy randomly applied in upright and lateral position. Spatial and temporal ventilation distribution was assessed.
Results
The proportion of ventilation directed to the dependent lung significantly increased in lateral position compared to upright in healthy and CF. This effect was enhanced with CPAP but neutralised with PEP, whereas the effect of PEP was larger in the healthy group. Temporal ventilation distribution showed exactly the opposite with homogenisation during CPAP and increased inhomogeneity with PEP.
Conclusions
PEP shows distinct differences to CPAP with respect to its impact on ventilation distribution in healthy adults and CF subjects EIT might be used to individualise respiratory physiotherapy.
... A number of devices, collectively referred to as vest chest physiotherapy (VCPT), are now available that allow patients to perform airway clearance without the aid of a second person to apply the therapy [1] . Several studies demonstrate the superiority of chest physiotherapy over no chest physiotherapy with regard to clinical outcomes [2]. Chest physiotherapy increases mucus clearance as assessed by mucus volume measurements [3]. ...
Background. Vest chest physiotherapy (VCPT) enhances airway clearance in cystic fibrosis (CF) by an unknown mechanism. Because cilia are sensitive to nitric oxide (NO), we hypothesized that VCPT enhances clearance by changing NO metabolism. Methods. Both normal subjects and stable CF subjects had pre- and post-VCPT airway clearance assessed using nasal saccharin transit time (NSTT) followed by a collection of exhaled breath condensate (EBC) analyzed for NO metabolites (NO x ). Results. VCPT shorted NSTT by 35% in normal and stable CF subjects with no difference observed between the groups. EBC NO x concentrations decreased 68% in control subjects after VCPT (before = 115 ± 32 μ M versus after = 37 ± 17 μ M; P < 0.002). CF subjects had a trend toward lower EBC NO x . Conclusion. We found an association between VCPT-stimulated clearance and exhaled NO x levels in human subjects. We speculate that VCPT stimulates clearance via increased NO metabolism.
... Airway clearance techniques, inhaled medications, and exercise are frequently used to promote mucus clearance in an attempt to slow the progression of infection and lung damage (Bye and Elkins 2007, Dwyer et al 2011, Kuys et al 2011, Pryor and Prasad 2008). Physiotherapists may apply manual techniques, such as percussion and vibration, or teach independent techniques, such as breathing through a positive expiratory pressure device (Elkins et al 2006a, Main et al 2009, van der Schans et al 2005). These techniques are believed to promote mucus clearance by accelerating expiratory airflow, reducing airway obstruction or closure, and improving the rheology of mucus (App et al 1998, Dasgupta et al 1995). ...
Question:
Among adults with cystic fibrosis, does the timing of hypertonic saline relative to airway clearance techniques affect lung function, perceived efficacy, tolerability, or satisfaction with the entire airway clearance regimen, and is the preferred timing regimen stable over time?
Design:
A randomised crossover trial with concealed allocation, intention-to-treat analysis, and blinded assessors.
Participants:
50 adults with cystic fibrosis and stable lung function at the end of a hospital admission.
Intervention:
Participants performed 3 sessions of airway clearance techniques per day for 3 days. On each day, participants were randomised to inhale hypertonic saline either before, during, or after the airway clearance techniques. Participants readmitted within one year repeated the 3-day study.
Outcome measures:
The primary outcome was the change in forced expiratory volume in one second (FEV(1)) from before to 2 hours after an entire airway clearance session. Secondary outcomes were change in forced vital capacity, perceived efficacy, tolerability, satisfaction, adverse events, and adherence.
Results:
All 50 participants completed the study. The effects on lung function were non-significant or were of borderline statistical significance favouring inhalation of hypertonic saline before airway clearance techniques. Satisfaction was rated significantly worse on a 100mm scale when hypertonic saline was inhaled after the airway clearance techniques: mean differences 20mm (95% CI 12 to 29) compared to before the airway clearance techniques and 15 mm (95% CI 6 to 24) compared to during the techniques. Perceived effectiveness showed similar effects but other outcomes were unaffected. All 14 participants who were readmitted repeated the study and most preferred the same timing regimen. Conclusion People with cystic fibrosis could be encouraged to time hypertonic saline before or during airway clearance techniques to maximise perceived efficacy and satisfaction, even though lung function may not be better with these timing regimens.
Trial registration:
ACTRN12611000673943.
... Treatment of sputum retention and the associated chronic infection in the airways of people with cystic fibrosis involves several therapeutic approaches. Antibiotics are administered to suppress infection (Southern et al 2004, Ryan et al 2003, Smyth and Walters 2003), manual physiotherapy techniques and other physical interventions are used to clear infected mucus from the airways (van der Schans et al 2000), and various mucoactive medications are used to improve the properties of the mucus to facilitate its clearance (Jones and Wallis 2010, Wark and McDonald 2009). One of these mucoactive medications is recombinant human deoxyribonuclease, or dornase alpha (Pulmozyme ® ). ...
Does the timing of inhalation of dornase alpha in relation to physical airway clearance techniques influence the effect of the entire airway clearance regimen?.
A randomised crossover trial with concealed allocation, intention-to-treat analysis and blinding of patients, therapists, and assessors.
Twenty adults with cystic fibrosis who were not taking dornase alpha were recruited, of whom 17 were randomised and completed the trial.
Participants performed an individually tailored session of physical airway clearance techniques for at least 15 minutes per day for 28 days. For 14 days, dornase alpha was inhaled before each session of airway clearance techniques and a placebo was inhaled after. For the other 14 days, placebo was inhaled before and dornase alpha after airway clearance techniques. The order of the two 14-day periods was randomised.
The primary outcome was the forced expiratory volume in 1 sec (FEV(1)). Secondary outcomes were forced vital capacity, 24-hour sputum production, sputum production during the airway clearance regimen, oxygen saturation, peak oxygen consumption during an incremental exercise test, oxygen desaturation during exercise, and quality of life.
Inhalation of dornase alpha after airway clearance techniques did not significantly affect the change in FEV(1) compared with inhalation before airway clearance techniques, mean difference 0.04 L, 95% CI -0.14 to 0.23. None of the secondary outcomes differed significantly between the study arms. There was good correlation between the change in FEV(1) and the change in quality of life scores.
Timing of dornase alpha can be selected according to convenience, patient preference, or to accommodate the timing of other medications in the treatment regimen.
ACTRN12611001041943.
... These findings suggest that patients prescribed the Flutter device are not likely to have high rates of adherence over time. If, in contrast, patients prescribed PD&P or Vest are more likely to be in the high-adherence trajectory, it is important to incorporate patient preference when making decisions about ACTs, especially given lack of evidence regarding efficacy differences between the three ACT methods (Main et al., 2005). Homnick (2007) has suggested the need to adapt ACTs based on disease severity and patient preference to encourage optimal adherence, with frequent monitoring to ensure health status does not decline. ...
Although cross-sectional studies have demonstrated poor adherence to airway clearance therapy (ACT) for patients with cystic fibrosis (CF), no studies have identified longitudinal patterns of adherence. The objective was to characterize and identify predictors of ACT adherence trajectories for individuals with CF.
Secondary data analyses were conducted for a randomized clinical trial examining differences in three ACTs. Participants (n = 153; M = 14.3 years, 55% male, 86% Caucasian, baseline FEV(1)% predicted: M = 86.7)/primary caregivers completed Daily Phone Diaries, an empirically supported adherence measure, every 4 months.
Group-based trajectory modeling revealed the best-fitting solution was a three-group model: low-adherence (14%), medium-adherence (49%), and high-adherence (37%) groups. ACT type was the only significant predictor of adherence trajectories.
Three trajectories of adherence to ACT for patients with CF were found. With the identification of trajectories, adherence interventions can be targeted for the subgroup at highest risk in order to prevent poor health outcomes.
... The clinical signs and symptoms of respiratory disease in CF are variable, but at some point cough becomes prominent, is usually associated with sputum and respiratory failure is the most common cause of death [6]. Cochrane reviews78910 have concluded that airway clearance techniques have the shortterm effect of increasing mucus transport and there appears to be no advantage of either 'conventional' chest physiotherapy or oscillating devices over other airway clearance techniques in the primary outcome measure of lung function, but there is little evidence on which to draw conclusions concerning the longterm effects. The objective of the current study was to demonstrate non-inferiority in the long-term. ...
Evidence indicates that there are no statistically significant differences in effectiveness among the airway clearance techniques (ACTs) of active cycle of breathing, autogenic drainage, positive expiratory pressure (PEP) or oscillating PEP in the short-term, but are there differences in the long-term (one year)? The objective of the study was to demonstrate non-inferiority in the long-term.
Seventy-five people with cystic fibrosis entered the prospective, randomised controlled trial of these five different ACTs. The primary outcome measure was forced expiratory volume in one second (FEV(1)). Secondary outcome measures included exercise capacity and health related quality of life.
Using intention to treat, data were available on 65 subjects at the end of the study period. There were no statistically significant differences among the regimens in the primary outcome measurement of FEV(1) (p=0.35).
In different countries either one or several airway clearance regimens are used. This study provides evidence in support of current practices.
Background:
Cystic fibrosis (CF) is an inherited life-limiting disorder. Over time persistent infection and inflammation within the lungs contribute to severe airway damage and loss of respiratory function. Chest physiotherapy, or airway clearance techniques (ACTs), are integral in removing airway secretions and initiated shortly after CF diagnosis. Conventional chest physiotherapy (CCPT) generally requires assistance, while alternative ACTs can be self-administered, facilitating independence and flexibility. This is an updated review.
Objectives:
To evaluate the effectiveness (in terms of respiratory function, respiratory exacerbations, exercise capacity) and acceptability (in terms of individual preference, adherence, quality of life) of CCPT for people with CF compared to alternative ACTs.
Search methods:
We used standard, extensive Cochrane search methods. The latest search was 26 June 2022.
Selection criteria:
We included randomised or quasi-randomised controlled trials (including cross-over design) lasting at least seven days and comparing CCPT with alternative ACTs in people with CF.
Data collection and analysis:
We used standard Cochrane methods. Our primary outcomes were 1. pulmonary function tests and 2. number of respiratory exacerbations per year. Our secondary outcomes were 3. quality of life, 4. adherence to therapy, 5. cost-benefit analysis, 6. objective change in exercise capacity, 7. additional lung function tests, 8. ventilation scanning, 9. blood oxygen levels, 10. nutritional status, 11. mortality, 12. mucus transport rate and 13. mucus wet or dry weight. We reported outcomes as short-term (seven to 20 days), medium-term (more than 20 days to up to one year) and long-term (over one year).
Main results:
We included 21 studies (778 participants) comprising seven short-term, eight medium-term and six long-term studies. Studies were conducted in the USA (10), Canada (five), Australia (two), the UK (two), Denmark (one) and Italy (one) with a median of 23 participants per study (range 13 to 166). Participant ages ranged from newborns to 45 years; most studies only recruited children and young people. Sixteen studies reported the sex of participants (375 males; 296 females). Most studies compared modifications of CCPT with a single comparator, but two studies compared three interventions and another compared four interventions. The interventions varied in the duration of treatments, times per day and periods of comparison making meta-analysis challenging. All evidence was very low certainty. Nineteen studies reported the primary outcomes forced expiratory volume in one second (FEV1)and forced vital capacity (FVC), and found no difference in change from baseline in FEV1 % predicted or rate of decline between groups for either measure. Most studies suggested equivalence between CCPT and alternative ACTs, including positive expiratory pressure (PEP), extrapulmonary mechanical percussion, active cycle of breathing technique (ACBT), oscillating PEP devices (O-PEP), autogenic drainage (AD) and exercise. Where single studies suggested superiority of one ACT, these findings were not corroborated in similar studies; pooled data generally concluded that effects of CCPT were comparable to those of alternative ACTs. CCPT versus PEP We are uncertain whether CCPT improves lung function or has an impact on the number of respiratory exacerbations per year compared with PEP (both very low-certainty evidence). There were no analysable data for our secondary outcomes, but many studies provided favourable narrative reports on the independence achieved with PEP mask therapy. CCPT versus extrapulmonary mechanical percussion We are uncertain whether CCPT improves lung function compared with extrapulmonary mechanical percussions (very low-certainty evidence). The annual rate of decline in average forced expiratory flow between 25% and 75% of FVC (FEF25-75) was greater with high-frequency chest compression compared to CCPT in medium- to long-term studies, but there was no difference in any other outcome. CCPT versus ACBT We are uncertain whether CCPT improves lung function compared to ACBT (very low-certainty evidence). Annual decline in FEF25-75 was worse in participants using the FET component of ACBT only (mean difference (MD) 6.00, 95% confidence interval (CI) 0.55 to 11.45; 1 study, 63 participants; very low-certainty evidence). One short-term study reported that directed coughing was as effective as CCPT for all lung function outcomes, but with no analysable data. One study found no difference in hospital admissions and days in hospital for exacerbations. CCPT versus O-PEP We are uncertain whether CCPT improves lung function compared to O-PEP devices (Flutter device and intrapulmonary percussive ventilation); however, only one study provided analysable data (very low-certainty evidence). No study reported data for number of exacerbations. There was no difference in results for number of days in hospital for an exacerbation, number of hospital admissions and number of days of intravenous antibiotics; this was also true for other secondary outcomes. CCPT versus AD We are uncertain whether CCPT improves lung function compared to AD (very low-certainty evidence). No studies reported the number of exacerbations per year; however, one study reported more hospital admissions for exacerbations in the CCPT group (MD 0.24, 95% CI 0.06 to 0.42; 33 participants). One study provided a narrative report of a preference for AD. CCPT versus exercise We are uncertain whether CCPT improves lung function compared to exercise (very low-certainty evidence). Analysis of original data from one study demonstrated a higher FEV1 % predicted (MD 7.05, 95% CI 3.15 to 10.95; P = 0.0004), FVC (MD 7.83, 95% CI 2.48 to 13.18; P = 0.004) and FEF25-75 (MD 7.05, 95% CI 3.15 to 10.95; P = 0.0004) in the CCPT group; however, the study reported no difference between groups (likely because the original analysis accounted for baseline differences).
Authors' conclusions:
We are uncertain whether CCPT has a more positive impact on respiratory function, respiratory exacerbations, individual preference, adherence, quality of life, exercise capacity and other outcomes when compared to alternative ACTs as the certainty of the evidence is very low. There was no advantage in respiratory function of CCPT over alternative ACTs, but this may reflect insufficient evidence rather than real equivalence. Narrative reports indicated that participants prefer self-administered ACTs. This review is limited by a paucity of well-designed, adequately powered, long-term studies. This review cannot yet recommend any single ACT above others; physiotherapists and people with CF may wish to try different ACTs until they find an ACT that suits them best.
Most of the important airway diseases of childhood are associated with mucus hypersecretion. Structural airway differences between children and adults are evident. Self- and assisted airway cleaning techniques are important to prevent worsening of children’s respiratory diseases.Airflow obstruction secondary to retained secretions increases the work of breathing, produces ventilation-perfusion mismatch, and can result in gas exchange abnormalities. Retained secretions can serve as a source of infection and inflammation.KeywordsAirway clearanceChildCough
Children and young people with CF (CYPwCF) get advice about using positive expiratory pressure (PEP) or oscillating PEP (OPEP) devices to clear sticky mucus from their lungs. However, little is known about the quantity (number of treatments, breaths, or sets) or quality (breath pressures and lengths) of these daily airway clearance techniques (ACTs) undertaken at home. This study used electronic pressure sensors to record real time breath-by-breath data from 145 CYPwCF (6–16y) during routine ACTs over 2 months. ACT quantity and quality were benchmarked against individual prescriptions and accepted recommendations for device use. In total 742,084 breaths from 9,081 treatments were recorded. Individual CYPwCF maintained consistent patterns of ACT quantity and quality over time. Overall, 60% of CYPwCF did at least half their prescribed treatments, while 27% did fewer than a quarter. About 77% of pre-teens did the right number of daily treatments compared with only 56% of teenagers. CYPwCF usually did the right number of breaths. ACT quality (recommended breath length and pressure) varied between participants and depended on device. Breath pressures, lengths and pressure-length relationships were significantly different between ACT devices. PEP devices encouraged longer breaths with lower pressures, while OPEP devices encouraged shorter breaths with higher pressures. More breaths per treatment were within advised ranges for both pressure and length using PEP (30–31%) than OPEP devices (1–3%). Objective measures of quantity and quality may help to optimise ACT device selection and support CYPwCF to do regular effective ACTs.
Introduction/objectives:
The aim of our study was to assess the safety, efficacy and feasibility of an Expiratory Flow Accelerator (EFA) device, Free Aspire, in reducing the need for daily suctions in tracheostomized (TCS) patients.
Methods:
Twenty-five patients (13 males, 12 females, aged 69.88±9.06 years) were investigated. The number of superficial/deep suctions, shallows, Arterial Blood Gas analysis (ABG), perception of mucus encumbrance (Visual Numeric Scale, VNS) and adverse event were recorded for five days. On the first two days (T1-T2) suctioning was performed as usual, on the following three days (T3, T4, T5) patients were treated also with Free Aspire (20 mins, 3 times a day).
Results/conclusion:
The use of the non-invasive device was associated with a decrease of total number of aspirations from T2 to T5 (8.48±2.62 vs. 4.48±3.08, p=0.0003). Total number of daily aspirations decreased over the five days (8.68±3.64 vs. 4.48±3.08, p=0.0009). Deep aspirations decreased from T1 to T5 (6.16±3.53 vs.1.80±1.50, P=0.0001). ABG data confirmed that no significant side effects occurred. VNS score decreased from 7.03±1.42 at T1 to 4.05±1.80 at T5 (p<0.0001). These data suggest that EFA may be useful for managing secretions in TCS patients, as it can reduce the number of daily suctions, particularly the deep ones, and may improve the perception of mucus encumbrance, without side effects. More studies are needed to confirm these data and to understand in which categories of TCS patients this device can be introduced. This article is protected by copyright. All rights reserved.
CF of mucoviscidose is de meest voorkomende autosomaal recessieve erfelijke aandoening van het Kaukasische ras. Respiratoire en gastro-intestinale symptomen staan bij deze aandoening op de voorgrond. De diagnose wordt bevestigd door een gestegen chloorconcentratie in het zweet. Pancreasenzymen, inhalatiemedicijnen en antibiotica enerzijds en fysiotherapie anderzijds vormen de belangrijkste pijlers van de huidige behandeling. Fysiotherapeutische technieken beogen de luchtwegweerstand te doen afnemen, de mucusklaring op te drijven en zodoende de ventilatie en uiteindelijk de bloedgaswaarden te verbeteren. Nieuwere drainagetechnieken aangevuld met hulptoestellen die eindexpiratoir druk opbouwend, oscillerend en luchtstroommodulerend zijn hebben de weinig efficiënte oudere technieken zoals tapotage en posturale drainage succesvol vervangen. Het is belangrijk dat de fysiotherapeut zich bekwaamt in de nieuwere technieken en deze individueel aanpast aan zijn patiënt. De opvoeding tot en een blijvende begeleiding naar ‘fysiotherapeutische zelfstandigheid’ van de patiënt is hierbij onontbeerlijk. Ook de begeleiding voor gebruik en aanpassing van de inhalatietoestellen behoort tot zijn terrein.
Sufferers of cystic fibrosis and other chronic lung diseases benefit from daily physiotherapy such as Positive Expiratory Pressure (PEP). For children, however, such repetitive daily exercises become a burden and may lead to confrontation with the family. Using a system comprised of a PEP mask, a computer- connected pressure monitor and a suite of games of varying types, a series of tests will determine with both objective statistics and subjective feedback how effective the system is at encouraging children and young adults to participate in daily therapy. With longer and more advanced games, coupled with unobtrusive data gathering functionality, we determine what effect long-term use of such a game system has on young sufferers. The study has shown that games based PEP physiotherapy is a desirable, viable alternative that can perform at least similarly to the existing approaches in terms of the amount of time children spend engaging in breathing exercises and with potentially many additional benefits including the capture of detailed data about the amount and quality of physiotherapy which is currently impossible with conventional, non-computerized methods.
Cystic fibrosis (CF) is the most common autosomal-recessive genetic disease among Caucasian populations. CF exhibits a particular affinity for the respiratory and digestive systems, and its clinical manifestations are characterised by chronic and suppurative pulmonary obstruction and gastrointestinal malabsorptive disorders. Although CF is classically known as a lethal disease, with patients not surviving until adulthood, several advances over recent decades have dramatically changed that outlook. Treatment is based on measures to combat airway obstruction, inflammation, and infection, in addition to ensuring satisfactory nutrition. Intensive treatment following a multidisciplinary approach and judicious use of the wide scope of available therapeutic resources have contributed to delayed CF progression and afford timely treatment of complications, resulting in a substantial increase in patient survival and quality of life. Measures to improve mucociliary clearance and lung ventilation, including respiratory physical therapy, are among the treatment pillars. Antibiotics are primarily used under the following three circumstances: upon initial identification of a microorganism (eradication), maintenance treatment, and exacerbations. In addition to antibiotics, other therapeutic possibilities are being developed to fight microorganisms, including hyperimmune gamma-globulin G and a recombinant human antibody. Drugs that are correctors and potentiators of the activity of CF transmembrane conductance regulator are currently being developed and tested. Presently, lung transplantation is a relevant tool to improve patient life expectancy and quality of life in cases with severe pulmonary involvement.
Primary Ciliary Dyskinesia Cystic Fibrosis Physiotherapy and Promoting Independence Exercise Physiotherapy Management of Babies and Young Children Physiotherapy Management of Older Children and Teenagers Nursing Management for Cystic Fibrosis Care in the Community Conclusion References
Introduction:
The role of respiratory physiotherapy (RP) in lower respiratory tract infections (LRTI) has been questioned. However, studies have focused on hospitalised patients, and the presence/absence of an underlying disease has been neglected.
Objectives:
To assess the effects of a RP session in community patients with LRTI and to explore the differences between patients with pneumonia (restrictive disease - AR) and those with exacerbations of an obstructive disease (AO).
Methods:
A pre/post-test study was conducted. A RP session was applied to patients with LRTI and crackles, wheezes, dyspnoea, perception of sputum and oxygen saturation were collected pre/post session. Comparisons were performed using paired t-tests or Wilcoxon tests.
Results:
Thirty patients (14 males, 55.23±17.78yrs) with pneumonia (AR, n=12), exacerbations of chronic obstructive pulmonary disease, acute bronchitis and asthma (AO, n=18) were enrolled. After treatment, the total sample presented lower wheeze rates at trachea (p=0.02; r=-0.54) and less sputum (p=0.01; r=-0.47). AR patients presented a decrease in the number of crackles (p<0.05; 0.30<dz <0.26) and number and rate of wheezes at chest locations (p<0.05; -0.56<r<-0.48). AO patients showed an increase in the number of crackles (p<0.05; 0.20<dz <0.31), wheeze frequency (p=0.03; r=-0.27) and dyspnoea (p=0.04; r=-0.55); and a decrease in the number of wheezes at trachea (p=0.02; r=-0.54).
Conclusions:
RP seems effective in reducing wheezes and perception of sputum in patients with LRTI. However, when considering AR and AO diseases separately, further changes in respiratory sounds and dyspnoea emerged. This highlights the importance of considering subgroups of patients with LRTI to develop RP evidence-base practice. This article is protected by copyright. All rights reserved.
Con el objetivo de evaluar el cumplimiento de las recomendaciones en rehabilitación respiratoria (ReR), planteadas por la British Thoracic Society (BTS) en pacientes con fibrosis quística (FQ) se realizó un estudio transversal entre 224 fisioterapeutas colombianos para identificar el tipo de intervenciones y las características de los programas de ReR como componentes del cumplimiento de las guías clínicas basadas en la evidencia de la BTS. Un elevado porcentaje de profesionales respondieron “realizar siempre” intervenciones con alto nivel de evidencia (grado A) como: técnicas de higiene bronquial (54,0%) y ciclo activo de la respiración (35,3%). Se observaron también intervenciones con menor grado de recomendación (grado D) como: uso de solución salina hipertónica y broncodilatador para evitar el broncoespasmo (33,9%), y técnicas de terapia manual o ejercicios de movilidad torácica y resistida (38,4%) para corregir problemas posturales y respiratorios. En conclusión, se encontraron importantes discrepancias con las intervenciones y componentes sugeridos por BTS en pacientes con FQ.
To determine if adequacy of randomisation and allocation concealment is associated with changes in effect sizes (ES) when comparing physical therapy (PT) trials with and without these methodological characteristics.
Meta-epidemiological study.
A random sample of randomised controlled trials (RCTs) included in meta-analyses in the PT discipline were identified.
Data extraction including assessments of random sequence generation and allocation concealment was conducted independently by two reviewers. To determine the association between sequence generation, and allocation concealment and ES, a two-level analysis was conducted using a meta-meta-analytic approach.
association between random sequence generation and allocation concealment and ES in PT trials.
393 trials included in 43 meta-analyses, analysing 44 622 patients contributed to this study. Adequate random sequence generation and appropriate allocation concealment were accomplished in only 39.7% and 11.5% of PT trials, respectively. Although trials with inappropriate allocation concealment tended to have an overestimate treatment effect when compared with trials with adequate concealment of allocation, the difference was non-statistically significant (ES=0.12; 95% CI -0.06 to 0.30). When pooling our results with those of Nuesch et al, we obtained a pooled statistically significant value (ES=0.14; 95% CI 0.02 to 0.26). There was no difference in ES in trials with appropriate or inappropriate random sequence generation (ES=0.02; 95% CI -0.12 to 0.15).
Our results suggest that when evaluating risk of bias of primary RCTs in PT area, systematic reviewers and clinicians implementing research into practice should pay attention to these biases since they could exaggerate treatment effects. Systematic reviewers should perform sensitivity analysis including trials with low risk of bias in these domains as primary analysis and/or in combination with less restrictive analyses. Authors and editors should make sure that allocation concealment and random sequence generation are properly reported in trial reports.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Background:
The management of cystic fibrosis (CF) includes adherence to a home management program (airway clearance, medication, nutritional advice, and exercise). This has led to an increase in life expectancy, although the benefits depend greatly on a patient's level of adherence to daily treatments at home. To date, no systematic review has established adherence rates to all World Health Organization guidelines in the home setting; hence, this review was undertaken.
Methods:
The review comprised 3 phases. A methodological assessment of databases (Embase, CINAHL, PsychINFO, PEDro, PubMed, Cochrane Central Register of Controlled Trials) identified potentially relevant papers. These papers were screened for inclusion criteria by 2 independent reviewers, data were extracted, and the internal validity was rated using a valid and reliable scale. Results were categorized into 4 themes: medication, nutrition, airway clearance techniques, and exercise.
Results:
The search generated a total of 26 papers, 24 of which were rated as being poor quality. Adherence to a treatment program for CF patients is generally low (from 22% for nutritional guidelines to 130% for oral antibiotics), and it varies greatly depending on the type of treatment and the method of assessment employed (objective tool vs self-reported questionnaires).
Conclusions:
Consensus on how to measure adherence is lacking, and the quality of studies addressing adherence in this population is generally poor. Overall, studies using self-reported measures yielded higher adherence scores than those that used objective measures, suggesting that current efforts to improve methods of adherence are appropriate. The prevalence of non-adherence remains unclear due to these limitations.
Osteoporosis is an increasing public health problem. The bisphophonates are the most useful treatment used through the world to prevent osteoporotic fractures. Their large prescription revealed an unpredictable side effect: the atypical fracture. These fractures appear in the subtrochanteric or diaphysal femoral proximal site, spontaneously or after a low trauma, and could be bilateral. X-rays shows a transversal or oblique fracture with a spur in the cortex and with a diffuse thickening of the cortical of the proximal femur. Expert's recommendations are current in progress to well understand and managed this problem. Here we report three cases of atypical femur fractures occurred in our Centre of bone diseases with some management and treatment propositions.
La fibrosis quistica (FQ) es la enfermedad autosomica recesiva letal mas comun en la poblacion blanca del Reino Unido, con una incidencia estimada en 1/2000 recien nacidos vivos (1). En los Estados Unidos, el 50% de los pacientes con FQ son diagnosticados a la edad de 6 meses y el 90% a la edad de 8 anos (2). La edad promedio de sobrevida estimada en ninos Europeos nacidos en la decada del 90 se calcula en 40 anos, lo cual representa el doble de lo que fue en los ultimos 20 anos; en donde solo la mitad de ellos son ahora adultos (3). Definitivamente, este incremento en la sobrevida es el resultado de un buen trabajo en el area de la fisioterapia, nutricion y un tratamiento antibiotico agresivo; y por supuesto un incremento considerable del entendimiento de esta enfermedad. El presente articulo es una revision de algunos aspectos de la fisiopatologia, microbiologia y terapeuticos de la FQ, al celebrarse el 15 aniversario de la clonacion del gen y su vez es una actualizacion del ultimo articulo publicado en esta misma revista.
A significant increase in life expectancy in successive birth cohorts of people with cystic fibrosis (CF) is a result of more effective treatment for the disease. It is also now widely recognized that outcomes for patients cared for in specialist CF Centres are better than for those who are not. Key to the effectiveness of the specialist CF Centre is the multidisciplinary team (MDT), which should include consultants, clinical nurse specialist, microbiologist, physiotherapist, dietitian, pharmacist, clinical psychologist, social worker, clinical geneticist and allied healthcare professionals, all of whom should be experienced in CF care. Members of the MDT are also expected to keep up to date with developments in CF through continued professional development, attendance at conferences, auditing and involvement in research. Specialists CF Centres should also network with other Centres both nationally and internationally, and feed Centre data to registries in order to further the understanding of the disease. This paper provides a framework for the specialist CF Centre, including the organisation of the Centre and the individual roles of MDT members, as well as highlighting the value of CF organisations and disease registries.
Disease processes can impair ciliary function, alter secretion production and mucus rheology, and interfere with the cough reflex. Airway clearance therapy has been a cornerstone of therapy aimed at minimizing the devastating effects of airway obstruction, infection, and inflammation due to mucus stasis on the conducting airways and lung parenchyma. Although challenges to performing clinical studies evaluating the effectiveness of airway clearance therapeutic modalities exist, resources are available in the literature. In addition to device evaluations and original clinical research, the expert opinion, systematic reviews, and evidence-based practice guidelines can be found. These tools can be used to develop protocols and pathways to guide our practice. Monitoring and reporting patient, process, and financial outcomes are essential steps germane to the implementation of evidence-based care.
Background:
Enhancement of mucociliary clearance by pulmonary rehabilitation (PR) is advocated in primary ciliary dyskinesia (PCD). Our primary aim was to compare the efficacy and safety of postural drainage, percussion and vibration [conventional PR (CPR)], and high frequency chest wall oscillation (HFCWO) by studying change in pulmonary function. Our secondary aim was to evaluate patient preferences regarding the two methods.
Methods:
This was a controlled randomized crossover study. PCD patients between the ages of 7 and 18 years were assigned to two groups, first group performed airway clearance with CPR at hospital for 5 days and after a 2-day washout period HFCWO was applied to the same group at home. HFCWO was applied first to the other group and then these patients were hospitalized for CPR. The primary outcome measure of the study was pulmonary function test (PFT). The secondary outcomes were pulse arterial oxygen saturation (SpO2 ) and the perceived efficiency and comfort level.
Results:
PFT values of patients increased significantly after both PR methods (before/after): CPR: FVC: 77.0 ± 14.1/81.8 ± 13.0 (P = 0.002); FEV1 : 72.9 ± 14.8/78.7 ± 13.5 (P = 0.001); PEF: 73.8 ± 14.5/82.5 ± 14.5 (P = 0.001); FEF25-75 : 68.6 ± 27.6/74.9 ± 29.3 (P = 0.007).
Hfcwo fvc:
75.1 ± 15.3/80.3 ± 13.9 (P = 0.002); FEV1 : 71.4 ± 16/77.4 ± 14.6 (P = 0.001); PEF: 70.9 ± 18.0/78.3 ± 17.7 (P = 0.002); FEF25-75 : 70.5 ± 23.4/76.4 ± 25.6 (P = 0.006). There were no significant differences in % predicted FVC, FEV1 , PEF, and FEF25-75 increased values with CPR and HFCWO. HFCWO was found more comfortable (P = 0.04). Two PR methods were found efficient and no desaturation occurred during PR.
Conclusions:
PFTs were significantly increased after both PR methods. There were no differences in PFTs and SpO2 between the CPR and HFCWO groups. Both PR methods were found efficient. HFCWO was found more comfortable. HFCWO may be an option in patients with chronic pulmonary disease and low adherence to PR.
The aim was to evaluate compliance with the recommendations in respiratory rehabilitation (ReR), raised by the British Thoracic Society (BTS) in patients with cystic fibrosis. A cross-sectional study was conducted in 224 Colombian physiotherapists to identify interventions and components of ReR programs as recommended by the BTS. Interventions with high level of evidence (Grade A) such as: Bronchial Hygiene Therapy (54.0%), and Active Cycle of Breathing Techniques (35.3%) were identified. However, high percentage of physiotherapists practiced interventions with lower grade of recommendation (Grade D) such as: hypertonic saline and bronchodilator to prevent bronchospasm (33.9%), and using manual therapy techniques and thoracic mobility exercises (38.4%) to correct postural and breathing problems. In conclusions we confirm important differences in therapeutic assistant components of the ReR raised by the BTS for patients with cystic fibrosis.
We studied the ability of 4 single-breath gas washout (SBW) tests to measure immediate effects of airway clearance in children with CF.
25 children aged 4-16years with CF performed pulmonary function tests to assess short-term variability at baseline and response to routine airway clearance. Tidal helium and sulfur hexafluoride (double-tracer gas: DTG) SBW, tidal capnography, tidal and vital capacity nitrogen (N2) SBW and spirometry were applied. We analyzed the gasses' phase III slope (SnIII - normalized for tidal volume) and FEV1 from spirometry.
SnIII from tidal DTG-SBW, SnIII from vital capacity N2-SBW, and FEV1 improved significantly after airway clearance. From these tests, individual change of SnIII from tidal DTG-SBW and FEV1 exceeded short-term variability in 10 and 6 children.
With the tidal DTG-SBW, an easy and promising test for peripheral gas mixing efficiency, immediate pulmonary function response to airway clearance can be assessed in CF children.
Nonostante la riabilitazione abbia ormai una “storia” piuttosto antica, la sua applicazione alle malattie respiratorie è relativamente
recente: solo negli ultimi 30 anni infatti si è assistito ad una sua diffusione via via più estesa, passando da arte a scienza.
Nel 1975, infatti uno “stato dell’arte” sulla diagnosi e trattamento della COPD pubblicato su JAMA metteva per la prima volta
in risalto gli effetti benefici della riabilitazione su questo tipo di pazienti. Nel corso degli ultimi tre decenni, poi una
grande mole di studi ne ha messo a fuoco i principi, e ne ha esteso sempre più le applicazioni, che attualmente non sono più
limitate soltanto ai pazienti COPD, ma comprendono numerose altre patologie, respiratorie e non.
The global development of airway clearance techniques (ACTs) for cystic fibrosis (CF) and corresponding research spans over four decades. Five Cochrane reviews synthesising the evidence from a plethora of early short and medium term studies have not uncovered any superior method. Four recent long term RCT studies exposed fundamental shortcomings in the standard RCT trial design and the insensitivity of FEV1 in physiotherapy studies. Strong patient preference, lack of blinding and the requirement for effortful and demanding participation over long intervals will continue to derail efforts to find the best ACT for CF, unless they are addressed in future clinical trials.
Despite conflicting evidence, chest physiotherapy has been widely used as an adjunctive treatment for adults with pneumonia.
To assess the effectiveness and safety of chest physiotherapy for pneumonia in adults.
We searched CENTRAL 2012, Issue 11, MEDLINE (1966 to November week 2, 2012), EMBASE (1974 to November 2012), Physiotherapy Evidence Database (PEDro) (1929 to November 2012), CINAHL (2009 to November 2012) and CBM (1978 to November 2012).
Randomised controlled trials (RCTs) assessing the efficacy of chest physiotherapy for treating pneumonia in adults.
Two authors independently assessed trial eligibility, extracted data and appraised trial quality. Primary outcomes were mortality and cure rate. We used risk ratios (RR) and mean difference (MD) for individual trial results in the data analysis. We performed meta-analysis and measured all outcomes with 95% confidence intervals (CI).
Six RCTs (434 participants) appraised four types of chest physiotherapy (conventional chest physiotherapy; osteopathic manipulative treatment (which includes paraspinal inhibition, rib raising and myofascial release); active cycle of breathing techniques (which include active breathing control, thoracic expansion exercises and forced expiration techniques); and positive expiratory pressure).None of the physiotherapies (versus no physiotherapy or placebo) improved mortality rates of adults with pneumonia.Conventional chest physiotherapy (versus no physiotherapy), active cycle of breathing techniques (versus no physiotherapy) and osteopathic manipulative treatment (versus placebo) did not increase the cure rate or chest X-ray improvement rate.Osteopathic manipulative treatment (versus placebo) and positive expiratory pressure (versus no physiotherapy) reduced the mean duration of hospital stay by 2.0 days (mean difference (MD) -2.0 days, 95% CI -3.5 to -0.6) and 1.4 days (MD -1.4 days, 95% CI -2.8 to -0.0), respectively. Conventional chest physiotherapy and active cycle of breathing techniques did not.Positive expiratory pressure (versus no physiotherapy) reduced fever duration (MD -0.7 day, 95% CI -1.4 to -0.0). Osteopathic manipulative treatment did not.Osteopathic manipulative treatment (versus placebo) reduced the duration of intravenous (MD -2.1 days, 95% CI -3.4 to -0.9) and total antibiotic treatment (MD -1.9 days, 95% CI -3.1 to -0.7).Limitations of this review are that the studies addressing osteopathic manipulative treatment were small, and that six published studies which appear to meet the inclusion criteria are awaiting classification.
Based on current limited evidence, chest physiotherapy might not be recommended as routine additional treatment for pneumonia in adults.
Objectives:
To explore whether consensus exists about content and professional identity represented within pre-registration cardiorespiratory physiotherapy (CPT) curricula, and to establish whether the curricula feature contemporary themes evident in policy and professional guidance in order to test whether CPT education is demonstrating responsiveness and relevance to practice.
Design:
An exploratory qualitative case study design employing documentary analysis of curricula materials related to CPT.
Participants:
Fourteen UK higher education institutions offering undergraduate physiotherapy qualifying programmes agreed to participate.
Intervention:
Relevant curriculum documentation was requested, such as student module guides, programme handbooks and institutional module descriptors, encompassing information including indicative content, teaching and learning methods, and modes of assessment. Document analysis combined deduction (through content analysis) and induction (through thematic analysis).
Results:
Consensus was observed on core content, underpinning philosophy and professional identity across institutions. The projected identity appeared to be strongly biomedical in focus, and was less well influenced by some of the contemporary aspects promoted by the Chartered Society of Physiotherapy, such as promotion of a patient-centred model of practice and acknowledgement of the emotional challenges existing within this area of work.
Conclusion:
Continuing critical review of the content and approach promoted within curricula is needed to ensure that learning remains relevant and responsive to current agendas. This study supports the need for course teams to reconsider the emphasis within individual curricula to ensure that responsiveness and relevance to the practice setting are made explicit.
Advances in medical management of children with cystic fibrosis has resulted in a cohort of apparently healthy infants who, nevertheless, have a life-long multisystem disorder. Physiotherapy approaches need to keep pace by adapting and developing techniques which are appropriate for families caring for seemingly asymptomatic babies. However, in the era of evidence-based medicine, adopting new approaches without a substantial evidence base risks the loss of potentially beneficial elements of traditional treatments. Early diagnosis (particularly neonatal screening), early aggressive prophylactic antibiotic therapy, and attention to nutrition have contributed to a significant change in the clinical status of many newborn infants and babies with cystic fibrosis. Most babies and young children attending cystic fibrosis centres now have good nutritional status, with a body mass index within normal limits. Physiotherapists caring for babies with cystic fibrosis face the dilemma of instigating routine therapy on diagnosis or waiting until the baby shows signs of respiratory symptoms. This issue has caused much disagreement amongst specialist physiotherapists internationally. This debate explores the arguments for and against new ideas in the physiotherapy management of asymptomatic infants and young children with cystic fibrosis.
RationaleAirway secretion clearance therapies are a cornerstone of cystic fibrosis care, however longitudinal comparative studies are rare. Our objectives were to compare three therapies [postural drainage and percussion: (postural drainage), flutter device (FD), and high frequency chest wall oscillation: (vest)], by studying (1) change in pulmonary function; (2) time to need for intravenous (IV) antibiotics, (3) use of pulmonary therapies, (4) adherence to treatment, (5) treatment satisfaction, and (6) quality of life.Methods
Participants were randomly assigned to one of three therapies twice daily. Clinical outcomes were assessed quarterly over 3 years.ResultsEnrollment goals were not met, and withdrawal rates were high, especially in postural drainage (51%) and FD (26%), compared to vest (9%), resulting in early termination. FEV1 decline, time to need IV antibiotics, and other pulmonary therapies were not different. The annual FEF25–75% predicted rate of decline was greater in those using vest (P = 0.02). Adherence was not significantly different (P = 0.09). Overall treatment satisfaction was higher in vest and FD than in postural drainage (P < 0.05). Health-related quality of life was not different. The rate of FEV1 decline was 1.23% predicted/year.Conclusions
The study was ended early due to dropout and smaller than expected decline in FEV1. Patients were more satisfied with vest and FD. The longitudinal decline in FEF25–75% was faster in vest; we found no other difference in lung function decline, taken together this warrants further study. The slow decline in FEV1 illustrates the difficulty with FEV1 decline as a clinical trial outcome. Pediatr Pulmonol. 2010; 45:291–300. © 2010 Wiley-Liss, Inc.
Previous work suggests benefit from outpatient exercise and physiotherapy in children with cystic fibrosis (CF), namely improved exercise capacity and lung function measures, as well reduced intravenous (IV) antibiotic needs. Our study aim was to investigate the effect of a year-long supervised outpatient exercise and physiotherapy programme in children with CF. Subjects with CF aged ≥10 years who had received ≥4 courses of IV antibiotics in 2009 were enrolled and seen fortnightly for supervised exercise and physiotherapy throughout 2010. In addition, they were expected to exercise three times weekly, and if unwell complete additional physiotherapy sessions extra to usual chest physiotherapy. Assessments of exercise capacity using the Modified Shuttle Test (MST) and quality of life (QOL; CFQ-UK) were recorded at baseline and after 1 year. Regular spirometry was performed before and throughout the study. Data were collected on IV antibiotic days. 12 subjects (6 female) were enrolled with mean (95% CI) age of 13.3 (11.8-14.6) years at study entry. A significant reduction in IV antibiotic days from 60 (56-64) days in 2009 to 50 (44-56) in 2010 (P = 0.02) was noted, along with improved MST distance (m) [735 (603-867) vs. 943 (725-1,161), P = 0.04] and level attained [9.4 (8.4-10.5) vs. 11.1 (9.6-12.6), P = 0.04]. Significant improvements in CFQ-UK scores for physical [59 (47-72) vs. 83 (74-92), P = 0.001], emotional [63 (55-72) vs. 84 (74-93), P < 0.001], treatment [41 (30-51) vs. 61 (48-73), P = 0.002], and respiratory [54 (42-66) vs. 76 (70-82), P = 0.002] domains were noted. The mean (95% CI) rate of change of FEV(1) was -4 (-18, +10)% in 2009, but was +6 (-2, +13)% in 2010, although this did not reach statistical significance. Supervised, outpatient exercise and physiotherapy are associated with improvements in QOL and exercise tolerance, a reduction in IV antibiotic days, and a trend towards reducing lung function decline in children with CF. The cost of IV antibiotics was reduced by £66,384 ($104,000) in 2010 when compared with 2009. Such cost-benefit may have implications for workforce planning and service provision. Pediatr Pulmonol. © 2012 Wiley Periodicals, Inc.
Inhalation of hypertonic saline improves sputum rheology, accelerates mucociliary clearance and improves clinical outcomes of people with cystic fibrosis.
To determine whether the timing of hypertonic saline inhalation (in relation to airway clearance techniques or in relation to time of day) has an impact on its clinical efficacy in people with cystic fibrosis.
We identified relevant randomised and quasi-randomised controlled trials from the Cochrane Cystic Fibrosis Trials Register, the Physiotherapy Evidence Database (PEDro), and international cystic fibrosis conference proceedings.Date of the last search of the Group's Cystic Fibrosis Trials Register: 6 December 2011.
Any trial of hypertonic saline in people with cystic fibrosis where timing of inhalation was the randomised element in the study protocol with either: inhalation up to six hours before airway clearance techniques compared to inhalation during airway clearance techniques compared to inhalation up to six hours after airway clearance techniques; or morning compared to evening inhalation with any definition provided by the author.
Both authors independently assessed the trials identified by the search for potential inclusion in the review.
The search strategy identified 50 trial reports which represented 24 unique studies. One study, published only as an abstract, is awaiting further assessment. None of the other studies compared timing regimens for the inhalation of hypertonic saline and we excluded these from the review.
This review did not identify any evidence comparing the timing of hypertonic saline inhalation in relation to airway clearance physiotherapy. Until such evidence becomes available, clinicians could advise patients to inhale hypertonic saline before airway clearance, because this is the only regimen evaluated in the studies that established the efficacy of the use of hypertonic saline. This review also did not identify any evidence comparing the timing of hypertonic saline inhalation in relation to time of day. Until such evidence becomes available, clinicians could advise patients to inhale hypertonic saline morning and evening; but if only one dose per day is tolerated, the time of day at which it is inhaled could be based on convenience or tolerability.Given the competing theoretical rationales about why hypertonic saline could be more effective if inhaled at certain times, a trial comparing these various timing regimens should be conducted.
To assess whether improvements in pulmonary function and microbial pathogenic findings can be achieved by endoscopic sinus surgery in a pediatric population with cystic fibrosis.
Retrospective medical record review.
Academic research.
Forty-one patients with cystic fibrosis who had undergone endoscopic sinus surgery at a single tertiary academic pediatric otolaryngology practice.
Changes in pulmonary function test values or respiratory tract microbial pathogens after endoscopic sinus surgery were examined.
Endoscopic sinus surgery did not improve pulmonary function test results in this population. Examination of respiratory tract microbial colonization showed that endoscopic sinus surgery did not affect microbial pathogens. The most common organisms isolated were Staphylococcus aureus and Pseudomonas aeruginosa.
The lack of effect of endoscopic sinus surgery on pulmonary function test results and respiratory tract microbial pathogens in our study highlights the need for prospective assessments of postoperative quality-of-life improvement and of adjunct medical therapy efficacy.
This study was designed to investigate the efficacy, safety and patients' acceptance of a novel system for sputum clearance--Hydro Acoustic Therapy (HAT) in patients with cystic fibrosis (CF). This is a prospective crossover study where 18 patients received 6 sessions of physiotherapy over 6 separate days. These consisted of 2 sessions of either HAT, flutter valve or and sitting in the bath with sounds without vibration (placebo) for 30 minutes each. The efficacy was investigated by measuring the weight of wet and dry sputum after each session and by change in spirometry values. The preference was assessed by a questionnaire completed by patients at the end of the study about their preference of which type of physiotherapy received. The weight of both dry and wet sputum produced was similar in the 3 arms of the study. Spirometry values but not oxygen saturation were reduced after HAT and flutter therapy sessions. HAT therapy was preferred to flutter and placebo in terms of breathlessness, ease of sputum production and relaxation. Of the patients, 70% stated that they would choose HAT as their preferred physiotherapy method compared to 0% for flutter (χ(2) = 20.3, p < 0.0001). There were no procedure-related complications in any of the 3 arms of the study. HAT was found to be safe, well tolerated and favoured by the majority of CF patients. The effect of HAT, however, on sputum production was not superior to flutter or placebo.
Cystic fibrosis (CF) patients commonly use a high-frequency chest-wall compression (HFCWC) device for airway clearance that generates oscillatory flow with a sine-wave configuration. Typical HFCWC settings combine a lower Vest inflation pressure setting (eg, 5 on the Vest's arbitrary 1-10 scale for the setting that controls the background pressure of the inflatable vest) with mid-range frequency (14-16 Hz) (lower-pressure/mid-frequency HFCWC).
To determine whether HFCWC with higher pressure settings (6-10 on the Hill-Rom Vest's arbitrary 1-10 scale) combined with variable mid-frequencies (8, 9, and 10 Hz, plus 18, 19, and 20 Hz) (higher-pressure/variable-frequency HFCWC) results in greater sputum expectoration than lower-pressure/mid-frequency HFCWC.
This was a controlled randomized crossover study. Sixteen clinically stable, adult CF patients participated. Patients performed airway clearance with HFCWC, once each with lower-pressure/mid-frequency HFCWC and higher-pressure/variable-frequency HFCWC, on separate occasions. All sputum produced during each session was collected. Patients completed pulmonary function tests before and after each session.
Median sputum wet weight was greater with higher-pressure/variable-frequency HFCWC than with lower-pressure/mid-frequency HFCWC (6.4 g, range 0.49-22.0 g, versus 4.8 g, range 0.24-15.0 g, P = .02). Dry sputum weight differences did not reach statistical significance (higher-pressure/variable-frequency HFCWC 0.20 g, range 0.009-0.62 g, lower-pressure/mid-frequency HFCWC 0.12 g, range 0.0001-1.0 g, P = .23). Higher-pressure/variable-frequency HFCWC and lower-pressure/mid-frequency HFCWC resulted in similar increases in FEV(1) (70 mL vs 90 mL, P = .21) and forced vital capacity (80 mL vs 80 mL, P = .94). Post-therapy sputum viscoelastic properties did not differ. Patients perceived the 2 regimens as equally comfortable and effective (P = .35 and P = .35, respectively).
In adult CF patients, single-session higher-pressure/variable-frequency HFCWC resulted in greater sputum expectoration by wet weight, but not other differences, compared to the commonly used lower-pressure/mid-frequency settings. Longer-term comparisons are needed in a larger, more diverse population to determine whether sustained use of the higher-pressure/variable-frequency settings results in clinically important differences in outcomes.
Respiratory therapy in cystic fibrosis (CF) consists of airway clearance, infection control, and reduction of airway inflammation. It is well recognized that physical activity as well as daily chest physiotherapy, enhance airway clearance. We investigated the effects of pulmonary rehabilitation, including physical activity and chest physiotherapy, on airway inflammation in children with CF.
Eighteen children with stable CF (six females), aged 8.2-16.2 years, participating in a 3-week multidisciplinary inpatient rehabilitation program were recruited. Assessment at the beginning and the end of the program included clinical score, pulmonary function test, exhaled breath condensate (EBC) and sputum analysis. Sputum supernatant and EBC were analyzed for interleukin (IL)-1b, 6, 8, 10, 12, tumor necrosis factor-alpha (TNF-alpha) and LTB4.
Median (IQR) symptom scores decreased from 19 [23] to 16 [21], P = 0.005. Vital capacity and FVC increased significantly (P < 0.05). However no difference was found for the total sputum cells and sputum as well as EBC cytokines between the two visits. Significant correlations were found for sputum IL-1 (+), IL-6 (-), and IL-8 (+) to total sputum cell count and neutrophils and for IL-8 to TNF-alpha.
We have shown that a short-term inpatient rehabilitation for children with stable CF with intensive physical activity mainly improve subjective clinical symptoms and measures of lung function such as VC and FVC but does not influence airflow obstruction and airway inflammation as assessed by sputum and EBC analysis.
Respiratory care is universally recognised as useful, but its indications and practice vary markedly. In order to improve the appropriateness of respiratory care in our hospital, we developed evidence-based local guidelines in a collaborative effort involving physiotherapists, physicians and health service researchers.
Recommendations were developed using the standardised RAND appropriateness method. A literature search was conducted based on terms associated with guidelines and with respiratory care. A working group prepared proposals for recommendations which were then independently rated by a multidisciplinary expert panel. All recommendations were then discussed in common and indications for procedures were rated confidentially a second time by the experts. The recommendations were then formulated on the basis of the level of evidence in the literature and on the consensus among these experts.
Recommendations were formulated for the following procedures: non-invasive ventilation, continuous positive airway pressure, intermittent positive pressure breathing, intrapulmonary percussive ventilation, mechanical insufflation-exsufflation, incentive spirometry, positive expiratory pressure, nasotracheal suctioning and non-instrumental airway clearance techniques. Each recommendation referred to a particular medical condition and was assigned to a hierarchical category based on the quality of the evidence from the literature supporting the recommendation and on the consensus among the experts.
Despite a marked heterogeneity of scientific evidence, the method used allowed us to develop commonly agreed local guidelines for respiratory care. In addition, this work fostered a closer relationship between physiotherapists and physicians in our institution.
Objetivos: nos últimos 70 anos, a fibrose cística emergiu da obscuridade para o reconhecimento como a mais importante doença hereditária, potencialmente letal, incidente na raça branca. Embora seja uma doença genética, na qual o defeito básico acomete células de vários órgãos, nem todos os indivíduos expressam respostas clínicas na mesma intensidade. Várias manifestações clínicas, principalmente pulmonares e digestivas, podem ocorrer durante a vida dos pacientes fibrocísticos. O objetivo deste artigo é propiciar ao pediatra geral uma visão atualizada dos principais assuntos referentes à fibrose cística. Fontes dos dados: revisão sistemática e atualizada em fonte de dados oficial (Medline). Síntese dos dados: foram revisados 79 artigos sobre fibrose cística, de periódicos internacionais, colocando, de modo atual e crítico, os principais eventos relacionados com a incidência, a fisiopatogenia, as manifestações clínicas, o diagnóstico e o tratamento da fibrose cística. Conclusões: apesar de não existir cura para essa doença, muitos conhecimentos novos sobre a etiologia e a fisiopatologia, adquiridos nas duas últimas décadas, propiciaram uma nova abordagem para o tratamento da fibrose cística. A compreensão dos mecanismos básicos da doença pulmonar, bem como das manifestações digestivas na fibrose cística, decorrente dos conhecimentos de pesquisas recentes, tem sido a chave para o aumento da sobrevida e a melhora da qualidade de vida dos pacientes.
It has been suggested that the quality of clinical trials should be assessed by blinded raters to limit the risk of introducing bias into meta-analyses and systematic reviews, and into the peer-review process. There is very little evidence in the literature to substantiate this. This study describes the development of an instrument to assess the quality of reports of randomized clinical trials (RCTs) in pain research and its use to determine the effect of rater blinding on the assessments of quality. A multidisciplinary panel of six judges produced an initial version of the instrument. Fourteen raters from three different backgrounds assessed the quality of 36 research reports in pain research, selected from three different samples. Seven were allocated randomly to perform the assessments under blind conditions. The final version of the instrument included three items. These items were scored consistently by all the raters regardless of background and could discriminate between reports from the different samples. Blind assessments produced significantly lower and more consistent scores than open assessments. The implications of this finding for systematic reviews, meta-analytic research and the peer-review process are discussed.
Although airway obstruction and chronic endobronchial infection have long been recognized as major factors in the pathogenesis of lung disease in cystic fibrosis (CF), only recently has it been recognized that the inflammatory process itself may be responsible in a major way for destroying the lungs. The most characteristic feature of inflammation in the CF lung is the persistent infiltration of massive numbers of neutrophils into the airways. Although neutrophils help to control infection, when present in great excess, they cause more harm than good. Major advances in our understanding of the inflammatory process in the CF lung have come from the use of bronchoscopy and bronchoalveolar lavage (BAL) to analyze the inflammatory process in patients who are relatively symptom free and/or do not regularly produce sputum. Recent BAL studies suggest that neutrophil-rich inflammation begins very early, even in infants without clinically apparent lung disease. A number of chemoattractants from epithelial cells, macrophages, neutrophils themselves, and bacterial products contribute to the neutrophil influx. Surprisingly, some infants have inflammation even in the apparent absence of infection, leading to the speculation that inflammation may precede infection. Links between the basic defect in CF and inflammation have been postulated, with dysregulation of cytokine production and abnormal epithelial host defenses being implicated as causal factors of sustained inflammation. Regardless of the details of how this process is initiated and/or perpetuated, it has become clear that inflammation begins at a very early stage and progresses throughout life, gradually worsening and destroying the lungs. For these reasons, anti-inflammatory therapy should be initiated in early life. Additional studies are necessary to define the optimal antiinflammatory drugs and regimens, and to confirm their long-term safety and efficacy.
Chest physiotherapy, aiming to clear bronchopulmonary secretions, has become a mainstay in the respiratory management of cystic fibrosis (CF). Early diagnosis and new therapeutic interventions have dramatically improved the outlook for patients with this disorder and it is no longer a disease of childhood. Along with these changes chest physiotherapy has also progressed, with the development of several treatment modalities that are more effective and can be performed by the patient without assistance. This allows older children and adults with CF to lead more normal and independent lifestyles. Despite this progress questions remain regarding the efficacy and consequences of airway clearance techniques, the scientific evidence available to support the selection of the most appropriate treatment modality and, not least, the problems associated with the treatment-related burden that is placed on patients and their families.
Chest physiotherapy is widely used in patients with cystic fibrosis in order to clear mucus from the airways.
To determine the effectiveness and acceptability of chest physiotherapy compared to no treatment or spontaneous cough alone to improve mucus clearance in cystic fibrosis.
Relevant trials are identified in the Cochrane Cystic Fibrosis and Genetic Disorders Group Specialised Register of Controlled Trials. This register was compiled by conducting computerised searches of Medline from 1966 to present and from Embase from 1974 to 1995. The register of randomised controlled trials is updated every three months. Unpublished work has been identified by searching through the abstract books of the three major cystic fibrosis conferences; the International Cystic Fibrosis Conference: the European Cystic Fibrosis Conference and the North American Cystic Fibrosis Conference. Date of the most recent search of the Group's specialised register: November 1999.
Randomised or quasi-randomised clinical trials in which a form of chest physiotherapy (airway clearance technique) were taken for consideration in patients with cystic fibrosis compared with either no physiotherapy treatment or spontaneous cough alone.
There were no randomised controlled trials or cross over trials eligible for inclusion in the review.
There were no randomised controlled trials or cross over trials eligible for inclusion in the review.
Short-term crossover trials, which had to be excluded from this review, suggest that airway clearance regimens could have beneficial effects in patients with cystic fibrosis. However based on this review there is currently no robust scientific evidence to support the hypothesis that chest physiotherapy for the purpose of clearing airway secretions has a beneficial effect in patients with cystic fibrosis.
Chest physical therapy: mucus mobilizing techniques
- van Schans CP der
- van Mark Th W der
- Rubin BK
- Postma DS
- Koëter GH
Assessing the quality of reports of randomized clinical trials: Is blinding neccesary?
- Jadad AR
- Moore A
- Carroll D
- Jenkinson C
- Reynolds DJM
- Gavaghan DJ
Chest physical therapy: mucus mobilizing techniques
- Schans