PHYSIOTHERAPY CANADA

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 Physiotherapy Canada Advancing health through scientific inquiry and knowledge translation Volume 73 • Number 1 • Winter 2021 Pour l’avancement de la santé par l’enquête scientifique et la transmission du savoir Fifth Issue in a Special Series on Paediatric Physiotherapy: A Celebration of the Breadth of Our Practice Highlights Guest Editorial Transforming the Provision of Physiotherapy in the Time of COVID-19: A Call to Action for Telerehabilitation / Transformer les services de physiothérapie à l’ère de la COVID-19 : un appel à l’action pour la téléréadaptation Articles • K nee Osteoarthritis: An Investigation into the Clinical Practice of Physiotherapists in Canada by B.J. Tittlemier, K.D. Wittmeier, D.B. Robinson, and S.C. Webber • M aking Decisions about Service Provision for Clients with Low Back Pain: Perspectives of Canadian Physiotherapy Professionals by T. Orozco, M. Laliberté, B. Mazer, M. Hunt, B. Williams-Jones, and D. Ehrmann Feldman • C oncussion Management Practices for Youth Who Are Slow to Recover: A Survey of Canadian Rehabilitation Clinicians by D.M. Dobney and I. Gagnon Official Journal of the Canadian Physiotherapy Association Revue officielle de l’Association canadienne de physiothérapie

CONTEMPORARY MEDICAL ACUPUNCTURE Neurofunctional Treatment of Pain and Dysfunction https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 Presents the Original McMaster University Medical Acupuncture Program 22+ years of training excellence Since 1998, more than 400+ SPRING 2021 PROGRAM PROGRAM SCOPE Physiotherapists have graduated from the program, achieving UNIT 1 March 5-6-7, 2021 The McMaster University Contemporary their training goals. Introduccon to Neurofuncconal Acupuncture Program has been teaching Neurofuncconal Electroacupuncture to $125 .....................A...c..u..p...u..n...c..t..u..r..e............................................................ health care professionals for over 20 UNIT 2 March 26-27-28, 2021 years. Physiotherapists trained through VOUCHER .....................U...p...p..e..r...E...x..t..r.e...m...i.t..y...P...r..o..b...l.e..m....s...-...A...c..u..t..e...P...a..i.n......... the program have consistently achieved UNIT 3 April 16-17-18, 2021 their goals. Code #100847 .....................A...x..i.a..l..S...k..e..l.e...t.a..l..P...r..o..b...l.e..m...s...-...V...i.s..c..e...r.a..l..R...e..g...u..l.a..a...o...n Expires: UNIT 4 May 14-15-16, 2021 The scope of the Program is beyond simple needle inserron; it provides the Feb 22, 2021 Head & Face Problems - praccconer with a unique framework for .....................C...h..r..o..n...i.c...P...a..i.n....S..y...n..d...r.o...m...e...s..................................... assessment and treatment. www.McMasterAcupuncture.com UNIT 5 June 4-5-6, 2021 The Neurofuncconal Operaang System Lower Extremity Problems - has been shown to consistently generate Integrated Management clinical results above and beyond tradiional treatment models. Registraaon Deadline: February 5, 2021 Visit our website for tessmonials at McMASTER CERTIFICATE www.mcmasteracupuncture.com 300 hours Connnuing Educaaon in Neurofuncconal STUDENTS RATES AVAILABLE Acupuncture. The program is Evidence-Based and clinically oriented, with over 100 hours of hands-on workshops on funcconal anatomy palpaaon, needle inserron techniques, anatomy laboratory, condiion- specific blueprint treatment design, and over 30 real paaent case studies. CONTACT US: 905-521-2100 x75175 / [email protected]

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 Physiotherapy Canada Advancing health through scientific inquiry and knowledge translation Pour l’avancement de la santé par l’enquête scientifique et la transmission du savoir Volume 73 • Number 1 • Winter 2021 • ISSN 0300-0508 • E-ISSN 1708-8313 TABLE OF CONTENTS GUEST EDITORIAL 1 Transforming the Provision of Physiotherapy in the Time of COVID-19: A Call to ARTICLES Action for Telerehabilitation A. Quigley, H. Johnson, and C. McArthur PAEDIATRIC PHYSIOTHERAPY SERIES 3 Transformer les services de physiothérapie à l’ère de la COVID-19 : un appel à l’action pour la téléréadaptation A. Quigley, H. Johnson et C. McArthur 6 Efficacy of Respiratory Physiotherapy Interventions for Intubated and Mechanically Ventilated Adults with Pneumonia: A Systematic Review and Meta-Analysis L. van der Lee, A.-M. Hill, A. Jacques, and S. Patman 19 Improving Cultural Knowledge to Facilitate Cultural Adaptation of Pain Management in a Culturally and Linguistically Diverse Community G.P. Bostick, K.E. Norman, A. Sharma, R. Toxopeus, G. Irwin, and R. Dhillon 26 Psychometric Properties of the OSPRO-YF Screening Tool in Patients with Shoulder Pathology H. Razmjou, V. Palinkas, S. Robarts, and D. Kennedy 37 Knee Osteoarthritis: An Investigation into the Clinical Practice of Physiotherapists in Canada B.J. Tittlemier, K.D. Wittmeier, D.B. Robinson, and S.C. Webber 47 Making Decisions about Service Provision for Clients with Low Back Pain: Perspectives of Canadian Physiotherapy Professionals T. Orozco, M. Laliberté, B. Mazer, M. Hunt, B. Williams-Jones, and D. Ehrmann Feldman 56 Joint Protection Programmes for People with Osteoarthritis and Rheumatoid Arthritis of the Hand: An Overview of Systematic Reviews P. Bobos, J.C. MacDermid, G. Nazari, E.A. Lalone, L. Ferreira, and R. Grewal 66 Do Paediatric Physiotherapists Promote Community-Based Physical Activity for Children and Youth with Disabilities? A Mixed-Methods Study J. Shannon, D. Legg, and L. Pritchard-Wiart 76 Exploring the Effects of Power Mobility Training on Parents of Exploratory Power Mobility Learners: A Multiple-Baseline Single-Subject Research Design Study L.K. Kenyon, N.J. Aldrich, J.P. Farris, B. Chesser, and K. Walenta

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 90 Concussion Management Practices for Youth Who Are Slow to Recover: A Survey of Canadian Rehabilitation Clinicians D.M. Dobney and I. Gagnon COCHRANE COLLABORATION 100 What Does Cochrane Say about ... Physical Activity Promotion in Children? INSTRUCTIONS FOR AUTHORS 101

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 Physiotherapy Canada Advancing health through scientific inquiry and knowledge translation Pour l’avancement de la santé par l’enquête scientifique et la transmission du savoir SCIENTIFIC EDITOR EDITORIAL OFFICE Dina Brooks, PhD, MSc, BSc (PT) University of Toronto Press - Journals Division Professor, Vice-Dean & Executive Director 5201 Dufferin St., North York, ON M3H 5T8 Canada Tel.: 416- School of Rehabilitation Science, McMaster University, 667-7777 ext. 7787, Fax: 416-667-7832 or 1-800-221-9985 Hamilton, ON E-mail: [email protected], www.utpjournals.press ASSOCIATE EDITORS INTERNATIONAL ADVISORY BOARD Denise Connelly, PhD, BScPT Rik Gosselink, PhD, PT Associate Professor, School of Physical Therapy, University of Professor, Department of Rehabilitation Sciences, Katholieke Western Ontario, London, ON Universiteit Leuven, Leuven University, Belgium Isabelle Gagnon, pht, PhD Karen Grimmer-Somers, PhD, MMedSci, BPhty, Assistant Professor, School of Physical and Occupational CertHealthEc, LMusA Therapy, McGill University, Montreal, QC Professor, School of Health Sciences Director, Centre for Allied Health Evidence, University of South Australia, Australia S. Jayne Garland, PhD, PT Professor and Department Head, Department of Physical Meg E. Morris, BAppSC(Physio), MAppSc, Grad Dip(Geron), Therapy, University of British Columbia, Vancouver, BC PhD, FACP Professor and Chair, School of Physiotherapy, University of Crystal MacKay, PhD, PT Melbourne, Australia Scientist, West Park Healthcare Centre Assistant Professor, Department of Physical Therapy, University of Toronto, ON Kenneth J. Ottenbacher, OT, PhD Russel Shearn Moody Distinguished Chair in Neurological Marilyn MacKay-Lyons, BSc(PT), MSc(PT), PhD Rehabilitation, Senior Associate Dean for Graduate Research Professor, School of Physiotherapy, Dalhousie University, Education, School of Allied Health Sciences, University of Halifax, NS Texas Medical Branch, USA Maxi Miciak, PhD, PT Carol L. Richards, PhD, PT, FCAHS Adjunct Associate Professor, Faculty of Rehabilitation Professor and Canada Research Chair in Rehabilitation, Medicine, University of Alberta; Principal, Maxi Miciak Department of Rehabilitation Medicine, Laval University, Consulting, Edmonton, AB Quebec City, QC Stephanie Nixon, PhD Peter Rosebaum, MD, CM, FRCP(C) Associate Professor, Department of Physical Therapy, Professor, Department of Pediatrics, McMaster University University of Toronto, Toronto, ON Hamilton, ON Kathleen E. Norman, BScPT, PhD Julius Sim, BA, MSc(Soc), MSc(Stat), PhD Associate Professor and Associate Director (Research and Primary Care Musculoskeletal Research Centre, Keele Post-Professional Programs), School of Rehabilitation Therapy, University, UK Queen’s University, Kingston, ON STATISTICAL CONSULTANT Brenda O’Neill, BScPT, Fellow HEA, PhD Centre for Health and Rehabilitation Technologies (CHART), Paul Stratford, PT, MSc Institute Nursing and Health Research, Sch Health Sciences, Professor Emeritus, School of Rehabilitation Science, Ulster University, Northern Ireland McMaster University, Hamilton, ON Marco Pang, BScPT, PhD PUBLISHER Assistant Professor, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong Canadian Physiotherapy Association 955 Green Valley Crescent, Suite 270, Ottawa, ON Michelle Ploughman, PhD, PT K2C 3V4 Canada Associate Professor of Medicine and Canada Research Chair, Tel.: 613-564-5454 or 800-387-8679, Fax: 613-564-1577 Memorial University of Newfoundland, St. John’s, NL E-mail: [email protected] www.physiotherapy.ca James Shaw, PT, PhD Competing Interest Statements for Physiotherapy Canada Scientist, Women’s College Hospital; Research Director Editorial Board members are available online at and Assistant Professor, University of Toronto, Toronto, ON https://www.utpjournals.press/journals/ptc/editorial-board

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 STATEMENT OF PURPOSE OBJECTIF Physiotherapy Canada is the official, scholarly, refereed journal of the Canadian Physiotherapy Association, giving direction to excellence in Physiotherapy Canada est la publication scientifique officielle révisée en clinical science and reasoning, knowledge translation, therapeutic skills profondeur de l’Association canadienne de physiothérapie. and patient-centred care. Son objectif est de fournir des orientations à l’excellence en sciences et en Recognized as one of the top five evidence-based journals of raisonnement clinique, transmission du savoir, compétences physiotherapy worldwide, Physiotherapy Canada publishes the results of thérapeutiques et soins centrés sur le patient. qualitative and quantitative research including systematic reviews, meta analyses, meta syntheses, public/health policy research, clinical practice Reconnu comme l’un des cinq grands journaux de physiothérapie guidelines, and case reports. Key messages, clinical commentaries, case reposant sur des faits scientifiques dans le monde, Physiotherapy Canada studies, evidence-based practice articles, brief reports, and book reviews publie les résultats de recherches qualitatives et quantitatives, notamment support knowledge translation to clinical practice. des revues systématiques, des méta-analyses, des métasyntheses, des recherches en politiques de la santé ou en politiques publiques, des Founded in 1923, Physiotherapy Canada meets the diverse needs of directives en pratique clinique et des études de cas. Ses messages clés, national and international readers and serves as a key repository of commentaires cliniques, études de cas, articles fondés sur des faits inquiries, evidence and advances in the practice of physiotherapy. scientifiques, résumés de discussions et comptes-rendus de livres favorisent la transmission du savoir à la pratique clinique. Physiotherapy Canada (ISSN 0300-0508) is published four times per year in spring, summer, fall and winter by the University of Toronto Fondée en 1923, Physiotherapy Canada répond aux divers besoins de Press for the Canadian Physiotherapy Association. lecteurs canadiens et étrangers et se positionne comme un véritable recueil sur la recherche, les faits scientifiques et les progrès dans la pratique de la physiothérapie. EDITORIAL SUBMISSIONS PRESENTATIONS D’ARTICLES Physiotherapy Canada welcomes manuscripts reporting results of qualitative or quantitative research. Systematic reviews, meta analyses Physiotherapy Canada accepte les articles qui font état de résultats de (quantitative), meta syntheses (qualitative), public/health policy recherche qualitative ou quantitative. Les examens systématiques, les méta- research, clinical practice guidelines, case reports (quantitative), case analyses (quantitatives), les métasynthèses (qualitatives), les recherches sur studies (qualitative), evidence-based practice articles and brief reports les politiques publiques et de santé, les guides de pratique clinique, les are also welcomed. Submissions are now being accepted online via rapports de cas (quantitatifs), les études de cas (qualitatives), les articles sur la Physiotherapy Canada’s online peer-review system ScholarOne. To log pratique factuelle et les rapports de mémoire sont aussi les bienvenus. Vous in or see submission guidelines, please go to https://mc04. pouvez présenter vos articles en ligne grâce au système électronique manuscriptcentral.com/ptc. For technical support information or d’examen par les pairs ScholarOne de Physiotherapy Canada. Pour ouvrir une questions regarding the editorial process please contact us at session ou pour connaître les lignes directrices sur la présentation d’un [email protected]. article, consultez la page https://mc04.manuscriptcentral.com/ptc. Pour obtenir un soutien technique ou des réponses à vos questions concernant le Physiotherapy Canada is indexed by Allied and Complementary processus rédactionnel, veuillez communiquer avec nous à ptc@utpress. Medicine Database (AMED), CrossRef, Cumulative Index to Nursing utoronto.ca. and Allied Health Literature (CINAHL), Google Scholar, National Archives Publishing Co., Online Computer Library Center (OCLC), Physiotherapy Canada est indexée par Allied and Complementary PEDro, PubMed Central (PMC), Rehabilitation & Sports Medicine Medicine Database (AMED), CrossRef, l’index cumulatif des publications Source, ScholarsPortal, Scopus, SIPX, and the Web of Science (Science sur les soins infirmiers et les soins paramédicaux (CINAHL), Google Citation Index Expanded). Scholar, National Archives Publishing Co., Online Computer Library Center (OCLC), PEDro, PubMed Central (PMC), Rehabilitation & Sports The statements and opinions in this journal are solely those of the Medicine Source, ScholarsPortal, Scopus, SIPX et Web of Science (Science contributors and not those of the publisher or of the Canadian Citation Index Expanded). Physiotherapy Association. Les opinions publiées dans cette revue sont celles des contributeurs et ne COPYRIGHT représentent pas les opinions de l’éditeur ou de l’Association canadienne © Canadian Physiotherapy Association, 20201. All rights reserved. No de physiotheérapie. part of this material may be reproduced, stored in a retrieval system, or transcribed in any form or by any means, electronic, mechanical, DROIT D’AUTEUR photocopying, recording, or otherwise, without written permission from the Canadian Physiotherapy Association and its publisher, © Association canadienne de physiothérapie, 20201. Tous droits réservés. University of Toronto Press. 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ADVERTISING ABONNEMENTS Physiotherapy Canada is distributed nationally and internationally to more than 11,300 individuals. For advertising rates and contracts, Les particuliers et les établissements peuvent s’abonner à l’adresse contact the Canadian Physiotherapy Association at advertising physiotherapy.ca. https://physiotherapy.ca/advertise suivante : www.utpjournals.press/loi/ptc. The appearance of an advertisement in the journal is not a warranty, PUBLICITÉ endorsement, or approval of the product(s) or service(s) offered, or of their effectiveness, quality, or safety. The publisher and Canadian Physiotherapy Canada est distribuée dans tout le pays et à l’étranger à plus Physiotherapy Association disclaim any responsibility for any injury to de 11 300 personnes. Pour connaître les tarifs de publicité et pour passer persons or property resulting from any ideas or products referred to in un contrat, communiquez avec l’Association canadienne de articles or advertisements. physiothérapie à [email protected]. https://physiotherapy. ca/ fr/advertise PUBLICATIONS MAIL La parution d’une publicité dans la revue n’est pas une garantie, un PM40600510 Printed in Canada endossement ou une approbation des produits ou des services offerts, ni de leur efficacité, de leur qualité ou de leur sécurité. L’editeur et l’Association Return undeliverable items to: University of Toronto Press, 5201 canadienne de physiothérapie déclinent toute responsabilité en matière de préjudices corporels ou matériels découlant d’idées ou de produits mentionnés dans les articles ou les publicités. 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https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 GUEST EDITORIAL / ÉDITORIALISTES INVITÉES Transforming the Provision of Physiotherapy in the Time of COVID-19: A Call to Action for Telerehabilitation Adria Quigley, PhD;* Helen Johnson, MSc;†‡ Caitlin McArthur, PhD§ ABSTRACT The emergence of coronavirus disease 2019 (COVID-19) has presented a global health threat, and it poses challenges to how physiotherapists deliver health care. Physiotherapists have an ethical obligation not only to reduce the spread of COVID-19 but also to provide client-centred care and to improve or maintain function among those living in the community. Telerehabilitation provides an opportunity to maintain function, prevent future hospitalizations, and assist with discharge from hospitals while maintaining physical distancing recommendations. This editorial outlines the evidence for telerehabilitation, key considerations for its use, challenges to its use, and we issue a call to action. Key Words: COVID-19; prevention; telerehabilitation; virtual rehabilitation. The emergence of coronavirus disease 2019 (COVID-19) conditions and after elective musculoskeletal surgeries;3 has presented a global health threat, posing challenges to (2) exercise outcomes for people with chronic obstruc- health care delivery among physiotherapists. Outpatient tive pulmonary disease;6 and (3) activities of daily living, physiotherapy clinics have closed, and in-patient therapists balance, health-related quality of life, and depressive are working on the front lines to treat clients. In the acute symptoms after stroke.4 In some instances, telerehabili- care setting, referral to physiotherapy is recommended for tation has been more effective than traditional therapy: clients at significant risk of developing functional limita- a meta-analysis determined that it reduced pain and tions.1 Physiotherapists can also help individuals living improved function more effectively than usual care (rang- in the community who are susceptible to functional lim- ing from education to standard rehabilitation) among itations, falls, and subsequent hospitalization. Clinicians individuals after total knee replacement.2 have an ethical obligation to reduce the spread of COVID- 19 but also to provide client-centred care and to improve KEY CONSIDERATIONS or maintain function for those living in the community. Although telerehabilitation is a viable solution at a time Telerehabilitation provides an opportunity to maintain function, prevent future hospitalizations, and assist with when physical distancing is necessary to prevent viral discharge from hospitals while maintaining physical dis- transmission, modifications to standard practice proce- tancing recommendations. In this editorial, we outline the dures should be considered: evidence for telerehabilitation, key considerations for its use, challenges to its use, and we issue a call to action. • Review your professional liability coverage for telere- habilitation; you must have coverage to provide it. EVIDENCE FOR TELEREHABILITATION INTERVENTIONS The evidence for the effectiveness of telerehabilitation • You must be a registered member of the physiother- apy regulatory body in the jurisdiction in which you for musculoskeletal, neurological, and cardiorespiratory and the client reside. conditions is emerging. 2–7 Several recent meta-analyses have revealed that telerehabilitation is, at minimum, as • Check with the client’s insurance provider to deter- effective as face-to-face therapy for improving (1) physical mine whether it provides telerehabilitation coverage. function and pain in individuals with arthritis and spinal Some insurance providers that do are Blue Cross, Manulife, Chamber of Commerce, Canada Life, and Sun Life.8 From the: *Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Que.; †Seniors Health Division, Canadian Physiotherapy Association, Ottawa; §GERAS Centre for Aging Research, McMaster University, Hamilton, Ont.; ‡International Association of Physical Therapists Working with Older People, London. Correspondence to: Adria Quigley, Centre for Outcomes Research and Evaluation, McGill University Health Centre, 5252 de Maisonneuve, Montreal, QC H4A 3S5; [email protected]. Physiotherapy Canada 2021; 73(1); 1–2; doi:10.3138/ptc-2020-0031-gee 1

2 Physiotherapy Canada, Volume 73, Number 1 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 • Screen the client to ensure that telerehabilitation skills and creativity to provide care to keep people mov- is appropriate for the client’s assessment and treat- ing, functional, and out of hospitals while maintaining ment needs. physical distancing. It is time to take our practice online. • Consider whether the client will require physical or REFERENCES cognitive assistance from a family member during the session, and if so, arrange this ahead of time. 1. Thomas P, Baldwin C, Bissett B, et al. Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice • Obtain consent from the client, which includes the recommendations. J Physiother. 2020;66(2):73–82. https://doi. typical information included in consent but also org/10.1016/j.jphys.2020.03.011. information about the security of the computer platform used. 2. Wang X, Hunter DJ, Vesentini G, et al. Technology-assisted rehabilitation following total knee or hip replacement for people • Use a secure platform such as Embodia,9 Doxy,10 or with osteoarthritis: a systematic review and meta-analysis. BMC Jane.11 Musculoskelet Disord. 2019;20:506. https://doi.org/10.1186/ s12891-019-2900-x. • Before starting the session, identify yourself and your jurisdiction to the client and ask the client to 3. Cottrell MA, Galea OA, O’Leary SP, et al. Real-time telerehabilitation identify her- or himself verbally. for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and • Use normal documentation (e.g., a SOAP note [sub- meta-analysis. Clin Rehabil. 2017;31(5):625–38. https://doi. jective, objective, assessment, and plan]), including org/10.1177/0269215516645148. what services you have provided and the fact that you used telerehabilitation. 4. Laver KE, Adey-Wakeling Z, Crotty M, et al. Telerehabilitation services for stroke. Cochrane Database Syst Rev. 2020;(1):CD010255. https:// • Provide the client with an invoice that states that doi.org/10.1002/14651858.CD010255.pub3. you used telerehabilitation. The Canadian Physio- therapy Association provides an invoice template.12 5. Khan F, Amatya B, Kesselring J, et al. Telerehabilitation for persons with multiple sclerosis. Cochrane Database Syst Rev. CHALLENGES AND A CALL TO ACTION 2015;(4):CD010508. https://doi.org/10.1002/14651858.CD010508. Until the COVID-19 pandemic struck, the uptake of pub2 telerehabilitation into physiotherapy practice had been 6. Chan C, Yamabayashi C, Syed N, et al. Exercise telemonitoring and slow. A recent systematic review identified the global bar- telerehabilitation compared with traditional cardiac and pulmonary riers to telemedicine among providers and clients, includ- rehabilitation: a systematic review and meta-analysis. Physiother ing a lack of technical knowledge, resistance to change, Can. 2016;68(3):242–51. https://doi.org/10.3138/ptc.2015-33. cost, and a lack of reimbursement for services provided.13 Since the crisis began, many insurance companies across 7. Vasilopoulou M, Papaioannou AI, Kaltsakas G, et al. Home- Canada have agreed to cover telerehabilitation services, based maintenance tele-rehabilitation reduces the risk for and the Canadian Physiotherapy Association has offered acute exacerbations of COPD, hospitalisations and emergency webinars to help physiotherapists learn how to deliver department visits. Eur Respir J. 2017;49(5):1602129. https://doi. them.14 As uptake increases incrementally, initial telere- org/10.1183/13993003.02129-2016. habilitation caseloads will be small, and self-employed physiotherapists will face significantly reduced finan- 8. Grant T. Hands off: Nova Scotia physiotherapists cial compensation. Thus, the Government of Canada learn to make adjustment to virtual care [Internet]. must financially support physiotherapists as they provide Toronto: CBC News; 2020 [cited 2020 Apr 6]. Available telerehabilitation. from: https://www.cbc.ca/news/canada/nova-scotia/ nova-scotia-physiotherapists-adjust-covid-19-1.5522473. While the COVID-19 outbreak continues to spread throughout the world, telerehabilitation may be the new 9. Embodia. What is Embodia? [Internet]. 2020 [cited 2020 Apr 3]. norm because people need care to maintain their function Available from: https://www.embodiaacademy.com/. and quality of life. Fortunately, it appears that clients are ready and open to this form of treatment; a survey of 254 10. Doxy.me [Internet]. 2020 [cited 2020 Apr 3]. Available from: https:// individuals with chronic respiratory diseases determined doxy.me/. that 57% indicated that they were technologically compe- tent, and 60% were willing to use telerehabilitation.15 Tel- 11. Jane Software Inc. Jane [Internet]. North Vancouver, BC: Jane erehabilitation offers physiotherapists opportunities to Software Inc.; 2020 [cited 2020 Apr 3]. Available from: https://jane. provide innovative, effective movement-, exercise-, and app/. education-based treatments. 12. Canadian Physiotherapy Association. Consent to use electronic COVID-19 represents a serious threat to the health and communications to provide telehealth services. Ottawa: The well-being of all Canadians. Physiotherapists have the Association; 2020 [cited 2020 Apr 3]. Available from: https:// physiotherapy.ca/sites/default/files/covid-19_telehealth_consent_ form_cpa_0.pdf. 13. Kruse C, Karem P, Shifflett K, et al. Evaluating barriers to adopting telemedicine worldwide: a systematic review. J Telemed Telecare. 2018;24(1):4–12. https://doi.org/10.1177/1357633X16674087. 14. O’Neil J. Tele-rehabilitation in times of COVID-19 [Internet]. Ottawa: Canadian Physiotherapy Association; 2020 [cited 2020 Apr 3]. Available from: https://physiotherapy.ca/times-covid-19. 15. Seidman Z, McNamara R, Wootton S, et al. People attending pulmonary rehabilitation demonstrate a substantial engagement with technology and willingness to use telerehabilitation: a survey. J Physiother. 2017;63(3):175–81. https://doi.org/10.1016/j. jphys.2017.05.010.

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 GUEST EDITORIAL / ÉDITORIALISTES INVITÉES Transformer les services de physiothérapie à l’ère de la COVID-19 : un appel à l’action pour la téléréadaptation Adria Quigley, Ph. D.;* Helen Johnson, M. Sc.;†‡ Caitlin McArthur, Ph. D.§ RÉSUMÉ L’émergence de la maladie à coronavirus 2019 (COVID-19) constitue une menace pour la santé mondiale et pose des défis à l’égard du mode de prestation des services de physiothérapie. Les physiothérapeutes ont l’obligation éthique non seulement de réduire la propagation de la COVID-19, mais également d’offrir des soins axés sur les clients et d’améliorer ou de maintenir le fonctionnement des personnes qui vivent dans la communauté. La téléréadaptation permet de maintenir le fonctionnement, de prévenir de futures hospitalisations et de favoriser les congés des hôpitaux tout en respectant les recommandations relatives à la distanciation physique. Dans le présent éditorial, les autrices exposent les données probantes sur la téléréadaptation, les éléments fondamentaux en justifiant l’utilisation et les difficultés qui s’y rattachent et elles proposent un appel à l’action. Mots-clés : COVID-19; prévention; réadaptation virtuelle; téléréadaptation L’émergence de la maladie à coronavirus 2019 (COVID- DES DONNÉES PROBANTES SUR LES INTERVENTIONS EN 19) constitue une menace pour la santé mondiale et pose TÉLÉRÉADAPTATION des défis à l’égard du mode de prestation des services de physiothérapie. Les cliniques de physiothérapie ambu- Des données probantes se dégagent sur l’efficac- latoires ont fermé, tandis que les thérapeutes qui s’occu- ité de la téléréadaptation pour traiter des problèmes pent de patients hospitalisés travaillent en première ligne musculosquelettiques, neurologiques et cardiorespira- pour traiter leurs clients. En milieu de soins aigus, il est toires2-7. Plusieurs méta-analyses récentes révèlent que recommandé de diriger les clients très à risque de limi- la téléréadaptation est à tout le moins aussi efficace tations fonctionnelles vers des services de physiothéra- que la thérapie face aux patients pour 1) améliorer le pie1. Les physiothérapeutes peuvent également aider les fonctionnement physique et atténuer la douleur chez membres de la communauté qui sont vulnérables à des les personnes atteintes d’arthrite et de troubles médul- limitations fonctionnelles, des chutes et une hospitalisa- laires et après des opérations musculosquelettiques tion subséquente. Les cliniciens ont l’obligation éthique non urgentes3, 2) optimiser les résultats de l’exercice de réduire la propagation de COVID-19, mais également chez les personnes atteintes d’une maladie pulmonaire de prodiguer des soins axés sur les clients et d’améliorer obstructive chronique6 et 3) promouvoir les activités ou de maintenir le fonctionnement des personnes qui de la vie quotidienne, l’équilibre, la qualité de vie liée vivent dans la communauté. La téléréadaptation permet de à la santé et les symptômes dépressifs après un acci- maintenir le fonctionnement, de prévenir de futures hos- dent vasculaire cérébral4. Dans certaines situations, pitalisations et de favoriser les congés des hôpitaux tout en la téléréadaptation est plus efficace que le traitement respectant les recommandations relatives à la distanciation classique : une méta-analyse a déterminé qu’elle réduit physique. Dans le présent éditorial, les autrices exposent la douleur et améliore le fonctionnement avec plus les données probantes sur la téléréadaptation, les éléments d’efficacité que les soins habituels (variant entre la fondamentaux en justifiant l’utilisation et les difficultés qui remise d’information et la réadaptation standard) chez s’y rattachent et elles proposent un appel à l’action. les personnes qui ont subi une arthroplastie totale du genou2. Affiliation : *Centre de recherche évaluative en santé, Centre universitaire de santé McGill, Montréal (Québec); †Division de la santé des aînés, Association canadienne de physiothérapie, Ottawa (Ontario); §GERAS Centre for Aging Research, McMaster University, Hamilton (Ontario); ‡International Association of Physical Therapists Working with Older People, Londres (Royaume-Uni) Correspondance à : Adria Quigley, Centre universitaire de santé McGill, Centre de recherche évaluative en santé, 5252, boul. de Maisonneuve, Montréal (Québec) H4A 3S5; [email protected] Physiotherapy Canada 2021; 73(1); 3–5; doi:10.3138/ptc-2020-0031-gef 3

4 Physiotherapy Canada, Volume 73, Number 1 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 LES ÉLÉMENTS FONDAMENTAUX des webinaires pour enseigner aux physiothérapeutes à La téléréadaptation est une solution viable en cette les donner14. L’adoption de la téléréadaptation augmen- tera progressivement, mais la charge de travail initiale des période où la distanciation physique s’impose pour physiothérapeutes sera limitée, et ceux qui travaillent à prévenir la transmission virale, mais il faut envisager les leur compte recevront une rémunération sensiblement modifications suivantes aux pratiques standards pour la réduite. Ainsi, le gouvernement du Canada doit soute- pratiquer : nir financièrement les physiothérapeutes qui font de la téléréadaptation. • Vérifiez votre régime d’assurance responsabilité professionnelle en matière de téléréadaptation; Puisque la pandémie de COVID-19 continue de se vous devez être assuré pour pouvoir prodiguer ce propager dans le monde, la téléréadaptation doit deve- type de soins. nir la nouvelle norme dans un avenir prévisible pour soigner les personnes qui ont besoin de maintenir leur • Assurez-vous d’être membre de l’organisme de régle- fonctionnement et leur qualité de vie. Heureusement, il mentation de la physiothérapie de la région où votre semble que les clients soient prêts et ouverts à profiter de client et vous habitez, car c’est une obligation. cette forme de traitement. Un sondage auprès de 254 per- sonnes atteintes d’une maladie respiratoire chronique a • Vérifiez si l’assureur de votre client couvre la téléré- révélé que 57 % d’entre elles étaient compétentes sur le adaptation. Certains, comme la Croix Bleue, Manu- plan de la technologie, et que 60 % étaient prêtes à faire vie, la Chambre de commerce, Canada-Vie et Sun appel à la téléréadaptation15. La téléréadaptation per- Life8, le font. met aux physiothérapeutes de prodiguer des traitements novateurs et efficaces fondés sur le mouvement, l’exer- • Procédez au dépistage du client pour vous assurer cice et l’information. que la téléréadaptation convient à ses besoins d’évaluation et de traitement. La COVID-19 représente une grave menace pour la santé et le bien-être de tous les Canadiens. Les physio- • Évaluez si le client aura besoin d’une assistance thérapeutes possèdent les compétences et la créativité physique ou cognitive de la part d’un membre de sa nécessaires pour prodiguer les soins qui permettront à famille pendant la séance et, s’il y a lieu, planifiez-le. leurs clients de se déplacer, d’être fonctionnels et de ne pas être hospitalisés tout en respectant la distanciation • Obtenez le consentement du client, ce qui inclut physique. Il est temps de transposer notre pratique en l’information habituellement incluse dans le for- ligne. mulaire de consentement, mais également l’infor- mation sur la sécurité de la plateforme informatique RÉFÉRENCES utilisée. 1. Thomas P, Baldwin C, Bissett B et coll. Physiotherapy management • Utilisez une plateforme sécurisée, comme celle for COVID-19 in the acute hospital setting: clinical practice d’Embodia9, de Doxy10 ou de Jane11. recommendations. J Physiother. 2020;66(2):73–82. https://doi. org/10.1016/j.jphys.2020.03.011. • Avant le début de la séance, présentez-vous, préci- sez votre lieu de travail au client et demandez-lui de 2. Wang X, Hunter DJ, Vesentini G et coll. Technology-assisted s’identifier verbalement. rehabilitation following total knee or hip replacement for people with osteoarthritis: a systematic review and meta-analysis. BMC • Utilisez les modes habituels de consignation au Musculoskelet Disord. 2019;20:506. https://doi.org/10.1186/ dossier (p. ex., méthode SOAP [subjective, objective, s12891-019-2900-x. évaluation et plan]), y compris les services que vous avez prodigués et le fait que vous avez fait appel à la 3. Cottrell MA, Galea OA, O’Leary SP et coll. Real-time telerehabilitation réadaptation. for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and • Remettez à votre client un formulaire sur lequel meta-analysis. Clin Rehabil. 2017;31(5):625–38. https://doi. vous précisez que vous offrez des services de téléré- org/10.1177/0269215516645148. adaptation. L’Association canadienne de physio- thérapie en fournit un modèle12. 4. Laver KE, Adey-Wakeling Z, Crotty M et coll. Telerehabilitation services for stroke. Cochrane Database Syst Rev. 2020;(1):CD010255. LES DÉFIS ET UN APPEL À L’ACTION https://doi.org/10.1002/14651858.CD010255.pub3. Avant la pandémie de COVID-19, l’intégration de la 5. Khan F, Amatya B, Kesselring J et coll. Telerehabilitation for téléréadaptation à la physiothérapie a été lente à décol- persons with multiple sclerosis. Cochrane Database Syst Rev. ler. Une analyse systématique récente a permis d’établir 2015;(4):CD010508. https://doi.org/10.1002/14651858.CD010508. les obstacles globaux à la télémédecine chez les dispen- pub2 sateurs et les clients, y compris le peu de connaissances techniques, la résistance au changement, le coût et le 6. Chan C, Yamabayashi C, Syed N et coll. Exercise telemonitoring and non-remboursement des services13. Depuis le début de la telerehabilitation compared with traditional cardiac and pulmonary crise, de nombreuses sociétés d’assurance du Canada ont rehabilitation: a systematic review and meta-analysis. Physiother accepté de rembourser les services de téléréadaptation, Can. 2016;68(3):242–51. https://doi.org/10.3138/ptc.2015-33. et l’Association canadienne de physiothérapie a proposé 7. Vasilopoulou M, Papaioannou AI, Kaltsakas G et coll. Home- based maintenance tele-rehabilitation reduces the risk for

Quigley et al. Transformer les services de physiothérapie à l’ère de la COVID-19 5 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 acute exacerbations of COPD, hospitalisations and emergency 12. Association canadienne de physiothérapie. Consentement quant à department visits. Eur Respir J. 2017;49(5):1602129. https://doi. l’utilisation de communications électroniques pour la prestation de org/10.1183/13993003.02129-2016. services de télésanté. Ottawa : L’Association; 2020 [consulté le 3 avril 8. Grant T. Hands off: Nova Scotia physiotherapists learn 2020]. Disponible à : https://physiotherapy.ca/sites/default/files/ to make adjustment to virtual care [Internet]. Toronto : french_-_covid-19_telehealth_consent_form_cpa.pdf. CBC News; 2020 [consulté le 6 avril 2020]. Disponible à : https://www.cbc.ca/news/canada/nova-scotia/ 13. Kruse C, Karem P, Shifflett K et coll. Evaluating barriers to adopting nova-scotia-physiotherapists-adjust-covid-19-1.5522473. telemedicine worldwide: a systematic review. J Telemed Telecare. 9. Embodia. What is Embodia? [Internet]. 2020 [consulté le 3 avril 2020]. 2018;24(1):4–12. https://doi.org/10.1177/1357633X16674087. Disponible à : https://www.embodiaacademy.com/. 10. Doxy.me [Internet]. 2020 [consulté le 3 avril 2020]. Disponible à : 14. O’Neil J. Tele-rehabilitation in times of COVID-19 [Internet]. Ottawa : https://doxy.me/. Association canadienne de physiothérapie; 2020 [consulté le 3 avril 11. Jane Software Inc. Jane [Internet]. North Vancouver, BC : Jane 2020]. Disponible à : https://physiotherapy.ca/times-covid-19. Software Inc.; 2020 [consulté le 3 avril 2020]. Disponible à : https:// jane.app/. 15. Seidman Z, McNamara R, Wootton S et coll. People attending pulmonary rehabilitation demonstrate a substantial engagement with technology and willingness to use telerehabilitation: a survey. J Physiother. 2017;63(3):175–81. https://doi.org/10.1016/j.jphys.2017.05.010.

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 ARTICLE Efficacy of Respiratory Physiotherapy Interventions for Intubated and Mechanically Ventilated Adults with Pneumonia: A Systematic Review and Meta-Analysis Lisa van der Lee, BSc, PhD;*† Anne-Marie Hill, PhD;‡ Angela Jacques, MBiostat;‡§ Shane Patman, PhD† ABSTRACT Purpose: A systematic review was conducted to investigate the effect of respiratory physiotherapy on mortality, quality of life, functional recovery, intensive care length of stay, duration of ventilation, oxygenation, secretion clearance, and pulmonary mechanics for invasively ventilated adults with pneumonia. Method: Five databases were searched for randomized trials published between January 1995 and November 2018. Study quality was assessed using a standardized Joanna Briggs Institute critical appraisal tool, and Review Manager software was used to pool the studies.The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the level of certainty of the evidence. Results: A total of 14 studies of moderate quality included 251 subjects with pneumonia. Eight studies were pooled for meta-analysis. Interventions that increased inspiratory volume appeared to benefit secretion clearance by nearly 2 grams (mean difference [MD] 1.97; 95% CI: 0.80, 3.14; very low GRADE evidence) and increase static lung compliance immediately after treatment by more than 5 millilitres/centimetre H20 (MD 5.40 mL/cm H2O; 95% CI: 2.37, 8.43; very low GRADE evidence) or by more than 6 millilitres/centimetre H2O after a 20- to 30-minute delay (MD 6.86 mL/cm H O; 95% CI: 2.86, 10.86; very low GRADE evidence). No adverse events were found. Conclusions: Respiratory physiotherapy 2 that increases tidal volume may benefit secretion clearance and lung compliance in invasively ventilated adults with pneumonia, but its impact on other outcomes, including mortality, length of stay, and other patient-centred outcomes, is unclear, and further research is required. Key Words: critical care; physical therapy modalities; pneumonia; respiratory therapy; systematic review. RÉSUMÉ Objectif : analyse systématique pour explorer l’effet de la physiothérapie respiratoire sur la mortalité, la qualité de vie, le rétablissement fonctionnel, la durée de séjour en soins intensifs, la durée de la ventilation, l’oxygénation, la clairance des sécrétions et la mécanique pulmonaire d’adultes atteints de pneumonie sous assistance respiratoire invasive. Méthodologie : recherche dans cinq bases de données pour en extraire les études aléatoires publiées entre janvier 1995 et novembre 2018. Les chercheurs ont évalué la qualité des études à l’aide de l’outil d’évaluation critique standardisé du Joanna Briggs Institute et ont utilisé le logiciel Review Manager pour regrouper les études. Ils ont utilisé la méthode GRADE (Grading of Recommendations Assessment, Development and Evaluation) pour évaluer le degré de certitude des données probantes. Résultats : au total, 14 études de qualité modérée incluaient 251 sujets atteints de pneumonie. Les chercheurs ont regroupé huit études en vue de la méta-analyse. Les interventions qui améliorent le volume inspiratoire semblaient accroître la clairance des sécrétions de près de 2 g (différence moyenne [DM] 1,97; IC à 95 % : 0,80, 3,14; données probantes GRADE très basses) et la compliance pulmonaire statique immédiatement après le traitement de plus de 5 millilitres par centimètre d’eau (DM 5,40 mL/cm d’eau; IC à 95 % : 2,37, 8,43; données probantes GRADE très basses) ou de plus de 6 millilitres par centimètre d’eau après une période de 20 à 30 minutes (DM 6,86 mL/cm d’eau; IC à 95 % : 2,86, 10,86; données probantes GRADE très basses). Aucun événement indésirable n’a été trouvé. Conclusion : la physiothérapie respiratoire qui accroît le volume courant peut contribuer à la clairance des sécrétions et à la compliance pulmonaire chez les adultes atteints de pneumonie sous assistance respiratoire invasive, mais ses effets sur d’autres résultats cliniques, comme la mortalité, la durée d’hospitalisation et d’autres résultats axés sur le patient ne sont pas clairement établis. D’autres recherches s’imposent. Mots-clés : analyse systématique; modalités de la physiothérapie; thérapie respiratoire; pneumonie; soins intensifs Pneumonia is the most common infection around the to an intensive care unit (ICU),3–5 and 70% of them require world, and it results in high morbidity and mortality, par- intubation and mechanical ventilation.5 Clinical diagnosis ticularly for persons aged 65 years and older and those is made on the basis of the presence of the triad of infec- with chronic disease.1–3 Approximately 10%–30% of those tion (fever or chills and leucocytosis), respiratory signs and admitted to hospital with pneumonia require admission symptoms, and signs of new consolidation on chest X-ray.6 From the: *School of Physiotherapy; §Institute for Health Research, University of Notre Dame, Fremantle; †Physiotherapy Department, Fiona Stanley Hospital, Mur- doch; ‡School of Physiotherapy and Exercise Science, Curtin University, Perth, W.A., Australia. Correspondence to: Lisa van der Lee, Intensive Care Unit, Fiona Stanley Hospital, Locked Bag 100, Palmyra DC, WA 6961, Australia; [email protected]. Contributors: All authors designed the study; or collected, analyzed, or interpreted the data; and drafted or critically revised the article and approved the final draft. Competing Interests: None declared. Physiotherapy Canada 2021; 73(1); 6–18; doi:10.3138/ptc-2019-0025 6

van der Lee et al. Efficacy of Respiratory Physiotherapy Interventions for Intubated and Mechanically Ventilated Adults with Pneumonia 7 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 Physiotherapists working in the ICU provide interventions METHODS for sedated and mechanically ventilated patients with This review was undertaken according to an a priori pneumonia,7 aiding airway clearance, optimizing pulmo- nary mechanics, improving gas exchange, and facilitat- protocol,26 and it was reported in accordance with the ing weaning from mechanical ventilation and functional Preferred Reporting Items for Systematic reviews and recovery.8–10 However, clinical practice varies regarding the Meta-Analyses Statement.27 type, duration, and frequency of the physiotherapy inter- vention delivered, and no standard of practice exists.7 Search strategy The search strategy has been described previously.26 The literature indicates that the role of respiratory physiotherapy is limited for patients admitted to hospital We carried out a three-step search process using Medical with uncomplicated pneumonia who are spontaneously Subject Headings terminology and text words to ensure breathing, do not require mechanical ventilation, can inde- that all relevant studies were captured. Full details of the pendently mobilize, and can expectorate secretions.11,12 A search strategy, including databases, are set out in online recent systematic review13 indicated no benefit from respi- Appendix 1. ratory physiotherapy as a treatment for patients with pneu- monia; however, the review excluded studies that involved Inclusion and exclusion criteria adult patients who required mechanical ventilation. The evidence for respiratory physiotherapy in spontaneously Types of study breathing patients with pneumonia cannot be extrapo- We included randomized trials, written in English, that lated to those who are sedated and invasively ventilated because respiratory mechanics are altered14 and respi- were published between January 1995 and November ratory drive, cough reflexes, and mucociliary clearance 2018.26 are suppressed.14,15 Moreover, these consequences place intubated patients at greater risk of retaining secretions,16 Types of patients experiencing a mismatch in ventilation perfusion,14 and We included studies involving subjects aged 18 years subsequent further atelectasis and secondary infection.17 Therefore, a gap in the literature exists, and this review or older, with a medical diagnosis of pneumonia, who aimed to address it to provide clinical guidance for the were intubated and received either partial or complete treatment of invasively ventilated adults with pneumonia. respiratory assistance from a mechanical ventilator.26 Studies have shown that intubated and mechanically Interventions ventilated patients with pneumonia show some benefit of Included studies investigated the effect of a respira- respiratory physiotherapy treatment.18,19 In addition, some studies of mixed diagnostic cohorts (including patients tory physiotherapy intervention either by comparing with a type of pneumonia) have indicated some evidence the effects of two or more interventions or by comparing of short-term benefits for physiological outcomes of spu- an intervention group with a control group. Interven- tum clearance and pulmonary mechanics.20,21 However, tions could involve, but were not limited to, positioning, those studies did not investigate the impact of physio- gravity-assisted drainage, manual hyperinflation, venti- therapy intervention on patient-centred outcomes.22 lator hyperinflation, percussion or chest wall vibrations, Patient-important outcomes,23 such as survival, func- and expiratory rib cage compression (ERCC). We excluded tion, and health-related quality of life,24 are essential to any studies that combined any of these interventions with include in evidence-based reviews because they form the early mobilization or exercise because of the potential for cornerstone of contemporary evidence-based practice confounding effects on the outcomes.26 as adopted by the Grading of Recommendations Assess- ment, Development and Evaluation (GRADE) system.25 Types of outcome Patient-important outcomes have also recently been rec- The primary outcomes were patient-important out- ognized in the literature as essential drivers of both ICU clinical practice and research to optimize the quality and comes of mortality, health-related quality of life, func- cost of health care.24 tional recovery, and ICU and hospital LOS.23 The secondary outcomes were duration of mechanical ventilation and The purpose of this systematic review was to synthe- physiological variables such as oxygenation, secretion size the best available evidence for the effectiveness of clearance, lung compliance, and respiratory resistance. We respiratory physiotherapy interventions in respect to also explored rates of adverse events. mortality, quality of life, functional recovery, ICU length of stay (LOS), duration of ventilation, oxygenation, secre- Assessment of methodological quality tion clearance, and pulmonary mechanics for intubated We selected studies that met the inclusion and exclu- and mechanically ventilated adults with pneumonia. sion criteria for full-text review, which was conducted separately by two investigators (LV, SP) and assessed for methodological quality using a standardized critical appraisal instrument, the Joanna Briggs Institute’s System for the Unified Management, Assessment and Review of Information (SUMARI; Joanna Briggs Institute, University of Adelaide, Adelaide, SA, Australia).28,29

8 Physiotherapy Canada, Volume 73, Number 1 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 We conducted a risk-of-bias assessment of the included and the I2 statistic (which measures heterogeneity).32 For studies that was also independently performed by two continuous outcomes, we calculated the mean difference reviewers (LV, SP) using the computer programme Review (MD), SD, and SE using the inverse-variance DerSimo- Manager (RevMan; Version 5.3; Nordic Centre, Copenha- nian and Laird method.31 Statistical significance was set gen) and Cochrane methodology.30 at p  0.05 for all analyses (two-sided). We evaluated the certainty of the evidence according to GRADE using the Data extraction and analysis GRADE Pro Guideline Development Tool (Evidence Prime We extracted data from the included studies and Inc., Hamilton, ON) and presented a narrative synthesis when statistical pooling of studies was not possible.33 entered them into RevMan using double data entry. Data extraction and synthesis were performed independently RESULTS by two investigators (LV, SP). Studies that investigated the same outcomes were pooled for meta-analysis using Study selection RevMan. A fixed-effects model was used to calculate esti- The search yield by source and number of studies mates.31 Heterogeneity was assessed using a combination of visual inspection of the forest plot along with the χ2 test included and excluded is presented in Figure 1. Records identified by database searching Additional records (n = 1002) identified through Medline (n = 70), CINAHL (n = 321), other sources PEDrO (n = 496), Cochrane (n = 115) Google Scholar (n = 1280) Records after duplicated removed (n = 495) Records screened Records excluded (n = 495) (n = 454) Full-text articles reviewed Full-text articles excluded with reasons (n = 27) to determin(e eligibility - No pneumonia at baseline (n = 18) (n = 41) - No randomisation (n = 3) - Subjects not ventilated (n = 6) Studies included in - Insufficient methods reported (n = 3) qualitative synthesis - Treatment not standardised between groups (n = 6) (n = 2) - Treatment included mobilisation (n = 3) Studies included in - Not available in English (n = 1) quantitative synthesis - JBI score < 5 (n = 4) (meta-analysis) (n = 8) Figure 1 Flow diagram of search results and study selection. Note: Some full-text articles had more than 1 reason for exclusion. PEDro = Physiotherapy Evidence Database; JBI = Joanna Briggs Institute.

van der Lee et al. Efficacy of Respiratory Physiotherapy Interventions for Intubated and Mechanically Ventilated Adults with Pneumonia 9 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 Methodological quality included studies are presented in Appendix 2 online. The The critical assessment of methodological quality was average retention rate was 95% across the 14 studies; 99% of the subjects included in the review (n = 459) completed independently completed by two reviewers (LV, SP) for their final assessments. the 14 full-text reviews that satisfied the inclusion and exclusion criteria.26 The included studies had fair meth- Interventions odological quality, with scores ranging between 5 and 9, There was heterogeneity among the studies with regard as presented in Table S1 online. The overall risk of bias for the 14 included studies is presented in Figure 2. The risk of to the mode and delivery of the interventions investigated, bias for individual studies is presented in Figure 3. These including the position of the subjects (e.g., supine, side figures indicate that the majority of studies had unclear lying, sitting upright, head down). Most studies (12; 86%) risk of selection bias as a result of unclear randomization evaluated single intervention episodes, and only two or allocation concealment and high or unclear risk of per- studies evaluated a course of intervention (see Appendix 2 formance or detection bias as a result of unclear reporting online). on whether blinding of participants, personnel, or out- comes assessment was performed. Effects of intervention: primary outcomes Description of included studies Functional recovery and health-related quality of life Of the 14 included studies, 9 (64%) were randomized No studies evaluated the effect of respiratory physio- cross-over trials, and 5 (36%) were randomized controlled therapy interventions on functional recovery or health-re- trials. A detailed presentation of the characteristics of the lated quality of life. included studies is available in Appendix 2 online. The excluded studies and reasons for exclusion are presented Length of stay and mortality in Appendix 3 online. Two studies evaluated the outcomes of LOS and mortal- Participants ity but measured them differently.37,38 Berti and colleagues More than half of the studies had subjects with a evaluated the impact of providing manual hyperinflation to increase inspiratory volume, combined with ERCC, on mixed diagnosis (8; 57%). Of the 463 subjects included ICU LOS and 30-day mortality.37 They found that ICU LOS in the review, 251 (54%) had a diagnosis of pneumonia. was shorter in the intervention group than in the control The studies used broad inclusion criteria for diagnosis, group from Day 3 on; 25% of the intervention patients based on aggregate scores of clinical presentation such as were discharged from ICU by Day 3 compared with none the Murray Score,34 Clinical Pulmonary Infection Score,35 in the control group. No deaths occurred in either group unspecified laboratory and radiological criteria, and fre- during the 5-day period, and 30-day mortality was not quency of requirements for airway suction.18 No studies significantly different between the intervention and con- used a criterion of medical diagnosis, which is also based trol groups at 26% and 19%, respectively.37 on broad and often non-specific clinical presentation.36 The types of pneumonia diagnosis for subjects in the Patman and colleagues38 evaluated the impact of pro- viding respiratory physiotherapy, which included posi- tioning, manual hyperinflation, and airway suctioning Figure 2 Overall risk of bias of included studies.

10 Physiotherapy Canada, Volume 73, Number 1 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 Barker and Adams34 Random sequence generation (selection bias) Berney and Denehy14 Allocation concealment (selection bias) Berti and colleagues37 Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Choi and Jones19 Incomplete outcome data (attrition bias) Chuang and colleagues43 Selective reporting (reporting bias) da Silva Naue and colleagues41 Other bias Guimaraes and colleagues35 Hodgson and colleagues20 Hodgson and colleagues39 Jones and colleagues42 Kohan and colleagues36 Lemes and colleagues18 Patman and colleagues38 Unoki and colleagues40 Figure 3 Risk of bias of individual studies. + = criteria were met; – = criteria were not met; ? = unclear whether criteria were met. every 4 hours, on outcomes of ICU and hospital LOS and Effects of intervention: secondary outcomes mortality. No significant differences were found between the intervention (n = 17) and control groups (n = 16) for Duration of mechanical ventilation hospital LOS (MD 14.10 days; 95% CI: –8.03, 36.23) or Both Berti and colleagues37 and Patman and col- mortality, either in the ICU or overall (OR 0.93; 95% CI: 0.12, 7.55). leagues38 also investigated the effect of respiratory phys- iotherapy on the duration of mechanical ventilation. Berti

van der Lee et al. Efficacy of Respiratory Physiotherapy Interventions for Intubated and Mechanically Ventilated Adults with Pneumonia 11 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 and colleagues reported that the duration was shorter in volume rather than wet weight.18,35 Lemes and colleagues18 the intervention group than in the control group from compared 30 minutes of ventilator hyperinflation to a Day 2 on and that the identified between-groups differ- peak inspiratory pressure of 40 centimetres H2O in the ences were significant on Days 2 and 3 (both ps < 0.01), side-lying position with the more affected lung uppermost as well as on Days 4 and 5 (both ps < 0.05).37 However, (n = 30) with side-lying alone (n = 30) and demonstrated patient-level data for each group were not presented. Pat- that the intervention resulted in significantly greater spu- man and colleagues demonstrated that the overall effect tum volume (MD 1.3 mL; 95% CI: 0.13, 2.47). Guimaraes of respiratory physiotherapy on the duration of mechani- and colleagues35 found that, compared with a control cal ventilation was not significant between groups (MD –9 group (n = 20) without ERCC, an intervention (n = 20) of h; 95% CI: –131.83, 113.83).38 5 minutes of ERCC followed by 10 minutes of ventilator hyperinflation to a peak inspiratory pressure of 35 cen- Oxygenation timetres H2O, but in the supine 30° head-up position, Four studies evaluated the effect of respiratory phys- cleared 34% greater secretions, which was statistically significant (p < 0.04). However, insufficient patient-level iotherapy on oxygenation (two were pooled for meta- data were available for this study, which precluded pool- analysis). No studies demonstrated significant between- ing of results. No significant benefit was seen for ERCC in groups differences (see online Appendix 4). the side-lying position (see Appendix 4 online). Sputum clearance Lung compliance Six studies evaluated the effect of respiratory physio- Nine studies evaluated the effect of respiratory phys- therapy on sputum wet weight.20,21,39–42 Data from three iotherapy on lung compliance.18–21,34,35,39–41 There was no studies that compared the intervention group (n = 67) with standardisation among the studies in terms of whether a control group (n = 65) were pooled for meta-analysis (see static or dynamic lung compliance was measured or how Figure 4) because these interventions had a similar aim long after the intervention lung compliance was mea- of increasing inspiratory volume to clear secretions.20,41,42 sured. Therefore, it was not possible to pool these studies One study used the side-lying position with the affected for meta-analysis. lung uppermost,20 and the other two used the supine 30° head-up position.41,42 The results demonstrated low het- Four studies that evaluated the effect of hyperinfla- erogeneity (I2 = 0%) and that overall the intervention had tion (n = 53) compared with a control group (n = 53) on significant benefit: the control group produced nearly static lung compliance immediately after intervention 2 grams less sputum (MD 1.97; 95% CI: 0.80, 3.14). were pooled for meta-analysis (see Figure 5).18–20,35 The studies used side lying with the affected lung uppermost Two studies investigated the effect of respiratory phys- iotherapy to increase inspiratory volume on sputum * da Silva Naue and colleagues41 3.5 3.8 34 1.7 1.6 32 70.7% 1.80((0.41, 3.19)) 6.4 18 3.5 2.4 18 13.7% 2.00(–(–1.16, 5.16)) Hodgson and colleagues20 5.5 4.7 15 4.3 3.5 15 15.6% 2.70(–(–0.27, 5.67) ) Jones and colleagues42 7 () c df p – – zp Figure 4 Forest plot of the overall effect of respiratory physiotherapy, compared with the control group, on sputum wet weight. * All measurements are in grams. IV = independent variable. * Choi and Jones19 43.1 6.4 15 36.5 5 15 54.5% 6.60 (2.49, 10.71) 12 20 38.7 10.3 20 19.2% 3.50 (–3.43, 10.43) Guimaraes and colleagues35 42.2 18.34 18 38.6 16.1 18 7.2% 6.40 (–4.87, 17.67) 13.8 30 50.9 13.6 30 19.1% 3.50 (–3.43, 10.43) Hodgson and colleagues20 45 () Lemes and colleagues18 54.4 – c df p – zp Figure 5 Forest plot of overall effect of respiratory physiotherapy, compared with the control group, on static lung compliance immediately after intervention. * All measurements are in millilitres/centimetre H2O. IV = independent variable.

12 Physiotherapy Canada, Volume 73, Number 1 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 or supine 30° head-up as positions for both groups.18–20,35 studies used a broad definition that did not specify param- The results demonstrated low heterogeneity (I2 = 0%), and eters.36,40 Three studies presented results on physiological overall there was a significant benefit of the intervention parameters that indicated that the participants’ haemo- of more than 5 mL/cm H20 (MD 5.40 mL/cm H2O; 95% CI: dynamic stability was maintained (Table S2 online).18,42,43 2.37, 8.43). GRADE summary of findings Berney and Denehy compared manual hyperinfla- A summary of the review findings and certainty of the tion (n = 20) and ventilator hyperinflation (n = 20) in the side-lying position with the affected lung uppermost and evidence according to GRADE is presented in Table 1.32 found no significant difference between the interven- The certainty of the evidence was downgraded to very tions,21 although both resulted in a statistically significant low, in accordance with the GRADE system, because of increase in static lung compliance both immediately after the moderate or unclear risk of bias, serious or very seri- intervention and after a 30-minute delay when compared ous indirectness as a result of the subjects having mixed with baseline. These results could not be pooled because diagnoses other than pneumonia, and very serious impre- of insufficient patient-level data and no control group cision because of the low sample sizes of each study. data. DISCUSSION Two studies evaluating the effect of respiratory phys- This review has synthesized the best available evidence iotherapy involving manual hyperinflation (n = 33) versus a control group (n = 33) on static lung compliance after to date for the efficacy of respiratory physiotherapy for a 20- to 30-minute delay after intervention were pooled invasively ventilated adults with pneumonia and found for meta-analysis (see Figure 6).19,20 The results demon- that there may be some benefits in undertaking respi- strated low heterogeneity (I2 = 0%) and an overall signifi- ratory physiotherapy for secretion clearance and lung cant benefit of the intervention of more than 6 mL/cm compliance. Critical gaps in the evidence have been iden- H2O (MD 6.86 mL/cm H2O; 95% CI: 2.86, 10.86). These tified, highlighting a need for further research, especially two studies used different positions, as noted earlier. into whether any treatment benefit exists for patient-im- Five other studies,34,35,39,40,41 two pooled for meta- portant outcomes such as ICU and hospital LOS because, analysis and three reported separately, found no significant so far, few studies have investigated these. differences in lung compliance with respiratory physiother- apy (see online Appendix 4). Despite moderate-quality evidence according to the Joanna Briggs Institute and Cochrane approaches, our Respiratory resistance appraisal according to GRADE indicated very low cer- Three studies comparing the effect of respiratory tainty overall about the efficacy of a respiratory phys- iotherapy intervention for invasively ventilated adults physiotherapy using a manual hyperinflation technique with pneumonia.32 The review identified only 14 stud- (n = 65) with a control group (n = 65) on respiratory resis- ies, all with small sample sizes. Half of the studies were tance were pooled and demonstrated low heterogeneity conducted in cohorts of mixed aetiology; only half of the (I2 = 0%).18,19,35 Overall, there was no significant between- subjects had a diagnosis of pneumonia, and the studies groups difference (MD 0.17 mL/cm H2O per second; 95% did not include a subgroup analysis or provide sufficient CI: –1.44, 1.79). patient-level data to enable us to isolate them for analysis. Moreover, the majority of the included studies primarily Adverse events examined short-term physiological outcomes, such as Of the 14 included studies, 10 (71%) specifically secretion clearance and lung compliance. It is unclear how changes in these physiological outcomes translate to reported no adverse events as a result of the intervention. benefits in more meaningful outcomes for patients, such Four studies did not report on the presence or absence as recovery of physical function and quality of life. of adverse events.34,38,42,43 Six studies provided definitions for what constituted an adverse event,18,21,35,36,39,40 and two Choi and Jones19 * 6.7 15 36.8 5 15 89.3% 6.70 (2.47, 10.93) Hodgson and colleagues20 21 18 38.8 16.1 18 10.7% 8.20 (–4.02, 20.42) 43.5 47 () c df p – – zp Figure 6 Forest plot of overall effect of respiratory physiotherapy, compared with the control group, on static lung compliance 20–30 min after intervention. * All measurements are in millilitres/centimetre H2O. IV = independent variable.

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 Table 1 GRADE Summary of Evidence for Respiratory Physiotherapy versus Control for Intubated and Mechanically Ventilated Adults with Pneumonia van der Lee et al. Efficacy of Respiratory Physiotherapy Interventions for Intubated and Mechanically Ventilated Adults with Pneumonia Certainty assessment Sample size, n Effect (95% CI) No. of Study Other Respiratory No respiratory studies design Risk of bias Inconsistency Indirectness Imprecision considerations physiotherapy physiotherapy Relative Absolute Certainty Importance Health-related quality of life; functional recovery – not measured –– – – – – – Critical 0 –– – – Very serious‡ None 17 16 17 16 OR 0.93 8 fewer per 1,000 Very low Critical Mortality (at 90 days)38 Very serious‡ None 1 RCT Serious* Not serious Serious† 17 16 17 16 (0.12, 7.55) (108 fewer to 394 more) Hospital length of stay38 Serious* Not serious Serious† 119 119   MD 14.1 d more Very low Important 1 RCT 67 65 30 30 (8.03 less to 36.23 53 53 more) ICU length of stay38 Serious* Not serious Serious† Very serious‡ None – MD 13.2 h less Very low Important 1 RCT (139.77 less to 113.37 more) Duration of mechanical ventilation38 Not serious Serious† Very serious‡ None – MD 9 h less Very low Important 1 RCT Serious* (131.83 less to 113.83 more) Oxygenation20,36,40 Serious§,¶ Serious** Serious††,‡‡ Serious‡ None – MD 3.21 mmHg lower Very low Important 3 Randomized (12.3 lower to 5.88 trials higher) Sputum wet weight19,20,41 Serious§§ Not serious Serious‡‡ Very serious‡ None – MD 1.97 g more Very low Important 3 RCT (0.8 more to 3.14 more ) Sputum volume18 Serious§ Not serious Not serious Very serious‡ None – MD 1.3 mL more Very low Important 1 Randomized Serious¶,¶¶ Not serious Serious‡‡ Very serious‡ None trials (0.13 more to 2.47 more) Static compliance19,20,35 – MD 5.85 mL/cm H2O Very low Not important 3 Randomized trials higher (2.47 higher to 9.22 higher) (Continued ) 13

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 Table 1 (Continued) Certainty assessment Sample size, n Effect (95% CI) 14 Physiotherapy Canada, Volume 73, Number 1 No. of Study Other Respiratory No respiratory studies design Risk of bias Inconsistency Indirectness Imprecision considerations physiotherapy physiotherapy Relative Absolute Certainty Importance Very low Not important Dynamic compliance35,40 Serious¶,*** Serious** Serious‡‡ Very 51 51 – MD 0.86 mL/cm H2O 2 Randomized serious‡,††† 65 65 higher Very low Not important trials (3.6 lower to 5.32 higher) Respiratory resistance18,19,35 Serious¶,¶¶ Serious** None Very 3 Randomized serious‡,††† – MD 0.17 cm H2O/l/s trials higher (1.44 lower to 1.79 higher) Note: Dash indicates not available. * Subject group allocation in Part A of the study may have affected response to outcomes in Part B. † Evidence downgraded because subjects had ventilator-associated pneumonia after acquired brain injury, the pathophysiology and management of which may have affected recovery trajectory. ‡ Evidence downgraded because of small sample size (< 400). § No blinding. ¶ Concerns about randomization. ** Results not consistent across studies because of the use of different interventions. †† Less than 25% of participants in all studies had diagnosis of pneumonia. ‡‡ Sample population heterogeneous with only a portion having pneumonia; no subgroup analysis. §§ Evidence downgraded because the study with the largest weighting demonstrated limitations in methodology likely to lower confidence in estimate of effect. ¶¶ Concerns about blinding of outcomes assessment. *** Concerns regarding blinding of personnel. ††† Insufficient reporting of outcome data precluding inclusion in meta-analysis. GRADE = Grading of Recommendations Assessment, Development and Evaluation; RCT = randomized controlled trial; MD = mean difference; ICU = intensive care unit.

van der Lee et al. Efficacy of Respiratory Physiotherapy Interventions for Intubated and Mechanically Ventilated Adults with Pneumonia 15 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 This review identified an overall statistically signifi- The majority of studies (12; 86%) investigated the cant effect favouring respiratory physiotherapy interven- effect of a single session of intervention rather than a tion for sputum wet weight and static lung compliance course of intervention. Patients admitted to the ICU with both immediately after intervention and after a 20- to pneumonia requiring invasive mechanical ventilation 30-minute delay; however, the clinical significance of typically have an ICU LOS of approximately 1–2 weeks.53,54 these effects remains unclear because the minimal clini- Therefore, to determine the efficacy of respiratory phys- cally important difference for changes in these outcomes iotherapy intervention on patient-important outcomes is unknown. Nevertheless, these small but significant for this cohort, more studies need to investigate the effect findings may be important to ICU physiotherapists and of a course of respiratory physiotherapy over the length of patients, and therefore further work is necessary to estab- ICU stay and beyond. lish a minimal clinically importance difference for these outcomes. As a result of the lack of standardization of outcome measures among the studies, we could not pool for com- A recent national survey of Australian ICU senior phys- parison those studies with interventions that had similar iotherapists indicated that there is a strong physiotherapy treatment aims according to the treatment position used. treatment rationale to improve secretion clearance, alve- Hence, it was not possible to determine whether a differ- olar recruitment, and gas exchange for intubated patients ence in treatment effect existed between the side-lying with community-acquired pneumonia that has not pro- position with the affected lung uppermost and the supine gressed to acute respiratory distress syndrome.7 Most 30° head-up position. Some studies were unclear about survey participants reported using respiratory interven- position choice and whether it related to the location of tions such as manual or ventilator hyperinflation, chest the lung pathology; patient position can influence the wall vibrations, and positioning to target the affected lung effectiveness of intervention, as previous research has regions to achieve these aims. These survey findings con- demonstrated.55 Therefore, the optimal position for respi- curred with those of two other studies on physiotherapy ratory physiotherapy intervention remains unclear. usual care in the ICU.44,45 For future research, intervention modes, including In patients with pneumonia who are invasively venti- patient position for treatment, need to be standardized lated in the ICU, lung compliance is reduced and puru- and appropriately controlled to isolate the benefit of the lent secretions are often present in the airways as a result individual components or combinations of therapies. of the disease process.3,46–48 If secretions are retained in In addition, it is necessary to standardize the outcome the airways, atelectasis due to secondary obstruction measures among studies so as to enable the results of will occur.49 Not only does this worsen gas exchange and individual studies to be pooled and meta-analyzed in a hypoxaemia,46 but it also increases the risk of further meaningful way. Using patient-centred outcomes in addi- pulmonary infection17,50 – namely, ventilator-associated tion to physiological outcomes is necessary to establish pneumonia, which has been associated with longer the presence of any meaningful, long-term impact from a duration of mechanical ventilation and ICU LOS, higher course of intervention. It may also enable researchers to morbidity and mortality, and greater health care costs.51 identify a link between physiological and patient-centred The sequelae of invasive mechanical ventilation, such as outcomes and whether a minimal clinically important inspiratory flow bias predisposing to secretion impac- difference in outcomes exists. tion,52 impaired mucociliary clearance,14,15 ventilation– perfusion mismatching,14 reduced cough effectiveness,17,50 Clinicians use short-term physiological outcomes, such and reduced surfactant,14 are likely to be further com- as secretion clearance and oxygenation to guide daily prac- pounded in patient cohorts who have increased pro- tice,7 whereas longer-term outcomes, such as duration of duction of sputum as a result of their underlying disease mechanical ventilation, LOS, time to achieve functional process, such as those with pneumonia, thereby placing recovery, quality of life, and mortality should be used to them at even greater risk of secretion retention and sub- measure the effect of a course of physiotherapy interven- sequent superimposed, iatrogenic pulmonary infection.50 tion over time and any impact on the lives of patients. Hence, developing a core set of outcome measures for The findings of this review suggest that a plausible evaluating respiratory physiotherapy would be an advan- rationale exists for using respiratory physiotherapy inter- tageous next step for future research. A large body of liter- ventions for intubated patients with pneumonia – in ature is evolving on the benefits of early mobilization for particular, for using interventions that aim to increase ICU patients.56 Because it is uncertain whether any ben- inspiratory volume, such as lung hyperinflation, because efit to providing respiratory interventions exists, future of the demonstrated overall benefit favouring interven- research with cohorts with acute respiratory illness should tion for physiological outcomes of sputum clearance and also examine the effects of respiratory intervention not lung compliance. However, which types of pneumonia only in isolation but also in comparison with a combina- may respond best to respiratory physiotherapy during tion of respiratory care and early mobilization. the intubated period and at what stage remain unknown. Further research is required to investigate this. A total of 10 studies (71%) specifically reported that no adverse events arose from the intervention. This result

16 Physiotherapy Canada, Volume 73, Number 1 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 concurs with previous research,15,57 which has indicated mortality. Therefore, further high-quality research that that physiotherapy in ICU, including respiratory inter- evaluates respiratory physiotherapy for these patient- vention using hyperinflation and endotracheal suction centred outcomes is required. for invasively ventilated patients, is safe. Adverse events during physiotherapy intervention are infrequent15,57 and KEY MESSAGES occur less than during general intensive care;57 however, some deterioration in cardiovascular status has been What is already known on this topic reported when positive pressure or the right side-lying Physiotherapists working in the intensive care unit position was used with patients who received medium to high doses of vasoactive medication, had unstable base- commonly provide respiratory treatment to patients who line haemodynamic values, or had pre-existing cardiac are intubated and mechanically ventilated with pneu- comorbidities.57 Subjects with cardiac or haemodynamic monia to improve alveolar recruitment and facilitate instability were excluded from the included studies; secretion clearance. Studies of intervention with lung therefore, caution is warranted when generalizing these hyperinflation have shown its benefit for improving lung review findings to the clinical population. Future trials compliance, airway resistance, and secretion clearance in should specifically report adverse events against defined small samples of invasively ventilated adult patients. criteria. What this study adds This review had several limitations. First, although This review provides a comprehensive summary of the we conducted it according to a rigorous protocol, which included a thorough search strategy, and we hoped to evidence investigating the effect of respiratory physio- identify specific studies that evaluated the efficacy of therapy intervention for invasively ventilated adults with respiratory physiotherapy for patients diagnosed with pneumonia. Meta-analysis indicates a treatment bene- community-acquired pneumonia, we found none. There- fit for the physiological outcomes of improved sputum fore, we examined the best available evidence for respira- clearance and lung compliance, compared with control tory physiotherapy for intubated patients with any type groups, of interventions that increase tidal volumes, such of pneumonia. Second, we used the Cochrane Library in as hyperinflation in mechanically ventilated patients. our search instead of the Cochrane Database of System- atic Reviews because it is more comprehensive, but we The review highlights critical gaps in the evidence limited the search to studies published in English, so it is for the efficacy of intervention for patient-important possible that we missed important studies published in outcomes such as mortality and functional recovery. other languages. Meta-analysis was difficult because of the lack of stan- dardisation of respiratory treatments and outcomes. This Next, studies that included patients with varied diagno- evidence should be treated with caution when applying it ses did not perform subgroup analyses on those with pneu- to patients with pneumonia because certainty is very low monia, so we could not compare treatment effects between according to the Grading of Recommendations Assess- subjects with and without a pneumonia diagnosis. Finally, ment, Development and Evaluation approach: half the the respiratory physiotherapy interventions and outcome patients had mixed diagnoses other than pneumonia, measures used were not standardized among the studies, and the studies had small sample sizes and moderate to precluding us from including almost 50% of them (6) in our unclear risk of bias. meta-analysis. This, together with the small sample sizes, reduces the certainty of the evidence. REFERENCES CONCLUSION 1. Gibson J, Loddenkemper R, Sibille Y, et al. Acute lower respiratory This is the first systematic review to synthesize the evi- infections [Internet]. In: Gibson J, Loddenkemper R, Sibille Y, Lundbäck B, editors. European lung white book. Sheffield dence for the efficacy of respiratory physiotherapy inter- (UK): European Respiratory Society; 2018 [cited 2018 Jan 14]. ventions for intubated and mechanically ventilated adults Available from: https://www.erswhitebook.org/chapters/ with pneumonia. The review found very low GRADE acute-lower-respiratory-infections/. evidence to guide clinicians when intervening with this population. This evidence applies to some short-term 2. Tong N. Priority medicines for Europe and the world: A public positive benefits favouring intervention for physiological health approach to innovation [Internet]. Background Paper 6.22: outcomes of secretion clearance and lung compliance. Pneumonia. 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18 Physiotherapy Canada, Volume 73, Number 1 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 with acquired brain injury. Intensive Care Med. 2009;35(2):258–65. 48. Molina C, Walker DH. The pathology of community-acquired https://doi.org/10.1007/s00134-008-1278-2. Medline:18813910 pneumonia. In: Marrie TJ, editor. Community-acquired pneumonia. 39. Hodgson C, Ntoumenopoulos G, Dawson H, et al. The Mapleson C New York: Springer; 2007. p. 179–89. circuit clears more secretions than the Laerdal circuit during manual hyperinflation in mechanically-ventilated patients: a randomised 49. Nolan TJM, McCormack DG. Intensive care unit management of cross-over trial. Aust J Physiother. 2007;53(1):33–8. https://doi. pneumonia. In: Marrie TJ, editor. Community-acquired pneumonia. org/10.1016/s0004-9514(07)70059-4. New York: Springer; 2007. p. 193–203. 40. Unoki T, Kawasaki Y, Mizutani T, et al. Effects of expiratory rib-cage compression on oxygenation, ventilation, and airway-secretion 50. Li Bassi G. Causes of secretion retention: patient factors, ventilation, removal in patients receiving mechanical ventilation. Respir Care. devices, drugs. Curr Resp Med Rev. 2014;10(3):143–50. https://doi.org/ 2005;50(11):1430–7. 10.2174/1573398x10666141126221255. 41. da Silva Naue W, Forgiarini AF Jr, Dias AS, et al. Increasing pressure support does not enhance secretion clearance if applied during 51. Torres A, Niederman MS, Chastre J, et al. International ERS/ manual chest wall vibration in intubated patients: a randomised ESICM/ESCMID/ALAT guidelines for the management of hospital- trial. J Physiother. 2011;57(1):21–6. https://doi.org/10.1016/ acquired pneumonia and ventilator-associated pneumonia. Eur s1836-9553(11)70003-0. Respir J. 2017;50(3). https://doi.org/10.1183/13993003.00582-2017. 42. Jones CU, Kluayhomthong S, Chaisuksant S, et al. Breathing exercise Medline:28890434 using a new breathing device increases airway secretion clearance in mechanically ventilated patients. Heart Lung. 2013;42(3):177–82. 52. Ntoumenopoulos G, Shannon H, Main E. Do commonly used https://doi.org/10.1016/j.hrtlng.2012.12.009. Medline:23474003 ventilator settings for mechanically ventilated adults have the 43. Chuang M-L, Chou Y-L, Lee C-Y, et al. Instantaneous responses potential to embed secretions or promote clearance? Respir Care. to high-frequency chest wall oscillation in patients with acute 2011;56(12):1887–92. https://doi.org/10.4187/respcare.01229. pneumonic respiratory failure receiving mechanical ventilation: a Medline:21682986 randomized controlled study. Medicine. 2017;96(9):1–8. https://doi. org/10.1097/md.0000000000005912. Medline:28248854 53. Tellioğlu E, Balci G, Mertoglu A. Duration of stay of patients with 44. Skinner EH, Haines KJ, Berney S, et al. Usual care physiotherapy community-acquired pneumonia in influenza season. Turk Thorac during acute hospitalization in subjects admitted to the ICU: an J. 2018;19(4):1–5. https://doi.org/10.5152/turkthoracj.2018.17108. observational cohort study. Respir Care. 2015;60(10):1476–85. https:// Medline:30407163 doi.org/10.4187/respcare.04064. Medline:26374909 45. Ntoumenopoulos G, Hammond N, Watts NR, et al. Secretion 54. Williams S, Gousen S, DeFrances C. National Hospital Care Survey clearance strategies in Australian and New Zealand intensive care demonstration projects: pneumonia inpatient hospitalizations and units. Aust Crit Care. 2018;31(4):191–6. https://doi.org/10.1016/j. emergency department visits [Internet]. Atlanta (GA): Centers for aucc.2017.06.002. Medline:28662942 Disease Control and Prevention; 2018 [cited 2019 Mar 24]. Available 46. Patrick W. Pathophysiology of community-acquired pneumonia and from: www.cdc.gov/nchs/data/nhsr/nhsr116.pdf. the clinical consequences. In: Marrie TJ, editor. Community-acquired pneumonia. New York: Springer; 2007. p. 179–89. 55. Stiller K, Jenkins S, Grant R, et al. Acute lobar atelectasis: a 47. Wunderink RG, Waterer GW. Community-acquired pneumonia. comparison of five physiotherapy regimens. Physiother Theory N Eng J Med. 2014;370(6):543–51. https://doi.org/10.1056/ Pract. 1996;12(4):197–209. https://doi.org/10.3109/0959398 nejmcp1214869. Medline:24499212 9609036437. 56. Tipping C, Harrold M, Holland A, et al. The effects of active mobilization and rehabilitation in ICU on mortality and function: a systematic review. Intensive Care Med. 2017;43(2):171–83. https:// doi.org/10.1007/s00134-016-4612-0. Medline:27864615 57. Zeppos L, Patman S, Berney S, et al. Physiotherapy in intensive care is safe: an observational study. Aust J Physiother. 2007;53(4):279–83. https://doi.org/10.1016/s0004-9514(07)70009-0.

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 ARTICLE Improving Cultural Knowledge to Facilitate Cultural Adaptation of Pain Management in a Culturally and Linguistically Diverse Community Geoff P. Bostick, BScPT, PhD;* Kathleen E. Norman, BScPT, PhD;† Astha Sharma, BScPT;‡ Renee Toxopeus, MScPT;§ Grant Irwin, BScPT;‡ Raj Dhillon, BScPT¶ ABSTRACT Purpose: Health care disparities exist for people from culturally and linguistically diverse (CALD) communities. Addressing the cultural competence of health care providers could limit these disparities. The aim of this study was to improve cultural knowledge of and humility regarding pain in a CALD community. Method: This interpretive description qualitative study used focus group discussions (FGDs) to generate ideas about how South Asian culture could influence how health care providers manage pain. A total of 14 people with pain and of South Asian background (6 women and 8 men, aged 28–70 y) participated. Two investigators independently analyzed the data. This process involved repeatedly reading the transcripts, then manually sorting the key messages into categories.The investigators compared their categorizations and resolved differences through discussion. Next, similar categories and concepts were grouped into ideas (potential themes). These ideas, along with supporting categories and verbatim quotes, were presented to the full research team for feedback. After compiling the feedback, the ideas formed the thematic representation of the data. Results: The data from the FGDs revealed how pain management could be culturally adapted. The FGDs generated four themes about South Asian cultural perspectives that could influence the pain management experience for people living with pain: (1) cultural and linguistic impediments to communication, (2) understanding of pain in terms of the extent to which it interferes with function and work, (3) nurturing or personal attention as a marker of good care, and (4) value attributed to traditional ideas of illness and treatment. Conclusion: This study demonstrates how engaging with CALD people living with pain can lead to improved cultural knowledge and humility that can form the basis for adapting pain management. Through this process, it is more likely that a meaningful and client-centred pain management plan can be developed. Key Words: cultural competency; culture; pain management; physical therapy specialty; qualitative research. RÉSUMÉ Objectif : les membres de communautés linguistiques et culturelles diversifiées (CLCD) font face à des disparités en matière de soins. Si les dispensateurs de soins acquéraient des compétences culturelles, il serait possible d’atténuer ces disparités. La présente étude visait à améliorer les connaissances et l’humilité culturelle au sujet de la douleur dans les CLCD. Méthodologie : étude qualitative descriptive et interprétative faisant appel à des entrevues de groupe pour générer des idées sur la manière dont la culture sud-asiatique peut influencer les modes de gestion de la douleur par les dispensateurs de soins. Au total, 14 personnes d’origine sud­ asiatique qui souffrent de douleur y ont participé (six femmes et huit hommes de 28 à 70 ans). Deux chercheurs ont analysé les données de manière indépendante. Ce processus incluait la lecture répétée des comptes rendus, puis la catégorisation manuelle des principaux messages. Les chercheurs ont comparé les catégories et résolu leurs différends par des discussions. Ils ont ensuite regroupé les catégories et les concepts semblables en idées (thèmes potentiels). Les idées, de même que les catégories et les citations textuelles qui les appuyaient, ont ensuite été présentées à l’ensemble de l’équipe de recherche pour qu’elle y réagisse. Une fois les réactions compilées, les idées ont formé la représentation thématique des données. Résultats : les données tirées des entrevues de groupe ont révélé des manières d’adapter la gestion de la douleur à la culture. Les entrevues ont produit quatre thèmes sur les points de vue de la culture sud-asiatique qui pourraient influer sur l’expérience de gestion de la douleur des personnes qui vivent avec la douleur : 1) les obstacles culturels et linguistiques à la communication, 2) la compréhension de l’importance de l’entrave que représente la douleur pour le fonctionnement et le travail, 3) l’accompagnement ou l’attention personnelle comme marqueur de bons soins et 4) la valeur attribuée aux idées traditionnelles de la maladie et du traitement. Conclusion : la présente étude démontre que le fait d’engager un dialogue avec des personnes de CLCD qui vivent avec la douleur peut améliorer les connaissances et l’humilité culturelles sur lesquelles reposeront les mesures d’adaptation. Grâce à ce processus, il est plus probable d’établir un plan concret de gestion de la douleur, axé sur le client. Mots-clés : compétence culturelle; culture; gestion de la douleur; recherche qualitative; spécialité de la physiothérapie The bio-psychosocial perspective on health includes rather than the traditional biological one.1 For example, biological, psychological, and social factors that interact studies of experimental pain (pain evoked in a laboratory to generate a comprehensive view of health and illness setting) clearly demonstrate that responses to noxious From the: *Department of Physical Therapy, University of Alberta; ‡Tawa Physical Therapy; ¶Pivotal Physiotherapy, Edmonton; §Lifemark Physiotherapy, Calgary, Alta.; †School of Rehabilitation Therapy, Queen’s University, Kingston, Ont. Correspondence to: Geoff P. Bostick, Department of Physical Therapy, 2-50 Corbett Hall, University of Alberta, Edmonton, AB T5T 4A7; [email protected]. Contributors: All authors designed the study; or collected, analyzed, or interpreted the data; and drafted or critically revised the article and approved the final draft. Competing Interests: None declared. Acknowledgements: The authors thank Mohammad Shoiab for the thoughtful review of and critical feedback on the manuscript of this article. Physiotherapy Canada 2021; 73(1); 19–25; doi:10.3138/ptc-2019-0027 19

























32 Physiotherapy Canada, Volume 73, Number 1 Table 4 Cross-Sectional Associations between the OSPRO–YF and Relevant Constructs r (95% CI) https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 OSPRO–YF item* HADS (D) HADS (A) QuickDASH ÖMPSQ–10 Negative mood domain PHQ–9 0.60 (0.52, 0.68) – – – 0.68 (0.60, 0.74) – – STAI – – – – 0.50 (0.40, 0.59) 0.65 (0.57, 0.72) STAXI – 0.68 (0.60, 0.74) 0.60 (0.51, 0.67) 0.68 (0.61, 0.75) Full domain 0.66 (0.59, 0.73) – 0.63 (0.55, 0.70) 0.76 (0.70, 0.80) – 0.68 (0.61, 0.74) Fear avoidance domain – – 0.69 (0.61, 0.75) – – 0.75 (0.68, 0.80) FABQ–PA – 0.68 (0.61, 0.75) – 0.79 (0.73, 0.83) 0.69 (0.62, 0.75) 0.65 (0.57, 0.71) FABQ–W – –0.77 (–0.82, –0.71) – – –0.61 (–0.63, –0.45) TSK–11 – – – –0.75 (–0.73, –0.59) – – –0.73 (–0.78, –0.67) PCS – –0.64 (–0.71, –0.56) –0.64 (–0.71, –0.55) PASS–20 – Full domain 0.68 (0.61, 0.74) Positive affect–coping domain PSEQ – SER – CPAQ – Full domain –0.65 (–0.71, –0.57) Note: Dashes indicate no correlation statistic was calculated for those factors (they were not considered relevant to one another). * The negative mood and fear avoidance domains have a positive cutoff and the positive affect domain has a negative cutoff. OSPRO–YF = Optimal Screening for Prediction of Referral and Outcome Yellow Flag; HADS (D) = Hospital Anxiety and Depression Scale, Depression; HADS (A) = Hospital Anxiety and Depression Scale, Anxiety; QuickDASH = Quick Disabilities of the Arm, Shoulder and Hand; ÖMPSQ–10 = Örebro Musculoskeletal Pain Screening Questionnaire–10; PHQ–9 = Patient Health Questionnaire–9; STAI = State–Trait Anxiety Inventory; STAXI = State–Trait Anger Expression Inventory; FABQ–PA = Fear-Avoidance Beliefs Questionnaire Physical Activity sub-scale; FABQ–W = Fear-Avoidance Beliefs Questionnaire Work sub-scale; TSK–11 = Tampa Scale of Kinesiophobia–11; PCS = Pain Catastrophizing Scale; PASS–20 = Pain Anxiety Symptoms Scale–20; PSEQ = Pain Self-Efficacy Questionnaire; SER = Self- Efficacy for Rehabilitation; CPAQ = Chronic Pain Acceptance Questionnaire. Table 5 Known-Groups Analysis Based on Having a Work-Related Compensation Claim No. (%) of participants OSPRO–YF item* Compensation claim; n  = 80 No compensation claim; n  = 160 2; p-value OR (95% CI) Negative mood domain 42 (53) 45 (28) 2  = 13.71; < 0.001 2.82 (1.62, 4.93) PHQ–9 51 (64) 72 (45) 1 2.15 (1.24, 3.73) STAI 51 (64) 78 (49) 1.85 (1.07, 3.21) STAXI 21 = 7.50; 0.006 54 (68) 59 (37) 21 = 4.83; 0.028 3.56 (2.02, 6.27) Fear avoidance domain 68 (85) 83 (52) 5.26 (2.64, 10.46) FABQ–PA 62 (78) 82 (51) 2  = 20.07; < 0.001 3.28 (1.78, 6.03) FABQ–W 57 (71) 76 (48) 1 2.74 (1.54, 4.87) TSK–11 75 (94) 151 (94) 0.89 (0.29, 2.76) PCS 21 = 25.08; < 0.001 PASS–20 14 (18) 86 (54) 21 = 15.31; < 0.001 5.48 (2.85, 10.55) 18 (23) 67 (42) 21 = 12.18; < 0.001 2.48 (1.34, 4.57) Positive affect domain 16 (20) 83 (52) 21 = 0.04; 0.85 4.31 (2.30, 8.09) PSEQ SER 21 = 28.83; < 0.001 CPAQ 21 = 8.75; 0.003 21 = 22.36; < 0.001 * The negative mood and fear avoidance domains have a positive cutoff and the positive affect domain has a negative cutoff. OSPRO–YF = Optimal Screening for Prediction of Referral and Outcome Yellow Flag; PHQ–9 = Patient Health Questionnaire–9; STAI = State–Trait Anxiety Inventory; STAXI = State–Trait Anger Expression Inventory; FABQ–PA = Fear-Avoidance Beliefs Questionnaire Physical Activity sub-scale; FABQ–W = Fear-Avoidance Beliefs Questionnaire Work sub-scale; TSK–11 = Tampa Scale of Kinesiophobia–11; PCS = Pain Catastrophizing Scale; PASS–20 = Pain Anxiety Symptoms Scale–20; PSEQ = Pain Self-Efficacy Questionnaire; SER = Self-Efficacy for Rehabilitation; CPAQ = Chronic Pain Acceptance Questionnaire.