Journal of Physiotherapy 67 (2021) 27–40 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Research Advanced telehealth technology improves home-based exercise therapy for people with stable chronic obstructive pulmonary disease: a systematic review Tristan Bonnevie a,b, Pauline Smondack a, Mark Elkins c,d, Benoit Gouel e, Clément Medrinal b,f, Yann Combret g,h, Jean-François Muir a,b,i, Antoine Cuvelier a,b,i, Guillaume Prieur b,f,h, Francis-Edouard Gravier a,b a ADIR Association, Rouen University Hospital, Rouen, France; b Haute Normandie Research and Biomedical Innovation, Normandy University, Rouen, France; c Faculty of Medicine and Health, University of Sydney, Sydney, Australia; d Centre for Education and Workforce Development, Sydney Local Health District, Sydney, Australia; e School of Physiotherapy Rouen University Hospital, Rouen, France; f Intensive Care Unit Department, Le Havre Hospital, Le Havre, France; g Physiotherapy Department, Le Havre Hospital, Le Havre, France; h Institute of Experimental and Clinical Research (IREC), Pole of Pulmonology, ORL and Dermatology, Catholic University of Louvain, Brussels, Belgium; i Pulmonary, Thoracic Oncology and Respiratory Intensive Care Department, Rouen University Hospital, Rouen, France KEY WORDS ABSTRACT COPD Questions: How effective is home-based exercise therapy delivered using advanced telehealth technology Telerehabilitation (ATT-ET) for people with chronic obstructive pulmonary disease (COPD) compared with: no exercise Pulmonary rehabilitation therapy (ET), in/outpatient ET, and home-based ET without ATT? Design: Systematic review and meta- Exercise analysis of randomised trials. Participants: People with stable COPD referred for ET. Intervention: ATT-ET. Telehealth Outcome measures: Exercise capacity, quality of life, functional dyspnoea, cost-effectiveness and various Meta-analysis secondary outcomes. Results: Fifteen eligible trials involved 1,522 participants. Compared with no ET, ATT-ET improved exercise capacity (four studies, 6-minute walk test MD 15 m, 95% CI 5 to 24) and probably improved quality of life (four studies, SMD 0.22, 95% CI 0.00 to 0.43) and functional dyspnoea (two studies, Chronic Respiratory Questionnaire-Dyspnoea MD 2, 95% CI 0 to 4). ATT-ET had a similar effect as in/outpa- tient ET on functional dyspnoea (two studies, SMD –0.05, 95% CI –0.39 to 0.29) and a similar or better effect on quality of life (two studies, SMD 0.23, 95% CI –0.04 to 0.50) but its relative effect on exercise capacity was very uncertain (three studies, 6-minute walk test MD 6 m, 95% CI –26 to 37). ATT-ET had a similar effect as home-based ET without ATT on exercise capacity (three studies, 6-minute walk test MD 2 m, 95% CI –16 to 19) and similar or better effects on quality of life (three studies, SMD 0.79, 95% CI –0.04 to 1.62) and func- tional dyspnoea (two studies, Chronic Respiratory Questionnaire-Dyspnoea MD 2, 95% CI 0 to 4). ATT-ET had effects on most secondary outcomes that were similar to or better than each comparator. Conclusion: ATT-ET improves exercise capacity, functional dyspnoea and quality of life compared with no ET, although some benefits may be small. Its benefits are generally similar to in/outpatient ET and similar to or better than home-based ET without ATT. Registration: PROSPERO CRD42020165773. [Bonnevie T, Smondack P, Elkins M, Gouel B, Medrinal C, Combret Y, Muir J-F, Cuvelier A, Prieur G, Gravier F-E (2021) Advanced telehealth technology improves home-based exercise therapy for people with stable chronic obstructive pulmonary disease: a systematic review. Journal of Physiotherapy 67:27–40] © 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Introduction the limited availability of pulmonary rehabilitation centres and transport issues.9–11 Home-based pulmonary rehabilitation may Chronic obstructive pulmonary disease (COPD) is a major cause of disability and mortality worldwide, with a growing burden.1,2 This address these difficulties. Recent meta-analyses have shown that it progressive respiratory disease leads to physical inactivity, muscle may be an effective alternative to traditional in/outpatient pulmonary deconditioning, worsening dyspnoea and reduced quality of life.3 rehabilitation.12,13 There is Level 1 evidence that pulmonary rehabilitation improves exercise capacity, dyspnoea and quality of life, regardless of disease In addition to formal exercise training in a pulmonary rehabili- severity.4,5 Despite this robust evidence, as little as 5% of people who would benefit from pulmonary rehabilitation undertake it,6–8 with tation program, people with COPD also benefit from increasing their low referral (, 15%),8,9 high non-attendance (up to 50%)10 and poor free-living physical activity.14 Therefore, physiotherapists also use completion (up to 30%) rates.10 A common factor associated with both non-attendance and non-completion of pulmonary rehabilitation is independent exercise therapy (ET), such as an independent walking program, to encourage people with COPD to be more active. The term telerehabilitation has been used to describe the delivery of rehabilitation (such as pulmonary rehabilitation or other ET) using telecommunication technology.15 However, this definition can be https://doi.org/10.1016/j.jphys.2020.12.006 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
28 Bonnevie et al: Advanced telerehabilitation for stable COPD unhelpfully broad because it includes interventions ranging from real- Box 1. Inclusion criteria. time supervised and monitored exercise sessions16 to unsupervised training with telephone calls as a way to follow-up participants,17 the Design latter of which overlaps with many home-based exercise rehabilitation Randomised parallel or cross-over trial programs. Therefore, we use the term advanced telehealth technology Published in English, French, Spanish or Portuguese ET (ATT-ET) to describe delivery of home-based pulmonary rehabilita- Participants tion or other ET using any more-advanced telehealth technology than People with COPD phone contact alone. For example, ATT-ET could take the form of real- No exacerbation in the previous 4 weeksa time videoconferencing, web-based interactive platforms or smart- Intervention phone applications providing either therapist or algorithm-mediated Initial home-based ET (automated) individualised feedback and goals. This approach en- Delivered using ATT ables: peer support; direct, prompt or automated feedback to individ- Primary outcome measures ualise training; and monitoring for safety, adherence and early signs of Exercise capacity measured either by field tests, endurance exacerbations.18,19 Although ATT-ET uses new technologies, it has been shown to be feasible and well accepted by people attending pulmonary tests (constant workload test or endurance shuttle walk rehabilitation.19,20 Because ATT-ET uses new technologies, it incurs an test) or incremental tests (CPETor incremental shuttle walk additional burden and cost compared with other home-based ET, test) particularly where minimal resources are used.17,21,22 To be considered Quality of life (general or disease-specific) worthwhile, ATT-ET therefore needs to provide advantages over Functional dyspnoea equivalent ET where ATT are not used. Cost-effectiveness Secondary outcome measures To date, systematic reviews on the topic have considered both Health status (CAT or other validated questionnaire) cardiac and pulmonary rehabilitation,15,23 had methodological limi- Peripheral muscle strength tations24 and/or not included research published after 2015.23 Physical activity, measured objectively or subjectively Therefore, there is a need to summarise current evidence about the Respiratory function effects of ATT-ET for people with COPD compared with no interven- Anxiety and depression tion, in/outpatient ET or home-based ET that does not use ATT. Self-efficacy using questionnaires Exacerbations, hospitalisations, mortalityb Therefore, the research questions for this systematic review were: Adherencea and completion Adverse events 1. How effective is ATT-ET for people with COPD, compared with no Comparisons ET? ATT-ET versus no intervention ATT-ET versus in/outpatient ET 2. How effective is ATT-ET for people with COPD, compared with in/ ATT-ET versus home-based ET without ATT outpatient ET? a Defined according to the individual study’s criteria. 3. How effective is ATT-ET for people with COPD, compared with b Only long-term data were considered. home-based ET that does not use ATT? Method phone contact without additional telehealth technology to follow participants and adapt individualised goals. The three comparisons in The prospectively registered protocol of this systematic review Box 1 were analysed separately. To define eligible ET, this study used was designed according to the Cochrane Handbook for Systematic the broad definition of McCarthy et al: a program with a duration of Reviews of Interventions and reported according to the PRISMA 4 weeks that includes exercise therapy with or without any form of statement.25 education and/or psychological support.4 The exercise had to be aerobically demanding and therefore respiratory muscle training, Identification and selection of studies breathing exercises, Tai Chi and yoga interventions were ineligible. Maintenance programs following initial pulmonary rehabilitation Electronic searches were also excluded. The primary and secondary outcomes are listed MEDLINE, CENTRAL, Science Direct, Scopus, PEDro, Greylist and in Box 1. OpenGrey were searched from inception to May 2020 for relevant Selection of studies studies. Additional hand searching was performed through the ab- Two authors (TB, FEG) independently assessed the retrieved stracts of the European Respiratory Society congress (2011 to 2019) and American Thoracic Society congress (2009 to 2019). Reference studies for eligibility. Any disagreement was resolved by discussion lists of the included studies and relevant systematic reviews were and the intervention of a third author (CM). The level of agreement also checked for additional eligible studies. The sensitivity- was assessed using a kappa statistic. maximising strategy combined terms related to: COPD or chronic lung disease; telehealth or telerehabilitation; home care; technology; Data extraction pulmonary rehabilitation or exercise training; and methods of remote contact such as videoconferencing, telephone-based and web-based. Two authors from a pool of three (TB and FEG or PS) indepen- For the detailed search strategy, see Appendix 1 on the eAddenda. dently extracted data about the study characteristics and outcomes. For continuous outcomes, mean (SD) change from baseline and/or Eligibility criteria mean (SD) post-treatment values for each group were extracted. Studies meeting the criteria in Box 1 were eligible, regardless of When the data were unavailable in another format, they were extracted from graphs using softwarea. Skewed data were converted whether reported as full text or abstract only. Studies enrolling some into mean (SD).26,27 The number of participants with an event was people with other respiratory disease(s) or unstable COPD could be recorded for count outcomes. Data from cross-over studies were included if the data for the participants with stable COPD could be managed according to the Cochrane Handbook.25 Studies were extracted separately or accounted for . 95% of the data. Trials were pooled if they had the same comparator intervention: no ET, in/ only eligible if they assessed the effects of initial home-based ET (ie, outpatient ET, or home-based ET not using ATT. For outcomes pulmonary rehabilitation or other exercise) delivered using ATT. Trials measured multiple times, matched timepoints were considered for were ineligible if they examined a pedometer-based intervention or analysis (short term: 1 to 4 months; long term: 9 to 12 months).
Research 29 Assessment of risk of bias Records identified by electronic searching The same authors independently assessed the included studies, as of databases and hand searching of references lists and congress abstracts described in the Cochrane Handbook,25 using the criteria: random (n = 759) sequence generation, allocation concealment, blinding, incomplete outcome data, selective reporting and other potential bias. The risk of Exclusion of duplicates bias in the ‘blinding’ domain may differ between outcomes within a (n = 154) study, so the risk of bias was assessed independently for patient- reported outcomes, observer-reported outcomes involving some Records screened by title judgement and observer-reported outcomes not involving judgement. and abstract (n = 605) Using a conservative approach, the highest risk of bias for any outcomes measured within a given study was reported as the main author’s Excluded after screening judgement of risk of bias. Disagreements were resolved by discussion or (n = 472) adjudication (ME). Data analysis Records assessed in full text (n = 133) Measures of treatment effect The effect of the treatment was estimated using (standardised) Records excluded after assessment of full text (n = 99) mean differences for continuous outcomes and risk ratio for counts, • ineligible intervention (n = 40) with their corresponding confidence intervals. When calculating the • ineligible study design (n = 30) SMD, only post-intervention data were pooled, and patient-reported • ineligible participants (n = 10) outcomes (such as quality of life) were converted so that a higher • ongoing study (n = 17) score always indicated a better outcome. The clinical usefulness of the • ineligible outcome measures (n = 2) estimated treatment effects was assessed according to their respec- tive minimum clinically important difference (MCID) when available: Records identified as eligible 47 m for the incremental shuttle walk test (ISWT),28 25 m for the 6- (n = 34), reporting 15 trials minute walk test (6MWT),28 65 seconds for the endurance shuttle walk test,28 600 steps for the daily step count,29 0.5 for the Chronic Figure 1. Flow of studies through the review. Respiratory Questionnaire dyspnoea sub-score (CRQ-D),30 –0.6 points for the Clinical COPD Questionnaire,31 –4% for the Saint George’s Results Respiratory Questionnaire (SGRQ),30 –2.5 points for the COPD Assessment Test,31,32 1 point for the Pulmonary Rehabilitation Compliance with the registered protocol Adapted Index of Self-Efficacy,33 1 point for the modified Medical Research Council dyspnoea scale (mMRC),34 and –1.5 for the Hospital The registered protocol used the term ‘pulmonary rehabilitation’, Anxiety and Depression scale anxiety and depression sub-scores which was operationalised as ‘exercise therapy with or without any (HAD-A and HAD-D, respectively).31 form of education and/or psychological support’ for ‘at least 4 weeks’, according to the definition by McCarthy et al.4 Because this definition Authors from original studies were contacted to obtain comple- encompasses some forms of exercise prescription that many readers mentary data when necessary. Data unamenable to meta-analysis may not associate with PR, we use the term ‘exercise therapy’ to cover were reported narratively. both formal pulmonary rehabilitation and other ET (such as walking to achieve a progressively increased step count without a target Heterogeneity was assessed using the I2 and chi-square statistic, exercise intensity). considering I2 50% as a sign of moderate to high heterogeneity. The protocol for the systematic review stated that publication bias would Characteristics of the included studies be assessed by funnel plot if 10 studies were available for a given meta-analysis. Meta-analysis was performed with a fixed-effect After removal of duplicates, 605 records were retrieved from the model when heterogeneity was low (, 50%), using the inverse- initial database searching and one additional record was found after variance method (for continuous outcome and incidence rates) and an update in May 2020. After assessment of eligibility, 15 studies (34 the Mantel-Haenszel method (for dichotomous outcomes). In the case records) were included, involving a total of 1,522 participants of moderate-to-high heterogeneity, a random-effects model was (Figure 1). There was good agreement between authors for the study used. Meta-analysis softwareb was used for all analyses. The quality of selection (kappa 0.96). Characteristics of the included studies are evidence was rated independently for each outcome by two authors shown in Table 1. Fourteen studies were reported as full-text publi- (TB, FEG) using the Grading of Recommendations Assessment, cations16,35–51 and one as an abstract.52 ATT-ET was compared with Development and Evaluation (GRADE) system. no ET in seven studies,16,35–37,40,41,52 with in/outpatient ET in three studies,42–44,51,53,54 and with home-based ET not using ATT in six Additional analyses studies.39,45–50 One study compared ATT-ET with both no ET and Subgroup analyses were planned to assess the effects of the inter- home-based ET that did not use ATT.38 The ATT-ET consisted of real- time supervised/monitored exercise sessions in two studies,16,51,53,54 vention according to the type of intervention: real-time supervised/ unsupervised training but with a target/imposed tailored intensity monitored exercise sessions; unsupervised training but with a target/ and telehealth feedback in seven studies,38–40,42–44,47,48 and unsu- imposed tailored intensity and telehealth feedback (eg, walking at a pervised training based on increasing physical activity only and tel- given speed corresponding to a percentage of VO2 peak); or unsuper- ehealth feedback but without an imposed intensity in six vised training based on increasing physical activity only (steps/day with studies.35–37,41,45,49,50,52 The duration of the intervention ranged from automated and tailored goals) and telehealth feedback but without an 1 to 12 months and the frequency of exercise training varied from imposed intensity. Supervised exercise therapy was defined as any program that offered real-time supervision of the participants during exercise sessions by a therapist, whereas unsupervised exercise therapy was defined as any program that offered deferred supervision (eg, data monitoring after completion of the exercise sessions) or no supervision. A sensitivity analysis was planned to assess the consistency of the re- sults after removing studies at high risk of bias.
Table 1 Design Participants Characteristics of included studies. Study Advanced telehealth technology exercise therapy compared with no exercise therapy Demeyer (2017)35 Multicentre RCT 343 patients with stable COPD Exp (12 wks): usu Data collection at 12 wks who had not recently engaged in PR booklet with in-ho automated coachin Mean age 67 yrs investigators) and 64% males Follow-up: telepho Mean FEV1 56% pred technical problem Moy (2015)36 and RCT 239 sedentary veterans with COPD who Con: 5 to 10 min f Moy (2016)37 Data collection at 4 mths (initial were able to walk at least one block PA for people with Nguyen (2013)38,a intensive phase) and 8 mths and able to access and use the Internet medical treatment thereafter (maintenance phase) Priori (2017)52 Mean age 67 yrs Exp (12 mths): 4 m Tabak (2014a)40 Three-arm multicentre RCT 94% males weekly upload of Data collection at 3, 6 Mean FEV1 NS motivational mess and 12 mths phase (same progr 84 patients with stable COPD limited Follow-up: online RCT by dyspnoea who maintained an SpO2 Data collection at 2 mths 85% on 6L/min of oxygen at the Con: no instruction end of a 6MWT, who were able to and reported step RCT access and use the Internet and had Data collection at 1, 3, 6 not recently engaged in PR Exp (12 mths): in- and 9 mths individualised exe Mean age 69 yrs swimming; upper 55% males collaborative self-m Mean FEV1 51% pred (personal compute according to an in 21 patients with COPD prompt feedback a received individua Mean age 69 yrs modules and reinf % males NS Follow-up: biweek Mean FEV1 44% pred real-time alert to 29 patients with stable COPD who were able to access and use the Internet Con: home visit fr unrelated to lung Mean age 63 yrs information witho 50% males Mean FEV1 43% pred Exp (2 mths): auto feedback and coac Con: no interventi Exp (9 mths): acti daily activity beha motivational cues; (breathing exercis videos and adapte via a triage diary o teleconsultation. Follow-up: call to teleconsultation. Con: usual care, co
Intervention Outcome measures 30 Bonnevie et al: Advanced telerehabilitation for stable COPD ual care and telecoaching consisting of an initial motivational interview, Objective physical activity (steps/d), time at ome exercise, smartphone application and step counter providing daily MPA, walking time, movement intensity during ng through automatically adjusted activity goals (weekly, validated by walking, respiratory function, 6MWT, isometric quadriceps force, CAT, CCQ, mMRC, adverse d weekly message with tailored home activities. events one contact triggered if not wearing the step counter or if there was a m. face-to-face discussion and standard leaflet explaining the importance of SGRQ (total score and three dimensions), h COPD as well as information about PA recommendations and usual objective physical activity (steps/d), adverse t. events, exacerbation, emergency visit, mortality, study adherence mths of intensive phase – including website, daily use of a pedometer and step count, wkly automated individualised goals based on steps/d with CRQ-D, 6MWT, CPET (treadmill), BORG scale, arm endurance, CRQ, SF-36, self-efficacy, sage, education support from the website – and 8 mths of maintenance exercise behaviour, perception of support, ram without any new educational content or motivational message). satisfaction community forum (social support). Objective physical activity (activity monitor providing Active points), utilisation n to increase PA or step-count goals; only wore the pedometer every day p-count and adverse events monthly. -home dyspnoea and exercise consultation (motivational interview), ercise program (endurance: 30 min, 4/wk of walking, cycling or r limb strengthening: 3/wk) and adjusted according to the Borg scale, monitoring and reinforcement using technological enhanced support er/smartphone and a web-based tool to: uploaded real-time symptoms ndividualised action plan for exacerbation management and received as well as information/support; uploaded exercise performed; and alised goals settings by nurses), education and peer interaction (online forcement with live chat sessions). kly personalised reinforcement and feedback using a web-based tool, the nurse if worsening symptoms. rom one of the study staff, monthly face-to-face education sessions disease and biweekly phone contact to provide general health out exercise. omated coaching based on physical activity with weekly goals, daily ching messages. ion. ivity coach for ambulant activity monitoring and real-time coaching of Exacerbations, hospitalisations, length of stay, aviour (accelerometer and smartphone providing feedback, goals and emergency department visit, objective physical ; web-based individualised exercise program for home exercising activity (activity count via an accelerometer), ses, resistance and endurance, airway clearance) using text support and subjective physical activity (BPAQ), 6MWT, ed online by a physiotherapist; self-management of COPD exacerbations MFI20, CCQ, mMRC, EuroQol-5D, evaluation of on the web portal, including self-treatment of exacerbations; and the online appb the study office if the patients desired assistance or consultation, ould attend physiotherapist regularly if prescribed as part of usual care.
Table 1 (Continued) Design Participants Study Tabak (2014b)41 RCT 34 patients with stable COPD without Exp (4 wks): 2 ou long-term oxygen therapy who were activity registratio Data collection at 1, 2 able to access and use the Internet and diary for self-treat and 3 wks had not recently engaged in PR Control group: usu Tsai (2017)16 RCT Mean age 67 yrs usual care. Data collection at 8 wks 63% males Mean FEV1 53% pred Exp (8 wks): in-ho camera, cycle ergo 37 patients with COPD without exercise training ( long-term oxygen therapy who were 80% of the maxim able to access and use the Internet, scale) and muscle could walk independently without a Follow-up: real-tim walking frame and had not recently engaged in PR Control group: usu Mean age 74 yrs Exp (6 wks): acces 50% males video-based exerc Mean FEV1 64% pred educational videos Follow-up: contac Advanced telehealth technology exercise therapy compared with in/outpatient exercise therapy Con: 2 supervised Bourne (2017)42 RCT 90 patients with stable COPD and an Exercises and edu Data collection at 6 wks mMRC dyspnoea score 2 who were delivered face-to-f able to access and use the Internet, had no cognitive impairment and had not Exp (6 to 8 wks): recently engaged in PR provided a home walking (speed: 8 Chaplin (2017)43 and RCT Mean age 70 yrs VAS for perceived Barnes (2016)44 Data collection at 6 to 7 wks 58% males exacerbation man Mean FEV1 59% pred educational progra Follow-up: weekly 103 patients with COPD and a mMRC dyspnoea score between 2 and 5 who Con (4 wks superv were able to access and use the twice weekly and Internet and had not recently covering the same engaged in PR training (walking (based on the 1RM Mean age 66 yrs asked to complete 69% males Mean FEV1 57% pred Exp (10 wks): 60 conferencing, inclu Hansen (2020)51, Multicentre RCT 134 patients with severe to very strengthening (4 s Hansen (2019a)53 and severe COPD the Borg scale), 5- Hansen (2019b)54,c Data collection at the end of the intervention (3 mths) and at 3 Mean age 68 yrs Con (12 wks): out mths and 1 year of follow-up 45% males professional exerc Mean FEV1 33% pred exercise training ( sets of 8 to 25 repe 90 min of educatio
Intervention Outcome measures ut of the 4 modules from Tabak (2014a): activity coach for ambulant Objective physical activity (steps/d), CCQ, on and feedback (minimum of 4 d/wk); and web portal with a symptom mMRC, MFI20, use of the system, compliance tment of exacerbations and an overview of the measured activity levels. ual care; could attend physiotherapist regularly if prescribed as part of ome visit with provision of equipment (laptop computer with in-built ESWT, 6MWT, ISWT, CRQ, objective physical ometer and finger oximeter), real-time supervised/monitored group activity (energy expenditure, steps/d, metabolic (3 d/wk) via desktop videoconferencing including cycling/walking (60 to equivalents), physical performance (FPI-SF), mal capacity derived from the 6MWT and adjusted according to the BORG CAT, mMRC, HAD, self-efficacy (PRAISE), e strengthening (3x10 repetitions). adverse events me supervision of exercise session. ual care without any exercise training. ss at least 5 time/wk to myPR website (myMHealth) providing an online 6MWT, CAT, SGRQ, HAD, adverse events cise program (10 exercises of increasing duration over 6 wks) and Research 31 s: www.mymhealth.com/mycopd ct from the patient as necessary d outpatient session and three in-home unsupervised session/wk. ucational content were similar to the experimental intervention but face. introductory session about website access and navigation. The website ISWT and ESWT, CRQ-SR, HADS, CAT, PRAISE, exercise program and goal setting, a daily basis training, including BCKQ, EQ-5D-5L, patient cost questionnaire, 85% baseline ISWT) and strength training both aimed to reach 4 to 7 on Euro-QOL, recruitment rate, completion rate, d exertion, an online exercise diary, an individual action plan for adverse events, physical activity (steps/hr, nagement (based on the ‘SPACE for COPD’ manual) and an online bouts of moderate activity), web-usage audit am. for the internet-based program, uptake and y online review and contact by a team member. drop out vised and 3 wks unsupervised): outpatient supervised sessions occurred 6MWD, CAT, HAD, EQ-5D, CCQ, objective lasted 2 hrs (1 hr of exercise training and 1 hr of education session physical activity (accelerometer), 30-s STS, hospitalisation rate, mortality, adverse events e topics as the experimental intervention). Exercise included aerobic speed based on the baseline ISWT or cycling) and muscle strengthening M) both adapted according to the BORG scale (13 to 15). Patients were e home exercise for the remaining days. min, 3/wk, supervised by healthcare professional through video uding a 5-min warm-up period, 30 min of peripheral exercise muscle sets of 8 to 25 repetitions at 40 to 80% of the 1RM adjusted according to -min cool-down period and 20 min of education. tpatient PR consisting of 60 min, 2/wk, supervised by healthcare cise sessions, including a 1-min warm-up period, 30 min of aerobic (cycling, walking, etc.), peripheral exercise muscle strengthening (2 to 3 etitions at 40 to 80% of the 1RM), 5 to 10-min cool-down period and 60 to on once per wk.
Table 1 (Continued) Study Design Participants Advanced telehealth technology exercise therapy compared with home-based exercise therapy not using such technologie Dinesen (2012)45 and RCT 111 patients with severe to very Exp: (4 mths of in Haesum (2012)46 Data collection at 10 mths severe COPD symptom and phy function) for early Mean age 68 yrs muscle strengthen % male NS Follow-up: health Mean FEV1 NS inputs) and provid between healthcar program. Franke (2016)47 Cross-over RCT 44 patients with stable COPD Con: patients wer Liu (2008)48 Data collection at 3 mths performing the ac Mean age 63 yrs Nguyen (2008)39,d Monocentric RCT % male NS Exp (3 mths): hom Data collection every month Mean FEV1 48% pred intensity adjusted during the first 3 mths and at 1 subsequently self- year (9 mths of follow-up) 48 patients with stable (very) Follow-up: weekly severe COPD but without Multicentre RCT long-term oxygen therapy Home-based PR: s Data collection at 3 and 6 mths Mean age 72 yrs Exp (3 mths): cell 100% males training (intensity Mean FEV1 46% pred individualised mu DVD providing ins 50 patients with stable COPD limited by Follow-up: trainin dyspnoea who maintained an SpO2 during the first 3 85% on 6L/min of oxygen at the training was misse end of a 6MWT, who were able to access and use the Internet and Con: home-based had not recently (without cell and engaged in PR walking exercise a Exp (6 mths): see The initial consult investigators. Con: same interve performed were m provided through Mean age 70 yrs Follow-up: phone 56% males worsening of sym Mean FEV1 50% pred The initial consult
Intervention Outcome measures 32 Bonnevie et al: Advanced telerehabilitation for stable COPD es SF-36, hospitalisation rate for exacerbation, costs, QALY, ICER ntervention and 6 mths of follow-up): a web portal providing in-home ysiological data telemonitoring (BP, HR, weight, oxygen level, lung y management of exacerbation and an exercise program (peripheral ning, stretching and walking with a step counter). hcare professionals could access the patient’s data (including training de feedback through a web portal and monthly videoconferencing re professionals to coordinate and discuss the patient’s individual re instructed on performing home exercises and made responsible for Daily cycle exercise time, CAT, subjective ctivities by themselves without any formal planned contact. physical activity (GLTEQ) me daily bicycle ergometer training (with exercise time telemonitored), ISWT, SF-12, respiratory function, BMI, BORG, d for the patient to be able to perform at least 30 min of exercise (and AECOD, hospitalisations, mortality, adherence -adjusted). CRQ-D, exercise behaviour, 6MWT, CRQ, SF-36, y phone call if mean exercise time/wk was , 20 min/d. COPD knowledge, self-efficacy, perception of support, preference, satisfaction same intervention without weekly phone call. l phone and application as a support to provide daily walking exercise y at 80% of the maximal capacity derived from the ISWT using an usic tempo as feedback for the appropriate walking speed), booklet and struction for home walking exercise. ng intensity adjusted during face-to-face visit in the clinic every 4 wks mths and every 3 mths for the next 9 mths, phone contact if walking ed for 1 d. PR consisting of verbal request to take daily walking exercise at home phone application), booklet and DVD providing instruction for home and phone follow-up every 2 wks for the first 3 mths. Nguyen (2013)38 tation was performed at the centre and a smartphone was provided by ention as the experimental intervention except: symptoms and exercise monitored through paper diaries send to the centre; and education was paper support and reinforcement performed face-to-face. call instead of the web-based tool and no real-time alert to the nurse if mptoms. tation was performed at the centre.
Table 1 (Continued) Design Participants Exp (12 mths): in- Study Three-arm multicentre RCT individualised exe Nguyen (2013)38,a,e 84 patients with stable COPD limited upper limb streng Data collection at 3, 6 by dyspnoea who maintained an self-monitoring an and 12 mths SpO2 85% on 6L/min of oxygen computer/smartph at the end of a 6MWT, who were an individualised able to access and use the Internet as well informatio and had not recently engaged in PR goals settings by n reinforcement wit Mean age 69 yrs Follow-up: biweek 55% males well as real-time a Mean FEV1 51% pred Con: the same int exercise performe education was pro Wan (2017)49 and RCT 114 veterans with stable COPD Follow-up: phone Robinson (2019)50 Data collection at 3 mths able to walk at least one block and worsening of sym not desaturate , 85% SpO2 during the 6MST, who were able to access Exp (3 mths): dail and use the Internet and had not website providing recently engaged in PR feedback, educatio online community Follow-up: online Mean age 69 yrs Con: daily pedome 98% males exercise but no ste Mean FEV1 63% pred ATS = American Thoracic Society, BCKQ = Bristol COPD knowledge questionnaire, BMI = body mass index, BP = blood pressure, group, COPD = chronic obstructive pulmonary disease, CPET = incremental cardiopulmonary exercise testing, CRQ = chron questionnaire, self-reported, eDSMP = internet-based dyspnoea self-management program, EQ-5D = EuroQol-5 dimensions fDSMP = face-to-face dyspnoea self-management program, FEV1 = forced expiratory volume in 1 second, FPI-SF = Performan heart rate, ICER = incremental cost-effectiveness ratio, ISWT = incremental shuttle walking exercise test, mMRC = modifi Activity, NS = not stated, PA = physical activity, PR = pulmonary rehabilitation, PRAISE = Pulmonary Rehabilitation Adapted Short Form-12 quality of life questionnaire, SF-36 = Short Form Health Survey, SGRQ = St George’s Respiratory Questionn 6MST = 6-minute stepper test, 6MWT = six-minute walk test, % pred = percentage of predicted value. a This study was a three-arm study and therefore appears in two parts of the table (advanced telehealth technology exercise exercise therapy that did not use advanced telehealth technology). b Use of the application, adherence to the online diary, adherence to the exercise schemes, satisfaction (Client Satisfaction c The schedule of supervised exercise provided to the two groups was not exactly comparable: weekly exercise volume w d The study stopped early due to technical difficulties. e Exercise interventions were unsupervised for the two groups but the dyspnoea management component differed.
Intervention Outcome measures CRQ-D, 6MWT, CPET (treadmill), BORG scale, -home dyspnoea and exercise consultation (motivational interview), arm endurance, CRQ, SF-36, self-efficacy, ercise program (endurance: 30 min, 4/wk, walking, cycling or swimming; exercise behaviour, perception of support, gthening: 3/wk) and adjusted according to the Borg scale, collaborative satisfaction nd reinforcement using technological enhanced support (personal hone and a web-based tool to: upload real-time symptoms according to Objective physical activity (steps/d), 6MWT, exercise adherence, respiratory function, SGRQ, action plan for exacerbation management and receive prompt feedback mMRC, Beck Depression Inventory, Bristol on/support; uploaded exercise performed; and received individualised COPD Knowledge Questionnaire, Exercise Self- nurses), education and peer interaction (online modules and Regulatory Efficacy Scale, Medical Outcome th live chat sessions). Study Social Support Survey, adverse events, kly personalised reinforcement and feedback using a web-based tool as exacerbation, self-reported physical health alert to the nurse if worsening of symptoms. Research 33 tervention as the experimental intervention except: symptoms and ed were monitored through paper diaries send to the centre; and ovided through paper support and reinforcement performed face-to-face. call instead of the web-based tool and no real-time alert to the nurse if mptoms. ly pedometer wearing, weekly update of the step count, access to a g weekly automated individualised goals setting, interactive step-count on/motivational content for self-management and self-efficacy) and y forum (social support). community support (no further information provided). eter use, monthly update of the step count, written materials about ep-count goals and no information provided on the website. BPAQ = Baecke Physical Activity Questionnaire, CAT = COPD assessment test, CCQ = clinical COPD questionnaire, Con = control nic respiratory questionnaire, CRQ-D = chronic respiratory questionnaire dyspnoea subscale, CRQ-SR = chronic respiratory s, ERS = European Respiratory Congress, ESWT = endurance shuttle walk walking exercise test, Exp = experimental group, nce Inventory – Short Form, GLTEQ = Godin Leisure Time Exercise Questionnaire, HAD = anxiety and depression scale, HR = fied Medical Research Council dyspnoea score, MFI20 = Multidimensional Fatigue Inventory 20, MPA = Moderate Physical d Index of Self-Efficacy, QALY = quality-adjusted life years, QOL = quality of life, RCT = randomised controlled trial, SF-12 = naire, SpO2 = pulsed oxygen saturation, STS = Sit To Stand, VAS = visual analogue scale, 1RM = one repetition maximum, therapy compared with no exercise therapy and advanced telehealth technology exercise therapy compared with home-based n Questionnaire 8). was 105 minutes across three sessions in the experimental group and 120 minutes across two sessions in the control group.
34 Bonnevie et al: Advanced telerehabilitation for stable COPD Random sequence generation (selection bias) A Type of ATT-ET MD (95% CI) Study Fixed Allocation concealment (selection bias) Real-time supervised/monitored ET Tsai 2017 Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (attrition bias) Selective reporting (reporting bias) low risk of bias Other bias 25 50 75 100 Unsupervised ET with telehealth feedback unclear risk of bias 0 Percentage of trials and target/imposed intensity high risk of bias Nguyen 2013 Tabak 2014a Figure 2. Risk of bias among the included studies. Review authors’ judgements about each risk of bias item presented as percentages across all included studies. For indi- Subtotal vidual study scores, see Appendix 3 on the eAddenda. three to seven times per week. In all studies, the mean forced expi- Unsupervised ET with telehealth feedback ratory volume in 1 second (FEV1) was 30% of the predicted value. without target/imposed intensity Risk of bias in the included studies Demeyer 2017 The risk of bias among the included studies is summarised in Total Figure 2, with more details in Appendices 2 and 3 on the eAddenda. The most common biases were the lack of blinding of the participants –200 –100 0 100 200 and outcome assessors. There were not enough studies to construct a Favours no ET (m) Favours ATT-ET funnel plot to assess publication bias for any outcome. B Type of ATT-ET MD (95% CI) Effect of ATT-ET compared with no ET Study Random Real-time supervised/monitored ET Seven studies involving 787 participants contributed data on the Hansen 2020 effects of ATT-ET compared with no ET.16,35–38,40,41,52 The follow-up periods ranged from 1 to 12 months. The GRADE summary of find- Unsupervised ET with telehealth feedback ings table for this comparison is presented in Appendix 4 on the and target/imposed intensity eAddenda. Bourne 2017 Exercise capacity The short-term effect of ATT-ET on exercise capacity was assessed Total using the ISWT16 and the 6MWT.16,35,38,40 Tsai et al (36 participants) –200 –100 0 100 200 estimated that ATT-ET does not improve the ISWT to any worthwhile Favours in/outpatient ET (m) Favours ATT-ET extent (MD 6 m, 95% CI –23 to 35),16 while the meta-analysis for the 6MWT (four studies,16,35,38,40 458 participants) found that ATT-ET C Type of ATT-ET MD (95% CI) produced a benefit (MD 15 m), although that benefit was too small Study Fixed to be worthwhile (95% CI 5 to 24, Figure 3A. For a more detailed forest Unsupervised ET with telehealth feedback plot, see Figure 4 on the eAddenda). One study (84 participants) and target/imposed intensity assessed the long-term effect of ATT-ET on the 6MWT. Although the Nguyen 2008 average benefit would be worthwhile (MD 25 m), this estimate was Nguyen 2013 very imprecise (95% CI –28 to 76).38 Endurance exercise capacity was Subtotal assessed in one study (36 participants) using the endurance shuttle walk test.16 ATT-ET was estimated to be very worthwhile at short- Unsupervised ET with telehealth feedback term (MD 340 seconds, 95% CI 153 to 527). without target/imposed intensity Quality of life Wan 2017 The short-term effect of ATT-ET on quality of life was assessed Total using: the Chronic Respiratory Questionnaire (CRQ), measured from 20 ‘worst’ to 140 ‘best’;16,38 the Clinical COPD Questionnaire, –200 –100 0 100 200 measured from 0 ‘best’ to 60 ‘worst’;40,41 and the SGRQ, measured Favours home ET (m) Favours ATT-ET from 0 ‘best’ to 100 ‘worst’.36,37 The meta-analysis (four studies,16,36–38,40 361 participants) found a small positive effect from Figure 3. Short-term effect (1 to 4 months) of advanced telehealth technology exercise ATT-ET (SMD 0.22), although the uncertainty around this estimate therapy on the 6MWT compared with (A) no ET, (B) in/outpatient ET and (C) home-based ranged from no benefit to a moderate benefit (95% CI 0.00 to 0.43, ET not using ATT. For a more detailed forest plot, see Figure 4 on the eAddenda. Figure 5A. For a more detailed forest plot, see Figure 6 on the eAd- ATT = advanced telehealth technology, ET = exercise therapy, 6MWT = six-minute walk denda). Converted back to original SGRQ units using data from an test. observational study,31 the estimate revealed a worthwhile improve- ment (MD –4%), although the uncertainty around this estimate CI –4 to 16). Moy et al36,37 (229 participants) found no worthwhile ranged from a clinically trivial benefit to a worthwhile benefit (95% CI effect of ATT-ET on the SGRQ (MD 1%, 95% CI –2 to 4). –7 to 0). Additionally, one study (29 participants) found that the ef- fect of ATT-ET on the Clinical COPD Questionnaire was uncertain (MD Functional dyspnoea –0.4, 95% CI –0.8 to 0.1).41 The long-term effect of ATT-ET was The short-term effect of ATT-ET on functional dyspnoea was assessed in two studies, which could not be pooled for meta-analysis. Ngyuen et al38 (84 participants) estimated that the effect of ATT-ET on assessed in three studies. Two studies used the CRQ-D (5 ‘worst’ to 35 the CRQ is beneficial, but the estimate was very uncertain (MD 6, 95% ‘best’)16,38 and one study used the mMRC dyspnoea score (0 ‘best’ to 4 ‘worst’), the latter of which could not be pooled for meta-analysis.41
Research 35 A Type of ATT-ET SMD (95% CI) A Type of ATT-ET MD (95% CI) Fixed Fixed Study Study Real-time supervised/monitored ET Real-time supervised/monitored ET Tsai 2017 Tsai 2017 Unsupervised ET with telehealth feedback Unsupervised ET with telehealth feedback and target/imposed intensity and target/imposed intensity Nguyen 2013 Nguyen 2013 Tabak 2014a Total Subtotal Unsupervised ET with telehealth feedback –10 –5 0 5 10 without target/imposed intensity Favours no ET Favours ATT-ET Moy 2015 Total –2 –1 0 1 2 B Type of ATT-ET SMD (95% CI) Fixed Favours no ET Favours ATT-ET Study Unsupervised ET with telehealth feedback and target/imposed intensity B Type of ATT-ET SMD (95% CI) Bourne 2017 Fixed Study Chaplin 2017 Real-time supervised/monitored ET Total Hansen 2020 Unsupervised ET with telehealth feedback –2 –1 0 1 2 and target/imposed intensity Favours in/outpatient ET Favours ATT-ET Bourne 2017 Total C Type of ATT-ET MD (95% CI) Fixed Study –1 –0.5 0 0.5 1 Unsupervised ET with telehealth feedback Favours in/outpatient ET Favours ATT-ET and target/imposed intensity Nguyen 2008 Nguyen 2013 C Type of ATT-ET Total Study SMD (95% CI) Random Unsupervised ET with telehealth feedback and target/imposed intensity –10 –5 0 5 10 Favours home ET Favours ATT-ET Liu 2008 Nguyen 2008 Figure 7. Short-term effect (1 to 4 months) of advanced telehealth technology exercise therapy on functional dyspnoea compared with (A) no ET using the CRQ-D, (B) in/ Nguyen 2013 outpatient ET and (C) home-based ET using the CRQ-D. For a more detailed forest plot, see Figure 8 on the eAddenda. Total ATT = advanced telehealth technology, ET = exercise therapy, CRQ-D = Chronic Res- piratory Questionnaire dyspnoea sub-score. –10 –5 0 5 10 Favours home ET Favours ATT-ET Figure 5. Short-term effect (1 to 4 months) of advanced telehealth technology exercise (354 participants).16,35 The meta-analysis estimated that ATT-ET does therapy on quality of life compared with (A) no ET, (B) in/outpatient ET and (C) home- not improve health status to any worthwhile extent (MD –1, 95% CI based ET. For a more detailed forest plot, see Figure 6 on the eAddenda. –2 to 0). ATT = advanced telehealth technology, ET = exercise therapy. Quadriceps force The meta-analysis of two studies (120 participants) estimated a One study (318 participants) assessed the short-term effect of ATT- worthwhile improvement on the CRQ-D (MD 2), although this esti- mate came with uncertainty ranging from a clinically trivial benefit to ET on quadriceps force and found that any benefit would be trivial a very worthwhile benefit (95% 0 to 4, Figure 7A. For a more detailed (MD 0 kg, 95% CI –1 to 2).35 forest plot, see Figure 8 on the eAddenda).16,38 The other study (29 participants) estimated that the effect on the mMRC dyspnoea scale is Objective physical activity unlikely to be worthwhile (MD 0, 95% –1 to 1).41 The long-term effect The short-term effect of ATT-ET on physical activity was assessed was assessed in one study (84 participants), which reported a very uncertain effect of ATT-ET on the CRQ-D (MD 2, 95% CI –1 to 5).38 using steps per day,16,35–37,41 as well as ‘activity count’ raw units using various activity monitoring devices.16,40,52 The meta-analysis of the Health status effect on steps per day (four studies,16,35–37,41 510 participants) found The short-term effect of ATT-ET on health status was assessed a worthwhile positive effect (MD 946 steps/day), although the un- certainty around this estimate ranged from a clinically trivial benefit using the COPD Assessment Test (0 ‘best’ to 40 ‘worst’) in two studies to a very worthwhile benefit (95% CI 425 to 1,466). The meta-analysis of the effects on ‘activity count’ (two studies,16,52 54 participants) produced a very imprecise estimate (SMD 0.36, 95% CI –0.19 to 0.91).
36 Bonnevie et al: Advanced telerehabilitation for stable COPD One study was not pooled due to extreme baseline difference be- Other outcomes tween groups.40 One study (238 participants) estimated that ATT-ET No data were available for cost-effectiveness, respiratory function does not improve steps per day to any worthwhile extent in the long-term (MD –108 steps), although there was considerable uncer- and adherence. tainty in the estimate (95% CI –720 to 504).36,37 Effect of ATT-ET compared with in/outpatient ET Subjective physical activity The short-term effect of ATT-ET on subjective physical activity was Three studies (327 participants) contributed data on the effects of ATT-ET compared with in/outpatient ET.42–44,51,53,54 The follow-up assessed in two studies (56 participants) using the Functional Per- periods ranged from 1.5 to 12 months. The GRADE summary of formance Inventory-Short Form (0 ‘worst’ to 96 ‘best’),16 and the findings table for this comparison is presented in Appendix 5 on the Baecke Physical Activity Questionnaire (3 ‘worst’ to 15 ‘best’).41 The eAddenda. meta-analysis estimated that there might be a small beneficial effect on subjective physical activity (SMD 0.34) but this estimate came Exercise capacity with a very high uncertainty (95% CI –0.19 to 0.87). Two studies (224 participants) contributed data on exercise ca- Anxiety and depression pacity in the short-term using the 6MWT. The meta-analysis esti- One study involving 36 participants contributed data on the short- mated that the effect of ATT-ET was similar to the effect of in/ outpatient ET (MD 6 m) but this estimate came with very high un- term effect of the intervention on anxiety and depression using the certainty (95% CI –26 to 37, Figure 3B).42,51,53,54 One study (134 par- HAD-A and HAD-D (0 ‘best’ to 21 ‘worst’).16 It estimated that there ticipants) produced a very uncertain estimate about the relative effect may be a worthwhile beneficial effect of ATT-ET on anxiety and of ATT-ET versus in/outpatient ET on the 6MWT in the long-term (MD depression (both MD –2), although these estimates came with un- 6 m, 95% CI –25 to 36).53,54 Endurance exercise capacity was assessed certainty ranging from a clinically trivial benefit to a very worthwhile in one study (62 participants).43,44 It estimated that ATT-ET and in/ benefit (both 95% CI –4 to 0). outpatient ET had similar effects on the endurance shuttle walk test in the short-term (1 to 4 months) but this was a very uncertain es- Self-efficacy timate (MD 5 seconds, 95% CI –112 to 121). The short-term effect of ATT-ET on self-efficacy was assessed in Quality of life two studies16,38 (120 participants) using the Pulmonary Rehabilita- The short-term effects of ATT-ET compared with in/outpatient ET tion Adapted Index of Self-Efficacy (15 ‘worst’ to 60 ‘best’)16 and a validated question (0 ‘worst’ to 10 ‘best’).38 The meta-analysis esti- on quality of life was assessed using the SGRQ42 and the Clinical COPD mated a moderate benefit from the intervention (SMD 0.59), although Questionnaire.51,53,54 The meta-analysis (two studies, 224 partici- the uncertainty around this estimate ranged from virtually no benefit pants) found a small relative positive effect from ATT-ET (SMD 0.23), to a very worthwhile benefit (95% CI 0.02 to 1.17). The long-term although the uncertainty around this estimate ranged from no benefit effect was assessed in one study38 (84 participants) using a vali- to a moderate benefit (95% CI –0.04 to 0.50, Figure 5B). Converted dated question but it generated an imprecise estimate of the effect of back to an original unit (SGRQ) using the SD of 17.1 from an obser- the intervention (MD 0.6, 95% CI –0.7 to 1.9). vational study,31 the estimate revealed a worthwhile relative effect (MD –4%) but this estimate came with similar uncertainty (95% CI –9 Exacerbations to 0). The long-term effect was assessed in one study involving 238 Functional dyspnoea participants, which produced an uncertain estimate (RR 1.3, 95% CI The short-term effect of the intervention compared with in/ 0.7 to 2.2).36,37 outpatient ET was assessed using the CRQ-D43,44 and the mMRC Hospitalisation dyspnoea scale.42 The meta-analysis (two studies, 152 participants) The long-term effects of the intervention on the hospitalisation found similar effects between interventions (SMD –0.05, 95% CI –0.39 to 0.29, Figure 7B). Converting this result back to the original units of risk was assessed in two studies (262 participants).36,37,40 The meta- the mMRC scale using data from an observational study,55 the esti- analysis produced an uncertain estimate (RR 1.3, 95% CI 0.9 to 2.1). mate revealed that ATT-ET had essentially the same effect as in/ outpatient ET (MD 0, 95% CI 0 to 0). Mortality The long-term effect was assessed in one study36,37 (238 partici- Health status Two studies (224 participants) assessed the short-term effect of pants), which produced a very imprecise estimate (RR 1.6, 95% CI 0.3 to 7.9). the intervention on health status using the COPD Assessment Test and found that ATT-ET was similar to or better than in/outpatient ET Withdrawal (MD –1, 95% CI –3 to 0).42,51,53,54 Estimates about the likelihood of withdrawal were imprecise in Objective physical activity the short-term (RR 1.1, 95% CI 0.7 to 1.9, seven studies,16,35–38,40,41 765 One study (134 participants) found that the relative short-term participants) and long-term (RR 0.6, 95% CI 0.2 to 1.9, two studies,38,40 113 participants). effect of ATT-ET was similar to or better than in/outpatient ET on steps/day (MD 436, 95% CI –138 to 1,010).51,53,54 Additionally, the Adverse events same study generated an uncertain estimate regarding active time Three studies16,35–37 (582 participants) contributed data on the (MD 7.7 minutes, 95% CI –49 to 52). risk of musculoskeletal adverse events. These included back pain, Anxiety and depression knee inflammation or rib fracture and were considered in each of One study (134 participants) assessed the short-term effect of the the studies as mild events that did not cause study discontinuation or resolved without treatment. The meta-analysis estimated a sub- intervention on anxiety and depression using the HAD-A and HAD-D stantial increase in risk associated with the use of ATT-ET (RR 5.7, and estimated that ATT-ET may be slightly better than in/outpatient 95% CI 2.5 to 12.9). One study involving 238 participants also found a ET (both MDs were –1). However, the uncertainty around these es- substantial increase in risk of musculoskeletal adverse events timates ranged from no benefit to a worthwhile benefit (95% CI –2 to associated with the intervention in the long-term (RR 2.9, 95% CI 1.5 0 for both).51,53,54 Additionally, Bourne et al42 (90 participants) to 5.9).36,37
Research 37 reported the short-term HADS total score and estimated that ATT-ET clinically trivial benefit to a very worthwhile benefit (95% CI 0 to 4, had a similar effect to in/outpatient ET (MD –1, 95% CI –3 to 2). Figure 7C). Additionally, Wan et al49,50 (involving 109 participants) estimated that the effects of the two forms of ET were similar on the Adherence mMRC dyspnoea score (MD 0, 95% CI –1 to 0). One study (84 par- Two studies (224 participants) produced a very uncertain estimate ticipants) found a very worthwhile relative effect in the long-term of ATT-ET over home-based ET not using ATT on the CRQ-D (MD 3), of the relative effect of the interventions in the short-term (RR 1.0, although this estimate came with uncertainty ranging from no 95% CI 0.9 to 1.3).42,51,53,54 benefit to a very worthwhile benefit (95% CI 0 to 6).38 Withdrawal Cost-effectiveness Three studies (327 participants) contributed data on withdrawal One study involving 105 participants reported an uncertain rela- at short-term.42–44,53,54 The meta-analysis produced a very uncertain tive effect on total cost in the long-term (MD –V288, 95% CI –3,998 to estimate of the relative effect of the interventions (RR 1.1, 95% CI 0.3 3,424) as well as in the incremental quality-adjusted life years (MD to 3.4). 0.03, 95% CI 0.00 to 0.06).45,46 Adverse events Health status Two studies (224 participants) assessed minor adverse events in One cross-over study (44 participants) estimated that the relative the short-term and produced a uncertain estimate of the relative effect of ATT-ET was similar to or better than home-based ET without effect of the interventions (RR 0.24, 95% CI 0.1 to 1.1).42,51,53,54 ATT to improve the COPD Assessment Test in the short-term (MD 0, 95% CI –3 to 2).47 Other outcomes No data were available for cost-effectiveness, quadriceps force, Objective physical activity One study involving 109 participants found the ATT-ET had a subjective physical activity, respiratory function, self-efficacy, exac- erbations, hospitalisation and mortality. substantially greater effect on steps/day than home ET not using ATT in the short-term (MD 804 steps). However, this estimate came with Effect of ATT-ET compared with home-based ET without ATT uncertainty ranging from a clinically trivial benefit to a very worth- while benefit (95% CI 105 to 1,503).49,50 Six studies (451 participants) contributed data on the effects of ATT-ET compared with home-based ET that did not use ATT.38,39,45–50 Subjective physical activity The follow-up periods ranged from 3 to 12 months. The GRADE One cross-over study (44 participants) found uncertain short-term summary of findings table for this comparison are presented in Appendix 6 on the eAddenda. relative effect on the Godin Total Leisure Activity score (measured from 0 to no formal upper limit, higher score indicates higher sub- Exercise capacity jective physical activity) (MD 3, 95% CI –2 to 7).47 Exercise capacity was assessed using the ISWT48 and Anxiety and depression 6WMT.38,39,49,50 Although Liu et al48 (48 participants) found sub- One study (109 participants) found that ATT-ET and home ET not stantially better ISWT results with ATT-ET both in the short-term (MD 77 m) and long-term (MD 69 m), these estimates came with uncer- using ATT had very similar short-term effects on the Beck Anxiety tainty, ranging from trivially better to very markedly better (95% CIs Inventory (0 ‘best’ to 63 ‘worst’), with mean difference of 0 (95% CI –2 26 to 127 and 21 to 118, respectively). The meta-analysis for the to 2).49,50 6MWT (three studies,8,39,49,50 231 participants) estimated a similar relative effect (MD 2 m, 95% CI –16 to 19, Figure 3C). One study (84 Self-efficacy participants) estimated a similar relative effect in the long-term but Self-efficacy was assessed in two studies using one validated this was a very uncertain estimate (MD 6 m, 95% CI –46 to 58).38 question (measured from 0 ‘worst’ to 10 ‘best’)38,39 and in one study Quality of life using the Exercise Self-Regulatory Efficacy scale (measured from 1 The effect of ATT-ET compared with home-based ET on quality of ‘worst’ to 160 ‘best’), the latter of which could not be meta- analysed.49,50 The meta-analysis (two studies, 123 participants) esti- life was assessed using the Short Form-12 health questionnaire (0 mated that ATT-ET may have a better short-term effect than home ET ‘worst’ to 100 ‘best’),48 the CRQ38,39 and the SGRQ.49,50 The meta- without ATT on the validated question (MD 1, 95% CI 0 to 2). Addi- analysis (three studies, 171 participants) estimated that ATT-ET had tionally, Wan et al (109 participants) did not identify any clear a much better effect at short-term (SMD 0.79) but this estimate came difference on the Exercise Self-Regulatory Efficacy scale (MD 4, 95% with uncertainty ranging from essentially similar effects through to a CI –4 to 12).49,50 One study (84 participants) found uncertain relative very worthwhile benefit (95% CI –0.04 to 1.62, Figure 5C). Converted effect in the long-term between interventions on the validated back to the original units of the SGRQ using the SD of 17.1 from an question (MD 1, 95% CI 0 to 2).38 observational study,31 the estimate revealed a very worthwhile relative effect (MD –14%) but again with substantial uncertainty (95% Exacerbations CI –28 to 1). Additionally, Wan et al49,50 (109 participants) found a The long-term effect was assessed in one study (48 participants), very uncertain relative effect on the SGRQ (MD 0%, 95% CI –5 to 4). Two studies (132 participants) estimated that ATT-ET had a markedly which estimated a worthwhile relative effect on the risk of exacer- better effect on quality of life in the long-term (SMD 1.05), although bations (RR 0.2, 95% CI 0.1 to 0.8) and on the incidence rate of ex- this estimate came with substantial uncertainty (95% CI –0.37 to acerbations (Rate Ratio 0.1, 95% CI 0.0 to 0.6).48 2.47).38,48 Converted back to an original unit (SGRQ), the estimate revealed a very worthwhile benefit (MD –18%) but still with sub- Hospitalisation stantial uncertainty (95% CI –42 to 4). Two studies (153 participants) estimated an uncertain long-term Functional dyspnoea relative effect in the risk of hospitalisation between interventions The short-term effects of the interventions on functional dysp- (RR 0.5, 95% CI 0.2 to 1.5)45,46,48 and one study involving 134 par- ticipants also found an uncertain relative effect in the time to first noea were assessed using the CRQ-D38,39 and the mMRC dyspnoea hospitalisation (HR 1.2, 95% CI 0.8 to 1.8).53,54 score.49,50 The meta-analysis (two studies,38,39 123 participants) estimated that ATT-ET had substantially greater benefit on the CRQ-D Mortality (MD 2), although the estimate came with uncertainty ranging from a One study (48 participants) produced a very uncertain estimate of the relative effect in the long-term on mortality (RR 0.3, 95% CI 0.0 to 7.8).48
38 Bonnevie et al: Advanced telerehabilitation for stable COPD Adherence events were rare in the included studies, leading to imprecise estimates. One study (109 participants) found an uncertain short-term relative effect in adherence (RR 1.0, 95% CI 0.9 to 1.2),49,50 but Although ATT-ET increased adverse events, these were only minor musculoskeletal events and their occurrence was as frequent (10 to another study (48 participants) reported a very worthwhile benefit of 20%), as in other studies assessing high-risk populations resuming ATT-ET over home ET not using ATT on long-term adherence (RR 2.4, physical activity.60 95% CI 1.4 to 4.2).48 Withdrawal ATT-ET compared with in/outpatient ET One study (84 participants) produced a very uncertain estimate of ATT-ET had similar effects as in/outpatient ET on functional the short-term relative effect on withdrawal between interventions dyspnoea and similar or better effects on quality of life, health status, (RR 0.2, 95% CI 0.0 to 3.9).38 The meta-analysis of four studies (369 objective physical activity and anxiety/depression. However, these participants) produced an uncertain estimate of the long-term rela- estimates came with some uncertainty. tive effect between interventions (RR 1.0, 95% CI 0.5 to 1.9).38,45,46,48–50 Based on the three available trials, ATT-ET seemed similarly effective as centre-based ET, although there was some uncertainty Adverse events in the effects on exercise capacity (see Appendix 5 on the eAddenda). One study (114 participants) produced an uncertain estimate of The effects on the 6MWT seemed similar, although in one trial,51,53,54 the groups differed in their weekly exercise volume by 15 minutes the short-term relative effect on the risk of adverse events (RR 1.3, (see Table 1), which may have influenced the pooled result. For the 95% CI 0.6 to 2.6) and on the incidence rate of adverse events (Rate endurance shuttle walk test, the relative effect was very uncertain. Ratio 1.3, 95% CI 0.6 to 2.6).49 Unless future studies clarify an important difference in their effects, ATT-ET may be a valuable alternative for those people who cannot Other outcomes attend centre-based programs. No data were available for quadriceps force or respiratory ATT-ET compared with home-based ET without ATT function. ATT had similar effects on exercise capacity and similar or Additional analyses better effects on quality of life, objective physical activity, func- tional dyspnoea, health status and self-efficacy. Further research Due to the limited number of studies available per outcome, should be performed to refine these estimates because their con- subgroup and sensitivity analyses were not undertaken. However, fidence intervals do not exclude the possibility that the effects studies were displayed in their corresponding subgroup to offer differ to an important degree. Given this uncertainty, the cost- further visual insight on the forest plots. effectiveness and the cost-utility of adding telehealth technology to home-based ET (which may be expensive when it includes an Discussion internet-enabled device such as desktop, laptop, smartphone, tablet, smart TV, connected cycle ergometer or remote pulse ox- ATT-ET compared with no ET imetry system) also warrant further investigation. ATT-ET was superior at reducing exacerbations, although this was based on ATT-ET was found to increase exercise capacity and objective only one study. physical activity, and probably improves quality of life, functional dyspnoea, self-efficacy and anxiety/depression. It is unclear whether ATT-ET with automated feedback facilitated long-term adherence these benefits are clinically worthwhile. to ET (RR 2.4, 95% CI 1.4 to 4.2),48 which would be expected to maintain long-term benefit, although this notion has recently been Although ATT-ET improved the 6MWT (MD 15 m, 95% CI 5 to 24) questioned.61 The use of ATT to maintain ET following an initial and ISWT (MD 6 m, 95% CI –23 to 35), these effects were less than the pulmonary rehabilitation program is a new research area with MCIDs of 25 m and 47 m, respectively.28 Also, in a less direct com- promising results.62,63 parison, the upper bound of the estimate for the 6MWT fell below the 95% CI reported by McCarthy et al (MD 44 m, 95% CI 33 to 55) for Strength and limitations pulmonary rehabilitation compared with usual care.4 Altogether, these results suggest that the effect of ATT-ET on the 6MWT is un- Some strengths of this review included prospective registration, a likely to be clinically worthwhile. Although widely used, the 6MWT is thorough search strategy, duplicate data processes and minimal not as responsive as endurance exercise testing to assess exercise language bias. Most trials did not blind participants and outcome capacity following an intervention in people with COPD, which may assessors, which should be implemented where possible in future explain the lack of clinical effect found in the present analysis.56 This trials. Despite a substantial pool of included studies, the dataset was explanation is supported by the fact that Tsai et al16 found a very insufficient for the planned subgroup and sensitivity analyses. worthwhile improvement from ATT-ET on the endurance shuttle walk Therefore, we were unable to determine robust estimates for each test, for which the lower bound of the estimates (MD 340 seconds, individual form of ATT-ET. We acknowledge that some of the in- 95% CI 153 to 527) greatly exceeded the established MCID for this terventions were only based on increasing daily physical activity, outcome (65 seconds).28 which may differ from structured exercise training in their ability to improve exercise capacity. Further studies should directly compare Unlike exercise training programs, which do not necessarily in- these interventions when delivered using ATT. Although the GRADE crease physical activity,57,58 ATT-ET clearly improved steps per day ratings were very low for some outcomes (primarily patient-reported (MD 946 steps, 95% CI 425 to 1,466). The improvement in physical outcomes and those related to rare events, as shown in Appendices 4 activity may be explained by the fact that ATT-ET may: facilitate the to 6), other outcomes had evidence rated as moderate and had effects integration of exercise into the daily routine; improve functional large enough and estimated precisely enough to make recommen- dyspnoea and self-efficacy to manage dyspnoea (two positive effects dations for clinical practice. also found in the present review); and promote autonomous exercise. Although the lower bound of the 95% CI was below the MCID for Conclusion steps/day, the effect might be clinically valuable anyway, not only because the mean estimate is higher than the MCID (600 steps/day) In conclusion, compared with no ET, ATT-ET improved exercise but also because increases in physical activity are inversely associated capacity, objective physical activity, and probably quality of life, with cardiovascular events, hospitalisations and mortality among people with COPD.14,29,59 This could not be confirmed because such
Research 39 functional dyspnoea, self-efficacy and anxiety/depression. However, 7. Méndez A, Labra P, Pizarro R, Baeza N. Low rates of participation and completion of these effects may not be clinically important. The effects of ATT-ET: pulmonary rehabilitation in patients with chronic obstructive pulmonary disease appeared similar or better than in/outpatient ET on functional in primary health care. Rev Med Chil. 2018;146:1304–1308. dyspnoea, quality of life, health status, objective physical activity and anxiety/depression; and were equal to or exceeded those of 8. Steiner M, Holzhauer-Barrie O, Lowe D, Searle L, Skipper E, Welham S, et al. Pul- home-based ET without ATT on exercise capacity, quality of life, monary rehabilitation: time to breathe better. National Chronic Obstructive Pulmonary objective physical activity, functional dyspnoea, health status, self- Disease (COPD) Audit Programme: resources and organisation of pulmonary rehabil- efficacy and exacerbations. High-quality studies are still warranted itation services in England and Wales 2015. National Organisational Audit Report to refine the uncertain estimates in this review and to examine London: RCP; 2015. cost-effectiveness. 9. Cox NS, Oliveira CC, Lahham A, Holland AE. Pulmonary rehabilitation referral and What was already known on this topic: People with chronic participation are commonly influenced by environment, knowledge, and beliefs obstructive pulmonary disease benefit from exercise therapy about consequences: a systematic review using the Theoretical Domains Frame- programs such as pulmonary rehabilitation. Many people cannot work. J Physiother. 2017;63:84–93. access centre-based programs. For exercise therapy programs undertaken at home, advanced telehealth technology can provide 10. Keating A, Lee A, Holland AE. What prevents people with chronic obstructive some of the monitoring and interactivity that occurs in centre- pulmonary disease from attending pulmonary rehabilitation? A systematic review. based programs. Chron Respir Dis. 2011;8:89–99. What this study adds: In people with chronic obstructive pulmonary disease, exercise therapy delivered using advanced 11. Keating A, Lee AL, Holland AE. Lack of perceived benefit and inadequate transport telehealth technology improved some measures of exercise ca- influence uptake and completion of pulmonary rehabilitation in people with pacity and objective physical activity, and probably also quality chronic obstructive pulmonary disease: a qualitative study. J Physiother. of life, functional dyspnoea, self-efficacy and anxiety/depres- 2011;57:183–190. sion, although these benefits may not all be large enough to be clinically worthwhile. Exercise therapy with advanced telehealth 12. Neves LF, Reis MH, Goncalves TR. Home or community-based pulmonary reha- technology seemed to have largely similar effects to centre- bilitation for individuals with chronic obstructive pulmonary disease: a systematic based programs, although the relative benefit on exercise ca- review and meta-analysis. Cad Saude Publica. 2016;32:6. pacity was unclear. Advanced telehealth technology: improved the effects of home-based exercise therapy on incremental ex- 13. Wuytack F, Devane D, Stovold E, McDonnell M, Casey M, McDonnell TJ, et al. ercise capacity, physical activity and risk of exacerbations; Comparison of outpatient and home-based exercise training programmes for probably improved the effect on functional dyspnoea and quality COPD: A systematic review and meta-analysis. Respirology. 2018;23:272–283. of life; and may have improved the effect on several other outcomes. 14. McKeough Z, Cheng SWM, Alison J, Jenkins C, Hamer M, Stamatakis E. Low leisure- based sitting time and being physically active were associated with reduced odds Footnotes: a GetData Graph Digitizer 2.24, ShareIt!, Cologne, of death and diabetes in people with chronic obstructive pulmonary disease: a Germany. cohort study. J Physiother. 2018;64:114–120. b Review Manager (RevMan) [Computer program]. Version 5.3.5. 15. Hwang R, Bruning J, Morris N, Mandrusiak A, Russell T. A systematic review of the Copenhagen: The Nordic Cochrane Centre, The Cochrane Collabora- effects of telerehabilitation in patients with cardiopulmonary diseases. tion, 2014. J Cardiopulm Rehabil Prev. 2015;35:380–389. eAddenda: Figures 4, 6 and 8, and Appendices 1-6 can be found 16. Tsai LL, McNamara RJ, Moddel C, Alison JA, McKenzie DK, McKeough ZJ. Home- online at https://doi.org/10.1016/j.jphys.2020.12.006. based telerehabilitation via real-time videoconferencing improves endurance ex- ercise capacity in patients with COPD: The randomized controlled TeleR Study. 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Journal of Physiotherapy 67 (2021) 68 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Appraisal of Clinical Practice Guideline: 2018 update of the EULAR recommendations for the management of hand osteoarthritis Date of latest update: August 2018. Date of next update: Not specified. Patient group: People treatment, incorporating non-pharmacological, pharmacological and surgical treatment op- with hand osteoarthritis (OA). Intended audience: Not specified. Additional versions: Eu- tions. In addition to these five overarching principles,10 recommendations were also made by ropean League Against Rheumatism (EULAR) hand OA guideline published in 2007. Expert the task force, as summarised in Table 1 of the guideline. The first three recommendations are working group: The expert working group comprised one convenor, one methodologist, one related to the non-pharmacological treatment options for hand OA management. The next five fellow, and a further task force of 10 rheumatologists, one plastic surgeon, three healthcare recommendations (recommendations 4 to 8) illustrate the role of pharmacological options for professionals in the field of physiotherapy and occupational therapy, two patient research treating hand OA, including topical treatments, oral analgesics, chondroitin sulfate, and intra- partners, and two Emerging EUlar NETwork (EMEUNET) members. Funded by: This clinical articular glucocorticoids (not recommended). Recommendations 9 and 10 focus on surgical practice guideline was funded by EULAR. Consultation with: No consultations beyond the considerations and follow-up of the hand OA patients, respectively. A research agenda for hand expert working group were specified. Approved by: The final manuscript was reviewed, OA is created and presented in Table 2 of the guideline. This agenda covers different themes, revised and approved by all task force members, followed by a final review by the EULAR from pathophysiology to different treatment options for hand OA. Executive Committee. Location: https://doi.org/10.1136/annrheumdis-2018-213826. Description and key recommendations: The 2018 EULAR guidelines were developed to Provenance: Invited. Not peer reviewed. update an existing guideline published in 2007 for the evidence-based management of hand OA. The level of evidence and grade of evidence were computed regarding each recommen- Armaghan Dabbagh and Joy C MacDermid dation, according to the Oxford Centre for Evidence-Based Medicine standards. According to School of Physical Therapy, Western University, London, Canada the results of this guideline, based on expert opinion and research evidence, five overarching principles were agreed upon. These overarching principles were related to goals of treatment, https://doi.org/10.1016/j.jphys.2020.07.002 providing enough information to patients, individualising the treatment according to each patient, shared decision-making, and having a multidisciplinary approach to hand OA Appraisal of Clinical Practice Guideline: Physiotherapy for cystic fibrosis in Australia and New Zealand Date of latest update: 2019. Date of next update: Not stated. Patient group: People with (recommendations 11 to 15); musculoskeletal management (recommendations 16 to 18); cystic fibrosis in Australia and New Zealand. Intended audience: Physiotherapists. Addi- management of urinary incontinence (recommendations 19 to 21); managing the newly tional versions: This guideline builds on a previous consensus statement published in 20081 diagnosed patient with cystic fibrosis (recommendations 22 to 23); delivery of non- and an evaluation of its uptake and impact published in 2013.2 The guideline can be accessed invasive ventilation (recommendations 24 to 28); and physiotherapy management before as a published journal article,3 as well as an Executive Summary and Comprehensive Version and after lung transplantation (recommendations 29 to 30). These are summarised at the end from the Thoracic Society of Australia and New Zealand website.4 Expert working group: All of each chapter. Elements of clinical practice that were considered important but lacked physiotherapists providing regular care for people with cystic firobsis in paediatric or adult research evidence were highlighted as 47 ‘Practice Points’. These provided additional in- settings in Australia or New Zealand were invited to participate. The final expert working formation on the aforementioned practice areas, as well as the areas of: physiotherapy for group included: one chairperson, one editor, 12 group leaders and another 25 members, pregnancy, labour and the post-natal period (5 points); the transition from paediatric to adult who were all physiotherapists working with indivudals with cystic fibrosis. Funded by: care (1 point); adherence to physiotherapy (3 points); infection control during physiotherapy The guidelines were partially funded by a grant from Cystic Fibrosis Australia. The prior (7 points); and delivery of physiotherapy to inpatients and outpatients (3 points). The 2008 consensus statement was partially funded by Roche Pharmaceuticals and Solvay guidelines conclude with 10 ‘Directions for future research’, which encourage research on: Pharmaceuticals. Consultation with: The draft document was reviewed by stakeholders, effectiveness of individual respiratory techniques; combination of inhalation therapies with including: physicians caring for people with cystic fibrosis, people with cystic fibrosis, physiotherapy techniques; effectiveness of exercise and strength training; management of allied health professionals and expert physiotherapists who were not part of the writing musculoskeletal complications; and optimal care for people with chronic respiratory failure. group. Approved by: The original 2008 consensus statement was endorsed by the Thoracic Society of Australia and New Zealand. Chapters in the current clinical guidelines Provenance: Invited. Not peer reviewed. were drafted by a writing group and circulated to the whole expert group for comment and revision. The document was then compiled into one text by the editor and circulated Leanne M Johnston to the group for review. Location: Journal article: https://doi.org/10.1111/resp.12764; School of Health & Rehabilitation Sciences, The University of Queensland, Executive Summary and Comprehensive version: https://www.thoracic.org.au/journal- publishing/area?command=record&id=37. Description and key recommendations: The Brisbane, Australia 2016 clinical practice guidelines were developed to update a 2008 consensus statement. The aim was to optimise physiotherapy management of infants, children and adults with https://doi.org/10.1016/j.jphys.2020.11.013 cystic fibrosis in Australia and New Zealand by standardising physiotherapy care and providing a reference tool to support training of physiotherapists and isolated References practitioners. Recommendations were drawn from a systematic review of published literature, relevant conference proceedings and stakeholder review. Recommendations 1. Physiotherapy for cystic fibrosis in Australia: a consensus statement. http://www. were formulated based on the quality, quantity and level of the evidence according to thoracic.org.au/documents/papers/physiotherapyforcf.pdf. National Health and Medical Research Council guidelines; the consistency of the body of evidence; the likely clinical impact; and generalisability and applicability to physiotherapy 2. Holland AE, Button BM. Respirology. 2013;18:652–656. practice in Australia and New Zealand. Thirty recommendations were made across eight 3. Button BM, et al. Respirology. 2016;21:656–667. domains of physiotherapy practice for children and adults with cystic fibrosis, including: 4. https://www.thoracic.org.au/journal-publishing/area?command=record&id=37. airway clearance therapy (recommendations 1 to 5); inhalation therapy as an adjunct to physiotherapy (recommendations 6 to 10); exercise assessment and training 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Journal of Physiotherapy 67 (2021) 68 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Appraisal of Clinical Practice Guideline: 2018 update of the EULAR recommendations for the management of hand osteoarthritis Date of latest update: August 2018. Date of next update: Not specified. Patient group: People treatment, incorporating non-pharmacological, pharmacological and surgical treatment op- with hand osteoarthritis (OA). Intended audience: Not specified. Additional versions: Eu- tions. In addition to these five overarching principles,10 recommendations were also made by ropean League Against Rheumatism (EULAR) hand OA guideline published in 2007. Expert the task force, as summarised in Table 1 of the guideline. The first three recommendations are working group: The expert working group comprised one convenor, one methodologist, one related to the non-pharmacological treatment options for hand OA management. The next five fellow, and a further task force of 10 rheumatologists, one plastic surgeon, three healthcare recommendations (recommendations 4 to 8) illustrate the role of pharmacological options for professionals in the field of physiotherapy and occupational therapy, two patient research treating hand OA, including topical treatments, oral analgesics, chondroitin sulfate, and intra- partners, and two Emerging EUlar NETwork (EMEUNET) members. Funded by: This clinical articular glucocorticoids (not recommended). Recommendations 9 and 10 focus on surgical practice guideline was funded by EULAR. Consultation with: No consultations beyond the considerations and follow-up of the hand OA patients, respectively. A research agenda for hand expert working group were specified. Approved by: The final manuscript was reviewed, OA is created and presented in Table 2 of the guideline. This agenda covers different themes, revised and approved by all task force members, followed by a final review by the EULAR from pathophysiology to different treatment options for hand OA. Executive Committee. Location: https://doi.org/10.1136/annrheumdis-2018-213826. Description and key recommendations: The 2018 EULAR guidelines were developed to Provenance: Invited. Not peer reviewed. update an existing guideline published in 2007 for the evidence-based management of hand OA. The level of evidence and grade of evidence were computed regarding each recommen- Armaghan Dabbagh and Joy C MacDermid dation, according to the Oxford Centre for Evidence-Based Medicine standards. According to School of Physical Therapy, Western University, London, Canada the results of this guideline, based on expert opinion and research evidence, five overarching principles were agreed upon. These overarching principles were related to goals of treatment, https://doi.org/10.1016/j.jphys.2020.07.002 providing enough information to patients, individualising the treatment according to each patient, shared decision-making, and having a multidisciplinary approach to hand OA Appraisal of Clinical Practice Guideline: Physiotherapy for cystic fibrosis in Australia and New Zealand Date of latest update: 2019. Date of next update: Not stated. Patient group: People with (recommendations 11 to 15); musculoskeletal management (recommendations 16 to 18); cystic fibrosis in Australia and New Zealand. Intended audience: Physiotherapists. Addi- management of urinary incontinence (recommendations 19 to 21); managing the newly tional versions: This guideline builds on a previous consensus statement published in 20081 diagnosed patient with cystic fibrosis (recommendations 22 to 23); delivery of non- and an evaluation of its uptake and impact published in 2013.2 The guideline can be accessed invasive ventilation (recommendations 24 to 28); and physiotherapy management before as a published journal article,3 as well as an Executive Summary and Comprehensive Version and after lung transplantation (recommendations 29 to 30). These are summarised at the end from the Thoracic Society of Australia and New Zealand website.4 Expert working group: All of each chapter. Elements of clinical practice that were considered important but lacked physiotherapists providing regular care for people with cystic firobsis in paediatric or adult research evidence were highlighted as 47 ‘Practice Points’. These provided additional in- settings in Australia or New Zealand were invited to participate. The final expert working formation on the aforementioned practice areas, as well as the areas of: physiotherapy for group included: one chairperson, one editor, 12 group leaders and another 25 members, pregnancy, labour and the post-natal period (5 points); the transition from paediatric to adult who were all physiotherapists working with indivudals with cystic fibrosis. Funded by: care (1 point); adherence to physiotherapy (3 points); infection control during physiotherapy The guidelines were partially funded by a grant from Cystic Fibrosis Australia. The prior (7 points); and delivery of physiotherapy to inpatients and outpatients (3 points). The 2008 consensus statement was partially funded by Roche Pharmaceuticals and Solvay guidelines conclude with 10 ‘Directions for future research’, which encourage research on: Pharmaceuticals. Consultation with: The draft document was reviewed by stakeholders, effectiveness of individual respiratory techniques; combination of inhalation therapies with including: physicians caring for people with cystic fibrosis, people with cystic fibrosis, physiotherapy techniques; effectiveness of exercise and strength training; management of allied health professionals and expert physiotherapists who were not part of the writing musculoskeletal complications; and optimal care for people with chronic respiratory failure. group. Approved by: The original 2008 consensus statement was endorsed by the Thoracic Society of Australia and New Zealand. Chapters in the current clinical guidelines Provenance: Invited. Not peer reviewed. were drafted by a writing group and circulated to the whole expert group for comment and revision. The document was then compiled into one text by the editor and circulated Leanne M Johnston to the group for review. Location: Journal article: https://doi.org/10.1111/resp.12764; School of Health & Rehabilitation Sciences, The University of Queensland, Executive Summary and Comprehensive version: https://www.thoracic.org.au/journal- publishing/area?command=record&id=37. Description and key recommendations: The Brisbane, Australia 2016 clinical practice guidelines were developed to update a 2008 consensus statement. The aim was to optimise physiotherapy management of infants, children and adults with https://doi.org/10.1016/j.jphys.2020.11.013 cystic fibrosis in Australia and New Zealand by standardising physiotherapy care and providing a reference tool to support training of physiotherapists and isolated References practitioners. Recommendations were drawn from a systematic review of published literature, relevant conference proceedings and stakeholder review. Recommendations 1. Physiotherapy for cystic fibrosis in Australia: a consensus statement. http://www. were formulated based on the quality, quantity and level of the evidence according to thoracic.org.au/documents/papers/physiotherapyforcf.pdf. National Health and Medical Research Council guidelines; the consistency of the body of evidence; the likely clinical impact; and generalisability and applicability to physiotherapy 2. Holland AE, Button BM. Respirology. 2013;18:652–656. practice in Australia and New Zealand. Thirty recommendations were made across eight 3. Button BM, et al. Respirology. 2016;21:656–667. domains of physiotherapy practice for children and adults with cystic fibrosis, including: 4. https://www.thoracic.org.au/journal-publishing/area?command=record&id=37. airway clearance therapy (recommendations 1 to 5); inhalation therapy as an adjunct to physiotherapy (recommendations 6 to 10); exercise assessment and training 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Journal of Physiotherapy 67 (2021) 67 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Clinimetrics: eHealth Literacy Scale Summary Description: eHealth literacy is a dynamic process defined by the Among different tools designed to measure eHealth literacy, individual’s ability to search, access, comprehend appraise and use eHEALS is the most widely used instrument.6 Besides its original specific health information from electronic sources to make appro- priate health decisions.1 The eHealth Literacy Scale (eHEALS) is a self- version in English, eHEALS is available in Italian, Greek, Dutch, reported tool developed to measure consumers’ perceived skills, Chinese, Japanese, Persian and Hebrew. knowledge and comfort towards eHealth.2 It is based on a model of Psychometric properties: Although there is some discussion six overlapping core skills that drive consumer engagement with on the existence of potential subscales within eHEALS, its unidi- eHealth: traditional (reading and writing), health, information, sci- mensionality (all items measure a single construct) was confirmed entific (placing information in appropriate context), media and by several studies through Rasch or factor analysis.2,3,5 Factor computer literacies.1,2 The tool consists of eight items, which can be loadings ranged from 0.60 to 0.84 among the eight items, sup- rated through a 5-point Likert scale ranging from 1 (strongly porting the unidimensional nature of the tool.2 eHEALS appears to disagree) to 5 (strongly agree) according to the perceptions of the be reliable and it shows high internal consistency (Cronbach’s respondents.3 The total score ranges from 8 to 40, with higher scores alpha ranging from 0.88 to 0.91).2,5 Correlation between items ranged from 0.51 to 0.76.2 eHEALS also showed a moderate test- indicating higher self-perceived and self-referred eHealth literacy. retest reliability (r = 0.49 to 0.68). Intra-class correlation between There is no suggested cut-off in the literature. The eHEALS is not scores at baseline and 6-month follow-up was 0.49.2 Weak-to- disease specific and has been used in the general Internet user pop- moderate correlation was found between eHEALS and the health- ulation, specific clinical populations, and healthy adolescent, adult related Internet use scale (p , 0.001; r = 0.26 to 0.40).7 Data and older poeple.2–4 When applied to a setting of chronic musculo- from eHEALS in adults showed evidence of monotonicity (direct skeletal pain, for example, it can be a skills-based guide for the relationship) in all items. This shows that eHEALS accurately cor- development and/or adjustment of educational material and physical relates self-perceived eHealth literacy to the ‘agree’ and ‘strongly exercises, thus supporting self-management and self-efficacy.2,4 eHEALS is a brief scale: it takes around 5 minutes to be completed agree’ response options, and those with lower scores presented greatest probability of selecting the options ‘disagree’ or ‘strongly and no training is required for it to be administered. Studies report disagree’.5 Floor and ceiling effects are considered acceptable, with the use of paper, web-based and telephone-based interfaces.2,3,5 few participants scoring the worst or the best possible.3,7 Commentary Accessing health information online (eHealth information) con- As a self-reported tool, eHEALS only measures consumers’ perceived skills; it does not measure their skills directly.2 Thus, the tributes to building self-efficacy in the individual and in the com- scale is susceptible to response bias and overestimation of consumers’ munity, as it potentially improves knowledge of healthy lifestyles, perception towards their eHealth knowledge and skills.7 disease-specific conditions and self-management strategies. Poor Provenance: Invited. Not peer reviewed. eHealth literacy can impair participation in prevention and treatment programs and reduce adherence to medical treatments.6 Identifying Lívia Gaspar Fernandesa,b and Bruno T Saragiottoa,b aMasters and Doctoral Programs in Physical Therapy, Universidade eHealth literacy levels in general or specific clinical populations can guide strategies to digitally deliver tailored orientation and to Cidade São Paulo (UNICID), São Paulo, Brazil develop interventions to improve eHealth literacy skills.6–8 In tele- bCentre for Pain, Health, and Lifestyle (CPHL), NSW, Australia rehabilitation, for example, physiotherapists will need to understand References their patients’ perceived eHealth skills and, consequently, how to 1. Norman CD, Skinner HA. J Med Internet Res. 2006;8:e9. enhance their patients’ abilities. This can help reduce digital 2. Norman CD, Skinner HA. J Med Internet Res. 2006;8:e27. inequality and contribute to self-efficacy.4 Self-efficacy and adequate 3. Nguyen J, et al. JMIR Public Health Surveill. 2016;2:e24. eHealth literacy predict engagement in self-management strategies, 4. Paige SR, et al. Patient Educ Couns. 2017;100:320–326. which are a key part of the treatment of chronic conditions.4,9 5. Stellefson M, et al. J Med Internet Res. 2017;19:e362. 6. Del Giudice P, et al. J Med Internet Res. 2018;20:e281. Performance-based instruments provide a deeper insight into 7. van der Vaart R, et al. J Med Internet Res. 2011;13:e86. 8. van der Vaart R, Drossaert C. J Med Internet Res. 2017;19:e27. individuals’ eHealth literacy skills. They may also allow for a broader 9. Lin I, et al. Br J Sports Med. 2020;54:79–86. overview of skills that play an important role in eHealth interactions, including interactive skills.8 Nevertheless, performance-based or hybrid scales are usually long, more complex, time-consuming for patients and professionals, and might not be feasible in specific settings.7 https://doi.org/10.1016/j.jphys.2020.07.004 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Journal of Physiotherapy 67 (2021) 66 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Clinimetrics: Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Summary Description: The Grading of Recommendations, Assessment, intervention represents a wise use of resources. Online learning Development and Evaluation (GRADE) is a framework for assessing the modules are available for the training of authors of systematic reviews quality (or certainty) of evidence and grading the strength of recommendations in healthcare.1 The GRADE system has been and guideline developers, with most modules lasting no longer than 20 minutes.7 The GRADE Working Group website also provides a list of endorsed by many organisations and it is becoming an international publications and an online handbook for using GRADE and GRADEpro standard for use in judging the evidence in systematic reviews and software.8 clinical guidelines. This Clinimetrics paper only considers GRADE when Clinimetric properties: In the first iteration of GRADE there was used to judge evidence on treatment effects,2 although the GRADE ‘fair’ inter-rater reliability for rating quality of evidence (kappa = 0.40).2 system can also rate the quality of evidence from diagnostic,3 After more guidance on how to use GRADE there was ‘good’ inter-rater prognostic4 and qualitative research.5 reliability among inexperienced raters who received training on the The quality of evidence is applied to each outcome and is rated at one of four levels: high, moderate, low and very low.1 These levels imply a GRADE methodology (intraclass correlation coefficient [ICC] = 0.66) and among members of the GRADE Working Group (ICC = 0.72).9 The gradient of confidence in estimates of summary measures of treatment effect. Randomised controlled trials begin as high quality and observa- inter-rater reliability for quality of evidence has been shown to increase tional studies begin as low quality. The confidence in the evidence can be with training and with ratings by groups of three or four raters, but not decreased for five reasons: study limitations (risk of bias, such as lack of when GRADE was assessed through a consensus rating.9 allocation concealment or blinding); inconsistency of results (heteroge- The inter-rater reliability for the individual GRADE domains was neity or variability of point estimates and overlap of confidence intervals); indirectness of evidence (differences in populations, interventions, ‘poor’ to ‘moderate’ for risk of bias (kappa = 0.06 to 0.41), ‘fair’ to ‘excellent’ for inconsistency (kappa = 0.37 to 0.84), and ‘poor’ to comparators or outcomes); imprecision of estimates (wide confidence intervals crossing a decision threshold); and publication bias (missing ‘moderate’ for imprecision (kappa = 0.18 to 0.21), while for indirectness agreement varied between 41% and 100% of cases.10 Among evidence, typically from studies that show no effect). Three situations guideline panel members, there was ‘fair’ inter-rater reliability for bal- could upgrade the quality of evidence: when the magnitude of the ance of benefit and harms (kappa = 0.4) and use of resources (kappa = 0.28), ‘moderate’ for patients’ preferences and values (kappa = 0.44), treatment effect is very large, if all plausible biases (confounding) would ‘fair’ for assessing the strength of recommendations (kappa = 0.39), and reduce a demonstrated effect and if there is evidence of a dose-response ‘good’ for making recommendations (kappa = 0.74).11 relationship. The standard GRADE assessment had ‘good’ agreement (kappa = 0.66) with Trial Sequential Analysis for rating imprecision,12 and ‘fair’ GRADE provides two levels of recommendations – strong or weak – in favour of or against an intervention.6 The strength of recommen- agreement (kappa = 0.35) for rating quality of evidence with the Semi- dation considers three factors: the balance between benefits and Automated Quality Assessment Tool, which is a 30-item checklist harms, variability in patients’ preferences and values, and whether the covering key determinants of the five GRADE domains.13,14 Commentary GRADE is an essential tool for reviewers and decision-makers as it Charis X Xie and Gustavo C Machado provides an indication of the confidence they can place in the results Institute for Musculoskeletal Health, Faculty of Medicine and Health, and a mechanism with which to translate the evidence into clinical practice guidelines. The initial work on GRADE reliability was con- The University of Sydney, Sydney, Australia ducted when limited guidance was available, resulting in many dis- agreements, but more detailed guidance seems to have improved inter- References rater reliability. Specific training on GRADE methodology is recom- mended for inexperienced raters, and two independent raters are 1. Guyatt GH, et al. BMJ. 2008;336:924–926. sufficient to reliably assess the quality of evidence. The basis for 2. Atkins D, et al. BMC Health Serv Res. 2005;5:25. judgements should be made transparent and reported. Application of 3. Schünemann HJ, et al. BMJ. 2008;336:1106–1110. GRADE can be complex, as evidenced by a series of publications15 and a 4. Huguet A, et al. Syst Rev. 2013;2:71. lengthy handbook with over 10 chapters.8 Different applications of 5. Lewin S, et al. Implement Sci. 2018;13:2. GRADE and adaptations are likely to yield inconsistencies in ratings, 6. Guyatt GH, et al. BMJ. 2008;336:1049–1051. which could influence decision-making. To maximise agreement, 7. The GRADE Working Group. https://cebgrade.mcmaster.ca. further research on assistive tools for GRADE assessment13,14 is war- 8. The GRADE Working Group. https://gradepro.org. ranted. 9. Mustafa RA, et al. J Clin Epidemiol. 2013;66:736–742. 10. Hartling L, et al. PLoS One. 2012;7:e34697. Provenance: Invited. Not peer reviewed. 11. Kumar A, et al. J Clin Epidemiol. 2016;75:115–118. 12. Castellini G, et al. Syst Rev. 2018;7:110. 13. Llewellyn A, et al. PLoS One. 2016;10:e0123511. 14. Meader N, et al. Syst Rev. 2014;3:82. 15. Guyatt GH, et al. J Clin Epidemiol. 2011;64:380–382. https://doi.org/10.1016/j.jphys.2020.07.003 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Journal of Physiotherapy 67 (2021) 72–73 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Correspondence: Functioning assessment by the World Health Organization Disability Assessment Schedule 2.0 – WHODAS I appreciate the opportunity to discuss functioning, in order to cultural reasons. Therefore, these cut-off points must be estab- encourage the clinical and academic use of WHODAS. Some comments lished for each population, respecting the underlying context. But, presented here are aimed at improving the published text,1 as well as more importantly, we must critically ponder about it. In this context, reinforcing the value and importance of WHODAS. some questions arise: What is the difference between someone with 40 points and someone with 42 points on the WHODAS score? Is First of all, two amendments need to be made. It is said in the this difference more important than that between a person with 42 paper that ‘With an increased focus on measuring function and dis- points and another with 56? From the answers to these questions, ability.’ In fact, WHODAS assesses functioning and disability. Func- we can see how fragile and dangerous the use of cut-off points tion is merely one of the components of the ‘Body function and can be. Structure’ domain of the International Classification of Functioning, Disability and Health (ICF) framework and should not be used in place In addition to what was indicated, I would like to emphasise that of functioning. It is imperative to make it clear that functioning is a there is a publication that provides an online spreadsheet for the broader construct that encompasses ‘Body function and Structure’ as complex calculation of the WHODAS scores when working with well as the other five domains.2 If ‘Function’ is used instead of groups of patients.4 ‘Functioning’, all other relevant aspects (domains) to understanding people’s functioning will be ignored. It is essential that conceptual Finally, it is necessary to highlight two strengths from WHODAS misunderstandings are not allowed in academic discussions about that have not been addressed. As a patient-reported outcome functioning, since one of the ICF’s proposals is to serve as a measure, WHODAS allows the health professional to plan patient- universal standard language.2 The article also says that WHODAS centred interventions. In addition, when producing scores ranging ‘. allows assessment of three ICF domains (body functions and from 0 to 100 to quantify the functioning or disability profile, structures, activities and participation, and personal factors).’ As a WHODAS takes a step forward to other ICF-based instruments that matter of fact, WHODAS uses two questions about functions to work only from the perspective of classification. construct its scores and the others are all related to the Activity and Participation domain.3 Personal factors information is collected but Shamyr Sulyvan Castro has no role in the scores. Master Program in Physiotherapy and Functioning, Federal University of Two used references were published before 2010, which was the Ceará, Fortaleza, Brazil year of the launch of the current version of WHODAS. Due to this, it may be uncertain whether the information from these references https://doi.org/10.1016/j.jphys.2020.11.004 should be applied here. References The cut-off point to identifying people with disability must be addressed as well. As can be inferred from the ICF model, func- 1. Paton M, Lane R. J Physiother. 2020;66:199. tioning and disability are context dependent.2 Environmental and 2. WHO. http://www.who.int/classifications/icf/en/. personal factors can vary for geographical, social, economic and 3. Üstün TB, et al. Bull World Health Organ. 2010;88:815–823. 4. Castro S, et al. Cad Saude Publica. 2019;35. Correspondence: Reply to Castro We appreciate the interest in our publication and the use of the participation and personal factors)’ was to highlight the capacity of the WHODAS 2.0 to provide information for the user. We agree that WHODAS 2.0. the WHODAS 2.0 technically produces ‘domain-specific scores for six different functioning domains: cognition, mobility, self-care, getting We agree with Prof Castro’s comment that ‘functioning is a along, life activities (household and work) and participation’2 and broader construct’ and as such agree that our sentence would have that personal factors, although recorded, do not contribute to the been better as ‘With an increased focus on measuring functioning and disability.’ We were trying to highlight the focus of medical research scoring of the tool. in identifying patient-specific limitations with performing natural In relation to the used references being before publication of the activities (incorporated by the definition of ‘function’1), but agree that limitations are not just in the ‘Body function and Structure’ ICF current tool, we agree that Soberg et al3 relates to the previous tool domain, so the use of the term ‘functioning’ instead of ‘function’ (WHODAS II); however, the statement made in relation to this would have been in line with the ICF universal language.2 reference (that the WHODAS is repeatable and sensitive to Our statement that the WHODAS 2.0 ‘allows assessment of change) has been supported by many other publications across three ICF domains (body functions and structures, activities and various populations.4–7 The publication from Andrews et al,8 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Journal of Physiotherapy 67 (2021) 74–75 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Correspondence: High positive airway pressure could shorten the drainage period in haemothorax but not physiotherapy intervention Dos Santos et al conducted a thorough randomised controlled trial of CPAP therapy at 15 cmH20 showed good tolerability and can be with high methodological quality,1 in which they attempted to evaluate safely integrated into clinical practice. This would be true in young whether mobilisation and respiratory techniques shorten the drainage men with haemothorax but cannot be generalised to older patients period and length of hospital stay in patients with pleural effusion. with associated pulmonary comorbidities and heart failure or other Their second objective was to evaluate whether such a strategy patients with pleural effusions.4,5 combined with continuous positive airway pressure (CPAP) could further improve the benefits. They compared three groups (ie, standard The authors brought some interesting suggestions on a topic that care versus physiotherapy techniques versus physiotherapy techniques is usually supported by scarce evidence. Nevertheless, before and CPAP set at 15 cmH2O) and concluded that the combination of extrapolating these results, the following questions need to be CPAP with physiotherapy techniques reduced the duration of chest addressed first. Will CPAP therapy be associated with the same drainage and length of hospitalisation. tolerance and benefits in patients with other types of pleural effu- sion? Do physiotherapy interventions alone improve clinical param- With these conclusions, the authors give the impression that eters in patients with pleural effusions? To what extent would physiotherapy interventions had an independent effect on the res- physiotherapy interventions be able to improve mobility in older and olution of pleural effusions and that adding CPAP may have pro- frail patients with a pleural effusion who are unable to walk? vided a supplemental benefit. However, looking at the reported results one could argue that the implementation of respiratory Marius Lebreta, Guillaume Prieurb,c,d, Tristan Bonneviec,e, physiotherapy interventions (including incentive spirometry, airway Francis-Edouard Gravierc,e, Yann Combretb,c,d and clearance techniques and walking 100 metres) in patients with Clément Medrinalc,d pleural effusion did not have any added value. Indeed, the results clearly showed no clinical or statistical difference between the aInstitut Universitaire de Cardiologie et Pneumologie de Québec (IUCPQ), participants who received physiotherapy and those who received Québec, Canada standard care. In fact, only CPAP seemed to provide a beneficial effect, since the participants in experimental group 2 (physio- bInstitut de Recherche Expérimentale et Clinique (IREC), Pôle de therapy and CPAP) had fewer days of thoracic drainage compared Pneumologie, ORL & Dermatologie, Groupe de Recherche en Kinésithérapie with those in experimental group 1 (physiotherapy alone) or those in the control group. Respiratoire, Université Catholique de Louvain, Brussels, Belgium cHaute Normandie Research and Biomedical Innovation, Normandie Another relevant point is the strikingly high prevalence of pleural effusions due to traumatic causes (94%) in their cohort. This should be University, Rouen, France taken with caution, as haemothorax is not comparable or managed dPulmonology Department and Pulmonary Rehabilitation Department, comparably to other causes of pleural effusion.2 Moreover, it would have been relevant to report the baseline volume of the pleural Groupe Hospitalier du Havre, Montivilliers, France effusion, as this would have enabled comparison of the daily eADIR Association, Rouen University Hospital, Rouen, France amount of liquid drained in each group. https://doi.org/10.1016/j.jphys.2020.11.006 Finally, the population was younger compared with a standard population presenting with non-malignant pleural effusions.3 This is References presumably linked to the fact that pleural effusions were mainly caused by thoracic trauma. Yet, the authors concluded that the use 1. dos Santos EC, et al. J Physiother. 2020;66:19–26. 2. Hooper C, et al. Thorax. 2010;65:ii4–ii17. 3. DeBiasi EM, et al. Eur Respir J. 2015;46:495–502. 4. Cassidy SS, et al. J Appl Physiol. 1979;47:453–461. 5. Kiely JL, et al. Thorax. 1998;53:957–962. Correspondence: Reply to Lebret et al We thank Dr Lebret and colleagues for their interest and comments received. The only time we discussed the effect of mobilisation and regarding our randomised trial.1 Initially, they summarise our respiratory techniques alone was in relation to the other experimental conclusion that the combination of continuous positive airway group, and we concluded that it did not differ from control. In the pressure (CPAP) with mobilisation and respiratory techniques reduced analysis of Dr Lebret and colleagues, however, the effect obtained in the duration of chest drainage and length of hospitalisation. They the group that received CPAP, mobilisation and respiratory techniques then comment that this conclusion gives the impression that the could only have been due to the CPAP alone. We cannot agree or mobilisation and respiratory techniques had an independent effect on disagree with this interpretation. Perhaps it is correct (for the reasons the resolution of pleural effusion. We do not understand why Lebret that Lebret et al describe), but it is equally possible that the effect of et al think that we gave that impression because we only referred to the CPAP is mediated or enhanced by mobilisation and/or respiratory the effect of the combination of interventions that this group techniques (even though they do not independently improve 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Journal of Physiotherapy 67 (2021) 76–77 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Correspondence: Re: de Oliveira et al We write in relation to the recent publication ‘Directed vertebral manipulation, and we observe that approach used clinically when manipulation is not better than generic vertebral manipulation in considering regional interdependence. patients with chronic low back pain: a randomised trial’.1 We recognise the complexity of chronic low back pain, the We do not agree that the findings ‘corroborate those of other studies’ development of the biopsychosocial model and the progress of pain favouring non-specific treatments.1 A regional interdependence neuroscience education in treating this condition. approach has been well researched when treating the thoracic spine for neck pain.7 We completed research indicating that, while specific Currently, there does not appear to be a preferred approach for treatment to the most hypomobile thoracic vertebrae produced better nonspecific chronic low back pain, even when the biopsychosocial cervical pain modulation and motion, thrust direction was irrelevant.8 model and a combination of treatments are considered.2 The We suggest that this process (similar to in the trial by de Oliveira International Association for the Study of Pain defines chronic pain as et al1) is a regional interdependence example and has less to do with ‘pain that persists or recurs for longer than three months’. Non- specificity in the painful region. Conversely, additional research shows specific low back pain is a term used ‘when the pathoanatomical better outcomes for neck pathology when a specific manipulative cause of the pain cannot be determined’.3 Given the difficulty in finding technique is used at the site of neck hypomobility and pain, rather the exact cause of chronic low back pain, we use classification systems, than the thoracic spine.9 which have been shown to improve outcomes. We must also work to improve our diagnostic skills and – perhaps a more daunting task – De Oliveira et al appear to conclude that non-specific treatment improve our manual therapy research quality.4,5 without assessment has little effect on non-specific chronic low back pain. Furthermore, standardised tools like the STarT Back Tool may be used to determine if more of a pain neuroscience education or psy- We have some suggestions regarding future research. Do not chologically informed rehabilitation process may be beneficial. We manipulate for regional interdependence without a complete exam- note that reviews and guidelines offer no overly compelling evidence ination and an attempt at specificity. Specificity may be a better for the use of manual therapy in non-specific chronic low back pain, approach than regional interdependence, but both have value. and consistent research to support its use is scarce. Consider treatment fidelity principles so that the study is reproduc- ible and respects the complexity of manual therapy. Use a classifi- In this study, the manipulative treatment in the lumbar spine is cation system, which allows a more homogenous sample, to avoid directed to ‘the most painful lumbar level’.1 This appears to imply that results with no significant differences. We cannot expect one treat- the increased pain at this site is also associated with a loss of motion, ment to be helpful in a wildly heterogenous population. Consider which would be one of the primary reasons to manipulate a segment, conclusions and complexity of a research question when selecting a considering a classification system or clinical reasoning. If this painful title, so the reader is not moved to a conclusion prior to reading the segment is hypermobile, manipulative treatment may be work. inappropriate. To our knowledge, no classification systems that refer to hypermobility, instability or motor control pathology advise We are grateful for the opportunity to comment on this valuable a primary manipulative intervention. work and we look forward to the authors’ reply. The authors chose very few inclusion and exclusion criteria, which Steve Karasa,b and Brett Windsorb appears to yield a heterogenous group of participants producing very aPhysical Therapy, Chatham University, Pittsburgh little treatment effect, which is a common issue with manual therapy bNorth American Institute of Orthopaedic Manual Therapy, Eugene, USA studies.6 This is a difficult clinical research issue because more homogenous participants consistent with a specific diagnosis or https://doi.org/10.1016/j.jphys.2020.11.007 classification would take longer and perhaps be more challenging to collect. References The conclusion that ‘there is no need to be specific about vertebral 1. de Oliveria RF, et al. J Physiother. 2020;66:174–179. levels when applying manipulation in patients with chronic low back 2. O’Keefe M, et al. J Pain. 2016;17:755–774. pain’ assumes that manipulation is an appropriate treatment for a 3. Maher C, et al. Lancet. 2017;389:736–747. painful segment and a treatment to a different spinal area without an 4. Alrwaily M, et al. Phys Ther. 2016;96:1057–1066. assessment of mobility is undertaken in a clinical setting. We wonder: 5. Fritz J, et al. Spine. 2000;25:106–114. what clinicians would randomly treat another region of the spine 6. Puentedura E, O’Grady W. Thrust Joint Manipulation Skill for the Spine. Minneapolis: with no reasoning or assessment of how it might be related? Perhaps hypomobility in the thoracic spine may be related to hypermobility Orthopedic Physical Therapy Products; 2008. in the lumbar spine requiring treatment other than general 7. Cross K, et al. J Orthop Sports Phys Ther. 2011;41:633–643. 8. Karas S, et al. J Man Manip Ther. 2018;26:1–10. 9. Puentedura E, et al. J Orthop Sports Phys Ther. 2011;41:208–220. 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Journal of Physiotherapy 67 (2021) 72–73 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Correspondence: Functioning assessment by the World Health Organization Disability Assessment Schedule 2.0 – WHODAS I appreciate the opportunity to discuss functioning, in order to cultural reasons. Therefore, these cut-off points must be estab- encourage the clinical and academic use of WHODAS. Some comments lished for each population, respecting the underlying context. But, presented here are aimed at improving the published text,1 as well as more importantly, we must critically ponder about it. In this context, reinforcing the value and importance of WHODAS. some questions arise: What is the difference between someone with 40 points and someone with 42 points on the WHODAS score? Is First of all, two amendments need to be made. It is said in the this difference more important than that between a person with 42 paper that ‘With an increased focus on measuring function and dis- points and another with 56? From the answers to these questions, ability.’ In fact, WHODAS assesses functioning and disability. Func- we can see how fragile and dangerous the use of cut-off points tion is merely one of the components of the ‘Body function and can be. Structure’ domain of the International Classification of Functioning, Disability and Health (ICF) framework and should not be used in place In addition to what was indicated, I would like to emphasise that of functioning. It is imperative to make it clear that functioning is a there is a publication that provides an online spreadsheet for the broader construct that encompasses ‘Body function and Structure’ as complex calculation of the WHODAS scores when working with well as the other five domains.2 If ‘Function’ is used instead of groups of patients.4 ‘Functioning’, all other relevant aspects (domains) to understanding people’s functioning will be ignored. It is essential that conceptual Finally, it is necessary to highlight two strengths from WHODAS misunderstandings are not allowed in academic discussions about that have not been addressed. As a patient-reported outcome functioning, since one of the ICF’s proposals is to serve as a measure, WHODAS allows the health professional to plan patient- universal standard language.2 The article also says that WHODAS centred interventions. In addition, when producing scores ranging ‘. allows assessment of three ICF domains (body functions and from 0 to 100 to quantify the functioning or disability profile, structures, activities and participation, and personal factors).’ As a WHODAS takes a step forward to other ICF-based instruments that matter of fact, WHODAS uses two questions about functions to work only from the perspective of classification. construct its scores and the others are all related to the Activity and Participation domain.3 Personal factors information is collected but Shamyr Sulyvan Castro has no role in the scores. Master Program in Physiotherapy and Functioning, Federal University of Two used references were published before 2010, which was the Ceará, Fortaleza, Brazil year of the launch of the current version of WHODAS. Due to this, it may be uncertain whether the information from these references https://doi.org/10.1016/j.jphys.2020.11.004 should be applied here. References The cut-off point to identifying people with disability must be addressed as well. As can be inferred from the ICF model, func- 1. Paton M, Lane R. J Physiother. 2020;66:199. tioning and disability are context dependent.2 Environmental and 2. WHO. http://www.who.int/classifications/icf/en/. personal factors can vary for geographical, social, economic and 3. Üstün TB, et al. Bull World Health Organ. 2010;88:815–823. 4. Castro S, et al. Cad Saude Publica. 2019;35. Correspondence: Reply to Castro We appreciate the interest in our publication and the use of the participation and personal factors)’ was to highlight the capacity of the WHODAS 2.0 to provide information for the user. We agree that WHODAS 2.0. the WHODAS 2.0 technically produces ‘domain-specific scores for six different functioning domains: cognition, mobility, self-care, getting We agree with Prof Castro’s comment that ‘functioning is a along, life activities (household and work) and participation’2 and broader construct’ and as such agree that our sentence would have that personal factors, although recorded, do not contribute to the been better as ‘With an increased focus on measuring functioning and disability.’ We were trying to highlight the focus of medical research scoring of the tool. in identifying patient-specific limitations with performing natural In relation to the used references being before publication of the activities (incorporated by the definition of ‘function’1), but agree that limitations are not just in the ‘Body function and Structure’ ICF current tool, we agree that Soberg et al3 relates to the previous tool domain, so the use of the term ‘functioning’ instead of ‘function’ (WHODAS II); however, the statement made in relation to this would have been in line with the ICF universal language.2 reference (that the WHODAS is repeatable and sensitive to Our statement that the WHODAS 2.0 ‘allows assessment of change) has been supported by many other publications across three ICF domains (body functions and structures, activities and various populations.4–7 The publication from Andrews et al,8 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Appraisal Correspondence 73 although published in 2009, has utilised the WHODAS 2.0 with the Michelle Patona,b and Rebecca Lanec correct scoring scale (as shown in Figure 1 of their publication), aAustralian and New Zealand Intensive Care Research Centre, meaning that this reference, and the comment regarding a cut-off of .10 to indicate people with significant impairments, is Department of Epidemiology and Preventative Medicine, relevant to our publication. We do, however, agree with Prof Monash University, Melbourne, Australia Castro’s comments that cut-off points need to be identified for each specific population, taking into account environmental and bDepartment of Physiotherapy, Monash Health, Melbourne, Australia personal factors. As stated in our publication, there is no agreed cCollege of Health and Biomedicine, Victoria University, Melbourne, cut-off, so these numbers were provided as more of a guide for Australia researchers. https://doi.org/10.1016/j.jphys.2020.11.003 We appreciate the highlighting of the online spreadsheet for calculation of the WHODAS scores (not just the downloadable References scoring sheets we had already mentioned in the scoring section of our publication), and the benefits of this tool being a patient- 1. “Function” OED Online. www.oed.com/viewdictionaryentry/Entry/11125. reported outcome that can quantify the functioning or disability 2. WHO. https://www.who.int/classifications/icf/en/. profile. All of these factors strengthen the evidence in relation to the 3. Soberg HL, et al. J Trauma. 2007;62:461–470. clinical utilisation of this robust tool for medical research moving 4. Shulman MA, et al. Anaesthesiology. 2015;122:524–536. forward. 5. Cwirlej-Sozanska A, et al. BMC Public Health. 2020;20:1203. 6. Üstün TB, et al. Bull World Health Organ. 2010;88:815–823. 7. Garin O, et al. Health Qual Life Outcomes. 2010;8:51. 8. Andrews G, et al. PLoS ONE. 2009;4:e8343.
Appraisal Correspondence 77 Correspondence: Reply to Karas and Windsor We thank Dr Karas and Dr Windsor for giving us the oppor- was carefully designed to investigate the use (or not) of specific tunity to discuss our recently published trial.1 We agree with them spinal manipulations. We found that both approaches offer similar that spinal manipulative therapy should be used in clinical practice results. Therefore, our results are actually positive and clinicians have more options. Patients would benefit from spinal manipula- for patients with back pain. This intervention has been endorsed tions regardless of which level is chosen by the therapist. Patients by clinical practice guidelines over the last two decades.2 and clinicians may feel more comfortable with either generic or specific manipulations. However, we strongly disagree that there is evidence that classification systems of manual therapy are likely to provide Ultimately, all we want is to offer effective options based upon better outcomes than non-classification systems in patients with high-quality evidence and respecting patient preferences. Patients do chronic low back pain.3 It is widely known that approaches such as not seek care because a spinal segment is hypomobile or hyper- the treatment-based classification show some advantages over mobile; they seek care because they are suffering from pain that is non-stratified approaches, but only in patients with symptom interfering with their daily activities. Our job, as clinicians, is to help duration of , 6 weeks,4 which was not the case in our trial. them to deal with their pain and disability. Our trial shows that both Although we think that subgrouping is an interesting idea, there options provide these benefits. are no available data demonstrating that stratifying a subgroup of Leonardo Oliveira Pena Costa and Ronaldo Fernando de Oliveira patients with chronic low back pain would have more benefit Masters and Doctoral Programs in Physical Therapy, Universidade Cidade with spinal manipulative therapy than not stratifying. At this de São Paulo, São Paulo, Brazil point this is simply not possible. We hope that more research will provide good evidence in the near future. https://doi.org/10.1016/j.jphys.2020.11.014 Our rationale of manipulating the most painful segment does not References imply that the site was also associated with loss of motion; that was 1. de Oliveira RF, et al. J Physiother. 2020;66:174–179. never the case. Although there is evidence showing that identifying 2. Qaseem A, et al. Ann Intern Med. 2017;166:514–530. hypomobile spinal segments is likely, it is virtually impossible to 3. Saragiotto BT, et al. J Clin Epidemiol. 2016;79:3–9. isolate a specific spinal segment during manipulation.5–10 On the 4. Hallegraeff JM, et al. Percept Mot Skills. 2009;108:196–208. other hand, there are reasons for manipulating the spine other than 5. Holt K, et al. J Manipulative Physiol Ther. 2018;41:571–579. 6. Beynon AM, et al. Chiropr Man Therap. 2018;26:49. for mobility. Spinal manipulative therapy aims to reduce pain and 7. de Oliveira RF, et al. Phys Ther. 2013;93:748–756. improve function.7 These clinical outcomes are much more 8. Learman K, et al. Physiother Can. 2014;66:359–366. 9. Sutlive TG, et al. Mil Med. 2009;174:750–756. important for patients with back pain than spinal mobility (a 10. Hancock MJ, et al. Eur Spine J. 2008;17:936–943. surrogate outcome).11 11. Chiarotto A, et al. Eur Spine J. 2015;24:1127–1142. Our inclusion criteria were indeed broad. The reason for this is quite clear: we wanted to generalise our findings to a wide variety of patients. While Dr Karas and Dr Windsor think this is an issue, we believe that this is one of the main strengths of our trial. Our trial
Journal of Physiotherapy 67 (2021) 74–75 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Correspondence: High positive airway pressure could shorten the drainage period in haemothorax but not physiotherapy intervention Dos Santos et al conducted a thorough randomised controlled trial of CPAP therapy at 15 cmH20 showed good tolerability and can be with high methodological quality,1 in which they attempted to evaluate safely integrated into clinical practice. This would be true in young whether mobilisation and respiratory techniques shorten the drainage men with haemothorax but cannot be generalised to older patients period and length of hospital stay in patients with pleural effusion. with associated pulmonary comorbidities and heart failure or other Their second objective was to evaluate whether such a strategy patients with pleural effusions.4,5 combined with continuous positive airway pressure (CPAP) could further improve the benefits. They compared three groups (ie, standard The authors brought some interesting suggestions on a topic that care versus physiotherapy techniques versus physiotherapy techniques is usually supported by scarce evidence. Nevertheless, before and CPAP set at 15 cmH2O) and concluded that the combination of extrapolating these results, the following questions need to be CPAP with physiotherapy techniques reduced the duration of chest addressed first. Will CPAP therapy be associated with the same drainage and length of hospitalisation. tolerance and benefits in patients with other types of pleural effu- sion? Do physiotherapy interventions alone improve clinical param- With these conclusions, the authors give the impression that eters in patients with pleural effusions? To what extent would physiotherapy interventions had an independent effect on the res- physiotherapy interventions be able to improve mobility in older and olution of pleural effusions and that adding CPAP may have pro- frail patients with a pleural effusion who are unable to walk? vided a supplemental benefit. However, looking at the reported results one could argue that the implementation of respiratory Marius Lebreta, Guillaume Prieurb,c,d, Tristan Bonneviec,e, physiotherapy interventions (including incentive spirometry, airway Francis-Edouard Gravierc,e, Yann Combretb,c,d and clearance techniques and walking 100 metres) in patients with Clément Medrinalc,d pleural effusion did not have any added value. Indeed, the results clearly showed no clinical or statistical difference between the aInstitut Universitaire de Cardiologie et Pneumologie de Québec (IUCPQ), participants who received physiotherapy and those who received Québec, Canada standard care. In fact, only CPAP seemed to provide a beneficial effect, since the participants in experimental group 2 (physio- bInstitut de Recherche Expérimentale et Clinique (IREC), Pôle de therapy and CPAP) had fewer days of thoracic drainage compared Pneumologie, ORL & Dermatologie, Groupe de Recherche en Kinésithérapie with those in experimental group 1 (physiotherapy alone) or those in the control group. Respiratoire, Université Catholique de Louvain, Brussels, Belgium cHaute Normandie Research and Biomedical Innovation, Normandie Another relevant point is the strikingly high prevalence of pleural effusions due to traumatic causes (94%) in their cohort. This should be University, Rouen, France taken with caution, as haemothorax is not comparable or managed dPulmonology Department and Pulmonary Rehabilitation Department, comparably to other causes of pleural effusion.2 Moreover, it would have been relevant to report the baseline volume of the pleural Groupe Hospitalier du Havre, Montivilliers, France effusion, as this would have enabled comparison of the daily eADIR Association, Rouen University Hospital, Rouen, France amount of liquid drained in each group. https://doi.org/10.1016/j.jphys.2020.11.006 Finally, the population was younger compared with a standard population presenting with non-malignant pleural effusions.3 This is References presumably linked to the fact that pleural effusions were mainly caused by thoracic trauma. Yet, the authors concluded that the use 1. dos Santos EC, et al. J Physiother. 2020;66:19–26. 2. Hooper C, et al. Thorax. 2010;65:ii4–ii17. 3. DeBiasi EM, et al. Eur Respir J. 2015;46:495–502. 4. Cassidy SS, et al. J Appl Physiol. 1979;47:453–461. 5. Kiely JL, et al. Thorax. 1998;53:957–962. Correspondence: Reply to Lebret et al We thank Dr Lebret and colleagues for their interest and comments received. The only time we discussed the effect of mobilisation and regarding our randomised trial.1 Initially, they summarise our respiratory techniques alone was in relation to the other experimental conclusion that the combination of continuous positive airway group, and we concluded that it did not differ from control. In the pressure (CPAP) with mobilisation and respiratory techniques reduced analysis of Dr Lebret and colleagues, however, the effect obtained in the duration of chest drainage and length of hospitalisation. They the group that received CPAP, mobilisation and respiratory techniques then comment that this conclusion gives the impression that the could only have been due to the CPAP alone. We cannot agree or mobilisation and respiratory techniques had an independent effect on disagree with this interpretation. Perhaps it is correct (for the reasons the resolution of pleural effusion. We do not understand why Lebret that Lebret et al describe), but it is equally possible that the effect of et al think that we gave that impression because we only referred to the CPAP is mediated or enhanced by mobilisation and/or respiratory the effect of the combination of interventions that this group techniques (even though they do not independently improve 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Appraisal Correspondence 75 outcomes). It is not possible to know which of these interpretations is Elinaldo da Conceição Dos Santosa, Juliana de Souza da Silvab, correct because the study did not have a comparator group using only Marcus Titus Trindade de Assis Filhob, Marcela Brito Vidalb, CPAP. A CPAP-only group was not included when we wrote the study Moisés de Castro Montec and Adriana Cláudia Lunardia,d protocol2 because we considered real clinical conditions. We argue that aMaster and Doctoral Program in Physical Therapy any treatment that requires hospitalisation for a few days should already include both respiratory care and physical rehabilitation for Universidade Cidade de São Paulo, São Paulo, Brazil the patient.3–6 bDepartment of Biological and Health Sciences Another comment was about the population included in our trial.1 Universidade Federal do Amapá, Macapá, Brazil We agree that most of the participants had pleural fluid after thoracic cDepartment of Physical Therapy trauma; indeed, this issue was raised as the first limitation of the study in the Discussion section. We appropriately indicated Faculdade de Macapá, Macapá, Brazil uncertainty (with the phrase may indicate) when we discussed the dDepartment of Physical Therapy results in relation to other types of pleural fluid collection. In our opinion, the study population does not diminish the importance of the School of Medicine, Universidade de São Paulo results. Clinical discussions around the use of high positive airway pressure in patients with chest drainage are often permeated by the São Paulo, Brazil physiotherapists’ and physicians’ fear of aerophagia, pleural fistula, air leakage or low patient compliance. These fears are refuted by our trial https://doi.org/10.1016/j.jphys.2020.11.015 for its population and by other studies for the populations they investigated.7,8 We agree that, in view of these good first results, trials References focusing on patients with other causes of pleural effusion should be conducted. In this way, physiotherapists can use the best and safest 1. dos Santos EDC, et al. J Physiother. 2020;66:19–26. intervention for each clinical population that receives chest drainage. 2. dos Santos EDC, Lunardi AC. J Physiother. 2015;61:93. 3. Doiron KA, et al. Cochrane Database Syst Rev. 2018;3:CD010754. 4. Silva YR, et al. Physiotherapy. 2013;99:187–193. 5. Tang CY, et al. Physiotherapy. 2010;96:1–13. 6. Moreno NA, et al. J Physiother. 2019;65:208–214. 7. Palleschi A, et al. J Thorac Dis. 2018;10:2829–2836. 8. Ludwig C, et al. Asian Cardiovasc Thorac Ann. 2011;19:10–13.
Journal of Physiotherapy 67 (2021) 65 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Critically appraised paper: A home-based standing frame program may improve motor function in people with progressive multiple sclerosis Synopsis Summary of: Freeman J, Hendrie W, Jarrett L, Hawton A, Barton A, Dennett randomisation. The minimum clinically important difference of the Amen- R, et al. Assessment of a home-based standing frame programme in ded Motor Club Assessment was pre-defined as 9 points. Secondary outcomes people with progressive multiple sclerosis (SUMS): a pragmatic, multi- included lower extremity muscle length, knee extensor strength, bladder and centre, randomised, controlled trial and cost-effectiveness analysis. Lan- bowel control, sitting balance, fall frequency, and self-rated multiple sclerosis cet Neurol 2019;18:736–747. impact on quality of life assessed post-intervention (20 weeks) and at follow- up (36 weeks). Cost-effectiveness was also evaluated. Results: A total of 122 Question: Does a home-based, self-managed standing frame program participants completed the primary outcome measure at the 36-week improve motor function in people with progressive multiple sclerosis and assessment. At 36 weeks, motor function scores were significantly higher in severe mobility impairment? Design: Pragmatic, randomised controlled, the experimental group compared with usual care, adjusted mean difference: multi-centre, superiority trial with unblinded participants, carers and thera- 4.7 points (95% CI 1.9 to 7.5). At 36 weeks, there were also significant differ- pists and blinded assessors for clinician-rated outcomes. Randomisation was ences in hip flexor and plantar flexor length in favour of the experimental stratified by recruitment region and baseline disability. Setting: Eight group. There were no between-group differences in falls over the study period. healthcare organisations in two regions of the United Kingdom. Participants: The experimental group reported more episodes of short-term musculoskel- Adults with primary or secondary progressive multiple sclerosis and etal pain but had a mean 0.018 (95% CI 20.014 to 0.051) additional quality- Expanded Disability Status Score of 6.5 to 8.0. Individuals who had dis- adjusted life-years compared with the control group. Conclusion: Use of a continued a multiple sclerosis disease-modifying drug in the last 3 months or progressive standing frame program in the home in people with progressive received steroid treatment in the last month were excluded. Randomisation of multiple sclerosis can improve motor function, but the magnitude of 140 participants allocated 71 to an experimental group and 69 to a control improvement may not be clinically meaningful. group. Interventions: Both groups received usual care. In addition, the experimental group received a standing frame and were asked to stand in the Provenance: Invited. Not peer reviewed. frame for 30 minutes, three times a week, for 20 weeks. Two 60-minute physiotherapy sessions were provided in the home to assist with set-up, Prudence Plummer implementation and progression of the standing frame program. These Department of Physical Therapy, MGH Institute of Health Professions, were supported by online advice, a DVD and six 15-minute scripted telephone calls to encourage behaviour change, promote self-efficacy and enhance long- USA term use. Outcome measures: The primary outcome was motor function assessed using the Amended Motor Club Assessment at 36 weeks after https://doi.org/10.1016/j.jphys.2020.11.011 1836-9553/© 2020 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). Commentary People with progressive multiple sclerosis and Expanded Disability Usual care for people with progressive multiple sclerosis typically does not Status Scale scores 6.5 are at the highest risk of physical inactivity, face the include ongoing rehabilitation; thus, it is probable that neither group greatest barriers to adequate physical inactivity and require ongoing inter- received the intervention necessary to elicit functional changes. Specifically, vention to sustain the benefits of increased physical activity.1,2 Furthermore, people with Expanded Disability Status Scale scores of 6.5 have motor people with Expanded Disability Status Scale scores 6.5 are inadequately function that can be leveraged to improve their impairment, function and represented in clinical trials.3 Trials like this are necessary to investigate quality of life. Comparison between this standing frame intervention and accessible and cost-effective interventions to increase physical activity in other interventions for people with Expanded Disability Status Scale scores severely disabled people with progressive multiple sclerosis. of 6.5 is warranted to fully assess the feasibility and cost-effectiveness of these various interventions. The number of enrolled participants and the percentage of those that desired to continue the intervention post-trial (70%) suggest that people Provenance: Invited. Not peer reviewed. with progressive multiple sclerosis are receptive to this intervention. Par- Deborah Backus ticipants were required to independently manoeuvre into the standing frame or only need assistance from one person, limiting feasibility of this Shepherd Center, Atlanta, USA intervention for people with greater impairment or without an able- bodied caregiver to assist them. Nonetheless, for those with the support, https://doi.org/10.1016/j.jphys.2020.11.012 the intervention offers a cost-effective opportunity to increase physical activity, at least in the UK. References This trial included people with Expanded Disability Status Scale scores of 1. Motl RW, et al. Mult Scler. 2005;11:459–463. 6.5 to 8.0. Even within scores of 6.5, there is significant functional variability.4 If 2. Charron S, et al. Mult Scler Relat Disord. 2018;20:169–177. or how participants with varying functional abilities distinctly responded to 3. Feinstein A, et al. Lancet Neurol. 2015;14:194–207. this intervention is unclear, but the wide range of functional ability may 4. Zarif M, et al. Neurol. 2016;86(Suppl.):P2.109. explain the lack of clinically meaningful change in outcomes in either group. 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Journal of Physiotherapy 67 (2021) 65 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Critically appraised paper: A home-based standing frame program may improve motor function in people with progressive multiple sclerosis Synopsis Summary of: Freeman J, Hendrie W, Jarrett L, Hawton A, Barton A, Dennett randomisation. The minimum clinically important difference of the Amen- R, et al. Assessment of a home-based standing frame programme in ded Motor Club Assessment was pre-defined as 9 points. Secondary outcomes people with progressive multiple sclerosis (SUMS): a pragmatic, multi- included lower extremity muscle length, knee extensor strength, bladder and centre, randomised, controlled trial and cost-effectiveness analysis. Lan- bowel control, sitting balance, fall frequency, and self-rated multiple sclerosis cet Neurol 2019;18:736–747. impact on quality of life assessed post-intervention (20 weeks) and at follow- up (36 weeks). Cost-effectiveness was also evaluated. Results: A total of 122 Question: Does a home-based, self-managed standing frame program participants completed the primary outcome measure at the 36-week improve motor function in people with progressive multiple sclerosis and assessment. At 36 weeks, motor function scores were significantly higher in severe mobility impairment? Design: Pragmatic, randomised controlled, the experimental group compared with usual care, adjusted mean difference: multi-centre, superiority trial with unblinded participants, carers and thera- 4.7 points (95% CI 1.9 to 7.5). At 36 weeks, there were also significant differ- pists and blinded assessors for clinician-rated outcomes. Randomisation was ences in hip flexor and plantar flexor length in favour of the experimental stratified by recruitment region and baseline disability. Setting: Eight group. There were no between-group differences in falls over the study period. healthcare organisations in two regions of the United Kingdom. Participants: The experimental group reported more episodes of short-term musculoskel- Adults with primary or secondary progressive multiple sclerosis and etal pain but had a mean 0.018 (95% CI 20.014 to 0.051) additional quality- Expanded Disability Status Score of 6.5 to 8.0. Individuals who had dis- adjusted life-years compared with the control group. Conclusion: Use of a continued a multiple sclerosis disease-modifying drug in the last 3 months or progressive standing frame program in the home in people with progressive received steroid treatment in the last month were excluded. Randomisation of multiple sclerosis can improve motor function, but the magnitude of 140 participants allocated 71 to an experimental group and 69 to a control improvement may not be clinically meaningful. group. Interventions: Both groups received usual care. In addition, the experimental group received a standing frame and were asked to stand in the Provenance: Invited. Not peer reviewed. frame for 30 minutes, three times a week, for 20 weeks. Two 60-minute physiotherapy sessions were provided in the home to assist with set-up, Prudence Plummer implementation and progression of the standing frame program. These Department of Physical Therapy, MGH Institute of Health Professions, were supported by online advice, a DVD and six 15-minute scripted telephone calls to encourage behaviour change, promote self-efficacy and enhance long- USA term use. Outcome measures: The primary outcome was motor function assessed using the Amended Motor Club Assessment at 36 weeks after https://doi.org/10.1016/j.jphys.2020.11.011 1836-9553/© 2020 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). Commentary People with progressive multiple sclerosis and Expanded Disability Usual care for people with progressive multiple sclerosis typically does not Status Scale scores 6.5 are at the highest risk of physical inactivity, face the include ongoing rehabilitation; thus, it is probable that neither group greatest barriers to adequate physical inactivity and require ongoing inter- received the intervention necessary to elicit functional changes. Specifically, vention to sustain the benefits of increased physical activity.1,2 Furthermore, people with Expanded Disability Status Scale scores of 6.5 have motor people with Expanded Disability Status Scale scores 6.5 are inadequately function that can be leveraged to improve their impairment, function and represented in clinical trials.3 Trials like this are necessary to investigate quality of life. Comparison between this standing frame intervention and accessible and cost-effective interventions to increase physical activity in other interventions for people with Expanded Disability Status Scale scores severely disabled people with progressive multiple sclerosis. of 6.5 is warranted to fully assess the feasibility and cost-effectiveness of these various interventions. The number of enrolled participants and the percentage of those that desired to continue the intervention post-trial (70%) suggest that people Provenance: Invited. Not peer reviewed. with progressive multiple sclerosis are receptive to this intervention. Par- Deborah Backus ticipants were required to independently manoeuvre into the standing frame or only need assistance from one person, limiting feasibility of this Shepherd Center, Atlanta, USA intervention for people with greater impairment or without an able- bodied caregiver to assist them. Nonetheless, for those with the support, https://doi.org/10.1016/j.jphys.2020.11.012 the intervention offers a cost-effective opportunity to increase physical activity, at least in the UK. References This trial included people with Expanded Disability Status Scale scores of 1. Motl RW, et al. Mult Scler. 2005;11:459–463. 6.5 to 8.0. Even within scores of 6.5, there is significant functional variability.4 If 2. Charron S, et al. Mult Scler Relat Disord. 2018;20:169–177. or how participants with varying functional abilities distinctly responded to 3. Feinstein A, et al. Lancet Neurol. 2015;14:194–207. this intervention is unclear, but the wide range of functional ability may 4. Zarif M, et al. Neurol. 2016;86(Suppl.):P2.109. explain the lack of clinically meaningful change in outcomes in either group. 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Journal of Physiotherapy 67 (2021) 63 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Critically appraised paper: A program of functional electrical stimulation cycling, goal-directed training and adapted cycling improves gross motor function in children with cerebral palsy Synopsis Summary of: Armstrong EL, Boyd RN, Horan SA, Kentish MJ, Ware RS, Carty 66) and goal performance and satisfaction measured with the 10-point CP. Functional electrical stimulation cycling, goal-directed training, and Canadian Occupational Performance Measure. Secondary outcome mea- adapted cycling for children with cerebral palsy: a randomized controlled sures included performance during the cycling test, participation in life trial. Dev Med Child Neuro. 2020;62:1406–1413. activities (assessed by Participation and Environment Measure – Children and Youth), and capacity across a range of areas using the Pediatric Evalu- Question: In children with cerebral palsy, does an 8-week program that ation of Disability Inventory Computer Adaptive Test. Results: All partici- includes a combination of goal-directed training, functional electrical pants completed the study. Immediately after the intervention period, stimulation and adapted cycling improve gross motor function, goal per- outcomes that favoured the treatment group were: Gross Motor Function formance/satisfaction or activity participation? Design: Randomised Measure (GMFM-88 MD 7.7 logits, 95% CI 2.3 to 12.6 and GMFM-66; MD 5.9 controlled trial with concealed allocation and blinded outcome assessment. logits, 95% CI 3.1 to 8.8]), goal performance (MD 4.4, 95% CI 3.9 to 5.3), Setting: A single tertiary hospital in Australia. Participants: Children were satisfaction (MD 5.2, 95% CI 4.0 to 6.4) and peak cycling resistance (MD 3.4 included if they: were aged 6 to 18 years with cerebral palsy, had gross Nm, 95% CI 1.0 to 5.8). There were no between-group differences for other motor function classification II to IV, were living within 100 km of the measures. Conclusion: In children with cerebral palsy, when compared with training site, and were able to communicate discomfort. Exclusion criteria usual care, an 8-week program of combined goal-directed exercise training, included being unable to tolerate electrical stimulation, or a history of functional electrical stimulation and adaptive cycling improved gross motor fractures, surgery or trauma in the preceding 12 months. Randomisation of function and performance and satisfaction with individualised goals. 21 participants allocated 11 to the intervention group and 10 to the usual However, changes were not observed in participation in life activities. care group. Interventions: Both groups received usual care including physiotherapy, occupational and/or speech therapy. In addition, the inter- Provenance: Invited. Not peer reviewed. vention group participated in an 8-week program. Each week, this comprised two 1-hour sessions at the hospital (30 minutes of goal-directed Alicia Spittle functional exercise training based upon individual goals and up to 30 mi- Department of Physiotherapy, University of Melbourne nutes of electrical stimulation cycling) and a 1-hour home exercise program (30 minutes of adapted cycling and 30 minutes of goal-directed exercises). Melbourne, Australia Outcome measures: The primary outcomes included gross motor function measured with the Gross Motor Function Measure (GMFM-88 and GMFM- https://doi.org/10.1016/j.jphys.2020.11.001 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/). Commentary Children with disabilities are more restricted in their sports participa- Armstrong et al reported that children were able to achieve their goals tion, have lower levels of fitness and have higher levels of obesity than their from participating in the trial and the corresponding satisfaction suggests that peers without disabilities.1–3 A barrier to participation in physical activity this intervention has merit. It would have been helpful to know the types of for children with cerebral palsy who have limited ambulation or who are goals that were improved by the intervention, particularly any around non-ambulant is accessibility to suitable activities.3,4 A strength of the enjoyment of exercise.6 Providing enjoyable options for children to increase study by Armstrong et al is the inclusion of non-ambulant children. The physical activity levels in childhood is important for developing lifelong functional electrical stimulation cycle intervention was accessible to fitness and improving long-term health.1 participants with gross motor function classification system levels II to IV. Provenance: Invited. Not peer reviewed. Children with disability need additional support or intervention to Noula Gibson enable them to participate in physical activity,3 particularly to attain a Department of Physiotherapy, Perth Children’s Hospital, Perth, Australia moderate-to-vigorous level of intensity of physical activity to achieve the https://doi.org/10.1016/j.jphys.2020.11.002 health-related benefits. It is recommended that individuals with cerebral palsy participate in continuous exercises involving large muscle groups for a References minimum duration of 20 minutes.5 These recommendations for continuous- 1. Lankhorst K, et al. J Strength Cond Res. 2019;13. intensity activity were met on the functional electrical stimulation cycle and 2. Neter JE, et al. J Ped. 2011;158:735–739. may provide a suitable option for children with cerebral palsy to achieve the 3. Morris A, et al. Dis Rehab. 2019;41:3043–3051. 4. Verschuren O, et al. J Ped. 2012;161:488–494. physical activity levels required for health-related benefits. The study also 5. Verschuren O, et al. Dev Med Child Neurol. 2016;58:798–808. provided an example of how the intervention, provided at a higher fre- 6. Soper AK, et al. Dis Rehab. 2020;1–7. quency and intensity level than traditional therapy, can be feasible and effective at improving functional capacity. Increased physical capacity has been linked to increased physical activity during childhood.1 In context, however, the program utilised specialised equipment that may have limited its accessibility due to cost, availability and expertise. 1836-9553/Crown Copyright © 2020 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Journal of Physiotherapy 67 (2021) 63 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Critically appraised paper: A program of functional electrical stimulation cycling, goal-directed training and adapted cycling improves gross motor function in children with cerebral palsy Synopsis Summary of: Armstrong EL, Boyd RN, Horan SA, Kentish MJ, Ware RS, Carty 66) and goal performance and satisfaction measured with the 10-point CP. Functional electrical stimulation cycling, goal-directed training, and Canadian Occupational Performance Measure. Secondary outcome mea- adapted cycling for children with cerebral palsy: a randomized controlled sures included performance during the cycling test, participation in life trial. Dev Med Child Neuro. 2020;62:1406–1413. activities (assessed by Participation and Environment Measure – Children and Youth), and capacity across a range of areas using the Pediatric Evalu- Question: In children with cerebral palsy, does an 8-week program that ation of Disability Inventory Computer Adaptive Test. Results: All partici- includes a combination of goal-directed training, functional electrical pants completed the study. Immediately after the intervention period, stimulation and adapted cycling improve gross motor function, goal per- outcomes that favoured the treatment group were: Gross Motor Function formance/satisfaction or activity participation? Design: Randomised Measure (GMFM-88 MD 7.7 logits, 95% CI 2.3 to 12.6 and GMFM-66; MD 5.9 controlled trial with concealed allocation and blinded outcome assessment. logits, 95% CI 3.1 to 8.8]), goal performance (MD 4.4, 95% CI 3.9 to 5.3), Setting: A single tertiary hospital in Australia. Participants: Children were satisfaction (MD 5.2, 95% CI 4.0 to 6.4) and peak cycling resistance (MD 3.4 included if they: were aged 6 to 18 years with cerebral palsy, had gross Nm, 95% CI 1.0 to 5.8). There were no between-group differences for other motor function classification II to IV, were living within 100 km of the measures. Conclusion: In children with cerebral palsy, when compared with training site, and were able to communicate discomfort. Exclusion criteria usual care, an 8-week program of combined goal-directed exercise training, included being unable to tolerate electrical stimulation, or a history of functional electrical stimulation and adaptive cycling improved gross motor fractures, surgery or trauma in the preceding 12 months. Randomisation of function and performance and satisfaction with individualised goals. 21 participants allocated 11 to the intervention group and 10 to the usual However, changes were not observed in participation in life activities. care group. Interventions: Both groups received usual care including physiotherapy, occupational and/or speech therapy. In addition, the inter- Provenance: Invited. Not peer reviewed. vention group participated in an 8-week program. Each week, this comprised two 1-hour sessions at the hospital (30 minutes of goal-directed Alicia Spittle functional exercise training based upon individual goals and up to 30 mi- Department of Physiotherapy, University of Melbourne nutes of electrical stimulation cycling) and a 1-hour home exercise program (30 minutes of adapted cycling and 30 minutes of goal-directed exercises). Melbourne, Australia Outcome measures: The primary outcomes included gross motor function measured with the Gross Motor Function Measure (GMFM-88 and GMFM- https://doi.org/10.1016/j.jphys.2020.11.001 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/). Commentary Children with disabilities are more restricted in their sports participa- Armstrong et al reported that children were able to achieve their goals tion, have lower levels of fitness and have higher levels of obesity than their from participating in the trial and the corresponding satisfaction suggests that peers without disabilities.1–3 A barrier to participation in physical activity this intervention has merit. It would have been helpful to know the types of for children with cerebral palsy who have limited ambulation or who are goals that were improved by the intervention, particularly any around non-ambulant is accessibility to suitable activities.3,4 A strength of the enjoyment of exercise.6 Providing enjoyable options for children to increase study by Armstrong et al is the inclusion of non-ambulant children. The physical activity levels in childhood is important for developing lifelong functional electrical stimulation cycle intervention was accessible to fitness and improving long-term health.1 participants with gross motor function classification system levels II to IV. Provenance: Invited. Not peer reviewed. Children with disability need additional support or intervention to Noula Gibson enable them to participate in physical activity,3 particularly to attain a Department of Physiotherapy, Perth Children’s Hospital, Perth, Australia moderate-to-vigorous level of intensity of physical activity to achieve the https://doi.org/10.1016/j.jphys.2020.11.002 health-related benefits. It is recommended that individuals with cerebral palsy participate in continuous exercises involving large muscle groups for a References minimum duration of 20 minutes.5 These recommendations for continuous- 1. Lankhorst K, et al. J Strength Cond Res. 2019;13. intensity activity were met on the functional electrical stimulation cycle and 2. Neter JE, et al. J Ped. 2011;158:735–739. may provide a suitable option for children with cerebral palsy to achieve the 3. Morris A, et al. Dis Rehab. 2019;41:3043–3051. 4. Verschuren O, et al. J Ped. 2012;161:488–494. physical activity levels required for health-related benefits. The study also 5. Verschuren O, et al. Dev Med Child Neurol. 2016;58:798–808. provided an example of how the intervention, provided at a higher fre- 6. Soper AK, et al. Dis Rehab. 2020;1–7. quency and intensity level than traditional therapy, can be feasible and effective at improving functional capacity. Increased physical capacity has been linked to increased physical activity during childhood.1 In context, however, the program utilised specialised equipment that may have limited its accessibility due to cost, availability and expertise. 1836-9553/Crown Copyright © 2020 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Journal of Physiotherapy 67 (2021) 62 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Critically appraised paper: In people with chronic oedema of the leg and cellulitis, compression therapy is more effective at reducing recurrence of cellulitis than conservative treatment Synopsis Summary of: Webb E, Neeman T, Bowden FJ, Gaida J, Mumford V, Bisset B. (assessed prior to and following initial treatment and then every 6 months Compression therapy to prevent recurrent cellulitis of the leg. New Engl J for 3 years). Results: On the basis of a post-hoc stopping rule, recruitment Med. 2020;383:630–639. ceased on 26 March 2019. At the time that the trial was stopped, 41 par- ticipants had been assigned to the experimental group and 43 to the Question: In people with chronic oedema of the leg and cellulitis, is control group. Twenty-three episodes of cellulitis had occurred and, compression therapy more effective than conservative treatment at compared with the control group, recurrence of cellulitis was lower in the reducing recurrence of cellulitis, hospital admission and leg volume? experimental group (HR 0.23, 95% CI 0.09 to 0.59; RR 0.37, 95% CI 0.16 to Design: Randomised controlled trial with concealed allocation. Setting: 0.84). The effect on hospital admissions for cellulitis was unclear (HR 0.38, Public hospital in Canberra. Participants: Inclusion criteria were adults 95% CI 0.09 to 1.59). At 12 months, compared with the control group, the with chronic oedema (ie, . 3 months) in one or both legs and a history of experimental group had reduced leg volume (MD –241 ml, 95% CI –365 to two or more episodes of cellulitis in the past 2 years. Exclusion criteria –117). Conclusion: In people with chronic oedema of the leg and cellulitis, were chronic oedema management that involved compression, wounds compression therapy resulted in a lower recurrence of cellulitis and lower requiring treatment that prevented use of compression therapy, and end- volume of leg oedema than conservative treatment. of-life care. Randomisation of 84 participants allocated 41 to an experi- mental group and 43 to a control group. Interventions: Both groups Provenance: Invited. Not peer reviewed. received usual care, which included education about cellulitis prevention at the initial and follow-up appointments. The experimental group was Vinicius Cavalheri instructed to wear compression garments throughout the day and pro- School of Physiotherapy and Exercise Science, Curtin University, Australia vided information on safety, cleanliness and application and removal of the garments. Participants in the control group who had an episode of https://doi.org/10.1016/j.jphys.2020.10.001 cellulitis crossed over to the compression group to receive compression therapy. Outcome measures: The primary outcome was recurrence of cellulitis. Secondary outcomes included cellulitis-related hospital admis- sion (assessed every 6 months for 3 years) and change in leg volume Commentary Recurrent cellulitis is commonly seen in chronic oedema of the leg.1 practitioners to collect data on the primary outcome. However, as the Cellulitis is a bacterial infection, and can potentially become life- trial design resembles clinical practice, it enables the translation of threatening if left untreated.2 Compression therapy is recommended for these findings to a clinic. the prevention of cellulitis, based on expert opinion; however, this recommendation needs to be supported by evidence. Compliance with compression therapy is essential for it to be effective in preventing cellulitis. Compliance with compression in this trial was The study by Webb and colleagues evaluated the role of compression higher than what is generally reported.3 Reinforcement from the therapy in the prevention of recurrent cellulitis in chronic oedema of the multidisciplinary team may improve compliance with compression leg. Randomisation and concealed allocation were adequate and the therapy and help in preventing cellulitis in chronic leg oedema. experimental group and the control group were well balanced at base- line. Compression therapy prevented recurrence of cellulitis and reduced Provenance: Invited. Not peer reviewed. limb volume. The findings of this trial were clinically significant because the participants had had three or more episodes of cellulitis and a body Vincent Singh Paramanandam mass index 33 kg/m2; they were therefore unlikely to have benefitted Department of Physiotherapy, Tata Memorial Hospital, Mumbai, India from prophylactic antibiotics.1 The trial protocol closely resembled clinical practice, which may be seen as a strength, but also a https://doi.org/10.1016/j.jphys.2020.10.002 limitation. For example, it was a strength that the choice of the device for compression therapy (lymphoedema practitioner applied References compression bandages, compression garments or wraps) was based on the participants’ clinical condition and feasibility. It was a limitation 1. Thomas KS, et al. N Engl J Med. 2013;368:1695–1703. that the diagnosis of cellulitis was made by medical practitioners who 2. Brindle RJ, et al. Curr Dermatol Rep. 2020;9:73–82. were not blinded to the allocation of groups. The authors have 3. Uhl J-F, et al. Phlebology. 2018;33:36–43. recognised that individual medical practitioners may have misdiagnosed the cellulitis. To overcome these limitations, the authors could have used a minimum of two independent and blinded medical 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Journal of Physiotherapy 67 (2021) 62 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Critically appraised paper: In people with chronic oedema of the leg and cellulitis, compression therapy is more effective at reducing recurrence of cellulitis than conservative treatment Synopsis Summary of: Webb E, Neeman T, Bowden FJ, Gaida J, Mumford V, Bisset B. (assessed prior to and following initial treatment and then every 6 months Compression therapy to prevent recurrent cellulitis of the leg. New Engl J for 3 years). Results: On the basis of a post-hoc stopping rule, recruitment Med. 2020;383:630–639. ceased on 26 March 2019. At the time that the trial was stopped, 41 par- ticipants had been assigned to the experimental group and 43 to the Question: In people with chronic oedema of the leg and cellulitis, is control group. Twenty-three episodes of cellulitis had occurred and, compression therapy more effective than conservative treatment at compared with the control group, recurrence of cellulitis was lower in the reducing recurrence of cellulitis, hospital admission and leg volume? experimental group (HR 0.23, 95% CI 0.09 to 0.59; RR 0.37, 95% CI 0.16 to Design: Randomised controlled trial with concealed allocation. Setting: 0.84). The effect on hospital admissions for cellulitis was unclear (HR 0.38, Public hospital in Canberra. Participants: Inclusion criteria were adults 95% CI 0.09 to 1.59). At 12 months, compared with the control group, the with chronic oedema (ie, . 3 months) in one or both legs and a history of experimental group had reduced leg volume (MD –241 ml, 95% CI –365 to two or more episodes of cellulitis in the past 2 years. Exclusion criteria –117). Conclusion: In people with chronic oedema of the leg and cellulitis, were chronic oedema management that involved compression, wounds compression therapy resulted in a lower recurrence of cellulitis and lower requiring treatment that prevented use of compression therapy, and end- volume of leg oedema than conservative treatment. of-life care. Randomisation of 84 participants allocated 41 to an experi- mental group and 43 to a control group. Interventions: Both groups Provenance: Invited. Not peer reviewed. received usual care, which included education about cellulitis prevention at the initial and follow-up appointments. The experimental group was Vinicius Cavalheri instructed to wear compression garments throughout the day and pro- School of Physiotherapy and Exercise Science, Curtin University, Australia vided information on safety, cleanliness and application and removal of the garments. Participants in the control group who had an episode of https://doi.org/10.1016/j.jphys.2020.10.001 cellulitis crossed over to the compression group to receive compression therapy. Outcome measures: The primary outcome was recurrence of cellulitis. Secondary outcomes included cellulitis-related hospital admis- sion (assessed every 6 months for 3 years) and change in leg volume Commentary Recurrent cellulitis is commonly seen in chronic oedema of the leg.1 practitioners to collect data on the primary outcome. However, as the Cellulitis is a bacterial infection, and can potentially become life- trial design resembles clinical practice, it enables the translation of threatening if left untreated.2 Compression therapy is recommended for these findings to a clinic. the prevention of cellulitis, based on expert opinion; however, this recommendation needs to be supported by evidence. Compliance with compression therapy is essential for it to be effective in preventing cellulitis. Compliance with compression in this trial was The study by Webb and colleagues evaluated the role of compression higher than what is generally reported.3 Reinforcement from the therapy in the prevention of recurrent cellulitis in chronic oedema of the multidisciplinary team may improve compliance with compression leg. Randomisation and concealed allocation were adequate and the therapy and help in preventing cellulitis in chronic leg oedema. experimental group and the control group were well balanced at base- line. Compression therapy prevented recurrence of cellulitis and reduced Provenance: Invited. Not peer reviewed. limb volume. The findings of this trial were clinically significant because the participants had had three or more episodes of cellulitis and a body Vincent Singh Paramanandam mass index 33 kg/m2; they were therefore unlikely to have benefitted Department of Physiotherapy, Tata Memorial Hospital, Mumbai, India from prophylactic antibiotics.1 The trial protocol closely resembled clinical practice, which may be seen as a strength, but also a https://doi.org/10.1016/j.jphys.2020.10.002 limitation. For example, it was a strength that the choice of the device for compression therapy (lymphoedema practitioner applied References compression bandages, compression garments or wraps) was based on the participants’ clinical condition and feasibility. It was a limitation 1. Thomas KS, et al. N Engl J Med. 2013;368:1695–1703. that the diagnosis of cellulitis was made by medical practitioners who 2. Brindle RJ, et al. Curr Dermatol Rep. 2020;9:73–82. were not blinded to the allocation of groups. The authors have 3. Uhl J-F, et al. Phlebology. 2018;33:36–43. recognised that individual medical practitioners may have misdiagnosed the cellulitis. To overcome these limitations, the authors could have used a minimum of two independent and blinded medical 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Journal of Physiotherapy 67 (2021) 64 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Critically appraised paper: Physiotherapy improved pain and functional disability more than glucocorticoid injection in people with knee osteoarthritis Synopsis Summary of: Deyle GD, Allen CS, Allison SC, Gill NW, Hando BR, Petersen option of an extra one to three more sessions at the 4-month and 9- EJ, et al. Physical therapy versus glucocorticoid injection for osteoarthritis month follow-ups. Outcome measures: The primary outcome was the of the knee. N Engl J Med 2020;382:1420-1429. total Western Ontario McMaster University Osteoarthritis Score (WOMAC, 0 = best knee function and 240 = worst knee function) at 1 Question: Is physiotherapy more effective at relieving pain and year. Secondary outcomes were alternate step test, Timed Up and Go improving physical function than glucocorticoid injection in patients test, Global Rating of Change scale and cost of knee-related healthcare with knee osteoarthritis? Design: Randomised controlled trial with utilisation. Results: A total of 150 (96%) participants completed the blinded outcome assessors. Participants and clinicians delivering in- study. At 1 year, the mean between-group difference in the primary terventions were not blinded. Setting: Two large hospitals in the US outcome was 19 points (95% CI 5 to 33) in favour of physiotherapy. In Military Health System. Participants: Active-duty or retired service the physiotherapy group, seven participants (9%) received a glucocor- members or their family members. Men and women aged 38 years ticoid injection; 14 participants (18%) received physiotherapy and three who met the American College of Rheumatology clinical classification (4%) had total knee replacement in the glucocorticoid injection group. criteria for knee osteoarthritis and had radiographic evidence of oste- Secondary outcomes favoured physiotherapy compared to glucocorti- oarthritis (Kellgren-Lawrence radiographic grade 1) were included. coid injection. Mean cost for all knee-related medical care over 1 year People were excluded if they had received glucocorticoid injections or was similar in both groups. Conclusion: In participants with knee physiotherapy for knee pain in the previous 12 months. Randomisation osteoarthritis, physiotherapy resulted in improved outcomes at 1-year of 156 participants allocated 78 to physiotherapy and 78 to glucocor- follow-up compared to glucocorticoid injection. ticoid injection. Interventions: For glucocorticoid injections, ortho- paedists or rheumatologists injected 1 ml of triamcinolone acetonide Provenance: Invited. Not peer reviewed. and 7 ml of 1% lidocaine in one or both knees. Up to three injections could be given over the 1-year trial period. The physiotherapy inter- Britt Elin Øiestad vention was personalised, consisting of joint mobilisations, hands-on Department of Physiotherapy, Oslo Metropolitan University, Oslo, manual techniques, stretching and active exercises to address strength and movement impairments associated with knee osteoar- Norway thritis and to reinforce the effects of the manual techniques. Up to eight treatment sessions were provided over the first 4 to 6 weeks, with the https://doi.org/10.1016/j.jphys.2020.11.010 Commentary severe knee osteoarthritis (Kellgren-Lawrence grades 3 and 4) were allocated to physiotherapy, only some patients allocated to glucocorticoid injection un- This commentary discusses four aspects of the trial from Deyle et al: the derwent surgery (three knee replacements and one arthroscopy). Given the additional provider contacts, the physiotherapy program, the clinical relevance potential for cost savings in the healthcare system associated with non-surgical of the results and the healthcare costs. First, participants in both groups were interventions,4 further large trials are needed to investigate whether allowed to have additional contact with health providers at 4 and 9 months. physiotherapy can avoid or even delay knee replacements in patients with These additional contacts provided opportunity for a continued plan of care and moderate-to-severe osteoarthritis. could explain why the within-group improvements achieved in the short-term (at 4 and 8 weeks) were sustained for a year.1 Second, the physiotherapy Provenance: Invited. Not peer reviewed. program – consisting of education, instructions on home exercises and manual therapy – contrasts with some recommendations from clinical Italo Ribeiro Lemes and Rafael Zambelli Pinto practice guidelines, such as the American College of Rheumatology guideline, Department of Physical Therapy, Universidade Federal de Minas Gerais which conditionally recommend against manual therapy.2 Future high- quality trials are still needed to clarify whether the addition of manual ther- (UFMG), Brazil apy to exercise therapy and education are more effective than exercise therapy and education alone. Third, the trial was designed to detect a 12 percentage https://doi.org/10.1016/j.jphys.2020.11.009 point difference between groups in total Western Ontario McMaster University Osteoarthritis Score (WOMAC) score, which is similar to previous between- References group differences reported in a Cochrane review of exercise for knee osteoar- thritis.3 Although the mean between-group difference of 18.8 WOMAC points 1. Abbott JH, et al. J Orthop Sports Phys Ther. 2015;45:975–983. corresponds to an approximate 17% improvement from baseline, and thus 2. Kolasinski SL, et al. Arthritis Care Res. 2020;72:149–162. could be considered clinically meaningful, the substantial uncertainty around 3. Fransen, et al. Cochrane Database Syst Rev. 2015;1:CD004376. the estimate of effect (ie, the true mean difference between groups lies between 4. Ackerman, et al. Osteoarthr Cartil Open. 2020. https://doi.org/10.1016/j.ocarto.2020. 5.0 and 32.6 WOMAC points) must be noted. Fourth, the knee-related medical costs were similar between groups; however, while more cases of moderate-to- 100070. 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Journal of Physiotherapy 67 (2021) 64 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Critically appraised paper: Physiotherapy improved pain and functional disability more than glucocorticoid injection in people with knee osteoarthritis Synopsis Summary of: Deyle GD, Allen CS, Allison SC, Gill NW, Hando BR, Petersen option of an extra one to three more sessions at the 4-month and 9- EJ, et al. Physical therapy versus glucocorticoid injection for osteoarthritis month follow-ups. Outcome measures: The primary outcome was the of the knee. N Engl J Med 2020;382:1420-1429. total Western Ontario McMaster University Osteoarthritis Score (WOMAC, 0 = best knee function and 240 = worst knee function) at 1 Question: Is physiotherapy more effective at relieving pain and year. Secondary outcomes were alternate step test, Timed Up and Go improving physical function than glucocorticoid injection in patients test, Global Rating of Change scale and cost of knee-related healthcare with knee osteoarthritis? Design: Randomised controlled trial with utilisation. Results: A total of 150 (96%) participants completed the blinded outcome assessors. Participants and clinicians delivering in- study. At 1 year, the mean between-group difference in the primary terventions were not blinded. Setting: Two large hospitals in the US outcome was 19 points (95% CI 5 to 33) in favour of physiotherapy. In Military Health System. Participants: Active-duty or retired service the physiotherapy group, seven participants (9%) received a glucocor- members or their family members. Men and women aged 38 years ticoid injection; 14 participants (18%) received physiotherapy and three who met the American College of Rheumatology clinical classification (4%) had total knee replacement in the glucocorticoid injection group. criteria for knee osteoarthritis and had radiographic evidence of oste- Secondary outcomes favoured physiotherapy compared to glucocorti- oarthritis (Kellgren-Lawrence radiographic grade 1) were included. coid injection. Mean cost for all knee-related medical care over 1 year People were excluded if they had received glucocorticoid injections or was similar in both groups. Conclusion: In participants with knee physiotherapy for knee pain in the previous 12 months. Randomisation osteoarthritis, physiotherapy resulted in improved outcomes at 1-year of 156 participants allocated 78 to physiotherapy and 78 to glucocor- follow-up compared to glucocorticoid injection. ticoid injection. Interventions: For glucocorticoid injections, ortho- paedists or rheumatologists injected 1 ml of triamcinolone acetonide Provenance: Invited. Not peer reviewed. and 7 ml of 1% lidocaine in one or both knees. Up to three injections could be given over the 1-year trial period. The physiotherapy inter- Britt Elin Øiestad vention was personalised, consisting of joint mobilisations, hands-on Department of Physiotherapy, Oslo Metropolitan University, Oslo, manual techniques, stretching and active exercises to address strength and movement impairments associated with knee osteoar- Norway thritis and to reinforce the effects of the manual techniques. Up to eight treatment sessions were provided over the first 4 to 6 weeks, with the https://doi.org/10.1016/j.jphys.2020.11.010 Commentary severe knee osteoarthritis (Kellgren-Lawrence grades 3 and 4) were allocated to physiotherapy, only some patients allocated to glucocorticoid injection un- This commentary discusses four aspects of the trial from Deyle et al: the derwent surgery (three knee replacements and one arthroscopy). Given the additional provider contacts, the physiotherapy program, the clinical relevance potential for cost savings in the healthcare system associated with non-surgical of the results and the healthcare costs. First, participants in both groups were interventions,4 further large trials are needed to investigate whether allowed to have additional contact with health providers at 4 and 9 months. physiotherapy can avoid or even delay knee replacements in patients with These additional contacts provided opportunity for a continued plan of care and moderate-to-severe osteoarthritis. could explain why the within-group improvements achieved in the short-term (at 4 and 8 weeks) were sustained for a year.1 Second, the physiotherapy Provenance: Invited. Not peer reviewed. program – consisting of education, instructions on home exercises and manual therapy – contrasts with some recommendations from clinical Italo Ribeiro Lemes and Rafael Zambelli Pinto practice guidelines, such as the American College of Rheumatology guideline, Department of Physical Therapy, Universidade Federal de Minas Gerais which conditionally recommend against manual therapy.2 Future high- quality trials are still needed to clarify whether the addition of manual ther- (UFMG), Brazil apy to exercise therapy and education are more effective than exercise therapy and education alone. Third, the trial was designed to detect a 12 percentage https://doi.org/10.1016/j.jphys.2020.11.009 point difference between groups in total Western Ontario McMaster University Osteoarthritis Score (WOMAC) score, which is similar to previous between- References group differences reported in a Cochrane review of exercise for knee osteoar- thritis.3 Although the mean between-group difference of 18.8 WOMAC points 1. Abbott JH, et al. J Orthop Sports Phys Ther. 2015;45:975–983. corresponds to an approximate 17% improvement from baseline, and thus 2. Kolasinski SL, et al. Arthritis Care Res. 2020;72:149–162. could be considered clinically meaningful, the substantial uncertainty around 3. Fransen, et al. Cochrane Database Syst Rev. 2015;1:CD004376. the estimate of effect (ie, the true mean difference between groups lies between 4. Ackerman, et al. Osteoarthr Cartil Open. 2020. https://doi.org/10.1016/j.ocarto.2020. 5.0 and 32.6 WOMAC points) must be noted. Fourth, the knee-related medical costs were similar between groups; however, while more cases of moderate-to- 100070. 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Journal of Physiotherapy 67 (2021) 3–4 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Editorial Elbow, wrist and hand disorders Jesús Blanquero a, Mark R Elkins b,c a Physiotherapy Department, University of Seville, Seville, Spain; b Faculty of Medicine and Health, University of Sydney, Sydney, Australia; c Editor, Journal of Physiotherapy This editorial introduces another of Journal of Physiotherapy’s article structured advice program in functional ability recovery at 7 and 24 collections.1–4 These are collections of papers in a specific field of weeks, during the rehabilitation phase following a distal radius research, published in the Journal of Physiotherapy within the past fracture. In addition, a systematic review by Bruder et al9 did not identify a clear therapeutic effect of many exercise programs in decade and curated to alert readers to important findings and research reducing impairments and improving activity following an upper trends in that field, while highlighing avenues for further research. limb fracture, demonstrating only that early exercise combined with a shorter immobilisation is more effective than starting exercise after a This article collection examines physiotherapy interventions for longer immobilisation, after fractures of the distal radius, radial head, and proximal humerus. They concluded that many exercise programs musculoskeletal disorders of the elbow, wrist and hand. Evidence in did not clearly show an effect on activity and impairment following an upper limb fracture. They suggested that one of the possible rea- this field of research is accumulating rapidly in the Physiotherapy sons for this finding is that the exercise regimen may have a dosage Evidence Database (PEDro), as shown in Figure 1. that is insufficient (in intensity, duration, repetition or progression) to achieve a remodelling of the soft tissues or a truly challenging effect Forearm, wrist and hand injuries represent a large challenge to on the neuromuscular system. Such an effect may be achieved with an advice program, because physiotherapists encourage patients to functioning in everyday life and are associated with disability, low continue with their daily life tasks, thus requiring strength and range productivity, and mental health problems.5 In addition to the large of motion of the elbow, wrist and hand. impact on functional ability, hand injuries have a high incidence, This notion of the need to optimise the exercises included in the representing 29% of all injuries that reach emergency departments.6 exercise programs towards a more functional, high repetition and challenging perspective was shared by Blanquero et al. In comparison Thus, a large economic burden to society is generated, ranking to conventional paper-based exercise programs, they observed greater therapeutic benefits from a new format of feedback-guided hand injuries first among the most expensive injuries, specifically 32% exercises by using touch-screens of Tablet devices, in two trials.15,16 more than lower limb fractures, 39% more than hip fractures and In people with bone and soft tissue injuries of the wrist, hand and/ 108% more than skull-brain injury.5 or fingers, adding these feedback-guided exercises to face-to-face therapy achieved: earlier return to work, reduced healthcare usage There is great potential for rehabilitation interventions to reduce and improved functional ability and strength at week 2, when the impact of these injuries.5 Among these interventions, exercise has compared to face-to-face therapy plus conventional paper-based exercise programs.15 This short-term improvement in functional been one of the most frequently investigated, proving to be beneficial ability compared to conventional exercises was also observed in with few adverse effects, not only in the upper limb but also in many people who had undergone carpal tunnel release, but using these other musculoskeletal disorders.7 However, there is still uncertainty feedback-guided exercises as single intervention (rather than in conjunction with face-to-face therapy).16 Blanquero et al suggested about the role of exercise and the best exercise combination in elbow, that the exercises may have an effect on brain plasticity, inducing a wrist and hand rehabilitation.8,9 reorganisation of the sensorimotor system after it has been affected by hand, wrist and finger injury, surgery or immobilisation. Among people on the waiting list for carpal tunnel surgery, ex- This trend to seek not only peripheral effects through in- ercises combined with splinting and education reduced the conver- terventions, but to achieve a central effect, can be partly related to the sion to carpal tunnel surgery.10 In this study with 105 participants, conclusions from Villafañe et al.17 They demonstrated in people with Lewis et al10 also demonstrated increases in perceived improvement thumb carpometacarpal osteoarthritis that radial nerve gliding applied to one symptomatic hand produced hypoalgesic effects in the and satisfaction in the intervention group when compared to the contralateral hand. They suggested that pain in osteoarthritis should not be ascribed only to peripheral nociception, and that peripherally waitlist control group. Similarly, exercises and advice were also directed therapies may modulate pain perception bilaterally. beneficial for people who had sustained a distal radial fracture. In the This suggestion towards the central approach, more specifically trial by Kay et al,11 exercises and advice reduced pain at 3 and 6 weeks towards central sensitisation, is also present in other pathologies such as lateral epicondylalgia (tennis elbow). Fortunately for readers of and increased activity at 3 weeks. Journal of Physiotherapy, the invited topical review18 by Prof Leanne More recently, new types and combinations of exercises within various rehabilitation programs have been investigated. For example, also in distal radius fracture, Reid et al12 estimated the effects of adding ‘mobilisation with movement’ exercises into supination and extension to a program of other exercises and advice. Adding these exercises produced faster and larger improvements in range of mo- tion and functional ability at 4 and 12 weeks. Another modification to a program of exercises and advice after distal radius fracture is the use of a dynamic splint. Jongs et al13 examined this in a trial of 40 people with contracture following their fracture. Adding the dynamic splint to the rehabilitation program did not have any therapeutic effects on active wrist extension, flexion, radial or ulnar deviation at the end of the 8-week intervention nor 4 weeks later. Nevertheless, the therapeutic effect of exercises has also been questioned. Bruder et al14 found no benefit from adding exercise to a https://doi.org/10.1016/j.jphys.2020.11.005 1836-9553/© 2020 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
4 Cumulative number of records clinical practice guidelines Editorial systematic reviews 1000 randomised trials therapeutic exercises are the best for rehabilitation of elbow, wrist 800 and hand disorders. Also, we need to determine what role and rele- 600 vance central mechanisms and effects on the sensorimotor system 400 have in these disorders, and how to approach these mechanisms to 200 improve outcomes for patients. Competing interest: Nil. Source of support: Nil. Acknowledgement: Nil. Provenance: Invited. Not peer reviewed. Correspondence: Mark Elkins, Centre for Education & Workforce Development, Sydney Local Health District, Sydney, Australia. Email: [email protected] 0 References 1960 1970 1980 1990 2000 2010 2020 Year 1. Bonnevie T, et al. J Physiother. 2020;66:3–4. 2. Dennett A, et al. J Physiother. 2020;66:70–72. Figure 1. Cumulative evidence on the Physiotherapy Evidence Database (PEDro) about 3. Hwang R, et al. J Physiother. 2020;66:193–195. the effects of physiotherapy interventions on musculoskeletal disorders of the elbow, 4. Dorsch S, et al. J Physiother. 2020;66:211–212. wrist and hand, based on the October 2020 update of the database. 5. De Putter CE, et al. J Bone Jt Surg - Ser A. 2012;94:e56. 6. Larsen CF, et al. Eur J Epidemiol. 2004;19:323–327. Bisset and Prof Bill Vicenzino expertly summarises the available ev- 7. Taylor NF, et al. Aust J Physiother. 2007;53:7–16. idence about the burden associated with the condition, its manage- 8. Ziebart C, et al. Hand Ther. 2019;24:69–81. ment (with a particular focus on physiotherapy interventions), and 9. Bruder AM, et al. J Physiother. 2017;63:205–220. future directions for research and clinical practice. 10. Lewis KJ, et al. J Physiother. 2020;66:97–104. 11. Kay S, et al. Aust J Physiother. 2008;54:253–259. In summary, this online article collection includes a range of 12. Reid SA, et al. J Physiother. 2020;66:105–112. important developments in the physiotherapy management of 13. Jongs RA, et al. J Physiother. 2012;58:173–180. elbow, wrist and hand disorders, mainly related to exercises. It also 14. Bruder AM, et al. J Physiother. 2016;62:145–152. highlights an important unanswered question: while exercises seem 15. Blanquero J, et al. J Physiother. 2020;66:236–242. to be effective in the rehabilitation of these disorders, are the 16. Blanquero J, et al. J Physiother. 2019;65:81–87. exercises that we currently use ideal or do we need to include other 17. Villafañe JH, et al. J Physiother. 2013;59:25–30. exercises, interventions or dosages? Future research should address 18. Bisset LM, et al. J Physiother. 2015;61:174–181. two important issues. First, we need to determine which types of Websites PEDro www.pedro.org.au Paper of the Year 2020 The Editorial Board of Journal of Physiotherapy is pleased to announce the 2020 Paper of the Year Award. The winning paper is judged by a panel of members of the International Advisory Board who do not have a conflict of interest with any of the papers under consideration. They vote for the paper published in the 2020 calendar year that, in their opinion, has the best combination of scientific merit and application to the clinical practice of physiotherapy. The winning paper is ‘Preoperative physiotherapy is cost-effective for preventing pulmonary complications after major abdominal surgery: a health economic analysis of a multicentre randomised trial.’1 The authors are Ianthe Boden, PhD, from Launceston General Hospital and The University of Melbourne, and her colleagues in Australia and New Zealand.1 The paper addressed uncertainty around the cost-effectiveness of preoperative physiotherapy for patients undergoing major abdominal surgery. Before major abdominal surgery, a single physiotherapy session involving education and training markedly reduces the incidence of postoperative pulmonary complications. However, uncertainty about the cost-effectiveness of preoperative physiotherapy may be making some hospitals reluctant to institute this intervention. The winning paper examined whether preoperative physiotherapy aimed at preventing postoperative pulmonary complications is cost-effective from the hospital’s perspective. Cost-effectiveness and quality-adjusted life year gains were most evident when experienced physiotherapists delivered the intervention. Nevertheless, even across a range of physiotherapists who participated in the study, preoperative physiotherapy aimed at preventing postoperative pulmonary complications was highly likely to be cost-effective. This is the second cardiorespiratory study that joins recent winners in the geriatrics, sports and neurology subdisciplines.2–5 The members of the Editorial Board congratulate Dr Boden and her co-authors on their success. References 1. Boden I, Robertson IK, Neil A, Reeve J, Palmer AJ, Skinner EH, Browning L, Anderson L, Hill C, Story D, Denehy L. Preoperative physiotherapy is cost-effective for preventing pulmonary complications after major abdominal surgery: a health economic analysis of a multicentre randomised trial. J Physiother. 2020;66:180–187. 2. Moreno NA, de Aquino BG, Garcia IF, Tavares LS, Costa LF, Giacomassi IWS, Lunardi AC. Physiotherapist advice to older inpatients about the importance of staying physically active during hospitalisation reduces sedentary time, increases daily steps and preserves mobility: a randomised trial. J Physiother. 2019;65:208–214. 3. McKeough Z, Cheng SWM, Alison J, Jenkins C, Hamer M, Stamatakis E. Low leisure-based sitting time and being physically active were associated with reduced odds of death and diabetes in people with chronic obstructive pulmonary disease: a cohort study. J Physiother. 2018;64:114–120. 4. Al Attar WSA, Soomro N, Pappas E, Sinclair PJ, Sanders RH. Adding a post-training FIFA 111 exercise program to the pre-training FIFA 111 injury prevention program reduces injury rates among male amateur soccer players: a cluster-randomised trial. J Physiother. 2017;63:235–242. 5. van den Berg M, Sherrington C, Killington M, Smith S, Bongers B, Hassett L, Crotty M. Video and computer-based interactive exercises are safe and improve task-specific balance in geriatric and neurological rehabilitation: a randomised trial. J Physiother. 2016;62:20–28. https://doi.org/10.1016/j.jphys.2020.12.003 1836-9553/
Journal of Physiotherapy 67 (2021) 41–48 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Research Lung ultrasound has greater accuracy than conventional respiratory assessment tools for the diagnosis of pleural effusion, lung consolidation and collapse: a systematic review Louise Hansell a,b, Maree Milross a, Anthony Delaney c,d,e,f, David H Tian g, George Ntoumenopoulos h a Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; b Physiotherapy Department, Royal North Shore Hospital, Sydney, Australia; c Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia; d Division of Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, Australia; e Northern Clinical School, Faculty of Medicine, The University of Sydney, Sydney, Australia; f ANZIC Research Centre, Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia; g Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, Australia; h Physiotherapy Department, St Vincent’s Hospital, Sydney, Australia KEY WORDS ABSTRACT Ultrasonography Question: In mechanically ventilated adults in intensive care, what is the accuracy of lung ultrasound (LUS) Pleural effusion for the diagnosis of pleural effusion, lung consolidation and lung collapse when compared with chest Systematic review radiograph (CXR) and lung auscultation, with computed tomography (CT) as the reference standard? Design: Diagnosis Systematic review with meta-analysis of prospective cohort studies. Participants: Adult patients admitted to Meta-analysis intensive care, with diagnostic uncertainty at enrolment regarding pleural effusion, lung consolidation and/ or collapse/atelectasis. Index test: The diagnostic accuracy of LUS as the index test was estimated against CXR and/or lung auscultation as comparators, with thoracic CT scan as the reference standard. Outcome measures: Measures of diagnostic accuracy. Results: Seven eligible studies were identified, five of which (with 253 participants) were included in the meta-analysis. It was found that LUS had a pooled sensitivity of 92% and 91% in the diagnosis of consolidation and pleural effusion, respectively, and pooled specificity of 92% for both pathologies. CXR had a pooled sensitivity of 53% and 42% and a pooled specificity of 78% and 81% in the diagnosis of consolidation and pleural effusion, respectively. A meta-analysis for lung auscultation was not possible, although a single study reported a sensitivity and specificity of 8% and 100%, respectively, for diagnosing consolidation, and a sensitivity and specificity of 42% and 90%, respectively, for diagnosing pleural effusion. Conclusion: This systematic review with meta-analysis demonstrated high sensitivity of LUS compared with CXR, with similar specificities when diagnosing pleural effusion and lung consolidation/ collapse. Registration: PROSPERO CRD42018095555. [Hansell L, Milross M, Delaney A, Tian DH, Ntoumenopoulos G (2021) Lung ultrasound has greater accuracy than conventional respiratory assessment tools for the diagnosis of pleural effusion, lung consolidation and collapse: a systematic review. Journal of Physiotherapy 67:41–48] © 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Introduction whether the respiratory treatment techniques selected by physio- therapists for intensive care patients are appropriate and effective.3 Physiotherapists working in intensive care rely heavily on bedside respiratory assessment tools such as portable chest radiograph (CXR) In addition to their poor diagnostic accuracy, each of the bedside and lung auscultation to diagnose pulmonary pathology. However, the poor accuracy of these assessment tools limits a physiotherapist’s assessment tools has other limitations. The limited diagnostic accu- ability to diagnose key pathologies such as lung collapse, consolida- tion and pleural effusion.1–3 In order to enable appropriate treatment racy of CXR has been reported to be a result of technical difficulties selection, differential diagnosis of these key pathologies is essential that limit image quality.4–11 Leech et al further suggested that if for physiotherapists.3 A narrative review by Leech et al published in 2015 highlighted that the accuracy of a physiotherapist’s diagnosis physiotherapists focus on the pathology identified on CXR, then based on clinical assessment, lung auscultation and CXR interpreta- tion was unknown.3 The poor diagnostic accuracy of current bedside potentially an assumption is made that this pathology is not subject respiratory assessment tools brings to light questions regarding to change over time.3 Although lung auscultation is used routinely by many physiotherapists,3 its inter-rater and intra-rater reliability are poor.3,12–14 Lack of consistency in the nomenclature used to identify lung sounds and the subjective nature of interpretation of sounds impact the accuracy and reliability of diagnosis of pulmonary pa- thology.3,7,12–15 Thoracic computed tomography (CT) is considered the https://doi.org/10.1016/j.jphys.2020.12.002 1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
42 Hansell et al: Diagnostic accuracy of lung ultrasound reference standard for diagnosing lung consolidation,5,9,16 pneumo- Box 1. Inclusion criteria. thorax, pleural effusion, atelectasis and alveolar-interstitial syn- drome.5,9,17 However, it is expensive, exposes patients to radiation, Design and requires transportation of patients to the radiology department, Prospective cohort studies which is complex in critical care.5,16,18 Participants Diagnostic lung ultrasound (LUS) for physiotherapists is a novel Adult patients (aged 18 years) and evolving bedside diagnostic tool for the assessment of pulmonary Admitted to an intensive care unit pathology.5 LUS also has some limitations, which are patient Invasively ventilated dependent. Large body habitus, presence of subcutaneous emphy- Diagnostic uncertainty at enrolment regarding pleural sema and thoracic dressings can limit examination.5,19 Nonetheless, effusion, lung consolidation and/or collapse/atelectasis studies comparing LUS with tools such as CT, CXR and lung auscul- tation1,5,7,15 show that LUS is highly accurate in diagnosing lung and Index test pleural pathology.7 It is seen as a promising alternative to other Lung ultrasound as the index test against CXR and/or lung bedside respiratory assessments, as it is non-invasive, repeatable, auscultation as comparators, with thoracic CT scan as the accurate and does not expose patients or staff to radiation.5 Addi- reference standard. tionally, bedside ultrasound equipment is immediately available in critical care.3 Outcome measures At least one measure of diagnostic accuracy The poor diagnostic accuracy of CXR and lung auscultation high- lights the need for a more accurate and reliable assessment tool. The CT = computed tomography, CXR = chest radiograph. ability to diagnose pleural effusion, lung consolidation and lung collapse is of great relevance to physiotherapists because differenti- Data extraction ation of these pathologies is imperative in making appropriate treatment choices. The details of the participants that were extracted from each included study were sample size, gender proportion and mean age. The In order to validate the use of LUS as a routine tool for bedside following details of the diagnostic tests were extracted from each respiratory assessment for physiotherapists in a mechanically included study: LUS technique and definitions of patterns; average ventilated, intensive care population, investigation into the diag- time to perform LUS; time between comparator and index tests; nostic accuracy of LUS for a range of lung pathologies is war- expertise of operator; and blinding. Where available, the following ranted, This systematic review is the first to estimate the diagnostic accuracy statistics were extracted from each study: sensi- diagnostic accuracy of LUS using CT as the only reference standard tivity and specificity; the number or proportion of true positives, true and with CXR and lung auscultation as comparators in this spe- negatives, false positives and false negatives; positive and negative cific population. predictive values; positive likelihood ratios (LR1) and negative likeli- hood ratios (LR–); area under the receiver operator characteristic (ROC) Therefore, the research question for this systematic review was: curve; diagnostic odds ratio; and diagnostic accuracy. In mechanically ventilated adults in intensive care, what is the Quality assessment accuracy of lung ultrasound in the diagnosis of pleural effusion, lung consolidation and lung collapse when compared with chest radio- The methodological quality of the included studies was assessed graph and lung auscultation, with computed tomography as the using the QUADAS-2 tool.20 The risk of bias for the four key areas of reference standard? Methods Records identified through database Additional records identified through searching (n = 8,891) other sources (n = 10) Identification and selection of the studies Records after duplicates removed (n = 7,323) A limited search was conducted in MEDLINE and EMBASE to identify and refine subject headings and keywords. Once the search Records screened (n = 7,323) Records excluded by title/abstract (n = 7,254) strategy was developed, testing was undertaken to ensure that the search identified known studies. A systematic search of electronic Full-text articles assessed for Full-text articles excluded (n = 63)ª databases was then conducted up until May 2018. Five databases eligibility (n = 69) y not clearly intubated/ventilated were used, including the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to present), Cochrane Library, participants (n = 33) Embase (1947 to present), Medline (1946 to present) and Web of y no CT (n = 29) Science. The detailed search strategy is available in Appendix 1 on the y unclear study participants (n = 21) eAddenda. This search was supplemented by manual searches of y no comparator (n = 10) ClinicalTrials.gov, Australia and New Zealand Clinical Trials Register, y not in intensive care (n = 6) European Union Clinical Trials Register, and the World Health Orga- y no measure of diagnostic test nization Clinical Trial Registry for grey literature. The reference lists of included studies were searched manually. accuracy (n = 4) Two reviewers (LH, GN) independently screened all identified ti- Records identified in search update (n = 1) tles and abstracts against the inclusion criteria. The inclusion criteria are presented in Box 1. Eligibility was not restricted by study size, Studies included in the publication year or language. A standardised data extraction sheet systematic review (n = 7) was used independently by two authors (LH, GN) to extract and y full-text articles (n = 5) compare data. Discrepancies were resolved through discussion with a y abstracts (n = 2) third reviewer (MM). Authors were contacted if additional informa- tion was required to determine eligibility. Figure 1. Design and flow of studies through the review. CT = computed tomography. a Articles may be excluded for more than one reason.
Table 1 Characteristics of included studies. Study Participants Severity Pathology Pathology Lung Country Demographics reporting zones Format Consolidation scanne n = 200 NS Pleural effusion on LUS Agmy29 Age (yr) = NS NS NS Egypt Gender = NS LIS 1.89 (0.76) Consolidation Abstract Pleural effusion per hemithorax BLUE n = 69 LIS 2.6 (0.8), Danish34 Age (yr) = NS ARDS 11 (6) Consolidation per lung zone 12b India Gender = NS ISS 38 (IQR 34 to 45), Pleural effusion Full text SAPS II 46 (10) per lung zone 12b n = 42 NS Pleural effusion Lichtenstein15 Age (yr) = 58 (15) NS NS France Gender = NS NS Consolidation Full text Pleural effusion per patient BLUE n = 22 APACHE II mBLU Rocco27 Age (yr) = NS 16.5 (6.5) Consolidation per hemithorax Italy Gender = NS Atelectasis 12b Full text n = 100a Consolidation Vaghasia30 Age (yr) = NS Pleural effusion USA Gender = NS Abstract n = 78 Wang26 Age (yr) = 56 (2.1) China Gender = 40 M, 38 F Full text n = 42 Xirouchaki28 Age (yr) = 57 (22) Greece Gender = 34 M, 8 F Full text APACHE II = acute physiologic assessment and chronic health evaluation score, ARDS = Adult Respiratory Distress Syndrome se severity score, LUS = lung ultrasound, M = male, mBLUE = modified Bedside Lung Ultrasound in Emergency protocol, NS = n Summary data are mean (SD), except they are median (IQR) where stated. a n = 13 with comparison to computed tomography. b Six per hemithorax.
g LUS operators Machine LUS equipment Ventilator s N Experience NS Transducer settings ed NS NS NS NS E1 . 2 yr SonoSite M-turbo 2 to 5 MHz curvilinear probe NS 1 ‘expert’ Hitachi 405 5 MHz microconvex transducer PEEP 12 (5) cmH2O 2 1 yr Aloka SSD 1700 Convex 3.5 MHz transducer VT 6.7 (1) ml/kg 2 NS NS NS PEEP 5 to 10 cmH2O VT 6 to 8 ml/kg NS E NS NS NS NS NS UE 1 NS Hitachi EUB 8500 5 to 9 MHz microconvex transducer NS everity score, BLUE = Bedside Lung Ultrasound in Emergency protocol, F = female, ISS = injury severity score, LIS = lung injury Research 43 not stated, PEEP = positive end expiratory pressure, SAPS II = simplified acute physiological score, VT = tidal volume.
44 Hansell et al: Diagnostic accuracy of lung ultrasound Risk of Applicability review.15,26–30 Two of these studies were abstracts only,29,30 and ef- bias concerns forts to contact the authors for further study detail were unsuccessful. Due to insufficient data, they were unable to be quantitatively syn- + Low Patient selection thesised and were therefore excluded from the meta-analysis. ? Unclear Index test – High Reference standard An updated search was performed on 2 April 2020. Four additional Flow and timing articles were screened for suitability,31–34 of which one was appro- Patient selection priate for inclusion in the review and meta-analysis.34 Another was Index test appropriate for inclusion pending additional data from authors.31 This Reference standard study presented data for patients who were both ventilated and non- ventilated in intensive care. Raw data for only mechanically venti- Agmy29 ? ? ? ? +?? lated patients were requested; however, authors were unable to Danish34 + + + + +++ provide this data and so the study was not included.31 The remaining Lichtenstein15 + ? + ? +++ two studies were not included in the review as one did not express Rocco27 + + ? ? +++ measures of diagnostic accuracy32 and the other did not use CXR or Vaghasia30 ? ? ? ? ??? auscultation as a comparator.33 ??? Wang26 ? ? ? + +++ The five studies included in the meta-analysis provided a com- Xirouchaki28 + + + + bined sample size of 253 participants.15,26–28,34 The two abstracts that were excluded from the meta-analysis had 213 participants.29,30 One Figure 2. Risk of bias and applicability concerns among the included studies using the study included in the meta-analysis was published in Chinese and QUADAS-2 tool. was therefore translated to English.26 patient selection, index test, reference standard and flow and timing Characteristics of the included studies were evaluated by two reviewers (LH and GN), with discrepancies resolved through discussion with a third reviewer (MM). Risk of bias The characteristics of the studies included in the review are was deemed ‘high’ for each key area when one or more of the summarised in Table 1. All studies included in the review enrolled questions in a domain was answered no, ‘low’ when all questions patients who were critically ill and mechanically ventilated. Where were answered yes, and ‘unclear’ when data were insufficient to reported, the mean age of participants in the included studies ranged make a clear judgement. from 56 to 58 years and the proportion of male participants ranged from 51 to 90%. Additionally, patient inclusion criteria varied, with Data analysis one study enrolling patients with adult respiratory distress syndrome (ARDS),15 one with thoracic trauma,27 one with acute lung injury34 A bivariate random-effects model was used for the meta-analysis of and another with respiratory failure.26 All included studies were diagnostic accuracy statistics.21 Separate meta-analyses were per- prospective in design and used CT as the reference test. Four of the formed for each diagnostic test (LUS and CXR) to estimate its ability to seven studies reported use of blinding to CT scan results prior to diagnose each pathology (pleural effusion and lung consolidation/ interpreting LUS results;15,27,28,34 the other three did not specify collapse) against CT as the referent. Pooled estimates for sensitivity and whether there was blinding.26,29,30 Five studies identified the pres- specificity were obtained with associated 95% confidence intervals (CIs). ence of lung consolidation and pleural effusion,15,28–30,34 one study Likelihood ratios were reported for each study but, as recommended,22 identified pleural effusion27 only and one study identified lung they were not meta-analysed. When considering these likelihood ratios consolidation/atelectasis.26 Studies did not differentiate between for individual studies, LR1 . 10 and LR– ,0.1 were considered strongly consolidation and atelectasis as two distinct pathologies. diagnostic.23 Summary receiver operating characteristic (SROC) curves were constructed using the bivariate model to produce prediction el- Study quality lipses (95% CI) for LUS and chest radiograph, taking into account the The risk of bias and applicability concerns from the QUADAS-2 possible correlations between sensitivity and specificity. An area under the curve (AUC) of 0.9 to 1.0 is indicative of a test having excellent tool are presented in Figure 2. Overall, the risk of bias of studies diagnostic accuracy, 0.8 to 0.9 very good accuracy, 0.7 to 0.8 good, 0.6 to included in the review was moderate. Two studies were excluded 0.7 sufficient, 0.5 to 0.6 bad, and , 0.5 not useful.24 The diagnostic odds from the meta-analysis as they were only available as abstracts and ratio (DOR) is valued from 0 to infinity, with a higher number indicating limited data were presented.29,30 Some studies lacked information better diagnostic accuracy.24,25 Random-effects meta-analysis of pro- regarding the amount of time that lapsed between LUS, CT and CXR. portions or means were performed to aggregate demographic details Some studies lacked detail about blinding of those interpreting the where at least 50% of studies reported such data. Calculations were results of each test. Additionally, the qualifications and number of performed using statistical software.a people carrying out each of the tests were not consistently reported. Results Meta-analysis Study selection Individual study data are presented in Table 2. We planned to perform a quantitative synthesis if the included studies were The PRISMA flow diagram of study selection is shown in Figure 1. considered sufficiently homogenous to allow meta-analysis. Meta- The initial search returned 8,901 results. After adjusting for dupli- analysis was conducted on five full-text included studies using re- cates, 7,323 articles remained for screening, after which 69 studies weighted data,15,26–28,34 as presented in Table 3. LUS had a pooled remained for assessment. Six studies were included in the systematic sensitivity of 92% and 91% in the diagnosis of consolidation and pleural effusion, respectively, and pooled specificity of 92% for both pathologies. The area under the SROC curve (AUC) was 0.96 for both pathologies, and the diagnostic odds ratio (DOR) was 160.22 for consolidation and 134.61 for pleural effusion. CXR had a pooled sensitivity of 53% for consolidation and 42% for pleural effusion. CXR had a pooled specificity of 78% for consolidation and 81% for pleural effusion. The AUC was 0.69 for consolidation and 0.57 for pleural effusion. The DOR was 4.29 for consolidation and 2.79 for pleural effusion. SROC curves for LUS and CXR are displayed in Figure 3.
Table 2 Individual study data against computed tomography as the reference standard. Study Pathology Test Sensitivity Specificity (%) (%) Agmy29 Consolidation LUS 100 87 CXR 40 85 Effusion LUS 100 100 CXR 55 84 Danish34 Consolidation LUS 82 100 CXR 47 60 Effusion LUS 93 100 CXR 48 72 Lichtenstein15 Consolidation LUS 93 100 CXR 68 95 Ausc 8 100 Effusion LUS 92 93 CXR 39 85 Ausc 42 90 Rocco27 Effusion LUS 92 95 CXR 23 94 Vaghasia30 Consolidation LUS R = 46, L = 18 R = -, L = 100 CXR R = 8, L = 36 R = -, L = 100 Effusion LUS R = 50, L = 43 R = 80, L = 83 CXR R = 38, L = 29 R = 100, L = 100 Wang26 Consolidation LUS 95 87 Xirouchaki28 Consolidation CXR 34a 75 LUS 100 78 CXR 38 89 Effusion LUS 100 100 CXR 65 81 CT = computed tomography, CXR = chest radiograph, DA = diagnostic accuracy, LR1 = positive likelihood ratio, LR– = negativ a Sensitivity was calculated from raw data. This differs from 31% that was reported in the published article.
DA PPV NPV LR1 LR– Prevalence (%) (%) - 95 - - -- - - 50 - - -- - 60 100 - - -- 72 65 - - -- 31 89 100 79 - 0.18 26 52 64 43 1.17 0.88 21 95 100 85 - 0.07 - 54 81 35 1.68 0.73 - - 97 100 97 0.07 - - 90 75 86 97 13.88 0.34 90 79 36 - - -- 75 93 82 97 13.1 0.09 47 48 80 2.58 0.72 61 - - -- 94 83 98 18.68 0.08 81 50 82 3.76 0.81 Research 45 - R = 100, L = 100 R = 0, L = 18 - - - R = 100, L = 100 R = 0, L = 22 - - - R = 80, L = 75 R = 50, L = 56 - - - R = 100, L = 100 R = 50, L =55 - - 94 98 70 7.66 0.05 38 92 12 1.37 0.88 95 94 100 4.5 0 49 93 28 3.4 0.7 100 100 100 -0 69 91 44 3.4 0.43 ve likelihood ratio, LUS = lung ultrasound, NPV = negative predictive value, PPV = positive predictive value.
46 Hansell et al: Diagnostic accuracy of lung ultrasound Table 3 Discussion Pooled results for the diagnostic accuracy of CXR and LUS in the diagnosis of consolidation and pleural effusion, using CT as the reference standard. This systematic review with meta-analysis was conducted to assess the diagnostic accuracy of LUS compared with CXR and Pathology Test Sensitivity (%) Specificity (%) DOR AUC auscultation against CT for pleural effusion, lung consolidation and collapse in mechanically ventilated intensive care patients. The (95% CI) (95% CI) included studies had significant methodological heterogeneity and moderate risk of bias. We found that LUS had a higher overall Consolidation CXR 53 (35 to 70) 78 (53 to 91) 4.29 0.69 sensitivity and specificity for detecting pleural effusion and lung LUS 92 (78 to 97) 92 (70 to 98) 160.22 0.96 consolidation than CXR. For thoracic pathologies that have the po- tential to impact physiotherapy decision making in relation to treat- Pleural effusion CXR 42 (32 to 53) 81 (67 to 90) 2.79 0.57 ment selection (eg, pleural effusion and lung consolidation/collapse), pooled analyses of the diagnostic accuracy of LUS showed very good LUS 91 (83 to 96) 92 (82 to 97) 134.61 0.96 results: sensitivity ranges from 91 to 92%, the area under the SROC curve (AUC) was 0.96 and the DOR ranged from 134 to 160. In diag- AUC = area under the curve, CT = computed tomography, CXR = chest radiograph, nosing consolidation or effusion, LR1s were higher for LUS than for DOR = diagnostic odds ratio, LUS = lung ultrasound. CXR, and LR–s were lower for LUS than for CXR (Table 2). Apart from one outlying study, the LR1s for LUS were .10 when diagnosing A meta-analysis was not possible for lung auscultation as it was effusion, indicating strong diagnostic utility. For all studies, the LR–s only used as a comparator in a single study,15 which reported sensi- for LUS were around 0.1 for the diagnosis of consolidation or effu- tivity of 8% and specificity of 100% for diagnosing consolidation, and sion, again indicating strong diagnostic utility. Therefore, LUS can be sensitivity of 42% and specificity of 90% for diagnosing pleural effu- considered more discriminatory than CXR when diagnosing pleural sion. Also, an analysis for lung collapse was not carried out because effusion and lung consolidation. This is an important consideration the included studies did not distinguish between collapse and because physiotherapy interventions are expected to be of benefit for consolidation as distinct, separate pathologies. lung consolidation/collapse as distinct from a pleural effusion, which may require medical interventions. The DOR and AUC for LUS suggest Additionally, the two abstract-only studies, which included 213 excellent diagnostic accuracy, and that LUS is more suitable than CXR patients,29,30 reported that LUS had sensitivity ranging from 18 to for detecting pleural effusion and lung consolidation. 100% and specificity ranging from 87 to 100% in the diagnosis of consolidation, and sensitivity ranging from 43 to 100% and specificity Previous systematic reviews have sought to summarise the diag- ranging from 80 to 100% in the diagnosis of pleural effusion. They also nostic accuracy of LUS;35–38 however, some reviews used multiple reported that CXR had sensitivity ranging from 8 to 40% and speci- ficity ranging from 85 to 100% in the diagnosis of consolidation, and sensitivity ranging from 29 to 55% and specificity ranging from 84 to 100% in the diagnosis of pleural effusion. A C 1.0 1.0 0.8 0.8 Sensitivity 0.6 0.6 Sensitivity 0.4 SROC 0.4 SROC 0.2 Confidence region 0.2 Confidence region 0.0 Individual study data 0.0 Individual study data Summary estimate Summary estimate 0.0 0.0 0.2 0.4 0.6 0.8 1.0 0.2 0.4 0.6 0.8 1.0 B False positive rate D False positive rate 1.0 1.0 0.8 0.8 Sensitivity 0.6 0.6 Sensitivity 0.4 0.4 0.2 SROC 0.2 SROC Confidence region Confidence region 0.0 Individual study data 0.0 Individual study data 0.0 Summary estimate 0.0 Summary estimate 0.2 0.4 0.6 0.8 1.0 0.2 0.4 0.6 0.8 1.0 False positive rate False positive rate Figure 3. Summary receiver operating characteristic (SROC) curves. SROC curves of chest radiography for detection of pleural effusion (A) and lung consolidation/collapse (B). SROC curves of lung untrasound for detection of pleural effusion (C) and lung consolidation/collapse (D). The vertical axis represents sensitivity; the horizontal axis represents the false positive rate (1 – specificity). Each triangle (D) represents a single study’s relationship between true positive rate and false positive rate. The bivariate summary estimate of sensitivity and specificity is presented with an open circle (B), surrounded by 95% confidence region.
Research 47 reference standards36–38 and some included both ventilated and non- there is a lack of standardisation using frameworks in reporting many ventilated patients.35,36 This is the first systematic review with meta- methodological aspects of LUS studies.45 This limitation of LUS analysis to isolate and analyse pulmonary and pleural pathologies studies also made application of the QUADAS-2 in this review diffi- cult, and provides some explanation regarding assigning of a high most pertinent to physiotherapists in determining appropriate chest number of ‘unclear’ judgements, which contributed to the rating of physiotherapy treatments, by pooling diagnostic data for pleural moderate risk of bias. effusion and lung consolidation/collapse. It further demonstrates the Studies examining the effects of chest physiotherapy in intensive diagnostic accuracy of LUS using CT as the only reference standard care have relied upon auscultation and CXR as diagnostic tools and outcome measures.2 This may have led physiotherapists to over or and with CXR and lung auscultation as comparators in the specific undertreat pulmonary pathologies.3 In a case study presented by mechanically ventilated intensive care population. We believe that Leech et al,46 the addition of LUS diagnosed a large pleural effusion, which was initially thought to be secretion retention according to only one other systematic review of diagnostic test accuracy has CXR and lung auscultation assessment. The new diagnosis resulted in focused on pooling results for multiple pathologies comparing LUS to a change in treatment, requiring the insertion of a chest drain for CXR;34 however, that review also included evidence about some pa- drainage of the pleural effusion. LUS has a higher sensitivity in detecting pleural effusion and consolidation than CXR. Therefore, by thologies where there is no theoretical mechanism by which phys- using LUS as an adjunct to auscultation and CXR, physiotherapists iotherapy techniques could improve them (eg, lung contusion). may improve their diagnostic capability in intensive care, leading to more appropriate treatment choices. Furthermore, LUS has the po- Additionally, this review included two studies in the meta-analysis tential to more accurately monitor change associated with chest that have not been included in previous meta-analyses.26,34 Our re- physiotherapy treatments and prove a useful outcome measure. sults confirm previous work35–38 suggesting that LUS outperforms CXR in the detection of pleural effusion and lung consolidation. In conclusion, this review confirms that LUS has superior diag- nostic accuracy to CXR in assessing lung consolidation and pleural However, overall sensitivity and specificity for LUS were slightly effusion in the intubated and mechanically ventilated patient, further lower than previously published. This difference may be due to our questioning the clinical role of CXR as the preferred diagnostic tool in critical care settings for these pathologies. LUS is readily available, inclusion criteria (which specified CT as the only reference standard), does not expose patients to radiation and is diagnostically superior to the combination of pathologies analysed and the inclusion of addi- CXR. Based on the available evidence, we recommend that LUS should be considered as an adjunct to usual bedside respiratory assessment tional studies. Furthermore, the re-weighting of the raw data to tools used by physiotherapists in the differential diagnosis of pleural reflect the number of participants rather than lung zones studied, effusion and lung consolidation/collapse in the intubated and me- reduced overall sensitivity. The two recent studies that were identi- chanically ventilated patient. In addition, given the lack of evidence in fied during the updated search for this systematic review, which were support of the diagnostic accuracy of auscultation for these pathol- not included in the meta-analysis, further indicate that LUS is a more ogies, and the reliance of physiotherapists on auscultation for accurate diagnostic tool than CXR in detecting consolidation, using CT assessment and treatment selection, we suggest that further research as the reference standard.31,32 Bitar et al reported a sensitivity and is needed to evaluate the feasibility of implementing LUS into stan- specificity for LUS (97% and 83%, respectively) in line with previous dard clinical practice for physiotherapists. literature, although this was in a study population of both ventilated and non-ventilated patients. Tierney et al32 reported that both lobe- What was already known on this topic: In order to make appropriate treatment selections, physiotherapists working with specific and lung-specific agreement were higher for LUS than CXR, ventilated patients in intensive care must be able to differentially with CT as the reference standard; however, traditional diagnostic diagnose relevant pathologies such as lung collapse, consolida- tion and pleural effusion. Chest radiography and lung ausculta- measures were not included in this study and therefore it was unable tion are commonly used in making these diagnoses, but they to be included in this review. have questionable diagnostic accuracy and other limitations. Lung ultrasound is a bedside diagnostic tool for the assessment Various methods of conducting LUS imaging are described in the of pulmonary pathology. literature. The BLUE protocol is a well-known method used to carry What this study adds: The available evidence confirms that out LUS imaging9,39 and was reported to be used by two studies in lung ultrasound has greater accuracy than chest radiograph in this systematic review.26,34 This protocol is most appropriately diagnosing lung consolidation and pleural effusion in intubated and mechanically ventilated patients. Limited evidence was applied in the emergency setting when rapid diagnosis is required. It found about the diagnostic accuracy of auscultation. has since been modified and used in comparison with the original protocol.26 Another method divides the chest into hemithoraces, and Footnotes: a R software V.3.6.2, R Foundation for Statistical each hemithorax into six zones for analysis.40 This method also al- Computing, Vienna. lows for monitoring changes in aeration.40 Most recently, another modified protocol assessed the lungs with nine lobe-specific points.32 eAddenda: Appendix 1 can be found online at DOI: https://doi. The heterogeneity in relation to the format in which LUS results are org/10.1016/j.jphys.2020.12.002. collected and presented makes diagnostic accuracy comparison be- Ethics approval: Not applicable. tween studies problematic. The use of a single standardised protocol Competing interests: Nil. Sources of support: This research did not receive any specific for carrying out LUS images would ensure standardised reporting of grant from funding agencies in the public, commercial or not-for- results, and greater ease of study comparison. profit sectors. Acknowledgements: We would like to acknowledge Yun Qing for The question about the diagnostic accuracy of auscultation when her assistance in translating one of the included articles and Prof. used by physiotherapists remains unanswered,3,12,14,15 as there are Deborah Black, of the University of Sydney, for statistical guidance. Provenance: Not invited. Peer reviewed. insufficient studies exploring its diagnostic accuracy. Despite this, lung Correspondence: Louise Hansell, Sydney School of Health Sci- auscultation continues to be used as a valued part of assessment for ences, Faculty of Medicine and Health, The University of Sydney, physiotherapists.12 This may be because it is safe, inexpensive, readily Australia. Email: [email protected] available and useful in the management of certain airway-related is- sues, including secretion retention and bronchospasm. A limitation of our review was the small number of suitable studies and their small sample sizes, as this could have affected the calculated sensitivity and specificity of diagnostic accuracy.41 The difficult comparison of studies due to variability in reporting of LUS results could have also affected the results. This review found only one study that reported years of experience of LUS operators, and no study reported the ultrasound qualifications of these operators. LUS is dependent on operator competence, where adequate experience in performing LUS is important in producing valuable images for interpretation.42,43 A push for standardisation in the reporting of LUS results is emerging, which will allow for ease of study comparison and consistency with teaching and training.44 In addition to this,
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