QUESTION: Does the instillation of normal saline before suctioning reduce the incidence of ventilator-associated pneumonia in intubated and ventilated adults? DESIGN: Randomised, controlled trial with blinded outcome ass...QUESTION: Does the instillation of normal saline before suctioning reduce the incidence of ventilator-associated pneumonia in intubated and ventilated adults? DESIGN: Randomised, controlled trial with blinded outcome assessment. SETTING: The medical/surgical intensive care unit of a tertiary oncology hospital in Brazil. PARTICIPANTS: Adults expected to require at least 72 hours of mechanical ventilation via an endotracheal or tracheostomy tube. Previous ventilation within the past month and contraindications to bronchoscopy were exclusion criteria. Randomisation of 262 participants allotted 130 to the intervention group and 132 to a control group. INTERVENTIONS: Closed tracheal suction systems with heat and moisture exchangers were used with both groups and were changed regularly. All patients were nursed with backrest elevation to 45 degrees. medical or nursing staff, who were blinded to group allocations, requested suctioning when any of the following occurred: visible or audible secretions, ventilator-patient asynchrony, and increased peak inspiratory pressures or decreased tidal volumes attributed to secretions. Respiratory therapists performed the suctioning according to a standardised procedure that included preoxygenation. The therapists instilled 8 mL of normal saline prior to suctioning in the intervention group only. OUTCOME MEASURES: The primary outcome was the incidence of ventilator-associated pneumonia (VAP). If VAP was suspected because of radiographic evidence plus either fever, leukocytosis, or purulent secretions, a bronchoscopy with standardised lavage was performed. VAP was considered confirmed if the bacterial density of the lavage fluid exceeded 1000 colony-forming units/mL. Secondary outcome measures included time to VAP, duration of mechanical ventilation, length of stay and mortality in the intensive care unit, unscheduled ventilation circuitry changes due to secretions, and number of suctions per day. RESULTS: all participants completed the study. Significantly fewer participants in the saline group developed VAP (14/130) than in the control group (31/132), relative risk reduction 0.54 (95% CI 0.18 to 0.74). This indicates that one patient will avoid developing VAP for every 8 patients in which saline instillation is used. Significant benefits of saline instillation were also seen in the incidence of VAP (9 vs 21 per 1000 days of mechanical ventilation, p = 0.01) and in the time to first VAP (p = 0.02). The groups did not differ significantly on the remaining secondary outcomes. CONCLUSION: Instillation of normal saline before tracheal suctioning decreases the incidence of VAP in mechanically ventilated adults.
QUESTIONS: Does the PEDro scale measure only one construct ie, the methodological quality of clinical trials? What is the hierarchy of items of the PEDro scale from least to most adhered to? Is there any effect of year o...QUESTIONS: Does the PEDro scale measure only one construct ie, the methodological quality of clinical trials? What is the hierarchy of items of the PEDro scale from least to most adhered to? Is there any effect of year of publication of trials on item adherence? Are PEDro scale ordinal scores equivalent to interval data? DESIGN: Rasch analysis of two independent samples of 100 clinical trials from the PEDro database scored using the PEDro scale. RESULTS: Both samples of PEDro data showed fit to the Rasch model with no item misfit. The PEDro scale item hierarchy was the same in both samples, ranging from the most adhered to item random allocation, to the least adhered to item therapist blinding. There was no differential item functioning by year of publication. Original PEDro ordinal scores were highly correlated with transformed PEDro interval scores (r = 0.99). CONCLUSION: The PEDro scale is a valid measure of the methodological quality of clinical trials. It is valid to sum PEDro scale item scores to obtain a total score that can be treated as interval level measurement and subjected to parametric statistical analysis.
QUESTIONS: How much of an effect do five common physiotherapy interventions need to have for patients with low back pain to perceive they are worth their cost, discomfort, risk, and incovenience? Are there any difference...QUESTIONS: How much of an effect do five common physiotherapy interventions need to have for patients with low back pain to perceive they are worth their cost, discomfort, risk, and incovenience? Are there any differences between the interventions? Do specific characteristics of people with low back pain predict the smallest important difference? DESIGN: Cross-sectional, observational study. PARTICIPANTS: 77 patients with non-specific low back pain who had not yet commenced physiotherapy intervention. OUTCOME MEASURES: The smallest worthwhile effect was measured in terms of global perceived change (0 to 4) and percentage perceived change. RESULTS: Participants perceived that intervention would have to make them 'much better', which corresponded to 1.7 (SD 0.7) on the 4-point scale, or improve their symptoms by 42% (SD 23), to make it worthwhile. There was little distinction made between interventions, regardless of whether smallest worthwhile effects were quantified as global perceived change (p = 0.09) or percentage perceived change (p = 1.00). Severity of symptoms independently (p = 0.01) predicted percentage perceived change explaining 9% of the variance, so that for each increase in severity of symptoms of 1 point out of 10 there was an increase of 4% in the percentage perceived change that participants considered would make intervention worthwhile. CONCLUSIONS: Typically people with low back pain feel that physiotherapy intervention must reduce their symptoms by 42%, or make them feel 'much better' for intervention to be worthwhile.
QUESTION: What factors do participants in exercise programs for chronic low back pain perceive to be important for engagement and participation? DESIGN: Qualitative study of three focus groups. PARTICIPANTS: 18 adults wi...QUESTION: What factors do participants in exercise programs for chronic low back pain perceive to be important for engagement and participation? DESIGN: Qualitative study of three focus groups. PARTICIPANTS: 18 adults with chronic low back pain who had participated in exercise programs for chronic low back pain. RESULTS: All focus group results concurred and two significant themes emerged from the focus group data. The first was that the experience of exercise informed participant preferences with respect to exercise environment and type of exercise. Participants described a range of positive and negative experiences, a desire to master exercise techniques, and a preference for exercise that matched their abilities and prior skills. The second significant theme was the helpful and empowering skills of the care-provider, and care-seeker ability to identify and articulate their own needs. Participants regarded carer expertise favourably when positive results were achieved early in the interaction, but were frustrated when they were not listened to and symptoms were aggravated. The relationship was enhanced by effective communication. Participants also recognised they needed to be aware of their own skills and abilities and, and that financial or family support incentives encouraged their adherence to a program. CONCLUSION: People are likely to prefer and participate in exercise programs that are designed with consideration of their preferences, circumstances, and past exercise experiences. We propose that information about patient exercise preferences should be collected systematically.
QUESTIONS: Do patients with a severe ankle injury (baseline ankle function score < or = 40) do worse in the short-term than patients with a mild injury (score > 40)? Does physiotherapy intervention have more effect on pa...QUESTIONS: Do patients with a severe ankle injury (baseline ankle function score < or = 40) do worse in the short-term than patients with a mild injury (score > 40)? Does physiotherapy intervention have more effect on patients with a severe injury compared with a mild injury in the short- or long-term? Is self-reported recovery related to ankle function score over time? DESIGN: Subgroup analysis of a randomised trial. PARTICIPANTS: 102 adults with an acute lateral ankle sprain. INTERVENTION: The experimental group received physiotherapist-supervised exercises in addition to conventional intervention. OUTCOME MEASURES: Outcomes were self-reported recovery, pain, and instability all measured on a 10-point visual analogue scale, and incidence of re-sprain. Measurements were collected at baseline, 4 and 8 weeks, 3 and 12 months. RESULTS: Participants with a severe injury did worse in 3 out of 7 outcomes than those with a mild injury at 4 weeks but not at 8 weeks. There was no difference in effect of physiotherapy intervention in those with a severe injury compared with a mild injury, at 8 weeks or 12 months. However, there was an effect of physiotherapy intervention in those with a severe injury in 3 out of 7 outcomes at 8 weeks. Self-reported recovery was related to ankle function score at all points in time (r = 0.48 to 0.79). CONCLUSION: The results of this study only partially support the recommendations regarding the use of the ankle function score in the 'Acute Ankle Injury' guideline of the Royal Dutch Society of Physiotherapists.
QUESTION: Does an eight-week exercise program reduce the intensity and prevalence of low back pain in 12-13 year old children? Does it decrease the childhood physical risk factors for low back pain and promote a sense of...QUESTION: Does an eight-week exercise program reduce the intensity and prevalence of low back pain in 12-13 year old children? Does it decrease the childhood physical risk factors for low back pain and promote a sense of well-being? DESIGN: Randomised trial with concealed allocation and assessor blinding. PARTICIPANTS: Seventy-two 12-13 year old children, who had complained of low back pain in the past three months. INTERVENTION: The experimental group completed eight exercise classes of 40-45 minutes duration over eight weeks conducted by a physiotherapist, whilst the control group received no intervention. OUTCOME MEASURES: The primary outcome was pain intensity measured on a 10-cm visual analogue scale. Secondary outcomes included 3-month prevalence of pain, childhood physical risk factors for low back pain, and sense of well-being. Measures were taken at baseline (Month 0), post-intervention (Month 3), and three months later (Month 6). RESULTS: Pain intensity over the past month had decreased by 2.2 cm (95% CI 1.0 to 3.5) more for the experimental group than the control group at Month 3 and was still 2.0 cm (95% CI 0.5 to 3.5) less than the control group at Month 6. The absolute risk reduction for 3-month prevalence in low back pain in the experimental group was 24% (95% CI 4 to 41) compared with the control group at Month 3, and 40% (95% CI 18 to 57) at Month 6. There were also statistically-significant between-group differences in neural mobility. CONCLUSION: Exercise is effective in reducing the intensity and prevalence of low back pain in children. TRIAL REGISTRATION: Clinical trials NCT00786864.
QUESTION: Is urinary incontinence associated with falls in community-dwelling older people? DESIGN: A systematic review and meta-analysis of observational studies investigating falls and urinary incontinence. PARTICIPANT...QUESTION: Is urinary incontinence associated with falls in community-dwelling older people? DESIGN: A systematic review and meta-analysis of observational studies investigating falls and urinary incontinence. PARTICIPANTS: Community-dwelling older people. OUTCOME MEASURES: Falls rather than fracture or injury, and any type of urinary incontinence. RESULTS: Odds ratios of nine studies were included in the meta-analysis. The odds of falling were 1.45 (95% CI 1.36 to 1.54) in the presence of any type of urinary incontinence. The odds of falling were 1.54 (95% CI 1.41 to 1.69) in the presence of urge incontinence. The odds of falling were 1.11 (95% CI 1.00 to 1.23) in the presence of stress incontinence. The odds of falling were 1.92 (95% CI 1.69 to 2.18) in the presence of mixed incontinence. CONCLUSION: Urge urinary incontinence, but not stress urinary incontinence, is associated with a modest increase in falls. Falls prevention programs need to include an assessment of incontinence and referral for interventions to ameliorate the symptoms of urge incontinence.
QUESTION: Do strengthening interventions increase strength without increasing spasticity and improve activity, and is there any carryover after cessation in children and adolescents with cerebral palsy? DESIGN: Systemati...QUESTION: Do strengthening interventions increase strength without increasing spasticity and improve activity, and is there any carryover after cessation in children and adolescents with cerebral palsy? DESIGN: Systematic review with meta-analysis of randomised trials. PARTICIPANTS: Children with spastic cerebral palsy between school age and 20 years. INTERVENTION: Strengthening interventions that involved repetitive, strong, or effortful muscle contractions and progressed as ability changed, such as biofeedback, electrical stimulation, and progressive resistance exercise. OUTCOME MEASURES: Strength was measured as continuous measures of maximum voluntary force or torque production. Spasticity was measured as velocity-dependent resistance to passive stretch. Activity was measured as continuous measures, eg, 10-m Walk Test, or using scales eg, the Gross Motor Function Measure. RESULTS: Six studies were identified and five had data that could be included in a metaanalysis. Strengthening interventions had no effect on strength (SMD 0.20, 95% CI -0.17 to 0.56), no effect on walking speed (MD 0.02 m/s, 95% CI -0.13 to 0.16), and had a small statistically-significant but not clinically-worthwhile effect on Gross Motor Function Measure (MD 2%, 95% CI 0 to 4). Only one study measured spasticity but did not report the between-group analysis. CONCLUSION: In children and adolescents with cerebral palsy who are walking, the current evidence suggests that strengthening interventions are neither effective nor worthwhile.
QUESTION: What predicts short - and medium term activity limitation in people after ankle fracture? DESIGN: Inception cohort observational study. PARTICIPANT: Adults with ankle fracture recruited within days following ca...QUESTION: What predicts short - and medium term activity limitation in people after ankle fracture? DESIGN: Inception cohort observational study. PARTICIPANT: Adults with ankle fracture recruited within days following cast removal from physiotherapy departments of teaching hospital in Sydney, Australia. OUTCOME MEASURES: The predictive value of variables that were injury-related (fracture management, fracture severity, angle of the ankle during cast immobilisation, and time from cast removal to baseline) and performance-related (activity limitation, pain, mobility and dorsiflexion range of motion measured soon after cast removal) were examined in one dataset (n = 150) using univariate linear regression. Significant variables (p <or = 0.20) were further examined with a multivariate linear model. A clinical prediction rule was derived then validated using data from an independent dataset (n = 94). RESULTS: Fracture management, fracture severity, baseline activity limitation, pain, mobility and dorsiflexion had significant but weak univariate associations with activity limitation. Only pain and dorsiflexion range of motion contributed independently to the clinical prediction rule. When applied to the validation data, the rule explained 12% of the short-term and 9% of the medium-term variance in activity limitation. CONCLUSION: Performance-related variables were stronger predictors than injury-related variables. A clinical prediction rule consisting of pain and dorsiflexion range of motion explained a small amount of variance in short- and medium-term activity limitation, suggesting that it may be appropriate to identify people with high levels of pain and restricted dorsiflexion after ankle fracture and target intervention accordingly.