QUESTIONS: In adults undergoing rehabilitation after stroke, does 30 minutes of daily stretch of the wrist and finger flexors for four weeks prevent or reverse contracture, decrease pain, or improve upper-limb activity?...QUESTIONS: In adults undergoing rehabilitation after stroke, does 30 minutes of daily stretch of the wrist and finger flexors for four weeks prevent or reverse contracture, decrease pain, or improve upper-limb activity? Are any gains maintained one week and five weeks after the cessation of stretching? DESIGN: Randomised controlled trial with concealed randomisation, assessor blinding, and intention-to-treat analysis. PARTICIPANTS: 40 adults undergoing rehabilitation after stroke or stroke-like brain injury, who were unable to actively extend the affected wrist. INTERVENTION: Both groups received routine upper-limb retraining five days a week. In addition, the experimental group received 30 minutes daily stretch of the wrist and finger flexors five days a week for four weeks. OUTCOME MEASURES: The primary outcome was contracture, measured as torque-controlled passive wrist extension with the fingers extended. Secondary outcomes were pain at rest measured on a 10-cm visual analogue scale, and upper-limb activity measured using the Motor Assessment Scale. Outcomes were collected at baseline, post-intervention, and one and five weeks after cessation of intervention. RESULTS: The mean effect on passive range of wrist extension was 3.8 [corrected] degrees (95% CI -2.5 to 10.1) [corrected] after 4 weeks of daily stretch, 4.1 degrees (95% CI -4.0 to 12.3) after a week of no stretch, and 3.5 degrees (95% CI -4.6 to 11.7) after a further four weeks. CONCLUSION: These data suggest that four weeks of regular stretching has little or no effect on wrist contracture after stroke. However the estimate of the size of this effect is not sufficiently precise to rule out the possibility of a marginally worthwhile effect. The stretch had no significant effect on upper-limb pain, and did not result in significantly improved upper-limb activity.
QUESTIONS: Does a 12-week, predominantly home-based program of progressive resistance exercises reduce impairments, activity limitations, and participation restrictions in people with chronic obstructive pulmonary diseas...QUESTIONS: Does a 12-week, predominantly home-based program of progressive resistance exercises reduce impairments, activity limitations, and participation restrictions in people with chronic obstructive pulmonary disease? Are any gains maintained 12 weeks after the cessation of the program? DESIGN: Randomised controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis. PARTICIPANTS: 54 people with moderately severe chronic obstructive pulmonary disease not undergoing pulmonary rehabilitation. INTERVENTION: The experimental group performed six progressive resistance exercises three times per week (once a week hospital-based, twice a week home-based) for 12 weeks. Exercise intensity was three sets of 8 to 12 repetition maximum progressed against elasticised bands of increasing resistance. The control group received no intervention. OUTCOME MEASURES: Primary outcomes were strength (knee extensor, hip abductor, shoulder horizontal flexor, shoulder flexor) measured using hand-held dynamometry, and walking capacity measured by the 6-minute Walk Test performed before and after intervention and again at 12 weeks after the cessation of intervention. RESULTS: The experimental group increased their knee extensor strength by 4.9 kg (95% CI 1.1 to 8.7) more than the control group by Week 12. However, this gain was not maintained at Week 24. No difference between the groups was found for any of the other primary outcomes. CONCLUSIONS: A predominantly home-based progressive resistance exercise program led to modest improvements in knee extensor strength in people with chronic obstructive pulmonary disease. However, 44% of the experimental group were unable to complete the exercise program, highlighting the need to understand factors influencing adherence to exercise in this population.
QUESTIONS: What is the volume, quality, consistency, and generalisability of the evidence for breathing control? What is the effect on outcomes related to the target and mechanism of breathing control, as well as physiol...QUESTIONS: What is the volume, quality, consistency, and generalisability of the evidence for breathing control? What is the effect on outcomes related to the target and mechanism of breathing control, as well as physiological and clinical outcomes? DESIGN: Systematic review with meta-analysis. PARTICIPANTS: People with chronic respiratory disease, post-surgical, or asymptomatic individuals. INTERVENTION: Breathing control (relaxed basal, diaphragmatic, or abdominal breathing) as the sole intervention. OUTCOME MEASURES: All outcome measures providing continuous data. RESULTS: Twenty studies were included within the meta-analysis. A beneficial effect was found for abdominal movement (SMD 1.36, 95% CI 0.42 to 2.31), diaphragm excursion (SMD 1.39, 95% CI 1.00 to 1.77), respiratory rate (SMD -0.84, 95% CI -1.09 to -0.60), tidal volume (SMD 0.98, 95% CI 0.71 to 1.25), arterial oxygen saturation (SMD 0.63, 95% CI 0.25 to 1.02) and percutaneous oxygen (SMD 1.48, 95% CI 0.85 to 2.11). Breathing control had a detrimental effect on the work of breathing (SMD 1.06, 95% CI 0.52 to 1.60) and dyspnoea (SMD 1.47, 95% CI 0.88 to 2.05). CONCLUSION: When used as a sole intervention, there was a beneficial effect on outcomes related to the mechanism of breathing control as well as on short-term physiological outcomes. In people with severe respiratory disease, breathing control resulted in a detrimental effect on dyspnoea and work of breathing. There was no clear evidence of an effect on ventilation or long-term physiological outcomes related to gas exchange or the energy cost of breathing. Overall, evidence was satisfactory with studies demonstrating poor consistency, good generalisability, and satisfactory volume and quality.
QUESTIONS: Is loss of proprioception or loss of motor control related to functional ankle instability? Are proprioception and motor control related? Is there any difference in proprioception or motor control between ankl...QUESTIONS: Is loss of proprioception or loss of motor control related to functional ankle instability? Are proprioception and motor control related? Is there any difference in proprioception or motor control between ankles with different severity of functional ankle instability? DESIGN: Cross-sectional, observational study. PARTICIPANTS: Twenty people aged between 18 and 40 years with functional ankle instability associated with a history of ankle sprain more than one month prior. Twenty age-matched controls with no functional ankle instability or history of ankle sprain. OUTCOME MEASURES: Functional ankle instability was classified using the Cumberland Ankle Instability Tool, proprioception at the ankle was measured as movement detection at three velocities, and motor control was measured using the Landing Test and the Hopping Test. RESULTS: There was little if any relation between proprioception (r = 0.14 to 0.03, 95% CI 0.40 to 0.25) or motor control (r = 0.08 to 0.07, 95% CI 0.35 to 0.20) and functional ankle instability. There was also little if any relation between proprioception and motor control except for a low correlation between movement detection at 0.1 deg/s and the Landing Test (r = 0.35, 95% CI 0.09 to 0.58). Furthermore, there was no difference between the ankles with or without functional ankle instability in proprioception or motor control. CONCLUSION: By greater than one month after ankle sprain, loss of proprioception does not make a major contribution to functional ankle instability.
QUESTIONS: Are there any differences in the displacement and endurance of an elevating voluntary pelvic floor muscle contraction in standing and in crook-lying? Are there any differences in these variables between males...QUESTIONS: Are there any differences in the displacement and endurance of an elevating voluntary pelvic floor muscle contraction in standing and in crook-lying? Are there any differences in these variables between males and females in either test position? DESIGN: An experimental study. PARTICIPANTS: Forty-five nulliparous female and 20 male participants aged 23 years (SD 3) with no symptoms of urinary incontinence or low back pain. INTERVENTION: Voluntary pelvic floor muscle contraction was measured in both standing and crook-lying. OUTCOME MEASURES: Transabdominal ultrasound was used to measure the displacement (mm) and endurance (s) of pelvic floor elevation. RESULTS: Displacement was greater in standing than in crook-lying (mean difference 2.6 mm, 95% CI 1.5 to 3.7). There was no difference between males and females (mean difference 1.3 mm, 95% CI 0.5 to 3.2). Similarly, endurance of pelvic floor elevation was longer in standing than in crook-lying (mean difference 17.3 s, 95% CI 12.2 to 22.4). Again there was no difference between males and females (mean difference 0.5 s, 95% CI 9.3 to 8.3). CONCLUSION: Standing was found to be a more effective position for achieving and sustaining an elevation of the pelvic floor compared to crook-lying, regardless of sex, and this should be taken into account when assessing and training pelvic floor muscle contraction.
QUESTION: What is the effect of sitting and side-lying on the distribution of ventilation during tidal breathing in healthy older people? DESIGN: Randomised, within-participant, experimental study. PARTICIPANTS: Ten heal...QUESTION: What is the effect of sitting and side-lying on the distribution of ventilation during tidal breathing in healthy older people? DESIGN: Randomised, within-participant, experimental study. PARTICIPANTS: Ten healthy people more than 65 years old. INTERVENTION: Tidal breathing during sitting and right side-lying. OUTCOME MEASURES: Distribution of ventilation as a percentage of total counts using Technetium-99m Technegas lung ventilation imaging. RESULTS: In sitting, the ratio of the distribution of ventilation to apical: middle: basal regions was 1: 3.5: 3.3 in the right lung, and 1: 2.9: 2.3 in the left lung. In right side-lying, 32% (95% CI 22 to 43) more ventilation was distributed to the right lung than to the left lung. The ratio of the distribution of ventilation to apical: middle: basal regions was 1: 2.8: 2.2 in the right lung, and 1: 2.4: 1.9 in the left lung. CONCLUSIONS: In both sitting and right side-lying, ventilation was distributed more to the middle than to the basal region, which may be related to age-associated changes in the respiratory system.
QUESTION: How do physiotherapists working in private practice understand and interpret the meaning and significance of informed consent in everyday clinical practice? DESIGN: Qualitative study using semi-structured inter...QUESTION: How do physiotherapists working in private practice understand and interpret the meaning and significance of informed consent in everyday clinical practice? DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: Seventeen physiotherapists purposefully recruited from metropolitan private practices where treatment was on a one-on-one basis. RESULTS: Therapists defined informed consent as an implicit component of their routine clinical explanations, rather than a process of providing explicit patient choices. Therapists' primary concern was to provide information that led to a (therapist-determined) beneficial therapeutic outcome, rather than to enhance autonomous patient choice. Explicit patient choice and explicit informed consent were defined as important only if patients requested information or therapists recognised risks associated with the treatment. CONCLUSION: Physiotherapists defined informed consent within a context of achieving therapeutic outcomes rather than a context of respect for patient autonomy and autonomous choice. Physiotherapy practice guidelines developed to ensure compliance with ethical and legal obligations may therefore be followed only if they fit with therapists' understanding and interpretation of a desired therapeutic outcome.
QUESTION: Does a recruitment manoeuvre after suctioning have any immediate or short-term effect on ventilation and gas exchange in mechanically-ventilated paediatric patients? DESIGN: Randomised controlled trial with con...QUESTION: Does a recruitment manoeuvre after suctioning have any immediate or short-term effect on ventilation and gas exchange in mechanically-ventilated paediatric patients? DESIGN: Randomised controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis. PARTICIPANTS: Forty-eight paediatric patients with heterogeneous lung pathology. Fourteen patients were subsequently excluded from analysis due to large leaks around the endotracheal tube. INTERVENTION: The experimental group received a single standardised suctioning procedure followed five minutes later by a standardised recruitment manoeuvre. The control group received only the single suctioning procedure. OUTCOME MEASURES: Measurements of ventilation (dynamic lung compliance, expiratory airway resistance, mechanical and spontaneous expired tidal volume, respiratory rate) and gas exchange (transcutaneous oxygen saturation) were recorded, on three occasions before and on two occasions after the recruitment manoeuvre, using a respiratory profile monitor. RESULTS: There was no difference between the experimental and the control group in dynamic compliance, expired airway resistance, or oxygen saturation either immediately after the recruitment manoeuvre, or after 25 minutes. The experimental group decreased mechanical expired tidal volume by 0.3 ml/kg (95% CI 0.1 to 0.6), increased spontaneous expired tidal volume by 0.3 ml/kg (95% CI 0.0 to 0.6), and increased total respiratory rate by 3 bpm (95% CI 1 to 4) immediately after the recruitment manoeuvre compared with the control group, but these differences disappeared after 25 minutes. CONCLUSION: There is insufficient evidence to support performing recruitment manoeuvres after suctioning infants and children.
QUESTION: Is low level laser therapy an effective adjuvant intervention for chronic low back pain? DESIGN: Randomised trial with concealed allocation, blinded assessors and intention-to-treat analysis. PARTICIPANTS: Sixt...QUESTION: Is low level laser therapy an effective adjuvant intervention for chronic low back pain? DESIGN: Randomised trial with concealed allocation, blinded assessors and intention-to-treat analysis. PARTICIPANTS: Sixty-one patients who had low back pain for at least 12 weeks. INTERVENTION: One group received laser therapy alone, one received laser therapy and exercise, and the third group received placebo laser therapy and exercise. Laser therapy was performed twice a week for 6 weeks. OUTCOME MEASURES: Outcomes were pain severity measured using a 10-cm visual analogue scale, lumbar range of motion measured by the Schober Test and maximum active flexion, extension and lateral flexion, and disability measured with the Oswestry Disability Index on admission to the study, after 6 weeks of intervention, and after another 6 weeks of no intervention. RESULTS: There was no greater effect of laser therapy compared with exercise for any outcome, at either 6 or 12 weeks. There was also no greater effect of laser therapy plus exercise compared with exercise for any outcome at 6 weeks. However, in the laser therapy plus exercise group pain had reduced by 1.8 cm (95% CI 0.1 to 3.3, p = 0.03), lumbar range of movement increased by 0.9 cm (95% CI 0.2 to 1.8, p < 0.01) on the Schober Test and by 15 deg (95% CI 5 to 25, p < 0.01) of active flexion, and disability reduced by 9.4 points (95% CI 2.7 to 16.0, p = 0.03) more than in the exercise group at 12 weeks. CONCLUSION: In chronic low back pain low level laser therapy combined with exercise is more beneficial than exercise alone in the long term.
QUESTION: What is the feasibility and effectiveness of a novel weight-bearing strengthening program compared with that of a traditional non-weight-bearing strengthening program for older inpatients undergoing rehabilitat...QUESTION: What is the feasibility and effectiveness of a novel weight-bearing strengthening program compared with that of a traditional non-weight-bearing strengthening program for older inpatients undergoing rehabilitation? DESIGN: Randomised, controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis. PARTICIPANTS: Eighty-eight inpatients (11% loss to follow-up) aged on average 82 years old from three rehabilitation units with no contraindications to exercise. INTERVENTION: Both the weight-bearing and non-weight-bearing strengthening programs were supervised by physiotherapists and were of similar intensities (10 to 15 RM) for two weeks. OUTCOME MEASURES: The primary outcomes were standing up performance measured as minimum chair height, and strength measured as maximum isometric knee extensor force of both legs. The secondary outcomes were other mobility measures such as standing-up rate, walking, standing and overall mobility, and other strength measures such as maximum isometric hip extensor, hip abductor, and knee flexor force of both legs. RESULTS: After the two-week intervention, the weight-bearing strengthening group had decreased their minimum chair height by 5.3 cm (95% CI 0.7 to 9.8) and increased their hip extensor strength on the weaker leg by 9 N (95% CI 1 to 17) more than the non-weight-bearing strengthening group. There were no clinically-worthwhile or statistically-significant differences between the groups for any other measures. CONCLUSION: This novel weight-bearing strengthening program was feasible and safe in an inpatient rehabilitation setting and had some additional benefits over a traditional non-weight-bearing strengthening program.