Correspondence: British Thoracic Society guideline on pulmonary rehabilitation in adults: Does objectivity have a sliding scale?

This article is made available through the Brunel Open Access Publishing Fund. Copyright © 2014 BMJ Publishing Group Ltd & British Thoracic Society. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: http://creativecommons.org/licenses/ by-nc/3.0/No abstract available (Letter

Should we abandon manual muscle strength testing in the ICU?

Intensive-care-unit-acquired weakness is a major complication in critically ill patients. The paper by Hough and coworkers suggests that the current method of manual muscle strength testing with the Medical Research Council sum score is of limited value in the intensive care unit. However, their results raise a number of questions and provide important lessons for implementation of such evaluations in the intensive care unit

Physical activity counselling during pulmonary rehabilitation in patients with COPD : a randomised controlled trial

Background Pulmonary rehabilitation programs only modestly enhance daily physical activity levels in patients with chronic obstructive pulmonary disease (COPD). This randomised controlled trial investigates the additional effect of an individual activity counselling program during pulmonary rehabilitation on physical activity levels in patients with moderate to very severe COPD. Methods Eighty patients (66 +/- 7 years, 81% male, forced expiratory volume in 1 second 45 +/- 16% of predicted) referred for a six-month multidisciplinary pulmonary rehabilitation program were randomised. The intervention group was offered an additional eight-session activity counselling program. The primary outcomes were daily walking time and time spent in at least moderate intense activities. Results Baseline daily walking time was similar in the intervention and control group (median 33 [interquartile range 16-47] vs 29 [17-44]) whereas daily time spent in at least moderate intensity was somewhat higher in the intervention group (17[4-50] vs 12[2-26] min). No significant intervention*time interaction effects were observed in daily physical activity levels. In the whole group, daily walking time and time spent in at least moderate intense activities did not significantly change over time. Conclusions The present study identified no additional effect of eight individual activity counselling sessions during pulmonary rehabilitation to enhance physical activity levels in patients with COPD

Standardizing the analysis of physical activity in patients with COPD following a pulmonary rehabilitation program

BACKGROUND: There is a wide variability in measurement methodology of physical activity. This study investigated the effect of different analysis techniques on the statistical power of physical activity outcomes aft er pulmonary rehabilitation. METHODS: Physical activity was measured with an activity monitor armband in 57 patients with COPD (mean +/- SD age, 66 +/- 7 years; FEV 1, 46 +/- 17% predicted) before and aft er 3 months of pulmonary rehabilitation. The choice of the outcome (daily number of steps [STEPS], time spent in at least moderate physical activity [TMA], mean metabolic equivalents of task level [METS], and activity time [ACT]), impact of weekends, number of days of assessment, post-processing techniques, and influence of duration of daylight time (DT) on the sample size to achieve a power of 0.8 were investigated. RESULTS: The STEPS and ACT (1.6-2.3 metabolic equivalents of task) were the most sensitive outcomes. Excluding weekends decreased the sample size for STEPS (83 vs 56), TMA (160 vs 148), and METS (251 vs 207). Using 4 weekdays (STEPS and TMA) or 5 weekdays (METS) rendered the lowest sample size. Excluding days with, 8 h wearing time reduced the sample size for STEPS (56 vs 51). Differences in DT were an important confounder. CONCLUSIONS: Changes in physical activity following pulmonary rehabilitation are best measured for 4 weekdays, including only days with at least 8 h of wearing time (during waking hours) and considering the difference in DT as a covariate in the analysis

Public sector physiotherapists’ organisation and profile: Implications for intensive care service

Background: Physiotherapists are essential in the management of hospitalised patients. The way in which a physiotherapy service is offered in intensive care units (ICUs) can affect ICU patient outcomes. Objectives: To provide a clear picture of the organisation and structure of physiotherapy departments, the number and types of ICUs requiring physiotherapy services and the profile of physiotherapists working in South African public-sector central, regional and tertiary hospitals that house Level I–IV ICUs. Method: Cross-sectional survey design using SurveyMonkey, analysed descriptively. Results: One hundred and seventy units (the majority Level I, functioning as mixed [37%, n = 58] and neonatal [22%, n = 37] units) are serviced by 66 physiotherapy departments. The majority of physiotherapists (61.5%, n = 265) were younger than 30 years, had a bachelor’s degree (95.1%, n = 408) and were employed in production Level I and community service posts (51%, n = 217) with a physiotherapy-to-hospital-bed ratio of 1:69. Conclusion: Insight into the organisational structure of physiotherapy departments and physiotherapists working in public-sector hospitals with ICU facilities in South Africa was provided. It is evident that physiotherapists employed within this sector are young and early in their career development. The large number of ICUs functioning within these hospitals and high bed-to-physiotherapist ratio is concerning, highlighting the high burden of care within this sector and the possible effect on physiotherapy services in the ICUs. Clinical implications: A high burden of care is placed on public-sector hospital-based physiotherapists. The number of senior-level posts within this sector raises concern. It is not clear how the current staffing levels, physiotherapist profile and structure of hospital-based physiotherapy departments affect patient outcomes

Effects of controlled inspiratory muscle training in patients with COPD: a meta-analysis

The purpose of this meta-analysis is to review studies investigating the efficacy of inspiratory muscle training (IMT) in chronic obstructive pulmonary disease (COPD) patients and to find out whether patient characteristics influence the efficacy of IMT. A systematic literature search was performed using the Medline and Embase databases. On the basis of a methodological framework, a critical review was performed and summary effect-sizes were calculated by applying fixed and random effects models. Both IMT alone and IMT as adjunct to general exercise reconditioning significantly increased inspiratory muscle strength and endurance. A significant effect was found for dyspnoea at rest and during exercise. Improved functional exercise capacity tended to be an additional effect of IMT alone and as an adjunct to general exercise reconditioning, but this trend did not reach statistical significance. No significant correlations were found for training effects with patient characteristics. However, subgroup analysis in IMT plus exercise training revealed that patients with inspiratory muscle weakness improved significantly more compared to patients without inspiratory muscle weakness. From this review it is concluded that inspiratory muscle training is an important addition to a pulmonary rehabilitation programme directed at chronic obstructive pulmonary disease patients with inspiratory muscle weakness. The effect on exercise performance is still to be determined

Functional recovery of diaphragm paralysis: A long-term follow-up study

SummaryBackgroundLong-term functional outcome of diaphragm paralysis is largely unknown.MethodsA retrospective study was conducted in 23 consecutive patients (21 males, 56±9 years) with uni- or bilateral diaphragm paralysis to examine whether functional respiratory recovery can be predicted from the compound motor action potential (CMAP) of the diaphragm at the time of diagnosis. Pulmonary function and CMAP were evaluated at baseline and at follow-up. CMAP amplitude and latency were recorded by surface electromyography with percutaneous electrical stimulation of the phrenic nerve. Patients were followed for (median) 15 months up to 131 months (range 5–131). Functional respiratory recovery was defined as an increase in forced vital capacity >400ml.ResultsFunctional recovery occurred in 43% of the patients after 12 months (10 out of 23) and in 52% after 24 months (12 out of 23). Type and etiology of paralysis did not influence recovery. CMAP, anthropometric characteristics and baseline pulmonary function did not predict functional respiratory recovery. Whether respiratory muscle training improved pulmonary function is uncertain. Moreover, it did not result in a greater percentage functional respiratory recovery. Relapse after an initial improvement was observed in 26% of the patients.ConclusionsThe present study indicates that functional recovery of diaphragm paralysis is difficult to predict and may occur years after the onset of the paralysis

The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients : synthesis of evidence and expert opinion and its translation into practice

The original publication is available at http://cre.sagepub.com/content/early/2011/04/15/0269215510397677Includes bibliographyObjective: To facilitate knowledge synthesis and implementation of evidence supporting early physical activity and mobilization of adult patients in the intensive care unit and its translation into practice, we developed an evidence-based clinical management algorithm. Methods: Twenty-eight draft algorithm statements extracted from the extant literature by the primary research team were verified and rated by scientist clinicians (n¼7) in an electronic three round Delphi process. Algorithm statements which reached a priori defined consensus – semi-interquartile range <0.5 – were collated into the algorithm. Results: The draft algorithm statements were edited and six additional statements were formulated. The 34 statements related to assessment and treatment were grouped into three categories. Category A included statements for unconscious critically ill patients; Category B included statements for stable and cooperative critically ill patients, and Category C included statements related to stable patients with prolonged critical illness. While panellists reached consensus on the ratings of 94% (32/34) of the algorithm statements, only 50% (17/34) of the statements were rated essential.Medical Research Council of South AfricaPost-prin