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"Exercise Test methods Practice Guideline."
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Practical guide to cardiopulmonary exercise testing in adults
Unexplained exertional dyspnoea or fatigue can arise from a number of underlying disorders and shows only a weak correlation with resting functional or imaging tests. Noninvasive cardiopulmonary exercise testing (CPET) offers a unique, but still under-utilised and unrecognised, opportunity to study cardiopulmonary and metabolic changes simultaneously. CPET can distinguish between a normal and an abnormal exercise response and usually identifies which of multiple pathophysiological conditions alone or in combination is the leading cause of exercise intolerance. Therefore, it improves diagnostic accuracy and patient health care by directing more targeted diagnostics and facilitating treatment decisions. Consequently, CPET should be one of the early tests used to assess exercise intolerance. However, this test requires specific knowledge and there is still a major information gap for those physicians primarily interested in learning how to systematically analyse and interpret CPET findings. This article describes the underlying principles of exercise physiology and provides a practical guide to performing CPET and interpreting the results in adults.
Journal Article
Physiotherapy in the intensive care unit: an evidence-based, expert driven, practical statement and rehabilitation recommendations
Objective:
To develop evidence-based recommendations for effective and safe diagnostic assessment and intervention strategies for the physiotherapy treatment of patients in intensive care units.
Methods:
We used the EBRO method, as recommended by the ‘Dutch Evidence Based Guideline Development Platform’ to develop an ‘evidence statement for physiotherapy in the intensive care unit’. This method consists of the identification of clinically relevant questions, followed by a systematic literature search, and summary of the evidence with final recommendations being moderated by feedback from experts.
Results:
Three relevant clinical domains were identified by experts: criteria to initiate treatment; measures to assess patients; evidence for effectiveness of treatments. In a systematic literature search, 129 relevant studies were identified and assessed for methodological quality and classified according to the level of evidence. The final evidence statement consisted of recommendations on eight absolute and four relative contra-indications to mobilization; a core set of nine specific instruments to assess impairments and activity restrictions; and six passive and four active effective interventions, with advice on (a) physiological measures to observe during treatment (with stopping criteria) and (b) what to record after the treatment.
Conclusions:
These recommendations form a protocol for treating people in an intensive care unit, based on best available evidence in mid-2014.
Journal Article
Risk Stratification in Pediatric Wolff-Parkinson-White: Practice Variation Among Pediatric Cardiologists and Electrophysiologists
Background
Published guidelines provide recommendations for risk stratification in pediatric Wolff-Parkinson-White (WPW). There are no data on provider concordance with these guidelines. We hypothesized that significant practice variation exists between pediatric cardiologists (PC) and electrophysiologists (EP).
Method
The records of all patients, age 8 to 21 years, with a new ECG diagnosis of WPW between 1/1/2013 and 12/31/2018, from a single center, were retrospectively reviewed. Subjects were categorized on the basis of symptoms and resting ECG findings as one of the following: asymptomatic intermittent WPW, asymptomatic persistent WPW, or symptomatic WPW. The performance and results of diagnostic testing, including Holter monitor, event monitor, exercise stress test (EST), and electrophysiology study (EPS), were recorded. The primary outcome was concordance with published guidelines. A secondary outcome was documentation of a discussion of sudden cardiac death (SCD) risk.
Results
615 patient encounters were analyzed in 231 patients with newly diagnosed WPW pattern on ECG (56% male; mean age at diagnosis 13.9 ± 2.5 years). EP were observed to have a significantly higher rate of guideline concordance than PC (95% vs. 71%, p < 0.001). There was significant practice variation between PC and EP in the documentation of a discussion of SCD risk: 96% in EP vs. 39% in PC (p < 0.001).
Conclusion
Significant practice variation exists in the non-invasive and invasive risk stratification of pediatric WPW, with lower concordance to published guidelines amongst PC, when compared to EP. This report highlights the need to promote awareness of current WPW guidelines in the pediatric cardiology community at large.
Journal Article
Graded Progressive Home-Based Resistance Combined with Aerobic Exercise in Community-Dwelling Older Adults with Sarcopenia: A Randomized Controlled Trial
This randomized parallel controlled trial aimed to determine the effectiveness of graded progressive home-based resistance combined with aerobic exercise in improving physical fitness in community-dwelling older adults with sarcopenia.
Community-dwelling older adults (≥60 years) with sarcopenia were randomly assigned to the intervention group (IG), receiving 12 weeks of graded progressive home-based resistance and aerobic exercise training, and the control group (CG), maintaining lifestyle unchanged. The primary outcomes were knee extensor muscle strength and the six-minute walk distance (6MWD). Intention-to-treat analysis was applied to the data from all participants in the CG and IG. Post-intervention differences between the intervention and control groups were determined using a generalized estimated equation model with pre-values adjusted.
Data from all the participants in the IG (n=41) and CG (n=45) were analyzed. After the intervention, knee extensor muscle strength (95% CI: 0.140-3.460,
=0.036), 6MWD (95% CI: 35.350-80.010,
<0.001), flexor muscle strength and the results of 30s bicep curls, 30s chair stand, the chair sit and reach test and back stretch test in the IG were larger and value of the timed up-and-go test was smaller than those in the CG (
<0.05). The body composition, quality of life and their changes showed no group differences. The attendance rates were 82.9% and 85.4% for resistance and aerobic exercise, respectively.
The 12-week graded progressive home-based resistance and aerobic exercise intervention improved muscle strength, balance, flexibility, and cardiorespiratory fitness in community-dwelling older adults with sarcopenia, whereas body composition and quality of life remained unchanged. The research was approved by the Ethics Committee of Soochow University (ECSU-2019000161) and registered at the Chinese Clinical Trial Registry (ChiCTR1900027960, http://www.chictr.org.cn/showproj.aspx?proj=45968).
Journal Article
Inter- and intra-unit reliability of the COSMED K5: Implications for multicentric and longitudinal testing
To evaluate the intra-unit (RELINTRA) and inter-unit reliability (RELINTER) of two structurally identical units of the metabolic analyser K5 (COSMED, Rome, Italy) that allows to utilize either breath-by-breath (BBB) or dynamic mixing chamber (DMC) technology.
Identical flow- and gas-signals were transmitted to both K5s that always operated simultaneously either in BBB- or DMC-mode. To assess RELINTRA and RELINTER, a metabolic simulator was applied to simulate four graded levels of respiration. RELINTRA and RELINTER were expressed as typical error (TE%) and Intraclass Correlation Coefficient (ICC). To assess also inter-unit differences via natural respiratory signals, 12 male athletes performed one incremental bike step test each in BBB- and DMC-mode. Inter-unit differences within biological testing were expressed as percentages.
In BBB, TE% of RELINTRA ranged 0.30-0.67 vs. RELINTER 0.16-1.39 and ICC ranged 0.57-1.00 vs. 0.09-1.00. In DMC, TE% of RELINTRA ranged 0.38-0.90 vs. RELINTER 0.03-0.86 and ICC ranged 0.22-1.00 vs. 0.52-1.00. Mean inter-unit differences ranged -2.30-2.20% (Cohen's ds (ds) 0.13-1.52) for BBB- and -0.55-0.61% (ds 0.00-0.65) for DMC-mode, respectively. Inter-unit differences for [Formula: see text] and RER were significant (p < 0.05) at each step.
Two structurally identical K5-units demonstrated accurate RELINTRA with TE < 2.0% and similar RELINTER during metabolic simulation. During biological testing, inter-unit differences for [Formula: see text] and RER in BBB-mode were higher than 2% with partially large ES in BBB. Hence, the K5 should be allocated personally wherever possible. Otherwise, e.g. in multicenter studies, a decrease in total reliability needs to be considered especially when the BBB-mode is applied.
Journal Article
A Physiological Approach to Prolonged Recovery From Sport-Related Concussion
Management of the athlete with postconcussion syndrome (PCS) is challenging because of the nonspecificity of PCS symptoms. Ongoing symptoms reflect prolonged concussion pathophysiology or conditions such as migraine headaches, depression or anxiety, chronic pain, cervical injury, visual dysfunction, vestibular dysfunction, or some combination of these. In this paper, we focus on the physiological signs of concussion to help narrow the differential diagnosis of PCS in athletes. The physiological effects of exercise on concussion are especially important for athletes. Some athletes with PCS have exercise intolerance that may result from altered control of cerebral blood flow. Systematic evaluation of exercise tolerance combined with a physical examination of the neurologic, visual, cervical, and vestibular systems can in many cases identify one or more treatable postconcussion disorders.
Journal Article
Can Dynamic Assessment Identify Language Disorder in Multilingual Children? Clinical Applications From a Systematic Review
Purpose: Multilingual children are disproportionately represented on speech pathology caseloads, in part due to the limited ability of traditional language assessments to accurately capture multilingual children's language abilities. This systematic review evaluates the evidence for identification of language disorder in multilingual children using dynamic assessment and considers clinical applications of the evidence. Method: A systematic search of the Cumulative Index to Nursing and Allied Health Literature, Education Resources Information Centre, Education Source, Google Scholar, Linguistics, Medline, and PsycINFO databases produced 10 articles that met the inclusion criteria: between-groups comparison studies that used dynamic assessment to identify language disorder in children under 12 years old that spoke a different language at home to the majority society language. Articles were critically appraised using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) protocol. Results: Nine of the 10 studies reported that their dynamic assessment identified language disorder in multilingual children. However, small sample sizes, limited language pairs, variability in the reference standard, and design deficiencies resulted in poor ratings for all studies on QUADAS-2. Conclusions: The studies in this review reflected an emergent area of research. Preliminary guidelines for clinical application indicate that dynamic assessment may be a suitable and time-efficient complementary method of diagnosis of language disorder in multilingual children. Further recommendations about age of use, language of instruction, and relevant scores are included.
Journal Article
Pocket closure after repeated subgingival instrumentation: a stress test to the EFP guideline for stage III-IV periodontitis
ObjectivesTo study the effects of one or two repeated subgingival instrumentations (RSI) in achieving the endpoints of therapy (EoT) in open pockets [residual probing pocket depth (PPD) ≥ 6 mm and PPD 4–5 mm with bleeding on probing (BoP)] after steps I-II of therapy.Materials and methodsTwenty-five patients (3,552 total sites; 1,450 open pockets) with stage III-IV periodontitis received steps I-II of periodontal therapy and were re-evaluated after 4–6 weeks (T1). Residual pockets received RSI at T1 and at 3 months (T2). EoT (PPD < 4 or PPD < 6 BoP-) rate at T1, T2 and 6 months (T3) was computed. The number of needed surgeries and treatment costs were calculated.ResultsAt T1, 67.6% of open pockets achieved EoT. At residual PPD ≥ 6 mm at T1 (n = 172), one and two RSI resulted in 33.1% and 45.9% of EoT at T2 and T3, respectively. At residual PPD 4–5 mm with BoP at T1 (n = 298), one and two RSI resulted in 66.8% and 72.1% of EoT at T2 and T3, respectively. PPD at T1 predicted EoT after RSI in both cases, while tooth type only in residual PPD 4–5 mm BoP + . At T1, mean number of surgeries per patient and associated costs were significantly higher than after one/two RSI.ConclusionsRSI may achieve EoT in residual PPD 4–5 mm BoP + and PPD ≥ 6 mm in a considerable number of cases.Clinical relevanceThese findings may support the administration of one/two cycles of RSI prior to surgical approach.Protocol registrationClinicalTrials.gov identification number: NCT04826926.
Journal Article
Treatment preferences of patients with chronic low back pain in physical therapy clinics in Saudi Arabia: a cross-sectional study
Low back pain (LBP) is a prevalent musculoskeletal disorder that significantly contributes to disability and health care burden. Clinical practice guidelines (CPGs) recommend non-pharmacological interventions, such as those delivered by physical therapists, to improve clinical outcomes. Incorporating patient preferences into treatment decisions is essential for promoting patient-centered care and enhancing adherence to CPGs. This study aimed to explore the physical therapy treatment preferences of patients with chronic LBP (CLBP) in Saudi Arabia and to evaluate their alignment with CPG recommendations.
This cross-sectional survey-based study was conducted across three healthcare centers in Saudi Arabia. Patient preferences were assessed using a validated questionnaire that listed available physical therapy treatments for CLBP. The participants were provided with a standardized explanation of evidence-based treatment options based on the updated CPGs for LBP before selecting their preferred treatments. Data analysis included descriptive statistics and chi-square tests to assess the alignment of preferences with CPG recommendations.
A total of 138 participants were included, with 60.1% of the selected treatments aligning with CPG recommendations (
< 0.001). Sociodemographic factors, such as sex, prior physical therapy experience, and body mass index (BMI), influenced treatment preferences. Exercise was the most preferred treatment, aligning with CPGs, while passive modalities, such as interferential therapy, were also frequently chosen despite not being recommended.
This study highlights the importance of understanding patient preferences to improve adherence to CPGs and promote evidence-based care for CLBP. Educational interventions tailored to the cultural context can bridge the gap between patient preferences and evidence-based recommendations, empower patients, and enhance clinical outcomes.
Journal Article