Effectiveness of group aerobic and/or resistance exercise programs associated with pelvic floor muscle training during prenatal care for the prevention and treatment of urinary incontinence: A systematic review.

AIM: To evaluate the effectiveness of aerobic and/or resistance group exercise programs associated with pelvic floor muscle training (PFMT) during prenatal care for the prevention and treatment of urinary incontinence (UI) using the best level of evidence. METHODS: A search was carried out in the MEDLINE/PubMed, LILACS, PEDro, CENTRAL, and SCOPUS databases, without restrictions. The terms "urinary incontinence" and "pregnant woman" were used. Randomized and quasi-randomized clinical trials were included using aerobic and/or resistance exercise programs plus PFMT as an intervention compared to usual care. The Cochrane tool (RoB 2.0) and GRADE were used to assess risk of bias and certainty of evidence, respectively. Quantitative analysis was assessed by meta-analyses. RESULTS: Five publications were included. There was a reduction in the reports of UI postintervention at 16 weeks (RR: 0.83; 95% CI: 0.74-0.93, one study, 762 women, random effects: p = 0.002) and after 3 months (RR: 0.76; 95% CI: 0.60-0.95, one study, 722 women, random effects: p = 0.02), based on moderate certainty of evidence and improvement in UI-specific quality of life (MD: -2.42; 95% CI: -3.32 to -1.52, one study, 151 women, random effects: p < 0.00001), based on low quality of evidence. Other results showed no difference between the postintervention groups, with low and very low evidence. CONCLUSION: There is moderate evidence that the aerobic and/or resistance exercise program associated with PFMT compared to usual care can reduce postintervention UI, as well as 3 months postintervention, and that it can improve UI-specific quality of life, but with low-evidence certainty.

Techniques for Registration of Myoelectric Activity of Women's Pelvic Floor Muscles: A Scoping Review.

INTRODUCTION AND HYPOTHESIS: Surface electromyography is commonly applied to measure the electrophysiological activity of the neuromuscular system. However, there is no consensus regarding the best protocol to assess pelvic floor muscles. METHODS: A scoping literature review was carried out in six databases, using MeSH descriptors. It included studies with electromyographic assessment in adult women presenting or not with pelvic floor dysfunction. The results were presented in categories to contribute to the development of a protocol considering the most used parameters for non-invasive assessment of myoelectric activity of pelvic floor muscles. RESULTS: A total of 1,074 articles were identified, and 146 studies were selected for analysis. The intravaginal probe was used in 80.8% of the studies, the bipolar sensor with metallic plates placed on both sides of the vagina was the most frequent (71.3%), with a reference electrode positioned on the anterior superior iliac spine (33.5%). The supine position with hip and knee flexed (45.2%) was the most frequent position used. Of the studies, 44.5% normalized the data by maximum voluntary contraction (MVC) whereas 44.5% performed an average of 3 MVCs. CONCLUSIONS: The most frequently used protocol for the pelvic floor is the bipolar intracavitary probe with metal plates positioned at 3-9 o'clock and introduced distally to the vaginal introitus with the volunteer in the supine position and the hip and knee flexed with the reference placed on the anterior-superior iliac spine.

Postural Sway Velocity of Deaf Children with and without Vestibular Dysfunction.

BACKGROUND: Sensory information obtained from the visual, somatosensory, and vestibular systems is responsible for regulating postural control, and if damage occurs in one or more of these sensory systems, postural control may be altered. OBJECTIVE: To evaluate and compare the postural sway velocity between children with normal hearing and with sensorineural hearing loss (SNHL), matched by sex and age group, and to compare the postural sway velocity between children with normal hearing and with SNHL, with and without vestibular dysfunction. METHODS: Cross-sectional study that evaluated 130 children (65 with normal hearing and 65 with SNHL), of both sexes and aged between 7 and 11 years, from public schools of the city of Caruaru, Pernambuco state, Brazil. The postural sway velocity of the center of pressure (COP) was assessed by a force platform, in two directions, anteroposterior (AP) and mediolateral (ML)), in three positions, namely bipedal support with feet together and parallel (parallel feet (PF)), bipedal support with one foot in front of the other (tandem foot (TF)), and single-leg support (one foot (OF)), evaluated with the eyes open and closed. RESULTS: Children with SNHL demonstrated greater postural sway velocity compared to children with normal hearing in all the positions evaluated, with significant differences in the AP direction, with the eyes open (PF: p = 0.001; TF: p = 0.000; OF: p = 0.003) and closed (PF: p = 0.050; TF: p = 0.005). The same occurred in the ML direction, with the eyes open (PF: p = 0.001; TF: p = 0.000; OF: p = 0.001) and closed (PF: p = 0.002; TF: p = 0.000). The same occurred in relation to vestibular function, where the children with SNHL with an associated vestibular dysfunction demonstrated greater postural sway velocity compared to children with normal hearing in all the positions evaluated, demonstrating significant differences in the AP direction, with the eyes open (TF: p = 0.001; OF: p = 0.029) and eyes closed (PF: p = 0.036; TF: p = 0.033). The same occurred in the ML direction, with the eyes open (TF: p = 0.000) and with the eyes closed (PF: p = 0.008; TF: p = 0.009). CONCLUSIONS: Children with SNHL demonstrated greater instability of postural control than children with normal hearing in all the directions assessed. Children with SNHL and an associated vestibular dysfunction demonstrated the greatest instability of postural control in this study.

Use of Virtual Reality-Based Games to Improve Balance and Gait of Children and Adolescents with Sensorineural Hearing Loss: A Systematic Review and Meta-Analysis.

BACKGROUND: Children and adolescents with sensorineural hearing loss (SNHL) often experience motor skill disturbances, particularly in balance and gait, due to potential vestibular dysfunctions resulting from inner ear damage. Consequently, several studies have proposed the use of virtual reality-based games as a technological resource for therapeutic purposes, aiming to improve the balance and gait of this population. OBJECTIVE: The objective of this systematic review is to evaluate the quality of evidence derived from randomized or quasi-randomized controlled trials that employed virtual reality-based games to enhance the balance and/or gait of children and adolescents with SNHL. METHODS: A comprehensive search was conducted across nine databases, encompassing articles published in any language until 1 July 2023. The following inclusion criteria were applied: randomized or quasi-randomized controlled trials involving volunteers from both groups with a clinical diagnosis of bilateral SNHL, aged 6-19 years, devoid of physical, cognitive, or neurological deficits other than vestibular dysfunction, and utilizing virtual reality-based games as an intervention to improve balance and/or gait outcomes. RESULTS: Initially, a total of 5984 articles were identified through the searches. Following the removal of duplicates and screening of titles and abstracts, eight studies remained for full reading, out of which three trials met the eligibility criteria for this systematic review. The included trials exhibited a very low quality of evidence concerning the balance outcome, and none of the trials evaluated gait. The meta-analysis did not reveal significant differences in balance improvement between the use of traditional balance exercises and virtual reality-based games for adolescents with SNHL (effect size: -0.48; [CI: -1.54 to 0.57]; p = 0.37; I2 = 0%). CONCLUSION: Virtual reality-based games show promise as a potential technology to be included among the therapeutic options for rehabilitating the balance of children and adolescents with SNHL. However, given the methodological limitations of the trials and the overall low quality of evidence currently available on this topic, caution should be exercised when interpreting the results of the trials analyzed in this systematic review.

Electromyographic analysis of pelvic floor muscles during the execution of pelvic patterns of proprioceptive neuromuscular facilitation-concept: An observational study.

OBJECTIVE: To assess the effect of pelvic patterns of proprioceptive neuromuscular facilitation (PNF-concept) on pelvic floor muscles (PFM) recruitment, as well as the electromyographic activity of muscles synergic to the pelvic floor in healthy women. METHODS: Observational study conducted with 31 women aged between 18 and 35 years, with mean age of 23.3 ± 3.2 (22.1-24.4). PFM activity was monitored by surface electromyography during the combination of isotonics technique of four pelvic patterns of PNF-concept (i.e., anterior elevation, posterior depression, anterior depression, and posterior elevation). The electromyographic signal was analyzed using root mean square amplitude. Two-way repeated measures analysis of variance was performed to analyze differences in PFM activity between types of contraction (i.e., concentric, isometric, and eccentric) and the four pelvic patterns. RESULTS: PFM activity did not differ among the four pelvic pattens. However, PFM activity was significantly different between the combination of isotonics technique and baseline, F(1.6, 48.2) = 71.5; p < 0.000, with a large effect size (partial ƞ² = 0.705). Concentric (22.4 µV ± 1.1), isometric (17.3 µV ± 0.6), and eccentric (15 µV ± 0.5) contractions of combination of isotonics technique increased PFM activity compared with baseline (10.8 µV ± 0.4) in all pelvic patterns. By analyzing the electromyographic activity of the muscles synergistic to the pelvic floor, there is effect of the interaction of the type of contraction, the pelvic pattern of the PNF concept, and the synergistic muscles on the myoelectric activity of the external anal sphincter, F(3.2, 96.5) = 5.6; p < 0.000, with a large magnitude of effect (partial ƞ² = 0.15). In the anterior elevation pattern, the muscles synergistic to the pelvic floor present synergy in phase with the PFM, and in the posterior patterns there was a decrease in the activity level of all synergistic muscles, without changing the activity level of the PFM. CONCLUSION: PFM activity did not differ among the four pelvic patterns of PNF-concept. Nonetheless, the combination of isotonics technique showed a significant effect on PFM compared with baseline, with greater PFM activity during concentric contraction. Pelvic patterns of PNF-concept may be used to increase PFM recruitment in young healthy women.

Effectiveness of the peanut ball use for women with epidural analgesia in labour: a systematic review and meta-analysis.

This meta-analysis aimed to evaluate, using the best level of evidence, the possible benefits and advantages of using peanut ball (PB) in women with an epidural during labour on the maternal and neonatal outcomes. This research was conducted using MEDLINE/PubMed, Embase, LILACS, CINAHL, CENTRAL, PEDro, Web of Science and SCOPUS databases, with no period or language restrictions. The terms 'labor' and 'peanut ball' were used. Clinical trials (randomised and non-randomised) were included when comparing a group of parturients using PB with a control group under usual care. Randomised clinical trials (RCTs) or quasi-randomised were eligible for this systematic review. Two reviewers independently screened studies, extracted data and assessed the quality of evidence which was evaluated by the GRADE system. Quantitative analysis through meta-analysis was also applied whenever possible. In this updated review, we included four studies with a total of 818 women in labour after the use of pharmacological analgesia. Our GRADE ratings of evidence ranged from high to low quality. Overall, the included studies varied in their risk of bias, in which most were considered with some concerns. There is high evidence that the use of PB after epidural analgesia reduces the duration of the first period of labour by 87 minutes and moderate evidence that it increases the chance of vaginal delivery 11%. However, there is no evidence about other maternal and neonatal outcomes.Impact StatementWhat is already known on this subject? The peanut ball (PB) is used after the use of pharmacological analgesia, as it favours the opening of the pelvic canal and helps women to adopt more comfortable postures, but its real effects are not clear.What do the results of this study add? Our results suggest that using the PB reduces the duration of the first period of labour after an epidural and increases the chance of a vaginal birth.What are the implications of these findings for clinical practice and/or further research? These findings recommend the use of a PB after an epidural and further research with women without the use of pharmacological analgesia.

Efficacy of spontaneous pushing with pursed lips breathing compared with directed pushing in maternal and neonatal outcomes.

This is a quasi-randomised clinical trial, with 62 low-risk pregnant women in the second stage of labour. They were randomly allocated in control (CG) (n = 31) and intervention (IG) (n = 31) groups. The IG performed spontaneous pushing with pursed lips breathing while the CG was oriented to perform directed pushing associated with Valsalva Manoeuvre (VM). There was no difference between the groups regarding the occurrence of episiotomy (RR 1,1; 95%IC 1,0 to 1,2). However, there was a decrease in the duration of the maternal pushing by 3.2 min (MD 3,2; 95%CI 1,4 to 5,1) and a difference in maternal anxiety (Md (IQR) IG 46 (35-52), CG 51 (44-56) p:0,049), both favouring the IG. Spontaneous pushing was effective in reducing the duration of the pushing and showed a difference in maternal anxiety but did not decrease the maternal and neonatal outcomes. Brazilian Clinical Trials Registry (ReBEC) under the identifier: RBR-556d22IMPACT STATEMENTWhat is already known on the subject? Spontaneous pushing reduces the duration of pushing time when compared to directed pushing with VM but has no effect on other maternal and neonatal outcomes, based on a low quality of evidence.What do the results of this study add? No subject has been published on the subject. Our results suggest that the use spontaneous pushing with pursed lips breathing reduces the duration of the pushing by 3.2 min, also showing a difference in maternal anxiety. This result may indicate its use for emotional control when compared to the directed pushing.What are the implications of these findings for clinical practice and/or further research? These findings may signal an attitude in decision-making about guiding the breathing pattern in the expulsive stage.

Assessment of the strength and electrical activity of the pelvic floor muscles of male-to-female transgender patients submitted to gender-affirming surgery: A case series.

AIMS: To assess the strength and electrical activity of the pelvic floor muscles (PFMs) of male-to-female transgender individuals submitted to gender-affirming surgery (GAS). METHODS: A case series study was conducted from October 2016 to August 2018. Transgender women, who were scheduled for GAS, participated in the study. The volunteers were submitted to a clinical evaluation of the PFM followed by digital palpation (PERFECT method) and electromyography in the preoperative, 15, and 30 days after GAS. They responded to the International Consultation on Incontinence Questionnaire-Urinary Incontinence (UI)-Short Form to evaluate the effect of UI on quality of life and to questions related to the urinary, anorectal, and sexual symptoms. Fifteen days after the GAS, patients were instructed to perform perineal exercises at home, twice a day. RESULTS: The study sample consisted of 15 transgender women with an average age of 30.6 (SD = 6.7) years. There was a decline in median strength and sustained muscle contraction duration (PERFECT), in the electrical muscle activity (RMSmean and RMSmax) between pre-GAS and 15 days after GAS (p < 0.05). However, there was an increase in these parameters between 15 and 30 days after GAS (p < 0.05). Moreover, six patients exhibited pre-GAS UI, which continued after surgery, with a worsening of urgency symptoms and improvement in nocturia and postmicturition leakage. CONCLUSION: Strength, sustained muscle contraction duration, and PFM electrical activity may decline 15 days after GAS, returning to pre-GAS values in the first month after surgery.

"Posterior Tibial Nerve" or "Tibial Nerve"? Improving the reporting in health papers.

AIMS: The primary objective of this study is to identify which term is the most appropriate to use according to anatomical nomenclature: "posterior tibial nerve" or "tibial nerve." Furthermore, this paper intends to show how the use of these terms in papers indexed in important health databases is numerous and to describe the anatomical characteristics of such nerve, to improve future scientific publications. METHODS: This is a descriptive study about the importance of standardizing the use of the terms "posterior tibial nerve" and "tibial nerve" and its anatomy. It comprises three phases: the first is a search in the main databases to identify the use of the terms "posterior tibial nerve" and "tibial nerve." The second phase refers to the consultation of international anatomical terminology to identify the most appropriate term to refer to the nerve, while the third phase is related to the study of the anatomy of this nerve. RESULTS: The term "tibial nerve" is more commonly used, but the use of the term "posterior tibial nerve" is still very substantial. According to international anatomical terminology, the correct term is "tibial nerve," which is a branch of the sciatic nerve. CONCLUSIONS: "Tibial nerve" is the term standardized by international anatomical terminology. The use of terms in accordance with Terminologia Anatomica is important to facilitate the process of teaching and learning, as well as to improve the reporting and interpretation of papers regarding health, and the evidence-based clinical practice.

Urinary incontinence in pregnant adolescents: A case series.

AIMS: Determine the severity of urinary incontinence (UI) and its effect on the quality of life (QoL) of pregnant adolescents, as well as explore the strategies used to manage UI and the reporting/investigation of this condition by healthcare professionals. METHODS: A case series was conducted in three Brazilian public hospitals that offer prenatal care. Inclusion criteria were: age between 10 and 19 years, gestational age of 27 weeks or more, and reported UI in the third trimester of pregnancy. All volunteers responded to the Incontinence Severity Index (to assess severity of UI) and the International Consultation on Incontinence Questionnaire for Urinary Incontinence-Short Form (to evaluate the effect of UI on QoL). A descriptive analysis of data were done. RESULTS: A total of 329 incontinent pregnant adolescents with mean age of 17.09 years (95%CI 16.92-17.26), who reported voiding urgency (72.0%), increased daytime urinary frequency (75.1%), nocturia (96.7%), and mixed UI (44.1%) were included in the study. UI was considered moderate to severe (79.3%) and had a moderate effect on QoL (mean 9.84; 95%CI 9.40-10.28). The volunteers used UI management strategies (66.6%), with bladder emptying prior to activities (56.8%) and the use of sanitary pads (29.5%) most frequently reported. UI is not disclosed voluntarily (89.1%) or explored by healthcare professionals (91.2%). CONCLUSION: UI can be moderate to severe and has a moderate effect on QoL in incontinent pregnant adolescents, who use strategies to manage this condition. Healthcare professionals do not identify this urinary symptom during prenatal care.

Correlation between electromyography and perineometry in evaluating pelvic floor muscle function in nulligravidas: A cross-sectional study.

OBJECTIVE: To correlate the results of electromyography and perineometry in the assessment of PFM function in nulligravidas. METHODS: The cross-sectional observational study was approved by the internal review board of the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) and was conducted in the Instituto Paraibano de Pesquisa Professor Joaquim Amorim Neto (IPESQ). Thirty-eight nulligravidas aged 18-39 years of age, who had already initiated their sexual life, participated in the study. Exclusion criteria consisted of the presence of genital prolapse, a history of pelvic or urogenital surgery and the presence of neurological disease producing muscle disorders. For the evaluation procedure, the women were submitted to a clinical evaluation of the pelvic floor muscles followed by electromyography. Perineometry was performed 72 h later. Prior to electromyography and perineometry, the women were given standardized training with electromyographic biofeedback to teach them to contract only their pelvic floor muscles. RESULTS: A highly positive, statistically significant correlation (r = 0.968; P < 0.001) was found between the electromyographic and perineometric findings. CONCLUSIONS: A strong correlation was found between perineometric and electromyographic findings of pelvic floor muscle function.

Multiparity, age and overweight/obesity as risk factors for urinary incontinence in pregnancy: a systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: Multiparity, age and high body mass index (BMI) are the most widely investigated factors associated with urinary incontinence (UI) during pregnancy. We hypothesized that multiparity, age 35 years or older and high BMI (prepregnancy and during pregnancy) are risk factors for the occurrence of UI in pregnant women. METHODS: Searches were done on MEDLINE/PubMed (1966-2017), LILACS/BIREME (1982-2017), CINAHL/Ebsco (1981-2017) and Scopus/Elsevier (1950-2017). The following criteria were used for study eligibility: (1) population: low-risk pregnant women in any trimester and without age restriction; (2) exposure factors: multiparity (≥ 2 deliveries), age 35 years or older and high BMI (overweight and obesity); (3) outcome: UI during pregnancy; (4) study design: cohort, case-control or cross-sectional studies that used multivariate logistic analysis. Two independent reviewers performed the entire systematic review process. Data extraction of each article was done and, when possible, included in a meta-analysis. Risk of study bias was assessed by NOS and quality of evidence by GRADE. A significance level of p ≤ 0.05 was adopted. The PROSPERO registration number was CRD42014013193. RESULTS: Of 1176 articles identified through searches, 13 were included after screening and application of eligibility criteria. Very low quality of evidence shows that multiparity (OR = 2.09; 95% CI: 1.07 to 4.08), age 35 years or older (OR = 1.53; 95% CI: 1.45 to 1.62) and overweight and obesity during pregnancy (OR = 1.53; 95% CI: 1.28 to 1.83) are risk factors for UI in pregnancy. CONCLUSIONS: The exposure factors investigated are risk factors for UI in pregnancy based on a very low quality of evidence.

Analysis of Test-Retest Reliability, Construct Validity, and Internal Consistency of the Brazilian Version of the Pelvic Girdle Questionnaire.

OBJECTIVE: The purpose of this study was to evaluate test-retest reliability, construct validity, and internal consistency of the Brazilian version of the Pelvic Girdle Questionnaire (PGQ-Brazil). METHODS: Analysis of the measurement properties was carried out in 4 steps. Step 1 was the pilot study, on which basis 4 hypotheses were formulated. These hypotheses were tested during the next step (construct validity, step 2) by completion of the questionnaire by the 2 groups (in pain [n = 105] and not in pain [n = 52]). For implementation of the PGQ-Brazil in the group with pain, we calculated the internal consistency (step 3) and, 7 days later, test-retest reliability (step 4) by re-application of the instrument in this group. RESULTS: First, the PGQ-Brazil was able to discriminate between these groups (construct validity). Second, test-retest reliability (intraclass correlation coefficients for Activities subscale [0.97 with 95% confidence interval of 0.95-0.98] and Symptoms subscale [0.98 with 95% confidence interval of 0.97-0.98] and κ coefficient between 0.50 and 0.89 for the items) was found to be good; the Bland-Altman test indicated satisfactory agreement. The Rasch analysis indicated good internal consistency, and the instrument's ability to divide the participants into at least 3 levels of skills was confirmed. In contrast, a ceiling effect was observed, as 24% of pregnant women exhibited skills superior to what the PGQ-Brazil could evaluate. CONCLUSIONS: The PGQ-Brazil had good internal consistency, test-retest reliability, and construct validity in assessment of limitations in activities and symptoms of pregnant women with pelvic girdle pain.

Electromyographic assessment of women's pelvic floor: What is the best place for a superficial sensor?

AIMS: To compare the electromyographic signal of different surface electrodes and to identify the channel that presents the highest level of electromyographic activity through the mean and peak of Root Mean Square (RMS). METHODS: Thirty healthy women participated in this study. Each woman completed three collections (on different days) of electromyographic data. Three maximal voluntary contractions of the pelvic floor muscles were requested. The electromyographic signal was recorded by intravaginal probe and surface electrodes placed on the perianal region and on the region immediately below the labia majora. To analyze the signal, an epoch of 500 ms was selected during the second contraction. The Kruskal-Wallis test followed by a post hoc Mann-Whitney test was used to compare means and to identify differences. The Bland-Altman method was used to verify the agreement between the measurements. A significance level of P ≤ 0.05 was adopted. RESULTS: There was agreement only between the measurements from perianal electrodes and intravaginal probe. Furthermore, there was no difference between the perianal electrodes and intravaginal probe in RMS mean (P = 0.225) and RMS peak (P = 0.315). However, these electrodes locations presented greater values than the electrodes in the region immediately below the labia majora (RMS mean: P < 0.001; P = 0.016. RMS peak: P < 0.001; P = 0.02). CONCLUSIONS: The intravaginal probe and the surface electrodes in perianal region are equivalent for healthy nulliparous women. The choice must be done according to the values and preferences of the patient.

Cuffed versus uncuffed endotracheal tubes for general anaesthesia in children aged eight years and under.

BACKGROUND: Since the introduction of endotracheal intubation in paediatrics, uncuffed endotracheal tubes (ETTs) have been the standard of care for children under eight years old, based on the presumption that complications, particularly postoperative stridor, are higher with cuffed ETTs. The major disadvantages of uncuffed ETTs cited for this shift in procedure include the difficulty in achieving tidal volumes due to leakage around an uncuffed ETT. To seal the airway adequately, uncuffed tubes may need to be exchanged for another tube with a larger diameter, which sometimes requires several attempts before the appropriate size is found. Uncuffed tubes also allow waste anaesthetic gases to escape, contributing significantly to operating room contamination and rendering the anaesthetic procedure more expensive. Our review summarizes the available data, to provide a current perspective on the use of cuffed versus uncuffed endotracheal tubes in children of eight years old or less. OBJECTIVES: To assess the risks and benefits of cuffed versus uncuffed endotracheal tubes during general anaesthesia in children up to eight years old. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS and Google Scholar databases from their inception until March 2017. We also searched databases of ongoing trials, and checked references and citations. We imposed no restriction by language. SELECTION CRITERIA: We included randomized and quasi-randomized controlled trials in which the effects of using cuffed and uncuffed tubes were investigated in children up to eight years old undergoing general anaesthesia. We excluded studies conducted solely in newborn babies. DATA COLLECTION AND ANALYSIS: We applied standard methodological procedures, as defined in the Methodological Expectations of Cochrane Intervention Reviews (MECIR). MAIN RESULTS: We included three trials (2804 children), comparing cuffed with uncuffed ETTs. We rated the risks of bias in all three trials as high. Outcome data were limited. The largest trial was supported by Microcuff GmbH, who provided the cuffed tubes used. The other two trials were small, and should be interpreted with caution. Based on the GRADE approach, we rated the quality of evidence as low to very low.Two trials comparing cuffed versus uncuffed ETTs found no difference between the groups for postextubation stridor (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.65 to 1.33; 2734 children; quality of evidence very low). However, those two trials demonstrated a statistically significantly lower rate of endotracheal tube exchange in the cuffed ETT group (RR 0.07, 95% CI 0.05 to 0.10; 2734 children; quality of evidence very low).One trial with 70 participants found that costs per case were lower in the cuffed ETT group (mean difference (MD) EUR 19.0 lower; 95% CI 24.23 to 13.77 lower; quality of evidence low), since the higher cost of the cuffed tubes may be offset by the savings made with anaesthetic gases.No clear evidence emerged to suggest any difference between cuffed and uncuffed tubes for outcomes such as the need to treat postextubation stridor with tracheal re-intubation (RR 1.85, 95% CI 0.17 to 19.76; 115 children; 2 trials; quality of evidence very low), epinephrine (RR 0.70, 95% CI 0.38 to 1.28; 115 children; 2 trials; quality of evidence very low) or corticosteroid (RR 0.87, 95% CI 0.51 to 1.49; 102 children; 1 trial; quality of evidence very low), or need for intensive care unit (ICU) admission to treat postextubation stridor (RR 2.77, 95% CI 0.30 to 25.78; 102 children; 1 trial; quality of evidence very low).None of the trials included in this review evaluated the ability to deliver appropriate tidal volume. AUTHORS' CONCLUSIONS: Implications for practiceWe are unable to draw definitive conclusions about the comparative effects of cuffed or non-cuffed endotracheal tubes in children undergoing general anaesthesia. Our confidence is limited by risks of bias, imprecision and indirectness. The lower requirement for exchange of tubes with cuffed ETTs was very low-quality evidence, and the requirement for less medical gas used and consequent lower cost was low-quality evidence. In some cases, tracheal re-intubation is required to guarantee an open airway when adequate oxygenation is difficult after removal of the tube, for a variety of reasons including stridor, muscle weakness or obstruction. No data were available to permit evaluation of whether appropriate tidal volumes were delivered. Implications for researchLarge randomized controlled trials of high methodological quality should be conducted to help clarify the risks and benefits of cuffed ETTs for children. Such trials should investigate the capacity to deliver appropriate tidal volume. Future trials should also address cost effectiveness and respiratory complications. Such studies should correlate the age of the child with the duration of intubation, and with possible complications. Studies should also be conducted in newborn babies. Future research should be conducted to compare the effects of the different types or brands of cuffed tubes used worldwide. Finally, trials should be designed to perform more accurate assessments and to diagnose the complications encountered with cuffed compared to uncuffed ETTs.

Pushing/bearing down methods for the second stage of labour.

BACKGROUND: Maternal pushing during the second stage of labour is an important and indispensable contributor to the involuntary expulsive force developed by uterine contraction. There is no consensus on an ideal strategy to facilitate these expulsive efforts and there are contradictory results about the influence on the mother and fetus. OBJECTIVES: To evaluate the benefits and possible disadvantages of different kinds of techniques regarding maternal pushing/breathing during the expulsive stage of labour on maternal and fetal outcomes. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register (19 September 2016) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs assessing the effects of pushing/bearing down techniques (type and/or timing) performed during the second stage of labour on maternal and neonatal outcomes. Cluster-RCTs were eligible for inclusion, but none were identified. Studies using a cross-over design and those published in abstract form only were not eligible for inclusion in this review. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. Data were checked for accuracy. MAIN RESULTS: In this updated review, we included 21 studies in total, eight (884 women) comparing spontaneous pushing versus directed pushing, with or without epidural analgesia and 13 (2879 women) comparing delayed pushing versus immediate pushing with epidural analgesia. Our GRADE assessments of evidence ranged from moderate to very low quality; the main reasons for downgrading were study design limitations and imprecision of effect estimates. Overall, the included studies varied in their risk of bias; most were judged to be at unclear risk of bias. Comparison 1: types of pushing: spontaneous pushing versus directed pushingThere was no clear difference in the duration of the second stage of labour (mean difference (MD) 10.26 minutes; 95% confidence interval (CI) -1.12 to 21.64 minutes, six studies, 667 women, random-effects, I² = 81%) (very low-quality evidence). There was no clear difference in 3rd or 4th degree perineal laceration (risk ratio (RR) 0.87; 95% CI 0.45 to 1.66, one study, 320 women) (low-quality evidence), episiotomy (average RR 1.05; 95% CI 0.60 to 1.85, two studies, 420 women, random-effects, I² = 81%), duration of pushing (MD -9.76 minutes, 95% CI -19.54 to 0.02; two studies; 169 women; I² = 88%) (very low-quality evidence), or rate of spontaneous vaginal delivery (RR 1.01, 95% CI 0.97 to 1.05; five studies; 688 women; I² = 2%) (moderate-quality evidence). For primary neonatal outcomes such as five-minute Apgar score less than seven, there was no clear difference between groups (RR 0.35; 95% CI 0.01 to 8.43, one study, 320 infants) (very low-quality evidence), and the number of admissions to neonatal intensive care (RR 1.08; 95% CI 0.30 to 3.79, two studies, 393 infants) (very low-quality evidence) also showed no clear difference between spontaneous and directed pushing. No data were available on hypoxic ischaemic encephalopathy. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural)For the primary maternal outcomes, delayed pushing was associated with an increase of 56 minutes in the duration of the second stage of labour (MD 56.40, 95% CI 42.05 to 70.76; 11 studies; 3049 women; I² = 91%) (very low-quality evidence), but no clear difference in third or 4th degree perineal laceration (RR 0.94; 95% CI 0.78 to 1.14, seven studies. 2775 women) (moderate-quality evidence) or episiotomy (RR 0.95; 95% CI 0.87 to 1.04, five studies, 2320 women). Delayed pushing was also associated with a 19-minute decrease in the duration of pushing (MD -19.05, 95% CI -32.27 to -5.83; 11 studies; 2932 women; I² = 95%) (very low-quality evidence) and an increase in spontaneous vaginal delivery (RR 1.07; 95% CI 1.02 to 1.11, 12 studies, 3114 women) (moderate-quality evidence).For the primary neonatal outcomes, there was no clear difference between groups in admission to neonatal intensive care (RR 0.98; 95% CI 0.67 to 1.41, three studies, n = 2197) (low-quality evidence) and five-minute Apgar score less than seven (RR 0.15; 95% CI 0.01 to 3.00; three studies; 413 infants) (very low-quality evidence). There were no data on hypoxic ischaemic encephalopathy. Delayed pushing was associated with a greater incidence of low umbilical cord blood pH (RR 2.24; 95% CI 1.37 to 3.68, 4 studies, 2145 infants) and increased the cost of intrapartum care by CDN$ 68.22 (MD 68.22, 95% CI 55.37, 81.07, one study, 1862 women). AUTHORS' CONCLUSIONS: This updated review is based on 21 included studies of moderate to very low quality of evidence (with evidence mainly downgraded due to study design limitations and imprecision of effect estimates).Timing of pushing with epidural is consistent in that delayed pushing leads to a shortening of the actual time pushing and increase of spontaneous vaginal delivery at the expense of an overall longer duration of the second stage of labour and an increased risk of a low umbilical cord pH (based only on one study). Nevertheless, there was no clear difference in serious perineal laceration and episiotomy, and in other neonatal outcomes (admission to neonatal intensive care, five-minute Apgar score less than seven and delivery room resuscitation) between delayed and immediate pushing.Therefore, for the type of pushing, with or without epidural, there is no conclusive evidence to support or refute any specific style as part of routine clinical practice, and in the absence of strong evidence supporting a specific method or timing of pushing, the woman's preference and comfort and clinical context should guide decisions.Further properly well-designed RCTs, addressing clinically important maternal and neonatal outcomes are required to add evidence-based information to the current knowledge. Such trials will provide more complete data to be incorporated into a future update of this review.

Pushing/bearing down methods for the second stage of labour.

BACKGROUND: Maternal pushing during the second stage of labour is an important and indispensable contributor to the involuntary expulsive force developed by uterus contraction. Currently, there is no consensus on an ideal strategy to facilitate these expulsive efforts and there are contradictory results about the influence on mother and fetus. OBJECTIVES: To evaluate the benefits and possible disadvantages of different kinds of techniques regarding maternal pushing/breathing during the expulsive stage of labour on maternal and fetal outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2015) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised and quasi-randomised assessing the effects of pushing/bearing down techniques (type and/or timing) performed during the second stage of labour on maternal and neonatal outcomes. Cluster-RCTs were eligible for inclusion but none were identified. Studies using a cross-over design and those published in abstract form only were not eligible for inclusion.We considered the following comparisons.Timing of pushing: to compare pushing, which begins as soon as full dilatation has been determined versus pushing which begins after the urge to push is felt.Type of pushing: to compare pushing techniques that involve the 'Valsalva Manoeuvre' versus all other pushing techniques. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias. Two review authors independently extracted data. Data were checked for accuracy. MAIN RESULTS: We included 20 studies in total, seven studies (815 women) comparing spontaneous pushing versus directed pushing, with or without epidural analgesia and 13 studies (2879 women) comparing delayed pushing versus immediate pushing with epidural analgesia. The results come from studies with a high or unclear risk of bias, especially selection bias and selective reporting bias. Comparison 1: types of pushing: spontaneous pushing versus directed pushingOverall, for this comparison there was no difference in the duration of the second stage (mean difference (MD) 11.60 minutes; 95% confidence interval (CI) -4.37 to 27.57, five studies, 598 women, random-effects, I(2): 82%; T(2): 220.06). There was no clear difference in perineal laceration (risk ratio (RR) 0.87; 95% CI 0.45 to 1.66, one study, 320 women) and episiotomy (average RR 1.05 ; 95% CI 0.60 to 1.85, two studies, 420 women, random-effects, I(2) = 81%; T(2) = 0.14). The primary neonatal outcomes such as five-minute Apgar score less than seven was no different between groups (RR 0.35; 95% CI 0.01 to 8.43, one study, 320 infants), and the number of admissions to neonatal intensive care (RR 1.08; 95% CI 0.30 to 3.79, two studies, n = 393) also showed no difference between spontaneous and directed pushing and no data were available on hypoxic ischaemic encephalopathy.The duration of pushing (secondary maternal outcome) was five minutes less for the spontaneous group (MD -5.20 minutes; 95% CI -7.78 to -2.62, one study, 100 women). Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural)For the primary maternal outcomes, delayed pushing was associated with an increase of 54 minutes in the duration of the second stage of labour (MD 54.29 minutes; 95% CI 38.14 to 70.43; 10 studies, 2797 women, random-effects; I(2) = 91%; T(2) = 543.38), and there was no difference in perineal laceration (RR 0.94; 95% CI 0.78 to 1.14, seven studies. 2775 women) and episiotomy (RR 0.95; 95% CI 0.87 to 1.04, five studies, 2320 women). Delayed pushing was also associated with a 20-minute decrease in the duration of pushing (MD - 20.10; 95% CI -36.19 to -4.02, 10 studies, 2680 women, random-effects, I(2) = 96%; T(2) = 604.37) and an increase in spontaneous vaginal delivery (RR 1.07; 95% CI 1.03 to 1.11, 12 studies, 3114 women).For the primary neonatal outcomes, there was no difference between groups in admission to neonatal intensive care (RR 0.98; 95% CI 0.67 to 1.41, three studies, n = 2197) and five-minute Apgar score less than seven (RR 0.15; 95% CI 0.01 to 3.00, three studies, n = 413). There were no data on hypoxic ischaemic encephalopathy. Delayed pushing was associated with a greater incidence of low umbilical cord blood pH (RR 2.24; 95% CI 1.37 to 3.68) and increased the cost of intrapartum care by CDN$ 68.22 (MD 68.22, 95% CI 55.37, 81.07, one study, 1862 women). AUTHORS' CONCLUSIONS: This review is based on a total of 20 included studies that were of a mixed methodological quality.Timing of pushing with epidural is consistent in that delayed pushing leads to a shortening of the actual time pushing and increase of spontaneous vaginal delivery at the expense of an overall longer duration of the second stage of labour and double the risk of a low umbilical cord pH (based only on one study). Nevertheless, there was no difference in the caesarean and instrumental deliveries, perineal laceration and episiotomy, and in the other neonatal outcomes (admission to neonatal intensive care, five-minute Apgar score less than seven and delivery room resuscitation) between delayed and immediate pushing. Futhermore, the adverse effects on maternal pelvic floor is still unclear.Therefore, there is insufficient evidence to justify routine use of any specific timing of pushing since the maternal and neonatal benefits and adverse effects of delayed and immediate pushing are not well established.For the type of pushing, with or without epidural, there is no conclusive evidence to support or refute any specific style or recommendation as part of routine clinical practice. Women should be encouraged to bear down based on their preferences and comfort.In the absence of strong evidence supporting a specific method or timing of pushing, patient preference and clinical situations should guide decisions.Further properly well-designed randomised controlled trials are required to add evidence-based information to the current knowledge. These trials should address clinically important maternal and neonatal outcomes and will provide more complete data to be incorporated into a future update of this review.

Active pelvic movements on a Swiss ball reduced labour duration, pain, fatigue and anxiety in parturient women: a randomised trial.

QUESTION: How much do active pelvic movements on a Swiss ball during labour affect maternal and neonatal outcomes? METHOD: A randomised trial with concealed allocation, blinded assessors and intention-to-treat analysis. PARTICIPANTS: Two-hundred parturient women. INTERVENTION: The experimental group performed pelvic anteversion and retroversion, lateral pelvic tilts and circular hip movements according to individual obstetric evaluation (foetal station and position, cervical dilatation and the presence of early pushing urge) on a Swiss ball. The control group received usual care. Both groups were permitted to walk and shower. OUTCOME MEASURES: The primary outcome was the duration of the first stage of labour. The secondary outcomes were the duration of the second stage of labour, pain intensity, delivery mode, medication use, local swelling, fatigue, anxiety, satisfaction and neonatal outcomes. RESULTS: The experimental intervention reduced the duration of labour by 179 minutes (95% CI 146 to 213) in stage one and 19 minutes (95% CI 13 to 25) in stage two. It decreased pain by approximately 2 points (95% CI 2 to 2) on a 0-to-10 scale at 30, 60 and 90 minutes. It reduced the risk of a caesarean section (ARR 0.14, 95% CI 0.03 to 0.25; NNT 7, 95% CI 4 to 32) and vulvar swelling (ARR 0.11, 95% CI 0.03 to 0.19; NNT 9, 95% CI 5 to 31). It reduced fatigue by 18 points (95% CI 16 to 21) on a 15-to-75-point scale and anxiety by 9 points (95% CI 8 to 11) on an 18-to-72-point scale. Other effects were negligible or unclear. CONCLUSION: Active pelvic movements on a Swiss ball during labour reduced the duration of labour, pain intensity, and maternal fatigue and anxiety; they also lowered the risk of caesarean section and vulvar swelling. Several effects exceeded the smallest worthwhile effect. REGISTRATION: NCT04124835.

Eficácia E Custo-Utilidade De Intervenções Para O Tratamento Da Enurese Em Crianças E Adolescentes Sob A Perspectiva Do Sistema Único De Saúde Brasileiro: Effectiveness and Cost-Utility of Interventions for Enuresis Treatment in Children and Adolescents From the Brazilian Single Health System Perspective.

OBJECTIVES: This study aimed to estimate the cost-utility of effective interventions for enuresis treatment in children and adolescents and to calculate the incremental cost-utility ratio from the perspective of the Brazilian Unified Health System in a 1-year time horizon. METHODS: The economic analysis is in 7 stages: (1) survey of evidence of treatments for enuresis, (2) performing the network meta-analysis, (3) estimation of the probability of cure, (4) cost-utility analysis, (5) model sensitivity analysis, (6) analysis of acceptability of interventions by acceptability curve, and (7) monitoring the technological horizon. RESULTS: The association between desmopressin and oxybutynin is the therapeutic strategy with the highest probability of success in the treatment of enuresis in children and adolescents compared with placebo (relative risk [RR] 2.88; 95% confidence interval [CI] 1.65-5.04), followed by the combination therapy between desmopressin and tolterodine (RR 2.13; 95% CI 1.13-4.02), alarm (RR 1.59; 95% CI 1.14-2.23), and neurostimulation (RR 1.43; 95% CI 1.04-1.96). Combination therapy between desmopressin and tolterodine was the only 1 considered not to be cost-effective. Neurostimulation, alarm therapy, and therapy had the respective incremental cost-utility ratio values: R$5931.68, R$7982.92, and R$29 050.56/quality-adjusted life-years. CONCLUSION: Among the therapies that are on the borderline of efficiency, the combined therapy between desmopressin and oxybutynin presents the greatest incremental benefit at an incremental cost that is still feasible, given that it does not exceed the reference value of the cost-effectiveness threshold established in Brazil.

Effectiveness of the aquatic physical therapy exercises to improve balance, gait, quality of life and reduce fall-related outcomes in healthy community-dwelling older adults: A systematic review and meta-analysis.

BACKGROUND: Opting to use aquatic or land-based physical therapy exercises to improve balance, gait, quality of life and reduce fall-related outcomes in community-dwelling older adults (CDOAs) is still a questionable clinical decision for physiotherapists. OBJECTIVE: Assess the quality of evidence from randomized or quasi-randomized controlled trials that used aquatic physical therapy exercises to improve balance, gait, quality of life and reduce fall-related outcomes in CDOAs. METHODS: Articles were surveyed in the following databases: MEDLINE/PubMed, EMBASE, SCOPUS, LILACS, Web of Science, CENTRAL (Cochrane Central Register of Controlled Trials), PEDro, CINAHL, SciELO and Google Scholar, published in any language, up to July 31, 2023. Two independent reviewers extracted the data and assessed evidence quality. The risk of bias of the trials was evaluated by the Cochrane tool and evidence quality by GRADE approach. Review Manager software was used to conduct the meta-analyses. RESULTS: 3007 articles were identified in the searches, remaining 33 studies to be read in full, with 11 trials being eligible for this systematic review. The trials included presented low evidence quality for the balance, gait, quality of life and fear of falling. Land-based and aquatic physical therapy exercises improved the outcomes analyzed; however, aquatic physical therapy exercises were more effective in improving balance, gait, quality of life and reducing fear of falling in CDOAs. The meta-analysis showed that engaging in aquatic physical therapy exercises increases the functional reach, through of the anterior displacement of the center of pressure of CDOAs by 6.36cm, compared to land-based physical therapy exercises, assessed by the Functional Reach test: [CI:5.22 to 7.50], (p<0.00001), presenting low quality evidence. CONCLUSIONS: Aquatic physical therapy exercises are more effective than their land-based counterparts in enhancing balance, gait, quality of life and reducing the fear of falling in CDOAs. However, due to methodological limitations of the trials, this clinical decision remains inconclusive. It is suggested that new trials be conducted with greater methodological rigor, in order to provide high-quality evidence on the use of the aquatic physical therapy exercises to improve the outcomes analyzed in CDOAs.