Outcomes of different pulmonary rehabilitation protocols in patients under mechanical ventilation with difficult weaning: a retrospective cohort study.

BACKGROUND: The endeavor of liberating patients from ventilator dependence within respiratory care centers (RCCs) poses considerable challenges. Multiple factors contribute to this process, yet establishing an effective regimen for pulmonary rehabilitation (PR) remains uncertain. This retrospective study aimed to evaluate existing rehabilitation protocols, ascertain associations between clinical factors and patient outcomes, and explore the influence of these protocols on the outcomes of the patients to shape suitable rehabilitation programs. METHODS: Conducted at a medical center in northern Taiwan, the retrospective study examined 320 newly admitted RCC patients between January 1, 2015, and December 31, 2017. Each patient received a tailored PR protocol, following which researchers evaluated weaning rates, RCC survival, and 3-month survival as outcome variables. Analyses scrutinized differences in baseline characteristics and prognoses among three PR protocols: protocol 1 (routine care), protocol 2 (routine care plus breathing training), and protocol 3 (routine care plus breathing and limb muscle training). RESULTS: Among the patients, 28.75% followed protocol 1, 59.37% protocol 2, and 11.88% protocol 3. Variances in age, body-mass index, pneumonia diagnosis, do-not-resuscitate orders, Glasgow Coma Scale scores (≤ 14), and Acute Physiology and Chronic Health Evaluation II (APACHE) scores were notable across these protocols. Age, APACHE scores, and abnormal blood urea nitrogen levels (> 20 mg/dL) significantly correlated with outcomes-such as weaning, RCC survival, and 3-month survival. Elevated mean hemoglobin levels linked to increased weaning rates (p = 0.0065) and 3-month survival (p = 0.0102). Four adjusted models clarified the impact of rehabilitation protocols. Notably, the PR protocol 3 group exhibited significantly higher 3-month survival rates compared to protocol 1, with odds ratios (ORs) ranging from 3.87 to 3.97 across models. This association persisted when comparing with protocol 2, with ORs between 3.92 and 4.22. CONCLUSION: Our study showed that distinct PR protocols significantly affected the outcomes of ventilator-dependent patients within RCCs. The study underlines the importance of tailored rehabilitation programs and identifies key clinical factors influencing patient outcomes. Recommendations advocate prospective studies with larger cohorts to comprehensively assess PR effects on RCC patients.

Impairment of scapular control in individuals with chronic obstructive pulmonary disease (COPD): Systematic review and meta-analysis.

BACKGROUND: Upper quadrant geometrical changes in individuals with chronic obstructive pulmonary disease (COPD) appear to have negative influences on geometrical arrangements of the thorax and scapula. OBJECTIVE: The purpose of this systematic review was to assess the impairment of scapular control in individuals with COPD as compared with healthy controls. METHODS: We systematically searched seven electronic databases from inception to June 2021 and updated the searches again in December 2021. Eligible studies included the participants with COPD and compared scapular control outcomes (scapular/shoulder kinematic or related muscle activity) with a control group. Two researchers independently searched for, screened, extracted data from, and evaluated the quality of all articles. RESULTS: Seven studies met the inclusion criteria and only five studies with 190 subjects were included in the meta-analyses. Subgroup analyses showed that the control group exhibited more scapular anterior tilt (SMD: 0.46; 95% CI: 0.01 to 0.90) and shoulder flexion (SMD: -1.02; 95% CI: -1.79 to -0.26) as compared with the COPD group. Conversely, the COPD group exhibited more scapular elevation (SMD: -1.03; 95% CI: -1.69 to -0.37), internal rotation (SMD: -1.65; 95% CI: -3.19 to -0.10), and protraction (SMD: -0.75; 95% CI: -1.18 to -0.32) compared with the control group. All other outcomes revealed non-significant findings. CONCLUSION: This review demonstrated scapular control impairments, such as scapular elevation, internal rotation, protraction, and anterior tilt in a static position in patients with COPD. To validate these findings, high-quality randomized control trials with large sample sizes and reliable outcome measures should be conducted.

Effectiveness of low level laser therapy versus cryotherapy in cancer patients with oral mucositis: Systematic review and network meta-analysis.

OBJECTIVE: The purpose of this network meta-analysis was to analyze the relative effects of low level laser therapy (LLLT) and/or cryotherapy in cancer patients with oral mucositis (OM). METHODS: This literature search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and the Physiotherapy Evidence Database (PEDro) up to 2020. Only randomized control trials which involved comparisons of groups receiving the interventions of combined cryotherapy and LLLT, LLLT, cryotherapy and usual care (the control group) in patients with cancer were eligible for inclusion. The effect sizes are presented as odds ratios for the occurrence of severe, moderate and none/mild OM. The mixed treatment comparison was conducted using generalized linear mixed models to analyze the direct and indirect comparisons of interventions. The critical appraisal was assessed using Cochrane Collaboration's tool. Heterogeneity between studies was assessed using I2 statistics, and publication bias was evaluated by constructing a funnel plot. RESULTS: Twenty-six randomized controlled trials with a total enrollment of 1830 cancer patients with OM were included. The outcome of none/mild OM is desirable, and odds ratios of more than 1 favor the intervention group. Moderate and severe OM are defined as adverse outcomes, and ORs less than 1 favor the intervention group. The treatment effects of the combined cryotherapy and LLLT were better than those of usual care for none/mild and severe OM (ORs = 106.23 [95% CI = 12.15 to 929.17] and 0.01 [95% CI = 0 to 0.57], respectively). Treatment effects with cryotherapy alone and LLLT alone were better than those with usual care for none/mild and severe OM (ORs = 3.13 [95%CI = 1.56 to 6.27]; ORs = 7.56 [95%CI = 3.84 to 14.88] and 0.25 [95%CI = 0.11 to 0.54]; ORs = 0.13 [95%CI = 0.07 to 0.24], respectively). Nevertheless, for patients with none/mild OM, treatment effects with combined use of cryotherapy and LLLT were better than those with only LLT or cryotherapy (ORs = 14.06 [95%CI = 1.79 to 110.30] and 33.95 [95%CI = 3.50 to 329.65], respectively). For patients with moderate OM, treatment effect did not reach statistical significance among comparisons. The limitations include the wide variability in treatment protocols and the non-uniform outcome measurements across the studies examined. CONCLUSION: Compared with no intervention, the treatment effects of combined cryotherapy and LLLT, laser alone, and cryotherapy alone are beneficial for the reduction of severe OM. There is no difference in treatment effects among cryotherapy and/or LLLT intervention in cancer patients with moderate OM. Results of this study provide an implicative basis for LLLT and cryotherapy as viable interventions that can significantly improve severe OM.

Effectiveness of stretching exercise versus kinesiotaping in improving length of the pectoralis minor: A systematic review and network meta-analysis.

OBJECTIVE: Shortness of the pectoralis minor (PM) is a potential mechanism underlying shoulder impingement syndrome. Few studies have examined the effects of kinesiotaping and stretching exercise on PM length or index. This systematic review and network meta-analysis investigated the effects of stretching exercise and kinesiotaping on PM length and index in adults. METHODS: This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomised controlled trials including adults with or without symptomatic shoulders were included. Heterogeneity between studies was assessed using I2 statistics, and publication bias was evaluated by constructing a funnel plot. RESULTS: We extracted data from six randomised controlled trials that included 263 participants (age range: 18-50 years). Compared with usual care, kinesiotaping resulted in greater improvement in PM length (mean difference, 1.15 cm; 95% confidence interval [CI]: 0.20-2.10 cm). Compared with usual care and kinesiotaping, proprioceptive neuromuscular facilitation (PNF) stretching increased PMI significantly, with a mean difference of 1.40 (95% CI: 1.17-1.63) and 1.08 (95% CI: 0.29-1.87) cm, respectively. CONCLUSION: Compared with no intervention, kinesiotaping is beneficial for lengthening the PM. Intervention with static stretching alone has no effect on PM length. Compared with kinesiotaping alone and no intervention, PNF stretching increases PMI.

Incidence and risk of major adverse cardiovascular events in middle-aged patients with chronic kidney disease: a population-based cohort study.

PURPOSE: For early prevention, information regarding the incidence of major adverse cardiovascular events (MACEs) in middle-aged patients with chronic kidney disease (CKD) may be more beneficial than that regarding MACE prevalence. But, literature comparing the incidence and risk of MACEs in middle-aged patients with CKD with the controls using a population-based cohort study is scant. Our aim was to estimate the incidence and risk of MACEs, such as congestive heart failure (CHF) and ischemic heart disease (IHD), in middle-aged patients with advanced (stages 3-5) CKD. METHODS: From the National Health Insurance Research Database, 261 patients aged 35-65 years who had received advanced CKD diagnoses in 2000 and 1305 age-, sex-, and comorbidity-matched controls were recruited. Patients with CHF alone (MACE 1), IHD alone (MACE 2), or CHF and IHD (MACE 3) diagnoses between January 1, 2001, and December 31, 2008, were identified in the CKD and control groups. RESULTS: Patients (mean age ± standard deviation, 50.0 ± 8.3 years; female, 56%) exhibited a higher incidence of MACE 1, MACE 2, and MACE 3 (11.9 vs. 1.4/1000, 30.7 vs. 13.4/1000, and 13.4 vs. 1.7/1000 person-years, respectively, all p < 0.001) and were at a higher risk of experiencing MACEs than the controls (adjusted hazard ratios: MACE 1, MACE 2, and MACE 3: 8.57, 2.26, and 3.80, respectively, all p < 0.001). CONCLUSIONS: CKD is an independent risk factor for CHF and IHD among patients aged 35-65 years. Early intervention for preventing CHF and IHD in middle-aged patients with CKD is crucial.

Effects and predictors of shoulder muscle massage for patients with posterior shoulder tightness.

BACKGROUND: Clinical approaches like mobilization, stretching, and/or massage may decrease shoulder tightness and improve symptoms in subjects with stiff shoulders. We investigated the effect and predictors of effectiveness of massage in the treatment of patients with posterior shoulder tightness. METHODS: A randomized controlled trial was conducted in a hospital-based outpatient practice (orthopedic and rehabilitation). Forty-three women and 17 men (mean age = 54 years, range 43-73 years) with posterior shoulder tightness participated and were randomized into massage and control groups (n = 30 per group). A physical therapist provided the massage on the posterior deltoid, infraspinatus, and teres minor of the involved shoulder for 18 minutes [about 6 minutes for each muscle] two times a week for 4 weeks. For the control group, one therapist applied light hand touch on the muscles 10 minutes two times a week for 4 weeks. Glenohumeral internal rotation ROM, functional status, and muscle tightness were the main outcomes. Additionally, the potential factors on the effectiveness of massage were analyzed by multivariate logistic regression. For this analysis, patients with functional score improvement at least 20% after massage were considered responsive, and the others were considered nonresponsive. RESULTS: Fifty-two patients completed the study (29 for the massage and 23 for the control). The overall mean internal rotation ROM increased significantly in the massage group compared to the control (54.9° v.s. 34.9°; P ≤ 0.001). There were 21 patients in the responsive group and 8 in the nonresponsive group. Among the factors, duration of symptoms, functional score, and posterior deltoid tightness were significant predictors of effectiveness of massage. CONCLUSIONS: Massage was an effective treatment for patients with posterior shoulder tightness, but was less effective in patients with longer duration of symptoms, higher functional limitation, and less posterior deltoid tightness. TRIAL REGISTRATION: This clinical trial is registered at Trial Registration "Trial registration: Clinicaltrials.gov NCT01022827".

Physical training is beneficial to functional status and survival in patients with prolonged mechanical ventilation.

BACKGROUND/PURPOSE: Early physical training is necessary for severely deconditioned patients undergoing prolonged mechanical ventilation (PMV), because survivors often experience prolonged recovery. Long-term outcomes after physical training have not been measured; therefore, we investigated outcome during a 1-year period after physical training for the PMV patients. METHODS: We conducted a prospective randomized control trial in a respiratory care center. Thirty-four patients were randomly assigned to the rehabilitation group (n = 18) and the control group (n = 16). The rehabilitation group participated in supervised physical therapy training for 6 weeks, and continued in an unsupervised maintenance program for 6 more weeks. The functional independence measurement (FIM) was used to assess functional status. Survival status during the year after enrollment, the number of survivors discharged, and the number free from ventilator support were collected. These outcome parameters were assessed at entry, immediately after the 6 weeks physical therapy training period, after 6 weeks unsupervised maintenance exercise program, and 6 months and 12 months after study entry. RESULTS: The scores of total FIM, motor domain, cognitive domain, and some sub-items, except for the walking/wheelchair sub-item, increased significantly in the rehabilitation group at 6 months postenrollment, but remained unchanged for the control group. The eating, comprehension, expression, and social interaction subscales reached the 7-point complete independence level at 6 months in the rehabilitation group, but not in the control group. The 1-year survival rate for the rehabilitation group was 70%, which was significantly higher than that for the control group (25%), although the proportion of patients discharged and who were ventilator-free in the rehabilitation and control groups did not differ significantly. CONCLUSION: Six weeks physical therapy training plus 6 weeks unsupervised maintenance exercise enhanced functional levels and increased survival for the PMV patients compared with those with no such intervention. Early physical therapy interventions are needed for the PMV patients in respiratory care centers.

Quantification of shoulder tightness and associated shoulder kinematics and functional deficits in patients with stiff shoulders.

Measurement of anterior/posterior shoulder tightness, humeral external/internal rotation range of motion (ROM), scapular upward rotation/tipping ROM, and functional limitations were made in 46 patients with unilateral stiff shoulders (SSs) using a clinical measurement (shoulder tightness), a three-dimensional electromagnetic tracking device (shoulder ROM), and self-reports of function. Patients with SSs in their dominant shoulder demonstrated statistically greater posterior shoulder tightness compared to nondominant shoulder. Control dominant shoulders demonstrated decreased internal ROM as compared with control nondominant shoulders (p=0.021). In SSs, significant relationships were found between humeral internal rotation ROM and posterior shoulder tightness (R=0.49, p<0.0005), humeral external rotation ROM and anterior shoulder tightness (R=0.59, p=0.0002), scapular tipping and anterior shoulder tightness (R=0.57, p=0.004). Specifically, in patients with dominant SSs, posterior shoulder tightness and functional limitation were related (R=0.56, p=0.002). In patients with dominant involved shoulders, emphasise on posterior tightness stretch may improve functional ability directly. In addition to stretching program in patients with SSs, internal rotation ROM of control dominant shoulder is also important to consider in the rehabilitation of patients with SSs.

Proprioception assessment in subjects with idiopathic loss of shoulder range of motion: joint position sense and a novel proprioceptive feedback index.

We examined the effects of elevation range and plane on shoulder joint proprioception in subjects with idiopathic loss of shoulder range of motion (ROM). Joint position sense (JPS) and a novel proprioceptive feedback index (PFI), including difference magnitude and the similarity index, were used to assess proprioception. Twelve subjects (eight male, four female) with involved stiff shoulders and normal opposite shoulders were recruited from a university hospital. Subjects attempted to repeat six target positions. Target positions consisted of arm elevation in three planes (frontal, scapular, and sagittal planes) and two ranges (end/mid range). Six trials of each target position were used to determine acceptable trials for stabilization of the data, less than 5% of the cumulative mean values for at least three successive trials. The data stabilized at the sixth repetition. Compared to control shoulders, involved shoulders had enhanced proprioception during end range movements (p < 0.05). The magnitude of the repositioning error and difference magnitude decreased (1.6 degrees -3.5 degrees for repositioning error and 22.2 degrees -62.1 degrees for difference magnitude), whereas similarity index improved at end range movements compared to mid range movements (p < 0.05) in involved stiff shoulders. Results of JPS and PFI suggest that both capsuloligamentous and musculotendinous mechanoreceptors play an important role in proprioception feedback during active movements in subjects with idiopathic loss of shoulder ROM.

Shoulder kinematic features using arm elevation and rotation tests for classifying patients with frozen shoulder syndrome who respond to physical therapy.

Physical therapy is an intervention commonly used in the treatment of subjects with frozen shoulder symptoms, with limited proven effect. The purpose of this study was to identify the kinematic features of patients with frozen shoulder who are more likely to respond to physical therapy. Thirty-four subjects presenting frozen shoulder syndrome were studied to determine altered shoulder kinematics and functional disability. Subjects received the same standardized treatment with passive mobilization/stretching techniques, physical modalities (i.e. ultrasound, shortwave diathermy and/or electrotherapy) and active exercises twice a week for 3 months. Initially, subjects were asked to perform full active motion in 3 tests: abduction in the scapular plane, hand-to-neck and hand-to-scapula. During the test, shoulder kinematics were measured using a 3-D electromagnetic motion-capturing system. In the initial and follow-up sessions, the self-reported Flexilevel Scale of Shoulder Function (FLEX-SF) was used to determine functional disability from symptoms. Improvement with treatment was determined using percent change in FLEX-SF scores over three months of treatment [(final score-initial score)/initial score x 100, >20% improvement and < = 20% nonimprovement]. Shoulder kinematics were first analysed for univariate accuracy in predicting improvement and then combined into a multivariate prediction method. A prediction method with two variables (scapular tipping >8.4 degrees during arm elevation, and external rotation >38.9 degrees during hand to neck) were identified. The presence of these two variables (positive likelihood ratio=15.71) increased the probability of improvement with treatment from 41% to 92%. It appears that shoulder kinematics may predict improvement in subjects with frozen shoulder syndrome. Prospective validation of the proposed prediction method is warranted.

Mobilization techniques in subjects with frozen shoulder syndrome: randomized multiple-treatment trial.

BACKGROUND AND PURPOSE: The purpose of this study was to compare the use of 3 mobilization techniques--end-range mobilization (ERM), mid-range mobilization (MRM), and mobilization with movement (MWM)--in the management of subjects with frozen shoulder syndrome (FSS). SUBJECTS: Twenty-eight subjects with FSS were recruited. METHODS: A multiple-treatment trial on 2 groups (A-B-A-C and A-C-A-B, where A=MRM, B=ERM, and C=MWM) was carried out. The duration of each treatment was 3 weeks, for a total of 12 weeks. Outcome measures included the functional score and shoulder kinematics. RESULTS: Overall, subjects in both groups improved over the 12 weeks. Statistically significant improvements were found in ERM and MWM. Additionally, MWM corrected scapulohumeral rhythm significantly better than ERM did. DISCUSSION AND CONCLUSION: In subjects with FSS, ERM and MWM were more effective than MRM in increasing mobility and functional ability. Movement strategies in terms of scapulohumeral rhythm improved after 3 weeks of MWM.

Trapezius muscle imbalance in individuals suffering from frozen shoulder syndrome.

This aim of this study was to characterize upper and lower trapezius muscle activity for patients experiencing frozen shoulder syndrome (FSS) compared to asymptomatic subjects. Fifteen patients suffering from unilateral FSS and 15 asymptomatic subjects voluntarily participated in this study. Data were gathered on electromyographic (EMG) activity obtained from the upper and lower trapezius muscles during maximal static arm elevations at six different testing positions: 60 and 120 degrees of flexion, abduction in the frontal plane, and abduction in the scapular plane. The group with FSS revealed increased upper trapezius EMG activity at the 60 degrees (mean difference = 12%, p < 0.003) and 120 degrees (mean difference = 24%, p < 0.004) testing positions, and increased lower trapezius EMG activity at the 120 degrees testing positions (mean difference = 6%, p < 0.002), compared to asymptomatic subjects. Higher ratios of the upper trapezius to lower trapezius EMG activity were also found in the patient group (p < 0.0005) compared to asymptomatic subjects. The results of this study indicate that the increased trapezius muscle activity may contribute to scapular substitution movement in compensation for impaired glenohumeral motion in patients with FSS. The insufficiency of the increased lower trapezius muscle activity should be an important consideration in the rehabilitation of patients experiencing FSS.