From bedside to recovery: exercise therapy for prevention of post-intensive care syndrome.

BACKGROUND: As advancements in critical care medicine continue to improve Intensive Care Unit (ICU) survival rates, clinical and research attention is urgently shifting toward improving the quality of survival. Post-Intensive Care Syndrome (PICS) is a complex constellation of physical, cognitive, and mental dysfunctions that severely impact patients' lives after hospital discharge. This review provides a comprehensive and multi-dimensional summary of the current evidence and practice of exercise therapy (ET) during and after an ICU admission to prevent and manage the various domains of PICS. The review aims to elucidate the evidence of the mechanisms and effects of ET in ICU rehabilitation and highlight that suboptimal clinical and functional outcomes of ICU patients is a growing public health concern that needs to be urgently addressed. MAIN BODY: This review commences with a brief overview of the current relationship between PICS and ET, describing the latest research on this topic. It subsequently summarises the use of ET in ICU, hospital wards, and post-hospital discharge, illuminating the problematic transition between these settings. The following chapters focus on the effects of ET on physical, cognitive, and mental function, detailing the multi-faceted biological and pathophysiological mechanisms of dysfunctions and the benefits of ET in all three domains. This is followed by a chapter focusing on co-interventions and how to maximise and enhance the effect of ET, outlining practical strategies for how to optimise the effectiveness of ET. The review next describes several emerging technologies that have been introduced/suggested to augment and support the provision of ET during and after ICU admission. Lastly, the review discusses future research directions. CONCLUSION: PICS is a growing global healthcare concern. This review aims to guide clinicians, researchers, policymakers, and healthcare providers in utilising ET as a therapeutic and preventive measure for patients during and after an ICU admission to address this problem. An improved understanding of the effectiveness of ET and the clinical and research gaps that needs to be urgently addressed will greatly assist clinicians in their efforts to rehabilitate ICU survivors, improving patients' quality of survival and helping them return to their normal lives after hospital discharge.

Reliability and validity of sit-to-stand test protocols in patients with coronary artery disease.

Background: Sit-To-Stand (STS) tests are reported as feasible alternatives for the assessment of functional fitness but the reliability of these tests in people with coronary artery disease (CAD) has not been reported. This study explored the test-retest reliability, convergent and known-groups validity of the five times, 30-sec and 1-min sit-to-stand test (FTSTS test, 30-s STS test and 1-min STS test respectively) in patients with CAD. The feasibility of applying these tests to distinguish the level of risk for cardiovascular events in CAD patients was also investigated. Methods: Patients with stable CAD performed a 6MWT and 3 STS tests in random order on the same day. Receiver operating characteristic (ROC) curve analyses were conducted using STS test data to differentiate patients with low or high risk of cardiovascular events based on the risk level determined by distance covered in the 6MWT as > or ≤ 419 m. Thirty patients repeated the 3 STS tests on the following day. Results: 112 subjects with diagnoses of atherosclerosis or post-percutaneous coronary intervention, or post-acute myocardial infarction (post-AMI) participated in the validity analysis. All 3 STS tests demonstrated moderate and significant correlation with the 6MWT (coefficient values r for the FTSTS, 30-s STS and 1-min STS tests were-0.53, 0.57 and 0.55 respectively). Correlations between left ventricular ejection fraction (LVEF) and all STS tests and between 6MWT and LVEF were only weak (r values ranged from 0.27 to 0.31). Subgroup analysis showed participants in the post-AMI group performed worse in all tests compared to non-myocardial infarction (non-MI) group. The area under the curve (AUC) was 0.80 for FTSTS (sensitivity: 75.0%, specificity: 73.8%, optimal cut-off: >11.7 sec), and the AUC, sensitivity, specificity and optimal cut-off for 30-s STS and 1-min STS test were 0.83, 75.0%, 76.2%, ≤ 12 repetitions and 0.80, 71.4%, 73.8%, ≤ 23 repetitions respectively. The intraclass correlation coefficients (ICC) for repeated measurements of the FTSTS, 30-s STS and 1-min STS tests were 0.96, 0.95 and 0.96 respectively, with the minimal detectable change (MDC95) computed to be 1.1 sec 1.8 repetitions and 3.9 repetitions respectively. Conclusions: All STS tests demonstrated good test-retest reliability, convergent and known-groups validity. STS tests may discriminate low from high levels of risk for a cardiovascular event in patients with CAD.

Stroke volume and cardiac output during 6 minute-walk tests are strong predictors of maximal oxygen uptake in people after stroke.

BACKGROUND AND OBJECTIVES: The 6-minute walk test (6MWT) is a field test commonly used to predict peak oxygen consumption (VO2peak) in people after stroke. Inclusion of cardiodynamic variables measured by impedance cardiography (ICG) during a 6MWT has been shown to improve prediction of VO2peak in healthy adults but these data have not been considered in people after stroke. This study investigates whether the prediction of VO2peak can be improved by the inclusion of cardiovascular indices derived by impedance cardiography (ICG) during the 6MWT in people after stroke. METHODS: This was a cross-sectional study. Patients diagnosed with stroke underwent in random order, a maximal cardiopulmonary exercise test (CPET) and 6MWT in separate dates. Heart rate (HR), stroke volume (SV) and cardiac output (CO) were measured by ICG during all tests. Oxygen consumption was recorded by a metabolic cart during the CPET. Recorded data were subjected to multiple regression analyses to generate VO2peak prediction equations. RESULTS: Fifty-nine patients, mean age 50.0±11.7 years were included in the analysis. The mean distance covered in the 6MWT (6MWD) was 294±13 m, VO2peak was 19.2±3.2 ml/min/kg. Mean peak HR, SV and CO recorded during 6MWT were 109±6 bpm, 86.3±8.8 ml, 9.4±1.2 L/min and during CPET were 135±14 bpm, 86.6±9 ml, 11.7±2 L/min respectively. The prediction equation with inclusion of cardiodynamic variables: 16.855 + (-0.060 x age) + (0.196 x BMI) + (0.01 x 6MWD) + (-0.416 x SV6MWT) + (3.587 x CO 6MWT) has a higher squared multiple correlation (R2) and a lower standard error of estimate (SEE) and SEE% compared to the equation using 6MWD as the only predictor. CONCLUSION: Inclusion of SV and CO measured during the 6MWT in stroke patients further improved the VO2peak prediction power compared to using 6MWD as a lone predictor.

Postoperative Pulmonary Complications in Patients With Transcatheter Tricuspid Valve Implantation-Implications for Physiotherapists.

Objectives: To investigate the incidence of postoperative pulmonary complications (PPCs) and short-term recovery after transcatheter tricuspid valve implantation (TTVI). Methods: A total of 17 patients diagnosed with severe tricuspid regurgitation who received a LuX-valve TTVI were included in this study. Spirometry lung function, maximal inspiratory pressure (MIP), and 6-min walk test distance (6MWD) were recorded. Prior to surgery, patients were stratified into high or low pulmonary risk groups based on published predefined criteria. A physiotherapist provided all patients with education on thoracic expansion exercises, effective cough and an inspiratory muscle training protocol at 50% of MIP for 3 days preoperatively. All patients received standard post-operative physiotherapy intervention including positioning, thoracic expansion exercises, secretion removal techniques and mobilization. Patients were assessed for PPCs as defined by the Melbourne-Group Score-version 2. Clinical characteristics and hospital stay, cost, functional capacity, and Kansas City Cardiomyopathy Questionnaire (KCCQ) heart failure score were recorded at admission, 1-week, and 30-days post-op. Results: The mean (SD) age of the 17 patients was 68.4 (8.0) years and 15 (88%) were female. Pre-surgical assessment identified 8 patients (47%) at high risk of PPCs. A total of 9 patients (53%) developed PPCs between the 1st and 3rd day post-surgery, and 7 of these 9 patients were amongst the 8 predicted as "high risk" prior to surgery. One patient died before the 30 day follow up. Pre-operative pulmonary risk assessment score, diabetes mellitus, a low baseline MIP and 6MWD were associated with a high incidence of PPCs. Compared to those without PPCs, patients with PPCs had longer ICU and hospital stay, and higher hospitalization cost. At 30 days post-surgery, patients without PPCs maintained higher MIP and 6MWD compared to those with PPCs, but there were no significant between-group differences in other lung function parameters nor KCCQ. Conclusion: This is the first study to report the incidence of PPCs post TTVI. Despite a 3-day prehabilitation protocol and standard post-operative physiotherapy, PPCs were common among patients after TTVI and significantly impacted on hospital and short-term recovery and outcomes. In the majority of patients, PPCs could be accurately predicted before surgery. A comprehensive prehabilitation program should be considered for patients prior to TTVI. Clinical Trial Registration: [www.ClinicalTrials.gov], identifier [ChiCTR2000039671].

Comparison of 6-Month Outcomes of Survivors of COVID-19 versus Non-COVID-19 Critical Illness.

Rationale: The outcomes of survivors of critical illness due to coronavirus disease (COVID-19) compared with non-COVID-19 are yet to be established. Objectives: We aimed to investigate new disability at 6 months in mechanically ventilated patients admitted to Australian ICUs with COVID-19 compared with non-COVID-19. Methods: We included critically ill patients with COVID-19 and non-COVID-19 from two prospective observational studies. Patients were eligible if they were adult (age ⩾ 8 yr) and received ⩾24 hours of mechanical ventilation. In addition, patients with COVID-19 were eligible with a positive laboratory PCR test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Measurements and Main Results: Demographic, intervention, and hospital outcome data were obtained from electronic medical records. Survivors were contacted by telephone for functional outcomes with trained outcome assessors using the World Health Organization Disability Assessment Schedule 2.0. Between March 6, 2020, and April 21, 2021, 120 critically ill patients with COVID-19, and between August 2017 and January 2019, 199 critically ill patients without COVID-19, fulfilled the inclusion criteria. Patients with COVID-19 were older (median [interquartile range], 62 [55-71] vs. 58 [44-69] yr; P = 0.019) with a lower Acute Physiology and Chronic Health Evaluation II score (17 [13-20] vs. 19 [15-23]; P = 0.011). Although duration of ventilation was longer in patients with COVID-19 than in those without COVID-19 (12 [5-19] vs. 4.8 [2.3-8.8] d; P < 0.001), 180-day mortality was similar between the groups (39/120 [32.5%] vs. 70/199 [35.2%]; P = 0.715). The incidence of death or new disability at 180 days was similar (58/93 [62.4%] vs. 99/150 [66/0%]; P = 0.583). Conclusions: At 6 months, there was no difference in new disability for patients requiring mechanical ventilation for acute respiratory failure due to COVID-19 compared with non-COVID-19. Clinical trial registered with www.clinicaltrials.gov (NCT04401254).

Immuno-modulation with lifestyle behaviour change to reduce SARS-CoV-2 susceptibility and COVID-19 severity: goals consistent with contemporary physiotherapy practice.

Lifestyle-related non-communicable diseases (NCDs) and their risk factors are unequivocally associated with SARS-CoV-2 susceptibility and COVID-19 severity. NCD manifestations and their lifestyle risks are associated with chronic low-grade systemic inflammation (CLGSI). This review supports that immuno-modulation with positive lifestyle change aimed at reducing SARS-CoV-2 susceptibility and COVID-19 severity, is a goal consistent with contemporary physiotherapy practice. Physiotherapists have a long tradition of managing a , thus, managing CLGSI is a logical extension. Improving patients' lifestyle practices also reduces their NCD risks and increases activity/exercise capacity, health and wellbeing - all principal goals of contemporary physiotherapy. The COVID-19 pandemic lends further support for prioritising health and lifestyle competencies including smoking cessation; whole food plant-based nutrition; healthy weight; healthy sleep practices; and stress management; in conjunction with reducing sedentariness and increasing physical activity/exercise, to augment immunity as well as function and overall health and wellbeing. To support patients' lifestyle change efforts, physiotherapists may refer patients to other health professionals. The authors conclude that immuno-modulation with lifestyle behaviour change to reduce susceptibility to viruses including SARS-CoV-2, is consistent with contemporary physiotherapy practice. Immuno-modulation needs to be reflected in health competencies taught in physiotherapy professional education curricula and taught at standards comparable to other established interventions.

The impact of COVID-19 critical illness on new disability, functional outcomes and return to work at 6 months: a prospective cohort study.

BACKGROUND: There are few reports of new functional impairment following critical illness from COVID-19. We aimed to describe the incidence of death or new disability, functional impairment and changes in health-related quality of life of patients after COVID-19 critical illness at 6 months. METHODS: In a nationally representative, multicenter, prospective cohort study of COVID-19 critical illness, we determined the prevalence of death or new disability at 6 months, the primary outcome. We measured mortality, new disability and return to work with changes in the World Health Organization Disability Assessment Schedule 2.0 12L (WHODAS) and health status with the EQ5D-5LTM. RESULTS: Of 274 eligible patients, 212 were enrolled from 30 hospitals. The median age was 61 (51-70) years, and 124 (58.5%) patients were male. At 6 months, 43/160 (26.9%) patients died and 42/108 (38.9%) responding survivors reported new disability. Compared to pre-illness, the WHODAS percentage score worsened (mean difference (MD), 10.40% [95% CI 7.06-13.77]; p < 0.001). Thirteen (11.4%) survivors had not returned to work due to poor health. There was a decrease in the EQ-5D-5LTM utility score (MD, - 0.19 [- 0.28 to - 0.10]; p < 0.001). At 6 months, 82 of 115 (71.3%) patients reported persistent symptoms. The independent predictors of death or new disability were higher severity of illness and increased frailty. CONCLUSIONS: At six months after COVID-19 critical illness, death and new disability was substantial. Over a third of survivors had new disability, which was widespread across all areas of functioning. Clinical trial registration NCT04401254 May 26, 2020.

Limiting potential COVID-19 contagion in squatting public toilets.

BACKGROUND: Since the outbreak of the SARS-CoV-2 virus in December 2019, the COVID-19 pandemic continues to threaten global stability. Transmission of SARS-CoV-2 is mostly by respiratory droplets and direct contact but viral RNA fragments have also been detected in the faecal waste of patients with COVID-19. Cleanliness and effective sanitation of public toilets is a concern, as flushing the toilet is potentially an aerosol generating procedure. When the toilets are of the squatting type and without a cover, there exists a risk of viral contamination through the splashing of toilet water and aerosol generation. OBJECTIVE: This study aims to determine whether the cleanliness of public toilets was a concern to the general population during the COVID-19 pandemic, and whether a squatting toilet was preferred to a seated design. METHODS: A questionnaire was designed and posted on "WeChat" contact groups of the investigators. RESULTS: The survey showed that 91% of participants preferred squatting toilets, but that 72% were apprehensive of personal contamination when using public toilets. Over 63% of the respondents had encountered an incidence of water splash and would prefer public toilets to be covered during flushing and 83% of these respondents preferred a foot-controlled device. CONCLUSION: This survey suggests that consideration should be given to the installation of a simple foot-controlled device to cover public squatting toilets to help restrict potential COVID-19 contamination and to meet hygienic expectations of the public.

Cardiodynamic variables measured by impedance cardiography during a 6-minute walk test are reliable predictors of peak oxygen consumption in young healthy adults.

Accurate prediction of aerobic capacity is necessary to guide appropriate exercise prescription. It is common to use 6-minute walk distance (6MWD) to predict peak oxygen uptake (VO2peak) in the clinical environment. The aim of this study was to determine whether prediction of VO2peak can be improved by the inclusion of cardiovascular indices derived by impedance cardiography (ICG) during the 6MWT. A total of 62 healthy university students aged 21±1 years completed in separate days, a cardiopulmonary exercise test (CPET) and two 6MWTs (30 min apart), during which heart rate (HR), stroke volume (SV) and cardiac output (CO) were measured by ICG (PhysioFlow® PF07 EnduroTM). The CPET was conducted with the Ergoselect 200 Ergoline and oxygen consumption measured by a MasterScreenTM CPX breath-by-breath metabolic cart. Multiple regression analyses were conducted to generate VO2peak prediction equations using 6MWD with, or without the cardiovascular indices recorded at the end of the best performed 6MWT as predictor variables. The mean peak HR (bpm), SV (ml) and CO (L/min) recorded during 6MWT were 156±18, 95.6±9, 15±2.8 and during CPET were 176±16, 91.3±8, 16.2±2.7, respectively. Analyses revealed the following VO2peak prediction equation: VO2peak = 100.297+(0.019x6MWD)+(-0.598xHR6MWT)+(-1.236xSV6MWT) + (8.671 x CO6MWT). This equation has a squared multiple correlation (R2) of 0.866, standard error of the estimate (SEE) of 2.28 mL/kg/min and SEE:VO2peak (SEE%) of 7.2%. Cross-validation of equation stability using predicted residual sum of squares (PRESS) statistics showed a R2 (Rp2), SEE (SEEp) and SEEp% of 0.842, 2.38 mL/kg/min and 7.6% respectively. The minimal shrinkage of R2 implied regression model stability. Correlation between measured and predicted VO2peak using this equation was strong (r = 0.931, p<0.001). When 6MWD alone was used as the predictor for VO2peak, the generated equation had a lower R2 (0.549), and a higher SEE (4.08 mL/kg/min) and SEE% (12.9%). This is the first study which included cardiac indices during a 6MWT as variables for VO2peak prediction. Our results suggest that inclusion of cardiac indices measured during the 6MWT more accurately predicts VO2peak than using 6MWD data alone.

Physical Therapist Management of COVID-19 in the Intensive Care Unit: The West China Hospital Experience.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) has dominated the attention of health care systems globally since January 2020. Various health disciplines, including physical therapists, are still exploring the best way to manage this new disease. The role and involvement of physical therapists in the management of COVID-19 are not yet well defined and are limited in many hospitals. This article reports a physical therapy service specially commissioned by the Health Commission of Sichuan Province to manage COVID-19 during patients' stay in the intensive care unit (ICU) at the Public Health Clinical Center of Chengdu in China. METHODS: Patients diagnosed with COVID-19 were classified into 4 categories under a directive from the National Health Commission of the People's Republic of China. Patients in the "severe" and "critical" categories were admitted to the ICU irrespective of mechanical ventilation was required. Between January 31, 2020, and March 8, 2020, a cohort of 16 patients was admitted to the ICU at the Public Health Clinical Center of Chengdu. The median (minimum to maximum) hospital and ICU stays for these patients were 27 (11-46) and 15 (6-38) days, respectively. Medical management included antiviral, immunoregulation, and supportive treatment of associated comorbidities. Physical therapist interventions included body positioning, airway clearance techniques, oscillatory positive end-expiratory pressure, inspiratory muscle training, and mobility exercises. All patients had at least 1 comorbidity. Three of the 16 patients required mechanical ventilation and were excluded for outcome measures that required understanding of verbal instructions. In the remaining 13 patients, respiratory outcomes-including the Borg Dyspnea Scale, peak expiratory flow rate, Pao2/Fio2 ratio, maximal inspiratory pressure, strength outcomes, Medical Research Council Sum Score, and functional outcomes (including the Physical Function in Intensive Care Test score, De Morton Mobility Index, and Modified Barthel Index)-were measured on the first day the patient received the physical therapist intervention and at discharge. RESULTS: At discharge from the ICU, while most outcome measures were near normal for the majority of the patients, 61% and 31% of these patients had peak expiratory flow rate and maximal inspiratory pressure, respectively, below 80% of the predicted value and 46% had De Morton Mobility Index values below the normative value. CONCLUSION: The respiratory and physical functions of some patients remained poor at ICU discharge, suggesting that long-term rehabilitation may be required for these patients. IMPACT: Our experience in the management of patients with COVID-19 has revealed that physical therapist intervention is safe and appears to be associated with an improvement in respiratory and physical function in patients with COVID-19 in the ICU.

Establishing essential cardiopulmonary physiotherapy services in acute care settings in China.

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Noninvasive investigation of the cardiodynamic response to 6MWT in people after stroke using impedance cardiography.

This is a cross-section observational study that investigated the cardiodynamic response to a 6-minute walk test (6MWT) in patients after stroke using impedance cardiography (ICG). Patients diagnosed with stroke were invited to participate in a 6MWT on consecutive days. Heart rate (HR), cardiac output (CO), stroke volume (SV) and cardiac index (CI) were measured by ICG using the PhysioFlow® PF07 EnduroTM at 1-second intervals for 10 minutes prior to, during and for 10 minutes after each 6MWT. Oxygen saturation, perceived exertion score (modified Borg scale) and the distance covered at the end of each 6MWT were recorded. Twenty-nine patients (mean age 55.6±10.9 years) completed the study. The mean duration of stroke after diagnosis was 14.4±19.1 months. There were no differences in the measured data between the first and second 6MWT (mean intraclass correlation coefficient (ICC) range: 0.87-0.95). The 6 minute walk distance (6WMD) covered in the two 6MWTs was 246±126 and 255±130m respectively (p>0.05). Mean measured data for each subject at rest, and at the end of the better performed 6MWT were, respectively: HR 78±11 and 100±18 bpm; CO 5.5±1.2 and 8.9±2.6 l/min, SV 71.3±16 and 89.3±18.6 ml/beat and CI 3.0±0.6 and 4.9±1.3 l/min/m2. After commencement of the 6MWT, the increase in SV took 30 sec before the rise approaching a plateau, whereas HR, CO and CI continued to rise steeply for 90 sec before leveling off to a steady rise. After completion of the 6MWT, all parameters had returned to baseline by a mean of 3.5 min. Sub-group analysis showed that the increase in cardiac output was predominantly contributed by an increase in heart rate in participants diagnosed with stroke for less than 1 year, whereas both stroke volume and heart rate contributed similarly to the increase in cardiac output in participants with diagnosis of stroke for longer than 1 year. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) both returned to baseline within 2 minutes post 6MWT. HR recorded at the end of the 6MWT was 60.8±10.6% of the predicted maximal heart rate and perceived exertion score was 5±2. Correlations between 6MWD and HR, and between 6MWD and SV were weak, with correlation coefficients Spearman's rho (rs) =0.46, and 0.42, respectively (p<0.05). Correlation between 6MWD and CO and CI were higher (rs= 0.66 and 0.63, respectively (p<0.01)). This is the first study to report cardiac responses during a 6MWT in stroke patients. ICG is a reliable, non-invasive, repeatable method of measuring cardiodynamic data in stroke patients.

Acceptance of the 'Assessment of Physiotherapy Practice (Chinese)' as a standardised evaluation of professional competency in Chinese physiotherapy students: an observational study.

BACKGROUND: Development of an entry-level physiotherapy curriculum in China currently follows the World Confederation for Physical Therapy (WCPT) guidelines, however there is no standard, validated, assessment tool for physiotherapy practice in use in China. This article reports the process of translation of the "Assessment of Physiotherapy Practice" (APP), a validated assessment instrument adopted by all universities in Australia and New Zealand, into Chinese (APP-Chinese) and its implementation by Chinese physiotherapy clinical educators (CEs) and students during clinical placements. METHODS: The process of forward and backward translation of the APP was undertaken by a team of academics from universities in Shanghai, Hong Kong, United States and Australia. An APP-Chinese version was produced and used for assessment of the clinical performance of 4th year students at a university in Shanghai. Feedback on the implementation of the APP-Chinese was solicited from students and CEs using the same two questionnaires employed to assess implementation of the original APP. RESULTS: All CEs agreed that the rules used to score the APP-Chinese were helpful in assessing student performance. Over 90% of the CEs considered the APP-Chinese was pragmatic for use in the clinical environment in China. All students agreed with the rating of their performance on the APP-Chinese marked by their educators, and that the performance indicators were useful in guiding their expected performance behaviour. CONCLUSION: The APP-Chinese is the first standardised assessment tool for evaluation of clinical performance of physiotherapy students in China and was shown to be well accepted by both students and CEs in the clinical education unit and university involved in this study.

Trunk muscle endurance in Chinese adults.

BACKGROUND: Previous studies in non-Chinese populations have found a relationship between performance on isometric trunk muscle endurance tests and low back pain (LBP). However, the relationship between trunk muscle endurance and LBP in Chinese populations has received little attention and age-referenced data have not been reported. OBJECTIVE: Evaluate the relationship between age-referenced isometric trunk muscle endurance values and LBP in a Chinese cohort. METHODS: One hundred and eighty-eight participants (20-59-years) performed four timed-endurance tests (Biering-Sørensen, plank, left/right side bridge) in random order. Participants with a history of LBP completed an Oswestry Disability Index (ODI) and pain scale. Holding-times for the four tests were summed and receiver operating characteristic (ROC) curve analysis was performed to differentiate participants with and without LBP. RESULTS: Data were grouped by age. Analysis revealed similar endurance values to those reported in non-Chinese populations, except longer holding times were recorded in the 50-59 yr Chinese cohort. Pain scores were positively correlated with ODI scores. ROC curve analysis showed that the area under the curve was 0.723 and optimal cut-off was 288 sec (sensitivity and specificity both 0.75). CONCLUSIONS: This study is the first to describe trunk muscle endurance reference data in Chinese people. Individuals with a summed endurance time of < 288 seconds appear more likely to suffer LBP.

Acu-TENS Reduces Breathlessness during Exercise in People with Chronic Obstructive Pulmonary Disease.

Background. Exertional dyspnoea limits level of physical activity in people with Chronic Obstructive Pulmonary Disease (COPD). This randomized, double-blinded, crossover study evaluated the effect of Acu-TENS, application of Transcutaneous Electrical Nerve Stimulation on acupoints, on breathlessness during exercise in people with COPD. Methods. Twenty-one participants, mean% predicted FEV1 50 ± 21%, attended assessment followed by two intervention days, one week apart. On each intervention day, participants performed two endurance shuttle walk tests (ESWT) (Walk 1 and Walk 2). Walk 1 was performed without intervention and Walk 2 was performed with either Acu-TENS or Sham-TENS, in random order, for 45 minutes before and during Walk 2. Duration of each ESWT and dyspnoea score at isotime of Walk 1 and Walk 2 on each intervention day were compared. Between-group differences in ESWT duration and isotime dyspnoea were also compared. Results. At isotime of Walk 1 and Walk 2, Acu-TENS showed significant reduction in dyspnoea of -0.8 point (95% CI -0.2 to -1.4) but not in Sham-TENS [0.1 point (95% CI -0.4 to 0.6)]. Compared to Sham-TENS, Acu-TENS showed significant reduction in dyspnoea of -0.9 point (95% CI -0.2 to -1.6) while no between-group significance was found in ESWT duration. Conclusion. Acu-TENS alleviated dyspnoea during walking in people with COPD but did not increase walking duration.

Predicted VO2max and effectiveness of external chest compression by Chinese nurses.

OBJECTIVES: The aims of this study were to assess the influence of sex and body position on external chest compression (ECC) to a manikin by Chinese nurses and to determine the relationship between rescuer's predicted VO2max and ECC depth. PARTICIPANTS AND METHODS: A total of 40 nurses performed ECC on a manikin for 5 min in the standing (S) and bed-mount kneeling (K) position, then completed a Chester step-test, in 3 separate days. The rate and depth of compressions and oxygen consumption during ECC were measured. RESULTS: Mean compression rate recorded was above 100/min in both positions throughout ECC. Mean compression depth for male participants was more than 38 mm for 5 min in the K-position but only 3 min in the S-position. Female participants achieved this compression depth for less than 90 s in the K-position but not at all in the S-position. CONCLUSION: Irrespective of sex, the K-position appears to facilitate effective ECC. The relationship between aerobic fitness of female nurses and their ability to perform effective cardiopulmonary resuscitation warrants further investigation.

Repeatability of the endurance shuttle walk test in people with chronic obstructive pulmonary disease.

INTRODUCTION: Walking tests, including the endurance shuttle walk test (ESWT), have been used to assess functional capacity in people with chronic obstructive pulmonary disease (COPD). Learning effects through repeated practice have been reported for some field walking tests. However, the repeatability of ESWT at various time points, i.e. within the same day, within the week and one week apart, has not been examined. OBJECTIVES: This study aimed to evaluate the repeatability of ESWT overtime to determine whether or not a learning effect existed. METHODS: Twenty-two participants diagnosed with COPD [age 71 ± 6 years; FEV1 % predicted 54 ± 24%] were recruited. Participants performed two incremental shuttle walk tests to determine the walking speed for the ESWT and a practice ESWT (Ep ) to determine whether the ESWT level was appropriate. ESWT 1(E1 ) and ESWT 2(E2 ) were performed on the same day, 30 min apart; ESWT 3(E3 ) was performed within a week from E2 ; ESWT 4(E4 ) was performed one week after E3 . Duration walked in each ESWT was recorded. The repeatability of the four ESWTs was analyzed using repeated measures analysis of variance. RESULTS: The mean durations of E1 to E4 were 368 ± 203 s, 371 ± 182 s, 386 ± 213 s and 367 ± 223 s, respectively, with no time effect (F=0.18, P=0.79). CONCLUSION: There was no evidence of learning effect when ESWT was repeated within one day, within one week and one week apart, once the appropriate baseline level was established, showing that ESWT is repeatable in people with moderate COPD.

Tai Chi for chronic obstructive pulmonary disease (COPD).

BACKGROUND: Tai Chi, a systematic callisthenic exercise first developed in ancient China, involves a series of slow and rhythmic circular motions. It emphasises use of 'mind' or concentration to control breathing and circular body motions to facilitate flow of internal energy (i.e. 'qi') within the body. Normal flow of 'qi' is believed to be essential to sustain body homeostasis, ultimately leading to longevity. The effect of Tai Chi on balance and muscle strength in the elderly population has been reported; however, the effect of Tai Chi on dyspnoea, exercise capacity, pulmonary function and psychosocial status among people with chronic obstructive pulmonary disease (COPD) remains unclear. OBJECTIVES: • To explore the effectiveness of Tai Chi in reducing dyspnoea and improving exercise capacity in people with COPD.• To determine the influence of Tai Chi on physiological and psychosocial functions among people with COPD. SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register of trials (which included the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Allied and Complementary Medicine Database (AMED) and PsycINFO); handsearched respiratory journals and meeting abstracts; and searched Chinese medical databases including Wanfang Data, Chinese Medical Current Contents (CMCC), Chinese Biomedical Database (CBM), China Journal Net (CJN) and China Medical Academic Conference (CMAC), from inception to September 2015. We checked the reference lists of all primary studies and review articles for relevant additional references. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing Tai Chi (Tai Chi alone or Tai Chi in addition to another intervention) versus control (usual care or another intervention identical to that used in the Tai Chi group) in people with COPD. Two independent review authors screened and selected studies. DATA COLLECTION AND ANALYSIS: Two independent review authors extracted data from included studies and assessed risk of bias on the basis of suggested criteria listed in the Cochrane Handbook for Systematic Reviews of Interventions. We extracted post-programme data and entered them into RevMan software (version 5.3) for data synthesis and analysis. MAIN RESULTS: We included a total of 984 participants from 12 studies (23 references) in this analysis. We included only those involved in Tai Chi and the control group (i.e. 811 participants) in the final analysis. Study sample size ranged from 10 to 206, and mean age ranged from 61 to 74 years. Programmes lasted for six weeks to one year. All included studies were RCTs; three studies used allocation concealment, six reported blinded outcome assessors and three studies adopted an intention-to-treat approach to statistical analysis. No adverse events were reported. Quality of evidence of the outcomes ranged from very low to moderate.Analysis was split into three comparisons: (1) Tai Chi versus usual care; (2) Tai Chi and breathing exercise versus breathing exercise alone; and (3) Tai Chi and exercise versus exercise alone.Comparison of Tai Chi versus usual care revealed that Tai Chi demonstrated a longer six-minute walk distance (mean difference (MD) 29.64 metres, 95% confidence interval (CI) 10.52 to 48.77 metres; participants = 318; I(2) = 59%) and better pulmonary function (i.e. forced expiratory volume in one second, MD 0.11 L, 95% CI 0.02 to 0.20 L; participants = 258; I(2) = 0%) in post-programme data. However, the effects of Tai Chi in reducing dyspnoea level and improving quality of life remain inconclusive. Data are currently insufficient for evaluating the impact of Tai Chi on maximal exercise capacity, balance and muscle strength in people with COPD. Comparison of Tai Chi and other interventions (i.e. breathing exercise or exercise) versus other interventions shows no superiority and no additional effects on symptom improvement nor on physical and psychosocial outcomes with Tai Chi. AUTHORS' CONCLUSIONS: No adverse events were reported, implying that Tai Chi is safe to practise in people with COPD. Evidence of very low to moderate quality suggests better functional capacity and pulmonary function in post-programme data for Tai Chi versus usual care. When Tai Chi in addition to other interventions was compared with other interventions alone, Tai Chi did not show superiority and showed no additional effects on symptoms nor on physical and psychosocial function improvement in people with COPD. With the diverse style and number of forms being adopted in different studies, the most beneficial protocol of Tai Chi style and number of forms could not be commented upon. Hence, future studies are warranted to address these topics.

Whole-Body Vibration Intensities in Chronic Stroke: A Randomized Controlled Trial.

PURPOSE: A single-blinded randomized controlled study was conducted to investigate the effects of different whole-body vibration (WBV) intensities on body functions/structures, activity, and participation in individuals with stroke. METHODS: Eighty-four individuals with chronic stroke (mean age = 61.2 yr, SD = 9.2) with mild to moderate motor impairment (Chedoke-McMaster Stroke Assessment lower limb motor score: median = 9 out of 14, interquartile range = 7-11.8) were randomly assigned to a low-intensity WBV, high-intensity WBV, or control group. The former two groups performed various leg exercises while receiving low-intensity and high-intensity WBV, respectively. Controls performed the same exercises without WBV. All individuals received 30 training sessions over an average period of 75.5 d (SD = 5.2). Outcome measurements included knee muscle strength (isokinetic dynamometry), knee and ankle joint spasticity (Modified Ashworth Scale), balance (Mini Balance Evaluation Systems Test), mobility (Timed-Up-and-Go test), walking endurance (6-Minute Walk Test), balance self-efficacy (Activities-specific Balance Confidence scale), participation in daily activities (Frenchay Activity Index), perceived environmental barriers to societal participation (Craig Hospital Inventory of Environmental Factors), and quality of life (Short-Form 12 Health Survey). Assessments were performed at baseline and postintervention. RESULTS: Intention-to-treat analysis revealed a significant time effect for muscle strength, Timed-Up-and-Go distance, and oxygen consumption rate achieved during the 6-Minute Walk Test, the Mini Balance Evaluation Systems Test, the Activities-specific Balance Confidence scale, and the Short-Form 12 Health Survey physical composite score domain (P < 0.05). However, the time-group interaction was not significant for any of the outcome measures (P > 0.05). CONCLUSION: The addition of the 30-session WBV paradigm to the leg exercise protocol was no more effective in enhancing body functions/structures, activity, and participation than leg exercises alone in chronic stroke patients with mild to moderate motor impairments.

Effects of Vibration Intensity, Exercise, and Motor Impairment on Leg Muscle Activity Induced by Whole-Body Vibration in People With Stroke.

BACKGROUND: Whole-body vibration (WBV) has increasingly been used as an adjunct treatment in neurological rehabilitation. However, how muscle activation level changes during exposure to different WBV protocols in individuals after stroke remains understudied. OBJECTIVE: The purpose of this study was to examine the influence of WBV intensity on the magnitude of biceps femoris (BF) and tibialis anterior (TA) muscle activity and its interaction with exercise and with severity of motor impairment and spasticity among individuals with chronic stroke. METHODS: Each of the 36 individuals with chronic stroke (mean age=57.3 years, SD=10.7) performed 8 different static exercises under 3 WBV conditions: (1) no WBV, (2) low-intensity WBV (frequency=20 Hz, amplitude=0.60 mm, peak acceleration=0.96g), and (3) high-intensity WBV (30 Hz, 0.44 mm, 1.61g). The levels of bilateral TA and BF muscle activity were recorded using surface electromyography (EMG). RESULTS: The main effect of intensity was significant. Exposure to the low-intensity and high-intensity protocols led to a significantly greater increase in normalized BF and TA muscle electromyographic magnitude in both legs compared with no WBV. The intensity × exercise interaction also was significant, suggesting that the WBV-induced increase in EMG activity was exercise dependent. The EMG responses to WBV were similar between the paretic and nonparetic legs and were not associated with level of lower extremity motor impairment and spasticity. LIMITATIONS: Leg muscle activity was measured during static exercises only. CONCLUSIONS: Adding WBV during exercise significantly increased EMG activity in the TA and BF muscles. The EMG responses to WBV in the paretic and nonparetic legs were similar and were not related to degree of motor impairment and spasticity. The findings are useful for guiding the design of WBV training protocols for people with stroke.