Motor neuroprosthesis for promoting recovery of function after stroke.

BACKGROUND: Motor neuroprosthesis (MN) involves electrical stimulation of neural structures by miniaturized devices to allow the performance of tasks in the natural environment in which people live (home and community context), as an orthosis. In this way, daily use of these devices could act as an environmental facilitator for increasing the activities and participation of people with stroke. OBJECTIVES: To assess the effects of MN for improving independence in activities of daily living (ADL), activities involving limbs, participation scales of health-related quality of life (HRQoL), exercise capacity, balance, and adverse events in people after stroke. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (searched 19 August 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (August 2019), MEDLINE (1946 to 16 August 2019), Embase (1980 to 19 August 2019), and five additional databases. We also searched trial registries, databases, and websites to identify additional relevant published, unpublished, and ongoing trials. SELECTION CRITERIA: Randomized controlled trials (RCTs) and randomized controlled cross-over trials comparing MN for improving activities and participation versus other assistive technology device or MN without electrical stimulus (stimulator is turned off), or no treatment, for people after stroke. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, extracted data, and assessed risk of bias of the included studies. Any disagreements were resolved through discussion with a third review author. We contacted trialists for additional information when necessary and performed all analyses using Review Manager 5. We used GRADE to assess the certainty of the evidence. MAIN RESULTS: We included four RCTs involving a total of 831 participants who were more than three months poststroke. All RCTs were of MN that applied electrical stimuli to the peroneal nerve. All studies included conditioning protocols to adapt participants to MN use, after which participants used MN from up to eight hours per day to all-day use for ambulation in daily activities performed in the home or community context. All studies compared the use of MN versus another assistive device (ankle-foot orthosis [AFO]). There was a high risk of bias for at least one assessed domain in three of the four included studies. No studies reported outcomes related to independence in ADL. There was low-certainty evidence that AFO was more beneficial than MN on activities involving limbs such as walking speed until six months of device use (mean difference (MD) -0.05 m/s, 95% confidence interval (CI) -0.10 to -0.00; P = 0.03; 605 participants; 2 studies; I2 = 0%; low-certainty evidence); however, this difference was no longer present in our sensitivity analysis (MD -0.07 m/s, 95% CI -0.16 to 0.02; P = 0.13; 110 participants; 1 study; I2 = 0%). There was low to moderate certainty that MN was no more beneficial than AFO on activities involving limbs such as walking speed between 6 and 12 months of device use (MD 0.00 m/s, 95% CI -0.05 to 0.05; P = 0.93; 713 participants; 3 studies; I2 = 17%; low-certainty evidence), Timed Up and Go (MD 0.51 s, 95% CI -4.41 to 5.43; P = 0.84; 692 participants; 2 studies; I2 = 0%; moderate-certainty evidence), and modified Emory Functional Ambulation Profile (MD 14.77 s, 95% CI -12.52 to 42.06; P = 0.29; 605 participants; 2 studies; I2 = 0%; low-certainty evidence). There was no significant difference in walking speed when MN was delivered with surface or implantable electrodes (test for subgroup differences P = 0.09; I2 = 65.1%). For our secondary outcomes, there was very low to moderate certainty that MN was no more beneficial than another assistive device for participation scales of HRQoL (standardized mean difference 0.26, 95% CI -0.22 to 0.74; P = 0.28; 632 participants; 3 studies; I2 = 77%; very low-certainty evidence), exercise capacity (MD -9.03 m, 95% CI -26.87 to 8.81; P = 0.32; 692 participants; 2 studies; I2 = 0%; low-certainty evidence), and balance (MD -0.34, 95% CI -1.96 to 1.28; P = 0.68; 692 participants; 2 studies; I2 = 0%; moderate-certainty evidence). Although there was low- to moderate-certainty evidence that the use of MN did not increase the number of serious adverse events related to intervention (risk ratio (RR) 0.35, 95% CI 0.04 to 3.33; P = 0.36; 692 participants; 2 studies; I2 = 0%; low-certainty evidence) or number of falls (RR 1.20, 95% CI 0.92 to 1.55; P = 0.08; 802 participants; 3 studies; I2 = 33%; moderate-certainty evidence), there was low-certainty evidence that the use of MN in people after stroke may increase the risk of participants dropping out during the intervention (RR 1.48, 95% CI 1.11 to 1.97; P = 0.007; 829 participants; 4 studies; I2 = 0%). AUTHORS' CONCLUSIONS: Current evidence indicates that MN is no more beneficial than another assistive technology device for improving activities involving limbs measured by Timed Up and Go, balance (moderate-certainty evidence), activities involving limbs measured by walking speed and modified Emory Functional Ambulation Profile, exercise capacity (low-certainty evidence), and participation scale of HRQoL (very low-certainty evidence). Evidence was insufficient to estimate the effect of MN on independence in ADL. In comparison to other assistive devices, MN does not appear to increase the number of falls (moderate-certainty evidence) or serious adverse events (low-certainty evidence), but may result in a higher number of dropouts during intervention period (low-certainty evidence).

Physical therapy for the management of global function, fatigue and quality of life in amyotrophic lateral sclerosis: systematic review and meta-analyses.

OBJECTIVES: To critically evaluate the effectiveness of physical therapy interventions in improving global function, quality of life and fatigue in individuals with amyotrophic lateral sclerosis (ALS). DESIGN: Systematic review and meta-analyses. DATA SOURCES: MEDLINE, EMBASE, Cochrane Library (CENTRAL) and Physiotherapy Evidence Database (PEDro) were searched through 31 January 2023. ELIGIBILITY CRITERIA: We included randomised clinical trials (RCTs) that compared physical therapy interventions that act on global function, fatigue and quality of life in individuals with ALS with any other non-physiotherapeutic methods and techniques, placebo or non-intervention. The primary outcome measure was the evaluation of global function. Secondary outcomes were quality of life, fatigue and adverse events. DATA EXTRACTION AND SYNTHESIS: Two independent authors used a researcher-developed extraction form and the Rayyan software to search, screen and code included studies. The risk of bias was assessed using the PEDro scale. Meta-analyses were conducted employing random effects. Outcomes were succinctly presented in Grading of Recommendations, Assessment, Development and Evaluation evidence profiles. RESULTS: Our searches identified 39 415 references. After study selection, three studies were included in the review. Such studies involved 62 participants with a mean age of 54.6 years. In the evaluated trials, 40 were male, while 22 participants were female. Regarding the type of onset of the disease, 58 participants had spinal onset of ALS, and four had bulbar. CONCLUSIONS: Physical therapy intervention may improve the global function of individuals with ALS in the short term; however, clinically, it was inconclusive. In terms of quality of life and fatigue, physical therapy intervention is not more effective than control in the short term. Adverse events are not increased by physical therapy intervention in the short term. Due to significant methodological flaws, small sample sizes, wide CIs and clinical interpretation, our confidence in the effect estimate is limited. PROSPERO REGISTRATION NUMBER: CRD42021251350.

Physical performance testing in post-COVID-19 patients: protocol for a systematic review of psychometric measurement properties.

INTRODUCTION: COVID-19 is an infectious disease that causes severe acute respiratory syndrome. A large variety of exercise capacity tests are used for the evaluation of post-COVID-19 patients, but the psychometric properties of these exercise tests remain undetermined in this population. This study aims to critically appraise, compare and summarise the psychometric properties (validity, reliability and responsiveness) of all physical performance tests that are used to assess exercise capacity in post-COVID-19 patients. METHODS AND ANALYSIS: This systematic review protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. We will include studies with hospitalised adult post-COVID-19 patients (aged 18 years or older and with a confirmed diagnosis of COVID-19). The research will cover randomised controlled trials (RCTs), quasi-RCTs and observational studies published in English and performed in the following settings: hospital, rehabilitation centre, outpatient clinic. We will search the following databases with no date restrictions: PubMed/MEDLINE, EMBASE, SciELO, Cochrane Library, CINAHL and Web of Science. Two authors will independently assess the risk of bias (using the Consensus-Based Standards for the Selection of Health Measurement Instruments Risk of bias checklist) and the certainty of evidence (using the Grading of Recommendations, Assessment, Development and Evaluations). According to the results obtained, data will be meta-analysed or reported narratively. ETHICS AND DISSEMINATION: No ethical approval is required for this publication since it will be based on published data. Results of this review will be disseminated via peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42021242334.

Reliability of maximal respiratory nasal pressure tests in healthy young adults.

INTRODUCTION: Sniff nasal inspiratory (SNIP) and expiratory pressure (SNEP) may complement the assessment of respiratory muscle strength. Thus, specifying their reliability is relevant to improving the clinical consistency of both tests. OBJECTIVE: To assess the reliability of SNIP and SNEP in healthy young adults. METHODS: This cross-sectional study included self-reported healthy aged 18 to 29 years. SNIP was performed using a plug to occlude one nostril, while SNEP was conducted using a facemask. Participants performed 20 SNIP and SNEP maneuvers with 30-second intervals in between. The intraclass correlation coefficient (ICC), standard error of measurement (SEM), and minimum detectable change (MDC) assessed the reliability of SNIP and SNEP. Analyses were conducted between the highest peak pressure and the first reproducible maneuver in men and women. RESULTS: The total sample comprised 32 participants: 16 men and 16 women. The ICC, SEM, and MDC for SNIP maneuvers were 0.994 (95%CI 0.988 to 0.997), 1.820 cmH2O, and 5.043 cmH2O, respectively. For SNEP, these parameters were 0.950 (95%CI 0.897 to 0.976), 6.03 cmH2O, and 16.716 cmH2O. The SNIP and SNEP in men showed ICC of 0.992 (95%CI 0.977 to 0.997) and 0.877 (95%CI 0.648 to 0.957), SEM of 2.07 and 7.66 cmH2O, and MDC of 5.74 and 21.23 cmH2O. In women, SNIP and SNEP presented ICC of 0.992 (95%CI 0.977 to 0.997) and 0.957 (95%CI 0.878 to 0.985), SEM of 1.15 and 6.11 cmH2O, and MDC of 3.19 and 16.95 cmH2O. Also, 60% of the highest SNIPs occurred among the 11th and 20th maneuvers in men and women. In men, 55% of the highest SNEPs occurred among the 11th and 20th maneuvers; this value was 50% in women. CONCLUSION: SNIP and SNEP showed excellent reliability. The reliability of SNIP and SNEP in men was good and excellent, respectively, whereas both tests had excellent reliability in women. Also, women reached the highest peak pressure faster than men in both tests.

Effects of respiratory physiotherapy in patients with amyotrophic lateral sclerosis: protocol for a systematic review of randomised controlled trials.

INTRODUCTION: Respiratory muscle weakness and ventilatory failure are common complications in patients with amyotrophic lateral sclerosis (ALS) and may lead to death. Respiratory physiotherapy may improve lung function in this population. This study aims to investigate the effects of respiratory physiotherapy on lung function, cough efficacy and functional status of patients with ALS. METHODS AND ANALYSIS: A protocol was published on the International prospective register of systematic reviews (PROSPERO). The research will cover randomised controlled trials, with no language or publication date restriction, available in the following databases: MEDLINE/PubMed, EMBASE, Cochrane Library, Web of Science and Physiotherapy Evidence Database. The research question will be answered using a search strategy adapted for each database. Searches in databases will be conducted from January 2021 to December 2022. Two authors using the Cochrane risk of bias tool for randomised trials V.2 and Grading of Recommendations, Assessment, Development and Evaluations, respectively, will assess risk of bias and quality of evidence independently. According to the results obtained, data will be reported as a meta-analysis or a narrative report. ETHICS AND DISSEMINATION: No previous ethical approval is required for this publication since data used are already published. Results of this review will be disclosed via peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42021251842.

Electrical activity and fatigue of respiratory and locomotor muscles in obstructive respiratory diseases during field walking test.

INTRODUCTION: In subjects with obstructive respiratory diseases the increased work of breathing during exercise can trigger greater recruitment and fatigue of respiratory muscles. Associated with these changes, lower limb muscle dysfunctions, further contribute to exercise limitations. We aimed to assess electrical activity and fatigue of two respiratory and one locomotor muscle during Incremental Shuttle Walking Test (ISWT) in individuals with obstructive respiratory diseases and compare with healthy. METHODS: This is a case-control study. Seventeen individuals with asthma (asthma group) and fifteen with chronic obstructive pulmonary disease (COPD group) were matched with healthy individuals (asthma and COPD control groups). Surface electromyographic (sEMG) activity of sternocleidomastoid (SCM), scalene (ESC), and rectus femoris (RF) were recorded during ISWT. sEMG activity was analyzed in time and frequency domains at baseline and during the test (33%, 66%, and 100% of ISWT total time) to obtain, respectively, signal amplitude and power spectrum density (EMG median frequency [MF], high- and low-frequency bands, and high/low [H/L] ratio). RESULTS: Asthma group walked a shorter distance than controls (p = 0.0007). sEMG amplitudes of SCM, ESC, and RF of asthma and COPD groups were higher at 33% and 66% of ISWT compared with controls groups (all p<0.05). SCM and ESC of COPD group remained higher until 100% of the test. MF of ESC and RF decreased in asthma group (p = 0.016 and p < 0.0001, respectively) versus controls, whereas MF of SCM (p < 0.0001) decreased in COPD group compared with controls. H/L ratio of RF decreased (p = 0.002) in COPD group versus controls. CONCLUSION: Reduced performance is accompanied by increased electromyographic activity of SCM and ESC and activation of RF in individuals with obstructive respiratory diseases during ISWT. These are susceptible to be more pronounced respiratory and peripheral muscle fatigue than healthy subjects during exercise.

Psychometric properties of the sit-to-stand test for patients with pulmonary hypertension: A systematic review protocol.

BACKGROUND: Pulmonary hypertension (PH) is a complex syndrome characterized by increased pulmonary arterial pressure and classified into five groups, according to dyspnea on exertion and systemic muscle dysfunction. These symptoms can be identified using the sit-to-stand test (STS), which indirectly evaluates exercise tolerance and lower limb muscle strength. Previous studies used the STS in PH; however, psychometric properties to understand and validate this test were not described for patients with PH. OBJECTIVE: To evaluate the psychometric properties (validity, reliability, and responsiveness) of different STS protocols in patients with PH. METHODS AND ANALYSES: This is a systematic review protocol that will include studies using STS in patients with PH. Searches will be conducted on PubMed/MEDLINE, EMBASE, SciELO, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science databases following PICOT mnemonic strategy and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P). Rayyan software will be used for study selection. The Risk of bias will be assessed using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) tool, while the quality of evidence will be assessed using the modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Two researchers will independently conduct the study, and a third researcher will be consulted in case of disagreement. The psychometric properties will be evaluated according to the COSMIN. This protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO, no. CRD42021244271). CONCLUSION: This systematic review will attempt to identify and show the available evidence on STS for different groups of PH and report validity, reliability, and responsiveness of different protocols.

Physical therapy for the management of motor symptoms in amyotrophic lateral sclerosis: protocol for a systematic review.

INTRODUCTION: The prescription of an intervention plan can be challenging for the physical therapist, considering clinical phenotypes, individual prognosis and the rapid, progressive and deteriorating nature of amyotrophic lateral sclerosis (ALS). In this context, therapeutic exercises (eg, resistance and aerobic exercises) for patients with ALS remain controversial and may influence the treatment plan. Therefore, this review aims to critically assess whether physical therapy interventions are effective for improving functional capacity, quality of life and fatigue of individuals with ALS. METHODS AND ANALYSIS: Studies will be selected according to eligibility criteria, and language, geographical area or publication date will not be restricted. Four databases will be used: MEDLINE, EMBASE, Cochrane Library (CENTRAL) and Physiotherapy Evidence Database (PEDro). Searches will also be conducted on ClinicalTrials.gov and references from included studies. We plan to conduct the searches between October and December 2022. Two independent authors will examine titles and abstracts and exclude irrelevant studies and duplicates. We will assess the quality of studies and quality of evidence, and disagreements will be resolved with a third researcher. The findings will be presented in the text and tables; if possible, we will perform meta-analyses. ETHICS AND DISSEMINATION: No ethical approval is required because this study does not involve human beings. We will publish our findings in peer-reviewed journals. PROSPERO REGISTRATION NUMBER: CRD42021251350.

Effects of an optimised approach to home-based respiratory care in individuals with amyotrophic lateral sclerosis: a study protocol for a randomised controlled trial.

INTRODUCTION: This study aims to investigate the effects of an optimal home-based respiratory care protocol in individuals with amyotrophic lateral sclerosis (ALS). METHODS AND ANALYSIS: This is a randomised, blinded controlled trial involving patients diagnosed with ALS, both sexes, age between 18 and 80 years. Patients will be randomly allocated into the conventional respiratory care (CRC) group and the optimised respiratory care home-based (ORC) group. Primary outcomes will be peak cough flow, the number of exacerbations and ALS Functional Rating Scale Revised. Secondary outcomes will include chest wall volumes, maximal respiratory pressures, sniff nasal inspiratory pressure, nasal expiratory pressure and forced vital capacity (FVC), forced expiratory volume in the 1st second (FEV1) and FEV1/FVC. The CRC group will receive educational information about respiratory care at the clinic. The ORC group will receive conventional care and home-based care. The clinical status of all individuals will be monitored weekly through telephone calls. A 6-month intervention is planned, the outcomes will be assessed every 3 months and 3 and 6 months follow-up after final evaluation. The primary and secondary results will be described as average or median for continuous variables and absolute and relative frequencies for qualitative variables. Treatment effects or differences between the outcomes (baseline, 3 months and 6 months) of the study groups will be analysed using an analysis of variance. The level of significance will be set as p≤0.05. ETHICS AND DISSEMINATION: The research ethics committee approved the study. It is expected to evaluate respiratory function in patients with ALS in the short, medium and long terms with home-based care protocol applied. The disease's rapid progression is a limitation for performing a long-term clinical study. TRIAL REGISTRATION NUMBER: RBR-3z23ts; Pre-results.

Effects of diaphragmatic control on multiparametric analysis of the sniff nasal inspiratory pressure test and inspiratory muscle activity in healthy subjects.

BACKGROUND: We investigated the influence of diaphragmatic activation control (diaphC) on the relaxation rate, contractile properties and electrical activity of the inspiratory muscles of healthy subjects. Assessments were performed non-invasively using the sniff inspiratory pressure test (SNIP) and surface electromyography, respectively. METHODS: Twenty-two subjects (10 men and 12 women) performed 10 sniff maneuvers in two different days: with and without diaphC instructions. For the SNIP test with diaphC, the subjects were instructed to perform intense activation of the diaphragm. The tests with the best SNIP values were used for analysis. RESULTS: The maneuver with diaphC when compared to the maneuver without diaphC exhibited significant lower values for: SNIP (p <0.01), maximum relaxation rate (MRR) (p <0.01), maximum rate of pressure development (MRPD) (p <0.01), contraction times (CT) (p = 0.02) and electrical activity of the sternocleidomastoid (SCM) (p <0.01), scalene (SCL) (p = 0.01) and intercostal (CI) (p = 0.03) muscles. In addition, the decay constant (tau, τ) and relaxation time (½ RT) did not present any changes. CONCLUSION: The diaphragmatic control performed during the SNIP test influences the inspiratory pressure and the contractile properties of inspiratory muscles. This occurs due to changes in the pattern of muscle recruitment, which change force velocity characteristics of the test. Thus, instruction on diaphC should be encouraged for better performance of the SNIP test and for evaluation targeting the diaphragm muscle activity.

Weaning from mechanical ventilation in people with neuromuscular disease: a systematic review.

OBJECTIVE: This systematic review aimed in assessing the effects of different weaning protocols in people with neuromuscular disease (NMD) receiving invasive mechanical ventilation, identifying which protocol is the best and how different protocols can affect weaning outcome success, duration of weaning, intensive care unit (ICU) and hospital stay and mortality. DESIGN: Systematic review. DATA SOURCES: Electronic databases (MEDLINE, EMBASE, Web of Science and Scopus) were searched from January 2009 to August 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised controlled trials (RCTs) and non-RCT that evaluated patients with NMD (adults and children from 5 years old) in the weaning process managed with a protocol (pressure support ventilation; synchronised intermittent mandatory ventilation; continuous positive airway pressure; 'T' piece). PRIMARY OUTCOME: Weaning success. SECONDARY OUTCOMES: Weaning duration, ICU stay, hospital stay, ICU mortality, complications (pneumothorax, ventilation-associated pneumonia). DATA EXTRACTION AND SYNTHESIS: Two review authors assessed the titles and the abstracts for inclusion and reviewed the full texts independently. RESULTS: We found no studies that fulfilled the inclusion criteria. CONCLUSIONS: The absence of studies about different weaning protocols for patients with NMD does not allow concluding the superiority of any specific weaning protocol for patients with NMD or determining the impact of different types of protocols on other outcomes. The result of this review encourages further studies. PROSPERO REGISTRATION NUMBER: CRD42019117393.

Normal range of values for contractility and relaxation parameters of inspiratory muscles in healthy children: An exploratory study.

OBJECTIVES: To estimate normal range of values for the contractility and relaxation parameters of inspiratory muscles and compare them by sex, age, nutritional status and level of physical activity in healthy children. WORKING HYPOTHESIS: We hypothesized that healthy children present similar range of values for the contractility and relaxation parameters of inspiratory muscles. STUDY DESIGN: Exploratory study conducted between 2017 and 2018. PATIENT-SUBJECT SELECTION: Healthy children aged 6 to 11 years without history of respiratory, cardiac, cerebrovascular or neuromuscular disease as well as no nasal congestion, influenza or known septum deviation were included. METHODOLOGY: Anthropometric, spirometry and respiratory muscle strength data were assessed. Maximum rate of pressure development (MRPD), maximum relaxation rate (MRR), time constant of decay curve (τ), contraction time (CT) and half-relaxation time (½ RT) were calculated from the nasal inspiratory pressure curve. RESULTS: The sample was composed of 110 children (55 boys) with 1.045 as mean z-BMI-score. MRPD range of values was 8.09% to 10.86% rise/10 ms, MRR range of values was 8.09% to 10.86% fall/10 ms, τ range of values was 36.41 to 49.88 ms, CT range of values was 200 to 276 ms, ½ RT range of values was 117.5 to 148 ms and MRPD/MRR range of values was 0.71 to 1.04. The contractility and relaxation parameters did not present significant differences among children when compared by sex, age, nutritional status, or level of physical activity groups (P > .05). CONCLUSIONS: The contractility and relaxation parameters present similar values among children and they are not influenced by age, sex, nutritional status or physical activity level.

Supervised exercise protocol for lower limbs in subjects with chronic venous disease: an evaluator-blinded, randomized clinical trial.

BACKGROUND: Chronic venous insufficiency (CVI) causes pathophysiological changes in the lower-limb muscles, particularly the calf muscles, and limits ankle range of motion (ROM). These changes reduce functional activities and decrease quality of life (QOL). Although several studies have shown the benefits of exercise (strengthening the calf muscles to improve calf-muscle pumping and QOL) in patients with CVI, few studies are randomized controlled trials. This has led to a weak indication of exercise for the treatment of patients with CVI. The aim of this study is to analyze the effects of a supervised exercise program to improve calf-muscle endurance as well as QOL in patients with CVI. METHODS/DESIGN: This is an evaluator-blind, randomized clinical trial with an 8-week duration and a follow-up evaluation at week 16. A pilot study with subjects with a CVI diagnosis will be performed to calculate sample size. The participants will be randomly allocated (1:1) into a treatment or a control group (usual care/no intervention). The treatment intervention consists of a bi-weekly supervised exercise program of the lower limbs that will include aerobic training, strengthening and cardiovascular exercises. The participants from both groups will participate in a health education lecture. Primary outcomes are changes in calf-muscle endurance and QOL score. Secondary outcomes are changes in exercise capacity, ankle ROM, electrical muscle activity and cardiac output. The first statistical comparison will be performed after 8 weeks' intervention. DISCUSSION: Patients with CVI may have an impaired calf-muscle pump and decreased exercise capacity. A randomized controlled trial evaluating a supervised exercise program should provide much needed information on the management of CVI to promote health and independence. TRIAL REGISTRATION: This study was registered on the Brazilian Clinical Trials Database (REBEC) (RBR-57xtk7). The results will be disseminated at scientific events, presentations, and publications in peer-reviewed journals.

Weaning from mechanical ventilation in people with neuromuscular disease: protocol for a systematic review.

INTRODUCTION: Neuromuscular diseases (NMD) are characterised by progressive muscular impairment. The muscle weakness is directly related to respiratory muscles weakness, causing reduction in vital capacity, especially when associated with mechanical ventilation (MV). Conventional MV weaning in NMD is generally difficult. Weaning process can be conducted in protocols such as: 'T' piece or Pressure Support Ventilaton. Weaning failure is frequent because of muscle weakness. Protocol aim is to assess the effects of different weaning protocols in NMD patients receiving invasive MV in weaning success rate, duration of weaning, intensive care unit (ICU) stay, hospital stay and ICU mortality. METHODS AND ANALYSIS: A search will be carried in the Cochrane Neuromuscular Specialised Register, MEDLINE, EMBASE, Web of Science, Scopus, United States National Institutes of Health Clinical Trials Registry, ClinicalTrials.gov and WHO International Clinical Trial Registry Protal, of randomised controlled trials (RCTs) and quasi-RCTs. Inclusion criteria of individuals are adults (above 16 years old) and children (from 5 to 16 years old), with clinical diagnosis of NMD (muscular dystrophy, amyotrophic lateral sclerosis, congenital myasthenia, myasthenia gravis, congenital myopathy, spinal muscular atrophy, Guillian Barré Syndrome, severe inherited neuropathies, metabolic myopathies, inflammatory myopathies, mitochondrial diseases) of any gender. All patients ventilated for at least 48 hours due to respiratory failure and clinically considered ready for weaning. Other respiratory or cardiovascular diagnosis associated will not be included. Intervention assessed will be weaning from MV using a protocol with 30 min to 2 hours of spontaneous breathing trial at the end point. All comparisons of different protocols will be considered. ETHICS AND DISSEMINATION: Formal ethical approval is not required as primary data will not be collected, since it will be a systematic review. All studies included should have ethical committee approval. The results will be disseminated through a peer-reviewed publication and in conferences and congresses or symposia. PROSPERO REGISTRATION NUMBER: CRD42019117393.

Effects of different modalities of inspiratory muscle training as an add-on to conventional treatment of patients with chronic obstructive pulmonary disease (COPD): study protocol for a randomized controlled trial.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) leads to peripheral and respiratory muscle dysfunctions. Nowadays, inspiratory muscle training can be geared toward strength or endurance gains. This study aims to investigate the effects of an inspiratory muscle training (IMT) protocol using different therapeutic modalities to be implemented in pulmonary rehabilitation programs. The effects of IMT on exercise capacity were considered as the primary endpoint, and the effects of IMT on inspiratory muscle function, health-related quality of life, and daily physical activity level were considered as the secondary outcomes. METHODS: This study is a blinded-investigator randomized controlled clinical trial. Sixty subjects will be randomly allocated into three groups: (1) pulmonary rehabilitation (PR) associated with inspiratory muscle training without any load (PRWIMT), (2) PR associated with inspiratory muscle training with a linear load (PRIMTLL), and (3) PR associated with inspiratory muscle training with isocapnic voluntary hyperpnea (PRIMTIVH). The protocol will be performed 5 days a week (3 days with supervision) for 10 weeks. The study will assess anthropometric data, lung function, respiratory muscle strength, and functional capacity by the Incremental Shuttle Walking Test and the Six-Minute Walk Test, lung volumes during the submaximal endurance test, peripheral muscle strength of the upper and lower limbs, dyspnea, and quality of life related to health, before and after the training protocol. Normality will be tested using the Kolmogorov-Smirnov test, and variables will be compared by two-way analysis of variance. The significance level was set at p < 0.05. Ethics approval was obtained from the Institutional Ethics Committee in Research (1.663.411). The study results will be disseminated through presentation at specific scientific conferences and publication in peer-reviewed journals. DISCUSSION: The different IMT protocols used in our study will be able to guide respiratory therapists to understand and to include in conventional PR programs the most effective respiratory muscle training type in subjects with COPD. TRIAL REGISTRATION: Brazilian Clinical Trials Registry, RBR-94v6kd . Registered on 11 March 2017.

Effects of positive expiratory pressure on chest wall volumes in subjects with stroke compared to healthy controls: a case-control study.

BACKGROUND: Alterations in respiratory system kinematics in stroke lead to restrictive pattern associated with decreased lung volumes. Chest physical therapy, such as positive expiratory pressure, may be useful in the treatment of these patients; however, the optimum intensity to promote volume and motion changes of the chest wall remains unclear. OBJECTIVE: To assess the effect of different intensities of positive expiratory pressure on chest wall kinematics in subjects with stroke compared to healthy controls. METHODS: 16 subjects with chronic stroke and 16 healthy controls matched for age, gender, and body mass index were recruited. Chest wall volumes were assessed using optoelectronic plethysmography during quiet breathing, 5 minutes, and recovery. Three different intensities of positive expiratory pressure (10, 15, and 20cmH2O) were administered in a random order with a 30 minutes rest interval between intensities. RESULTS: During positive expiratory pressure, tidal chest wall expansion increased in both groups compared to quiet breathing; however, this increase was not significant in the subjects with stroke (0.41 vs. 1.32L, 0.56 vs. 1.54L, 0.52 vs. 1.8L, at 10, 15, 20cmH2O positive expiratory pressure, for stroke and control groups; p<0.001). End-expiratory chest wall volume decreased in controls, mainly due to the abdomen, and increased in the stroke group, mainly due the pulmonary rib cage. CONCLUSION: Positive expiratory pressure administration facilitates acute lung expansion of the chest wall and its compartments in restricted subjects with stroke. Positive expiratory pressure intensities above 10cmH2O should be used with caution as the increase in end-expiratory volume led to hyperinflation in subjects with stroke.

Air Stacking: A Detailed Look Into Physiological Acute Effects on Cough Peak Flow and Chest Wall Volumes of Healthy Subjects.

BACKGROUND: Air stacking (AS) is a lung insufflation method that requires the use of a manual insufflator to provide air volumes higher than inspiratory capacity. Neuromuscular patients benefit the most from the maneuver; however, the acute effects of AS in healthy subjects are still unclear. METHODS: Twenty healthy subjects (8 males) were studied by optoelectronic plethysmography to investigate the immediate effects of AS on cough peak flow, operational volume variations, distribution of these volumes in the chest wall compartments (pulmonary rib cage, abdominal rib cage, and abdominal), breathing pattern, and shortening velocity of the respiratory muscles during a protocol that included vital capacity maneuvers and spontaneous coughs before and after AS. RESULTS: Statistically significant increases in cough peak flow (P < .03) and inspiratory capacity (P < .001) were found immediately after AS. During its application, the pulmonary rib cage compartment was the largest contributor (P = .002) to chest wall volume displacement. A significant increase in chest wall tidal volume (P < .001), mainly in the pulmonary rib cage (P < .001), was observed. Significant increases (P < .001) in end-inspiratory chest wall volume were observed with main distribution in pulmonary (P < .001) and abdominal rib cage (P = .01). Significant increases in shortening velocity index of inspiratory muscles (P < .001), expiratory muscles (P < .001), and diaphragm (P < .001) were also observed. In addition, significant decreases in expiratory time (P < .001) and increases in duty cycle (P = .02), breathing frequency (P = .02), minute ventilation (P < .001), maximum inspiratory (P < .001), and expiratory flow (P < .001) were observed. CONCLUSIONS: In healthy subjects, cough peak flow and chest wall volumes can be increased immediately after the application of the AS maneuver.

Effects of diaphragmatic control on the assessment of sniff nasal inspiratory pressure and maximum relaxation rate.

OBJECTIVE: To assess the influence of diaphragmatic activation control (diaphC) on Sniff Nasal-Inspiratory Pressure (SNIP) and Maximum Relaxation Rate of inspiratory muscles (MRR) in healthy subjects. METHOD: Twenty subjects (9 male; age: 23 (SD=2.9) years; BMI: 23.8 (SD=3) kg/m²; FEV1/FVC: 0.9 (SD=0.1)] performed 5 sniff maneuvers in two different moments: with or without instruction on diaphC. Before the first maneuver, a brief explanation was given to the subjects on how to perform the sniff test. For sniff test with diaphC, subjects were instructed to perform intense diaphragm activation. The best SNIP and MRR values were used for analysis. MRR was calculated as the ratio of first derivative of pressure over time (dP/dtmax) and were normalized by dividing it by peak pressure (SNIP) from the same maneuver. RESULTS: SNIP values were significantly different in maneuvers with and without diaphC [without diaphC: -100 (SD=27.1) cmH2O/ with diaphC: -72.8 (SD=22.3) cmH2O; p<0.0001], normalized MRR values were not statistically different [without diaphC: -9.7 (SD=2.6); with diaphC: -8.9 (SD=1.5); p=0.19]. Without diaphC, 40% of the sample did not reach the appropriate sniff criteria found in the literature. CONCLUSION: Diaphragmatic control performed during SNIP test influences obtained inspiratory pressure, being lower when diaphC is performed. However, there was no influence on normalized MRR.

Muscle impairment in neuromuscular disease using an expiratory/inspiratory pressure ratio.

BACKGROUND: Neuromuscular diseases (NMDs) lead to different weakness patterns, and most patients with NMDs develop respiratory failure. Inspiratory and expiratory muscle strength can be measured by maximum static inspiratory pressure (PImax) and maximum static expiratory pressure (PEmax), and the relationship between them has not been well described in healthy subjects and subjects with NMDs. Our aim was to assess expiratory/inspiratory muscle strength in NMDs and healthy subjects and calculate PEmax/PImax ratio for these groups. METHODS: Seventy (35 males) subjects with NMDs (amyotrophic lateral sclerosis, myasthenia gravis, and myotonic dystrophy), and 93 (47 males) healthy individuals 20-80 y of age were evaluated for anthropometry, pulmonary function, PImax, and PEmax, respectively. RESULTS: Healthy individuals showed greater values for PImax and PEmax when compared with subjects with NMDs. PEmax/PImax ratio for healthy subjects was 1.31 ± 0.26, and PEmax%/PImax% was 1.04 ± 0.05; for subjects with NMDs, PEmax/PImax ratio was 1.45 ± 0.65, and PEmax%/PImax% ratio was 1.42 ± 0.67. We found that PEmax%/PImax% for myotonic dystrophy was 0.93 ± 0.24, for myasthenia gravis 1.94 ± 0.6, and for amyotrophic lateral sclerosis 1.33 ± 0.62 when we analyzed them separately. All healthy individuals showed higher PEmax compared with PImax. For subjects with NMDs, the impairment of PEmax and PImax is different among the 3 pathologies studied (P < .001). CONCLUSIONS: Healthy individuals and subjects with NMDs showed higher PEmax in comparison to PImax regarding the PEmax/PImax ratio. Based on the ratio, it is possible to state that NMDs show different patterns of respiratory muscle strength loss. PEmax/PImax ratio is a useful parameter to assess the impairment of respiratory muscles in a patient and to customize rehabilitation and treatment.