L.M. Fuller

Physiotherapy for cystic fibrosis in Australia and New Zealand: A clinical practice guideline

Physiotherapy management is a key element of care for people with cystic fibrosis (CF) throughout the lifespan. Although considerable evidence exists to support physiotherapy management of CF, there is documented variation in practice. The aim of this guideline is to optimize the physiotherapy management of people with CF in Australia and New Zealand. A systematic review of the literature in key areas of physiotherapy practice for CF was undertaken. Recommendations were formulated based on National Health and Medical Research Council (Australia) guidelines and considered the quality, quantity and level of the evidence; the consistency of the body of evidence; the likely clinical impact; and applicability to physiotherapy practice in Australia and New Zealand. A total of 30 recommendations were made for airway clearance therapy, inhalation therapy, exercise assessment and training, musculoskeletal management, management of urinary incontinence, managing the newly diagnosed patient with CF, delivery of non‐invasive ventilation, and physiotherapy management before and after lung transplantation. These recommendations can be used to underpin the provision of evidence‐based physiotherapy care to people with CF in Australia and New Zealand.

Longer Versus Shorter Duration of Supervised Rehabilitation After Lung Transplantation: A Randomized Trial.

OBJECTIVE To investigate the effects of a supervised longer- (14wk) versus shorter-duration (7wk) rehabilitation program after lung transplantation (LTX). DESIGN Randomized controlled trial. SETTING Outpatient rehabilitation gym setting. PARTICIPANTS Post-LTX patients aged ≥18 years (N=66; 33 women; mean age, 51±13y) who had undergone either single LTX or bilateral LTX. INTERVENTION Outpatient rehabilitation program consisting of thrice-weekly sessions with cardiovascular training on bike ergometer and treadmill plus upper and lower limb strength training. MAIN OUTCOME MEASURES Measures were taken at baseline, 7 weeks, 14 weeks, and 6 months by assessors who were blinded to group allocation. Functional exercise capacity was measured by the 6-minute walk test (6MWT). Strength of quadriceps and hamstrings was measured on an isokinetic dynamometer and recorded as average peak torque of 6 repetitions for both muscles. Quality of life (QOL) was assessed with the Medical Outcomes Study 36-Item Short-Form Health Survey. RESULTS Of the participants, 86% had bilateral LTX and 41% had primary diagnosis of chronic obstructive pulmonary disease. The 6MWT increased in both groups with no significant difference between groups at any time point (mean 6mo 6MWD: short, 590±85m vs long, 568±127m; P=0.5). Similarly, at 6 months, there was no difference between groups in quadriceps average peak torque (mean, 115±38Nm vs 114±40Nm, respectively; P=.59), hamstring average peak torque (57±18Nm vs 52±19Nm, respectively; P=.36), or mental or physical health domains of quality of life. CONCLUSIONS Shorter duration (7wk) of rehabilitation achieves comparable outcomes with 14 weeks of supervised rehabilitation for functional exercise capacity, lower limb strength, and quality of life at 6 months after LTX.

Prospective, randomized, controlled trial of polymer cable ties versus standard wire closure of midline sternotomy

Objective Midline sternotomy remains the most common access incision for cardiac operations. Traditionally, the sternum is closed with stainless steel wires. Wires are well known to stretch and break, however, leading to pain, nonunion, and potential deep sternal wound infection. We hypothesized that biocompatible plastic cable ties would achieve a more rigid sternal fixation, reducing postoperative pain and analgesia requirements. Methods A prospective, randomized study compared the ZIPFIX (De Puy Synthes, West Chester, Pa) sternal closure system (n = 58) with standard stainless steel wires (n = 60). Primary outcomes were pain and analgesia requirements in the early postoperative period. Secondary outcome was sternal movement, as assessed by ultrasound at the postoperative follow‐up visit. Results Groups were well matched in demographic and operative variables. There were no significant differences between groups in postoperative pain, analgesia, or early ventilatory requirements. Patients in the ZIPFIX group had significantly more movement in the sternum and manubrium on ultrasound at 4 weeks. Conclusions ZIPFIX sternal cable ties provide reliable closure but no demonstrable benefit in this study in pain or analgesic requirements relative to standard wire closure after median sternotomy.

Physical Function in Subjects Requiring Extracorporeal Membrane Oxygenation Before or After Lung Transplantation

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is used as a rescue therapy before and after lung transplantation, but little is known about functional recovery or complications after ECMO in this cohort. This study aimed to describe early physical function and leg complications in subjects who received ECMO before or after lung transplantation, and to compare functional outcomes to a matched cohort of subjects who did not require ECMO. METHODS: A retrospective study was conducted over 2 years. Highest mobility level was assessed, in both the ECMO and non-ECMO groups, prior to ICU admission, at ICU discharge, and at hospital discharge, while 6-min walk distance was measured at hospital discharge and at 3 months. Strength was assessed at ICU discharge and at hospital discharge in the ECMO subjects only, and leg complications were recorded up until hospital discharge. RESULTS: 17 subjects (mean age 43 ± 13 y; 65% (11 of 17 subjects) female) required ECMO before or after lung transplant. Survival to hospital discharge was 82% (14 of 17 subjects). At ICU discharge, strength and mobility levels were poor, but both improved by hospital discharge (P < .001). Leg complications were reported in 50% of survivors (7 of 14 subjects). ECMO survivors spent longer in the ICU (P < .001) and hospital (P = .002) and had worse physical function (ie, lower mobility level at ICU discharge, mean difference −1, P = .02; 6-min walk distance at hospital discharge: mean difference −99 m, P = .004) than lung transplant recipients not requiring ECMO (n = 28). CONCLUSIONS: In subjects requiring ECMO before or after lung transplantation, 82% survived to hospital discharge, but leg complications were common and physical function was poor at ICU discharge. Physical function improved over time, however subjects who required ECMO had a longer period of hospitalization and worse physical function at ICU and hospital discharge than those who did not require ECMO.

Effect of Upper Limb Rehabilitation Compared to No Upper Limb Rehabilitation in Lung Transplant Recipients: A Randomized Controlled Trial

OBJECTIVE To investigate the effect of a supervised upper limb (UL) program (SULP) compared to no supervised UL program (NULP) after lung transplantation (LTx). DESIGN Randomized controlled trial. SETTING Physiotherapy gym. PARTICIPANTS Participants (N=80; mean age, 56±11y; 37 [46%] men) were recruited after LTx. INTERVENTIONS All participants underwent lower limb strength thrice weekly and endurance training. Participants randomized to SULP completed progressive UL strength training program using handheld weights and adjustable pulley equipment. MAIN OUTCOME MEASURES Overall bodily pain was rated on the visual analog scale. Shoulder flexion and abduction muscle strength were measured on a hand held dynamometer. Health related quality of life was measured with Medical Outcomes Study 36-item Short Form health Survey and the Quick Dash. Measurements were made at baseline, 6 weeks, 12 weeks, and 6 months by blinded assessors. RESULTS After 6 weeks of training, participants in the SULP (n=41) had less overall bodily pain on the visual analog scale than did participants in the NULP (n=36) (mean VAS bodily pain score, 2.1±1.3cm vs 3.8±1.7cm; P<.001) as well as greater UL strength than did participants in the NULP (mean peak force, 8.4±4.0Nm vs 6.7±2.8Nm; P=.037). At 12 weeks, participants in the SULP better quality of life related to bodily pain (76±17 vs 66±26; P=.05), but at 6 months there were no differences between the groups in any outcome measures. No serious adverse events were reported. CONCLUSIONS UL rehabilitation results in short-term improvements in pain and muscle strength after LTx, but no longer-term effects were evident.

Reliability of sternal instability scale (SIS) for transverse sternotomy in lung transplantation (LTX)

ABSTRACT A surgical incision for bilateral sequential lung transplantation (BSLTX) is the “clam shell” (CSI) approach via bilateral anterior thoracotomies and a transverse sternotomy to allow for sequential replacement of the lungs. This can be associated with significant post-operative pain, bony overriding or sternal instability. The sternal instability scale (SIS) is a non-invasive manual assessment tool that can be used to detect early bony non-union or instability following CSI; however, its reliability is unknown. Objective: This prospective blinded reliability study aimed to assess intra-rater and inter-rater reliability of the SIS following lung transplantation. Method: Participants post BSLTX aged older than 18 years underwent sternal assessment utilizing the SIS. Two assessors examined the sternum using a standardized protocol at two separate time points with a test–re-test time of 48 hours. The outcome measure was SIS tool using four categories from 0 (clinically stable) to 3 (separated sternum with overriding). Results: In total, 20 participants (75% female) with a mean age of 48 years (SD 17) and mean pain score of 3 out of 10 were included, 60% having well healed wounds and 25% reporting symptoms of sternal clicking. The most painful self-reported painful activity was coughing. The SIS demonstrated excellent reliability with a kappa = 0.91 by different assessors on the same day, and kappa = 0.83 for assessments by the same assessor on different days. Conclusion: The SIS is a reliable manual assessment tool for evaluation of sternal instability after CSI following BSLTX and may facilitate the timely detection and management of sternal instability.