International Physiotherapy Group for Cystic Fibrosis
|
|
|
|
|
| |
INTERNATIONAL PHYSIOTHERAPY PRACTICE IN INFANTS WITH CYSTIC FIBROSIS SURVEY RESULTS 1998 – 2000 .
Results.
Analysis of
Data
Completed questionnaires were returned in 1999 and 2000 from 27 of the 40 (67.5%)
member countries. A total of 166 completed questionnaires were analyzed. The pilot centres completed
the final questionnaire for inclusion in these results. North America, South America, The United
Kingdom, Western Europe, Eastern Europe, Northern and Southern Europe and Australasia were
represented in the completed questionnaires (see Table 1).
Size of CF centres
CF centres ranged in size from a few patients to 750 patients
(see Figure 1). The majority of centres had between 40 and 200 patients. A few centres had between
350 and 750 patients. The number of infants treated at individual centres varied widely. The mean
number of infants attending CF centres surveyed was 14.3 ?16 (range 1 – 113). Eighty-five percent of
centres treated up to 25 infants. A further 10% of centres had between 25 and 50 infants, while 4%
of centres had between 50 and 75 infants, 0.7% of centres had 75-100 infants and 0.7% had 100-125
infants (see Figure 1).
Physiotherapists’ experience treating infants with CF
The mean experience of the
161 responders was 12.5 ? 8 (range 0.5 – 39.5) years. The majority of therapists had 5 to 15 years
of respiratory physiotherapy experience treating patients with CF. However, 24 therapists had 0.5 to
5 years experience (see Figure 2).
Newborn
screening
Of the 144 responder centres surveyed 43% carried out newborn screening while
57% did not provide the service at the time of the survey.
Timing of introduction of daily physiotherapy
At centres with newborn screening,
physiotherapy was commenced at the time of diagnosis at 77% of centres. Similarly, at centres
without newborn screening, physiotherapy was commenced at the time of diagnosis at 86% of
centres.
Education of the provider of daily physiotherapy
for infants with CF
The CF physiotherapist was the primary educator at 93% of centres with
initial education
occurring in the inpatient and outpatient settings in equal proportions.
Parents,
grandparents, or guardians provided daily physiotherapy at 93% of centres.
Hospital
or community therapists and trained therapy assistants provided treatment at a few centres while
trained lay persons provided daily physiotherapy at 16% of responder centres. Others who
occasionally provided physiotherapy included extended family members, family friends, babysitters,
kindergarten assistants, older siblings, day care providers or community / home care
nurses.
Patient segregation and infection control
procedures
During hospital admissions patient segregation based on respiratory organisms
was carried out at 85% of the responder centres (116 centres) while 15% of centres did not practice
segregation (21 centres). In the setting of the Outpatient Clinic, a total of 68% of centres
segregated patients based on pulmonary organisms (95 centres) while 32% (44 centres) did not
segregate outpatients.
Inhalation therapy used as an adjunct to physiotherapy in clinically
asymptomatic versus symptomatic infants
Inhalation therapy in general was used frequently or
always at 74% of centres surveyed.
Hypertonic saline and propylene glycol were the least
frequently used inhalations. Fewer than a third of centres used bronchodilator agents or isotonic
saline with clinically asymptomatic infants. Bronchodilator and antibiotic inhalations were the most
frequently prescribed inhalations for symptomatic infants. RhDNase was used in less than 10% of
centres with clinically asymptomatic infants in contrast to about a third of centres with
symptomatic infants (see Table 2).
Physiotherapy
Techniques
The different physiotherapy and cough stimulating techniques used are
summarized in Table 3.
Postural drainage and modified postural drainage were used frequently or
always in similar proportions (55% and 47% respectively) at responder centres; manual techniques
(percussion or clapping) at 35%, vibration at 52%, mechanical vibration at 9%, positioning to
improve ventilation at 58%, assisted autogenic drainage (the adaptation of autogenic drainage in
infants: the physiotherapist manually increases the expiratory flow velocity and prolongs expiration
towards residual volume) at 19%, the French technique of manually increasing expiratory flow with
thoracic compression combined with cough stimulation at 17%, the German technique of contact
breathing with the infant altering respiration in response to the physiotherapist’s hands at 15%,
the Swedish technique of physical activity interspersed with assisted autogenic drainage maneuvers
at 19%, and positive expiratory pressure therapy (PEP) at 14% (see Table 3).
Use of cough stimulation
Cough stimulation techniques were used
at 31% of centres. The different types of cough stimulation used were nasopharyngeal or
oropharyngeal suction, stimulation of the back of the tongue, and tracheal pressure (see Table
3).
There were different reasons why some physiotherapists used cough stimulating techniques.
These included stimulation of a cough during assessment of the infant’s respiratory status,
intermittently during and/or at the end of a treatment session. Some therapists used cough
stimulation only in clinically symptomatic infants while other used them regardless of the infants’
respiratory status (see Table 3).
Physiotherapy Dosage
The number of different positions
recommended per treatment session
The majority of centres used four or six positions per
treatment with four being the most frequently used number for clinically asymptomatic and
symptomatic infants. The range in number of positions used per treatment was between 1 and 12. Those
using traditional postural drainage were the ones most likely to use 12 positions per treatment. For
a graphic summary of the number of positions used by the responder centres with asymptomatic and
symptomatic infants see Figure 3.
Total time per treatment session (including inhalation therapy)
recommended
The most frequently prescribed physiotherapy treatment time regardless of symptoms
was 26-30 minutes (inclusive of inhalation therapy). Extremely short or long treatments were seldom
used.
Number of treatments per day – asymptomatic versus symptomatic infants
Once daily was
most frequently prescribed for clinically asymptomatic infants while two to three times daily for
symptomatic infants. It was rare for physiotherapy to be prescribed more than three times daily.
Recommended timing of physiotherapy treatments in relation to infant meals
In this open ended
question some replied with more than one answer, for example, “before meals or at least 1 to 2 hours
after meals”. The majority (106 of 166) recommended physiotherapy before meals. If treatment was
undertaken after meals, the minority (14 of 166) recommended waiting less than an hour, while the
majority recommended at least an hour with some proposing treatment one to two hours after meals (51
of 166). A further minority suggested at least two hours after feeds (17 of 166) (see Figure
4).
Therapists opinions regarding common infant behaviors during physiotherapy
Approximately
one third of physiotherapists frequently or always allowed infants to suck on a pacifier during
treatment, one third never or rarely allowed non-nutritive sucking and a third occasionally used a
pacifier. Some therapists had no opinion on the topic. Nearly half of therapists allowed infants to
fall asleep during treatment, while others thought treatment would not be as effective if infants
slept through treatment. The majority of therapists ceased treating infants who became extremely
upset during treatment, while a small proportion said they would continue regardless of the infant’s
apparent distress. For detailed results of therapist’s opinions and recommendations related to
different infant behaviors during treatment see Table 4.
Management of gastro-oesophageal reflux
(GOR) in relation to physiotherapy
Clinical observation and history taking of signs such as
vomiting, regurgitation and re-swallowing, pain and irritability during physiotherapy possibly
associated with GOR were always or frequently carried out at 88% of 154 responder centres. Modified
positioning during physiotherapy (avoiding head down tilt) was used always or frequently at 75% of
centres surveyed.
|
|
|
|
|
|
|
| |
| |
|
|
