The clinical effects of combining postural exercises with chest physiotherapy in cystic fibrosis: A single-blind, randomized-controlled trial

Exercise intolerance, oxidative stress, and irisin in pediatric cystic fibrosis: Can telehealth-based exercise training make a difference?

BACKGROUND

Patients with cystic fibrosis (CF) experience increased oxidative stress. Tele-exercise can be a new method to improve exercise in CF.

OBJECTIVE

This study aimed to investigate the effect of telehealth-based exercise training using different modalities (combined exercise training group, CombG, core stabilization exercise group, SG), in comparison with control group (CG), on exercise capacity, oxidative stress, and irisin in children with CF.

METHODS

Thirty-nine children with CF (mean age=11.41±2.18 years, mean FEV1(z-score)=-0.66±1.96) were included in the study. The children were randomly allocated to groups. The CombG and SG performed core stabilization exercises (CS) 3 days per week for 8 weeks. The CombG also performed aerobic exercises 3 days per week in addition to CS. Physical activity (PA) recommendations were provided to the CG. Exercise capacity was evaluated using the Modified Shuttle Test (MST). Oxidative stress was assessed using total antioxidant status (TAS), total oxidant status (TOS), Oxidative Stress Index (OSI), malondialdehyde (MDA), and superoxide dismutase (SOD). The irisin level was also measured.

RESULTS

Children's baseline sex, age, BMI, and FEV1 z-scores were similar (p > 0.05). The MST distance (p = 0.047,np2=0.157) and%MST distance (p = 0.045, np2=0.159) significantly improved in the CombG compared with the SG and CG. Although TAS and SOD decreased over time (p < 0.05), no significant changes were observed for TAS, TOS, OSI, MDA, SOD, and irisin parameters between the groups after training (p > 0.05).

CONCLUSIONS

Combining aerobic exercise training with core stabilization applied using telehealth improved exercise capacity more than core stabilitation training only or PA recommendations in children with CF.

Clinimetric properties of field exercise tests in cystic fibrosis: a systematic review

OBJECTIVES

Accurate measurement of exercise capacity is an important prognostic indicator for people with cystic fibrosis (pwCF); however, gold-standard, cardiopulmonary exercise tests are commonly unavailable. This review systematically describes the clinimetric properties of field exercise tests for pwCF.

METHODS

A systematic review was undertaken for studies reporting field exercise tests in pwCF. Four electronic databases were searched for studies published from 1990 to January 2024. Where available, clinimetric properties reported included reliability, validity, responsiveness and interpretability.

RESULTS

4041 studies were identified with 153 eligible for inclusion. 10 different field exercise tests were described, including six walk/run tests (incremental shuttle walk test (ISWT), modified shuttle test-15 levels (MST-15), MST-25 levels (MST-25), 20-m shuttle test, 6-min walk test (6MWT) and 12-min walk test (12MWT)), three step tests (3-min step test (3MST), incremental step test and Alfred step test (A-STEP)) and the 1-min sit-to-stand test (1STS). Reliability was found for the ISWT, MST-15, 6MWT, 1STS and 3MST (intraclass correlation coefficients >0.80). The ISWT, MST-15 and 6MWT were found to be valid (concurrent and discriminate). Responsiveness was supported for the 6MWT only. Four tests (MST-15, 6MWT, 3MST and 1STS) demonstrated ceiling effects.

CONCLUSION

This review supports the reliability, validity and responsiveness of the 6MWT in pwCF. The ISWT and MST-15 were found to be valid. The 1STS is reliable and feasible, but its utility is limited by ceiling effects. The 3MST, MST-25, 20-m shuttle test, incremental step test, A-STEP and 12MWT require further investigations of their clinimetric properties.

Active cycle of breathing technique for cystic fibrosis

BACKGROUND

People with cystic fibrosis (CF) experience chronic airway infections as a result of mucus buildup within the lungs. Repeated infections often cause lung damage and disease. Airway clearance therapies aim to improve mucus clearance, increase sputum production, and improve airway function. The active cycle of breathing technique (ACBT) is an airway clearance method that uses a cycle of techniques to loosen airway secretions including breathing control, thoracic expansion exercises, and the forced expiration technique. This is an update of a previously published review.

OBJECTIVES

To compare the clinical effectiveness of ACBT with other airway clearance therapies in CF.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched clinical trials registries and the reference lists of relevant articles and reviews. Date of last search: 29 March 2021.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled clinical studies, including cross-over studies, comparing ACBT with other airway clearance therapies in CF.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened each article, abstracted data and assessed the risk of bias of each study. We used GRADE to assess our confidence in the evidence assessing quality of life, participant preference, adverse events, forced expiratory volume in one second (FEV1) % predicted, forced vital capacity (FVC) % predicted, sputum weight, and number of pulmonary exacerbations.

MAIN RESULTS

Our search identified 99 studies, of which 22 (559 participants) met the inclusion criteria. Eight randomised controlled studies (259 participants) were included in the analysis; five were of cross-over design. The 14 remaining studies were cross-over studies with inadequate reports for complete assessment. The study size ranged from seven to 65 participants. The age of the participants ranged from six to 63 years (mean age 18.7 years). In 13 studies follow up lasted a single day. However, there were two long-term randomised controlled studies with follow up of one to three years. Most of the studies did not report on key quality items, and therefore, have an unclear risk of bias in terms of random sequence generation, allocation concealment, and outcome assessor blinding. Due to the nature of the intervention, none of the studies blinded participants or the personnel applying the interventions. However, most of the studies reported on all planned outcomes, had adequate follow up, assessed compliance, and used an intention-to-treat analysis. Included studies compared ACBT with autogenic drainage, airway oscillating devices (AOD), high-frequency chest compression devices, conventional chest physiotherapy (CCPT), positive expiratory pressure (PEP), and exercise. We found no difference in quality of life between ACBT and PEP mask therapy, AOD, other breathing techniques, or exercise (very low-certainty evidence). There was no difference in individual preference between ACBT and other breathing techniques (very low-certainty evidence). One study comparing ACBT with ACBT plus postural exercise reported no deaths and no adverse events (very low-certainty evidence). We found no differences in lung function (forced expiratory volume in one second (FEV1) % predicted and forced vital capacity (FVC) % predicted), oxygen saturation or expectorated sputum between ACBT and any other technique (very low-certainty evidence). There were no differences in the number of pulmonary exacerbations between people using ACBT and people using CCPT (low-certainty evidence) or ACBT with exercise (very low-certainty evidence), the only comparisons to report this outcome.

AUTHORS' CONCLUSIONS

There is little evidence to support or reject the use of the ACBT over any other airway clearance therapy and ACBT is comparable with other therapies in outcomes such as participant preference, quality of life, exercise tolerance, lung function, sputum weight, oxygen saturation, and number of pulmonary exacerbations. Longer-term studies are needed to more adequately assess the effects of ACBT on outcomes important for people with cystic fibrosis such as quality of life and preference.

Physical activity and exercise training in cystic fibrosis

BACKGROUND

Physical activity (including exercise) may form an important part of regular care for people with cystic fibrosis (CF). This is an update of a previously published review.

OBJECTIVES

To assess the effects of physical activity interventions on exercise capacity by peak oxygen uptake, lung function by forced expiratory volume in one second (FEV1), health-related quality of life (HRQoL) and further important patient-relevant outcomes in people with cystic fibrosis (CF).

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. The most recent search was on 3 March 2022. We also searched two ongoing trials registers: clinicaltrials.gov, most recently on 4 March 2022; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), most recently on 16 March 2022.  SELECTION CRITERIA: We included all randomised controlled trials (RCTs) and quasi-RCTs comparing physical activity interventions of any type and a minimum intervention duration of two weeks with conventional care (no physical activity intervention) in people with CF.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected RCTs for inclusion, assessed methodological quality and extracted data. We assessed the certainty of the evidence using GRADE.  MAIN RESULTS: We included 24 parallel RCTs (875 participants). The number of participants in the studies ranged from nine to 117, with a wide range of disease severity. The studies' age demographics varied: in two studies, all participants were adults; in 13 studies, participants were 18 years and younger; in one study, participants were 15 years and older; in one study, participants were 12 years and older; and seven studies included all age ranges. The active training programme lasted up to and including six months in 14 studies, and longer than six months in the remaining 10 studies. Of the 24 included studies, seven implemented a follow-up period (when supervision was withdrawn, but participants were still allowed to exercise) ranging from one to 12 months. Studies employed differing levels of supervision: in 12 studies, training was supervised; in 11 studies, it was partially supervised; and in one study, training was unsupervised. The quality of the included studies varied widely. This Cochrane Review shows that, in studies with an active training programme lasting over six months in people with CF, physical activity probably has a positive effect on exercise capacity when compared to no physical activity (usual care) (mean difference (MD) 1.60, 95% confidence interval (CI) 0.16 to 3.05; 6 RCTs, 348 participants; moderate-certainty evidence). The magnitude of improvement in exercise capacity is interpreted as small, although study results were heterogeneous. Physical activity interventions may have no effect on lung function (forced expiratory volume in one second (FEV1) % predicted) (MD 2.41, 95% CI ‒0.49 to 5.31; 6 RCTs, 367 participants), HRQoL physical functioning (MD 2.19, 95% CI ‒3.42 to 7.80; 4 RCTs, 247 participants) and HRQoL respiratory domain (MD ‒0.05, 95% CI ‒3.61 to 3.51; 4 RCTs, 251 participants) at six months and longer (low-certainty evidence). One study (117 participants) reported no differences between the physical activity and control groups in the number of participants experiencing a pulmonary exacerbation by six months (incidence rate ratio 1.28, 95% CI 0.85 to 1.94) or in the time to first exacerbation over 12 months (hazard ratio 1.34, 95% CI 0.65 to 2.80) (both high-certainty evidence); and no effects of physical activity on diabetic control (after 1 hour: MD ‒0.04 mmol/L, 95% CI ‒1.11 to 1.03; 67 participants; after 2 hours: MD ‒0.44 mmol/L, 95% CI ‒1.43 to 0.55; 81 participants; moderate-certainty evidence). We found no difference between groups in the number of adverse events over six months (odds ratio 6.22, 95% CI 0.72 to 53.40; 2 RCTs, 156 participants; low-certainty evidence). For other time points (up to and including six months and during a follow-up period with no active intervention), the effects of physical activity versus control were similar to those reported for the outcomes above. However, only three out of seven studies adding a follow-up period with no active intervention (ranging between one and 12 months) reported on the primary outcomes of changes in exercise capacity and lung function, and one on HRQoL. These data must be interpreted with caution. Altogether, given the heterogeneity of effects across studies, the wide variation in study quality and lack of information on clinically meaningful changes for several outcome measures, we consider the overall certainty of evidence on the effects of physical activity interventions on exercise capacity, lung function and HRQoL to be low to moderate.

AUTHORS' CONCLUSIONS

Physical activity interventions for six months and longer likely improve exercise capacity when compared to no training (moderate-certainty evidence). Current evidence shows little or no effect on lung function and HRQoL (low-certainty evidence). Over recent decades, physical activity has gained increasing interest and is already part of multidisciplinary care offered to most people with CF. Adverse effects of physical activity appear rare and there is no reason to actively discourage regular physical activity and exercise. The benefits of including physical activity in an individual's regular care may be influenced by the type and duration of the activity programme as well as individual preferences for and barriers to physical activity. Further high-quality and sufficiently-sized studies are needed to comprehensively assess the benefits of physical activity and exercise in people with CF, particularly in the new era of CF medicine.

The effect of telerehabilitation on quality of life, anxiety, and depression in children with cystic fibrosis and caregivers: A single-blind randomized trial

BACKGROUND

Postural and aerobic exercises are essential in rehabilitation in cystic fibrosis (CF). The aim of this study is to examine the effect of telerehabilitation on the quality of life, depression, and anxiety levels of children with CF and their caregivers' mood and anxiety levels.

MATERIALS AND METHODS

Patients between the ages of 6-13 with CF were randomized into two groups. Study group received an exercise program three times a week via Zoom for 12 weeks. Cystic Fibrosis Revised Questionnaire (CFQ-R), Anxiety and Depression Scale in Children-Revised (RCADS) were applied to the patients and State-Trait Anxiety Scale (STAI) and Beck Depression Inventory (BDI) were applied to the caregivers in the beginning and at the end of the program. Patients' FEV1 levels and 6-min walk tests were also measured.

RESULTS

Twenty-eight patient-caregiver dyads, 14 dyads in each group, completed the study. The initial mean RCADS-Major depressive disorder score of the patients in the exercise group was 6.21 ± 3.11, and this value decreased to 3.92 ± 3.79 at the end of the study and was significantly better (p < 0.02). A similar significant change was observed when the RCADS-generalized anxiety disorder score decreased from the initial mean level of 6.28 ± 2.81 to 3.42 ± 2.65 (p < 0.01). There were significant changes in improvement in the body image in telerehabilitation group. Similar significant changes were not observed in the control group. Caregivers' anxiety and depression levels did not change significantly.

CONCLUSION

A short-term telerehabilitation program improved patients' anxiety and depression levels, body image, and functional status. However, caregiver anxiety and depression levels did not change significantly.