Publications by authors named "Rik Gosselink"

121 Publications

Inspiratory muscle training in intensive care unit patients: An international cross-sectional survey of physiotherapist practice.

Aust Crit Care 2021 Sep 8. Epub 2021 Sep 8.

Discipline of Physiotherapy, University of Canberra, Australia; Physiotherapy Department, Canberra Hospital, Australia. Electronic address:

Background: Inspiratory muscle training is safe and effective in reversing inspiratory muscle weakness and improving outcomes in patients who have experienced prolonged mechanical ventilation in the intensive care unit (ICU). The degree of worldwide implementation of inspiratory muscle training in such patients has not been investigated.

Objectives: The objectives of this study were to describe the current practice of inspiratory muscle training by intensive care physiotherapists and investigate barriers to implementation in the intensive care context and additionally to determine if any factors are associated with the use of inspiratory muscle training in patients in the ICU and identify preferred methods of future education.

Method: Online cross-sectional surveys of intensive care physiotherapists were conducted using voluntary sampling. Multivariate logistic regression analysis was used to identify factors associated with inspiratory muscle training use in patients in the ICU.

Results: Of 360 participants, 63% (95% confidence interval [CI] = 58 to 68) reported using inspiratory muscle training in patients in the ICU, with 69% (95% CI = 63 to 75) using a threshold device. Only 64% (95% CI = 58 to 70) of participants who used inspiratory muscle training routinely assessed inspiratory muscle strength. The most common barriers to implementing inspiratory muscle training sessions in eligible patients were sedation and delirium. Participants were 4.8 times more likely to use inspiratory muscle training in patients if they did not consider equipment a barrier and were 4.1 times more likely to use inspiratory muscle training if they aware of the evidence for this training in these patients. For education about inspiratory muscle training, 41% of participants preferred online training modules.

Conclusion: In this first study to describe international practice by intensive care therapists, 63% reported using inspiratory muscle training. Improving access to equipment and enhancing knowledge of inspiratory muscle training techniques could improve the translation of evidence into practice.
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http://dx.doi.org/10.1016/j.aucc.2021.08.002DOI Listing
September 2021

COVID-19 recovery: benefits of multidisciplinary respiratory rehabilitation.

BMJ Open Respir Res 2021 09;8(1)

Department of Respiratory Diseases, KU Leuven University Hospitals Leuven, Leuven, Belgium.

Many patients struggle with ongoing symptoms in different domains (physical, mental, cognitive) after hospitalisation for COVID-19, calling out for a multidisciplinary approach. An outpatient multidisciplinary rehabilitation programme, according to a respiratory rehabilitation strategy, was set up for adult patients who were able to attend group sessions during 12 weeks. Results of 22 adult patients with COVID-19, of which 15 had required intensive care, were analysed and some general impressions and challenges of rehabilitation in COVID-19 were reported. Impressive results on physical recovery were determined after 6 weeks and 3 months, with significant improvement of lung function, muscle force and exercise capacity variables. A positive evolution of mental and cognitive burden was present, although less pronounced than the physical recovery. These mental and cognitive consequences seem, next to musculoskeletal and medical complications, the most challenging aspect of rehabilitating patients with COVID-19. These real-world data show feasibility and efficiency of a multidisciplinary respiratory rehabilitation programme after moderate to severe COVID-19 disease.
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http://dx.doi.org/10.1136/bmjresp-2020-000837DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8423511PMC
September 2021

Measurement validity of an electronic training device to assess breathing characteristics during inspiratory muscle training in patients with weaning difficulties.

PLoS One 2021 26;16(8):e0255431. Epub 2021 Aug 26.

Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium.

Inspiratory muscle training (IMT) improves respiratory muscle function and might enhance weaning outcomes in patients with weaning difficulties. An electronic inspiratory loading device provides valid, automatically processed information on breathing characteristics during IMT sessions. Adherence to and quality of IMT, as reflected by work of breathing and power generated by inspiratory muscles, are related to improvements in inspiratory muscle function in patients with chronic obstructive pulmonary disease. The aim of this study was to investigate the validity of an electronic training device to assess and provide real-time feedback on breathing characteristics during inspiratory muscle training (IMT) in patient with weaning difficulties. Patients with weaning difficulties performed daily IMT sessions against a tapered flow-resistive load of approximately 30 to 50% of the patient's maximal inspiratory pressure. Airflow and airway pressure measurements were simultaneously collected with the training device (POWERbreatheKH2, POWERbreathe International Ltd, UK) and a portable spirometer (reference device, Pocket-Spiro USB/BT100, M.E.C, Belgium). Breath by breath analysis of 1002 breaths of 27 training sessions (n = 13) against a mean load of 46±16% of the patient's maximal inspiratory pressure were performed. Good to excellent agreement (Intraclass correlation coefficients: 0.73-0.97) was observed for all breathing characteristics. When individual differences were plotted against mean values of breaths recorded by both devices, small average biases were observed for all breathing characteristics. To conclude, the training device provides valid assessments of breathing characteristics to quantify inspiratory muscle effort (e.g. work of breathing and peak power) during IMT in patients with weaning difficulties. Availability of valid real-time data of breathing responses provided to both the physical therapist and the patient, can be clinically usefull to optimize the training stimulus. By adapting the external load based on the visual feedback of the training device, respiratory muscle work and power generation during IMT can be maximized during the training.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0255431PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8389486PMC
August 2021

High-Intensity Training for 6 Months Safely, but Only Temporarily, Improves Exercise Capacity in Selected Solid Organ Transplant Recipients.

Transplant Proc 2021 Jul-Aug;53(6):1836-1845. Epub 2021 May 25.

Department of Microbiology, Immunology, and Transplantation, Laboratory of Abdominal Transplantation, KU Leuven, Leuven, Belgium; Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium. Electronic address:

Background: Organ transplantation is a life-saving intervention that improves quality of life of patients with irreversible organ failure. Although exercise training immediately after transplantation has been suggested to be beneficial, such interventions remain rare in stable transplant recipients, whereas effects of high-intensity training (HIT) are even less frequently investigated. Moreover, sustainability of such interventions has not yet been reported. We investigated the effects of a 6-month, cycling-based HIT program on physical performance in long-term stable solid organ transplant (SOT) recipients, with follow-up evaluation after 6 months.

Methods: Forty-two adult, stable, and selected SOT recipients participated in a 6-month individualized home- and group-based HIT program. Exercise capacity (VOmax), maximal power (Wmax), and body mass index were measured before, at the end, and 6 months after completion of the intervention.

Results: The study comprised 12 heart, 7 lung, 8 liver, and 15 kidney recipients (mean age, 41.4 ± 11.1 years; median time posttransplant, 3.4 [1.7-8.0] years). For 6 months, VOmax increased in the heart, lung, and kidney groups, Wmax increased in the heart group, and body mass index decreased in the liver group. Six months after the HIT program, the achieved gain in exercise capacity had disappeared in all groups.

Conclusion: Despite voluntary participation selection bias, our observations indicate that HIT is safe and may result in a beneficial effect on physical performance in selected, stable SOT recipients. However, there was no sustained beneficial effect once training stopped. Larger scale and longer term studies are still required to investigate longevity of improvement and overall beneficial effects on clinical outcomes.
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http://dx.doi.org/10.1016/j.transproceed.2021.03.040DOI Listing
May 2021

Why COVID-19 strengthens the case to scale up assault on non-communicable diseases: role of health professionals including physical therapists in mitigating pandemic waves.

AIMS Public Health 2021 16;8(2):369-375. Epub 2021 Apr 16.

Division of Physiotherapy, School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden.

As SARS-CoV-2, the virus responsible for COVID-19, spread globally, the most severely affected sub-populations were the elderly and those with multi-morbidity largely related to non-communicable diseases (NCDs), e.g., heart disease, hypertension, type 2 diabetes, obesity. NCDs are largely preventable with healthy nutrition, regular activity, and not smoking. This perspective outlines the rationale for health professionals' including physical therapists' role in reducing COVID-19 susceptibility. Evidence is synthesized supporting the pro-inflammatory effects of the western diet, increasingly consumed globally, inactivity, and smoking; and the immune-boosting, anti-inflammatory effects of a whole food plant-based diet, regular physical activity, and not smoking. An increased background of chronic low-grade systemic inflammation associated with unhealthy lifestyle practices appears implicated in an individual's susceptibility to SARS-CoV-2. It is timely to re-double efforts across healthcare sectors to reduce the global prevalence of NCDs on two fronts: one, to reduce SARS-CoV-2 susceptibility; and two, to reduce the impact of subsequent waves given high blood pressure and blood sugar, common in people with multi-morbidity, can be improved within days/weeks with anti-inflammatory healthy lifestyle practices, and weight loss and atherosclerosis reduction/reversal, within months/years. With re-doubled efforts to control NCD risk factors, subsequent waves could be less severe. Health professionals including physical therapists have a primary role in actively leading this initiative.
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http://dx.doi.org/10.3934/publichealth.2021028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8116194PMC
April 2021

Impact of COVID-19: urging a need for multi-domain assessment of COVID-19 inpatients.

Eur Geriatr Med 2021 08 30;12(4):741-748. Epub 2021 Mar 30.

Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.

Objective: To retrospectively analyse data obtained from the multi-domain assessment of hospitalized COVID-19 patients, to describe their health status at discharge, and to investigate whether subgroups of patients, more specific ICU patients and older adults (> 70 years), had more (or less) risk to experience specific impairments.

Methods: Retrospective case series in the University Hospitals Leuven, Belgium of confirmed COVID-19 patients 'after surviving an ICU-stay', 'aged ≥ 70 years', or 'aged < 70 years with a length of hospitalization > 7 days'. Exclusion criteria were 'unwilling to cooperate', 'medically unstable', or 'palliative care policy'. Following tests were used: 'Five Times Sit To Stand Test', 'hand grip dynamometry', 'Barthel index', 'Swallowing screening', 'Montreal Cognitive Assessment', 'Hospital Anxiety and Depression Scale', and 'Nutritional Risk Screening 2002'.

Results: One or more tests were obtained in 135/163 patients (83.3%). Physical impairments were present in 43.2-82.8% of the patients. Median BI was 10/20 indicating limited self-dependency. Swallow impairments were present in 3/53 (5.7%) and 24/76 (31.6%) had risk of malnutrition. Impaired memory was seen in 26/43 (60.5%) and 22/47 (46.8%) had elevated anxiety/depression scores. Older adults had more physical, functional, and cognitive impairments. ICU patients had a lower hand grip force.

Conclusion(s): The high prevalence of physical, cognitive, psychological, and functional impairments in hospitalized COVID-19 patients, both ICU and non-ICU patients, indicates that assessment of impairments is imperative. These results imply that rehabilitation and follow-up is essential for these patients. This paper proposes a short, workable assessment composed with known outcome measures to assess different domains of COVID-19 patients.
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http://dx.doi.org/10.1007/s41999-021-00486-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8009466PMC
August 2021

Five-year outcome of respiratory muscle weakness at intensive care unit discharge: secondary analysis of a prospective cohort study.

Thorax 2021 06 12;76(6):561-567. Epub 2021 Mar 12.

Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium

Purpose: To assess the association between respiratory muscle weakness (RMW) at intensive care unit (ICU) discharge and 5-year mortality and morbidity, independent from confounders including peripheral muscle strength.

Methods: Secondary analysis of the prospective 5-year follow-up of the EPaNIC cohort (ClinicalTrials.gov: NCT00512122), limited to 366 patients screened for respiratory and peripheral muscle strength in the ICU with maximal inspiratory pressure (MIP) after removal of the artificial airway, and the Medical Research Council sum score. RMW was defined as an absolute value of MIP <30 cmHO. Associations between RMW at (or closest to) ICU discharge and all-cause 5-year mortality, and key measures of 5-year physical function, comprising respiratory muscle strength (MIP), hand-grip strength (HGF), 6 min walk distance (6MWD) and physical function of the SF-36 quality-of-life questionnaire (PF-SF-36), were assessed with Cox proportional hazards and linear regression models, adjusted for confounders including peripheral muscle strength.

Results: RMW was present in 136/366 (37.2%) patients at ICU discharge. RMW was not independently associated with 5-year mortality (HR with 95% CI 1.273 (0.751 to 1.943), p=0.352). Among 156five-year survivors, those with, as compared with those without RMW demonstrated worse physical function (MIP (absolute value, cmHO): 62(42-77) vs 94(78-109), p<0.001; HGF (%pred): 67(44-87) vs 96(68-110), p<0.001; 6MWD (%pred): 87(74-102) vs 99 (80-111), p=0.009; PF-SF-36 (score): 55 (30-80) vs 80 (55-95), p<0.001). Associations between RMW and morbidity endpoints remained significant after adjustment for confounders (effect size with 95% CI: MIP: -23.858 (-32.097 to -15.027), p=0.001; HGF: -18.591 (-30.941 to -5.744), p=0.001; 6MWD (transformed): -1587.007 (-3073.763 to -179.253), p=0.034; PF-SF-36 (transformed): 1.176 (0.144-2.270), p=0.036).

Conclusions: RMW at ICU discharge is independently associated with 5-year morbidity but not 5-year mortality.
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http://dx.doi.org/10.1136/thoraxjnl-2020-216720DOI Listing
June 2021

Detailing the mechanisms of chronic dyspnea in patients during cardiopulmonary exercise testing.

J Bras Pneumol 2021 02 24;47(1):e20210014. Epub 2021 Feb 24.

. Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Belgium.

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http://dx.doi.org/10.36416/1806-3756/e20210014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8332666PMC
February 2021

Training Specificity of Inspiratory Muscle Training Methods: A Randomized Trial.

Front Physiol 2020 3;11:576595. Epub 2020 Dec 3.

KU Leuven, Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, Leuven, Belgium.

Introduction: Inspiratory muscle training (IMT) protocols are typically performed using pressure threshold loading with inspirations initiated from residual volume (RV). We aimed to compare effects of three different IMT protocols on maximal inspiratory pressures (PImax) and maximal inspiratory flow (V̇Imax) at three different lung volumes. We hypothesized that threshold loading performed from functional residual capacity (FRC) or tapered flow resistive loading (initiated from RV) would improve inspiratory muscle function over a larger range of lung volumes in comparison with the standard protocol.

Methods: 48 healthy volunteers (42% male, age: 48 ± 9 years, PImax: 110 ± 28%pred, [mean ± SD]) were randomly assigned to perform three daily IMT sessions of pressure threshold loading (either initiated from RV or from FRC) or tapered flow resistive loading (initiated from RV) for 4 weeks. Sessions consisted of 30 breaths against the highest tolerable load. Before and after the training period, PImax was measured at RV, FRC, and midway between FRC and total lung capacity (1/2 IC). V̇Imax was measured at the same lung volumes against a range of external threshold loads.

Results: While PImax increased significantly at RV and at FRC in the group performing the standard training protocol (pressure threshold loading from RV), it increased significantly at all lung volumes in the two other training groups (all < 0.05). No significant changes in V̇Imax were observed in the group performing the standard protocol. Increases of V̇Imax were significantly larger at all lung volumes after tapered flow resistive loading, and at higher lung volumes (i.e., FRC and 1/2 IC) after pressure threshold loading from FRC in comparison with the standard protocol (all < 0.05).

Conclusion: Only training with tapered flow resistive loading and pressure threshold loading from functional residual capacity resulted in consistent improvements in respiratory muscle function at higher lung volumes, whereas improvements after the standard protocol (pressure threshold loading from residual volume) were restricted to gains in PImax at lower lung volumes. Further research is warranted to investigate whether these results can be confirmed in larger samples of both healthy subjects and patients.
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http://dx.doi.org/10.3389/fphys.2020.576595DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744620PMC
December 2020

Early neuromuscular electrical stimulation reduces the loss of muscle mass in critically ill patients - A within subject randomized controlled trial.

J Crit Care 2021 04 28;62:65-71. Epub 2020 Nov 28.

Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Herestraat 49, B-3000 Leuven, Belgium; Department of Intensive Care, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium. Electronic address:

Purpose: To investigate the effect of Neuromuscular Electrical Stimulation (NMES) on muscle thickness, strength and morphological and molecular markers of the quadriceps.

Materials And Methods: Adult critically ill patients with an expected prolonged stay received unilateral quadriceps NMES sessions for 7 consecutive days. Before and after the intervention period, quadriceps thickness was measured with ultrasound. After the intervention period, strength was assessed in cooperative patients and muscle biopsies were taken. Multivariable regression was performed to identify factors affecting muscle thickness loss.

Results: Muscle thickness decreased less in the stimulated leg (-6 ± 16% versus -12 ± 15%, p = 0.014, n = 47). Strength was comparable. Opioid administration, minimal muscle contraction and more muscle thickness loss in the non-stimulated muscle were independently associated with better muscle thickness preservation. Stimulated muscles showed a shift towards larger myofibers and higher MyHC-I gene expression. NMES did not affect gene expression of other myofibrillary proteins, MuRF-1 or atrogin-1. Signs of myofiber necrosis and inflammation were comparable for both muscles.

Conclusions: NMES attenuated the loss of muscle mass, but not of strength, in critically ill patients. Preservation of muscle mass was more likely in patients receiving opioids, patients with a minimal muscle contraction during NMES and patients more prone to lose muscle mass.

Trial Registration: clinicaltrials.govNCT02133300.
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http://dx.doi.org/10.1016/j.jcrc.2020.11.018DOI Listing
April 2021

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

Phys Ther 2021 01;101(1)

The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Australia.

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.
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http://dx.doi.org/10.1093/ptj/pzaa198DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7665725PMC
January 2021

High-intensity exercise impairs extradiaphragmatic respiratory muscle perfusion in patients with COPD.

J Appl Physiol (1985) 2021 02 29;130(2):325-341. Epub 2020 Oct 29.

Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium.

The study investigated whether high-intensity exercise impairs inspiratory and expiratory muscle perfusion in patients with chronic obstructive pulmonary disease (COPD). We compared respiratory local muscle perfusion between constant-load cycling[sustained at 80% peak work rate (WRpeak)] and voluntary normocapnic hyperpnea reproducing similar work of breathing (WoB) in 18 patients [forced expiratory volume in the first second (FEV): 58 ± 24% predicted]. Local muscle blood flow index (BFI), using indocyanine green dye, and fractional oxygen saturation (%StiO) were simultaneously assessed by near-infrared spectroscopy (NIRS) over the intercostal, scalene, rectus abdominis, and vastus lateralis muscles. Cardiac output (impedance cardiography), WoB (esophageal/gastric balloon catheter), and diaphragmatic and extradiaphragmatic respiratory muscle electromyographic activity (EMG) were also assessed throughout cycling and hyperpnea. Minute ventilation, breathing pattern, WoB, and respiratory muscle EMG were comparable between cycling and hyperpnea. During cycling, cardiac output and vastus lateralis BFI were significantly greater compared with hyperpnea [by +4.2 (2.6-5.9) L/min and +4.9 (2.2-7.8) nmol/s, respectively] ( < 0.01). Muscle BFI and %StiO were, respectively, lower during cycling compared with hyperpnea in scalene [by -3.8 (-6.4 to -1.2) nmol/s and -6.6 (-8.2 to -5.1)%], intercostal [by -1.4 (-2.4 to -0.4) nmol/s and -6.0 (-8.6 to -3.3)%], and abdominal muscles [by -1.9 (-2.9 to -0.8) nmol/s and -6.3 (-9.1 to -3.4)%] ( < 0.001). The difference in respiratory (scalene and intercostal) muscle BFI between cycling and hyperpnea was associated with greater dyspnea (Borg CR10) scores ( = -0.54 and = -0.49, respectively, < 0.05). These results suggest that in patients with COPD, ) locomotor muscle work during high-intensity exercise impairs extradiaphragmatic respiratory muscle perfusion and ) insufficient adjustment in extradiaphragmatic respiratory muscle perfusion during high-intensity exercise may partly explain the increased sensations of dyspnea. We simultaneously assessed the blood flow index (BFI) in three respiratory muscles during hyperpnea and high-intensity constant-load cycling sustained at comparable levels of work of breathing and respiratory neural drive in patients with COPD. We demonstrated that high-intensity exercise impairs respiratory muscle perfusion, as intercostal, scalene, and abdominal BFI increased during hyperpnea but not during cycling. Insufficient adjustment in respiratory muscle perfusion during exercise was associated with greater dyspnea sensations in patients with COPD.
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http://dx.doi.org/10.1152/japplphysiol.00659.2020DOI Listing
February 2021

Intensive care unit acquired muscle weakness in COVID-19 patients.

Intensive Care Med 2020 Nov 28;46(11):2083-2085. Epub 2020 Sep 28.

Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.

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http://dx.doi.org/10.1007/s00134-020-06244-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7520507PMC
November 2020

Early mobilization in clinical practice: the reliability and feasibility of the 'Start To Move' Protocol.

Physiother Theory Pract 2020 Aug 31:1-11. Epub 2020 Aug 31.

Department of Rehabilitation Sciences KU Leuven, Belgium.

Purpose: The properties of a local Intensive Care Unit early mobilization protocol ('Start To Move As Soon As Possible') in critically ill patients, consisting of an objective diagnostic assessment linked to six treatment levels were evaluated. This study aimed to investigate whether the protocol can be reliably applied by different health-care providers (reliability), to examine the associations between prescribed and delivered treatments (feasibility) and to explore safety and patient satisfaction with the protocol.

Methods: Cross-sectional observational study evaluating the reliability of the protocol between physiotherapist was evaluated with Cohen's kappa, percentage of agreement, and intraclass correlation coefficients in 61 patients. Feasibility was analyzed as agreement between prescribed and delivered treatments with Spearman's rank correlation coefficients in 60 patients. A satisfaction survey was used to evaluate patient satisfaction with the protocol.

Results: Excellent agreement was observed between physiotherapists for diagnostic level assignment (Kappa = 0.92), while the majority of the treatment proposals per level showed moderate to substantial agreement between the physiotherapists (Kappa range: 0.40-0.89). Three hundred and thirteen treatments were prescribed. Perfect agreement was observed between prescribed and delivered treatments in level 0 (Spearman's rho 1.00) and excellent associations for levels 1-5 (0.941, 0.995, 0.951, 0.998, and 0.999), respectively. Unwanted safety events rate was 3%. Most patients (92%) were very satisfied with physiotherapy.

Conclusion: Excellent inter-rater agreement for diagnostic level assignment and moderate to substantial agreement for proposed treatments support the reliability of the protocol. Perfect to excellent associations between prescribed and delivered treatments supports its feasibility. Complications were rare, and most patients were very positive regarding the care provided by physiotherapists during their stay in the ICU.
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http://dx.doi.org/10.1080/09593985.2020.1805833DOI Listing
August 2020

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

J Rehabil Med 2020 Jul 30;52(7):jrm00082. Epub 2020 Jul 30.

Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China.

Missing (Letter).
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http://dx.doi.org/10.2340/16501977-2715DOI Listing
July 2020

Translating COVID-19 Evidence to Maximize Physical Therapists' Impact and Public Health Response.

Phys Ther 2020 08;100(9):1458-1464

School of Physiotherapy, Division of Health Sciences, University of Otago, Dunedin, New Zealand.

Coronavirus disease 2019 (COVID-19) has sounded alarm bells throughout global health systems. As of late May, 2020, over 100,000 COVID-19-related deaths were reported in the United States, which is the highest number of any country. This article describes COVID-19 as the next historical turning point in the physical therapy profession's growth and development. The profession has had over a 100-year tradition of responding to epidemics, including poliomyelitis; 2 world wars and geographical regions experiencing conflicts and natural disasters; and, the epidemic of noncommunicable diseases (NCDs). The evidence-based role of noninvasive interventions (nonpharmacological/nonsurgical) that hallmark physical therapist practice has emerged as being highly relevant today in addressing COVID-19 in 2 primary ways. First, despite some unique features, COVID-19 presents as acute respiratory distress syndrome in its severe acute stage. Acute respiratory distress syndrome is very familiar to physical therapists in intensive care units. Body positioning and mobilization, prescribed based on comprehensive assessments/examinations, counter the negative sequelae of recumbency and bedrest; augment gas exchange and reduce airway closure, deconditioning, and critical illness complications; and maximize long-term functional outcomes. Physical therapists have an indisputable role across the contiuum of COVID-19 care. Second, over 90% of individuals who die from COVID-19 have comorbidities, most notably cardiovascular disease, hypertension, chronic lung disease, type 2 diabetes mellitus, and obesity. Physical therapists need to redouble their efforts to address NCDs by assessing patients for risk factors and manifestations and institute evidence-based health education (smoking cessation, whole-food plant-based nutrition, weight control, physical activity/exercise), and/or support patients' efforts when these are managed by other professionals. Effective health education is a core competency for addressing risk of death by COVID-19 as well as NCDs. COVID-19 is a wake-up call to the profession, an opportunity to assert its role throughout the COVID-19 care continuum, and augment public health initiatives by reducing the impact of the current pandemic.
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http://dx.doi.org/10.1093/ptj/pzaa115DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7337734PMC
August 2020

COVID-19 and pulmonary rehabilitation: preparing for phase three.

Eur Respir J 2020 Jun 25;55(6). Epub 2020 Jun 25.

Dept of Critical Care, University Hospital Leuven, Leuven, Belgium.

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http://dx.doi.org/10.1183/13993003.01822-2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7401308PMC
June 2020

Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations.

J Physiother 2020 04 30;66(2):73-82. Epub 2020 Mar 30.

Physiotherapy Department, Fiona Stanley Hospital, Perth, Australia.

This document outlines recommendations for physiotherapy management for COVID-19 in the acute hospital setting. It includes: recommendations for physiotherapy workforce planning and preparation; a screening tool for determining requirement for physiotherapy; and recommendations for the selection of physiotherapy treatments and personal protective equipment. It is intended for use by physiotherapists and other relevant stakeholders in the acute care setting caring for adult patients with confirmed or suspected COVID-19.
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http://dx.doi.org/10.1016/j.jphys.2020.03.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7165238PMC
April 2020

Effectiveness of an exercise training programme COPD in primary care: A randomized controlled trial.

Respir Med 2020 Apr - May;165:105943. Epub 2020 Mar 20.

Dept of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands.

Background: Pulmonary rehabilitation is very effective in improving exercise capacity, dyspnea and quality of life in the small group of patients with moderate to severe COPD. Given that little is known about exercise training in the large group of patients with mild to moderate COPD, we assessed the effectiveness of an exercise training programme in primary care.

Methods: In this RCT, 90 patients with mild to moderate COPD (FEV 74.2 ± 13.5%pred) participated in a 4-month exercise training programme or control treatment. Primary outcome was improvement in functional exercise capacity, assessed by the 6-min walking distance (6MWD). Secondary outcomes were breathlessness (MRC dyspnoea score), disease-specific quality of life (CCQ, CRQ), muscle strength and objective daily physical activity. There was a follow-up measurement at 6 months.

Results: At 4 months, we found a statistically and clinically relevant between-group difference in 6MWD of +26.6 m (95% CI: 4,3-49.0, p = 0.020). Shoulder strength significantly improved with a between-group difference of 23.9 Nm (p = 0.0350). At 6 months, there was a significant improvement in handgrip force and CRQ sub score mastery of respectively 1.9 KgF (p = 0.028) and 0.5 (p = 0.035). There were no significant between-group differences in breathlessness, quality of life, knee strength and daily physical activity.

Conclusion: The results indicate that exercise training in primary care is particularly effective in improving physical fitness (exercise capacity and strength), but not in breathlessness, health-related quality of life and daily physical activity. A broader assessment for COPD patients in primary care might be a necessary condition to offer the most effective intervention.
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http://dx.doi.org/10.1016/j.rmed.2020.105943DOI Listing
January 2021

Respiratory Muscle Rehabilitation in Patients with Prolonged Mechanical Ventilation: A Targeted Approach.

Crit Care 2020 Mar 24;24(1):103. Epub 2020 Mar 24.

Intensive Care Unit, Canberra Hospital, Garran, ACT, Australia.

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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http://dx.doi.org/10.1186/s13054-020-2783-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7092518PMC
March 2020

Brain Activations to Dyspnea in Patients With COPD.

Front Physiol 2020 24;11. Epub 2020 Jan 24.

Health Psychology, KU Leuven, Leuven, Belgium.

We compared the perception and neural processing of respiratory sensations between 20 COPD patients and 20 healthy controls by means of respiratory-related evoked potentials (RREP) in the electroencephalogram (EEG). RREPs were induced by short inspiratory occlusions while 129-channel EEG was measured. COPD patients rated the occlusions as more intense and unpleasant ('s < 0.001) and showed higher mean amplitudes for the RREP components P1 ( = 0.0004), N1 ( = 0.024), P2 ( = 0.019), and P3 ( = 0.018). Our results indicate that COPD patients demonstrate greater perception and neural processing of respiratory sensations, which presumably reflects the highly aversive and attention-demanding character of these sensations for COPD patients.
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http://dx.doi.org/10.3389/fphys.2020.00007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6992658PMC
January 2020

Five-year impact of ICU-acquired neuromuscular complications: a prospective, observational study.

Intensive Care Med 2020 06 22;46(6):1184-1193. Epub 2020 Jan 22.

Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.

Purpose: To assess the independent association between ICU-acquired neuromuscular complications and 5-year mortality and morbidity. To explore the optimal threshold of the Medical Research Council (MRC) sum score, assessing weakness, for the prediction of 5-year outcomes.

Methods: Sub-analyses of a prospective, 5-year follow-up study including 883 EPaNIC patients (Early versus Late Parenteral Nutrition in Intensive Care) (Clinicaltrials.gov:NCT00512122), systematically screened in ICU for neuromuscular complications with MRC sum score ('MRC-cohort', N = 600), electrophysiology on day 8 ± 1 to quantify compound muscle action potential ('CMAP-cohort', N = 689), or both ('MRC&CMAP-cohort', N = 415). Associations between ICU-acquired neuromuscular complications and 5-year mortality, hand-grip strength (HGF, %predicted), 6-min-walk distance (6-MWD, %predicted) and physical function of the SF-36 quality-of-life questionnaire (PF-SF-36) at 5-years were assessed with Cox regression and linear regression, adjusted for confounders. The optimal threshold for MRC at ICU discharge to predict 5-year outcomes was determined by martingale residual plots (survival) and scatterplots (morbidity).

Results: Both lower MRC sum score at ICU discharge, indicating less strength [HR, per-point-increase: 0.946 (95% CI 0.928-0.968), p = 0.001], and abnormal CMAP, indicating nerve/muscle dysfunction [HR: 1.568 (95% CI 1.165-2.186), p = 0.004], independently associated with increased 5-year mortality. In the MRC&CMAP-cohort, MRC [HR: 0.956 (95% CI 0.934-0.980), p = 0.001] but not CMAP [HR: 1.478 (95% CI 0.875-2.838), p = 0.088] independently associated with 5-year mortality. Among 205 survivors, low MRC independently associated with low HGF [0.866 (95% CI 0.237-1.527), p = 0.004], low 6-MWD [105.1 (95% CI 12.1-212.9), p = 0.043] and low PF-SF-36 [- 0.119 (95% CI - 0.186 to - 0.057), p = 0.002], whereas abnormal CMAP did not correlate with these morbidity endpoints. Exploratory analyses suggested that MRC ≤ 55 best predicted poor long-term morbidity and mortality. Both MRC ≤ 55 and abnormal CMAP independently associated with 5-year mortality.

Conclusions: ICU-acquired neuromuscular complications may impact 5-year morbidity and mortality. MRC sum score, even if slightly reduced, may affect long-term mortality, strength, functional capacity and physical function, whereas abnormal CMAP only related to long-term mortality.
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http://dx.doi.org/10.1007/s00134-020-05927-5DOI Listing
June 2020

Differences in Respiratory Muscle Responses to Hyperpnea or Loaded Breathing in COPD.

Med Sci Sports Exerc 2020 05;52(5):1126-1134

Laboratory of Research in Respiratory Physiotherapy (LFIP), Department of Physiotherapy, Universidade Estadual de Londrina (UEL), Londrina, BRAZIL.

Introduction: We aimed to compare acute mechanical and metabolic responses of the diaphragm and rib cage inspiratory muscles during two different types of respiratory loading in patients with chronic obstructive pulmonary disease.

Methods: In 16 patients (age, 65 ± 13 yr; 56% male; forced expiratory volume in the first second, 60 ± 6%pred; maximum inspiratory pressure, 82 ± 5%pred), assessments of respiratory muscle EMG, esophageal pressure (Pes) and gastric pressures, breathing pattern, and noninvasive assessments of systemic (V˙O2, cardiac output, oxygen delivery and extraction) and respiratory muscle hemodynamic and oxygenation responses (blood flow index, oxygen delivery index, deoxyhemoglobin concentration, and tissues oxygen saturation [StiO2]), were performed during hyperpnea and loaded breathing.

Results: During hyperpnea, breathing frequency, minute ventilation, esophageal and diaphragm pressure-time product per minute, cardiac output, and V˙O2 were higher than during loaded breathing (P < 0.05). Average inspiratory Pes and transdiaphragmatic pressure per breath, scalene (SCA), sternocleidomastoid, and intercostal muscle activation were higher during loading breathing compared with hyperpnea (P < 0.05). Higher transdiaphragmatic pressure during loaded breathing compared with hyperpnea was mostly due to higher inspiratory Pes (P < 0.05). Diaphragm activation, inspiratory and expiratory gastric pressures, and rectus abdominis muscle activation did not differ between the two conditions (P > 0.05). SCA-blood flow index and oxygen delivery index were lower, and SCA-deoxyhemoglobin concentration was higher during loaded breathing compared with hyperpnea. Furthermore, SCA and intercostal muscle StiO2 were lower during loaded breathing compared with hyperpnea (P < 0.05).

Conclusion: Greater inspiratory muscle effort during loaded breathing evoked larger rib cage and neck muscle activation compared with hyperpnea. In addition, lower SCA and intercostal muscle StiO2 during loaded breathing compared with hyperpnea indicates a mismatch between inspiratory muscle oxygen delivery and utilization induced by the former condition.
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http://dx.doi.org/10.1249/MSS.0000000000002222DOI Listing
May 2020

Assessing the effects of inspiratory muscle training in a patient with unilateral diaphragm dysfunction.

Breathe (Sheff) 2019 Jun;15(2):e90-e96

Faculty of Movement and Rehabilitation Sciences, Dept of Rehabilitation Sciences, Research Group for Cardiovascular and Respiratory Rehabilitation, KU Leuven - University of Leuven, Leuven, Belgium.

http://bit.ly/2QdxNFP.
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http://dx.doi.org/10.1183/20734735.0129-2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6876147PMC
June 2019

Why does oxygen supplementation during exercise training in COPD patients with exercise-induced desaturation not consistently improve exercise capacity?

Eur Respir J 2019 11 14;54(5). Epub 2019 Nov 14.

Respiratory Rehabilitation and Respiratory Division, University Hospital Leuven, Leuven, Belgium.

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http://dx.doi.org/10.1183/13993003.01586-2019DOI Listing
November 2019

Cerebral cortex and respiratory muscles perfusion during spontaneous breathing attempts in ventilated patients and its relation to weaning outcomes: a protocol for a prospective observational study.

BMJ Open 2019 10 31;9(10):e031072. Epub 2019 Oct 31.

Department of General Internal Medicine, University Hospitals Leuven, Medical Intensive Care Unit, Leuven, Belgium.

Introduction: In addition to the well-documented factors that contribute to weaning failure, increased energy demands of the respiratory muscles during spontaneous breathing trials (SBTs) might not be met by sufficient increases in energy supplies. This discrepancy may deprive blood and oxygen of other tissues. In this context, restrictions in perfusion of splanchnic organs and non-working muscles during SBT have been associated with weaning failure. However, alterations in perfusion of the brain during the weaning process are less well understood.

Objective And Hypothesis: To investigate whether cerebral cortex perfusion evolves differentially during the transition from mechanical ventilation (MV) to spontaneous breathing between patients failing or succeeding the SBT. We hypothesise that patients failing the SBT will exhibit reduced cerebral cortex perfusion during the transition from MV to spontaneous breathing as compared with patients succeeding the SBT.

Methods And Analysis: This single-centre, prospective, observational study will be conducted in a medical Intensive Care unit of University Hospital Leuven, Belgium in ready to wean patients. Blood flow index in the cerebral cortex (prefrontal area), inspiratory (scalene) and expiratory muscle (upper rectus abdominis) and a non-working muscle (thenar eminence) will be simultaneously assessed by near-infrared spectroscopy (NIRS) using the tracer indocyanine green dye. Measurements will be performed on the same day during MV and during SBT. NIRS-derived tissue oxygenation index and cardiac output (by pulse contour analyses) will be recorded continuously. Twenty patients failing an SBT are estimated to be sufficient for detecting a significant difference in the change of cerebral cortex perfusion from MV to SBT (primary outcome) between SBT failure and success patients.

Ethics And Dissemination: Ethics approval was obtained from the local ethical committee (Ethische Commissie Onderzoek UZ/KU Leuven protocol ID: S60516). Results from this study will be presented at scientific meetings and congresses and published in peer-reviewed journals.

Trial Registration Number: NCT03240263; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2019-031072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6830828PMC
October 2019

Five-year mortality and morbidity impact of prolonged versus brief ICU stay: a propensity score matched cohort study.

Thorax 2019 11 3;74(11):1037-1045. Epub 2019 Sep 3.

Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.

Purpose: Long-term outcomes of critical illness may be affected by duration of critical illness and intensive care. We aimed to investigate differences in mortality and morbidity after short (<8 days) and prolonged (≥8 days) intensive care unit (ICU) stay.

Methods: Former EPaNIC-trial patients were included in this preplanned prospective cohort, 5-year follow-up study. Mortality was assessed in all. For morbidity analyses, all long-stay and-for feasibility-a random sample (30%) of short-stay survivors were contacted. Primary outcomes were total and post-28-day 5-year mortality. Secondary outcomes comprised handgrip strength (HGF, %pred), 6-minute-walking distance (6MWD, %pred) and SF-36 Physical Function score (PF SF-36). One-to-one propensity-score matching of short-stay and long-stay patients was performed for nutritional strategy, demographics, comorbidities, illness severity and admission diagnosis. Multivariable regression analyses were performed to explore ICU factors possibly explaining any post-ICU observed outcome differences.

Results: After matching, total and post-28-day 5-year mortality were higher for long-stayers (48.2% (95%CI: 43.9% to 52.6%) and 40.8% (95%CI: 36.4% to 45.1%)) versus short-stayers (36.2% (95%CI: 32.4% to 40.0%) and 29.7% (95%CI: 26.0% to 33.5%), p<0.001). ICU risk factors comprised hypoglycaemia, use of corticosteroids, neuromuscular blocking agents, benzodiazepines, mechanical ventilation, new dialysis and the occurrence of new infection, whereas clonidine could be protective. Among 276 long-stay and 398 short-stay 5-year survivors, HGF, 6MWD and PF SF-36 were significantly lower in long-stayers (matched subset HGF: 83% (95%CI: 60% to 100%) versus 87% (95%CI: 73% to 103%), p=0.020; 6MWD: 85% (95%CI: 69% to 101%) versus 94% (95%CI: 76% to 105%), p=0.005; PF SF-36: 65 (95%CI: 35 to 90) versus 75 (95%CI: 55 to 90), p=0.002).

Conclusion: Longer duration of intensive care is associated with excess 5-year mortality and morbidity, partially explained by potentially modifiable ICU factors.

Trail Registration Number: NCT00512122.
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http://dx.doi.org/10.1136/thoraxjnl-2018-213020DOI Listing
November 2019

Comparison Between Manual and (Semi-)Automated Analyses of Esophageal Diaphragm Electromyography During Endurance Cycling in Patients With COPD.

Front Physiol 2019 10;10:885. Epub 2019 Jul 10.

Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium.

Electrocardiogram (ECG) contamination is present in diaphragm electromyography (EMGdi) recordings. Obtaining EMGdi without ECG contamination is crucial for EMG amplitude analysis. Manually selecting EMGdi in between QRS complexes has been most commonly applied in recent years (manual method). We developed a semi-automated analysis method based on Least Mean Square Adaptive Filtering combined with a synchronously recorded separate ECG channel to remove ECG artifacts from the EMGdi signals. We hypothesized that this approach would shorten analysis duration and might minimize the potential for inter-rater disagreement. We aimed to evaluate agreement between the semi-automated method and the manual method and inter-rater reliability of the manual method. Electromyography signals of seven patients with COPD were recorded using an esophageal catheter during an exercise test on a cycle ergometer. Four patients subsequently participated in an inspiratory muscle training (IMT) program for 8 weeks. After IMT, the tests were repeated. EMGdi/EMGdiMax as obtained either manually by the two assessors or retrieved from the semi-automated method were compared. Semi-automated EMGdi/EMGdiMax agreed well with values obtained by one of the two manual assessors (assessor 1) both at pre-intervention measurements (mean difference -0.5%, 95% CI: -19.6 to 18.6%) and for the pre/post IMT differences (mean difference 1.2%, 95% CI: -16.8 to 19.2%). Intra-class correlation coefficients between methods were 0.96 (95% CI: 0.94-0.97) at pre-intervention measurements and 0.78 (95% CI: 0.58-0.89) for pre/post IMT differences (both < 0.001). EMGdi/EMGdiMax from assessor 2 was systematically lower than from assessor 1 and agreed less well with the semi-automated method both at pre-intervention measurements (mean difference: 9.3%, 95% CI: -11.4 to 29.9%) and for pre/post IMT differences (mean difference 7.0%, 95% CI: -20.4 to 34.4%). Analysis duration of the semi-automated method was significantly shorter (29 ± 9 min) than the manual method (82 ± 20 min, < 0.001). The developed semi-automated method is more time efficient and will be less prone to inter-rater variability that was observed when applying the manual analysis method. It is, therefore, proposed as a new standard for objective EMGdi amplitude analyses in future studies.
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http://dx.doi.org/10.3389/fphys.2019.00885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6637315PMC
July 2019

Introduction of the harmonised respiratory physiotherapy curriculum.

Breathe (Sheff) 2019 Jun;15(2):110-115

Dept of Physiotherapy, Laboratory of Research in Respiratory Physiotherapy (LFIP), State University of Londrina (UEL), Londrina, Brazil.

Building on the core syllabus for postgraduate training in respiratory physiotherapy, published in 2014, the European Respiratory Society (ERS) respiratory physiotherapy task force has developed a harmonised and structured postgraduate curriculum for respiratory physiotherapy training. The curriculum outlines the knowledge, skills and attitudes which must be mastered by a respiratory physiotherapist working with adult or paediatric patients, together with guidance for minimal clinical exposures, and forms of learning and assessment. This article presents the rationale, methodology and content of the ERS respiratory physiotherapy curriculum. The full curriculum can be found in the supplementary material.
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http://dx.doi.org/10.1183/20734735.0124-2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6544793PMC
June 2019
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