PHYSIOTHERAPY IS treatment to restore, maintain, and make the most of a patient’s mobility, function, and well-being. Physiotherapy helps through physical rehabilitation, injury prevention, and health and fitness. Physiotherapists get you involved in your own recovery.

Physiotherapy, or physical therapy, is a healthcare discipline focused on enhancing and restoring physical function and mobility. It addresses a variety of conditions, including injuries, illnesses, or disabilities that affect the musculoskeletal, neurological, or respiratory system.

According to Dr Dave Foster, president of the Jamaica Physiotherapy Association (JPA), physiotherapists use a combination of exercises, manual therapy, education, and other techniques to reduce pain, improve strength, flexibility, and coordination.

“The goal is to help individuals regain or enhance their ability to perform daily activities, promoting overall health and well-being. Physiotherapy is often an integral part of rehabilitation programmes and can be beneficial in both preventing and managing various health issues,” Dr Foster said.

Physiotherapy is crucial for restoring and maintaining physical function and mobility in individuals with injuries, illnesses, or disabilities. It employs a holistic approach, addressing musculoskeletal, neurological, and respiratory issues.

Dr Foster said physiotherapists use exercises, manual therapy, and other interventions to alleviate pain, improve strength, and enhance flexibility.

“This proactive form of healthcare not only aids in recovery, but also prevents future injuries, promoting overall well-being. By tailoring treatments to individual needs, physiotherapy plays a pivotal role in enhancing quality of life, promoting independence, and optimising functional abilities for a diverse range of patients,” he said.

Physiotherapy, he said, is utilised across a broad spectrum of health conditions and situations. It is commonly employed in the rehabilitation of musculoskeletal injuries, such as fractures, sprains, and strains.

“Individuals recovering from orthopaedic surgeries, like joint replacements, also benefit from physiotherapy to regain strength and mobility,” Dr Foster said.

“Neurological conditions, including strokes, spinal cord injuries, and multiple sclerosis, often necessitate physiotherapy to address mobility challenges and enhance coordination. Patients with respiratory issues, such as chronic obstructive pulmonary disease, can benefit from breathing exercises and chest physiotherapy to improve lung function,” he said.

Chronic pain conditions like arthritis or lower back pain, he said, are frequently managed with physiotherapy interventions aimed at reducing discomfort and improving function. Sports injuries, whether acute or chronic, often involve physiotherapy to facilitate a safe return to physical activity.

Physiotherapy, he said, also extends its reach to cardiovascular health, aiding individuals recovering from heart attacks or cardiac surgeries through tailored exercise programmes. Additionally, it plays a crucial role in geriatric care, promoting balance and preventing falls among the elderly.

“Preventively, physiotherapy educates individuals on posture, ergonomic practices, and exercises to reduce the risk of injuries or musculoskeletal issues. Overall, physiotherapy is a versatile discipline that contributes significantly to improving the quality of life for individuals across various health conditions and stages of life,” Dr Foster said.

Dr Foster is the president of the Physiotherapy Association of Jamaica that represents the interests of Jamaican physiotherapists. “We are committed to promoting and protecting the profession of physical therapy in Jamaica; standardising clinical techniques and practices so as to maintain quality control; and achieving bargaining status,” he said.

The need for the local association for physical therapists was recognised, he said, to promote and protect the profession of physical therapy in Jamaica standardise clinical techniques and practices to help to maintain quality control achieve bargaining status.

The strategic goals of the organisation, he said, are to develop a culture of lifelong learning among the membership, and to make the JPA the advocate group for physiotherapy in Jamaica.

Other goals include to actively encourage and promote membership and participation of physiotherapists in Jamaica within the JPA; to facilitate continued research, with a view to increase evidence-based practice and professional recognition; to provide accessible information on physiotherapy through various media and extend services to the community through outreach programme; and to be actively involved in the development and implementation of health policies which impact on delivery of physiotherapy care to all persons in Jamaica.

Physiotherapists can join the association by visiting the JPA’s website, jpa.org.jm, and click the link ‘Join Us’, or the group may be contacted at (876) 202-0852 for more details.

WHAT YOU CAN EXPECT AT PHYSIOTHERAPY

Your session will be unique, because it is all about you and your particular needs. In general, here is what happens:

• The physiotherapist learns about your medical history;

• The physiotherapist assesses and diagnoses your condition;

• You receive a treatment plan that sets goals for you;

• You are prescribed a course of exercises and any assistive devices needed.

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We can collectively concur that after enduring a strenuous and exhausting day at work, there is nothing quite like the rejuvenation that comes from immersing oneself in a luxurious, warm bath. Indeed, for those fortunate enough to possess a bathtub, this experience can be unparalleled. However, the therapeutic embrace of a soothing, warm shower is no less remarkable. 

Now, envision an alternative to this relaxation ritual, one that swaps the soothing embrace of water for the enveloping resonance of sound. Enter the Gong bath, a practice replete with an array of benefits that extend far beyond the mere solace it offers, serving as a profound method for unwinding and revitalization. 

What is Gong bath meditation?

The Gong Bath is a unique and immersive experience, using the vibrations and harmonious tones produced by gongs to induce a profound sense of relaxation and well-being. The therapeutic resonance of gongs can be likened to the soothing embrace of water, providing a multi-sensory journey that not only eases the strains of a demanding day but also offers a myriad of holistic advantages.

As per Bambi Mathur, Sound and Vibration therapist, Mandala Wellness, "Gong Bath Meditation is not a recent trend but an ancient practice that dates back to various
cultures such as ancient Indian, Tibetan, Egyptian, Greek, and Roman civilizations. The Gong has the
widest range of sound that can sometimes instantly heal the mind body and soul from its core levels.
Sound can be an effective way to reprogram the vibrations in the body to a more optimal
state. For example, at the mental level, the drone-like sounds from a Gong can entrain the
brainwaves to a lower state like the alpha and theta states where the body's natural ability to
heal and restore occurs." 

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"Stress, anxiety and feelings of being overwhelmed are a result of the
mind going into overdrive. stressed, anxious and overwhelmed. When the mind can enter a
deep state of rest, that also helps relax the entire physical body. On the contrary, When the
body is in an optimal state of physical and mental health, all of the systems in your body are
working in harmony," she adds. 

What are the benefits of Gong bath meditation?

Now that we know what a gong bath actually is, there are many physical, mental and emotional benefits one can derive out of the same. Here are some of them: 

It helps in releasing stress and anxiety

The harmonic resonance of gongs induces a state of deep relaxation, lowering cortisol levels and alleviating stress and anxiety, providing a sanctuary for the mind to find tranquillity.

It helps nurture trauma issues

Gong bath meditation can act as a gentle yet powerful therapy for individuals dealing with emotional trauma, offering a non-invasive method to nurture and heal these deep-seated wounds.

It helps remove emotional blockages

The ethereal vibrations of gongs facilitate the release of pent-up emotions, allowing individuals to confront and resolve emotional blockages, leading to a sense of emotional liberation and inner peace.

It helps improve sleep patterns

Regular practice of Gong bath meditation is linked to improved sleep quality. The soothing sounds help calm a restless mind, promoting deeper and more restful slumber. 

It helps improve breathing and oxygen intake

The practice enhances mindfulness of breath, promoting efficient oxygen intake, which can be invaluable for respiratory health, reducing the likelihood of issues like shallow breathing.

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It helps relax the mind 

Gong bath meditation offers a sanctuary of serenity, where the mind can shed its burdens and experience profound relaxation, fostering mental clarity, creativity, and inner calm. 

It helps repair muscles and bones

The therapeutic vibrations can aid in the recovery of injured or fatigued muscles and bones, making it particularly advantageous for athletes or those on the path to physical rehabilitation.

It helps promote weight loss

By addressing stress-induced overeating and fostering mindfulness, gong bath meditation can complement weight loss efforts, making it a valuable addition to a wellness regimen. 

It improves blood pressure

Regular participation in this practice has been associated with improved blood pressure regulation, potentially reducing the risk of hypertension and cardiovascular complications. 

It removes the stagnant energy

The resonant waves of the gongs help dislodge stagnant energy within the body, facilitating a sense of rejuvenation and revitalisation, while also reducing feelings of stagnation or inertia.

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It helps unblock the chakras

The vibrations align with the body's energy centres (chakras), aiding in the removal of blockages and promoting harmonious energy flow, which can lead to greater balance and vitality. 

It improves the emotional and mental health 

The practice is known for reducing negative thought patterns and fostering a positive mindset, contributing to improved mental and emotional well-being. It also helps in bringing in confidence and a better self-image. 

It heals the nervous system

The gentle yet profound impact on the nervous system is particularly beneficial for individuals dealing with stress-related conditions, aiding in their healing journey. 

It helps complement fertility treatments

Gong bath meditation can create an environment of reduced stress and enhanced relaxation, which can be supportive for individuals undergoing fertility treatments, potentially increasing their chances of success.

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What is the process?

Bambi Mathur explains the entire process of this meditation bath. "A typical gong bath session lasts around 60 minutes. Before the session begins, participants are encouraged to work on their breathing to relax the mind and body. As the gong’s vibrations
wash over them, a profound healing process unfolds, nurturing emotional, physical, mental, and
spiritual levels. Gong baths have come to the forefront of healing. Science and technology have
been able to prove the rapid benefits of this ancient modality. It is safe to say that alongside medical help if required, it compliments one's recovery from their illness. 

Finally, through the harmonising effects of sound and vibrations, gong bath meditation provides
a powerful tool for soothing the mind, body, and soul. As stress and anxiety become more
prevalent in modern life, embracing this transformative technique may hold the secret to
regaining inner serenity and well-being."

So, a gong bath meditation is something one can definitely consider at least once. After all, who does not like to be rejuvenated? 

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Comprehensive Services Offered by ATI Physical Therapy Inc

ATI Physical Therapy Inc. has established itself as a top choice for physical rehabilitation, thanks to its comprehensive range of services. With a commitment to providing the highest quality care, ATI Physical Therapy Inc. offers a wide array of treatments and programs to help patients recover from injuries, manage chronic conditions, and improve their overall physical well-being.

One of the key services offered by ATI Physical Therapy Inc. is orthopedic rehabilitation. This specialized area focuses on the treatment of musculoskeletal injuries, such as fractures, sprains, and strains. ATI Physical Therapy Inc. employs a team of highly skilled physical therapists who are trained in the latest techniques and technologies to help patients regain strength, mobility, and function. Whether it’s post-surgical rehabilitation or non-operative treatment, ATI Physical Therapy Inc. has the expertise to provide effective care.

In addition to orthopedic rehabilitation, ATI Physical Therapy Inc. also offers sports medicine services. Athletes of all levels can benefit from the specialized care provided by ATI Physical Therapy Inc. The team of sports medicine experts at ATI Physical Therapy Inc. understands the unique needs of athletes and works closely with them to develop personalized treatment plans. From injury prevention to performance enhancement, ATI Physical Therapy Inc. is dedicated to helping athletes reach their full potential.

Another area of expertise offered by ATI Physical Therapy Inc. is hand therapy. Hand injuries can be debilitating, affecting a person’s ability to perform everyday tasks. ATI Physical Therapy Inc. has a team of certified hand therapists who are skilled in the treatment of hand and upper extremity conditions. Through a combination of manual therapy, therapeutic exercises, and custom splinting, ATI Physical Therapy Inc. helps patients regain strength, dexterity, and function in their hands.

ATI Physical Therapy Inc. also recognizes the importance of addressing the unique needs of older adults. The company offers geriatric rehabilitation services to help seniors maintain their independence and improve their quality of life. With a focus on fall prevention, balance training, and functional mobility, ATI Physical Therapy Inc. helps older adults stay active and engaged in their daily activities.

Furthermore, ATI Physical Therapy Inc. provides comprehensive women’s health services. Women often face unique physical challenges, such as pelvic pain, incontinence, and pregnancy-related musculoskeletal issues. ATI Physical Therapy Inc. has a team of specialized therapists who are trained in women’s health and can provide effective treatment for these conditions. By addressing these issues, ATI Physical Therapy Inc. helps women improve their overall well-being and quality of life.

In conclusion, ATI Physical Therapy Inc. stands out as a top choice for physical rehabilitation due to its comprehensive range of services. From orthopedic rehabilitation to sports medicine, hand therapy to geriatric rehabilitation, and women’s health services, ATI Physical Therapy Inc. offers specialized care for a wide range of conditions. With a team of highly skilled therapists and a commitment to providing the highest quality care, ATI Physical Therapy Inc. is dedicated to helping patients recover, improve their physical well-being, and achieve their goals.

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Newswise — Scientists have showed that medicine on the base of vitamin B6 can be used for treatment of post-COVID asthenia – condition when patients complain of rapid fatigability, problems with memory and sleep. Taking of this product enabled 35% patients to improve memory, 40% patients began to sleep well, 42% of people began to get tired more slowly. Besides this taking this medicine enabled patients to experience physical activity easier. Results of the research are published in Magazine of Infectology.

Prevalence of COVID -19 is decreasing all over the world, by this most cases proceed easily. However, many people, who had suffered from COVID, noticed that symptoms remained significantly longer than usually. In such cases doctors speak about “post-COVID syndrome” when symptoms remain during more than three weeks after the disease. Among people with mild and middle disease this syndrome occurs in 10-30% cases, and its frequency among patients with severe illness can reach 80%. In this case patients feel tired, have residual short breathing and chest pain, their smelling and sense of taste are worser, they complain of trouble sleeping, anxiety and depression. In general, these symptoms are called asthenic disturbances.

Scientists from Immanuel Kant Baltic Federal University estimated efficiency and safety of usage of combined medicine ethylmethylhydroxypyridine succinate with vitamin B6 (EMHPS / vitamin B6). Such combination is included in such medicine as MexiB6. EMHPS is antioxidant that means that it prevents harmful oxidative stress in brain cells. It also increases resistance of cells to oxygen deficit, protects cell membranes from injuries, that are caused by oxidative stress, and normalizes metabolism in neurons. EMHPS is used in treatment of cerebral blood flow when patients suffer from a stroke, psychosomatic diseases, neurotic disorder, decrease of attention and mental capacity. This medicine is used in Russia and neighboring countries, although there are no authoritative proofs of its efficiency. Vitamin B6, in its turn, is vitally necessary element, that people need for normal functioning of nervous system. It is included in many enzymes, takes part in synthesis and amino acid exchange and neuromediators.

Authors conducted research with participation of 33 people, both male and female, at the age from 22 to 68. During one-month patients took a combined medicine. Researchers visited their patients twice:  before taking medicine and at the end of the month. During their visits doctors questioned patients about their health and made a test using 6-minutes walking.

At the beginning of the experiment most patients complained of decreased memory, disturbance of sleep, easy fatiguability during normal physical and emotional activity. After taking of medicine 35% patients noticed that their memory improved, 40% mentioned that problems with sleep disappeared, 42 % patients made less complaints about easy fatiguability. Besides this after taking a medicine people passed during 6 minutes a distance that was in average by 7% longer than before taking, and that was a statistically reliable result. Thus, a medicine EMHPS/Vitamin B6 improved health of patients and helped to experience physical activity better. It can be recommended as an additional product for physical rehabilitation after CJVID -19.

“We were motivated to conduct this research and study the question of post-covid asthenia by frequent occurrence of “post-covid syndrome”. We estimated efficiency and safety of complex medicine among patients with asthenic and cognitive disorders after covid and discovered that it influenced patients positively. This direction will be developed, patients take part in such researches with great enthusiasm and note the improving of health, and we are glad to help them”, – Yana Belousova, clinical pharmacologist, member of Immanuel Kant Baltic Federal University.



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Nearly 65 million individuals who were infected with COVID-19 have been reported to have post-COVID-19 condition (PCC), with ranging symptoms that include mild impairment to severe systemic disease and multiple symptoms involving various organ systems. However, this number is increasing and is believed to be higher due to undocumented cases of infection. Published in JAMA Network, researchers conducted an analysis of 14 randomized clinical trials that examined different rehabilitation intervention programs for individuals with PCC that found improvements in PPC with functional exercise.

According to The World Health Organization, PCC is defined as a progression or development of new symptoms within 3 months of the initial diagnose of the SARS-CoV-2 infection that last for 2 months without signs of other illness. The press release noted that the most commonly observed symptoms include fatigue, headache, attention disorder, hair loss, and dyspnea.

An increased risk of PCC was found in women who reported a lower income. This is due to the challenge of attaining adequate rest in the early weeks after being infected with COVID-19, according to the researchers.

“There is an urgent need for evidence-based rehabilitation interventions to support people affected by PCCbecause current guidelines are primarily based on expert opinion and observational data,” said the study authors. “The purpose of this meta-analysis is to assess whether rehabilitation interventions are associated with improvements in physical capacity (functional exercise capacity, muscle function, dyspnea, and respiratory function) and quality of life in adults with PCC.”

Data searches were completed from January 2020 to February 2023 from MEDLINE, Scopus, CINAHL, and the Clinical trials Registry to find eligible clinical trials. The researchers used 14 randomized clinical trials that compared rehabilitation interventions with placebo, usual care, waitlist, or control in individuals with PCC. The rehabilitation interventions included respiratory training, aerobic exercises, and resistance exercises.

Image credit: Studio Romantic - stock.adobe.com

The researchers used eligible data from 1244 individuals with a median age of 50 years and 45% of female participants. Six of the trials included individuals who were hospitalized for COVID-19 infection and 5 of the trials included hospitalized individuals who were not hospitalized with COVID-19 infection.

Using a 6-minute walking test, the researchers’ primary outcome was the measure of functional exercise capacity with the closest postintervention time point. The individuals had a 6-week follow up that found an improvement in functional exercise capacity compared to usual care. The secondary outcomes involved fatigue, lower limb muscle function, dyspnea, respiratory function, and quality of life.

“The analysis consistently showed that rehabilitation interventions had a greater probability of being superior to usual care across all outcomes, with probabilities ranging between 85% and 99%. Additionally, rehabilitation interventions were associated with higher probability of reaching the predefined between-group MID threshold for functional aerobic capacity, functional lower limb strength and endurance, dyspnea, and quality of life, with probabilities ranging between 84% and 95%,” said the study authors.

However, due to a lack of data on safety outcomes, individuals should be closely monitored for adverse events and more trials must be conducted to assess results.

Reference

Rehabilitation Interventions for Physical Capacity and Quality of Life in Adults With Post–COVID-19 Condition. JAMA Network. News release. September 19, 2023. Accessed September 25, 2023. jamanetwork.com/journals/jamanetworkopen/fullarticle/2809670.

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Introduction

The fact that small airway disease is a part of the pathology of chronic obstructive pulmonary disease (COPD) was first described in the 19th century,1 and the concept was incorporated into the definition of COPD in the American Thoracic Society statement in 1987.2 More recently, expiratory mechanical constraints due to airflow obstruction in COPD, which is the main cause of exertional dyspnoea, and are caused primarily by small airway narrowing resulting in dynamic airway collapse and dynamic hyperinflation, have become more well-recognised.3–7 Although, to date, strategies centred on bronchodilators acting on peripheral airways and pulmonary rehabilitation including pursed-lip breathing have been tried to reduce airflow obstruction and improve the patients’ health status or endurance capacity, there is limited evidence on improvement in incremental exercise tolerance, that is, aerobic capacity, especially in patients with advanced COPD.8–12

Dynamic airway collapse of not only small airways, but also the glottis that is, the extramediastinal central airway, might play a role in expiratory mechanical constraints, often with dynamic hyperinflation, leading to the exertional dyspnoea and exercise intolerance in COPD. Baz et al13 reported that with progression of COPD, expiratory glottic narrowing occurs from rest to exertion, leading to exertional prolonged expiration and exercise intolerance. Separately, we reported that patients with COPD with exertional prolonged expiration and poor exercise tolerance tend to depend more on expiratory muscle strength for adequate expiration, and we hypothesised that expiratory pressure load training (EPT) might promote glottic widening, which would enable deep strong breathing that is fundamentally different from pursed-lip breathing, potentially improving exercise tolerance in these patients.14 Next, we conducted a pilot study of 11 patients with severe and very severe COPD who received 3-month EPT to test our hypothesis, and we demonstrated significant improvements in endurance time on the constant work rate exercise test (WRET) and in peak oxygen uptake (VO2) on the incremental exercise test.15 Further verification of the hypothesis might expand our understanding of how the underlying disorder in COPD causes pathophysiological abnormalities via airflow obstruction and enable us to identify the therapeutic targets that should be treated to improve exertional airflow obstruction.

This multicentre, prospective, randomised, controlled study was conducted to validate the effect and safety of 3-month EPT: (1) in patients with severe-to-very severe COPD using confirmatory analyses; (2) those with mild-to-moderate COPD as exploratory research; and (3) to show how EPT confers these benefits related to effective ventilation.

Materials and methods

This trial enrolled patients at two sites in Japan between August 2020 and March 2022. The study as shown in the online supplemental protocol was approved by the respective ethics committees at each site (National Hospital Organisation Osaka Toneyama Medical Centre, TNH-R-2020018; and Kitano Hospital, Tazuke Kofukai Medical Research Institute, P201200601), conducted in accordance with the Declaration of Helsinki, and registered with the University Hospital Medical Information Network-Clinical Trials Registry (UMIN000041250). All participating subjects provided written informed consent. Based on the results of our pilot study,15 a total sample size of n=40 patients was planned (for details regarding sample size determination, see the online supplemental methods).

Study subjects

Patients with mild-to-very severe COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades I–IV) according to airflow limitation severity, as categorised by the GOLD classification,3 were eligible for the study if they were aged between 40 and 80 years, were in stable condition and able to tolerate cardiopulmonary exercise testing (CPET) to ensure adequate evaluation, and provided signed agreement for study participation. Participants were excluded for any of the following reasons: (1) malignant tumours; (2) active infection; (3) severe heart disease; (4) asthma; (5) change in the treatment regimen during the study; (6) receiving pulmonary rehabilitation; (7) receiving oxygen therapy during exercise; (8) a history of pneumothorax or having the risk of developing pneumothorax; and (9) judged by their physician to be ineligible to participate in this study.

Randomisation and blinding

Adaptive random allocation was performed by a person not involved in data collection or recruitment. A computer-generated randomisation list was created by a senior manager independent of this research department. After baseline assessment including pulmonary functions, in each group with mild-to-moderate COPD (GOLD I–II) and severe-to-very severe COPD (GOLD III–IV), patients were randomly allocated at a ratio of 1:1 to receive EPT with standard of care or standard of care alone (control) with equal populations of GOLD grades in each group (figure 1). Owing to the nature of the intervention, it was not possible to mask the participants. Data collection and assessment were performed by a person outside our hospital blinded to the details of the intervention.

Figure 1
Figure 1

Consolidated Standards of Reporting Trials diagram for enrolment and study completion. AS, aortic valve stenosis; EGPA, eosinophilic granulomatosis with polyangiitis; EPT, expiratory pressure load training; GOLD, Global Initiative for Chronic Obstructive Lung Disease.

Intervention

Patients in the EPT group performed EPT of 30 repetitions a set, two sets a day for 3 months at home. The expiratory muscle strength trainer (EMST) 150 or EMST 75 (Aspire Products LLC, Atlanta, Georgia, USA) device was used for EPT. A cylindrical mouthpiece rather than a flat mouthpiece was used in this EPT. The load applied was divided into six levels. The training load was started at 20% of the maximum expiratory pressure (MEP) evaluated at baseline. Thereafter, if possible, the level was increased once every 2 weeks up to 50% of the maximum pressure. Patients received monthly instructions and feedback on how to perform their home training from experienced staff. Further details are presented in the online supplemental methods and online supplemental video. Patients in the control group received standard care alone without EPT.

Measures

The primary outcome was endurance time, evaluated by the constant WRET in GOLD III–IV patients with COPD. The secondary outcomes included: (1) endurance time, evaluated by the constant WRET in GOLD I–II patients with COPD; and (2) in both GOLD III–IV and GOLD I–II patients, (i) V′O2, minute ventilation (V′E), expiratory tidal volume (VTex), mean expiratory flow (VTex/TE), inspiratory tidal volume (VTin), VTin−VTex, ratio of inspiratory time to total respiratory cycle time (TI/Ttot) and dyspnoea (10-point modified Borg Scale) during the incremental exercise test or constant WRET, (2) the glottic dilatation ratio (GDR) using laryngoscopy during the incremental exercise test, (3) health status assessed by the St George’s Respiratory Questionnaire (SGRQ), (4) MEP and (5) respiratory function. All participants were included in the safety analyses.

Evaluation

Exertional variables and glottic movement

During the trial, three types of CPETs15 16 were performed for the evaluation of ventilatory variables at baseline and at the 3-month evaluation with a similar protocol. The incremental exercise test, which consisted of 1 min or 2 min increments of exercise intensity up to 10 W, and the constant WRET at 70% of the peak work load in the incremental exercise test at baseline were performed. The inflection points of VTex, end-tidal carbon dioxide pressure (PETCO2) and dyspnoea (Borg Scale) were investigated by confirming the contributions of VTex, PETCO2 and the Borg Scale to V′E during the incremental exercise test by plotting VTex, PETCO2 and the Borg Scale as a function of V′E.5 17–19 The larynx was examined using a fibreoptic nasendoscope,13 during a submaximal incremental exercise test. This test followed a similar protocol to the baseline evaluation, which was performed until 90% of the peak heart rate (HR) observed during the baseline incremental exercise test (defined as iso-90% HR) was reached. From the video recording, the image stills were captured every 1/3 s at iso-90% HR. Defining the period from the point of first maximum glottic opening to the next maximum opening as one breathing cycle, the glottic areas were measured during each of the stable two breathing cycles at iso-90% HR. The GDR was calculated relative to the first maximum glottic area as 1 (ie, respective glottic area/glottic area at first maximum opening, %). Next, a single breathing cycle was divided from 0 to 1 by intervals of 0.1 cycle, and the GDR in each breathing cycle was calculated by proportional calculation between the two GDRs measured at each 1/3 s, as shown in online supplemental figure S1. When the glottic area was the lowest, the GDR was evaluated as the GDRlowest for that breathing cycle. The averages of the two breathing cycles of the GDR, the GDRlowest and the breathing cycle where the GDRlowest was obtained, were evaluated. The area under the GDR curve (AUC) was evaluated (figure 2). More detailed information is provided in the online supplemental methods.

Figure 2
Figure 2

Exertional change in glottic dilatation during a breathing cycle in the incremental exercise test. (A) In patients with GOLD I–II COPD; (B) in patients with GOLD III–IV COPD. Dotted line: at baseline evaluation; solid line: at 3-month evaluation; shaded area: Δ area under the GDR curve (AUC); square: GDRlowest at maximum glottic collapse during a breathing cycle; Δ AUC and Δ GDRlowest: 3-month change from baseline of the AUC of GDR and GDRlowest, respectively. Δ AUCEPT − Δ AUCControl and Δ GDRlowest EPT − Δ GDRlowest Control: difference in estimated treatment effect between the EPT and control groups. EPT, expiratory pressure load training; GDR, glottic dilatation ratio; GOLD, Global Initiative for Chronic Obstructive Lung Disease.

Health status

The validated Japanese version of the SGRQ was used as previously described.20 21

Static respiratory variables

Maximal inspiratory pressure and MEP were measured,15 and pulmonary function tests were performed,22 as previously described.

Statistical analysis

Continuous data are presented as means (SD) or medians (IQR) depending on the normality of the distribution (Shapiro-Wilk test). Changes within each of the groups were compared using a paired t-test or Wilcoxon signed-rank test, depending on the normality of the distribution in within-group differences (Δ 3 months). Differences in response between groups were assessed as follows. When within-group differences were normally distributed in both groups: (1) if the hypothesis of homogeneity of variance was formed, an unpaired t-test was used, and (2) if it was not formed, Welch’s t-test was used, with the mean difference of Δ 3 months between groups (EPT−control) being reported as the treatment effect for both. For other patterns of within-group differences, the Wilcoxon rank-sum test was used with Hodges-Lehmann estimates as a treatment effect. χ2 tests or Fisher’s exact tests were used for categorical variables. If the data were normally distributed, Pearson’s correlation coefficient was used for quantifying correlation; otherwise, Spearman’s correlation coefficient was used. Bidirectional stepwise variable selection was performed to determine the more influential variables that correlate with the change in exercise tolerance among the exertional variables related to expiratory airflow constraints with variance inflation factors less than 3. These variables were evaluated in the incremental exercise test and constant WRET in the present study. First, age and sex, which are widely known to influence exercise tolerance,23 24 were included as mandatory adjustments in the stepwise variable selection process. Second, GDRlowest, peak incremental exercise test results [VTex, VTex/TE, VTin−VTex and TI/Ttot (peak – rest)] and VTex -V′E inflection during the incremental exercise test were added for the analysis related to peak VO2; and GDRlowest, constant WRET results at the limit of tolerance [VTex, VTex/TE, VTin−VTex and TI/Ttot (peak – rest)] and VTex −V′E inflection during the incremental exercise test were added for the analysis related to endurance time. Furthermore, all possible models by stepwise estimation were also investigated to confirm the most appropriate selection model based on the lowest value of the corrected Akaike Information Criterion (AICc). In the stepwise regression models, the p values were set at 0.20 for variables to both enter and stay. No missing data were observed in the present study except for data on laryngoscopy. Of the 40 patients, four were excluded from the per-protocol set to analyse GDR data. A p<0.05 was considered to indicate significance (JMP software, version 11, SAS Institute, Cary, North Carolina, USA).

Results

Forty-seven patients with COPD who were randomised to the EPT or control groups were subdivided into GOLD grades I–II and III–IV (figure 1). Of them, three discontinued participation before study completion, and four met one exclusion criterion during the study; data from the remaining 40 patients (n=20 each in GOLD I–II and III–IV) were analysed. Baseline characteristics were not significantly different between the study groups (table 1). There were no reported adverse events during this study.

Table 1

Baseline characteristics of the study subjects (n=40)

Primary outcome (endurance time)

In GOLD III–IV patients, (1) compared with controls, EPT increased endurance time on constant WRET by an estimated treatment effect (ETE) of +390 (95% CI: 205 to 574) s, p=0.0006 (table 2); with an ETE of +90% (95% CI: 53% to 126%), from baseline, p=0.0002; and (2) the minimum difference in endurance time from baseline in the EPT group was +93 s.

Table 2

Changes in constant work rate exercise test parameters at the limit of tolerance in GOLD stages III and IV

Secondary outcomes

Anaerobic capacity

Compared with controls, EPT increased peak VO2 on the incremental exercise test from baseline by an ETE of +2.1 (95% CI: 1.1 to 3.1) mL⋅min−1⋅kg−1, p=0.0004 (table 3), +17% (95% CI: 10% to 28%), p=0.0002 in GOLD III–IV patients, and +2.1 (95% CI: 0.6 to 3.6) mL⋅min−1⋅kg−1, p=0.0086 (table 4), +13% (95% CI: 4% to 22%), p=0.0085 in GOLD I–II patients. In GOLD III–IV patients, there were no cases in the EPT group in which peak VO2 was reduced from baseline.

Table 3

Changes in incremental exercise parameters at peak exercise and health status in GOLD stages III and IV

Table 4

Changes in incremental exercise parameters at peak exercise and health status in GOLD stages I and II

Peak incremental exercise test variables

The incremental exercise test results are presented in tables 3 and 4. In GOLD III–IV patients, compared with controls, EPT (1) increased VE (p=0.0017) due to the increased VTex (p=0.0120), while maintaining respiratory frequency; (2) reduced VTin−VTex (p=0.0194), improving exertional prolonged expiration, that is, TI/Ttot (peak – rest) (p=0.0462); and (3) reduced exertional dyspnoea, decreasing Borg Scale scores with an ETE of −1.0 (95% CI: ‒2 to 0), p=0.0341. The reasons for stopping exercise changed after 3-month EPT across the GOLD grades (n=20); the number of patients who stopped primarily because of dyspnoea changed from 13 at baseline to 7 after EPT (p=0.0160).

Inflection point during the incremental exercise test

In both GOLD III–IV and GOLD I–II patients, compared with controls, EPT increased: (1) VTex inf. y-component, that is, the VTex value at the VTex −V′E inflection-point (p=0.0075 in GOLD III–IV; p=0.0015 in GOLD I–II) and VTex inf. x-component, that is, the V′E value at the VTex −V′E inflection point (p=0.0097 in GOLD III–IV; p=0.0151 in GOLD I–II) as shown in figure 3A; (2) PETCO2 inf. x-component, that is, the V′E value at the PETCO2V′E inflection point (p<0.0001 in GOLD III–IV: p=0.0019 in GOLD I–II), which was investigated as a post hoc exploratory analysis as shown in figure 3B, and dyspnoea inf. x-component, that is, the V′E value at the dyspnoea-inflection point (p=0.0156 in GOLD III–IV; p=0.0286 in GOLD I–II) as shown in figure 3C.

Figure 3
Figure 3

Change of 3-month EPT in (A) expiratory tidal volume (VTex), (B) end-tidal carbon dioxide pressure (PETCO2) and (C) dyspnoea intensity from rest to peak exercise shown in response to minute ventilation (V′E) in the incremental exercise test in Global Initiative for Chronic Obstructive Lung Disease (GOLD) I–II and III–IV. Grey symbol: at baseline evaluation; black symbol: at 3-month evaluation; square: inflection point. After 3-month EPT, in GOLD I–II and III–IV patients, (1) each x-component of the VTex, PETCO2, and dyspnoea inflection point is significantly shifted to the positive direction of the x-axis and (2) each y-component of the VTex inflection point is shifted to the positive direction of the y-axis. In GOLD III–IV patients, dyspnoea intensity level is significantly reduced at peak exercise after 3-month EPT. Data are presented as mean±SE at rest, at 10 W, at 20 W (if GOLD I–II), at the inflection point and at peak exercise. *p<0.05, **p<0.01, ****p<0.0001 (x-component); p<0.05, ††p<0.01 (y-component): significant difference between groups at a given time-point. EPT, expiratory pressure load training; GOLD, Global Initiative for Chronic Obstructive Lung Disease.

Constant WRET variables

The constant WRET results are presented in table 2 and online supplemental tables S1–S3. In GOLD I–II patients, compared with controls, EPT increased endurance time from baseline by an ETE of +703 (95% CI: 376 to 1031) s, (p=0.0008), +176% (95% CI: 65% to 287%), (p=0.0058). At isotime, EPT improved dyspnoea (p=0.0018 in GOLD III–IV; p=0.0037 in GOLD I–II) and VTex (p=0.0340 in GOLD III–IV; p=0.0091 in GOLD I–II); VTin−VTex (p=0.0140) was decreased only in GOLD III–IV patients compared with controls.

Health status

In only GOLD III–IV patients, the EPT group experienced benefits compared with controls in SGRQ total with an ETE of −9.7 (95% CI: ‒16.6 to ‒2.8) from baseline (p=0.0088) and SGRQ impact (p=0.0165) (tables 3 and 4).

Dynamic glottic widening

GDR responses to 3-month EPT were investigated (figure 2A,B, n=36). Compared with controls, EPT increased the GDRlowest by an ETE of+28% (95% CI: 17% to 38%), p=0.0001 in GOLD III–IV patients and+19% (95% CI: 6% to 32%), p=0.0062 in GOLD I–II patients, but did not change the breathing cycle where the GDRlowest was detected; and increased the AUC of GDR during the breathing cycle in GOLD III–IV patients (ETE+16% ⋅ cycle (95% CI: 8% to 25% ⋅ cycle), p=0.0006), but not in GOLD I–II patients (ETE+6% ⋅ cycle (95% CI: ‒3% to 15% ⋅ cycle), p=0.1954).

Static respiratory variables

The results of static respiratory variables are shown in online supplemental tables S4 and S5. As a post hoc analysis, across all GOLD grades, among patients who received EPT, the 3-month change in MEP was negatively correlated with 3-month change in GDRlowest (r=−0.49, p=0.0413, n=18).

Post hoc analysis for contribution to exercise tolerance

First, the correlations between baseline GDR and other variables were investigated (n=36). Baseline exertional laryngeal collapse, expressed by GDRlowest, was correlated with exercise intolerance and poor health status across all GOLD grades (online supplemental table S6). Next, whether the 3-month changes in exercise tolerance affected 3-month changes in other variables was investigated. Across all GOLD grades, as shown in online supplemental table S7, the 3-month change in peak VO2 was correlated with 3-month changes in: (1) GDRlowest (r=0.70, p<0.0001, n=36, figure 4A); (2) in the incremental exercise test results at peak exercise, VTin − VTex (r=−0.39, p=0.0124, n=40, especially in GOLD III–IV: r=−0.66, p=0.0015, n=20), and VTex/TE (r=0.51, p=0.0009, n=40); and (3) during exercise in the incremental exercise test results, VTex inf. y-component (r=0.56, p=0.0002, n=40), and PETCO2 inf. x-component (r=0.65, p<0.0001, n=40). Moreover, in GOLD III–IV patients, the 3-month change in GDRlowest was negatively correlated with the 3-month change in VTin − VTex (r=−0.55, p=0.0180, n=18). In the constant WRET, across all GOLD grades, the 3-month change in endurance time was correlated with 3-month changes in: (1) GDRlowest (r=0.67, p<0.0001, n=36) and AUC of GDR (r=0.49, p=0.0027, n=36); VTex inf. y-component (r=0.62, p<0.0001, n=40, figure 4B), PETCO2 inf. x-component (r=0.65, p<0.0001, n=40) and dyspnoea inf. x-component (r=0.64, p<0.0001, n=40) during the incremental exercise test; and (3) SGRQ total (r=–0.77, p<0.0001) in GOLD III–IV patients (n=20). The investigations of more influential variables that correlate with the 3-month change in exercise tolerance across all GOLD grades among all peak, throughout exercise or submaximal exercise variables related to expiratory airflow constraints were performed using stepwise variable selection. The bidirectional stepwise method for the aforementioned purpose yielded the same results with and without age and sex adjustment. With adjustment for age and sex, as more influential variables that correlate with the 3-month change in peak VO2, the analysis selected the following three variables in the most appropriate model (R2=0.73, AICc=102.8): the 3-month changes in VTin − VTex (p=0.1124), VTex/TE (p<0.0001) and GDRlowest (p<0.0001) in the incremental exercise test; and as more influential variables that correlated with the 3-month change in endurance time, the analysis selected the following two variables in the most appropriate model (R2=0.47, AICc=518.7): the 3-month changes in GDRlowest (p=0.0117), and VTex inf. y-component (p=0.0017) in the incremental exercise test. Figure 5 shows an example GOLD III case illustrating the dynamic glottic response following 3-month EPT.

Figure 4
Figure 4

Correlation of (A) 3-month changes in peak oxygen uptake (VO2) (n=36) and (B) 3-month changes in endurance time (n=40) across all Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades. Δ 3-month: 3 month change from baseline; endurance time: time to the limit of tolerance on the constant work rate exercise test; GDRlowest: glottic dilatation ratio at maximum glottic collapse evaluated in the incremental exercise test; peak VO2: obtained in the incremental exercise test; closed circle: the EPT group; open circle: the control group. The shaded area indicates the CI. GDR, glottic dilatation ratio.

Figure 5
Figure 5

Example Global Initiative for Chronic Obstructive Lung Disease (GOLD) III case illustrating dynamic glottic narrowing: (A) before and (B) after 3 months of EPT in the incremental exercise test. Each still image was captured every 1/3 s from a continuous video recording at a HR of 85 beats⋅min−1, which was equal to 90% of the peak HR in the incremental exercise test at baseline evaluation (defined as iso-90% HR). With the maximum glottic area as 1 at the start of the breathing cycle (0), the GDR at each 1/3 s is calculated as the ratio of the respective glottic area to the glottic area at the first maximum opening. A single breathing cycle is divided from 0 to 1 at intervals of 0.1 cycles. After 3-month EPT, GDR at maximum glottal collapse (GDRlowest) changes from 6% at 0.71 breathing cycles to 43% at 0.5 breathing cycles.EPT, expiratory pressure load training; GDR, glottic dilatation ratio; HR, heart rate.

Discussion

Our study showed a key finding that EPT is well tolerated and results in pronounced improvement of aerobic capacity, while leading to greater glottic widening with the release of expiratory-mechanical constraints despite advanced COPD grade, thus reducing end-exercise dyspnoea, as well as in prolonged endurance time and improved health status.

Improved aerobic capacity provides physiological benefits. Peak VO2 is a gold standard index of aerobic capacity and is predictive of mortality in both healthy subjects and those with COPD.25 26 There are, however, only a few reports about the minimal clinically important difference (MCID) in peak VO2 in patients with COPD. However, Ward et al12 reported in a systematic review that exercise training produced small changes in peak VO2 with a standardised mean difference of +0.52 mL⋅min−1⋅kg−1, and that patients with advanced COPD achieved smaller improvements in peak VO2 compared with earlier stage patients. The reason for the small response to exercise training might be directly related to the degree of expiratory airflow constraints, although exercise intolerance in COPD occurs by a variety of mechanisms.7 In this study, the incremental exercise test results showed that across all GOLD grades, the 3-month change in peak VO2 had a significant positive correlation with 3-month change in VTex and VTex/TE at peak exercise and VTex inf. y-component during exercise, and a significant negative correlation with residual air in the lungs after expiration per breath, that is, VTin − VTex at peak exercise, more significantly in GOLD III–IV patients than in patients of all GOLD grades. Although, in the present study, exertional measurements of inspiratory capacity as a measure of dynamic hyperinflation were not performed, the VTin − VTex, which is evaluated unconsciously during exercise, might be a surrogate indicator of dynamic hyperinflation. The above findings might mean that improvement of exercise tolerance was more related to the reduction in dynamic hyperinflation with every breath by EPT in GOLD III–IV patients. Furthermore, given the report that the VTex − V′E inflection point can be detected in most COPD cases, and exertional dyspnoea related to the exertional acidosis is associated with the VTex − V′E inflection point regardless of the presence of dynamic hyperinflation,5 17–19 27 28 the release by EPT of the expiratory-mechanical constraints from the middle exercise phase where the inflection point occurs to peak exercise in both GOLD I–II and III–IV patients (tables 3 and 4, figure 3, and online supplemental table S7) may be helpful for increasing peak VO2, because VO2 is calculated using the product of ventilatory flow and oxygen extraction, that is, the difference between inspired O2 concentration (FiO2) and expired O2 concentration (FeO2) (ΔFO2) of the entire body,29 30 and in the present study, significant changes of EPT in ΔFO2 were not obtained in either GOLD I–II or III–IV patients (tables 3 and 4). Therefore, the effective ventilation obtained from EPT significantly increased peak VO2 in GOLD III–IV patients, with an ETE (2.1 mL⋅min−1⋅kg−1) similar to that in GOLD I–II patients (tables 3 and 4), representing contradictory results to those of Ward et al.12 Admittedly, even in patients with GOLD III–IV in whom ventilatory ability can only be minimally increased, EPT increased VE via an increase in VTex, reducing VTin − VTex and exertional dyspnoea, with an ETE of −1.0 on Borg Scale scores at peak exercise during the incremental exercise test (table 3 and figure 3). This improvement in exertional dyspnoea is noteworthy, because end-exercise dyspnoea is reportedly of similar intensity even after intervention,31 and a modified Borg Scale change of 1 is considered an MCID, but is only used as a reference.31 These findings suggest that EPT increases ventilatory variables from the middle exercise phase where the inflection point occurs to peak exercise and reduces residual air in the lungs and exertional dyspnoea evaluated in the incremental exercise test in GOLD III–IV patients, leading to a drastic increase in aerobic capacity, as with GOLD I–II patients. Given that an endurance time change of 100 s or 33% change is considered the MCID,31 the ETEs of EPT on endurance time in both GOLD III–IV and I–II patients are promising (table 2 and online supplemental table S1), although constant WRET in the present study was performed at 70% of the peak work rate in the incremental exercise test, with 75%–80% of peak work rate being typically selected.31 Interestingly, across all GOLD grades, the 3-month change in endurance time in the constant WRET was significantly correlated with 3-month changes in VT ex inf. y-component (figure 4B), PETCO2 inf. x-component and dyspnoea inf. x-component. These findings mean that, after EPT, an increase in VTex at the middle phase in the incremental exercise test was associated with the delayed dyspnoea-inflection point, coinciding with the plateau level of CO2 clearance, that was followed by a steeply accelerated dyspnoea level (figure 3), the response of which correlated with the prolonged endurance time. That is, after EPT, the inflection point could be shifted to the late exercise phase, allowing exercise with less dyspnoea relating to exertional acidosis if exercise load levels were lower. Therefore, the 3-month increase in endurance time correlated with an improvement in health status in GOLD III–IV patients. This is consistent with the already reported finding that the release of the VTex constraint during exercise is closely related to improvement in exercise tolerance and dyspnoea.32 33 Moreover, EPT was well tolerated without adverse events in the present study. The above findings thus verify the exertional benefit and safety of EPT indicated in our previous pilot study,15 which could not, however, show how EPT reduces expiratory airflow obstruction.

In COPD, the development of expiratory-mechanical constraints entails airway narrowing including the larynx, by which intrinsic positive end-expiratory pressure (PEEPi) is generated as one of the mechanisms.13 34 Although an optimal relationship between effective ventilation and exertional PEEPi for exercise performance could not be investigated in the present study, at least, the excessive dynamic laryngeal narrowing might be in large part responsible for expiratory airflow obstruction, as suggested by the fact that dynamic laryngeal widening by EPT correlated with improvement in exercise tolerance and health status especially in patients with advanced COPD. In the present study, at baseline evaluation, as GDRlowest decreased across all GOLD grades, aerobic capacity decreased, along with worsening of health status, which concurs with the report by Baz et al.13 Moreover, the stepwise method selected the greater increase of GDRlowest and expiratory flow as the more influential variables correlated with the major improvement of anaerobic capacity with EPT. This might be driven by the fact that GDR calculation by the area rather than the width of the glottis more directly evaluated the responses to EPT, because the resistance to flow through tubes is inversely related to the reduction in the radius raised to the fourth power, as indicated by the Hagen-Poiseuille law. Furthermore, the response of EPT on laryngeal widening was larger in GOLD III–IV than in GOLD I–II patients. Therefore, not only the release of expiratory-mechanical constraints but also a greater response in dynamic laryngeal widening by EPT might be more helpful for advanced COPD. Conversely, after EPT, the endurance time increased to a greater degree in GOLD I–II than in GOLD III–IV patients. This might be primarily attributed to the improved ventilation during exercise as indicated by the VTex − V′E inflection point rather than dynamic laryngeal widening, as the stepwise method selected. Unexpectedly, in patients who received EPT across all GOLD grades, the 3-month change in MEP was negatively, not positively, correlated with the 3-month change in GDRlowest. This reminds us that the respiratory or abdominal muscle fatigue might be eliminated secondarily following adequate ventilation with EPT, given that expiratory muscle activity is relatively increased in COPD, but fails to reduce airflow obstruction.18 35 36 However, based on the hypothesis in our previous study14 that more expiratory muscle strength might be needed for adequate expiratory ventilation to improve exercise intolerance, this unexpected post hoc result suggests that measurement of PEEPi may be helpful in clarifying the mechanism of EPT in the future. Since our previous study,14 we have assumed that EPT might train the laryngeal muscle groups to open the central airway like a stent to withstand obstruction for effective ventilation, even though higher levels of PEEPi or maintenance of a certain level of PEEPi are required for exercise. Though we were unable to investigate whether EPT results in an optimal relationship among respiratory system pressure, laryngeal narrowing and expiratory ventilation in the present study, our findings deepen our understanding of how excessive obstruction in the extramediastinal central airway, especially in advanced COPD, leads to stressful breathing by expiratory airflow constraints. Our findings suggest that excessive laryngeal narrowing should be considered a therapeutic target for improving expiratory airflow obstruction, and demonstrate that, even in advanced COPD, a greater response in dynamic laryngeal widening with the release of expiratory mechanical constraints by EPT might have effects on exercise tolerance and health status.

This study has some limitations. First, the number of participants was small. Second, during this trial, people’s movements were curtailed due to the COVID-19 pandemic, and some might have become more immobile, which might have affected the results to a greater degree in the control group than the EPT group. Third, it is possible that patients can still exercise without dyspnoea even if they are hypoxaemic after EPT, because ventilatory limitation rather than hypoxaemia is often the cause of exercise limitation in COPD.27 28 In one patient with GOLD III who received EPT, 3-month differences in peak VO2 and dyspnoea at peak exercise were, respectively, +1.1 mL⋅min−1⋅kg−1 and 0 on the Borg Scale, even though SpO2 at peak exercise decreased from 84% to 79%. Therefore, some patients with advanced COPD might need supplemental oxygen therapy despite an adequate EPT effect. Fourth, exertional expiratory laryngeal narrowing occurs even in healthy people.13 In the present study, although the severity of laryngeal narrowing increased with advancement of COPD grade, the response of GDR to EPT was greater. It is assumed that exertional laryngeal narrowing occurs with increased PEEPi13 or as a compensatory response to tracheal obstruction.37 38 For further clarification of the mechanism, investigation of how EPT affects such narrowing might provide further clues for ensuring adequate ventilation during exercise. Further investigations using measurements of respiratory system pressure or dynamic radiological imaging techniques37–40 might be helpful.

In conclusion, a large effect of EPT on anaerobic capacity, as well as endurance capacity, was found, and it was observed to improve the health status of patients with advanced COPD. On post hoc analysis, the optimal relationship for improvement in exercise intolerance between the release of expiratory mechanical constraints and laryngeal widening after EPT was assumed, which may be considered hypothesis generating and is a potential novel therapeutic target for COPD. While confirmation in a larger population is required, these results might suggest the importance of regulating the larynx as part of the upper airway to reduce expiratory airflow obstruction in lower respiratory tract diseases, such as COPD. We believe these findings are a step towards further large trials to verify the suggestion that EPT could be part of physical rehabilitation of patients with COPD in different clinical scenarios.

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Long Covid patient Shona Jagger at home with her dogs Paddy and Jet. Photo by Maxine Gordon <i>(Image: Maxine Gordon)</i>

Long Covid patient Shona Jagger at home with her dogs Paddy and Jet. Photo by Maxine Gordon (Image: Maxine Gordon)

AN award-winning York teacher told by her GP she was the worst long Covid patient they had ever seen is preparing to return to the classroom and wants more NHS support and treatments for patients.

Shona Jagger, 43, a PE teacher at Fulford School, became a shadow of herself as long Covid ravaged her health.

Breathlessness, brain fog, chronic fatigue, pins and needles, pain, digestive problems, insomnia and tinnitus are just some of the symptoms she has been left battling daily since the end of 2021 - and for which she takes a range of daily medicines.

Her breathing difficulties affected her speech and she has had to learn to talk again.

Miraculously, Shona returned to the job she loved last September and is preparing to go back again this week, although she admits every day is a battle.

She said: "I used to be fit and healthy. I played county hockey, taught PE and played five-a-side football with the men at school."

York Press: Shona Jagger enjoying a day out before long Covid struck

York Press: Shona Jagger enjoying a day out before long Covid struck

Shona Jagger enjoying a day out before long Covid struck

When she was first ill, she struggled to move from room to room in the house. But through determination, rehabilitation workshops, and her medications, she is now able to cycle the short distance to work each day and walk her dogs Jet and Paddy for up to half an hour at a time.

But all the while, she is battling fatigue and faces the risk that her legs may "give up" and she will need to sit or lie down.

She said: "You just have no energy. It is like when your phone runs out of charge. You physically cannot pick up your legs and arms and your brain doesn't work properly."

She added: "The hardest part is: 'why me?' But I can't just sit around asking that."

She said getting back to the job she loved would not have been possible without the support of her husband Joe and the staff and pupils of Fulford School, who she said have been "fantastic".

Shona made the headlines in 2015 along with other Fulford School staff who helped save the life of a pupil who had collapsed. Shona and her colleagues won the Teacher of the Year award in The Press's Community Pride awards afterwards.

York Press: Shona Jagger and fellow teachers winning a Community Pride award in 2015 for saving a pupil's life

York Press: Shona Jagger and fellow teachers winning a Community Pride award in 2015 for saving a pupil's life

Shona Jagger and fellow teachers winning a Community Pride award in 2015 for saving a pupil's life

As she prepares to return to Fulford for the new school year she is determined to keep going.

She said: "Everything is about being back at work.

"I have had to adapt how I do my lessons. I sit down at break times. I have learned to send emails rather than go find someone to talk to them face to face."

The same adaptations apply at home.

"At home, if I wash my hair I have to sit on a stool in the shower. If I am making tea I sit down at the breakfast bar to do it, or take it in stages."

Shona said she has had a lot of support along the way - from her GP, a long Covid clinic in York, as well as through the Nuffield, where she took part in two trials. The first trial was for physical rehabilitation which gave her basic exercises to do at home to improve her mobility and balance. The second was for CBD oil which she said helped with the pain in her legs and improved her sleep.

York Press: Shona with her husband Joe

York Press: Shona with her husband Joe

Shona with her husband Joe

The toll of long Covid affected her mental health too and Shona benefited from the IAPT service in York, which offers psychological treatments for stress, anxiety and depression. People can self refer into this service or access it via their GP.

Shona said: "They did behaviour activation therapy with me - it is brilliant for anyone suffering with their mental health. It works by setting little goals, from mastering easy skills like making a cup of tea, to harder ones like riding a bike or walking the dog."

"I have had very low moments but Joe, my family and school have all been fantastic."

And she has this advice for other people suffering with long Covid. "You can't wait around for the NHS so you need to set yourself little goals.

"Some nights I sit on the sofa and I can't move my legs, but I am not going to let this beat me."

She said long Covid needed to be recognised as an illness in its own right and more needs to be done to diagnose patients correctly and offer treatments.

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Plain Language Summary

Chronic obstructive pulmonary disease, COPD, is a common chronic disease and is treated with medication and exercises. To be beneficial, it is important to adhere to the exercise program prescribed by the physiotherapist or rehabilitation doctor. Research in the field has introduced various tools to measure this adherence. One such tool is the Rehabilitation Adherence Measure for Athletic Training, or RAdMAT for short. The results of these studies demonstrated that the RAdMAT has good psychometric properties in physiotherapy in general. In the Netherlands, a Dutch version of this questionnaire, known as the RAdMAT-NL, is available to rate adherence to prescribed exercises. The quality of these ratings – that is, the reliability and validity of the RAdMAT-NL - is unknown. Our study aimed to explore the structure and accuracy of the RAdMAT-NL in patients with COPD.

Almost 200 patients with COPD who received an exercise program from their physiotherapist in the Netherlands and Belgium participated in our study. For three months, these patients and their physiotherapist provided information about the exercises, including the scores given to patients on the RAdMAT-NL. By analyzing these scores, we found that the RAdMAT-NL consists of two subscales, “Participation” with 13 items and “Communication” with 3 items. The 13 items of Participation may be summed to a single score of adherence to the exercises that may help the doctor or physiotherapist in improving adherence to the exercises if needed.

Introduction

Physical rehabilitation involves self-management, and requires effort from patients themselves in following prescribed exercises at home. Adherence to exercise is therefore essential to enhance rehabilitation outcomes and to improve patients’ health and quality of life.1 Adherence is important in many fields of healthcare and patients who fail to adhere, may experience prolonged treatment and less favorable outcomes.2 To keep healthcare affordable and for improving patient outcomes, attention must be paid to adherence.3

Adherence is of particular importance in chronic obstructive pulmonary disease (COPD). Fewer than half of therapies for COPD are taken as prescribed.4 Medication adherence can be monitored by eg, confirming drug use and dose or pill counts.5 In rehabilitation, the assessment of exercise adherence is less straightforward because prescribed exercises largely take place at home, with patients and their caregivers making decisions as to whether exercises should be started or continued, often without consulting their healthcare provider.6 As a result, it is not always clear to professionals whether patients are adherent or not. Professionals tend to make their own judgements on patients’ adherence by simply asking or by observing treatment progress.7 The accuracy of their judgements however is uncertain. Therefore, standardized instruments are available to rate the extent and reasons for non-adherence.7 On the basis of early signals, the treatment might be adapted to the specific needs of a patient or measures can be taken for improvement.8

Literature shows that instruments are available to measure adherence to exercise in a rehabilitation setting.9 Two appear to be valid and reliable: the Sport Injury Rehabilitation Adherence Scale (SIRAS)10 and the Rehabilitation Adherence Measure for Athletic Training (RAdMAT).11 The SIRAS, with only three items, has been criticized for its limited ability to adequately capture the various behavioral aspects important for adherence.11 The RAdMAT allows for a more detailed and comprehensive assessment of adherence and includes 16 items on patients’ attitudes, communication and clinic behaviors. The RAdMAT has been examined within a broader physiotherapy setting in patients with shoulder problems and showed good psychometric properties.12 Previous validation (dimensionality and construct validity) of the RAdMAT recommended the use of three subscales, but suggested that a single score for overall adherence also might be calculated.10,11 Based on the acceptability of the RAdMAT, a Dutch version (RAdMAT-NL) was designed to be used for the Dutch-speaking population. This version was prepared by a native speaker based on the guidelines of translating questionnaires.13 The RAdMAT-NL showed a high inter-rater reliability in patients from a primary physiotherapy setting.14 Therefore, the RAdMAT-NL seems to be appropriate for quantifying adherence in patients with COPD. However, the validity of the RAdMAT-NL, especially its dimensionality and construct validity, is unknown.

The aim of this study was to evaluate the dimensionality and construct validity of the RAdMAT-NL in patients with chronic obstructive pulmonary disease undertaking pulmonary rehabilitation in a primary physiotherapy practice. Secondly, we examined if the items of the RAdMAT-NL could be summed to a single score of adherence.

Methods

The reporting of this study complies with the Strengthening The Reporting of Observational Studies in Epidemiology (STROBE) checklist for cohort studies.15

Participants

Participants of this prospective study were Dutch/Flemish-speaking patients aged ≥18 years who were recruited between January 2021 and December 2021 from 53 primary physiotherapy practices and from the COPD patient organizations from the Netherlands and Belgium. Included were patients with COPD, with airflow limitation stage Global Initiative for Chronic Obstructive Lung Disease (GOLD) II–IV16 and having rehabilitation sessions for at least once a month, for at least one month. The exclusion criteria were home-based rehabilitation and insufficient mastery of the Dutch/Flemish language to complete the questionnaires.

Physiotherapy practices were approached by email and social media for participation and patients were recruited by their attending physiotherapist. Patients who were willing to participate were contacted by the researcher per email for further information on their participation, and to obtain informed consent. For patients without an email address, this was done by their physiotherapist at their visit to the physiotherapy practice. Patients were also recruited via the COPD patient organization in the Netherlands and Belgium who, in turn, invited their physiotherapist for participation.

The study complies with the Declaration of Helsinki and was approved by the Ethical Committee Psychology of the University of Groningen (PSY-1920-S-0504).

Procedures

Before the start of the study, all participating physiotherapists received an email about the implementation of the study, including a manual on how to use and administer the RAdMAT-NL, the SIRAS and the Five Times Sit to Stand Test (FTSST).

After signing informed consent and inclusion, patients completed an online (Qualtrics; online survey software)17 or paper form on their demographic characteristics; age (years), gender (male/female), level of education (lower/middle/high), smoking status (never/stopped/still smoking). If applicable, a paper form was sent by the researcher to the participating physiotherapy practice for completion.

At the same time, the physiotherapist provided information on the characteristics of the disease; GOLD classification as determined by the pulmonologist (II/III/IV), Medical Research Council (MRC) dyspnea score18 as determined by the patient (0/1/2/3/4/5), time since onset of COPD (years), duration of physiotherapeutic rehabilitation (0–3 months/3-6 months/6-12 months/1-5 years/>5 years), and administered the FTSST to the patient. The patients provided information about their homework exercises and their health at one, two and three months after inclusion. After three months, the physiotherapist provided information and measurements on the patient’s rehabilitation.

Assessment Instruments

RAdMAT-NL

The RAdMAT-NL evaluates clinic-based adherence with 16-items using a four-point rating scale (never = 1, always = 4).14 The original RAdMAT consists of three subscales: Attendance/participation “follows the prescribed rehabilitation plan” (items 1–5, range 5–20 points), Communication “asks questions about his/her rehabilitation” (items 6–8, range 3–12 points), and Attitude/effort “gives 100% effort in rehabilitation sessions” (items 9–16, range 8–32 points). The total scale range is 16–64 points (maximal adherence). The RAdMAT-NL was completed by the physiotherapist after three months of rehabilitation, independent of the patient and not in their presence.

Sport Injury Rehabilitation Adherence Scale (SIRAS)

The SIRAS rates, on a five-point scale, adherence to clinic-based rehabilitation, using three items on amount of effort taken, on extent of following instructions and advice, and on receptiveness to change in the rehabilitation program.12 Scores may range between 3 and 15 points (maximal adherence).10 Like the RAdMAT-NL, the SIRAS was completed by the physiotherapist after three months of rehabilitation independent of the patient, and not in their presence.

Five Times Sit to Stand Test (FTSST)

Measuring exercise skills, eg, lower extremity strength, may be a way to assess adherence.19 If patients adhere to their rehabilitation program, their muscle strength will increase (or is at least stable) over time.19 The FTSST is a test of lower limb function to assess the fastest time taken to stand five times from a chair with arms folded.20 The FTSST was assessed by the physiotherapist during consultation two times, first after signing informed consent, and second after three months of rehabilitation.

Home-Based Adherence Form

Patients completed a form with four items, to rate the extent they had performed their prescribed exercises the past month21 using a five-point rating scale (as often as I had to = 1, not performed = 5).

The home-based adherence form was filled out by the patient after one, two and three months of rehabilitation. Patients could also indicate whether or not they had experienced a COVID-19 infection or a lung attack22 in that month. If so, those data were excluded from the psychometric analysis of the RAdMAT-NL.

Perceived Adherence and Percentage of Attendance

Perceived adherence and percentage of attendance were rated by patients after three months of rehabilitation. Perceived adherence (home-based and clinic-based) included the extent to which they succeeded to attend appointments, performed prescribed exercises, and the extent to which they asked questions and gave feedback about their rehabilitation. Adherence was rated on a five-point scale (did not succeed at all = 1, totally succeeded = 5).19

The percentage of attendance was calculated for each patient by the number of appointments attended divided by the number of appointments scheduled, multiplied by 100.12

Statistical Analysis

Data were analyzed using R version 4.0.3.23 using the {psych} and {eRm} package.

Only complete datasets were included in the analysis. Descriptive statistics were used to summarize the baseline demographic and clinical characteristics of the patients. Variables were expressed in percentages or as the median with interquartile range (IQR).

The dimensionality of the RAdMAT-NL ie, the number of dimensions present in the RAdMAT-NL itemset, was evaluated with Horn’s parallel analysis.24 Parallel analysis is a technique that works by creating a random dataset with the same numbers of observations and variables as the original data. The associated scree plots based on the actual and random data allow to distinguish true factors from factors that are obtained by chance.24 Based on the results of the parallel analysis, a forced exploratory factor analysis (EFA, principal axis factoring) was performed. Specificity of the extracted factors was evaluated by the absence of cross-loading items (>0.45) using the cut-offs according to sample size outlined by Hair.25 Fit of the factor model was assessed with the root mean square residuals (RMSR, ≤0.05), the Fit based upon off diagonal values (>0.95), and the Tucker Lewis Index (TLI, >0.90).26 Prior to performing the EFA, the appropriateness of the data for factor analysis was assessed with the Kaiser–Meyer–Olkin measure of sampling adequacy (KMO, >0.70) and Bartlett’s test of sphericity (p < 0.05).24

Subsequently, essential unidimensionality of the extracted RAdMAT-NL subscales was tested with the one parameter logistic Rasch model for binary item responses. The Rasch model is a formula describing the probability of an item response (0 or 1) as a function of trait level.27 The basic assumption is that with increasing trait levels an increasingly higher probability of a positive score is expected; 1 instead of 0 for a binary scored item.27 Rasch analysis estimates item measures (difficulty to endorse) and person trait measures which are both expressed on a common logit unit scale. To facilitate the Rasch model analysis, the item scores were dichotomized according to their mean (item score < mean = 0; item score > mean = 1). Item fit to the Rasch model was examined by mean square infit and outfit effect sizes (ranges 0.5 to 1.5 were considered acceptable).28

Construct validity of the RAdMAT-NL subscales was examined by calculating Spearman correlations with; SIRAS, percentage change on FTSST, self-reported home-based adherence, overall adherence and percentage attendance at scheduled rehabilitation appointments. The strength of correlations was interpreted based on the guidelines described by Cohen: small = 0.10–0.29, medium = 0.30–0.49 and large is 0.50–1.0.29

Results

Patients from 53 different physiotherapy practices participated in the study. Out of 199 patients who gave informed consent, data from 193 patients were analyzed (Additional File 1). The most common reasons for exclusion were; the physiotherapists did not provide any information, or the patient left the study (died or diagnosed with cancer).

Table 1 summarizes the demographic and disease characteristics of the patients. Characteristics of the participating physiotherapists are summarized in Additional File 2.

Table 1 Demographic and Disease Characteristics Patients (n = 193)

Dimensionality of the RAdMAT-NL

The KMO was 0.90, and all values for individual items were >0.76, exceeding the recommended minimum value of 0.7. Bartlett’s test of sphericity was, χ2 (120) = 1759.6, p < 0.001, below the needed p < 0.0523, indicating the appropriateness of conducting a factor analysis.

The parallel analysis indicated the presence of two dimensions emerging over chance (Figure 1). The blue line with the crosses (the factor eigenvalues) represents the original data scree plot. The red dashed line represents a scree plot based on the random data. The figure shows that eigen value of the second large factor is slightly above that obtained by chance. Table 2 shows the factor loadings of the subsequent forced two-factor model. The factors were labelled as Participation (13 items) and Communication (3 items) and explained 44% and 7% of the variance respectively. There were no cross-loadings, items loading >0.45 on both factors. Model fit statistics were within acceptable ranges (RMSR of 0.06, a Fit based upon off diagonal of 0.98, a TLI of 0.803).

Table 2 Item Frequency Distribution, Factor Loadings, Eigenvalues and Percentage of Explained Variance for the Two Factors of the RAdMAT-NL (n = 193)

Figure 1 Parallel analysis.

The RAdMAT-NL total scale and subscales (“Participation” and “Communication”) were subjected to the unidimensional Rasch model (Table 3). Both subscales showed adequate fit to the unidimensional model, except for item 14 from the Participation subscale where infit and outfit statistics fell slightly above the 1.5 cutoff. For the RAdMAT-NL total scale, the Rasch model was rejected. In line with the extracted subscales, Communication items 6 to 8 interfered with unidimensionality.

Table 3 Item Fit Statistics for Participation and Communication Scales and Total RAdMAT-NL

Construct Validity

The Spearman correlation coefficients between the subscales of the RAdMAT-NL and the other indicators or measures of adherence, SIRAS, percentage change on FTSST, self-reported home-based adherence, overall adherence and percentage attendance at scheduled rehabilitation appointments are presented in Table 4. As expected, the RAdMAT-NL subscale participation was positively associated with all other measures indicative of adherence. Self-reported home-based adherence had a medium positive correlation, all other measures had a large positive correlation with the RAdMAT-NL subscale Participation, demonstrating evidence for construct (convergent) validity.

Table 4 Construct Validity; Correlations with FTSST Change and Adherence Measures

Discussion

This study assessed the dimensionality and the construct validity of the Dutch version of the Rehabilitation Adherence Measure for Athletic Training (RAdMAT-NL) in patients with COPD undertaking pulmonary rehabilitation in a primary physiotherapy practice in the Netherlands and Belgium. The study also examined whether the 16 items of the RAdMAT-NL could be summed to a single score of adherence. The RAdMAT-NL exhibited two subscales (Participation and Communication) that fitted the unidimensional Rasch model for objective measurement. Construct validity was supported by convergence with other established measures of adherence.

Dimensionality of the RAdMAT-NL

The parallel analysis results of this study show a different number of dimensions present in the RAdMAT-NL compared to the original research;11 two factors instead of three factors. Factor 2, Communication, is the same factor as in the original research, however Factor 1 and 3 of the study of Granquist et al11 are reflected in our study as one factor, Participation. Fit statistics indicated a good fit for the two-factor solution. Rasch model fit statistics indicated unidimensionality for both dimensions. Only Participation item 14 had infit and outfit statistics slightly above the 1.5 cut-off, interfering with unidimensionality but not degrading for measurement.28

Granquist et al suggested the RAdMAT could be used as a single score but did not statistically show this.10 Since it may be convenient for research, in practice and in evaluation research to use a single sum score for adherence, it was tested whether this is allowed. The unidimensional Rasch model was rejected for a summed score of all 16 RAdMAT-NL items because of the Communication items. Granquist et al11 also made their own observation regarding the Communication items. They described that two previous studies30,31 addressed communication as an important factor for rehabilitation adherence, but that literature does not identify communication as a rehabilitation-adherence behavior.32 Granquist et al11 concluded that athletic trainers likely use other cues/communication and that this should be kept in mind when interpreting the results of adherence. Generally, we observed more score variation on the Communication items than on the Participation items (with the exception of item 16). The presence of more variation could indicate a wider range of opinions or perspectives among the physiotherapists. Although communication is an important aspect of rehabilitation, the Communication items involve the patient’s communication only, which is less appropriate for assessment of adherence in a medical rehabilitation setting. Items evaluating the quality of patient-therapist communication are probably more appropriate in a medical rehabilitation setting, where shared decision-making is central.

Construct Validity

In line with the results of Granquist et al11 and Clark et al,12 our results demonstrated large correlations between the RAdMAT-NL subscale Participation and SIRAS and between the RAdMAT-NL subscale Participation and percentage attendance. Furthermore, this study supported convergent validity by a medium correlation between the subscale Participation and self-reported home-based adherence, and large correlations with perceived overall adherence and the change on the FTSST. The overall observed positive correlations confirm that the RAdMAT-NL subscale Participation is associated with attendance to appointments, exercise skills and self-rated adherence which suggests the potential clinical relevance of the RAdMAT-NL.

Strengths and Limitations

The strengths of this study are inclusion of patients from 53 physiotherapy practices and from patient-organizations in The Netherlands and Belgium, which enhances the generalizability of the study results. Another strength is the use of parallel analysis; parallel analysis is considered one of the best options for determining the factors to retain in factor analysis because it provides a statistically rigorous approach. It addresses the issue of overestimating the number of factors to retain, which is a common challenge in exploratory factor analysis.24 Finally, a strength of this study is that prospective data were collected in a real-life setting of primary physiotherapy practices, increasing ecological validity.33

This study also has some limitations. This study was conducted during the COVID-19 pandemic and may have affected motivation of patients for physiotherapy and the way physiotherapists work. Counselling may not always have been able to take place physically, but also online and may have influenced the Communication items.

Follow-up research should further explore the validity of the RAdMAT-NL, preferably with a larger sample size, to assess the robustness of the results and especially to further investigate content validity with regard to the formulation of the Communication items and whether or not to retain Communication items to assess adherence in medical rehabilitation.

Implications

No Dutch language instrument for exercise adherence was available. The RAdMAT-NL in its current form could be used with some caution as an interim assessment instrument of exercise adherence for patients who are not progressing as expected. Low scores on the subscales of the RAdMAT-NL may indicate the need for interventions to enhance patient’s adherence. According to the American College of Sports Medicine (ACSM) guidelines, a score of at least 85% must be achieved to be adherent to the rehabilitation program.34 The RAdMAT-NL may also be used or studied in relation to the patient psychological determinants of adherence, such as motivation and perceived control. That is, while the RAdMAT-NL provides the professional’s perspective on the patient’s adherence, the psychological determinants may provide the patient perspective, and together they may predict adherence even better. To investigate whether this is indeed possible, we used the RAdMAT-NL in combination with the Theory of Planned Behavior, among others, to develop a prediction model for adherence.35

Conclusions

The RAdMAT-NL, with two subscales (Participation and Communication) and good construct validity, can be used to quantify exercise adherence in patients with COPD undertaking pulmonary rehabilitation in a primary physiotherapy practice. With only 16 items in a simple format, the RAdMAT-NL is also relatively easy to use, whether by healthcare providers in clinical practice or for research purposes.

Abbreviations

COPD, Chronic Obstructive Pulmonary Disease; EFA, Exploratory Factor Analysis; FTSST, Five Times Sit to Stand Test; GOLD, Global Initiative for Chronic Obstructive Lung Disease; IQR, Interquartile Range; KMO, Kaiser–Meyer–Olkin measure; MRC, Medical Research Council; MSQ, Mean Square; PR, Pulmonary Rehabilitation; RAdMAT-NL, Dutch version of the Rehabilitation Adherence Measure for Athletic Training; RMSR, Root mean square of the residuals; SIRAS, Sport Injury Rehabilitation Adherence Scale; TLI, Tucker Lewis Index.

Data Sharing Statement

Data are available on reasonable request. Data are available on reasonable request through the corresponding author Ellen Ricke, [email protected].

Ethics Approval and Informed Consent

This study is registered with the number METc 2020/392. The METc UMCG has concluded that the study is not clinical research with human subjects as meant in the Medical Research Involving Human Subjects Act (WMO). Also, the study was approved by the Ethical Committee Psychology of the University of Groningen (PSY-1920-S-0504).

Acknowledgments

The authors wish to acknowledge the contributions of the patients and physiotherapists involved in this study.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Disclosure

The authors declare that they have no competing interests.

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    4.1. Summary of Evidence

    This systematic review reveals a growing interest in telemedicine-driven pulmonary rehabilitation following the acute phase of COVID-19, although, as the pandemic reaches an end, it will be interesting to observe this trend in the upcoming years. The studies included in this review were conducted across diverse geographical settings, further supporting the potential global applicability of telemedicine interventions in post-acute COVID-19 management. It seems that regardless of the study design, the integration of telerehabilitation in post-acute care significantly improved several health outcomes among COVID-19 patients. These improvements were observed in physical and mental health, quality of life, and pulmonary function, albeit with variations across different studies.

    In terms of rehabilitation protocols, a significant amount of heterogeneity was observed among the studies. This could be reflective of the individualized approach necessary for addressing the distinct needs of post-acute COVID-19 patients, as well as the absence of a unified protocol for telerehabilitation in this setting. The protocols were designed to incorporate a balance of aerobic and resistance training, breathing exercises, and functional activities, often accompanied by counseling or motivational measures to promote adherence. The intensity, duration, and frequency of the sessions varied widely, suggesting the need for further studies to identify optimal parameters for telerehabilitation programs in this population.

    Different rehabilitation protocols emphasize various exercises, including deep breathing, inspiratory muscle training, and breathing control techniques, although the majority were performed in a hospital or institutional setting, contrary to our study [28,29,30,31]. These protocols often also incorporate physical exercises for strength and endurance, which help in functional improvement and disability reduction [32,33]. However, the question that arises is what degree of change and disability reduction is dependent on the PR setting. A holistic approach, encouraged by the American Thoracic Society (ATS) and the European Respiratory Society (ERS), expands beyond mere physical exercises, embracing comprehensive patient evaluation and lifestyle modifications [34]. Some studies have combined their rehabilitation protocols with educational sessions to address such issues as dyspnea, cough, fatigue, anxiety, memory, and daily activity management [35,36]. These integrative approaches have demonstrated significant improvements in functional abilities, patient’s quality of life, and reintroduction into professional life.
    Around 90% of COVID-19 patients in hospitals deal with debilitating lung effects, indicating the importance of physical and respiratory rehabilitation [37,38]. The most common symptoms include dyspnea, fatigue, and exercise intolerance. Thus, telerehabilitation, offering physiotherapy remotely, is a suitable option to address these issues, particularly during social distancing, while its convenience also encourages patient adherence [39]. Improvements in physical health outcomes, such as fatigue, pain, and exercise capacity, suggest that telerehabilitation can be an effective modality to enhance recovery and function after acute COVID-19. The improvements in mental health outcomes further support the potential of telerehabilitation in addressing the psychological impact of the disease, an aspect that is often overlooked in physical rehabilitation programs. The positive effect on quality-of-life measures is particularly encouraging, given the significant impact COVID-19 can have on overall well-being.
    The pandemic added challenges for research and trial participation due to strict control measures and economic struggles. Randomized trials showcased a variety of participant details, disease stage, telerehabilitation methods, and the varying telemonitoring options that could have impacted outcomes, such as smartphones, video conferences, and messaging applications [40,41]. The rush to introduce remote interventions often came with inadequate implementation guidance and professional training, which was evident in some of our included studies and other trials for acute COVID-19 [25,42]. Despite the variability in the measures used to assess pulmonary function, some significant improvements were reported. It is important to highlight that the effects on pulmonary function seem to depend on the severity of the disease, with the less severe cases showing more significant improvements. Thus, one hypothesis that this study suggests is that telerehabilitation might be more effective when initiated in the early post-acute phase before severe pulmonary sequelae develop.
    Moreover, further research is needed to examine the aspects of physical abilities and lung function that better represent changes during PR post-COVID-19. Notably, these parameters encompass Forced Vital Capacity (FVC), Forced Expiratory Volume in 1 s (FEV1), and Diffusing Capacity for Carbon Monoxide (DLCO), as used in other PR programs for COPD and ILD [43,44]. Furthermore, not only do these traditional lung function tests show improvement following a physical rehabilitation program, but the severity of dyspnea, or shortness of breath, also significantly decreased among adult survivors of COVID-19. This provides another practical measurement of improved respiratory function, as reducing the feeling of breathlessness is a critical component of the recovery process. In addition to the aforementioned tests, it may also be beneficial to consider other tests, such as the Total Lung Capacity (TLC) and the Peak Expiratory Flow (PEF), that may provide a more nuanced understanding of the impact of physical rehabilitation programs on lung function among COVID-19 survivors.

    The quality of the studies included in this review was generally good or excellent, suggesting reliable findings. However, it is worth noting that the higher-quality studies were all randomized trials conducted in 2022, indicating that the quality of research in this area is improving. Additionally, the higher-quality studies tended to have larger sample sizes, suggesting that they may provide more reliable evidence for the effectiveness of telerehabilitation in this setting.

    4.2. Limitations

    While the findings of this review are encouraging, it is important to acknowledge its limitations. The diversity of the rehabilitation programs, their duration, intensity, and the measures used to assess outcomes across studies make it challenging to draw definitive conclusions. There was also a wide age range among the participants, which might influence the outcomes of the rehabilitation programs. The gender distribution was not balanced across studies, and the severity of COVID-19 varied, factors that might also affect the response to rehabilitation. Furthermore, many studies did not provide detailed data about the length of hospitalization, making it difficult to explore its potential impact on outcomes. Moreover, the number of included studies was relatively small, indicating a need for more high-quality research in this field.

    By limiting the search to studies published in English, there may have been inadvertently introduced language bias, potentially excluding relevant studies published in other languages. In addition, this review did not include the gray literature, such as conference papers or technical reports, possibly leading to publication bias. Despite the robust measures used to assess this, the possibility of missing some relevant information cannot be entirely negated. Finally, our quality assessment was based on the National Heart, Lung, and Blood Institute (NHLBI) tool. Despite its wide acceptance and use, it possesses inherent limitations and subjectivity, which could potentially influence the conclusions drawn from this review. Future studies should strive for uniformity in their protocols and measures to allow for more direct comparisons and, potentially, meta-analyses.

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    A traumatic event can cause a person to experience post-traumatic stress disorder (PTSD), a mental health condition that is characterised by signs like anxiety, intrusive thoughts, nightmares and flashbacks. While therapy and medication are frequently used as traditional PTSD treatments, health experts insist that complementary modalities like Yoga and physiotherapy have shown promise in helping people manage their symptoms.

    Post traumatic stress disorder: How Yoga and physiotherapy can help in PTSD (Shutterstock)
    Post traumatic stress disorder: How Yoga and physiotherapy can help in PTSD (Shutterstock)

    In an interview with HT Lifestyle, Dr Amit Deshpande, Founder and Director of Activist, shared, “Post-traumatic stress disorder (PTSD) is a debilitating mental health condition that can occur after experiencing or witnessing a traumatic event. Fortunately, Yoga and physiotherapy offer promising avenues for healing and managing PTSD symptoms. Yoga provides a holistic approach by combining physical postures, breathing exercises and meditation, helping to regulate the nervous system and reduce anxiety and stress.”

    He gushed, “The mindful movements and deep breathing foster a sense of calmness and self-awareness, enhancing emotional resilience. Physiotherapy, on the other hand, focuses on restoring physical function and mobility through targeted exercises and manual therapy. It can address physical symptoms associated with trauma, such as muscle tension and pain. Additionally, both yoga and physiotherapy offer a safe and supportive environment, fostering a sense of community and connection, which can aid in the recovery process.”

    Dr Rajeev Rajesh, Chief Yoga Officer at Jindal Naturecure Institute in Banglore, explained, “Yoga is a mind-body discipline with its roots in the ancient Indian subcontinent. It combines physical postures, breathing techniques and meditation. It has been discovered to be successful in lowering anxiety, enhancing sleep, and fostering general wellbeing. Yoga can give people with PTSD a safe place to re-connect with their body and process their trauma in a nurturing setting. Yoga's physical asanas and deliberate breathing techniques work to control the autonomic nervous system, lowering hyperarousal and enhancing relaxation. Additionally, yoga's emphasis on mindfulness encourages people to be in the present moment, which helps to lessen intrusive thoughts and improve self-awareness.”

    He added, “On the other hand, physiotherapy focuses on enhancing functional movement and physical rehabilitation. Physiotherapy can help people with PTSD deal with the somatic symptoms, chronic pain, and other physical effects of trauma. Physiotherapy can assist people in releasing tension, restoring proper movement patterns, and improving body awareness through a variety of techniques like manual therapy, exercise, and body awareness training. Physiotherapy can indirectly reduce psychological distress and improve general wellbeing by addressing physical symptoms. Yoga and physiotherapy both provide holistic approaches to healing and can support existing PTSD treatments. It is crucial to remember that these methods might not be appropriate for everyone and should only be used under the supervision of trained experts. However, incorporating yoga and physical therapy into PTSD treatment plans can give patients more coping skills and tools to manage their symptoms and enhance their quality of life.”

    Bringing his expertise to the same, Dr Sumit Gupta PT, HOD- Department of Physiotherapy and Rehabilitation at Regency Health, highlighted that PTSD can also increase stress and anxiety leading to tension in the body but revealed how Yoga and physiotherapy is very helpful to prevent this condition:

    1. So many time patient complaint pain. Physiotherapist set goals. Strengthening exercise, stability exercise, joint mobilisation, needling and motion exercise is help to reduce pain.

    2. Breathing exercise - Physiotherapist can give their patient different breathing exercise (deep breathing, chest mobilisation, diaphragmatic breathing) which help to reduce stress or anxiety.

    3.Anxiety-regular exercise is an effective method in management anxiety and stress follow a prescribe exercise plan will allow the body to release chemical that can help in reducing stress and anxiety.

    He listed the benefits of regular exercise on PTSD symptoms as:

    • A few positive results physiotherapy can have on your physical health including generate mobility and flexibility increase strength weight loss and improvement in cardiovascular health.
    • Regular exercise can also have a positive effect on your mental health through the reduce the of depression and anxiety feelings.

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    “These investments highlight what the new markets tax credit investment sets out to do in communities all across the country,” said Greg Clements, Novogradac partner and conference chair. “They represent a wide swath of investments that help in rural and urban low-income communities.”

    Thirteen community development entities (CDEs) that made qualified low-income community investments (QLICIs) in five businesses have been named winners of the Novogradac Journal of Tax Credits QLICIs of the Year awards for 2023.

    The awards go to new markets tax credit (NMTC) stakeholders who strive for excellence in community development. This year’s winning CDEs earned the awards for the following investments:


    • DC Central Kitchen’s Klein Center for Jobs and Justice in Washington, D.C., as Metro QLICI of the Year.
    • Lauderdale Community Hospital in Ripley, Tennessee, as Nonmetro QLICI of the Year.
    • The Freelon at Sugar Hill in Detroit as Real Estate QLICI of the Year.
    • Detroit Food Commons in Detroit as Small Business QLICI of the Year.
    • Santa Cruz Community Health Centers–Live Oak Health Clinic in Santa Cruz, California, as Operating Business QLICI of the Year.

    The winners will be honored at the Novogradac 2023 Spring New Markets Tax Credit Conference June 8-9 at The Fairmont in Washington, D.C.

    “These investments highlight what the new markets tax credit investment sets out to do in communities all across the country,” said Greg Clements, Novogradac partner and conference chair. “They represent a wide swath of investments that help in rural and urban low-income communities.”

    DC Central Kitchen’s Klein Center for Jobs and Justice in Washington, D.C., is a new, 36,000-square-foot facility that serves as a 15-hour-a-day alternative to the traditional soup kitchen and includes a culinary training kitchen and production kitchen capable of producing 25,000 meals per day. CDEs CAHEC New Markets, Reinvestment Fund and Chase New Markets Corporation allocated a combined $18.5 million in QLICIs.

    Lauderdale Community Hospital replaces an aging hospital in rural Ripley, Tennessee, giving a multimillion-dollar upgrade to improve and expand its services for patients and staff due to NMTCs allocated by three CDEs. Upgrades include emergency cardiac and pulmonary rehabilitation, surgery services, radiology, laboratory, physical rehabilitation, acute care and respiratory care. DV Community Investment, Hope Enterprise Corporation and CCG Community Partners combined on $22 million in QLICIs.

    The Freelon at Sugar Hill, a mixed-use development in Midtown Detroit’s Sugar Hill Arts District, will provide high-quality modern housing options, including units set aside for veterans, as well as commercial space for properties that are either woman- or immigrant-led. Building America CDE, Michigan Community Capital, Cinnaire New Markets and PNC Community Partners combined for $29.5 million in QLICIs for the endeavor.

    The Detroit Food Commons a 31,000-square-foot, two-story building in Detroit’s North End neighborhood, will house the Detroit People’s Food Co-op–a community-owned, full-service grocery store including a deli and a café–on the first floor. On the second floor, there will be four teaching and shared-use commercial kitchens, a banquet hall/community meeting space and office spaces for the Detroit Black Community Food Security Network. New Markets Support Company, Michigan Community Capital and U.S. Bancorp Impact Finance combined to allocate nearly $20 million in QLICIs.

    Santa Cruz Community Health Centers–Live Oak Health Clinic in Santa Cruz, California, will help an additional 3,000 patients and accommodate 20,000 visits annually at the new health clinic. SCCHC is a federally qualified health center and a Health Resources & Services Administration-designed Healthcare for the Homeless provider. Primary Care Development Corporation and HEDC New Markets combined for $14.4 million in QLICIs for the development.

    Additional details about the award winners and information on how to nominate a development for the 2024 round of awards can be found at www.novoco.com/events/awards.

    About Novogradac

    Novogradac began operations in 1989 and has grown to more than 700 employees and partners with offices in more than 25 cities. Tax, audit and consulting specialty practice areas for Novogradac include affordable housing, community development, historic rehabilitation and renewable energy.

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    In their quest to relieve stress, many people turn to various tools and techniques. One such popular tool is the stress ball—a small, squeezable toy that promises to alleviate tension and promote relaxation.

    You’ve probably seen some of those semi-soft foam balls adorning virtually every corporate office, enticing people to release tension by squeezing them between their fingers. But do these ridiculous balls actually help people decompress? Should you regularly use them or is it a better idea to blow off some steam by throwing stress balls out the window?

    From work to school to romantic relationships, there’s no shortage of challenges in our lives. Often, this creates an internal conflict that manifests itself as stress. When left unchecked, stress will not only take its toll on our emotional and mental health but also on our physical well-being.

    Enter stress balls — a low-key and effective solution to managing temporary stress.

    How Do Stress Balls Work?

    It may sound implausible, but the answer to the question, “Do stress balls work?” is yes – at least from a physiological standpoint.

    Have you ever noticed how a comforting touch can instantly soothe your frayed nerves? Researchers believe that the power of tactile engagement lies at the heart of stress balls’ effectiveness. When you squeeze a stress ball, the muscles in your hand and forearm contract, triggering a series of physiological responses in your body. As you release the grip, these muscles relax, promoting a sense of relief and relaxation. 

    Stress ball
    Credit: Pixabay.

    In 2006, researchers found that stress balls can improve the focus and attention spans of sixth graders. Another study found that fidgeting with objects — squeezing a stress ball or twirling a pen, for instance — can help boost productivity by giving the mind a break, making it easier to pay attention to the task upon returning to it.

    According to MIT researchers, fidgeting objects designed to soothe or calm have to be smooth or squeezable, whereas fidgets meant to make people alert are generally clickable, sharp, or pokey. Yet another study found that stress balls helped relieve patients’ anxiety during surgery.

    However, the only study that specifically researched the effectiveness of stress balls in reducing the physiological symptoms of stress found that they don’t do much. The researchers at the University of Wisconsin-Madison found that stress balls are not effective in reducing heart rate, blood pressure, or skin conductance following an episode of induced acute stress in college-aged individuals. The sample size was rather small, though, and involved only 30 students.

    Do stress balls also work for anxiety? Studies suggest they do. Stress balls work to reduce stress because the act of squeezing improves the nervous system as well as decreases hormones, which can minimize stress levels. 

    Stress balls can squeeze out stress, but they’re no cure for chronic stress

    In light of its productivity-enhancing and anxiety-relieving properties, stress balls may be worth your time.

    Bear in mind that if you’re chronically stressed, no amount of squishy foam balls or teddy bears will help you in the long run. To release the physical and emotional tension in the body from ongoing stress, doctors recommend exercising, dancing, venting with friends, and — why not — letting it all out by crying or shouting.

    While stress balls offer a range of benefits, it is essential to acknowledge their limitations. While they may provide immediate relief, their effects are often temporary and may not address the underlying causes of stress.

    Additionally, stress balls may not be suitable for everyone. Individuals with certain hand conditions, such as arthritis or carpal tunnel syndrome, should consult with their healthcare provider before incorporating stress balls into their routine.

    What Are The Benefits of Using Stress Balls?

    A stress ball
    Credit: Pixabay.

    America’s favorite squeezable knick-knack has come a long way since it was invented in the 1980s by Alex Carswell, a 29-year-old TV writer who came up with the idea after an angry phone call with his boss compelled him to throw a magic marker at a framed photo of his mother.

    “It made me feel very good at the moment,” Carswell said later that year, “but I also had a broken picture of my mother and her dog I had to get reframed, and a mess to clean up.”

    Today, hundreds of millions of foam balls are being manufactured all over the world. But do they actually do anything?

    It might be tempting to laugh off the potential benefits of these handheld wonders, but in truth, we stand to gain a lot from them.  Stress balls have the capacity to enhance creativity, improve focus, reduce blood pressure, and even help you get a better night’s sleep. 

    And while they’re not exactly meant for bodybuilding, a stress ball can certainly strengthen your grip muscles as well as help alleviate arthritis pain.  So, if you’re wondering how stress balls work – they work on various different levels. Ultimately, a stress ball can be used as a distraction device, or a different focal point, essentially allowing you to manage stress levels in a healthy way.

    Speaking to the Huffington Post, David Posen, a stress expert and author of Is Work Killing You?: A Doctor’s Prescription for Treating Workplace Stress,” says that at least some of that stress energy can be channeled towards a physical object. Stress balls can work really well, Posen says, because they prompt you to squeeze and release, leaving you less tense.

    What Are The Different Types of Stress Balls?

    stress balls
    Credit: Pixabay.

    You might be surprised to learn there are over a dozen different types of stress balls.  In fact, there is a ball for pretty much every type of personality wanting to squeeze their way into a stress-free lifestyle. 

    In the US, the most popular choice is a bean bag type of stress reliever, but there are a variety of types all around the world.  Construction of these anxiety-reducing balls can range from gel-filled, water-filled, solid foam, rubber, or a filling mixed with gel and baking soda

    Since their inception, stress balls have evolved into all sorts of varieties such as porcupine balls, squeezy balls, kooshy balls, splat balls, puffer balls, and the list goes on. 

    The common denominator for all of these different types of stress balls is that, on some level, they are intended to release tension, therefore, reduce stress.    

    How Long Do Stress Balls Last?

    The answer to this question depends upon the type of ball you have and how much you’re using it.  In general, most stress balls last a few months.  If you have a high-quality ball made with durable materials, it could last up to a year or more.  Cheaper balls made with flimsy materials will begin to deteriorate quickly. 

    Of course, if your dog gets hold of your stress ball, it’s not going to last very long at all. In all seriousness, your ball should last a good, long time if it is made of sturdy materials, well-cared for, and used in moderation. 

    Are Stress Balls Good For Your Hands?

    Stress balls can be good for your hands because they build strength.  They can also be beneficial for building strength in your forearms and wrists. Using stress balls can increase flexibility and stimulate blood circulation, which leads to decreased stiffness and swelling. 

    When used in moderation, yes, stress balls can be therapeutic for your hands, fingers, wrists, and forearms. While stress balls are used for certain types of physical therapy, they are not always the best for your hands.  Overuse of stress balls can cause strains in tendons in the wrists or might cause pain.

    What Are the Symptoms of Stress?

    The curious thing about stress is that it manifests differently in each person. For instance, some people may exhibit stress by sweating profusely or hyperventilating.  Other people might show symptoms of stress emotionally by becoming irascible or aggressive, while others might express stress by withdrawing, becoming sullen, or succumbing to depression.  

    Moreover, stress can manifest itself in ways we normally wouldn’t, such as acting out, exhibiting nervous ticks such as nail-biting or using substances. While these are manifestations of stress, they are also behaviors that are symptoms of stress as many of us attempt to compensate or escape the unfavorable experience of stress. All in all, there are innumerable ways symptoms of stress might manifest in different people under various conditions.   

    Chronic stress can lead to headaches, an upset stomach, sleep problems, and fatigue. If left unchecked, stress can contribute to far more serious health problems, such as high blood pressure, diabetes, and obesity.

    One of the symptoms of stress is muscle tension. We literally clench our body’s muscles when feeling psychologically stressed, prompted by a flood of hormones like adrenaline, noradrenaline, and cortisol. Essentially, these chemicals prime the body for “fight or flight”.

    However, it’s not always an option to fight your boss or run away from work — this is where the ubiquitous stress ball might come in handy.

    Can Stress Be Measured? 

    Yes, stress can be measured. Observation of heart rate, pulse, breathing, and emotional responses and recording this data is the most common way to measure stress.  But how can stress be measured? 

    In many instances, we can measure our own stress levels by paying attention to our responses and reactions to stressful situations.  Through self-observation and recording our responses, we are better able to understand our stress levels and adjust accordingly.  

    Are there objective tests for stress? Yes. You can do a stress level test which can provide you with valuable information about your condition and guide you to solutions to reduce stress. You may also opt to get a medical stress test from your doctor or mental health care provider. The types of stress tests you choose will depend upon your desired outcome.  

    For instance, if your stress manifests on a physical level, you might consider getting a cardiac stress test to assess how stress is affecting your heart.  If you respond to stress more emotionally, then a mental health stress test administered by a mental professional will reveal insights that can help you manage your emotions more effectively while encountering stress.

    While stress balls may not hold the key to complete stress eradication, their simple yet effective design offers a tangible means of managing stress and promoting relaxation.

    The act of squeezing a stress ball engages both the body and the mind, providing a momentary respite from the pressures of everyday life.

    Scientific research supports their effectiveness, revealing their potential to reduce stress, enhance cognitive performance, alleviate anxiety, and aid in physical rehabilitation.

    Thanks for your feedback!

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    ANI |
    Updated:
    May 26, 2023 16:34 IST

    PNN
    Gurugram (Haryana) [India], May 26: HCAH, India's leading out-of-hospital care provider, announces its collaboration with fourteen major insurance players, becoming the first transition care provider in India to make insurance available for its patients. This is a significant milestone for HCAH as it becomes the first rehab provider to offer cashless insurance coverage for out-of-hospital care. This collaboration enables patients to receive high-quality rehabilitation services without worrying about financial burdens, while also enhancing HCAH's position as a leader in the healthcare industry.
    HCAH's TCCs focus on helping patients recover in a home-like environment outside of the hospital setting. HCAH aims to drive 100% recovery of a patient through high-end equipment, a multidisciplinary team, a milestone-based approach and protocolized delivery. HCAH supports patients across multiple areas, such as stroke recovery, head injury, spine injury, critical care, pulmonary rehab, cardiac rehab, dementia, Parkinson, Onco rehab and medical management.
    Placing emphasis on significant cost savings for its patients, HCAH is revolutionizing healthcare in India with its unwavering commitment to cost-effective care. By partnering with top insurance companies including Medi Assist Insurance, Manipal Cigna Health Insurance Company Ltd, SBI General Insurance Co. Ltd., Navi General Insurance Ltd to name a few from the list, HCAH is offering patients the dual benefits of financial security and quality care from trained professionals.
    HCAH's TCCs' affordable prices, which are only 50 per cent of hospital costs and one-third of critical care costs, make it a practical and feasible option for healthcare consumers in India. HCAH's tailored insurance policies are available at HCAH Suvitas in Domlur, Bangalore, and HCAH Suvitas in Banjara Hills, Hyderabad. These policies are designed for patients transitioning from hospital to home. They not only save costs but also provide the necessary support for patients to return to their professional lives quickly.
    Vivek Srivastava, CEO and Co-Founder, HCAH said that, "We are thrilled and equally excited to become the first company in the out-of-hospital care landscape, to introduce insurance partnerships with the key players in the insurance arena, enabling us to provide a comprehensive and holistic approach to transition care for our patients. Globally, this is a common step but in India this is a first in the realm of TCCs and rehab-care. These partnerships with top insurance providers in India will give our patients the peace of mind and financial protection they need during this critical time in their recovery process. HCAH has implemented this to ensure that its transition care centres remain affordable and accessible to all patients."

    Dr Gaurav Thukral, COO, HCAH also said, "Hospitals are there to save lives! We at HCAH, make people recover back to their normal life. The alliance with key insurance players in the market can help people utilize the same sum insured to recover in the comfort of HCAH's TCCs and would lead to early discharge from the hospital, having fastest recovery to normalcy. We are committed to providing the best possible care to our patients, and we take pride in working with some of the top insurance providers in India. We are excited about the possibilities they present for the future of transition care in India. This move also strengthens HCAH's position as a credible provider."
    The insurance benefits are available to all patients from the company's transition care program. The financial protection provided by these top insurers and HCAH's expertise in rehab care, enhances the quality, accessibility, and affordability of transition care in India. This is a significant step forward in the evolution of transition care in India.
    HCAH is a Delhi NCR-based health-tech company present in 70+ cities across the country. It has raised investments from the Burman Family (Promoters of Dabur), Founders of Healthcare at Home UK, Quadria Capital, a Singapore-based healthcare fund and ABC Impact. HCAH provides the best possible healthcare outcomes and quality of life outside of hospitals by building the most affordable and accessible healthcare ecosystem. HCAH has 3 segments in which it delivers its services: (i) Physical rehabilitation and recovery through its service range of Inpatient Rehab, Long Term Acute Care in transition care centres, digital and home rehab; Home ICU and palliative care services; and supply of rehab equipment (ii) Elderly care services including e-commerce and caregiver services (iii) Chronic Disease Management services including screening, diagnostics, infusions, dialysis, oncology treatments, patient support programs, pharmacy, PAPs and adherence programs in association with leading pharma companies. All these services are delivered through HCAH's proprietary technology platform in homes, centres and digitally.
    HCAH is the first company to be accredited under the QAI (India's homecare standards). HCAH has published/presented 40 papers in national and international journals on its outcomes. HCAH is the only out-of-hospital care provider to be certified Great Places to Work. Over the course of its existence, HCAH has maintained a NPS of 65 per cent +.
    With the recent acquisition of Nightingales, HCAH becomes India's largest out-of-hospital care platform. Moreover, with the acquisition of Seniority back in 2022, HCAH has emerged as India's largest senior care platform. The company is developing an end-to-end senior care vertical for the holistic well-being of the growing elderly population.
    For more information, visit www.hcah.in and www.seniority.in
    (Disclaimer: The above press release has been provided by PNN. ANI will not be responsible in any way for the content of the same)



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    Insufficient physical rehabilitation programs for patients with COVID-19 and their hesitancy to come to medical facilities during the COVID-19 pandemic were reasons why this study was conducted, said Franco Laghi, MD, a professor and pulmonologist affiliated with Loyola University Medical Center and Edward Hines, Jr. Veterans Affairs Hospital in Maywood, Illinois.

    The following questions are regarding an abstract titled “A Home-based, Remotely Monitored Program to Improve Physical Activity in Patients With Long COVID” presented at the American Thorasic Society's 2023 annual meeting.

    Transcript

    Why did you study home-based physical activity in patients with long COVID-19?

    Patients with COVID-19, particularly patients with COVID-19 that have required medical attention, tend to develop long COVID-19. And the symptoms that more commonly occur with patients with long COVID-19 are fatigue, decreased exhale capacity, and shortness of breath.

    So, from there [was] the idea of implementing an exercise rehabilitation program for these patients. The problem is that the availability of hospital-based supervised programs, physical rehab programs, is very limited, [and] from here [was] the idea of developing a home-based program. Now, what is attractive about that is that this type of program probably can be implemented when a future pandemic may happen.

    The other thing that pressed us to develop this program was that we noticed the reluctance of patients during the COVID-19 pandemic to come to the hospital and to clinics, and from here [came] the idea of developing something that could be delivered in the home environment.

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    The U of A houses one of the first clinics in Alberta dedicated to helping people manage long COVID.

    More than two years after he succumbed to the SARS-CoV-2 coronavirus, Doug Norman’s long COVID symptoms are so severe he still can’t return to work as a letter carrier with Canada Post.

    In addition to dizziness and brain fog, he can’t muster the concentration to drive. There is also his farm to run, which he does in fits and starts, taking breaks when overcome with exhaustion.

    “It feels like there's a big clamp squeezing my head,” said Norman. A few weeks ago, the 62-year-old was put on a steroid inhaler to ease his difficulty with breathing.

    “I do whatever I can, go as hard as I can until I have no energy left. Then I go back into the house. That’s how I live my life now. It’s not the best, but you do whatever you have to do to survive.”

    Most puzzling is that Norman’s original infection wasn’t severe. More like a head cold, he says, adding, "I just kept getting more symptoms as time went on."

    Norman is one of thousands in Alberta suffering from a range of post-COVID symptoms long after contracting the virus. According to Statistics Canada, almost 15 per cent of Canadian adults who have had, or thought they had, COVID-19 still struggle with symptoms at least three months after their initial infection.

    To meet the needs of that population, a post-COVID-19 clinic at the University of Alberta, the first and largest in the province, opened in June 2021. Since then, the Long COVID Clinic has seen about 800 patients — and had about 1,500 referred — who suffer from symptoms that persist at least 12 weeks beyond the original COVID-19 diagnosis. 

    A one-stop, multidisciplinary facility with a variety of physicians and therapists, the clinic began operating one half-day every two weeks when launched, but is now up to five half-days per week. Patients are referred to the clinic by their family physicians.

    “We’re seeing a lot of fatigue, shortness of breath and neurocognitive disturbances,” said clinic co-director Grace Lam.

    Patients with long COVID complain of myriad neurologic symptoms, adds clinic co-director Maeve Smith. They include persistent loss of sense of smell and taste, nerve pain and weakness, insomnia and problems with short-term memory, concentration and focus.

    “Patients are often unable to return to work because their physical and cognitive function isn’t where it needs to be," said Smith. “Or they have to find a daycare because they can’t run around after their toddler.”

    The median age of patients at the clinic is 49, “very much a working population,” she said, adding there also seems to be a “female predominance” among the cohort.

    “These are individuals at the height of their careers who tell us, ‘I can’t read a document. I finish one paragraph and can’t remember what I just read,’” said Lam. “If you think about who makes up the workforce, and the age range this affects — that’s a huge hit on society as a whole.”

    Perhaps most puzzling, say Lam and Smith, is that long COVID can affect anyone, regardless of the severity of the initial infection or even whether or not it was symptomatic. That means the latest variants of the virus could cause symptoms long after a mild illness.

    Included on the clinic’s team are a neurologist and experts in immunology, hematology and cardiology. There is also an expert in POTS disease — or postural orthostatic tachycardia syndrome — a condition affecting blood flow that can cause light-headedness, fainting and an uncomfortable rapid increase in heartbeat.

    So far, treatment for long COVID is limited, said Lam, because the root causes of symptoms are still poorly understood.

    Even conventional physical rehabilitation has its limits, according to Doug Gross, director of the U of A’s Rehabilitation Research Centre

    “The old-fashioned techniques of physical retraining and building muscles have been tried, and quite often they fail. We are learning that pacing and strategies for conserving energy may be more effective for some," he said.

    Alberta Health Services recommends people manage mild long-COVID symptoms at home with the support of online resources and their primary care team.

    As for Norman, every day continues to be a struggle as he searches for treatment solutions with specialists at the clinic. Because of his ongoing fatigue, he sees a rheumatologist who monitors him for signs of chronic fatigue syndrome.

    “The challenge is to find a happy medium — how much you can do every day,” he said. “Some days I talk to myself and say, ‘Doug, you gotta suck it up, you gotta battle a little harder. One day, everything's rolling along. And the next you're a totally different person.”

    But he says finding the post-COVID clinic has meant everything to his state of mind.

    “I told Dr. Lam on the phone, ‘Lucky thing you’re not here in person because I’d give you a big hug.’”

    Article courtesy of University of Alberta folio



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    The experienced staff from Eden Private Hospital.

    Eden Private Hospital is the Sunshine Coast’s longest operating private rehabilitation facility, with 48 dedicated medical, rehabilitation and mental health beds.

    Eden Private Hospital delivers comprehensive rehabilitation programs to both Inpatients and Outpatients, that are tailored to the patient’s specific needs and goals, and managed by a multidisciplinary team of allied health professionals under the care of a Rehabilitation Consultant.

    Our experienced staff work together to help patients regain strength and cardio fitness, balance and mobility as well as redevelop skills and ultimately function with the highest possible level of independence and confidence.

    Each program includes an individual consultation followed by physical rehabilitation and education sessions that are structured around the health diagnosis and patient goals. The programs are typically run twice a week, over a six week period and the duration of the programs can vary.

    The programs we offer which patients can be referred into include: Orthopaedic Program; Neurological Program; Reconditioning Program; Pain Program; Cardiac Rehabilitation; Cancer Rehabilitation; Falls Prevention Program; Pulmonary Rehabilitation Program; and Robotic Assistive Therapy.

    How to Be Referred:

    We accept referrals from General Practitioners, Specialists and Surgeons and Public and Private Hospitals. You would simply need to see your GP or Specialist and ask for a referral to be sent to Eden Private Hospital and our Admissions and Assessment team will be in contact with you once received.

    Cost:

    Eden Private Hospital has agreements with most private health funds as well as Tier One Provider Status with the Department of Veteran’s Affairs. The Outpatient Allied Health team also conduct sessions under Medicare’s Enhanced Primary Care program for Physiotherapy, Exercise Physiology and Occupational Therapy.

    For further support in navigating your care or to utilise this service as either an inpatient or outpatient, or to learn more about Eden Private Hospital, please contact our Admissions and Assessment team on 1800 333 674 or visit edenprivate.com.au.

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    Individuals with chronic obstructive pulmonary disease (COPD) experience pain at levels similar to or greater than levels reported in the general population, report authors of a new study.

    However, findings from this UK research groups’ systematic literature review suggest that nonpharmacologic and noninvasive interventions that have been investigated to date “do not currently improve chronic pain for people with COPD to a level that is clinically meaningful.”

    Further, studies into the impact of these interventions are fundamentally flawed, according to lead author Leah Avery, PhD, professor of applied health psychology in the School of Health and Life Sciences, Teesside University, Middlesbrough, UK, and colleagues.

    Current national and international COPD guidelines do not address chronic pain, write Avery et al in the journal Respiratory Medicine, nor are specific pain measures commonly used in persons with COPD. Pharmacologic treatment, while often the prescribed approach, is commonly ineffective, they add.


    Current national and international COPD guidelines do not address chronic pain, nor are specific pain measures commonly used in persons with COPD. Pharmacologic treatment, while often the prescribed approach, is commonly ineffective.


    With evidence accumulating that indicates the high prevalence of pain in this already vulnerable group, the investigators set out specifically to evaluate the efficacy of existing nonpharmacologic and noninvasive interventions for addressing chronic pain in those with COPD.

    The team conducted a search of 14 databases from May to June 2020, with an updated search for May to August 2022. Eligible studies were any nonpharmacologic, noninvasive intervention-based studies, with both randomized and nonrandomized controlled designs, that included patients with a confirmed diagnosis of stable COPD (ie, Global Initiative for Chronic Obstructive Lung Disease stages 1-4). Outcomes of interest were pain measures or pain subscale scores. Chronic pain was defined as pain occurring for at least 3 months with no underlying tissue damage in its etiology.

    From an original yield of 95 302 potentially relevant studies, Avery et al assessed 223 for eligibility, with 29 studies (n=3228) included in the final review. Of the studies, 25 were randomized controlled trials (RCT) and 4 had non-RCT designs, 1 with a mixed methods approach.

    FINDINGS

    A wide range of interventions were reported including physical rehabilitation (PR), education, various forms of exercise, breathing management techniques, self-management, and psychotherapeutic interventions; most of the interventions were not targeted specifically at pain.

    A clinically meaningful change in pain outcomes (minimal clinically important difference of ≥1) from pre-intervention to postintervention was reported in 7 studies, although results were statistically significant (P<.001) in only 2 studies, according to results. A third study did not find a clinically meaningful improvement but did show statistical significance (P =.0273).

    Light on specifics

    When Avery and team looked to identify specific behavior change techniques (BCT) associated with an effective intervention, they found very few studies reported descriptions of the interventions. In studies where descriptions were included, the BCT was reported to include “instructions on how to perform the behaviour,” “pulmonary rehabilitation,” or “goal setting” behaviour.

    The researchers emphasized that study interventions did not specifically focus on pain in COPD, but rather on a range of primary outcomes. Specific BCTs, therefore, were often targeting increased physical activity or improved emotional state.

    Mean pain scores ranged from 8.15 to 77.50 with an overall weighted mean of 54.53. The weighted mean SF-36 Physical Component and Mental Component scores were 33.34 and 42.43, respectively.

    Regarding the quality of evidence, 5 RCTs had a low risk of bias, 8 had a moderate risk of bias, 12 indicated a high risk of bias, and the 4 non-RCTs had a moderate risk of bias.

    Avery et al cite several limitations to the research, a significant one involving BCTs. BCT protocols require that interventions be coded only when the BCT is explicitly reported in the intervention description, and this process was limited by the detail of intervention methodology reported within each study.

    They add that “Intervention heterogeneity and methodological quality limit current knowledge about effectiveness of previously trialed non-pharmacological and non-invasive interventions on pain symptoms in people with COPD,” thus they could not use the data to recommend a specific intervention. “Future research should describe interventions in detail and more frequently assess pain in this population to inform the development of an intervention targeting pain management for people with COPD,” they concluded.


    Reference: Morris JR, Harrison SL, Robinson J, Martin D, Avery L. Non-pharmacological and non-invasive interventions for chronic pain in people with chronic obstructive pulmonary disease: a systematic review without meta-analysis. Respir Med. Published online March 6, 2023. doi:10.1016/j.rmed.2023.107191


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    Katy, TX - Apex Physical Rehabilitation & Wellness specializes in trusted physical therapy treatments, providing effective solutions for pain relief and improved mobility. Through a range of techniques, including hands-on therapy, exercises, and heat and cold therapy, the clinic aims to identify and address the underlying causes of discomfort to enhance the overall quality of life for patients.

    In addition to addressing existing issues, the clinic also emphasizes preventive healthcare to reduce the risk of future injuries. With expertise in treating postoperative pain, as well as knee, back, elbow, and neck pain, the clinic offers tailored treatment plans to meet the unique needs of each patient.

    For postoperative care, the physical therapy clinic offers targeted therapies that help patients recover motion and reduce inflammation following surgeries. These therapies can alleviate swelling, pain, limited joint mobility, cramping, and stiffness, with the ultimate goal of restoring patients' pre-surgery movement patterns. Customized treatment plans are designed to increase endurance and help patients return to their daily activities with restored strength.

    Apex Physical Rehabilitation & Wellness treats orthopedic-related dysfunctions. These focus on the musculoskeletal system and injuries to the tendons, ligaments, joints, muscles, and bones. The clinic provides therapeutic care and determines the right movement diagnosis to manage the current injury and prevent further damage. Their orthopedic-related treatments treat conditions like plantar fasciitis, swollen muscles and joints, bursitis, arthritis, scoliosis, torn rotator cuff, and more.

    The physical therapist in Katy also provides sports medicine treatments. They help athletes manage injury symptoms by manipulating the body structure through a hands-on approach. They restore the normal body structure, thereby relieving pain and inflammation. The clinic identifies any misalignments and blocked nerve pathways and provides physical therapy Katy to restore normal communication between the brain and body. The staff illustrates home exercises that enhance the athlete's healing process at home. The staff follows up to ensure therapies work as anticipated.

    A quote from the clinic's website stated this about their services,

    "The role of our physical therapy program is to help the patient regain the use of the painful body part. Through evaluation and the individualized treatment programs, we treat existing problems and provide excellent preventive health care to meet a variety of needs."

    In addition to physical therapy, the clinic provides aquatic therapy, spinal decompression, and work health services. They have a temperature-regulated pool for their aquatic therapy treatments, which aim at total body reconditioning and progressive rehabilitation. Their work health services provide solutions for injured workers, including prevention of injuries, management, post-injury treatments, and case closure. They have specialty services like vestibular rehabilitation therapy, fall risk assessment and prevention, balance and proprioception testing and training.

    To schedule a consultation, contact the physical therapy clinic at (832) 240-7773. Visit the clinic for more information on their physical therapy services, Apex Physical Rehabilitation & Wellness is located at 777 S Fry Rd #104, Katy, TX, 77450, US.

    Media Contact

    Company Name
    Apex Physical Rehabilitation & Wellness
    Contact Name
    Amir Kazemi
    Phone
    (832) 240-7773
    Address
    777 S Fry Rd #104
    City
    Katy
    State
    Texas
    Postal Code
    77450
    Country
    United States
    Website
    www.apexrehab.com/katy/

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