Original Paper

E v i d e n c e - B a s e d P h y s i o t h e r a p y in Intensive C a r e
Alice Jones, P h D , FACP, M P h i l , MSc, Cert PT

A b s t r a c t : T h e a i m o f t h i s p a p e r is t o a r o u s e p h y s i c a l t h e r a p i s t a w a r e n e s s o f t h e n e c e s s i t y f o r evidence-based
p r a c t i c e in t h e i n t e n s i v e c a r e e n v i r o n m e n t . T h i s a r t i c l e s u m m a r i z e s f i n d i n g s f r o m a n i n t e x f e t s e a r c h of
p h y s i o t h e r a p y - r e l a t e d c l i n i c a l t r i a l s o v e r t h e last 1 0 y e a r s . T h e f e a s i b i l i t y of p e r f o r m i n g r a n d o m i z e d - c o n t r o l l e d
t r i a l s a n d t h e r o l e o f t h e p h y s i c a l t h e r a p i s t in t h e i n t e n s i v e c a r e e n v i r o n m e n t a r e d i s c u s s e d . T h e r a p i s t s are
encouraged to consider appropriate casemix and o u t c o m e measures w h e n adducing evidence to support or
d i s p u t e t h e effect of a p h y s i o t h e r a p e u t i c technique.

Key w o r d s : e v i d e n c e - b a s e d , intensive care, physiotherapy

Introduction has changed from an expert opinion to an evidence-

Intensive care units (ICUs)&nre amongst the most expen-
sive a r e a s of h o s p i t a l a c t i v i t y [ 1 ] , a n d h a v e b e e n criti-
cized for u n p r o v e n efficacy w i t h r e g a r d to o u t c o m e
m e a s u r e s . It h a s b e e n a l l e g e d t h a t a l a r g e p r o p o r t i o n of
intensive care resources are either invested in patients
with poor outcomes or s q u a n d e r e d on the observation
of l o w - r i s k p a t i e n t s [ 1 ] . S e v e n t y p e r c e n t of h i g h - c o s t
intensive care patients die d u r i n g their admission [2],
a n d t h e r e s o u r c e s r e q u i r e d t o c a r e f o r 8 % of t h e h i g h -
cost a d m i s s i o n s to I C U s a r e e q u i v a l e n t t o 9 2 % of t h e
resources necessary to provide care for low-cost
patients [2].
U n d o u b t e d l y , it is d i f f i c u l t f o r p h y s i o t h e r a p i s t s i n
ICUs to justify their existence w h e n t h e discipline
i n t e n s i v e c a r e itself h a s b e e n c h a l l e n g e d b y a d m i n i s t r a -
t o r s ' r a t i o n a l i z a t i o n of l i m i t e d h e a l t h c a r e r e s o u r c e s .
E c o n o m i c c o n s t r i c t i o n o v e r t h e last 2 y e a r s , particularly
in S o u t h - E a s t Asia, h a s r e s u l t e d in a significant restric-
t i o n of h o s p i t a l b u d g e t s . A s a c o n s e q u e n c e , a p h e n o m -
e n o n called " n o referral for p h y s i o t h e r a p y " h a s recently
e m e r g e d in s o m e ICUs in H o n g K o n g a n d the United
Kingdom. Patients in the ICU are n o longer being re-
ferred for p h y s i o t h e r a p y t r e a t m e n t , b e c a u s e referrers
b e l i e v e t h e r e is i n s u f f i c i e n t e v i d e n c e t o p r o v e t h e effi-
c a c y of p h y s i o t h e r a p y . A s t h e p r e s s u r e o n t h e e c o n o m y
increases, the decision-makingprocess, w h i c h deter-
m i n e s the resource allocation to intensive care practice
based j u d g m e n t . O n e m a y ask, W h y s h o u l d e v i d e n c e b e
r e q u i r e d t o satisfy fiscal r a t i o n a l i s t s ? Q u i t e s i m p l y , g o v -
e r n m e n t h e a l t h o r g a n i z a t i o n s r e p r e s e n t t h e m a n d a t e of
t h e p e o p l e to e n s u r e t h a t t a x a t i o n r e v e n u e g e n e r a t e s t h e
m a x i m u m health-care mileage. Measurable outcome
i m p r o v e m e n t is d e m a n d e d f o r a c o n t i n u e d a l l o c a t i o n
of r e s o u r c e s . A n i n t e n s i v e c a r e p h y s i o t h e r a p y s e r v i c e
is p a r t of t h a t r e s o u r c e a l l o c a t i o n , a n d as such,
p h y s i o t h e r a p y interventions m u s t be d e m o n s t r a b l y cost-
effective, so t h a t p a t i e n t o u t c o m e at least b a l a n c e s m a n -
power costs.
W h a t e v i d e n c e is r e q u i r e d ?
of
E v i d e n c e - b a s e d m e d i c i n e h a s b e e n defined as t h e inte-
g r a t i o n of i n d i v i d u a l clinical expertise w i t h t h e best
available e x t e r n a l clinical e v i d e n c e f r o m s y s t e m a t i c re-
s e a r c h [ 3 ] , N e i t h e r d e f i n i t i o n a l o n e is s u f f i c i e n t f o r t h e
p r a c t i c e of g o o d m e d i c i n e . W i t h o u t e x t e r n a l e v i d e n c e ,
clinical practice m a y b e c o m e d a t e d , a n d yet at t h e s a m e
t i m e , e v i d e n c e of t h e h i g h e s t p r o b i t y m a y b e i n a p p l i c a b l e
o r i n a p p r o p r i a t e for a n i n d i v i d u a l p a t i e n t [ 3 ] . A f r a m e -
w o r k f o r c o m p a r a t i v e e v a l u a t i o n of e v i d e n t i a l s p e c t r a
w a s devised by the United States Preventive Services
T a s k F o r c e ( T a b l e 1) [ 4 ] . A p p l y i n g t h i s r a t i n g s y s t e m t o
s o m e c o m m o n l y q u o t e d s t u d i e s of p h y s i o t h e r a p y i n t e r -
v e n t i o n s i n i n t e n s i v e c a r e ( T a b l e 2 ) [ 5 - 1 0 ] , it is o b v i o u s

D e p a r t m e n t o f R e h a b i l i t a t i o n Sciences, T h e H o n g K o n g Polytechnic University, H o n g Kong.

Received: 30 D e c e m b e r 1999
R e p r i n t r e q u e s t s a n d c o r r e s p o n d e n c e t o : Alice J o n e s , Associate Professor, D e p a r t m e n t of R e h a b i l i t a t i o n Sciences, T h e H o n g K o n g
Polytechnic University, H u n g Horn, Kowloon, Hong Kong.

Hong Kong Physiotherapy Journal ? V o l u m e 18 ? N u m b e r 2 ? 2 0 0 0 47

 T a b l e ^ q . U ^ i t e d S 甘 a ^ e s P 紅 ^ v ^ m a ^ i w ' 駐 ^ ^ ^ ^ 沌 ^ ^ ^ ^ s 奴 F ^ r c e ' s w a t a n g O f 冉 ^ a l i t V Of e v i d e n c e r 4 ]

Category Description

I E v i d e n c e o b t a i n e d f r o m a s y s t e m a t i c r e v i e w of all r e l e v a n t r a n d o m i z e d - c o n t r o l l e d trials
II E v i d e n c e o b t a i n e d from at least o n e p r o p e r l y - d e s i g n e d r a n d o m i z e d - c o n t r o l l e d trial
Ill-i E v i d e n c e o b t a i n e d from w e l l - d e s i g n e d c o n t r o l l e d trials w i t h o u t r a n d o m i z a t i o n
III—ii Evidence obtained from well-designed cohort or case-control analytic studies preferably from m o r e t h a n
one centre
III-iii Evidence obtained from multiple t i m e series w i t h or w i t h o u t t h e i n t e r v e n t i o n , plus d r a m a t i c results in
uncontrolled experiments
IV O p i n i o n s of r e s p e c t e d a u t h o r i t i e s , b a s e d o n c l i n i c a l e x p e r i e n c e , d e s c r i p t i v e s t u d i e s , o r r e p o r t s of e x p e r t
committees

t h a t a l t h o u g h m a n y of t h e s e s t u d i e s p r o d u c e d favour- t h e i r small s a m p l e size a n d m o d e r a t e q u a l i t y [ 1 3 ] . Al-

able results for p h y s i o t h e r a p y , n o n e w e r e r a n d o m i z e d - t h o u g h physiotherapy t r e a t m e n t w a s s h o w n to i m p r o v e
c o n t r o l l e d t r i a l s ( R C T s ) a n d all c a n b e v a l i d l y c r i t i c i z e d p u l m o n a r y c l e a r a n c e (as m e a s u r e d b y s p u t u m p r o d u c -
for observer bias. tion a n d radioisotope clearance), t h e r e w a s n o signifi-
T h e scientific literature c o m m o n l y r e c o r d s conflict- cant improvement in pulmonary function.
i n g v i e w s r e g a r d i n g t h e e f f e c t i v e n e s s of p h y s i o t h e r a p y i n Understandably, the BHPT review concluded that there
different patient groups. For e x a m p l e , M a c k e n z i e states w a s insufficient evidence to support or refute a d m i n i s -
t h a t ' ' p n e u m o n i a m a y b e difficult t o d i a g n o s e (in a d u l t s ) t r a t i o n of B H P T t o p a t i e n t s w i t h a c u t e a n d s t a b l e COPD,
a n d m a y , in t h e early stages, r e s p o n d favourably to chest chronic bronchitis, or bronchiectasis [13].
p h y s i o t h e r a p y " [ 1 1 ] . I n c o n t r a s t , P h e l a n ' s v i e w is t h a t I n v i e w of c u r r e n t d e r i s o r y p e r c e p t i o n s o f p u l m o n a r y
"physiotherapy has an extremely limited role in the p h y s i c a l t h e r a p y , a n i n t e r n e t - b a s e d i n v e s t i g a t i o n of p u b -
m a n a g e m e n t of i n f a n t s a n d c h i l d r e n w i t h p n e u m o n i a . It l i s h e d p h y s i o t h e r a p y r e s e a r c h specifically r e l a t e d t o in?
s h o u l d n o t b e u s e d at all d u r i n g a c u t e s t a g e s a n d if tensive therapy was undertaken. T w o c o m m o n indices,
r e s o l u t i o n is r a p i d " [ 1 2 ] . A l t h o u g h r e f e r r i n g t o d i f f e r e n t M E D L I N E ? [21], a n d t h e C u m u l a t i v e I n d e x to N u r s i n g
p a t i e n t g r o u p s , t h e s e t y p e s of c o n t r a d i c t o r y a n a l y s e s a r e and Allied Health Literature (CINAHL?) [22] were
f u r t h e r s u p p o r t e d b y t h e C o c h r a n e L i b r a r y ' s r e v i e w of searched; limited to t h e English l a n g u a g e a n d u s i n g t h e
b r o n c h o p u l m o n a r y h y g i e n e p h y s i c a l t h e r a p y (BHPT) i n terms 'physiotherapy OR physical t h e r a p y AND inten-
chronic obstructive p u l m o n a r y disease (COPD) and sive care'. T h e M E D L I N E ? s e a r c h p r o d u c e d 4 4 articles
bronchiectasis. Fiscal rationalization also m o t i v a t e d this for t h e p e r i o d 1 9 8 9 t o 1 9 9 9 . A b s t r a c t e x a m i n a t i o n showed
review, because BHPT was viewed by few health au- 2 1 of t h e a r t i c l e s w e r e n o t r e l a t e d t o physiotherapy
thorities as l a b o u r intensive a n d expensive. F u r t h e r m o r e , techniques, eight w e r e review papers and one was a
B H P T s u p p o s e d l y p o s e d s o m e p o t e n t i a l p a t i e n t risks, a n d l e t t e r . Of t h e r e m a i n i n g 14 p h y s i o t h e r a p y - r e l a t e d clini-
t h e r e l a t i v e b e n e f i t of d i f f e r e n t t e c h n i q u e s w a s y e t t o b e cal trials, o n l y six w e r e R C T s . T h e r e w e r e m o r e articles
determined [13]. in t h e CINAHL? i n d e x a n d t h e search was limited to t h e
A n i n i t i a l t r a w l of t h e C o c h r a n e A i r w a y s Group period b e t w e e n 1993 and D e c e m b e r 1998. Applying the
database revealed 95 trials for analysis, w h i c h after s a m e search t e r m s , 99 articles w e r e disclosed a n d of
applying exclusion criteria filtering, resulted in only these there w e r e o n l y three RCTs in the 29 physi-
s e v e n RCTs* [ 1 4 - 2 0 ] . E v e n t h e s e t r i a l s w e r e c r i t i c i z e d f o r otherapy-related studies. F r o m a t o t a l of 1 4 3 a r t i c l e s ,

T a b l e 2. C o m m o n l y q u o t e d ( u n c o n t r o l l e d , n o n - r a n d o m i z e d ) s t u d i e s o f p h y s i o t h e r a p y t r e a t m e n t s in the
intensive care unit

? Radiological i m p r o v e m e n t w i t h o u t h y p o x a e m i a d e m o n s t r a t e d in mechanically ventilated patients w h o received

c h e s t p h y s i o t h e r a p y [5]
? Chest p h y s i o t h e r a p y w a s s h o w n to be equally effective w h e n c o m p a r e d w i t h t h e r a p e u t i c b r o n c h o s c o p y i n t h e
treatment of a c u t e l o b a r a t e l e c t a s i s i n p a t i e n t s i n t h e i n t e n s i v e c a r e u n i t [6, 7 ]
? I m p r o v e m e n t in total l u n g / t h o r a x compliance was d e m o n s t r a t e d following chest p h y s i o t h e r a p y / m a n u a l
i n f l a t i o n [7', 8 ]
? T h e effect of c h e s t p h y s i o t h e r a p y i n t h e m a n a g e m e n t of i n t e n s i v e c a r e p a t i e n t s w i t h p n e u m o n i a [9, 10]

48 ^ ^ q g K o n g P^ysiot乃er^p少^o^rn叮f? Volum^ I^ e Number 2 e 2000

Table 3 . A s u m m a r y of p h y s i o t h e r a p y findings from clinical trials r e p o r t e d d u r i n g t h e last 10 y e a r s

? Respiratory p h y s i o t h e r a p y i n t e r v e n t i o n s increase o x y g e n d e m a n d a n d induce stress [23-25]

? H a e m o d y n a m i c changes are unavoidable during a physiotherapy intervention [26, 2 7 ] , b u t that often these
m a n o e u v e r s a r e still c o n s i d e r e d t o b e s a f e [ 2 8 , 2 9 ]
? E a r l y m o b i l i z a t i o n is i m p o r t a n t a n d t h e e f f e c t i v e n e s s o f i n c e n t i v e s p i r o m e t r y is d e b a t a b l e [ 3 0 ]
? I m p r o v e m e n t in a i r w a y resistance a n d compliance after suctioning [31]
? R e d u c t i o n of i n t r a p u l m o n a r y s h u n t a f t e r a b d o m i n a l s u r g e r y w i t h a d d i t i o n a l ( e v e n i n g ) p h y s i o t h e r a p y [ 3 2 ]
? I m p r o v e m e n t in t h e 6 - m i n u t e - w a l k distance a n d m a x i m u m inspiratory m o u t h pressure in patients with
chronic obstructive p u l m o n a r y disease requiring mechanical ventilation after comprehensive early
pulmonary rehabilitation [33]

a b o u t o n e - t h i r d (47) w e r e n o t p h y s i o t h e r a p y - r e l a t e d frequently dispensed inappropriately. While this study

a n d a third (53) w e r e reviews or discussion papers.
N e a r l y all of t h e r e m a i n i n g c l i n i c a l t r i a l s ( 4 3 ) fell i n t o
C l a s s III e v i d e n c e c a t e g o r i e s b e c a u s e t h e y f a i l e d t o i n c o r -
porate a randomized, controlled design. The resultant
s t r e n g t h of a n y r e c o m m e n d a t i o n , for o r a g a i n s t t h e u s e
of a t e c h n i q u e , c o u l d a t b e s t , o n l y b e w e a k o r m o d e r a t e .
A b r i e f s u m m a r y of t h e c o n c l u s i o n s d r a w n f r o m t h e
clinical trials a n d e v i d e n c e i n s u p p o r t of p h y s i o t h e r a p y
is s h o w n i n T a b l e 3 [ 2 3 - 3 3 ] . P a e d i a t r i c r e s e a r c h m o s t l y
f o c u s e d o n t h e u s e of a s s e s s m e n t t o o l s a n d motor
d e v e l o p m e n t , h o w e v e r , t h e r e w e r e a n u m b e r of n e g a -
tive r e p o r t s o n t h e v a l u e of c h e s t p h y s i o t h e r a p y . C h e s t
physiotherapy increased skin blood flow in neonates
(signifying p a i n a n d discomfort) [34], b u t failed to p r e -
v e n t atelectasis [35]. F u r t h e r m o r e , direct tracheobron-
chial suctioning w a s reportedly superior to p h y s i o t h e r a p y
i n t h e t r e a t m e n t of p o s t - e x t u b a t i o n a t e l e c t a s i s i n
premature infants [36].
m a y d e m o n s t r a t e a f i n a n c i a l b e n e f i t , t h e s e c o n d a r m of
the conclusion does n o t necessarily follow. Failure to
d e t e r m i n e statistical p o w e r h a s r e s u l t e d in t w o flaws i n
this s t u d y . First, t h e o u t c o m e m e a s u r e s c h o s e n , n a m e l y ,
hospital stay a n d mortality rate, are t h e least sensitive
m e a s u r e s of t h e i m p a c t of p h y s i o t h e r a p y , e x c e p t i n
d e s p e r a t e l y - i l l p a t i e n t s . It is, t h e r e f o r e , n o t s u r p r i s i n g t o
f i n d t h a t t h e r e is n o d i f f e r e n c e b e t w e e n t h e patient
g r o u p s for these criteria in a p a t i e n t cohort t h a t lacks a
s t r o n g i n d i c a t i o n for c h e s t p h y s i o t h e r a p y in t h e first
place [42]. Second, cost estimates w e r e based o n t h e
n u m b e r of t r e a t m e n t s r a t h e r t h a n t r e a t m e n t - d u r a t i o n ,
a n d m a y n o t reflect t h e t r u e costs of c a r e . F o r e x a m p l e ,
a physiotherapist could assess a patient a n d c o n c l u d e
t h a t t h e m o s t a p p r o p r i a t e ' t r e a t m e n t ' is i n s t r u c t i o n o n
exercises to b e c o n d u c t e d at h o m e or advice o n daily
l i v i n g , w h i c h m a y r e q u i r e o n l y f i v e m i n u t e s of the
p h y s i o t h e r a p i s t ' s t i m e . M a n y of t h e n e g a t i v e r e p o r t s o n
t h e efficacy of c h e s t p h y s i o t h e r a p y r e s u l t f r o m t h e m i s -
m a t c h i n g of t h e p a t i e n t c o n d i t i o n w i t h t h e physiotherapy

D e m a n d for evidence t e c h n i q u e [ 4 3 ] b e c a u s e of t h e l a c k of d e f i n i t i o n of t r e a t -
m e n t c o m p o n e n t s , m a k i n g e v a l u a t i o n of a specific t e c h -

Questioning accepted practice, w h i c h has n o t b e e n based nique difficult.

o n high quality evidence, has led to a robust interroga- T h e a b s e n c e of h i g h - q u a l i t y e v i d e n c e h a s p r o v i d e d

t i o n o f t h e r o l e of r e s p i r a t o r y p h y s i o t h e r a p y . C a m p b e l l a m m u n i t i o n f o r t h e ' p r o s e c u t o r s ' of p h y s i o t h e r a p y , r e -

a n d c o l l e a g u e s in 1 9 7 5 w e r e t h e first t o d i s p u t e the sulting in broad unsubstantiated statements disparaging

e f f i c a c y of c h e s t p h y s i o t h e r a p y , w h e n t h e y r e p o r t e d t h a t
percussion caused a reduction in the forced expired
v o l u m e i n o n e s e c o n d ( F E V L 0 ) [ 3 7 ] . A n u m b e r of p r o -
vocative reviews followed in the literature: "Does Chest
Physical Therapy W o r k ? " [38]; "Chest Physiotherapy:
T i m e for Reappraisal" [39], a n d "Chest P h y s i o t h e r a p y
M a y be H a r m f u l in S o m e Patients" [40]. However,
scientific r i g o u r does n o t necessarily g u a r a n t e e logical
conclusions. In 1996/Alexandera n d colleagues d e m o n -
strated in a RCT that patients w h o w e r e allocated to
discontinue chest physiotherapy received 4 5 % fewer
t r e a t m e n t s c o m p a r e d w i t h t h e control g r o u p . This rep-
r e s e n t e d a n e s t i m a t e d c o s t s a v i n g of U S $ 3 1 9 , 0 0 0 with
n o i n c r e a s e i n m o r t a l i t y o r l e n g t h of h o s p i t a l s t a y [ 4 1 ] .
The authors concluded that, chest physiotherapy
t h e e f f e c t i v e n e s s of c h e s t p h y s i o t h e r a p y [39].
Feasibility of r a n d o m i z e d - c o n t r o l l e d
trials in p h y s i o t h e r a p y research
?
To p r o v i d e rigorous scientifically-sound e v i d e n c e , RCTs
are t h e gold s t a n d a r d , h o w e v e r , t h e s e trials a r e o f t e n n o t
feasible b e c a u s e t h e y are either too costly, or their
conduct raises serious ethical issues [44]. Additionally,
c l i n i c a l p r a c t i c e i t s e l f is c o m p l e x , m u l t i - f a c e t e d , d e e p a n d
situational; a n d singular scientific analysis m a y n o t b e
a p p r o p r i a t e . T h e e f f i c a c y of p h y s i o t h e r a p y is o f t e n i n f l u -
e n c e d b y t h e q u a l i t y of t h e p a t i e n t - t h e r a p i s t i n t e r a c t i o n ,
is plus factors s u c h as e x p e r i e n c e , intuition, m o t i v a t i o n ,

Hong Kong Physiotherapy Journal ? V o l u m e 18 ? N u m b e r 2 ? 2 0 0 0 49

p u r p o s e , j u d g e m e n t , a n d v a l u e , all of w h i c h c o n s t i t u t e improve lung volume, and maintain musculoskeletal

soft d a t a , b u t a r e m a j o r i m p a c t factors in d e t e r m i n i n g function without causing detriment to a patient's cardi-

p a t i e n t - v a l u e d o u t c o m e s , s u c h as, quality-of-life [44]. o p u l m o n a r y f u n c t i o n . A p h y s i o t h e r a p i s t ' s k n o w l e d g e of

A l t h o u g h t h e s e soft m e a s u r e s m a y a p p e a r to be of h u m a n anatomy, respiratory and muscle physiology,

m i n i m a l b e n e f i t t o a v e n t i l a t e d p a t i e n t per se, t h e y m a y biomechanics a n d b o d y m o v e m e n t science, together

provide considerable comfort to the patient's relatives w i t h p s y c h o l o g i c a l l y - p o l i s h e d c l i n i c a l skills, m a k e s p h y s i -

and f o r m a n i n t e g r a l c o m p o n e n t of a n advanced o t h e r a p y a particularly appropriate discipline to reha-

h e a l t h c a r e s y s t e m . It is t r u e t h a t p h y s i o t h e r a p y often bilitate a n d m o t i v a t e the patient. F u r t h e r m o r e , the

fails to p r o v i d e h a r d d a t a o r criteria t h a t a r e easily physiotherapist h a s a significant role in e d u c a t i n g pa-

measurable, particularly in the ICU e n v i r o n m e n t w h e r e t i e n t s a n d r e l a t i v e s i n t h e v a l u e o f s e l f - c a r e . If p a t i e n t s

t h e r e a r e s o m a n y c o n f o u n d i n g v a r i a b l e s . I t is o f t e n a r e a w a r e of h o w t o m a x i m i s e t h e i r l u n g f u n c t i o n , c o u g h

difficult t o d e t e r m i n e t h e p r i m a r y c o n t r i b u t i n g f a c t o r t o effectively, a n d self-administer p u l m o n a r y hygiene,

a favourable treatment outcome w h e n a patient receives the physiotherapist will not be r e q u i r e d to perform

more than one therapeutic intervention. While secretion-mobilization techniques. This does n o t m e a n

physiotherapists m a y very m u c h wish to p r o d u c e top that the physiotherapist has no healthcare role, but

c l a s s e v i d e n c e , t h e r e is a l s o t h e e t h i c a l i s s u e of w i t h - rather, a different role to play.

d r a w i n g s o m e historical intervention, believed to be R e g a r d l e s s of t h e i n t r i n s i c v a l u e of soft d a t a , hard

b e n e f i c i a l t o t h e p a t i e n t . If f u t u r e f u n d i n g a l l o c a t i o n is
b a s e d o n e v i d e n c e o f e f f i c a c y , a n d if t h a t e v i d e n c e is n o t
of t h e h i g h e s t r a n k , p h y s i o t h e r a p y a s a s p e c i a l t y r u n s t h e
r i s k of n o t b e i n g a s h i g h l y r e g a r d e d a s c o m p e t i n g d i s c i -
plines ? with resultant absorption.
T h e role of p h y s i o t h e r a p i s t s i n i n t e n s i v e
care units
It is g e n e r a l l y b e l i e v e d t h a t p h y s i o t h e r a p y is u s e f u l i n t h e
m a n a g e m e n t of p a t i e n t s w i t h e x c e s s i v e s e c r e t i o n s [ 4 5 ] .
F i f t y - t h r e e of 5 4 i n t e n s i v e c a r e d i r e c t o r s s u r v e y e d (14
from the United Kingdom, 20 from Australia, 8 from
C a n a d a , 6 f r o m S o u t h Africa, a n d 6 f r o m H o n g K o n g )
considered secretion-mobilization to be t h e p r i m a r y role
of t h e p h y s i o t h e r a p i s t i n t h e I C U [ 4 6 ] . A l a r m i n g l y , i n
response to a "yes" a n d "no" closed-ended question,
5 7 % of t h e s e i n t e n s i v e c a r e d i r e c t o r s c o n s i d e r e d t h a t t h e
physiotherapist's work could be covered by other
disciplines. P u l m o n a r y physiotherapists s h o u l d see their
role extending b e y o n d being a 'secretion mobilizer', to
include techniques that maximize tissue o x y g e n delivery,
e v i d e n c e of p h y s i o t h e r a p y e f f e c t i v e n e s s w i l l s t i l l b e
r e q u i r e d . To p r o v i d e this e v i d e n c e , physiotherapists
m u s t s h o w t h a t t h e y a r e c a p a b l e of a d a p t i n g t h e i r r o l e t o
t h e d i f f e r e n t t e m p o r a l r e q u i r e m e n t s of t h e d i s e a s e p r o c e s s .
To c o m b i n e clinical e x p e r i e n c e a n d expertise w i t h e x t e r -
n a l clinical e v i d e n c e , p h y s i o t h e r a p y research should
focus on matching the case-mix to the therapeutic
manoeuver and using appropriate outcome measures.
T e c h n i q u e s f o r m o b i l i z i n g s p u t u m w i l l n o t w o r k if t h e r e
is n o s p u t u m .
I n t h e I C U e n v i r o n m e n t , t h e r e a r e still m a n y i s s u e s
relating to p h y s i o t h e r a p y that h a v e n o t b e e n adequately
investigated. For example, the relationship between
b r e a t h i n g p a t t e r n , w o r k of b r e a t h i n g a n d ventilator
w e a n i n g ; t h e e f f e c t of m a n u a l i n f l a t i o n a n d mobilization
exercises on oxygen consumption; a n d sensory input
a n d p o s i t i o n i n g of p a t i e n t s w i t h a c u t e h e a d a n d chest
injury. To e n s u r e t h e results are w o r t h t h e effort, trials
should attempt to p r o d u c e the best quality evidence
p o s s i b l e (Table 4 ) .
The future, however, looks brighter. Nowadays, m o s t
physiotherapy students embrace a research culture dur-
i n g t h e i r clinical t r a i n i n g , b e c a u s e m a n y m o r e of t h e i r

Table 4. P r o c e d u r e s to consider w h e n u n d e r t a k i n g a clinical trial

Identify.an appropriate patient cohort

I d e n t i f y t h e r o l e of p h y s i o t h e r a p y i n . t h e . m a n a g e m e n t of t h i s t y p e of p a t i e n t
E m p l o y a specific t e c h n i q u e to a c h i e v e a specific objective
P e r f o r m a p o w e r analysis o n t h e p a r a m e t e r of i n t e r e s t a n d d e t e r m i n e s a m p l e size
Allocate patients r a n d o m l y to groups
Include a control group
Separate t h e o p e r a t o r a n d t h e assessor, a n d e n s u r e blinding
Measure appropriate outcome parameters
- physiological (temporal)
- psychological
- global/individual
Involve multiple centres

50 ^^打g Kong P八y@fot^er口py

^^^Mrn研f? V o l u m ^ I ^ O N u m b e r 2 e 2 0 0 0
 teachers are, themselves, research trained. While i m m e -
diate benefit m a y not be demonstrable, o n e can
to s e e a m o r e v i g o r o u s e v a l u a t i o n of physiotherapy
techniques by future physiotherapists with an extension
of t h e p h y s i o t h e r a p i s t ' s r o l e i n t h e I C U t o t h a t of a
clinical physiologist/psychologist.
Conclusion
Evidence-based medicine does not necessarily
i n d i v i d u a l clinical expertise. Proficiency a n d j u d g e m e n t
a c q u i r e d t h r o u g h clinical e x p e r i e n c e s h o u l d n o t be dis-
c a r d e d j u s t b e c a u s e t h e r e is n o i n v i o l a b l e
Principles of Critical Care. N e w Y o r k : M c G r a w - H i l l 1 9 9 2 : 1 2 4 9 .
expect 10. S t e v e n s R M , T e r e s D , S k i l l m a n J, et a l : P n e u m o n i a i n a n I C U .
Arch Intern Med 1 9 7 4 ; 1 4 3 : 1 0 6 - 1 1 .
1 1 . M a c k e n z i e C F : C l i n i c a l i n d i c a t i o n s a n d u s a g e of c h e s t
physiotherapy: A n a t o m y , Physiology, Physical E x a m i n a t i o n ,
a n d R a d i o l o g y of t h e A i r w a y s a n d C h e s t . I n : M a c k e n z i e CF,
I m l e P C , Ciesla N, e d s . Chest Physiotherapy in the Intensive Care
Unit. 2 n d e d . B a l t i m o r e : W i l l i a m s & W i l k i n s , 1 9 8 9 .
12. P h e l a n PD. R e s p i r a t o r y i l l n e s s i n c h i l d r e n . I n : Clinical Patterns
in Acute Respiratory Infection. 4 t h e d . O x f o r d : B l a c k w e l l S c i e n -
tific P u b l i c a t i o n s , 1 9 9 4 : 8 6 .
exclude 13. J o n e s AP, R o w e BH: B r o n c h o p u l m o n a r y h y g i e n e physical
t h e r a p y in chronic obstructive p u l m o n a r y disease a n d b r o n -
c h i e c t a s i s ( C o c h r a n e R e v i e w ) . I n : The Cochrane Library, Issue
scientific 2, O x f o r d u p d a t e s o f t w a r e 1 9 9 9 .

evidence.
Questioning evidence in a science oriented working
e n v i r o n m e n t is d e s i r a b l e , b u t t h e q u e s t i o n a s k e d s h o u l d
b e i m p o r t a n t a n d n o t trivial. O n e m u s t c o n s i d e r t h e role,
o b j e c t i v e , a n d e x p e c t e d o u t c o m e of t h e intervention.
T h e indicators for t r e a t m e n t m u s t be present, a n d
p a t i e n t p o p u l a t i o n or c o n d i t i o n a p p r o p r i a t e for t h e r a p y .
1 4 . B a t e m a n J, N e w m a n S, D a u n t K, e t al: Is c o u g h a s e f f e c t i v e a s
c h e s t p h y s i o t h e r a p y i n t h e r e m o v a l of e x c e s s i v e t r a c h e o b r o n -
c h i a l s e c r e t i o n s ? Thorax 1981;36:683-7.
1 5 . M a y B, M u n t P: P h y s i o l o g i c effects of c h e s t p e r c u s s i o n a n d
p o s t u r a l d r a i n a g e in p a t i e n t s w i t h stable c h r o n i c b r o n c h i t i s .
Chest 1979;75:29-32.
the 16. M o h s e n i f a r Z, R o s e n b u r g N, G o l d b e r g H, et al: M e c h a n i c a l
vibration a n d c o n v e n t i o n a l chest p h y s i o t h e r a p y in o u t -

T h a t is n o t t o m e n t i o n t h e o b v i o u s n e e d t o standardize p a t i e n t s w i t h s t a b l e c h r o n i c o b s t r u c t i v e l u n g d i s e a s e . Chest
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m e t h o d s a n d research strategies w h e r e appropriate.
17. N e w t o n D, B e v a n s H: P h y s i o t h e r a p y a n d intermittent
However, n o two patients are identical and different
p o s i t i v e - p r e s s u r e v e n t i l a t i o n of c h r o n i c b r o n c h i t i s . BMJ1978;
o u t c o m e s m a y be desired in different circumstances.
2:1525-8.
M o s t s t u d i e s t h a t h a v e r e p o r t e d n e g a t i v e efficacy of 18. O l d e n b u r g F, D o l o v i c h M , M o n t g o m e r y J , e t al: Effects of
physiotherapy treatment have done no more than alert postural drainage, exercise a n d c o u g h o n m u c o u s clearance in
readers to redirect their energy to increase investment c h r o n i c b r o n c h i t i s . Am RevResp Dis 1 9 7 9 ; 1 2 0 : 7 3 9 - 4 5 .
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in c h r o n i c obstructive p u l m o n a r y disease: forced e x p i r a t o r y
g r o u p s . It is i m p o r t a n t t h a t o n e m u s t n o t l e t e v i d e n c e -
t e c h n i q u e c o m b i n e d w i t h either postural drainage or positive
based practice b e c o m e evidence-constrained or evidence-
e x p i r a t o r y p r e s s u r e b r e a t h i n g . Resp Med 1 9 9 4 ; 8 8 : 4 3 5 - 4 0 .
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