Effectiveness of respiratory physiotherapy applied to mucociliary clearance in children with cerebral palsy: a systematic review

María Elena Nicolás Checa^4,5, Mercedes Franco Hidalgo-Chacón¹, Samuel Fernández Carnero¹, José Luis Arias Buría³, Vanessa González Bellido^1,2

¹Departamento Fisioterapia, Universidad Francisco de Vitoria, Pozuelo de Alarcón. ²Fisiobronquial, Centro Fisioterapia Respiratoria, Madrid, España. ³Departamento de Fisioterapia, Terapia Ocupacional, Rehabilitación y Medicina Física. Universidad Rey Juan Carlos, Alcorcón. ⁴Biome-Fisioterapia, Madrid, España; 5 Centro Médico Bienestar-Salud, Boadilla del Monte
Madrid, España.

Key words: Respiratory physiotherapy. Mucociliary clearance. Mechanical insufflation-exsufflation (MI-E). High frequency chest wall oscilation (HFCWO). Feedback respiratory training (FRT). Incentive spirometry exercise (IEE)

Background
Children cerebral palsy (CCP) is a complex condition, difficult to define and classify, involving motor damage, sometimes limiting functional movement. Deformation of rib cage and weakness of bulbar muscles, cause ineffective cough that leads to incorrect/ absent mucociliary clearance. Frequent bronchoaspirations favored by gastroesophageal reflux, result in increased morbidity and mortality associated to lower respiratory tract infections and varied respiratory pathology. Pneumonia, atelectasis or other acute bronchial diseases are most often direct causes of death. Objective: Evaluate by systematic review the efficacy and representativeness of diverse physiotherapeutic techniques and devices used for mucociliary clearance and drainage of secretions, as well as the effectiveness of chest physiotherapy in children with CP.

Methodology

An exhaustive search of reference scientific articles published in the last 15 years was carried out. To this end, up to 8 electronic databases (PUBMED, PEDro, sCielo, NARIC, CLINICALTRIALS, COCHRANE REVIEWS, WOS, SCOPUS) were consulted, together with additional sources in English or Spanish language. We selected randomized clinical trials (RCTs) that reached a minimum of 4 in PEDro Scale evaluation. Other experimental designs or non-published works were excluded. The inclusion criteria comprised children up to 18 years, diagnosed of CCP in any of its modalities, with respiratory dysfunction, stable health conditions, exacerbations that imply need for antibiotics and/or hospitalization. Respiratory physiotherapy or instrumental aids must be the interventions.

Results

We found more than 20 articles related to the subject but only 4 met the inclusion criteria. Different respiratory managements included the use of Mechanical Insufflation-Exsufflation (MI-E), Percussor, Feedback Respiratory Training (FRT), Incentive Spirometry Exercise (ISE), and High Frequency Chest Wall Oscillation (HFCWO).

Discussion

Demographic descriptors, number of hospitalizations, problems reported by intervention techniques, and different bronchial health variables were analyzed. With HFCWO, a trend in decreased number of hospital admissions and antibiotic intake is observed. Pulmonary function expressed by forced vital capacity (FVC) and forced expiratory volume at first second (FEV₁) improved with ISE and FRT. With dissimilar degrees of certainty, all techniques potentially improved respiratory function. The heterogeneity of the variables considered did not allow the accomplishment of meta-analysis. The recovered evidence was of medium-low quality.

Conclusions

The respiratory physiotherapy techniques analyzed in the selected studies are effective in CCP, contributing to bronchial clearance. For more conclusive evidence it is necessary to increase the number of object-oriented research.