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Objective: To determine the effectiveness of the McKenzie Method compared to any conservative interventions on pain and disability in patients with chronic low back pain (LBP) with directional preference (DP)., Methods: We searched six electronic databases up to September 2022. Eligible randomized controlled trials were those assessing the McKenzie Method delivered by credentialed therapists for chronic LBP with DP. Two reviewers independently selected studies, extracted data, assessed risk of bias with the revised Cochrane Risk of Bias 2.0 tool and certainty of evidence with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework., Results: Five trials ( n  = 743) were included. There was low-certainty evidence that the McKenzie Method, compared to all other interventions combined, produced clinically important reductions in short-term pain (mean difference [MD] -1.11 points on a 10-point scale; 95% CI -1.83 to -0.40) and in intermediate-term disability (standardized mean difference [SMD] -0.53; 95% CI -0.97 to -0.09). Low-to-moderate certainty evidence showed that the McKenzie Method also resulted in clinically important improvements in short-term pain (MD -1.53; 95% CI -2.51 to -0.54) and disability (SMD -0.50; 95% CI -0.74 to -0.25) when compared specifically to other exercise approaches, and in intermediate-term pain (MD -2.10; 95% CI -2.94 to -1.26) and disability (SMD -1.01; 95% CI -1.58 to -0.43) as well as long-term disability (SMD -0,59; 95% CI -1.14 to -0.03) when compared to minimal intervention. Low-certainty evidence showed usually small, clinically unimportant effects in comparison to manual therapy., Conclusion: We found low-to-moderate certainty evidence that the McKenzie Method was superior to all other interventions combined for up to 6 months for pain and up to 12 months for disability, with clinically important differences versus exercise in the short term and versus minimal interventions in the intermediate term. The only clinically important long-term effect was on disability compared to minimal intervention.

Background: Patients with Hemophilia are continually monitored at treatment centers to avoid and control bleeding episodes. This study estimated the direct and indirect costs per patient with hemophilia A in Brazil and evaluated the cost variability across different age groups., Methods: A prospective observational research was conducted with retrospective data collection of patients assisted at three referral blood centers in Brazil. Time-driven Activity-based Costing method was used to analyze direct costs, while indirect costs were estimated based on interviews with family and caregivers. Cost per patient was analyzed according to age categories, stratified into 3 groups (0-11;12-18 or older than 19 years old). The non-parametric Mann-Whitney test was used to confirm the differences in costs across groups., Results: Data from 140 hemophilia A patients were analyzed; 53 were 0-11 years, 29 were 12-18 years, and the remaining were older than 19 years. The median cost per patient per year was R$450,831 (IQR R$219,842; R$785,149; $174,566), being possible to confirm age as a cost driver: older patients had higher costs than younger's (p = 0.001; median cost: 0-11 yrs R$299,320; 12-18 yrs R$521,936; ≥19 yrs R$718,969)., Conclusion: This study is innovative in providing cost information for hemophilia A using a microcosting technique. The variation in costs across patient age groups can sustain more accurate health policies driven to increase access to cutting-edge technologies and reduce the burden of the disease., (© 2024. The Author(s).)

Objectives: This study aimed to estimate the cost-utility of effective interventions for enuresis treatment in children and adolescents and to calculate the incremental cost-utility ratio from the perspective of the Brazilian Unified Health System in a 1-year time horizon., Methods: The economic analysis is in 7 stages: (1) survey of evidence of treatments for enuresis, (2) performing the network meta-analysis, (3) estimation of the probability of cure, (4) cost-utility analysis, (5) model sensitivity analysis, (6) analysis of acceptability of interventions by acceptability curve, and (7) monitoring the technological horizon., Results: The association between desmopressin and oxybutynin is the therapeutic strategy with the highest probability of success in the treatment of enuresis in children and adolescents compared with placebo (relative risk [RR] 2.88; 95% confidence interval [CI] 1.65-5.04), followed by the combination therapy between desmopressin and tolterodine (RR 2.13; 95% CI 1.13-4.02), alarm (RR 1.59; 95% CI 1.14-2.23), and neurostimulation (RR 1.43; 95% CI 1.04-1.96). Combination therapy between desmopressin and tolterodine was the only 1 considered not to be cost-effective. Neurostimulation, alarm therapy, and therapy had the respective incremental cost-utility ratio values: R$5931.68, R$7982.92, and R$29 050.56/quality-adjusted life-years., Conclusion: Among the therapies that are on the borderline of efficiency, the combined therapy between desmopressin and oxybutynin presents the greatest incremental benefit at an incremental cost that is still feasible, given that it does not exceed the reference value of the cost-effectiveness threshold established in Brazil., (Copyright © 2023 International Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Background: The COVID-19 pandemic raised awareness of the need to better understand where and how patient-level costs are incurred in health care organizations, as health managers and other decision-makers need to plan and quickly adapt to the increasing demand for health care services to meet patients' care needs. Time-driven activity-based costing offers a better understanding of the drivers of cost throughout the care pathway, providing information that can guide decisions on process improvement and resource optimization. This study aims to estimate COVID-19 patient-level hospital costs and to evaluate cost variability considering the in-hospital care pathways of COVID-19 management and the patient clinical classification., Methods: This is a prospective cohort study that applied time-driven activity-based costing (TDABC) in a Brazilian reference center for COVID-19. Patients hospitalized during the first wave of the disease were selected for their data to be analyzed to estimate in-hospital costs. The cost information was calculated at the patient level and stratified by hospital care pathway and Ordinal Scale for Clinical Improvement (OSCI) category. Multivariable analyses were applied to identify predictors of cost variability in the care pathways that were evaluated., Results: A total of 208 patients were included in the study. Patients followed five different care pathways, of which Emergency + Ward was the most followed (n = 118, 57%). Pathways which included the intensive care unit presented a statistically significant influence on costs per patient (p <  0.001) when compared to Emergency + Ward. The median cost per patient was I$2879 (IQR 1215; 8140) and mean cost per patient was I$6818 (SD 9043). The most expensive care pathway was the ICU only, registering a median cost per patient of I$13,519 (IQR 5637; 23,373) and mean cost per patient of I$17,709 (SD 16,020). All care pathways that included the ICU unit registered a higher cost per patient., Conclusions: This is one of the first microcosting study for COVID-19 that applied the TDABC methodology and demonstrated how patient-level costs vary as a function of the care pathways followed by patients. These findings can be used to develop value reimbursement strategies that will inform sustainable health policies in middle-income countries such as Brazil., (© 2023. The Author(s).)

Introduction: Swallowing impairment (SI) is an underdiagnosed dysfunction frequently seen as an expected condition of aging. However, SI can lead to health complications and considerable social impact., Methods: The objective of this systematic review with meta-analysis was to evaluate the frequency and associated factors with SI in community-dwelling older persons. Searches were performed in 13 electronic databases including MEDLINE and EMBASE (from inception to September 18, 2021). Data extraction and methodological quality assessment of included studies were performed by two independent reviewers. Meta-analysis of proportions with 95% confidence interval (CI) and prediction interval (PI) was used to pool estimates. Subgroup analysis by Country and Assessment Method was performed. General meta-analysis was used to pool measures of association between potential risk factors and SI occurrence (odds ratio [OR] or prevalence ratio [PR])., Results: The worldwide estimated frequency of SI in community-dwelling older persons was 20.35% (95%CI 16.61-24.68%, 95%PI 4.79-56.45, I 2 99%, n = 33,291). This estimation varied across assessment methods and by country. The main factors associated with SI were a dry mouth (OR 8.1, 95%CI 4.9-13.4), oral diadochokinesis (OR 5.3, 95%CI 1.0-27.3), ≥ 80 years old (OR 4.9, 95%CI 2.6-9.2), genetic factor (SNPrs17601696) (OR 4.8, 95%CI 2.7-8.3), and partial dependence (OR 4.3, 95%CI 2.0-9.3). And the main factors associated with SI estimated by PR were dry mouth sensation (PR 4.1, 95%CI 2.6-6.5), oral sensorimotor alteration (PR 2.6, 95%CI 1.4-4.9), osteoporosis (PR 2.51, 95%CI 1.2-5.3), and heart diseases (PR 2.31, 95%CI 1.1-5.0)., Conclusion: One in five older adults worldwide are expected to experience SI and factors associated with this underdiagnosed dysfunction included biological and physiological changes related to aging, physical and psychological conditions, and poor oral health. Early assessment is paramount for the prevention of future clinical complications and should be a high priority in health care practices., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

The unsustainable increases in healthcare expenses and waste have motivated the migration of reimbursement strategies from volume to value. Value-based healthcare requires detailed comprehension of cost information at the patient level. This study introduces a clinical risk- and outcome-adjusted cost estimate model for stroke care sustained on time-driven activity-based costing (TDABC). In a cohort and multicentre study, a TDABC tool was developed to evaluate the costs per stroke patient, allowing us to identify and describe differences in cost by clinical risk at hospital arrival, treatment strategies and modified Rankin Score (mRS) at discharge. The clinical risk was confirmed by multivariate analysis and considered patients' National Institute for Health Stroke Scale and age. Descriptive cost analyses were conducted, followed by univariate and multivariate models to evaluate the risk levels, therapies and mRS stratification effect in costs. Then, the risk-adjusted cost estimate model for ischaemic stroke treatment was introduced. All the hospitals collected routine prospective data from consecutive patients admitted with ischaemic stroke diagnosis confirmed. A total of 822 patients were included. The median cost was I$2210 (interquartile range: I$1163-4504). Fifty percent of the patients registered a favourable outcome mRS (0-2), costing less at all risk levels, while patients with the worst mRS (5-6) registered higher costs. Those undergoing mechanical thrombectomy had an incremental cost for all three risk levels, but this difference was lower for high-risk patients. Estimated costs were compared to observed costs per risk group, and there were no significant differences in most groups, validating the risk and outcome-adjusted cost estimate model. By introducing a risk-adjusted cost estimate model, this study elucidates how healthcare delivery systems can generate local cost information to support value-based reimbursement strategies employing the data collection instruments and analysis developed in this study., (© The Author(s) 2022. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Executive Summary: Value-based initiatives are growing in importance as strategic models of healthcare management, prompting the need for an in-depth exploration of their outcome measures. This systematic review aimed to identify measures that are being used in the application of the value agenda. Multiple electronic databases (PubMed/MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials) were searched. Eligible studies reported various implementations of value-based healthcare initiatives. A qualitative approach was used to analyze their outcome measurements. Outcomes were classified according to a tier-level hierarchy. In a radar chart, we compared literature to cases from Harvard Business Publishing. The value agenda effect reported was described in terms of its impact on each domain of the value equation. A total of 7,195 records were retrieved; 47 studies were included. Forty studies used electronic health record systems for data origin. Only 16 used patient-reported outcome surveys to cover outcome tiers that are important to patients, and 3 reported outcomes to all 6 levels of our outcome measures hierarchy. A considerable proportion of the studies (36%) reported results that contributed to value-based financial outcomes focused on cost savings. However, a gap remains in measuring outcomes that matter to patients. A more complete application of the value agenda by health organizations requires advances in technology and culture change management., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Foundation of the American College of Healthcare Executives.)

Background: Previous studies have shown that aerobic exercise with cycle ergometer improves motor control., Purpose: The objective of this systematic review and meta-analysis are to evaluate evidence about the effects of aerobic exercise with cycle ergometer on the balance of post-stroke patients, evaluated by the Berg Balance Scale (BBS), and functional capacity, evaluated by the maximal oxygen intake and six-minute walk test (6MWT)., Methods: The research was conducted on MEDLINE, LILACS, Cochrane Library, EMBASE, Physiotherapy Evidence Database, and Google Scholar until March 2018 (CRD42015020146). Two independent reviewers performed the article selection, data extraction, and methodological quality assessment. The main outcome was balance assessed by the Berg scale and the secondary outcome was functional capacity of the maximal oxygen intake and the 6MWT. Meta-analysis was conducted using a random-effects method, and mean pre-post intervention difference with a 95% confidence interval (95%CI)., Results: The review included 5 papers and a total of 258 patients. It was observed that the cycle ergometer did not improve balance in this population (0.03 [-0.57 to 0.64] p  = 0.91) or functional capacity in maximal oxygen intake (2.40 [-0.24 to 5.04] p  = 0.07) and 6MWT (-40.49 [-131.70 to 50.72] p  = 0.38)., Conclusions: The cycle ergometer aerobic exercise did not seem to improve balance or functional capacity in post-stroke patients.IMPLICATIONS FOR REHABILITATIONAerobic exercise with cycle ergometer does not improve balance in patients after chronic stroke, but the results for functional capacity are more promising.Beneficial changes in functional capacity can be seen after 12-4 weeks of training, and are dependent on the initial level of physical fitness of each individual.The use of the cycle-ergometer to improve balance and functional capacity was not superior when compared to conventional physiotherapy; therefore, a combination of therapeutic modalities would be ideal for rehabilitation and post-stroke patients.

Purpose: To evaluate the effects and to compare transcutaneous electrical nerve stimulation protocols, alone or as additional therapy in chronic post-stroke spasticity through a systematic review and meta-analysis of randomized clinical trials. Methods: Search was conducted in MEDLINE, Cochrane Library, EMBASE and Physiotherapy Evidence Database through November 2017 (CRD42015020146). Two independent reviewers performed articles selection, data extraction and methodological quality assessment using the Cochrane Collaboration's risk of bias tool. The main outcome was spasticity assessed with Modified Ashworth Scale or other valid scale. Meta-analysis was conducted using random effects method, and pooled-effect results are mean difference with 95% confidence interval. Results: Of 6506 articles identified, 10 studies with 360 subjects were included in the review. Transcutaneous electrical nerve stimulation alone or as additional therapy is superior to placebo TENS to reduce post-stroke spasticity assessed with Modified Ashworth Scale (-0.52 [-0.74 to -0.30] p  < 0.0001, 6 studies), especially in lower limbs (-0.58 [-0.82 to -0.34] p  < 0.0001, 5 studies), which is in accordance with the studies that used other scales. Low frequency TENS showed a slightly larger improvement than high-frequency, but without significant difference between subgroups. Most studies present low or unclear risk of bias. Conclusion: Transcutaneous electrical nerve stimulation can provide additional reduction in chronic post-stroke spasticity, mainly as additional therapy to physical interventions. Studies with better methodological quality and larger sample are needed to increase evidence power.Implications for RehabilitationTranscutaneous electrical nerve stimulation as additional treatment to physical interventions can lead to additional reduction in chronic post-stroke spasticity.High and low frequency transcutaneous electrical nerve stimulation showed similar results, with a smaller numerical superiority of low frequency TENS.More studies are needed to substantiate the best protocol of transcutaneous electrical nerve stimulation to the treatment of spasticity.

Introduction: The ultrasound technique has been extensively used to measure echo intensity, with the goal of measuring muscle quality, muscle damage, or to detect neuromuscular disorders. However, it is not clear how reliable the technique is when comparing different days, raters, and analysts, or if the reliability is affected by the muscle site where the image is obtained from. The goal of this study was to compare the intra-rater, inter-rater, and inter-analyst reliability of ultrasound measurements obtained from two different sites at the rectus femoris muscle., Methods: Muscle echo intensity was quantified from ultrasound images acquired at 50% [RF 50 ] and at 70% [RF 70 ] of the thigh length in 32 healthy subjects., Results: Echo intensity values were higher ( p  = 0.0001) at RF 50 (61.08 ± 12.04) compared to RF 70 (57.32 ± 12.58). Reliability was high in both RF 50 and RF 70 for all comparisons: intra-rater (ICC = 0.89 and 0.94), inter-rater (ICC = 0.89 and 0.89), and inter-analyst (ICC = 0.98 and 0.99), respectively. However, there were differences ( p  < 0.05) between raters and analysts when obtaining/analyzing echo intensity values in both rectus femoris sites., Conclusions: The differences in echo intensity values between positions suggest that rectus femoris's structure is not homogeneous, and therefore measurements from different muscle regions should not be used interchangeably. Both sites showed a high reliability, meaning that the measure is accurate if performed by the same experienced rater in different days, if performed by different experienced raters in the same day, and if analyzed by different well-trained analysts, regardless of the evaluated muscle site., (© The British Medical Ultrasound Society 2019.)

Scientific and technological advances, coupled with the work of multidisciplinary teams in intensive care units, have increased the survival of critically ill patients. An essential life support resource used in intensive care is extracorporeal membrane oxygenation. Despite the increased number of studies involving critically ill patients, few studies to date have demonstrated the safety and benefits of physical therapy combined with extracorporeal membrane oxygenation support. This review identified the clinical outcomes of physical therapy in adult patients on extracorporeal membrane oxygenation support by searching the MEDLINE®, PEDro, Cochrane CENTRAL, LILACS, and EMBASE databases and by manually searching the references of the articles published until September 2017. The database search retrieved 1,213 studies. Of these studies, 20 were included in this review, with data on 317 subjects (58 in the control group). Twelve studies reported that there were no complications during physical therapy. Cannula fracture during ambulation (one case), thrombus in the return cannula (one case), and leg swelling (one case) were reported in two studies, and desaturation and mild vertigo were reported in two studies. In contrast, improvements in respiratory/pulmonary function, functional capacity, muscle strength (with reduced muscle mass loss), incidence of myopathy, length of hospitalization, and mortality in patients who underwent physical therapy were reported. The analysis of the available data indicates that physical therapy, including early progressive mobilization, standing, ambulation, and breathing techniques, together with extracorporeal membrane oxygenation, is feasible, relatively safe, and potentially beneficial for critically ill adult patients.

The renal damage and loss of kidney function that characterize chronic kidney disease (CKD) cause several complex systemic alterations that affect muscular homeostasis, leading to loss of muscle mass and, ultimately, to muscle atrophy. CKD-induced muscle atrophy is highly prevalent and, in association with common CKD comorbidities, is responsible for the reduction of physical capacity, functional independence, and an increase in the number of hospitalizations and mortality rates. Thus, this chapter summarizes current knowledge about the complex interactions between CKD factors and the pathophysiological mechanisms that induce muscle atrophy that, despite growing interest, are not yet fully understood. The current treatments of CKD-induced muscle atrophy are multidisciplinary, including correction of metabolic acidosis, nutritional supplementation, reducing insulin resistance, administration of androgenic steroids, resisted and aerobic exercise, neuromuscular electrical stimulation, and inspiratory muscle training. However, further studies are still needed to strengthen the comprehension of CKD-induced muscle atrophy and the better treatment strategies.