Physiotherapetic Approach in Elderly With COPD: A Systematic Review


 Background: The number of elderly individuals with chronic obstructive pulmonary disease (COPD) is increasing, resulting in high costs, especially in the Brazilian public health system. Scientific studies show that the physical therapy approach has benefits and assists in pulmonary rehabilitation, however, it is necessary to know the interventions that optimize the clinical and functional improvement of the individual. Objective: To analyze physical therapy interventions and their main outcomes in elderly with COPD. Methods: Five researchers independently searched the PUBMED, LILACS, SCIELO and SCOPUS databases. Publications in English, Portuguese and Spanish were delimited. The quality of the studies was assessed by the Consolidated Standards of Reporting Trials (CONSORT) guidelines. Study conducted according to PRISMA standards. Results: The sample consisted of 9 trials. Of these, 6 obtained a positive outcome from the proposed analysis and 3 of the studies did not obtain significant results. There was no homogeneity in study interventions. Conclusion: The interventions or techniques used in elderly patients with COPD who had significant positive outcomes were: Use of vibration devices to enhance strength exercises, the use of Kinesio Taping associated with other therapeutic interventions, resistance training programs, strength and balance and upper limb exercises with coordinated breathing.Systematic Review Record: CRD42020141337


Results
The study sample consisted of 9 trials that analyzed the effectiveness of various physical therapy treatments in elderly with COPD. Table 2 shows the score and the percentage of quality of articles based on the CONSORT criteria, demonstrating that they all have an average above 60%, ie, good quality. This is a systematic literature review guided by the following question: What are the physiotherapeutic interventions applied to elderly with COPD and their outcomes?
The search was conducted at the bases of PUBMED, LILACS, SCIELO and SCOPUS. The entire process of searching and selecting articles was conducted by ve independent researchers. When considered consensually eligible by the ve researchers, the articles were included in the study, when there was no consensus, the researchers discussed the study until reaching a common opinion. Standardized forms were used, following inclusion, exclusion criteria and the risk of bias was performed by the Consort Statement qualitative analysis tool.
Inclusion criteria for the selection of articles were: (a) studies that addressed some physical therapy treatment; (b) research conducted in the elderly population; (c) randomized and nonrandomized controlled clinical trials; (d) studies published from 2009 to 2019; (e) studies speci cally addressing elderly with COPD. The de nition of the last 10 years (from 2009 to 2019) was given as a broad and current time. The exclusion criteria determined were: (a) observational studies, editorials, letters, dissertations and theses; (b) studies that do not address physical therapy intervention; (c) duplicate articles; (d) studies addressing a pathology other than COPD; as shown in Table 1.

Discussion
In the design of the present study, 9 randomized and nonrandomized articles were analyzed, in which various types of physiotherapeutic interventions in the treatment of COPD in elderly patients were presented, from the analyzed trials, 6 studies obtained a positive outcome from the proposed analysis and 3 of the studies 14,15,18 did not obtain signi cant results.
One of the physiotherapeutic interventions used in the treatment of COPD is whole-body vibration that emerged in the early 1970s through training with Russian astronauts to prevent bone and muscle mass loss and subsequently to be employed in the training of athletes. Two of the included studies use the whole body vibration technique, one using the force exercise (squat) on the vibration platform and the other breathing exercise on the vibration platform. Due to the lack of data on the technique approach, the analyzed article demonstrates that the training modality is promising, allowing improvements for the exercise capacity, muscular strength and quality of life of these patients. 12,13,21 .
The Kinesio Taping method, developed in 1996 by Kenzo Kase, consists in the direct application of the therapeutic bandage, with the view of stimulation of the musculature to be treated, where its effects depend on the form and force of application produced by the stretch, to correct the function. weak muscle function, increased blood and lymphatic circulation, increased proprioception, and other repercussions 22,23 . The Daitx study 19 demonstrated that this technique associated with conventional respiratory physiotherapy has seen an increase in SpO2 in nonhypoxemic patients with COPD exacerbations.
Given the results of the study on resistance training, it was considered that through three procedures performed to evaluate the response in body composition, quality of life, dyspnea, muscle strength and exercise tolerance in patients with COPD, had signi cant improvements. on all parameters 20 . Relating the same with another study that reports that in the face of such procedures, exercises are indicated to be performed between 60-80% of the maximum load, promoting greater bene ts, thus generating positive actions to the symptoms of dyspnea, exercise tolerance and exercise. quality of life, preferably in patients with moderate to severe COPD 24 .
The study by Dolmage, et al 16 addresses the in uence of respiratory phase coordination on arm lift exercises. Such exercises are common in the treatment of COPD patients, due to the frequent di culties and dyspnea in tasks requiring arm elevation.
Other studies on arm lift exercise have already been done with the instruction to breathe in during arm lift or without speci c breathing instructions, but none compared these three practices. In this study comparing the three modalities, participants who were instructed to exhale during the survey showed signi cant improvements in activity performance and breathing sensation at the end of the exercise, suggesting that this strategy may help patients in rehabilitation, possibly due to, the mechanical advantage of shoulder exors during exhalation that causes increased strength in the arm lift movement 25,26 .
Pulmonary rehabilitation programs support the implementation of an educational program in its context, aiming at better educating the patient about their pathology and the proper care to be taken, among their bene ts are: the active participation of the patient in the care of their health, the assistance to the patient and family about how to deal with the disease, understanding of its functional changes, physical and psychological consequences. Aiming at this thinking, one study 27 used as an integral part of the pulmonary rehabilitation program the educational program as in the study by Blackstock, et al 18  hypersecretion and in patients in whom forced maneuvers can cause constrictions or proximal collapses that compromise secretion elimination. As the study analyzed, this procedure does not show greater bene t in the technique of wide methodological variation prevented the production of higher level of evidence. 28 .
In order to minimize the detrimental effects of explosive cough, in addition to reducing the large energy expenditure, reducing dyspnea and subjective perception of fatigue, in the forced expiration technique (hu ng), there should be an orientation to the patient regarding the knowledge of their effects. phases with reduced expiratory ow velocity 29 . Positive expiratory pressure (PEP) therapy involves expiratory respiration against a small resistance ranging from 10-20 cmH2O, and applying it with a PEP mask increases lung volumes and intrathoracic pressure. According to the study by OSADNIK, et al 15 there are no signi cant differences between the use of Hu ng and PEP, because regardless of any bene t derived from therapy there appears to be no mediation for improvements in ventilation due to changes in lung volumes 30 .
Balance training has not resulted in major improvements in primary measurements, but there are no comments on the long-term persistence of these effects, where it reports that balance training in patients with this condition is a relevant factor in functional limitation, decrease risk of falls, also noting improvements in lower limb strength and self-reported physical function, being well tolerable in patients with moderate to severe COPD. However, there is little scienti c evidence on the subject addressed. 17 .
During the elaboration of the study, recurrent limitations were observed on each included article, highlighting points such as: a short time of the applied protocols, heterogeneity of the conduct and lack of speci cation about the frequency of the interventions.

Conclusion
COPD is the fth leading cause of hospitalization in the public health system in Brazil. The implications of this condition have negative impacts on various conditions, especially quality of life, lung function, health service use and survival. However, a good elaboration of the therapeutic conduct establishes a better elaboration in the control of this disease 31 .
The different therapeutic modalities are used in patients with COPD, resulting in a wide range of resources to be used and / or added in standard pulmonary rehabilitation to optimize clinical outcomes, especially in the elderly requiring urgent discharge.
Of the articles included in this review, none used the same physical therapy modality. Thus, the interventions or techniques used in elderly patients with COPD were: the use of vibration devices to potentiate strength exercises, the use of Kinesio Taping associated with other therapeutic interventions, resistance training programs, strength and balance program. educational, coordinated breathing upper limb exercises, and breathing techniques such as ELTGOL, PEP therapy, and Hu ng. A wide methodological variety was analyzed, which hindered results with higher level of evidence.
This review highlights the need to conduct more clinical trials involving physiotherapeutic interventions in this population and with better methodological descriptions, with the purpose of assisting the therapeutic decision making by the physiotherapy professional and providing better outcomes to patients. PRISMAScRFillableChecklist11Sept2019.pdf