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https://www.commed.vcu.edu/Chronic_Disease/2012/cochranrvwrschbias.pdf

The Cochrane Collaboration's tool for assessing risk of bias in randomised trials

Alexis A. Topjian, MD, MSCE, Chair; Tia T. Raymond, MD, Vice-Chair; Dianne Atkins, MD; Melissa Chan, MD; Jonathan P. Duff, MD, Med; Benny L. Joyner Jr, MD, MPH; Javier J. Lasa, MD; Eric J. Lavonas, MD, MS; Arielle Levy, MD, Med; Melissa Mahgoub, PhD; Garth D. Meckler, MD, MSHS; Kathryn E. Roberts, MSN, RN; Robert M. Sutton, MD, MSCE; Stephen M. Schexnayder, MD; On behalf of the Pediatric Basic and Advanced Life Support Collaborators

https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000916

Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000918

Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Background
Most vaginal births are associated with trauma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including perineal massage, warm or cold compresses, and perineal management techniques have been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011.

Objectives
To assess the effect of perineal techniques during the second stage of labour on the incidence and morbidity associated with perineal trauma.

Search methods
We searched Cochrane Pregnancy and Childbirth's Trials Register (26 September 2016) and reference lists of retrieved studies.

Selection criteria
Published and unpublished randomised and quasi-randomised controlled trials evaluating perineal techniques during the second stage of labour. Cross-over trials were not eligible for inclusion.

Data collection and analysis
Three review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. We checked data for accuracy.

Main results
Twenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Overall, trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques.

Most studies did not report data on our secondary outcomes. We downgraded evidence for risk of bias, inconsistency, and imprecision for all comparisons.

Hands off (or poised) compared to hands on

Hands on or hands off the perineum made no clear difference in incidence of intact perineum (average risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.12, two studies, Tau² 0.00, I² 37%, 6547 women; moderate-quality evidence), first-degree perineal tears (average RR 1.32, 95% CI 0.99 to 1.77, two studies, 700 women; low-quality evidence), second-degree tears (average RR 0.77, 95% CI 0.47 to 1.28, two studies, 700 women; low-quality evidence), or third- or fourth-degree tears (average RR 0.68, 95% CI 0.21 to 2.26, five studies, Tau² 0.92, I² 72%, 7317 women; very low-quality evidence). Substantial heterogeneity for third- or fourth-degree tears means these data should be interpreted with caution. Episiotomy was more frequent in the hands-on group (average RR 0.58, 95% CI 0.43 to 0.79, Tau² 0.07, I² 74%, four studies, 7247 women; low-quality evidence), but there was considerable heterogeneity between the four included studies.

There were no data for perineal trauma requiring suturing.

Warm compresses versus control (hands off or no warm compress)

A warm compress did not have any clear effect on the incidence of intact perineum (average RR 1.02, 95% CI 0.85 to 1.21; 1799 women; four studies; moderate-quality evidence), perineal trauma requiring suturing (average RR 1.14, 95% CI 0.79 to 1.66; 76 women; one study; very low-quality evidence), second-degree tears (average RR 0.95, 95% CI 0.58 to 1.56; 274 women; two studies; very low-quality evidence), or episiotomy (average RR 0.86, 95% CI 0.60 to 1.23; 1799 women; four studies; low-quality evidence). It is uncertain whether warm compress increases or reduces the incidence of first-degree tears (average RR 1.19, 95% CI 0.38 to 3.79; 274 women; two studies; I² 88%; very low-quality evidence).

Fewer third- or fourth-degree perineal tears were reported in the warm-compress group (average RR 0.46, 95% CI 0.27 to 0.79; 1799 women; four studies; moderate-quality evidence).

Massage versus control (hands off or routine care)

The incidence of intact perineum was increased in the perineal-massage group (average RR 1.74, 95% CI 1.11 to 2.73, six studies, 2618 women; I² 83% low-quality evidence) but there was substantial heterogeneity between studies). This group experienced fewer third- or fourth-degree tears (average RR 0.49, 95% CI 0.25 to 0.94, five studies, 2477 women; moderate-quality evidence).

There were no clear differences between groups for perineal trauma requiring suturing (average RR 1.10, 95% CI 0.75 to 1.61, one study, 76 women; very low-quality evidence), first-degree tears (average RR 1.55, 95% CI 0.79 to 3.05, five studies, Tau² 0.47, I² 85%, 537 women; very low-quality evidence), or second-degree tears (average RR 1.08, 95% CI 0.55 to 2.12, five studies, Tau² 0.32, I² 62%, 537 women; very low-quality evidence). Perineal massage may reduce episiotomy although there was considerable uncertainty around the effect estimate (average RR 0.55, 95% CI 0.29 to 1.03, seven studies, Tau² 0.43, I² 92%, 2684 women; very low-quality evidence). Heterogeneity was high for first-degree tear, second-degree tear and for episiotomy - these data should be interpreted with caution.

Ritgen's manoeuvre versus standard care

One study (66 women) found that women receiving Ritgen's manoeuvre were less likely to have a first-degree tear (RR 0.32, 95% CI 0.14 to 0.69; very low-quality evidence), more likely to have a second-degree tear (RR 3.25, 95% CI 1.73 to 6.09; very low-quality evidence), and neither more nor less likely to have an intact perineum (RR 0.17, 95% CI 0.02 to 1.31; very low-quality evidence). One larger study reported that Ritgen's manoeuvre did not have an effect on incidence of third- or fourth-degree tears (RR 1.24, 95% CI 0.78 to 1.96,1423 women; low-quality evidence). Episiotomy was not clearly different between groups (RR 0.81, 95% CI 0.63 to 1.03, two studies, 1489 women; low-quality evidence).

Other comparisons

The delivery of posterior versus anterior shoulder first, use of a perineal protection device, different oils/wax, and cold compresses did not show any effects on perineal outcomes. Only one study contributed to each of these comparisons, so data were insufficient to draw conclusions.

Authors' conclusions
Moderate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent. Poor-quality evidence suggests hands-off techniques may reduce episiotomy, but this technique had no clear impact on other outcomes. There were insufficient data to show whether other perineal techniques result in improved outcomes.

Further research could be performed evaluating perineal techniques, warm compresses and massage, and how different types of oil used during massage affect women and their babies. It is important for any future research to collect information on women's views.

Perineal techniques during the second stage of labour for reducing perineal trauma

What do cochrane systematic reviews say about interventions for enuresis in children and adolescents? An overview of systematic reviews.

Objective. This systematic review aimed to assess the efficacy of manual therapies for headache relief. Method. A systematic search in MEDLINE, LILACS, Cochrane, CINAHL, Scopus and Web of Science databases was conducted for randomized and quasi-randomized trials, with no restrictions for language or year of publication. The de scriptors were ‘Headache’, ‘Headache disorders’ and ‘Musculoskeletal manipulations’, in addition to the keyword ‘Manual therapy’ and its equivalents in Portuguese. We included studies that compared massage, chiropractic manipulation, osteopathic manipulation and other spinal manipulation to groups with no intervention, other physiotherapeutic modalities or to a sham group. Results. Seven of the 567 articles initially screened were selected, including patients with tension type headache, cervicogenic headache or migraine. It was not possible to assess the magnitude of the treatment effect on the findings of this review. The main limitations were the absence of randomization and adequate allocation concealment, the lack of blinded evaluators and intention-to-treat analysis and inadequate statistical analysis. Conclusions. We were unable to determine the size of the treatment effect due to the selective description of findings. Owing to the high risk of bias in the articles included, the available evidence regarding the efficacy of manual therapies for headache relief is insufficient.

http://www.revistaneurociencias.com.br/edicoes/2015/2301/original/999original.pdf

Manual therapies for pain relief in patients with headache: a systematic review

Força muscular respiratória: comparação entre nuligestas e primigestas Respiratory muscle strength: comparison between nulliparous and primiparous

Objectives: To evaluate the effects of an exercise program on handgrip strength (HS) in elderly women with low bone mass. Subjects and methods: Thirty­six elderly women were randomi­zed to the intervention group – GI (n = 18) and control group – GC (n = 18). Participants were evaluated by means of a HS test, using a handgrip dynamometer. GI performed strength, balan­ce and functional mobility exercises, and GC performed stretching exercises. Both groups had sessions twice a week for 50 minutes, during 4 months. Results: GI had a significant increase in handgrip strength equal to 31.38%. No differences were observed in GC. There were correlations between HS test and bone mineral density (BMD) of the femoral neck (r = 0.582, p = 0.003) and total femur (r = 0.485, p = 0.01). Conclusion: Results indicate a propensity to increase elderly HS, and showed significant correlations between HS and BMD. Arq Bras Endocrinol Metab. 2012;56(5):313-8 Keywords Bone density; exercises; muscle strength; osteoporosis; elderly health; exercise therapy

/pdf/efeitos-de-um-programa-de-exercicios-em-grupo-sobre-a-forca-370wqfnqso.pdf

Efeitos de um programa de exercícios em grupo sobre a força de preensão manual em idosas com baixa massa óssea Effects of a group exercise program on handgrip strength of elderly women with low bone mass

Andrea Lemos

Papers

What do cochrane systematic reviews say about interventions for enuresis in children and adolescents? An overview of systematic reviews.

Manual therapies for pain relief in patients with headache: a systematic review

Força muscular respiratória: comparação entre nuligestas e primigestas Respiratory muscle strength: comparison between nulliparous and primiparous

Efeitos de um programa de exercícios em grupo sobre a força de preensão manual em idosas com baixa massa óssea Effects of a group exercise program on handgrip strength of elderly women with low bone mass

Effects of abdominal hypopressive gymnastics in the volume distribution of chest wall and the electromyographic activity of the respiratory muscles