contraindications to manual chest physiotherapy
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contraindications to manual chest physiotherapyThat is usually the journal article where the information was first stated. In most cases Physiopedia articles are a secondary source and so should not be used as references. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. Cite article This loosens the thick, sticky secretions from the walls of the lung allowing them to move more freely into the larger airways, especially when used with associated gravity positioning.Fingers should curve over the top of the shoulders.This may include modified postural drainage positions.However, avoid to much paddingA slow single handed technique may be more suitable if the patient is at risk of bronchospasmSupplementary oxygen may be required during treatmentThe therapist must be aware of their own posture to protect heir back.Chest Percussion as a Diagnostic Tool Therefore, a large proportion of the vibratory energy of percussion is reflected at the gas-tissue interface, yielding a clear, long-lasting sound described as resonant. However, in conditions such as a pneumothorax, where lung parenchyma is replaced by air, the acoustic mismatch is maximal so the underdamping is even more pronounced resulting in a sound of greater amplitude and duration (described as tympanic sound).Respiratory medicine. 1991 Jan 1;85(1):45-51. In: Bach JR, editor.Patients' views and the effects on oxygen saturation. Physiotherapy. 1995; 81: 753-757. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Read more. This includes turning, postural drainage, percussion, vibration, and cough. Patients may turn themselves or they may turned by the caregiver or by a special bed or device.http://www.danfort.lv/userfiles/dr-z-airbrake-manual.xml
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(21,22,33-35) Positions should generally be held for 3 to 15 minutes (longer in special situations).(4,6,13,16,18,20,29,38-40) Standard positions are modified as the patient's condition and tolerance warrant. The purpose of percussion is to intermittently apply kinetic energy to the chest wall and lung. This is accomplished by rhythmically striking the thorax with cupped hand or mechanical device directly over the lung segment(s) being drained. No convincing evidence demonstrates the superiority of one method over the other.(4,18,41-44) No conclusive evidence supports the efficacy of vibration, the superiority of either manual or mechanical methods, or an optimum frequency.(2,4,13,27,28,30,36,38,39,45-47) PDT can be performed in a wide variety of settings.Therapy should be provided for no longer than necessary to obtain the desired therapeutic results. Listed contraindications are relative unless marked as absolute (A). If patient becomes hypoxemic during treatment, administer 100 oxygen, stop therapy immediately, return patient to original resting position, and consult physician. Ensure adequate ventilation. Hypoxemia during postural drainage may be avoided in unilateral lung disease by placing the involved lung up-permost with patient on his or her side.(20,22,48-50) Administer oxygen and maintain an airway until Administer physician-ordered bronchodilators. The procedure has been used excessively and in patients in whom it is not indicated.(11,40,61-63) Because sputum production is affected by systemic hydration, apparently ineffective PDT probably should be continued for at least 24 hours after optimal hydration has been judged to be present. An increase in adventitious breath sounds can be a marked improvement over absent or diminished breath sounds. Note any effect that coughing may have on breath sounds. One of the favorable effects of coughing is clearing of adventitious breath sounds.http://certa-event.ru/images/dr-z400-manual.xml Feelings of pain, discomfort, shortness of breath, dizziness, and nausea should be considered in decisions to modify or stop therapy. Easier clearance of secretions and increased volume of secretions during and after treatments support continuation. Bradycardia, tachycardia, or an increase in irregularity of pulse, or fall or dramatic increase in blood pressure are indications for stopping therapy. Different clinical situations warrant the degree of training necessary to provide optimal respiratory care.Careful assessment and prudent clinical judgment must be exercised by the caregiver. Less acute patients should be turned every 2 hours as tolerated. PDT order should be re-evaluated at least every 48 hours based on assessments from individual treatments. An evaluation of the forced expiration technique as an adjunct to postural drainage. Physiotherapy 1979;65(10):305-307. Regional lung clearance of excessive bronchial secretions during chest physiotherapy in patients with stable chronic airways obstruction. Lancet 1979;1:294-297. Effects of postural drainage, exercise, and cough on muscle clearance in chronic bronchitis. Am Rev Respir Dis 1979;120:739-745. Is cough as effective as chest physiotherapy in the removal of excessive tracheo-bronchial secretions. Thorax 1981;36:683-687. Assessment of the forced expiration technique postural drainage and directed coughing in chest physiotherapy. Eur J Respir Dis 1983;64:62-68. Am Rev Respir Dis 1984;129:182-184. Techniques of respiratory physical therapy. Am Rev Respir Dis 1980;122(2, Part 2):133-146. Respir Care 1981;26(7):655-656. Respir Care 1981;26(7):657-659. Am Rev Respir Dis 1984;130:701-702. Does chest physical therapy work. Chest 1985;88(3):436-444. Clin Chest Med 1986;7(4):599-618. Evaluation of postural drainage by measurement of sputum volume and consistency. Am J Phys Med 1974;50(5):215-219. Effects of sputum on pulmonary function. Br J Med 1977;2:1181-1183. Pediatrics 1977;60:146-152. Chest 1979;75(1):29-32. Anesth Analg 1980;59(3):207-210. Chest percussion: help or hindrance to postural drainage. Irish Med J 1983;76(4):189-190. A prospective evaluation. Am Rev Respir Dis 1974; 110:49-55. Crit Care Med 1976;4:13-14. A new mechanical method to influence pulmonary perfusion in critically ill patients. Crit Care Med 1977;5:277-279. Can Anaesth Soc J 1983; 30:424-437. Acta Chir Scand 1954;107:193-205. Removal of foreign bodies from the tracheobronchial tree. J Pediatr Surg 1972; 7:119-122. A clinical, radiologic and physiologic evaluation of chest physiotherapy. J Maine Med Assoc 1972;63:142-145. Lancet 1978;2:228-230. Chest physiotherapy: the effect on arterial oxygenation. Anesth Analg 1978;57:28-30. Acute lobar atelectasis: a prospective comparison of fiberoptic broncho-scopy and respiratory therapy. Am Rev Respir Dis 1979;119:971-977. Chest 1990;98:1336-1340. Crit Care Med 1982;10:176-179. Improved oxygenation in patients with acute respiratory failure: the prone position. Am Rev Respir Dis 1977;115:559-566. Effect of a rotating bed on the incidence of pulmonary complications in critically ill patients. Crit Care Med 1988;16:783-786. J Crit Care 1989;4:45-53. The efficacy of an oscillating bed in the prevention of lower respiratory tract infection in critically ill victims of blunt trauma: a prospective study. Chest 1990; 97:132-137. Evaluation of the forced expiration technique as an adjunct to postural drainage in treatment of cystic fibrosis. Br Med J 1979;2:417-418. Postural drainage: variability of patients' responses. Arch Phys Med Rehabil 1982;63:423-426. Maximal expiratory flows after postural drainage. Am Rev Respir Dis 1979;119:239-245. Eur J Respir Dis 1985;66:233-239. Am Rev Respir Dis 1976;113:92-96. Arch Dis Child 1979;54:542-544. The effect of mechanical vibration physiotherapy on arterial oxygenation in acutely ill patients with atelectasis or pneumonia. Am Rev Respir Dis 1981;124:372-375. Respir Care 1982;27(5):556-563.https://istacover.com/images/continuing-education-policy-manual.pdf Monitoring during physiotherapy after open heart surgery. Physiotherapy 1978; 64(90):272-273. Chest physical therapy: the immediate effect on oxygenation in acutely ill patients. Chest 1980;78(4):559-564. Chest physical therapy for acute atelectasis. Phys Ther 1981;61(2):217-220. Effect of positive and expiratory pressure and body position in unilateral lung injury. J Appl Physiol 1982;52:147-154. Body position effect on gas exchange in unilateral pleural effusion. Chest 1983;83(5):784-786. Postural effects on gas exchange in infants. N Engl J Med 1983;308(25):1505-1508. Act Med Scand 1964; 175:715-719. N Engl J Med 1979;300(20):1155-1157. Chest physiotherapy: a review. Eur J Respir Dis 1982;63:188-201. Physical therapy: indications for and effects in surgical patients. Am Rev Respir Dis 1980;122:147-154. Phys Ther 1975; 55:1081-1084. Clin Pediatr 1973;12:270-276. Pediatrics 1976;58:362-367. Successful removal of an aspirated tooth by chest physiotherapy. Respir Care 1986; 31:1099-1101. Respir Care 1982;27:458-466. In: Chest physiotherapy in the intensive care unit.Effects of manual percussion on tracheobronchial clearance in patients with chronic airflow obstruction and excessive tracheobronchial secretions. Thorax 1986;41:448-452. Chest 1988;93:1038-1042. Respir Care 1991;36:270-282. Update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health care settings.Am Rev Respir Dis 1962;86:141-146. Physical adjuncts in the treatment of pulmonary diseases. Am Rev Respir Dis 1968;97:725-736. Effect of chest vibration in pulmonary emphysema: a preliminary report. Ann Allergy 1968; 26:10-17. Arch Phys Med Rehab 1972;52:528-530.Lefcoe NM, Paterson NAM. Adjunct therapy in chronic obstructive pulmonary disease. Am J Med 1973;54:343-350. The pathogenesis of post-operative atelectasis. Arch Surg 1973;107:846-850. The diagnosis and prophylaxis of pulmonary complications of surgical operation. Br J Surg 1973;60:129-134. Arch Surg 1974;109:537-541. Chest 1976;69(2):174-178. Am Rev Respir Dis 1977;115:1009-1014. Bronchodilators and physiotherapy during long term mechanical ventilation of the lungs. Anaesth Intens Care 1977;5:48-50. Physiotherapy and intermittent positive pressure ventilation of chronic bronchitis. Br Med J 1978;2:1525-1528. Effects of respiratory physiotherapy on arterial oxygen tension. Acta Anaesth Scand 1978;22:349-352. Effect of pulmonary hygiene measures on levels of arterial oxygen saturation in adults with chronic lung disease. Heart Lung 1978;7(2):315-319. Chest 1978;74:426. Effect of body position on gas exchange after thoracotomy. Thorax 1979;34:518. Crit Care Med 1981;9:819-822 Positional hypoxemia in unilateral lung disease. N Engl J Med 1981;304:523. Effect of chest physiotherapy on the removal of mucus in patients with cystic fibrosis. Am Rev Respir Dis 1982;126:131-135. Ann Surg 1982;195:451-455. Effects of selected bronchial drainage positions and percussion on blood pressure of healthy human subjects. Phys Ther 1983;63:325-330. Diaphragm function after upper abdominal surgery in humans. Am Rev Respir Dis 1983;127:431-436. Respir Care 1983;28:335-344. Respir Care 1983;28:1009-1013. Enhanced tracheal mucus clearance with high frequency chest wall compression. Am Rev Respir Dis 1983; 128:511-515. Am Rev Respir Dis 1984;129 (4, Part 2):A52. Postoperative chest percussion with postural drainage in obese patients following gastric stapling. Chest 1984;86:891-895. Tracheal mucus clearance in high-frequency oscillation. Am Rev Respir Dis 1984;130:703-706. Effect of chest Chest 1984;85(3):378-381. Br Med J 1985;290:1703-1704. Crit Care Med Hypoxemia during chest physiotherapy in patients with septic fibrosis. Ir J Med Sci 1986;155:345-348. Acute lobar atelectasis: effect of chest percussion and postural drainage (CPPL) on resolution (abstract). Am Rev Respir Dis 1987;135(4, Part 2):433. Prevention of hypoxemia in good risk patients during postoperative transport by positioning and deep breathing. Respir Care 1987;32(1):24-28. Lateral positioning of the stable ventilated very low birth weight infant.A comparison of postural drainage and positive expiratory pressure in the domiciliary management of patients with chronic bronchial sepsis. Physiotherapy 1988;74(5):251-254. Physiotherapy 1990;76(4):248-250 Acta Anaesthesiol Scand 1990;34:99-103. Please credit AARC and Respiratory. The technique, usually performed with two hands (depending on the size of the area), involves the rhythmical flexion and extension of the wrist onto the chest wall at a rate and pressure that is comfortable for the patient (see Manual Techniques video). Ideally there should be pauses after 20-30 seconds of continuous percussion and vibrations applied intermittently. For infants it may be performed with two or three fingers, an electric tooth brush or a small soft rubber face mask. Both manual and mechanical percussion have equal effects (Bauer 1994). This pressure change is transmitted through to the lung tissue and assists in dislodging secretions from the airway wall. While vibration is being administered, the patient is instructed to take slow deep breaths (thoracic expansion exercises) to enhance the effect of airflow on the movement of secretions. As the patient breathes out, a rapid oscillatory movement is applied in the direction of the normal movement of the ribs and is transmitted through the chest using body weight. The oscillations are of a larger amplitude and lower frequency than vibrations. On the other hand, using vibrations, there was no additional advantage in secretion clearance in non-CF bronchiectasis (Sutton 1985). When applied as a long-term treatment strategy for patients admitted with an acute exacerbation of COPD, no gain in quality of life or fewer number of admissions was associated with the addition of manual techniques compared to ACBT alone. No adverse effects were noted in patients with non-CF bronchiectasis (Mazzocco 1985). If the patient finds the technique clinically effective and there are no adverse effects, it can be continued. Digital Agency Melbourne. Information provided in these articles are meant only for general information and are not suggested as replacement to standard references. Any inaccurate information, if found, may be communicated to the editor. The bronchioles lead to the respiratory zone of the lungs, which consists of respiratory bronchioles, alveolar ducts and the alveoli, the multi-lobulated sacs in which most of the gas exchange occurs. It is these segments that are being drained. Its time period is 2 seconds. Here, the air is filtered, warmed, and humidified as it flows to the lungs This, average breath capacity is called tidal volume. Examples include: The following are the assessment criteria: Conditions requiring CPT, such atelectasis, and pneumonia, affects vital signs. Certain medications, particularly diuretics antihypertensive cause fluid and haemodynamic changes. These decrease patient’s tolerance to positional changes and postural drainage. Thoracic trauma and chest surgeries also contraindicate percussion and vibration. Participating in controlled cough techniques requires the patient to follow instructions. CPT maneuvers are fatiguing. Gradual increase in activity and through CPT, patient tolerance to the procedure improves. Patients may learn how to percuss the anterior chest as well. Vibration (at a rate of 200 per minute) can be done for several times a day. Spine should be straight to promote rib cage expansion Vibrate the chest wall as the patient exhales slowly through the pursed lips. Each position is done for 3-15 minutes The se symptoms may indicate hypoxemia. Discontinue if hemoptysis occurs. This is especially helpful for patients with large amount of secretions or ineffective cough. It is performed by professionally trained nurses in most settings. Fundamentals of Nursing. Lippincott’s Williams Philadelphia, 2006 Respir Care 39,213-226. Arch Dis Child 1999; 80:393-397. Chest physiotherapy: evaluating the effectiveness. Dimensions of Critical Care Nursing (DCCN), 1990 Mar-Apr; 9(2): 68-74. This article has been cited by other articles in PMC. Abstract Background Manual chest physiotherapy (MCP) techniques involving chest percussion, vibration, and shaking have long been used in the treatment of respiratory conditions. However, methodological limitations in existing research have led to a state of clinical equipoise with respect to this treatment. Thus, for patients hospitalised with an exacerbation of Chronic Obstructive Pulmonary Disease (COPD), clinical preference tends to dictate whether MCP is given to assist with sputum clearance. We standardised the delivery of MCP and assessed its effectiveness on disease-specific quality of life. Methods In this randomised, controlled trial powered for equivalence, 526 patients hospitalised with acute COPD exacerbation were enrolled from four centres in the UK. Patients were allocated to receive MCP plus advice on airway clearance or advice on chest clearance alone. The primary outcome was a COPD specific quality of life measure, the Saint Georges Respiratory Questionnaire (SGRQ) at six months post randomisation. Analyses were by intention to treat (ITT). This study was registered, ISRCTN13825248. Results All patients were included in the analyses, of which 372 (71) provided evaluable data for the primary outcome. Conclusions These data do not lend support to the routine use of MCP in the management of acute exacerbation of COPD. However, this does not mean that MCP is of no therapeutic value to COPD patients in specific circumstances. Background Chronic obstructive pulmonary disease (COPD) is characterised by exacerbations some of which result in increased cough and excessive sputum production caused by mucus hyper-secretion and ciliary dysfunction. Manual chest physiotherapy (MCP) involves external manipulation of the thorax using percussion and vibration techniques. Their purpose of these is to intermittently to apply kinetic energy to the chest wall to dislodge bronchial secretions. The patient then clears these secretions with an expiratory manoeuvre such as the forced expiration technique (FET). The assumption underlying the use of MCP is that removing sputum from the airway improves ventilation perfusion ratios and thus lung function. Methodological limitations inherent in existing studies include; heterogeneous populations, small samples, unstandardised interventions, and confining evaluations to short term outcomes. Thus, there is clinical equipoise about whether MCP confers any benefit to patients with COPD. This randomised trial, funded by National Institute of Health Research Health Technology Assessment, addresses the limitations of previous research by standardising the delivery of MCP and obtaining a sample size sufficient size to detect long term clinical effectiveness or equivalence for a patient-orientated, long term outcome. This paper summarises the efficacy of MCP administered to patients hospitalised with COPD exacerbation on disease-specific quality of life (QOL) at six months post intervention. Methods Study design and patients The MATREX trial was a pragmatic, multicentre, randomised controlled trial powered for equivalence. Between November 21, 2005, and April 30, 2008, 526 patients were enrolled in four centres in the UK. Patients who were admitted to hospital with an exacerbation of COPD were eligible for inclusion in the trial. We obtained written informed consent from all patients. The protocol’s aim was to clearly define the MCP to be delivered whilst allowing sufficient flexibility to preserve the profession’s ethos of providing treatment according to individual need. This comprises breathing control, thoracic expansion exercises and FET. The protocol emphasised defining the circumstances under which participants in the control arm would receive MCP, that is, if the physiotherapist or attending physician felt their condition had deteriorated to the extent that MCP was warranted. Essentially, these circumstances constituted a clinical working definition of respiratory failure (see consort diagram). Adult respiratory ward admission lists at participating hospitals were screened to identify potential study participants. Eligible patients were randomised by telephone using a voice-activated, automated system to stratify by site (block size six). Trial arm allocation was undertaken by an individual not involved in the recruitment process and communicated to participants after their baseline data had been collected. Patients allocated to the intervention arm were guided to perform ACBT whilst the physiotherapist delivered MCP. Therefore, oxygen saturation was monitored with a finger pulse oximeter and any sputum produced during treatment was collected. Following MCP, the physiotherapist provided the patient with advice on positioning regarding continuation of ACBT and provided an information sheet summarising this advice. The patient was asked to continue to collect all further expectorant produced during the remainder of their hospital stay. The content, number and duration of further MCP treatments during hospitalisation were at the discretion of the physiotherapist, according to perceived clinical need. For control arm patients the physiotherapist provided guidance on the elements of ACBT and advice on suitable positions to assist with sputum clearance and information sheet summarising this advice. Their oxygen saturation was recorded at baseline only and the patient was asked to collect any expectorant produced during their hospital stay. For six months post-randomisation, patients re-admitted to hospital with an exacerbation of their COPD continued to be treated according to the trial arm to which they had been allocated. Outcome measures The primary outcome measure was change in the Saint Georges Respiratory Questionnaire (SGRQ) score six months after randomisation. We followed up patients six months after enrolment by postal questionnaire to obtain information on COPD-specific QOL and other secondary outcomes. Finally, the number of days spent in hospital during the full six month study period was obtained retrospectively for each trial participant by scrutinising hospital databases at the end of follow up. Statistical analysis Sample size was based on the primary outcome measure, SGRQ score. To allow for a 15 drop out rate, we aimed to recruit 275 participants to each study arm, resulting in a total target sample size of 550 participants. Analyses of accumulating data were prepared by the trial statistician and reviewed at least once per year by an independent data monitoring committee. Baseline comparability between the treatment arms was evaluated by summarising and comparing means and standard deviations (SDs) for continuous variables or numbers and percentages for categorical variables. No adjustment for multiple testing was made. Analyses of all but one of the outcome measures were based on an analysis of covariance, with treatment as a fixed effect and baseline scores and site as covariates. Analysis of the number of days in hospital was based on a negative binomial regression model, with treatment as a fixed effect, site as a covariate and no baseline covariate. A pre-planned subgroup analysis of the primary outcome by sputum volume (15mls or less versus more than 15mls) was undertaken by testing for an interaction between the subgroup and the treatment arm in an analysis-of-covariance model, with treatment as a fixed effect and baseline scores, site and subgroup as covariates. All statistical analyses were undertaken using the STATA (Version 9.1 SE) statistical software package (STATACORP LP, Texas, USA). The majority of respiratory admissions screened at participating sites were either for patients who did not have COPD, or the reason for their admission was not a COPD exacerbation (85). The remaining exclusions were due to clinical contra-indications for MCP (8) or inability to give informed consent (7). 748 patients were approached to participate in the study, 526 of whom gave their consent (71). Nine participants did not receive the intervention to which they had been allocated. Four patients randomised to the control arm received MCP for clinical reasons, four patients allocated to receive MCP declined treatment, and one was discharged before the physiotherapist had time to treat them. There were five post randomisation exclusions due to retrospective changes in diagnosis (3), emergent contra-indication to MCP (1), and inadvertent repeat recruitment during subsequent hospitalisation (1). Other losses to follow up comprised death during the six month follow up (70), patient-initiated withdrawal (14), and non-response to questionnaires at six months post-randomisation (66). Open in a separate window Figure 1 Trial profile.ALL the following criteria were required to switch arm: i) clinical evidence of sputum retention (e.g. auscultation, chest x ray).In the majority of sessions (61) the physiotherapist selected two different positions in which to place the patient. With respect to oxygen saturation, 41 of MCP sessions were associated with decreasing oxygen level although only 6.6 resulted in a change of 4 or more to a value less than 90, 39 resulted in no change and 19 recorded an increase in oxygen saturation by the end of treatment. Adverse events comprised increased shortness of breath (5), pain (5), arrhythmia (3), bronchospasm (1), and thoracic haematoma (1). This includes MCP given at subsequent admissions during the 6 month follow up. With respect to SGRQ sub-scores, both unadjusted and adjusted CIs are also within the predefined limits of equivalence. No significant interactions were found in the subgroup analysis of SGRQ by sputum volume (data not shown).This perhaps reflects recent improvements in medical treatment with bronchodilators and steroids) that keep people out of hospital for longer until their condition is more severe. Anecdotal evidence suggests there has been an increasing trend for admitted patients to be very sick with end stage disease and multiple co-morbidities. MCP treatment protocol The MCP treatment protocol was designed both to reflect current practice and to comply with the best available research evidence at the time. Physiotherapists’ high level of adherence indicates that they found this protocol acceptable and so our aim to standardise the study intervention was achieved. Nonetheless, our findings do suggest that oxygen de-saturation is more common than previously reported, supporting the routine use of oxygen saturation monitoring during MCP, both to identify patients who need oxygen and assess the effect of the MCP itself. The relatively high baseline SGRQ scores found amongst our trial participants indicate a significant level of impairment and there is little robust information to guide clinicians on the risk of significant de-saturation in this patient group. Recruitment and retention The study successfully recruited 526 individuals in from 4 sites in just over 29 months, with the primary outcome recorded for 372 individuals. This was less than our target of 466, hence in order to ensure that we minimised our chance of a type II error we carried out a sensitivity analysis by imputing the incomplete data using multiple chain equations in STATA using all available baseline data in order to base the analyses on all 522 individuals. The results of this were in keeping with the conclusions of the presented analysis. Hence, it is unlikely that the results are due to a type II error. The effectiveness of MCP treatment This study found no gain in long term respiratory quality of life when MCP was included in the physiotherapy management of acute exacerbation of COPD. After adjusting for baseline, the mean difference in SGRQ score at six months was within our pre-specified limits of equivalence. Differences in SGRQ sub-scores also indicate statistical equivalence. The choice of a quality of life measure as the primary outcome to measure effectiveness is unusual as previous literature has focused on short term physiological measures such as FEV1, oxygen saturation and sputum volumes as measures of efficacy. However short term efficacy may be of little value to the patient unless there is longer term effectiveness. In order to assess this longer term effectiveness QOL is an appropriate patient reported outcome measure. Measure related to short term efficacy such as oxygen saturation and sputum volumes were collected but none of the secondary outcome measures yielded statistically significant results. MCP versus ACBT There is evidence that MCP is used less than before whilst the active cycle remains the treatment of choice. More than three quarters (77) responded that they did treat this patient group and that ACBT was employed in the vast majority of cases (88).