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CLINICAL PROBLEM SOLVINGThis is a new feature, based on a similar one in the New England Journal of Medicine— with their permission. The format will probably develop over time. Information about areal patient is presented in stages (in bold type), the rationale for the treatment is given bythe treating clinician. At the end of the article the treatment is discussed by a clinician fromanother institution, usually from another country. The intention is to promote discussionand the exchange of ideas about clinical problem solving.

To tip or not to tip?GILLIAN PHILLIPS, Royal Brompton Hospital, London.

Key words: cystic fibrosis, gastro-oesophageal reflux (GOF), infants, physiotherapy.

CM, a 4-month-old Caucasian girl, was admitted to hospital for investigation of‘failure to thrive’ following an uneventful gestation and birth. A diagnosis ofcystic fibrosis (CF) was made on the basis of two positive sweat tests of sodium>60 mmol/l on >100 mg of sweat. Genetic testing subsequently confirmed thediagnosis. The physiotherapist in the multidisciplinary team was asked to assessthe infant and to teach the parents the necessary physiotherapy techniques theywould be required to perform as part of the optimal management of their daugh-ter’s condition.

The essential role of chest physiotherapy in CF involves the use of techniques toenhance the clearance of broncho–pulmonary secretions to delay the onset and pro-gression of widespread pulmonary infection and destruction. Even in young infants,including those clinically asymptomatic, evidence exists of small airway inflamma-tion and obstruction (Khan et al., 1995). It is therefore our opinion that chest phys-iotherapy should begin at diagnosis and not with the first hospital admission forintravenous antibiotics.

CM’s parents were shown how to treat her by the use of positioning techniquesto allow gravity-aided drainage of pulmonary secretions, combined with periods ofchest clapping to help loosen and mobilise the mucus in the airways. Treating CMon a pillow over the lap, we demonstrated how to tip, head downwards, and supporther in positions to treat the lateral segments of both lower lobes, the lingula and theright middle lobe. Lying supine, the anterior segments of the upper lobes could betreated and, in upright sitting, the apical segments of the upper lobes. Havingobserved, and been observed performing physiotherapy, with opportunities for ques-tions and answers, the parents were judged competent to perform her treatments.They were encouraged to perform physiotherapy, under the supervision of the

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physiotherapist, for the remainder of CM’s hospital stay in rehearsal for goinghome. Initially, in the absence of an acute respiratory infection, they wereadvised to perform physiotherapy twice a day for 20 minutes, preferably justbefore a feed but at least 2 hours after.

Techniques of chest physiotherapy available for use with infants (<2 years of age)are limited as infants are unable to participate actively in their own treatment.Gravity-assisted positioning is considered an important mainstay of physiotherapy.In recent years however, there has been a growing interest in gastro-oesophagealreflux (GOR) and teaching the head downwards tipped position for physiotherapyhas become controversial. Broadly defined, GOR is the involuntary passage of gas-tric contents into the oesophagus. It is a normal physiological occurrence in infants,but the incidence within the infant CF population is increased (Malfoot & Dab,1991). GOR is important because of its link with respiratory symptoms (Simpson &Hampton, 1991), although both can occur independently and, as such, within thesame patient. Unfortunately, there is little evidence to determine whether tippingworsens GOR or not. There are very few studies which have looked at the effect ofphysiotherapy on GOR and none of these specifically examined the establishedtechniques of gravity-assisted positioning and chest clapping. Three studies (Fosteret al., 1983; Demont et al., 1991; Vandenplas et al., 1991) report that physiotherapycauses GOR, however incomplete descriptions of methodology make it unclearwhether the study subjects were actually tipped at all. From the published conclu-sions, generalisations appear to have been made using evidence of correlation as evidence of causality. Tipping head downwards is classical clinical practice withphysiotherapy in infants with CF, therefore tipping equals physiotherapy and thustipping equals the cause of GOR. Problems in interpreting the results of these stud-ies include: ‘physiotherapy’ treatments described in each study being different fromeach other; small study numbers where subjects’ ages range from 14 months to 15years with the number of infants unknown (Foster et al., 1983); routine use of addi-tional techniques, for example, ‘accelerated expiratory flow’, naso–pharyngeal andoro–pharyngeal suction (Demont et al., 1991) and the use of abdominal pressurethrusts and tracheal rubs (Vandenplas et al., 1991). Such techniques are unpleasantand in our opinion very rarely necessary in the management of infants with CF. Inthe absence of complete data sets, it is plausible that any, or all of these techniquescould have caused GOR in the study subjects, especially as it is documented that thecontrol subjects (non-CF) apparently also suffered regurgitations and vomitingduring the ‘physiotherapy’. Confounding variables within each study raise doubtsregarding the result interpretations and conclusions.

The multidisciplinary team was concerned that CM was frequently vomitingafter feeds. Vomiting is common in GOR and, if GOR was the cause, medicaltreatment was available. It was agreed with her parents that whilst she was stillan inpatient CM would undergo an 18-hour period of pH monitoring of the lowerend of the oesophagus to investigate the presence or absence of acid GOR. Thisinvolved siting a 3 mm antimony probe just above the lower oesophageal sphinc-ter by passing the probe nasally into the oesophagus. It was secured in place and,

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following the initial discomfort, CM continued her eating, sleeping, playing andphysiotherapy as usual. A continual visual data display of pH and minute time,afforded the physiotherapist the opportunity to examine specifically the infant’spH at 30-sec intervals during physiotherapy in gravity-assisted positions.

pH monitoring is well tolerated in infants under 10 months of age and is the pro-cedure of choice for investigating the presence of GOR in infants (Vandenplas et al.,1993). The position of the lower oesophageal sphincter is calculated by use of anomogram relating oesophageal length to height (Strobel et al., 1979) and its posi-tion checked on thoraco–abdominal X-ray. The probe, attached to a Synectics Med-ical Digitrapper system, continuously records pH and upon completion of the studyperiod the information is downloaded to a computer for storage and analysis. Thecomputer calculates the following:

• Number of episodes of reflux (where pH drops to <4.0).• Number of episodes lasting longer than 5 min.• Duration of the longest episode.• Percentage of total time where the pH was <4.0 (the Reflux Index).

The parents keep a diary during the monitoring period, and it was possible toidentify when and where, in relation to the infant’s positioning, activity and feeding,episodes of GOR occur. There is some doubt as to whether pH monitoring is sensi-tive enough to detect alkaline reflux, because the changes in hydrogen ions at con-centrations above pH 7 are extremely small (de Caestecker & Heading, 1990). Inpractice, however, compared with acid reflux, alkaline reflux is responsible for veryfew episodes of GOR. Detection of alkaline reflux involves nuclear medicine studieswith the infant’s feed labelled with isotope.

The results of the study showed a Reflux Index (RI) of 10.3% which wasinterpreted as evidence of abnormal GOR. According to the European Society ofPaediatric Gastroenterology and Nutrition (Vandenplas et al., 1993) a ‘normal’RI is 3.4%. First-phase management of GOR advises encouraging positioning ofinfants prone, lying with head and shoulders raised 30°, and makes dietary rec-ommendations of smaller, more frequent feeds, the use of thickening agents inmilk, and an alginic acid (for example, Gaviscon) to protect against oesophagitis.In the case of CM, the team opted for more aggressive management by the intro-duction of a prokinectic agent, Cisapride (Phase 2). Prokinectic agents act byenhancing gastrointestinal contractile amplitude and improving antro–duodenalcoordination, thus allowing faster emptying of the stomach after a meal. Cisapridehas been shown to increase the pressure of the lower oesophageal sphincter(Cecatelli, 1988). With the addition of a Phase 3 H2 blocker, ranitidine, CM’svomiting stopped and her rate of weight gain and wellbeing improved.

There are various mechanisms thought to be involved in causing GOR. Theseinclude: changes in thoracic and abdominal pressures; alterations in acid production;structural anomalies of the stomach, for example, an obtuse angle of Hiss; a moreintra-thoracic rather than intra-abdominal lower oesophageal sphincter; and

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oesophageal dysmotility. Reduced tone of the lower oesophageal sphincter and inap-propriate transient sphincter relaxation are believed to be particularly importantcauses of GOR in CF (Cucchiara et al., 1991).

Where CM’s physiotherapy involved chest clapping in gravity-assisted posi-tions, there was no evidence of acid reflux whilst she was tipped head down-wards, or when in the supine position. There was evidence of GOR duringphysiotherapy in the sitting upright position. Indeed, from her complete pH studythis was her worst position for GOR, a finding supported by Freidin et al.(1991). However, we now had a clinical dilemma — wondering whether this wasan indication for the modification of CM’s physiotherapy regimen to exclude theupright sitting position.

There were several clinical issues involved when considering modification ofCM’s physiotherapy:

• Would any beneficial effect on GOR gained from not performing physiotherapy inan upright sitting position outweigh the potential cost of not treating the apicalsegments of the upper lobes effectively when CM spends much of her day lying flat?

• If GOR is aggravated by physiotherapy in sitting, does it matter?• If CM coughed more during physiotherapy in sitting was this due to (a) cough stim-

ulation from micro-aspirations during GOR, or (b) more secretions mobilised fromthe apical segments?

• If (b) rather than (a) was true would it not be preferable to perform regular physio-therapy to clear secretions from the apical segments, rather than allow drainage andcoughing during meals with an increased risk of vomiting and aspiration?

• With the evidence that CM had abnormal GOR, would eliminating two 5-minsessions of sitting during physiotherapy markedly affect her GOR status?

• How exact was ‘normal’ GOR when there are obvious ethical issues involved in thepH monitoring of ‘normal’ infants and, therefore, how abnormal is an RI of 10.3%?

• If the infant is on optimum pharmacological medical management for her GOR, isit necessary to consider altering her physiotherapy regimen?

• Concerning lower oesophageal sphincter competence, there is a maturation effectwhich involves an increase in resting sphincter pressure over the first 6 months oflife (Sutphen, 1990).

Having considered the many issues involved and the likelihood of beneficialeffects of performing effective physiotherapy outweighing possible disadvantages,it was decided there was no indication to alter CM’s physiotherapy regimen. Sincebecoming mobile at 11 months, however, there was little indication to treat theapical segments of the upper lobes and the upright sitting position for physiother-apy was discontinued.

CM, now aged 15 months, is thriving and her treatment and management appearto have been successful. Based on clinical experience and sound scientific backing, ithas long been our clinical practice that physiotherapy for infants with CF shouldinvolve the techniques of gravity-assisted positioning, where not contraindicated,

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combined with periods of chest clapping. Contraindications to tipping wouldinclude: raised intra-cranial pressure or recent head/neck trauma or surgery; acutedistended abdomen; respiratory distress; tracheo–bronchial malacia; and cardiac dis-orders. It is of the utmost importance, we believe, that all infants must be assessedindividually and their treatment evaluated. Although CM did not suffer GORduring tipping for physiotherapy, we cannot say this is true for all CF infants. Aswith so many issues in physiotherapy more objective evidence is needed about theeffects, both beneficial and harmful, of positioning for physiotherapy on GOR. Weare currently undertaking an ethically approved, rigorous clinical trial to examinethe effect of chest physiotherapy, involving the recognised techniques of our clinicalpractice, on GOR. Preliminary study data suggest that tipping does not induceGOR, but other positions may be influential. There is, however, considerable inter-and intra-subject variability regarding the presence or absence of abnormal GOR.This individual variation is important as it highlights the potential folly of standard-ising physiotherapy treatments. Individual decisions have to be made about eachpatient using the best scientific evidence available at the time.

Based on an understanding of the anatomical and physiological factors involved incausing GOR and the albeit preliminary evidence from our studies, we believe tippinginfants for physiotherapy does not increase GOR, indeed, it may decrease it. In infantswith reduced lower oesophageal tone, an increase in intra-abdominal pressure mayovercome sphincter pressure allowing reflux. It is possible that GOR may be worse ininfants whilst sitting because poor spinal control (which creates a kyphosis) and gravity(acting on the abdominal contents pulling the diaphragm down) raises intra-abdomi-nal pressure. Theoretically, intra-abdominal pressure will be lowest in the tipped headdownwards position and the increase in intra-thoracic pressure by such positioning maynow oppose reflux. Where the diaphragm needs to work harder, for example, when abody is tipped, sphincter competence is enhanced (Sindel et al., 1989).

Considering all the evidence, we see no reason to radically modify our currentclinical practice concerning physiotherapy in CF infants. We are, however, continu-ing to perform careful, objective monitoring of all CF infants undergoing pH investi-gations with two goals in mind. Firstly, to determine decisively whether tipping forphysiotherapy is beneficial or not to GOR, and, more importantly, to optimise thephysiotherapy management for each individual.

DISCUSSION

Anne Lapin, MCSP, and Craig Lapin, MD.This case study reflected the ongoing dilemma physiotherapists face on a daily basis.The clinical decision to tip or not to tip the child with symptoms of GOR is always achallenge. The article highlights some excellent points in the physiotherapy man-agement of the infant with CF. We still have limited treatment modalities availablefor this age range. The importance of commencing chest physiotherapy in infantsthat are still clinically asymptomatic is supported by evidence of airway involvementthat has been described by Khan et al. (1995).

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An excellent summary of the questions to be considered each time when modifyingchest physiotherapy is provided. Physiotherapists must answer all of these questionswhen making their decision. Even the author states that ‘it is of the utmost impor-tance ... that all infants must be assessed individually and their treatment evaluated’. Asmentioned, there are very few studies that have examined or tried to isolate the effectsof physiotherapy on GOR. Preliminary data from the author’s group indicates thatphysiotherapy does not increase GOR; a viewpoint which conflicts with a similar earlystudy (Button et al., 1995) has been published suggesting that infants with CF andGOR should not be tipped. When the final results of these two ongoing clinical trialsare published, critical review of the patient populations and specific methods shouldprovide a more objective basis with which to make the decision ‘to tip or not to tip’.

REFERENCES

Button BM, Heine RG, Catto-Smith AG, Pheland PD, Olinsky A. Postural drainage in infants: to tipor not to tip, that is the question? Pediatric Pulmonology 1995; Suppl. 12: 108–109.

Cecatelli P. Cisapride restores the decreased lower oesophageal sphincter pressure in reflux patients. Gut1988; 29: 631–635.

Cucchiara S, Santamaria F, Andreotti MR, Minella R, Ercolini P, Oggero V, de Ritis G. Mechanisms ofgastro-oesophageal reflux in cystic fibrosis. Archives of Disease in Childhood 1991; 66: 617–622.

de Caestecker JS, Heading RC. Esophageal pH monitoring. Gastroenterology Clinics of North America1990; 19: 645–669.

Demont B, Escourrou P, Vinçon CL, Cambas H, Grisan A, Odièvre M. Effets de la kinésithérapie respi-ratoire et des aspirations naso–pharyngées sur le reflux gastro-oesophagien chez l’enfant de 0 à 1 an,avec et sans reflux pathologique. Archives Française Pédiatrie 1991; 48: 621–625.

Foster AC, Voyles JB, Murphy SA. Twenty-four hour pH monitoring in children with cystic fibrosis:association of chest physical therapy to gastroesophageal reflux. Pediatric Research 1983; 17iiSuppl: 188A.

Freidin N, Mittal RK, McCallum RW. Does body posture affect the incidence and mechanism of gastro-oesophageal reflux? Gut 1991; 32: 133–136.

Khan TZ, Wagener JS, Bost T, Martinez J, Accuroso FJ, Riches DWH. Early pulmonary inflammation ininfants with cystic fibrosis. American Review of Respiratory Disease and Critical Care Medicine1995; 151: 1075–1082.

Malfoot A, Dab I. New insights on gastro–oesophageal reflux in cystic fibrosis by longitudinal follow up.Archives of Disease in Childhood 1991; 66: 1339–1345.

Simpson H, Hampton F. Gastro-oesophageal reflux and the lung. Archives of Disease in Childhood1991; 66: 277–283.

Sindel BD, Maisels MJ, Ballantine TVN. Gastro-oesophageal reflux to the proximal oesophagus in infantswith bronchopulmonary dysplasia. American Journal of Disease in Childhood 1989; 143: 1103–1106.

Strobel CT, Byrne WJ, Ament M, Euler AR. Correlation of esophageal lengths in children with height:application to Tuttle test without prior esophageal manometry. Journal of Pediatrics 1979; 94: 81–84.

Sutphen JL. Pediatric gastroesophageal reflux disease. Gastroenterology Clinics of North America 1990;19: 617–629.

Vandenplas Y, Diericx A, Blecker U, Lanciers S, Deneyer M. Esophagheal pH monitoring data duringchest physiotherapy. Journal of Pediatric Gastroenterology and Nutrition 1991; 13: 23–26.

Vandenplas Y, Ashkenazi A, Belli D, et al. A proposition for the diagnosis and treatment of gastro-oesophageal reflux disease in children: a report from a working group on gastro-oesophageal refluxdisease. European Journal of Pediatrics 1993 152: 704–711.

Address correspondence to Gillian Phillips, MSc., MCSP, Senior 1 Physiotherapist, Royal Brompton Hospital,Sydney Street, London SW3 6NP, UK.

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