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2022 Recommendations of the AFU Lithiasis Committee: Postural therapy

Référence : Prog Urol, 2023, 14, 33, 888-892

Summary

Postural therapy is a postural procedure to fight against the gravity phenomenon responsible for the non-elimination of lower calyceal stones. It allows improving or accelerating their expulsion and it increases the stone-free rate. This procedure associates forced diuresis, postural inversion, and lumbar percussion. It allows a 50% improvement and an acceleration of fragment elimination. Despite its positive impact, postural therapy remains under-used. These are the first practical recommendations on postural therapy.

Methodology

These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (urolithiasis) [EAU Guidelines on urolithiasis. 2022] and whether they were adaptable to the French context.

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2022 Recommendations of the AFU Lithiasis Committee: Postural therapy

Recommandations 2022 du Comité lithiase de l’AFU : posturothérapie

Plan

English version

Definition

Efficacy and morbidity

Discussion du groupe de travail

Disclosure of interest

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English version

Definition

Postural therapy is a postural procedure to fight against the gravity phenomenon responsible for the non-elimination of lower calyceal stones. It allows improving or accelerating their elimination and increases the stone-free rate. It associates forced diuresis, postural inversion, and lumbar percussion, currently, in France, it is performed in some spa centers or by physiotherapists.

Efficacy and morbidity

The efficacy of postural therapy has been demonstrated for kidney stones in the lower calyces or in the pelvis: 50% of improvement and accelerated fragment expulsion [1] [level of evidence (LOE) 4] [2] (LOE4) [3] (LOE2) [4] (LOE2) [5] (LOE2) [6] (LOE4) [7] (LOE2) [8] (LOE1) [9] (LOE2) [10] (LOE2) [11] (LOE1) [12] (LOE2) [13] (LOE1) [14] (LOE2) [15] (LOE1) [16] (LOE1).

This procedure combines forced diuresis (fluid load or diuretics), postural inversion >30° (45–60°) (to verticalize the lower calyx) and percussion (hydraulic, manual, or mechanical with a vibrating device) [17] (LOE4) [12] (LOE2) [18] (LOE4) [19] (LOE2) [1] (LOE4) [4] (LOE2) [3] (LOE2) [7] (LOE2).

It is performed after extracorporeal shock wave lithotripsy (ESWL) or endoscopic treatment and may require several sessions [19] (LOE2) [9] (LOE2) [8] (LOE1) [3] (LOE2).

The literature data are not clear on when the first session should start, but it can be performed within 3 days after the intervention, and on the optimal number of sessions [3] (LOE2) [4] (LOE2) [20] (LOE2).

Although most studies did not report any important adverse effects, there is a potential risk of renal colic during fragment migration [3] (LOE2) [16] (LOE1). This risk suggests that it should not be performed in patients with fragments or stones>5mm.

Discussion

Despite its positive impact, postural therapy remains under-used in France. Indeed, access to spa centers is limited and only few physical therapy centers propose this approach because it remains unknown and not recognized (not included in the list of procedures reimbursed by the French health insurance system). Nevertheless, its use should be discussed to improve the elimination of residual fragments of lower calyceal stones after ESWL or ureterorenoscopy in the absence of contraindications and if available (Recommendation Table 1).

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Version Française

Définition

La posturothérapie consiste en un procédé postural qui a comme objectif de lutter contre le phénomène de gravité responsable de la non-élimination de calculs caliciels inférieurs. Elle permet d’en améliorer ou d’en accélérer l’élimination et notamment d’augmenter taux de SFR. Elle associe cure de diurèse, inversion posturale et percussion lombaire et est réalisée en France jusqu’à présent soit dans certains centres de thermalisme, soit par certaines équipes de kinésithérapeutes.

Efficacité/morbidité

L’efficacité de la posturothérapie a été démontrée pour les calculs rénaux de siège caliciel inférieur ou pyélique avec une amélioration de 50 % et une accélération de l’élimination des fragments [1] (NP4) [2] (NP4) [3] (NP2) [4] (NP2) [5] (NP2) [6] (NP4) [7] (NP2) [8] (NP1) [9] (NP2) [10] (NP2) [11] (NP1) [12] (NP2) [13] (NP1) [14] (NP2) [15] (NP1) [16] (NP1).

Elle nécessite l’association d’une diurèse forcée (apports hydriques ou diurétique), une inversion >30° (45–60°) (pour verticalisation du calice inférieur) et une percussion (hydraulique, manuelle ou mécanique à l’aide d’un appareil vibrateur) [17] (NP4) [12] (NP2) [18] (NP4) [19] (NP2) [1] (NP4) [4] (NP2) [3] (NP2) [7] (NP2).

Elle est réalisée après traitement par LEC ou par endoscopie et peut nécessiter plusieurs séances [19] (NP2) [9] (NP2) [8] (NP1) [3] (NP2).

Les données de la littérature ne sont pas claires vis-à-vis du délai de réalisation de la première séance, qui peut toutefois être effectuée dans les 3jours après traitement. Elles ne permettent pas non plus de définir un nombre optimal de séances [3] (NP2) [4] (NP2) [20] (NP2).

Si la plupart des études ne démontrent pas de survenue d’effet indésirable notable, il existe potentiellement un risque de colique néphrétique lors de la migration des fragments [3] (NP2) [16] (NP1). Ce risque suggère par précaution de ne pas la réaliser en cas de fragments ou de calculs>5mm chacun.

Discussion du groupe de travail

Malgré son impact positif, la posturothérapie reste sous-utilisée. En effet l’accessibilité aux centres de cure thermale est limitée et les centres de kinésithérapie qui la pratiquent restent marginaux car elle reste méconnue et non reconnue (acte hors nomenclature). Son utilisation doit cependant être discutée pour améliorer l’élimination des fragments résiduels du calice inférieur après LEC ou URSS en l’absence de contre-indication et en cas d’accès à un centre qui la réalise (Tableau de recommandations 1).

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Disclosure of interest

The authors declare that they have no competing interest.

Recommendation Table 1 - Postural therapy.

Tableau de recommandations 1 - Posturothérapie.

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	References

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