Australian Journal Of Physiotherapy

Journal of Physiotherapy 62 (2016) 169 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Outpatient-based physical rehabilitation does not affect exercise capacity in survivors of prolonged critical illness Synopsis Summary of: McWilliams DJ, Benington S, Atkinson D. Outpatient- change in exercise capacity, expressed as the peak rate of oxygen based physical rehabilitation for survivors of prolonged critical illness: A uptake and the anaerobic threshold, which were measured during a randomized controlled trial. Physiother Theory Pract. 2016;32:179-190. cardiopulmonary exercise test. The secondary outcome was change in health-related quality of life, which was assessed using the Short Form- Question: In survivors of prolonged critical illness, does a program 36 Health Survey Version 2. Results: A total of 63 participants of outpatient-based physical rehabilitation improve exercise capacity completed the study. At the end of the study period, there were no compared with no outpatient intervention? Design: Randomised, significant between-group differences in the change in peak rate of controlled trial with blinding of outcome assessors. Setting: Single oxygen uptake (MD 0.2 ml O2 kg-1 min-1, 95% CI –1.3 to 1.7) or tertiary centre in the United Kingdom. Participants: Inclusion criteria anaerobic threshold (MD 0.0 ml O2 kg-1 min-1, 95% CI –1.3 to 1.3). The were being aged > 18 years and requiring invasive mechanical changes in the health-related quality of life physical component ventilation for > 5 days. Exclusion criteria were: physical condition summary score and mental component summary score were greater in precluding participation in rehabilitation or cardiopulmonary exercise the intervention group compared with the control group (MD testing; psychiatric condition or impairment precluding informed 5.1 points, 95% CI 1.5 to 8.7 and MD 5.9 points, 95% CI 0.8 to 11.0, consent or rehabilitation compliance; participation in alternative respectively). Conclusion: Compared with no intervention, a 7-week rehabilitation; poorly controlled cardiorespiratory disease or terminal outpatient physical rehabilitation program did not change exercise illness. Randomisation of 73 participants allocated 37 to an interven- capacity, although improvements were observed in health-related tion group and 36 to a control group. Interventions: Participants quality of life. [95% CIs calculated by the CAP Editor] randomised to the intervention group received a 7-week outpatient- based exercise (circuit interval training sessions) and education Provenance: Invited. Not peer reviewed. program. Prescription of exercise intensity was titrated to the initial 6-minute walk distance. The rehabilitation program comprised three Elizabeth H Skinner 20-minute sessions per week (one supervised and two self-directed) Physiotherapy, Monash University, Australia with six 1-hour education sessions (including relaxation, smoking cessation and management of dyspnoea and anxiety). Participants http://dx.doi.org/10.1016/j.jphys.2016.05.005 randomised to the control group received no intervention during the study period. Outcome measures: The primary outcome was the ß 2016 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/). Commentary McWilliams and colleagues should be commended on their efforts The improvement in health-related quality of life, as indicated by the in conducting a randomised, controlled trial of rehabilitation for mental and physical component scores of the Short Form-36 Health patients surviving critical illness in the period after hospital discharge. Survey Version 2, is an important finding, despite the lack of statistically More than 900 patients were screened over a 4-year period in order significant between-group differences in exercise capacity. Group-based to randomise 73 participants into the trial; however, this was still exercise and educational aspects of rehabilitation programs warrant insufficient to achieve 80% power. While this makes drawing further investigation in this population, given the documented conclusions about the effectiveness of this intervention difficult, it psychological impact of critical illness.3 does highlight the challenges of recruitment and follow-up in this patient population, where returning to hospital can be both logistically This study has highlighted the need to better understand the and emotionally difficult.1 physical and mental components of recovery, in order to design individualised rehabilitation programs with the aim of improving This study conducted maximal cardiopulmonary exercise tests on survivorship for patients following critical illness. survivors of prolonged critical illness with no adverse events. However, specific results of the cardiopulmonary exercise tests, such as the Provenance: Invited. Not peer-reviewed. primary cause of exercise limitation (eg, cardiac, pulmonary or peripheral), were not reported and did not appear to influence the Meg Harrold exercise prescription component of the intervention. It is possible that School of Physiotherapy and Exercise Science, Curtin University, Australia the exercise prescription was neither appropriately targeted nor continued for an effective duration; therefore, the intervention may not References have translated into a measurable outcome. The authors have accurately acknowledged the limitations of the study, including the 1. Denehy L, et al. Crit Care. 2013;17:R156. omission of an endurance measure of exercise capacity, especially as 2. Jolley SE, et al. Chest. 2016. http://dx.doi.org/10.1016/j.chest.2016.03.045. [Epub this patient population has evidence of substantial muscle weakness and fatigue.2 ahead of print]. 3. Jackson J, et al. Lancet Resp Med. 2014;2:369–379. http://dx.doi.org/10.1016/j.jphys.2016.05.004 1836-9553/Crown Copyright ß 2016 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Journal of Physiotherapy 62 (2016) 169 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Outpatient-based physical rehabilitation does not affect exercise capacity in survivors of prolonged critical illness Synopsis Summary of: McWilliams DJ, Benington S, Atkinson D. Outpatient- change in exercise capacity, expressed as the peak rate of oxygen based physical rehabilitation for survivors of prolonged critical illness: A uptake and the anaerobic threshold, which were measured during a randomized controlled trial. Physiother Theory Pract. 2016;32:179-190. cardiopulmonary exercise test. The secondary outcome was change in health-related quality of life, which was assessed using the Short Form- Question: In survivors of prolonged critical illness, does a program 36 Health Survey Version 2. Results: A total of 63 participants of outpatient-based physical rehabilitation improve exercise capacity completed the study. At the end of the study period, there were no compared with no outpatient intervention? Design: Randomised, significant between-group differences in the change in peak rate of controlled trial with blinding of outcome assessors. Setting: Single oxygen uptake (MD 0.2 ml O2 kg-1 min-1, 95% CI –1.3 to 1.7) or tertiary centre in the United Kingdom. Participants: Inclusion criteria anaerobic threshold (MD 0.0 ml O2 kg-1 min-1, 95% CI –1.3 to 1.3). The were being aged > 18 years and requiring invasive mechanical changes in the health-related quality of life physical component ventilation for > 5 days. Exclusion criteria were: physical condition summary score and mental component summary score were greater in precluding participation in rehabilitation or cardiopulmonary exercise the intervention group compared with the control group (MD testing; psychiatric condition or impairment precluding informed 5.1 points, 95% CI 1.5 to 8.7 and MD 5.9 points, 95% CI 0.8 to 11.0, consent or rehabilitation compliance; participation in alternative respectively). Conclusion: Compared with no intervention, a 7-week rehabilitation; poorly controlled cardiorespiratory disease or terminal outpatient physical rehabilitation program did not change exercise illness. Randomisation of 73 participants allocated 37 to an interven- capacity, although improvements were observed in health-related tion group and 36 to a control group. Interventions: Participants quality of life. [95% CIs calculated by the CAP Editor] randomised to the intervention group received a 7-week outpatient- based exercise (circuit interval training sessions) and education Provenance: Invited. Not peer reviewed. program. Prescription of exercise intensity was titrated to the initial 6-minute walk distance. The rehabilitation program comprised three Elizabeth H Skinner 20-minute sessions per week (one supervised and two self-directed) Physiotherapy, Monash University, Australia with six 1-hour education sessions (including relaxation, smoking cessation and management of dyspnoea and anxiety). Participants http://dx.doi.org/10.1016/j.jphys.2016.05.005 randomised to the control group received no intervention during the study period. Outcome measures: The primary outcome was the ß 2016 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/). Commentary McWilliams and colleagues should be commended on their efforts The improvement in health-related quality of life, as indicated by the in conducting a randomised, controlled trial of rehabilitation for mental and physical component scores of the Short Form-36 Health patients surviving critical illness in the period after hospital discharge. Survey Version 2, is an important finding, despite the lack of statistically More than 900 patients were screened over a 4-year period in order significant between-group differences in exercise capacity. Group-based to randomise 73 participants into the trial; however, this was still exercise and educational aspects of rehabilitation programs warrant insufficient to achieve 80% power. While this makes drawing further investigation in this population, given the documented conclusions about the effectiveness of this intervention difficult, it psychological impact of critical illness.3 does highlight the challenges of recruitment and follow-up in this patient population, where returning to hospital can be both logistically This study has highlighted the need to better understand the and emotionally difficult.1 physical and mental components of recovery, in order to design individualised rehabilitation programs with the aim of improving This study conducted maximal cardiopulmonary exercise tests on survivorship for patients following critical illness. survivors of prolonged critical illness with no adverse events. However, specific results of the cardiopulmonary exercise tests, such as the Provenance: Invited. Not peer-reviewed. primary cause of exercise limitation (eg, cardiac, pulmonary or peripheral), were not reported and did not appear to influence the Meg Harrold exercise prescription component of the intervention. It is possible that School of Physiotherapy and Exercise Science, Curtin University, Australia the exercise prescription was neither appropriately targeted nor continued for an effective duration; therefore, the intervention may not References have translated into a measurable outcome. The authors have accurately acknowledged the limitations of the study, including the 1. Denehy L, et al. Crit Care. 2013;17:R156. omission of an endurance measure of exercise capacity, especially as 2. Jolley SE, et al. Chest. 2016. http://dx.doi.org/10.1016/j.chest.2016.03.045. [Epub this patient population has evidence of substantial muscle weakness and fatigue.2 ahead of print]. 3. Jackson J, et al. Lancet Resp Med. 2014;2:369–379. http://dx.doi.org/10.1016/j.jphys.2016.05.004 1836-9553/Crown Copyright ß 2016 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Journal of Physiotherapy 62 (2016) 168 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Pulsed electromagnetic fields can reduce pain in the short term in patients with knee osteoarthritis Synopsis Summary of: Bagnato GL, Miceli G, Marino N, Sciortino D, Western Ontario and McMaster Universities Osteoarthritis Index, Bagnato GF. Pulsed electromagnetic fields in knee osteoarthritis: subscale pain (WOMAC-pain); and the Medical Outcomes Study a double blind, placebo-controlled, randomized clinical trial. Short-Form 36 version-2 (SF-36) physical and mental component Rheumatology (Oxford) 2016;55:755-762. summary scores (0 to 100). Results: A total of 60 participants (91%) completed the assessment at 1 month. The mean difference was Question: Can daily treatment with pulsed electromagnetic 13.6 units (95% CI 7.9 to 19.3) in VAS-pain and 5.6 units (95% CI fields decrease pain in patients with knee osteoarthritis? Design: 2.9 to 8.4) in WOMAC-pain, both favouring the active pulsed A randomised, double-blind, placebo-controlled clinical trial. electromagnetic fields group. There were minor differences in Setting: One Italian rheumatology outpatient clinic. Participants: favour of the pulsed electromagnetic fields group in the SF-36 People aged over 40 years with a diagnosis of primary osteoar- physical health (mean difference 2.7 units, 95% CI 0.3 to 5.2) and thritis of the knee according to the American College of the SF-36 mental health (mean difference 0.5 units, 95% CI –1.5 to Rheumatology criteria; symptomatic disease for the last 6 months 2.6). Conclusion: In patients with painful knee osteoarthritis, with persistent pain defined as a minimal mean score of 40 mm on pulsed electromagnetic fields decreased pain, but had little impact a Visual Analogue Scale (VAS) despite receiving maximal tolerated on health-related quality of life. doses of conventional medication. Randomisation allocated 33 patients to active treatment and 33 to placebo treatment. Provenance: Invited. Not peer reviewed. Interventions: Participants in the treatment group were given a pulsed electromagnetic fields wearable device, while those in the Ka˚ re Birger Hagena and Margreth Grotleb placebo group received a device with no electromagnetic proper- aNational Advisory Unit on Rehabilitation in Rheumatology, ties. The devices that were used are commercially available and the placebo devices were identical to the active devices, including a Department of Rheumatology, Diakonhjemmet Hospital light-emitting diode light showing operation. The devices were bOslo and Akershus University College of Applied Sciences, Department used 12 hours daily for 1 month. Outcome measures: A blinded assessor administered the outcome measures at 1 month (end of of Physiotherapy, Oslo, Norway treatment): pain measured on a VAS (VAS-pain, 0 to 100); the http://dx.doi.org/10.1016/j.jphys.2016.05.006 Commentary compare and synthesise the evidence. F6DIC$]T_[ linical F7[ID]$pT_ ractice guidelines have not recommended electromagnetic therapy, despite contro- Despite substantial research on first-line treatment modalities versy in the literature during the last decade.1_TD]4F$I[ However, based on for mild-to-moderate knee osteoarthritis, there are few alternatives the results of this trial, pulsed electromagnetic fields therapy is that relieve pain and improve function besides drugs and exercise; worth considering for patients with mild-to-moderate symptom- both show, at best, moderate F$ID[T3e]_ ffects.1 Due to the side effects of atic knee osteoarthritis who do not respond to daily physical conventional pain-relieving drugs, physical activity and exercise are activity and personalised exercises. A large randomised, controlled currently the preferred approaches to improving pain and function. trial with a longer follow-up is warranted to confirm the positive Bagnato and colleagues reported reduced pain with pulsed effects of pulsed electromagnetic fields reported in this trial. electromagnetic fields in elderly men and women with symptom- atic knee osteoarthritis. The trial had a low risk of bias and the Provenance: Invited. Not peerD$_2IF][T reviewed. average benefit in pain reduction was probably clinically significant. However, the mechanism behind the effect is not]F$DT[1I_ fully understood_5[;]DF$IT Britt Elin Øiestad it is thought that the treatment gives a beneficial cartilage Institute of Physiotherapy, Oslo and Akershus University College of homeostasis that consequently reduces disease symptoms. Applied Sciences, Norway Despite these promising results, there are several consider- ations that need to be met before this intervention could be Reference recommended for clinical practice. The study had short-term follow-up; therefore, it is unknown if pulsed electromagnetic fields 1. Zhang W, et al. Osteoarthritis Cartilage. 2010;18:476–499. lead to sustained reduction in pain. In addition, the intervention involved using the device for more than 11 hours/day, which raises http://dx.doi.org/10.1016/j.jphys.2016.05.007 issues of feasibility. Current pulsed electromagnetic fields studies have used different intervention protocols, thus, it is hard to 1836-9553/ß 2016 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Journal of Physiotherapy 62 (2016) 168 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Pulsed electromagnetic fields can reduce pain in the short term in patients with knee osteoarthritis Synopsis Summary of: Bagnato GL, Miceli G, Marino N, Sciortino D, Western Ontario and McMaster Universities Osteoarthritis Index, Bagnato GF. Pulsed electromagnetic fields in knee osteoarthritis: subscale pain (WOMAC-pain); and the Medical Outcomes Study a double blind, placebo-controlled, randomized clinical trial. Short-Form 36 version-2 (SF-36) physical and mental component Rheumatology (Oxford) 2016;55:755-762. summary scores (0 to 100). Results: A total of 60 participants (91%) completed the assessment at 1 month. The mean difference was Question: Can daily treatment with pulsed electromagnetic 13.6 units (95% CI 7.9 to 19.3) in VAS-pain and 5.6 units (95% CI fields decrease pain in patients with knee osteoarthritis? Design: 2.9 to 8.4) in WOMAC-pain, both favouring the active pulsed A randomised, double-blind, placebo-controlled clinical trial. electromagnetic fields group. There were minor differences in Setting: One Italian rheumatology outpatient clinic. Participants: favour of the pulsed electromagnetic fields group in the SF-36 People aged over 40 years with a diagnosis of primary osteoar- physical health (mean difference 2.7 units, 95% CI 0.3 to 5.2) and thritis of the knee according to the American College of the SF-36 mental health (mean difference 0.5 units, 95% CI –1.5 to Rheumatology criteria; symptomatic disease for the last 6 months 2.6). Conclusion: In patients with painful knee osteoarthritis, with persistent pain defined as a minimal mean score of 40 mm on pulsed electromagnetic fields decreased pain, but had little impact a Visual Analogue Scale (VAS) despite receiving maximal tolerated on health-related quality of life. doses of conventional medication. Randomisation allocated 33 patients to active treatment and 33 to placebo treatment. Provenance: Invited. Not peer reviewed. Interventions: Participants in the treatment group were given a pulsed electromagnetic fields wearable device, while those in the Ka˚ re Birger Hagena and Margreth Grotleb placebo group received a device with no electromagnetic proper- aNational Advisory Unit on Rehabilitation in Rheumatology, ties. The devices that were used are commercially available and the placebo devices were identical to the active devices, including a Department of Rheumatology, Diakonhjemmet Hospital light-emitting diode light showing operation. The devices were bOslo and Akershus University College of Applied Sciences, Department used 12 hours daily for 1 month. Outcome measures: A blinded assessor administered the outcome measures at 1 month (end of of Physiotherapy, Oslo, Norway treatment): pain measured on a VAS (VAS-pain, 0 to 100); the http://dx.doi.org/10.1016/j.jphys.2016.05.006 Commentary compare and synthesise the evidence. F6DIC$]T_[ linical F7[ID]$pT_ ractice guidelines have not recommended electromagnetic therapy, despite contro- Despite substantial research on first-line treatment modalities versy in the literature during the last decade.1_TD]4F$I[ However, based on for mild-to-moderate knee osteoarthritis, there are few alternatives the results of this trial, pulsed electromagnetic fields therapy is that relieve pain and improve function besides drugs and exercise; worth considering for patients with mild-to-moderate symptom- both show, at best, moderate F$ID[T3e]_ ffects.1 Due to the side effects of atic knee osteoarthritis who do not respond to daily physical conventional pain-relieving drugs, physical activity and exercise are activity and personalised exercises. A large randomised, controlled currently the preferred approaches to improving pain and function. trial with a longer follow-up is warranted to confirm the positive Bagnato and colleagues reported reduced pain with pulsed effects of pulsed electromagnetic fields reported in this trial. electromagnetic fields in elderly men and women with symptom- atic knee osteoarthritis. The trial had a low risk of bias and the Provenance: Invited. Not peerD$_2IF][T reviewed. average benefit in pain reduction was probably clinically significant. However, the mechanism behind the effect is not]F$DT[1I_ fully understood_5[;]DF$IT Britt Elin Øiestad it is thought that the treatment gives a beneficial cartilage Institute of Physiotherapy, Oslo and Akershus University College of homeostasis that consequently reduces disease symptoms. Applied Sciences, Norway Despite these promising results, there are several consider- ations that need to be met before this intervention could be Reference recommended for clinical practice. The study had short-term follow-up; therefore, it is unknown if pulsed electromagnetic fields 1. Zhang W, et al. Osteoarthritis Cartilage. 2010;18:476–499. lead to sustained reduction in pain. In addition, the intervention involved using the device for more than 11 hours/day, which raises http://dx.doi.org/10.1016/j.jphys.2016.05.007 issues of feasibility. Current pulsed electromagnetic fields studies have used different intervention protocols, thus, it is hard to 1836-9553/ß 2016 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Editorial 123 family members with communities that are collectivist in nature. $]DTF[_RI5 eferences Similarly, physiotherapists promoting patient self-management may wish to consider how this is framed for patients who may be 1. Australian Bureau of Statistics. Perspectives on $DTFI]_M[2 igrants. March 2013. www.abs. more fatalistic in their beliefs.24 Finally, discussing the therapeutic gov.au/ausstats/abs@nsf/Latestproducts/3416. options and their implications should be performed with consid- 0Main+Features2Mar+2013. Accessed 20 February 2016. eration of the patient’s role within their ethnocultural community. Importantly, modifications to therapy should be performed on an 2. Department of Immigration and Border Protection. Australia’s Migration Trends 2013- individual basis and only after establishing the relationship 2014. 2014. https://www.border.gov.au/ReportsandPublications/Documents/ between a patient’s ethnocultural group membership and their statistics/migration-trends13-14.pdf. Accessed 20 Feburary 2016. illness presentation. Approaching culturally adapted treatments in this manner will ensure that physiotherapists avoid stereotyping 3. Institute for Community Ethnicity and Policy Alternatives (ICEPA) VictoriaD$FT_2I][ Univer- patients based on assumed ethnocultural identity. sity. Cultural responsivenessTDI$2[_F] framework]2DFT_3I[$ - Guidelines for Victorian healthD$T_2]IF[ services. Melbourne, Australia: Department of Health, Victoria; 2009. In conclusion, the capacity of physiotherapy to meet the needs of multicultural Australia is dependent on the profession’s capacity 4. National Health Medical Research Council. Cultural competency in health:A guide for to implement culturally responsive practices. Recognition of this policy, partnerships and participation. Canberra: NHMRC; 2005. emerging need should extend beyond competency statements and professional standards, and include all levels of physiotherapy 5. Physiotherapy Board of Australia, Physiotherapy Board of New2_TD$]F[I Zealand. Physio- practice. Entry-level programs may require redesign to ensure that therapy practice thresholds in Australia and Aotearoa New Zealand, 2015. Melbourne: students develop the necessary skills for practice in multicultural Physiotherapy Board of Australia; 2015. societies. Professional development activities should address the delivery of physiotherapy assessments and treatments within a 6. Australian Physiotherapy Council. Australian Standards forD]IT_2[$F Physiotherapy. Canberra, multicultural society, thereby equipping therapists with the skills Australia: Australian Physiotherapy Council; 2006. to deliver culturally responsive healthcare. Such approaches require support and engagement from all levels of the profession, 7. Helman C. Culture Health and Illness: An Introduction for Health Professionals. 2nd ed. from the student physiotherapist to senior members. Finally, Burlington: Elsevier Science; 2014. greater recognition of culturally responsive practice should be reflected in research priorities of the profession that promote and 8. Campbell CM, et al. Pain Manag. 2012;2:219–230. support research inclusive of culturally and linguistically diverse 9. Callister L, et al. Pain Manag Nurs. 2003;4:145–154. communities. 10. Kraemer T. J Phys Ther Educ. 2001;15:36. 11. Chipchase L. Connect Physiotherapy Conference 2015; 2015; Gold Coast, Australia. Ethics approval: N/A Competing interests: Nil. http://www.physiotherapy.asn.au/DocumentsFolder/CONFERENCE2015/ Source(s) of support: Nil. Program/Educators%20Final%205.pdf Acknowledgements: Nil. 12. Brady B, et al. Physotherapy Buisness, Education and Leadership Symposium: New Correspondence: Bernadette Brady, 6_]D[T$DIF epartments of Pain Frontiers; 1/11/2014, 2014; Cairns, Australia. http://www.physiotherapy.asn.au/ Medicine and Physiotherapy, Liverpool Hospital4[_TD,]FI$ Australia. Email: DocumentsFolder/CONFERENCE%202014/Program%20PDFs/ [email protected] Symposium%202014%20Program%20-%20web%20version%2018.9.2014.pdf 13. Redpath AA, et al. J Physiother. 2015;61:210–216. 14. Lee TS, et al. Physiotherapy. 2006;92:166–170. 15. Jaggi A, et al. Physiotherapy. 1995;81:330–337. 16. Lee TS, et al. Aust J Physiother. 2005;51:161–165. 17. Kale E, et al. Patient Educ Couns. 2010;81:187–191. 18. Brady B, et al. Pain. 2016;157:321–328. 19. Khoo S-E. J Pop Research. 2012;29:119–140. 20. Johnstone M-J, et al. Diversity in Health & Social Care. 2008;5:19–30. 21. Engel GL. Am J Psychiatry. 1980;137:535–544. 22. Synnott A, et al. J Physiother. 2015;61:68–76. 23. Flores G. Med Care Res Rev. 2005;62:255–299. 24. Black JD, et al. J Phys Ther Educ. 2002;16:3–10. 25. Greenwald AG, et al. J Pers Soc Psychol. 1998;74:1464–1480. 26. Kleinman A. The illness narratives: suffering, healing, and the human condition. New York: Basic Books; 1988. http://dx.doi.org/10.1016/j.jphys.2016.05.010 Readers’ Choice Award for 2015 The Editorial Board is pleased to announce the annual Readers’ Choice Award, which recognises the paper published in Journal of Physiotherapy that generates the most interest by readers of the journal. The winning paper is chosen based on the number of times that each paper published in a given year is downloaded in the six months after its day of publication. The winning paper from among those published in 2015 is ‘Physiotherapy management of lateral epicondylalgia’ by Dr Leanne Bisset from Griffith University and Professor Bill Vicenzino from University of Queensland and the NHMRC Centre for Research Excellence Spinal Pain, Injury and Health.1 The winning paper is one of the journal’s new Invited Topical Reviews. It deftly summarises the results of an enormous amount of research into the prevalence, diagnosis, assessment, prognosis and management of tennis elbow. The physiotherapy interventions considered by the paper include: exercise; manual therapy and manipulation; orthotics and taping; acupuncture and dry needling; various forms of electrotherapy; and multimodal programs. A clear and concise section on evidence-informed clinical reasoning helps to guide clinicians in how to apply the summarised research to individual patients. The only other Invited Topical Review2 published in the same year was also ranked within the top five, indicating the popularity of this relatively new category of paper in the journal. The Editorial Board of Journal of Physiotherapy congratulates Dr Bisset and Professor Vicenzino on their success. References 1. Bisset LM, Vicenzino B. Physiotherapy management of lateral epicondylalgia. J Physiother. 2015;61:174–181. 2. Sherrington C, Tiedemann A. Physiotherapy in the prevention of falls in older people. J Physiother. 2015;61:54–60. http://dx.doi.org/10.1016/j.jphys.2016.06.001

Journal of Physiotherapy 62 (2016) 138–144 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Research Respiratory muscle training increases respiratory muscle strength and reduces respiratory complications after stroke: a systematic review Keˆnia KP Menezes a]F$_TD8[I, Lucas R Nascimento a, Louise Ada b, Janaine C Polese a, Patrick R Avelino a, Luci F Teixeira-Salmela a a NeuroGroup, Discipline of Physiotherapy, Universidade Federal de Minas Gerais, Brazil; b Discipline of Physiotherapy, The University of Sydney, Sydney, Australia KEY WORDS ABSTRACT Stroke Question: After stroke, does respiratory muscle training increase respiratory muscle strength and/or Systematic review endurance? Are any benefits carried over to activity and/or participation? Does it reduce respiratory Respiratory muscle training complications? Design: Systematic review of randomised or quasi-randomised trials. Participants: Strength Adults with respiratory muscle weakness following stroke. Intervention: Respiratory muscle training Physical therapy aimed at increasing inspiratory and/or expiratory muscle strength. Outcome measures: Five outcomes were of interest: respiratory muscle strength, respiratory muscle endurance, activity, participation and respiratory complications. Results: Five trials involving 263 participants were included. The mean PEDro score was 6.4 (range 3 to 8), showing moderate methodological quality. Random-effects meta-analyses showed that respiratory muscle training increased maximal inspiratory pressure by 7 cmH2O (95% CI 1 to 14) and maximal expiratory pressure by 13 cmH2O (95% CI 1 to 25); it also decreased the risk of respiratory complications (RR 0.38, 95% CI 0.15 to 0.96) compared with no/sham respiratory intervention. Whether these effects carry over to activity and participation remains uncertain. Conclusion: This systematic review provided evidence that respiratory muscle training is effective after stroke. Meta- analyses based on five trials indicated that 30 minutes of respiratory muscle training, five times per week, for 5 weeks can be expected to increase respiratory muscle strength in very weak individuals after stroke. In addition, respiratory muscle training is expected to reduce the risk of respiratory complications after stroke. Further studies are warranted to investigate whether the benefits are carried over to activity and participation. Registration: PROSPERO (CRD42015020683). [Menezes KKP, Nascimento LR, Ada L, Polese JC, Avelino PR, Teixeira-Salmela LF (2016) Respiratory muscle training increases respiratory muscle strength and reduces respiratory complications after stroke: a systematic review. Journal of Physiotherapy 62: 138–144] ß 2016 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Introduction leading cause of non-vascular death after stroke.12 Thus, imple- menting interventions with the potential to prevent morbidity and Stroke is the second leading global cause of death and the leading mortality in people with stroke is vindicated.13 cause of disability.1TF_]DI$[1 After stroke, the loss of ability to generate normal amounts of force is a major contributor to activity One approach that has the potential to increase respiratory limitations and participation restrictions.2–4 Previous studies have muscle strength and reduce respiratory complications after stroke demonstrated that weakness after stroke affects not only the is respiratory muscle training. In this type of training, patients are muscles of the upper and lower limbs, but also those of the asked to perform repetitive breathing exercises against an external respiratory system.5,6 Patients typically demonstrate reduced load, using a flow-dependent resistance or a pressure thresh- maximal voluntary strength and decreased endurance of the old.14,15 Respiratory muscle training is based on the premise that inspiratory and expiratory muscles, as well as altered chest wall respiratory muscles respond to training stimuli by undergoing kinematics.7–9 Studies have reported mean values of maximal adaptations to their structure in the same manner as any other inspiratory DFTI_$p4[] ressure ranging from 17 to 57 cmH2O in people after skeletal muscles, when their fibres are overloaded. Respiratory stroke, compared with 13aD[T_FI$] pproximately 100 cmH2O in healthy adults, muscles can be overloaded by requiring them to work for longer, at and mean values of$DIT[]F21_ maximal expiratory [4F$]pD_TI ressure ranging from 25 to higher intensities, and/or more frequently than their typical 68 cmH2O, compared with FD$I]T_3a1[ pproximately 120 cmH2O in healthy workload.16,17 Also, because respiratory muscle training not only adults.7,9,10FD][$T_21I That is, respiratory muscle strength in people after imposes a resistance to the respiratory muscles, but also consists of stroke is less than half of that expected in healthy adults. In addition, hyperventilating for prolonged periods of time, it may have an decreased respiratory function is associated with deconditioning, additional effect on respiratory muscle endurance,16,17 which activity limitations, and respiratory complications,11 which are a could translate into a more efficient use of the respiratory muscles in activities of daily living. http://dx.doi.org/10.1016/j.jphys.2016.05.014 1836-9553/ß 2016 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Research 139 Two systematic reviews have examined the effect of inspiratory Box 1. Inclusion criteria. muscle strength training regimens on respiratory muscle strength after stroke, based on randomised, controlled trials. A Cochrane Design review15 included two randomised trials (representing three  randomised or quasi-randomised trials comparisons), but did not perform a meta-analysis. When Participants inspiratory muscle training was compared with no intervention,  adults (> 18 years old) the effect on maximal inspiratory pressure was 3 cmH2O (95% CI –2  diagnosis of stroke to 9); when compared with sham intervention, the effect was  respiratory muscle weakness (ie, < 90% normal maximal 46 cmH2O (95% CI 28 to 63); and when compared with other types of respiratory training, the effect was 0 cmH2O (95% CI –6 to 6). inspiratory or expiratory pressures) When these results of strength training were entered into a meta- Intervention analysis in a recent review,5 the pooled effect on maximal  respiratory TD[]F$Im_9 uscle training aimed at increasing strength inspiratory pressure was 7 cmH2O (95% CI 2 to 12), but with substantial statistical heterogeneity (I2 = 95%). of the inspiratory and/or expiratory muscles Outcome measure An updated review of the current evidence is warranted  inspiratory and/or expiratory muscle strength because these reviews5,15 included only two trials and did not Comparisons examine the effects on respiratory endurance, the carryover effects  respiratory TmDF9$][_I uscle training versus nothing/D_I0sF]T$[1 ham to activity or participation, nor the incidence of respiratory complications. respiratory intervention Therefore, the research questions for this systematic review Participants were: To be eligible for inclusion, trials had to involve adult 1. Does respiratory muscle training (inspiratory and/or expiratory) participants with respiratory muscle weakness following stroke. increase respiratory muscle strength and/or endurance after Participants were considered weak when the strength of their stroke? respiratory muscles, reported as maximal inspiratory or expiratory pressure, was < 90% of that predicted for age-matched and gender- 2. Are the benefits carried over to activity and/or participation? matched healthy subjects.7,18,19T$FD4]_1[I To describe each included trial, the 3. Does respiratory muscle training reduce the occurrence of number of participants and their gender, age, time since stroke, and magnitude of respiratory muscle weakness were recorded. respiratory complications? Interventions In order to make recommendations based on the highest level of The experimental intervention was respiratory muscle training evidence, this review included only randomised or quasi- randomised trials. that produced repetitive contractions of the respiratory muscles against resistance in order to increase strength. The control Method intervention could be nothing or a [T1_D$I0F]sham intervention (ie, the intervention was not delivered with enough specificity (non- Identification and selection of trials respiratory training) or dose (low-dose training) to have an effect). Searches were conducted in the CINAHL (1986 to April 2015), Outcome measures EMBASE (1980 to April 2015), LILACS (1986 to April 2015), Five outcomes were of interest: respiratory muscle strength MEDLINE (1946 to April 2015) and PEDro (to April 2015) databases for relevant studies, without date or language restrictions. The (inspiratory and expiratory), respiratory muscle endurance, activi- search strategy was registered at PubMed/Medline and the authors ty, participation, and occurrence of respiratory complications. received notifications regarding potential papers related to this systematic review. Search terms included words related to stroke, The strength measurement had to be representative of to randomised or quasi-randomised trials, and to respiratory muscle maximum voluntary contractions generated during maximum training (such as inspiratory muscle training, expiratory muscle resistance of inspiration or expiration (eg, maximal voluntary training, breathing exercises and respiratory therapy). See Appendix inspiratory pressure or maximal voluntary expiratory pressure).20 1 on the eAddenda for the full search strategy. Title and abstracts When multiple measures of strength were reported, the measure were displayed and screened by two reviewers (KKPM and PRA) to that reflected the trained muscle(s) was used. If both expiratory identify relevant studies. Full-text copies of peer-reviewed and inspiratory muscles had been trained and measured, the mean relevant papers were retrieved and their reference lists were (SD) of the two measurements were summed so that only data screened to identify further relevant studies. The method section of from independent groups were entered into the meta-analy- the retrieved papers was extracted and independently reviewed by ses.21,22 The endurance measurement had to be representative of two researchers (LRN and JCP) using pre-determined criteria the ability to breathe against increasing inspiratory or expiratory (Box 1). Both reviewers were blinded to authors, journals and loads, or the ability to breathe at a fixed load during a results of the studies. Disagreement or ambiguities were resolved predetermined amount of time (eg, 2-minute incremental load by discussion with a third reviewer (KKPM). method).7,20,23 The activity measurement had to be representative of the ability to execute tasks or actions, and the participation Assessment of characteristics of trials measurement had to be representative of the involvement of the individual in real-life situations.24 Direct measures or self-reported Quality questionnaires were used, regardless of whether they produced The quality of included trials was assessed by extracting continuous or ordinal data. Measures of general activity (eg, Barthel Index) were used if they were the only available measure of PEDro Scale scores from the Physiotherapy Evidence Database activity. Measures of quality of life were used if they were the only (www.pedro.org.au). The PEDro Scale has 11 items, designed for available measure of participation. Occurrence of respiratory rating the methodological quality (internal validity and statistical complications was defined as number of participants with information) of randomised trials. Each item, except for Item 1, diagnosis of respiratory complications (eg, lung infections and contributes one point to the total PEDro score (range 0 to pneumonia) after training commencement. 10 points). Where a trial was not included on the database, two reviewers, who had completed the PEDro scale training tutorial, Data analysis scored it independently. Two reviewers independently extracted information regarding the method (ie, design, participants, intervention, outcome

140 Menezes et al: Respiratory muscle training after stroke measures) and results (ie, number of participants and mean (SD) of groups were combined to create a single comparison, following respiratory outcomes), with checking by a third reviewer. When Cochrane recommendations.25$]0D1TFI[_ One paper9 delivered both inspira- information was not available in the published trials, details were tory and expiratory training to the experimental group. Figure 1 requested from the corresponding author. outlines the flow of papers through the review. Given that respiratory muscle strength was always reported as Characteristics of the included trials cmH2O, the pooled estimate of the mean difference between the groups (95% CI) was determined for both inspiratory and The five trials involved 263 participants and investigated the expiratory muscles. In addition, where possible, change scores effect of respiratory muscle training on inspiratory (n = 4) and rather than post-intervention scores were used to obtain the expiratory muscle strength (n = 3), inspiratory muscle endurance pooled estimate of the effect of the intervention, using a fixed- (n = 1), activity (n = 2), participation (n = 2) and respiratory effect model. In the case of significant statistical heterogeneity complications (n = 2) after stroke (Table 1). Four trials were (I2 > 40%), a random effects model was applied.25 Given that randomised clinical trials.7,9,27,28 In the other trial,29 the rando- respiratory complications were originally reported as number of misation criteria was the internment order, so it was classified as a events (ie, a dichotomous outcome), the relative risk with 95% CI quasi-randomised trial. was calculated. Commercial softwarea was used to perform the meta-analysis.26 The critical value for rejecting the null hypothesis Quality was set at a level of 0.05 (two-tailed). When data were unavailable The mean PEDro score of the included trials was 6.4 (range 3 to to be included in the pooled analyses, between-group results were reported. 8) (Table 2). All trials reported between-group differences as well as point estimate and variability. The majority of trials had: similar Results groups at baseline (80%), < 15% dropouts (80%), randomly allocated participants (80%), concealed allocation (80%), and Flow of trials through the review reported blinding of assessors (80%). However, only two trials reported an intention-to-treat analysis. No trials blinded partici- The electronic search strategy identified 3522 papers, but pants or therapists, which is difficult or impossible during this type 327 were duplicates. After screening titles, abstracts and reference of intervention. lists, 27 potentially relevant full papers were retrieved. Twenty- two papers failed to meet the inclusion criteria (see Appendix 2 on Participants the eAddenda for a summary of the excluded papers) and five The mean age of participants ranged from 54 to 66 years across papers were included in this systematic review. Four papers7,9,27,28 were included in the inspiratory training analysis and three trials. The mean time after stroke ranged from 9 days to 66 months. papers9,26,29 were included in the expiratory training analysis. For The majority of trials (80%) comprised participants in the sub- the outcome ‘respiratory complications’, one paper27 reported a acute phase of stroke (ie, < 6 months after stroke) on admission to trial with three arms of interest: inspiratory muscle training, the trial. The mean baseline strength of the inspiratory muscles expiratory muscle training and sham training. The experimental ranged from 41 to 57 cmH2O, whereas the mean baseline strength of the expiratory muscles ranged from 50 to 63 cmH2O. Table 1 Characteristics of included trials (n = 5). Study Design Participants Intervention Outcome measures Frequency and duration Parameters Britto RCT n = 18 Exp = IMT, Muscles = inspiratory Strength = MIP (cmH2O) Endurance = IME (cmH2O) et al[D$F].7TI_ (2011)7_T2ID$F][ Age (yr) = 54 (SD 11) 30 min x 5/wk x 8 wk Resistance = 30% of MIP Activity = Human Activity Profile (0 to 94) Time since stroke Con = sham, Device = threshold (mth)  9 30 min x 5/wk x 8 wk Progression = resistance adjusted to Participation = Nottingham MIP = 57 cmH2O 30% of maximal strength every 2 weeks Health Profile (score 0 to 38) MEP = NR Timing = 0, 8 wk Fernandes QRCT n = 36 Exp = EMT, Muscles = expiratory Strength = MEP (cmH2O) et al.]FID[7_T$ (2007)29 Age (yr) = 54 50 reps x 5/wk x 1 wk Resistance = 40% of MEP Timing = 0, 1 wk Time since stroke Con = nothing Device = threshold (mth)  3 Progression = not stated MIP = 42 cmH2O MEP = 50 cmH2O Kulnik RCT n = 78 Exp 1 = IMT, Muscles = inspiratory and expiratory Strength = MIP, MEP (cmH2O) et al. (2015)27D$]T_7[IF Age (yr) = 64 (SD 15) 50 reps x 7/wk x 4 wk Resistance = 50% of MIP and MEP Respiratory complications = pneumonia Time since stroke Exp 2 = EMT, Device = threshold incidencea (mth)  0.5 50 reps x 7/wk x 4 wk Progression = resistance adjusted to MIP = 42 cmH2O Con = sham, 50% of maximal strength every week Timing = 0, 4, 13 wk MEP = 61 cmH2O 50 reps x 7/wk x 4 wk Messaggi-Sartor RCT n = 101 Exp = IMT + EMT, Muscles = inspiratory and expiratory Strength = MIP, MEP (cmH2O) et al. (2015)9]F[ID$T_7 Age (yr) = 66 (SD 11) 100 reps x 5/wk x 3 wk Resistance = 30% of MEP Respiratory complications = lung infection Time since stroke Con = sham, Device = threshold and pulmonary thromboembolisma (mth)  1 100 reps x 5/wk x 3 wk Progression = resistance increased MIP = 41 cmH2O 10 cmH2O every week Timing = 0, 3 wk MEP = 63 cmH2O Sutbeyaz RCT n = 30 Exp = IMT, $DF_TM]1[I uscles = inspiratory Strength = MIP (cmH2O) et al. (2010)28F[ID$T_7] Age (yr) = 62 (SD 7) 30 min x 3/wk x 6 wk Resistance = 40% of MIP Activity = Barthel Index (score 0 to 100) Time since stroke Con = nothing Device = threshold Participation = Medical Outcomes Study (mth) = 5 (SD 1) Progression = resistance increased Short Form 36 (score 0 to 100) MIP = 50 cmH2O 5 to 10% every week until 60% Timing = 0, 6 wk MEP = 61 cmH2O of maximal strength a Outcome measures listed are only those that were analysed in this systematic review. Con = control group, EMT = expiratory muscle training, Exp = experimental group, IME = inspiratory muscle endurance, IMT = inspiratory muscle training, MEP = maximal expiratory pressure, MIP = maximal inspiratory pressure, NR = not reported, QRCT = quasi-randomised controlled trial, RCT = randomised clinical trial, reps = repetitions.

Research 141 Table 2 PEDro criteria and scores for the included papers (n = 5). Study Random Concealed Groups Participant Therapist Assessor < 15% Intention-to-treat Between-group Point Total allocation allocation similar at blinding blinding blinding dropouts analysis difference estimate and (0 to 10) baseline reported variability reported Britto et al7_F[.TD$I] (2011)7 Y Y Y N NYY N Y Y7 N Y Y3 Fernandes et al. (2007)29IT[DF]_$7 N N N N NNY Y Y Y7 Y Y Y8 Kulnik et alT7._I$D[F] (2015)27 Y Y Y N N YN N Y Y7 Messaggi-Sartor Y Y Y N NYY et al. (2015)9F$]DTI_7[ Sutbeyaz et al]DTFI$[_7. (2010)28 Y Y Y N NYY N = no, Y = yes. Intervention These pressures were reported in cmH2O in all trials. Inspiratory In all trials the experimental intervention was respiratory muscle muscle endurance was measured in one trial7 using the 2-minute incremental load method, which was reported in cmH2O. Activity training, which was delivered via threshold devices. The respiratory was measured in two trials7,28 using self-reported questionnaires: muscle training targeted the inspiratory muscles,7,28 expiratory Human Activity Profile (0 to 94 points) in one trial7 and Barthel muscles,29 a combination of inspiratory and expiratory muscles,9 or Index (0 to 100 points) in the other.28 Participation was measured inspiratory and expiratory muscles to separate participants.27 in two trials7,28 using self-reported questionnaires of quality of life: Participants undertook training for 30 minutes (or 50 to 100 repeti- Nottingham Health Profile (0 to 38 points) in one trial7 and Medical tions), three to seven times per week, for 1 to 8 weeks. Outcomes Study Short Form 36 (0 to 100 points) in the other.28 Occurrence of respiratory complications was measured in two In all trials, the control intervention was nothing or sham trials9,27 and reported as number of participants with pneumonia respiratory intervention. Two control groups did not receive any in one trial27 and as number of participants with lung infections or intervention28,29 and three control groups received a sham pulmonary thromboembolism in the other,9 after the commence- intervention.7,9,27 Sham intervention was delivered via a threshold ment of the training. device with a small resistance of 10% of the respiratory muscle strength,27 via a threshold device with a fixed workload of Effect of respiratory muscle training 10 cmH2O,9 and via a threshold device without the resistance valve.7 In three trials, usual therapy was delivered to both Inspiratory muscle strength experimental and control groups.9,27,28 The effect of inspiratory muscle training on inspiratory muscle Outcome measures strength was examined by pooling data from four trials Respiratory muscle strength was measured as maximum (n = 176 participants) with a mean PEDro score of 7.3, representing moderate quality. When a random effects model was applied, [(Figure_)TD$IG]p1 ressure generated during inspiration7,9,27,28 or expiration.9,27,29 inspiratory muscle training increased maximal inspiratory pres- sure by 7 cmH2O (95% CI 1 to 14, I2 = 33%), compared with no/sham intervention (Figure 2, see Figure 3 on the eAddenda for the detailed forest plot). Expiratory muscle strength The effect of expiratory muscle training on expiratory muscle strength was examined by pooling data from three trials (n = 165 participants) with a mean PEDro score of 6.0, representing moderate quality. When a random effects model was applied, expiratory muscle training increased maximal expiratory pressure by 13 cmH2O (95% CI 1 to 25, I2 = 12%), compared with no/sham respiratory intervention (Figure 4, see Figure 5 on the eAddenda for the detailed forest plot). Inspiratory muscle endurance One trial, with a PEDro score of 7, examined the effect of iguFre(_2)TD$IG][inspiratory muscle training on inspiratory muscle endurance after Study MD (95% CI) Britto7 Random Kulnik27 Messaggi-Sartor9 Sutbeyaz28 Pooled –40 –20 0 20 40 Favours con (cmH2O) Favours exp Figure 1. Flow of studies through the review. Figure 2. Mean difference (95% CI) of effect of inspiratory muscle training versus no/ aPapers may have been excluded for failing to meet more than one inclusion sham respiratory intervention on maximal DI$T3F][_inspiratory _p4ITFD$[] ressure, in cmH2O (n = 176). criterion.

]GI[F(ig$uDTr)e4_142 Menezes et al: Respiratory muscle training after stroke Study MD (95% CI) respiratory complications after stroke. However, the evidence Fernandez29 Random about whether the benefits are carried over to activity and Kulnik27 participation remains unclear. Messaggi-Sartor9 Pooled This review set out to answer three questions. The first examined whether respiratory muscle training increases respiratory –40 –20 0 20 40 muscle strength and/or endurance after stroke. The meta-analyses Favours con (cmH2O) Favours exp showed that the implementation of respiratory muscle training had a small positive effect on inspiratory and expiratory muscle Figure 4. Mean difference (95% CI) of effect of expiratory muscle training versus no/ strength. The pooled effect indicated that inspiratory muscle training resulted in 7 cmH2O greater maximal inspiratory pressure, ]GIF$DT6_erugi([)sham respiratory intervention on _[5T]$DIFmaximal I[_DF]6e$T xpiratory I$T_D4[pF] ressure, in cmH2O (n = 165). compared with no/sham inspiratory intervention. Although the dataset doubled in size, this estimate remained remarkably similar Study RR (95% CI) to that reported in a previous systematic review (MD 7 cmH2O, 95% Kulnik27 Random CI 3 to 11).5 The pooled data indicated that expiratory muscle Messaggi-Sartor9 training resulted in 13 cmH2O greater maximal expiratory Pooled pressure, compared with no/sham expiratory intervention. 0.01 0.1 1 10 100 This is the first systematic review to include only randomised or quasi-randomised clinical trials and to examine the effects of Favours exp Favours con respiratory muscle training on the expiratory muscles. A previous systematic review,30 which included uncontrolled clinical trials, Figure 6. Relative risk (95% CI) of respiratory complications after respiratory muscle did not demonstrate an improvement of expiratory strength after training versus no/sham respiratory intervention (n = 179). respiratory muscle training (MD –1 cmH2O, 95% CI –2 to 1). Therefore, the present review strengthens the evidence regarding stroke.7 Inspiratory muscle endurance was measured by using the the efficacy of respiratory muscle training for increasing respira- 2-minute incremental load method7 and reported as maximal load tory muscle strength, because the conclusion was based on in cmH2O sustained for at least 1 minute. The authors reported a meta-analyses of randomised and quasi-randomised trials with significant between-group difference of 15 cmH2O (95% CI 2 to 27) reasonable quality (mean PEDro Score of 6.7 out of 10). in favour of the experimental intervention. The significant but small increase in strength found in the Activity present review has important clinical implications. According to The effect of respiratory muscle training on activity was the 2002 American Thoracic Society/European Respiratory Society statement on respiratory muscle testing,31 a maximal inspiratory examined by two trials7,28 with a mean PEDro score of 7. Although pressure of 80 cmH2O is required to exclude clinically important both trials measured activity using a self-reported questionnaire, a inspiratory muscle weakness. In trials examining the effect of meta-analysis was not possible because only one trial7 reported respiratory muscle training in patients with neuromuscular or post-intervention data, with no significant difference in the pulmonary obstructive disease, a threshold of 60 cmH2O has been Human Activity Profile scores between the groups (MD 1, 95% used to differentiate weak and healthy participants.32,33 Since the CI –4 to 6). The other trial28 reported that Barthel Index scores average maximal inspiratory pressure of the participants in the improved significantly more in the experimental group than the present review was 46 cmH2O (SD 7), these participants could be control group, but did not report numerical data. considered very weak. In this context, an increase of 7 cmH2O represents a 16% increase, which is sufficient to be considered Participation clinically meaningful. Although there are no reference values that The effect of respiratory muscle training on participation was indicate how much expiratory strength is necessary to exclude clinically important expiratory muscle weakness, an increase of examined by two trials.7,28 Although both trials measured 13 cmH2O in participants with an average maximal expiratory participation using a self-reported questionnaire of quality of life, pressure of 58 cmH2O (SD 6) represents a 22% increase, which is a meta-analysis was not possible because only one trial7 reported also sufficient to be considered clinically meaningful. post-intervention data, with no significant difference in the Nottingham Health Profile score between the groups (MD –2, 95% After stroke, strength may be increased even more if training is CI –5 to 2). The other trial28 reported that the domains of physical of sufficient duration and intensity. Most of the adaptations in role, general health, and vitality of the Medical Outcomes Study respiratory muscle strength are typically apparent after 6 weeks of Short Form 36 improved significantly more in the experimental strength training;34 the minimal recommended duration is group than the control group, but did not report numerical data. 8 weeks.35 Only one trial has investigated 8 weeks of strengthening7 and the result was considerably higher (MD 23 cmH2O, 95% CI 1 to Respiratory complications 46), compared with the pooled effects found in the present review. The effect of respiratory muscle training on respiratory In addition, the exact amount of improvement in respiratory complications was examined by pooling the data from two muscle strength may not be important if the primary physiological trials9,27 (n = 179 participants) with a mean PEDro score of 7.5, mechanism by which the training improves clinical outcomes is via representing good quality. The likelihood of respiratory complica- improved respiratory muscle endurance.14 Only one included trial tions was significantly lower after respiratory muscle training (RR examined the effect of inspiratory muscle training on muscle 0.38, 95% CI 0.15 to 0.96, I2 = 0%), compared with no/sham endurance after stroke. The results were significantly higher in respiratory intervention (Figure 6, see Figure 7 on the eAddenda for favour of the experimental group (MD 15 cmH2O). A mechanism the detailed forest plot). involving endurance would be consistent with all the training regimens used, but more clinical trials investigating the effect of Discussion respiratory muscle training to increase endurance after stroke are necessary. This systematic review found that respiratory muscle training can increase respiratory muscle strength and decrease the risk of The second question examined whether the benefits of the respiratory muscle training are carried over to activity and participa- tion. There were insufficient data to determine whether the benefits of respiratory strength are carried over to activity or participation after stroke. Only two trials investigating this question were included and meta-analyses could not be performed. Therefore,

Research 143 further trials should measure the effects of respiratory muscle based on five trials indicated that 30 minutes of respiratory muscle training on activity and participation. If benefits are carried over to training, five times per week, for 5 weeks can be expected to increase an activity, such as walking capacity, the findings may have broader respiratory muscle strength in very weak individuals after stroke. In implications. For example, walking capacity has been shown to addition, respiratory muscle training is expected to reduce the risk predict physical activity levels and community participation after of respiratory complications (eg, pneumonia and lung infections) stroke.36,37 after stroke. Further studies are warranted to investigate whether the benefits of respiratory muscle training are carried over to The third question examined whether respiratory muscle activity and participation. training reduces the occurrence of respiratory complications after stroke. The meta-analysis showed that respiratory muscle training What is already known on this topic: Respiratory muscle reduced the relative risk of respiratory complications immediately weakness is common after stroke and is associated with and 6 months after the commencement of the intervention. A activity limitation and respiratory complications. retrospective observational cohort study indicated that pneumo- What this study adds: Respiratory muscle training increases nia and respiratory illness are the most common reasons inspiratory and expiratory muscle strength and reduces the risk associated with hospital readmissions after stroke, accounting of respiratory complications. It remains uncertain whether the for 15% of the readmissions.38 Pneumonia is described as the benefits carry over to benefits in activity and participation. leading cause of non-vascular death in acute12 and chronic39 phases after stroke. The adoption of interventions capable of Footnotes: a5TDF[$I_]1 Comprehensive Meta-Analysis program Version preventing the occurrence of respiratory complications may 3.0, Biostat, Englewood, USA. substantially improve the long-term outcomes of patients with stroke.40 However, although respiratory muscle training reduced eAddenda: Figures 3, 5 and 1_$D7[]IFT7, and Appendices 1 and 2 can be the occurrence of respiratory complications after stroke in the found online at doi:10.1016/j.jphys.2016.05.014. present review, the results were based on two trials with small-to- medium sample sizes.9,27 Furthermore, the procedures for detect- Competing interests: Nil ing and excluding lung infection and pneumonia reported by the Acknowledgements: Brazilian Government Funding Agencies trials were not sufficiently robust. First, in both studies, (CAPES, CNPq, and FAPEMIG) for the financial support. occurrences of lung infection or pneumonia between the end of Provenance: Not invited. Peer reviewed. the intervention period and the final follow-up were captured Correspondence: Keˆnia KP Menezes, Department of Physio- retrospectively with some loss to follow-up. Robust assessment therapy, Universidade Federal de Minas Gerais, Brazil. Email: methods would include prospective data collection in shorter [email protected] intervals, an independent review of each diagnosis by a blinded assessor, and possibly stratification into ‘definite’ and ‘suspected’ References pneumonia. Second, any definitive study of outcome lung infection and pneumonia after stroke will need to apply a statistical model 1. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart that adjusts for potential confounders, since it is well established disease and stroke statistics–2015 update: a report from the American Heart that there are several independent risk factors for post-stroke Association. Circulation. 2015; 27;131:e29–322. pneumonia.41,42 Therefore, the conclusions regarding the effect of the respiratory muscle training to reduce the occurrence of 2. Canning CG, Ada L, Adams R, O’Dwyer NJ. Loss of strength contributes more to respiratory complications should be interpreted with caution, and physical disability after stroke than loss of dexterity. Clin Rehabil. 2004;18:300– further studies with better methodological quality are warranted. 308. This review had both strengths and limitations. Given that a 3. Faria-Fortini I, Michaelsen SM, Cassiano JG, Teixeira-Salmela LF. Upper extremity score of 8 was likely to be the maximum achievable PEDro score, function in stroke subjects: relationships between the international classification because it was usually impossible to blind therapists or of functioning, disability, and health domains. J Hand Ther. 2011;24:257–264. participants, the mean PEDro score of 6.4 for the included trials represented moderate quality, suggesting that the findings were 4. Robinson CA, Shumway-Cook A, Matsuda PN, Ciol MA. Understanding physical credible. Another source of bias was lack of reporting whether an factors associated with participation in community ambulation following stroke. intention-to-treat analysis was undertaken. Additionally, the Disabil Rehabil. 2007;33:1033–1042. number of participants per group (mean 22, range 9 to 39) was quite low, opening the results to small-trial bias. On the other 5. Pollock RD, Rafferty GF, Moxham J, Kalra L. Respiratory muscle strength and hand, heterogeneity among the trials pooled in the meta-analysis, training in stroke and neurology: a systematic review. Int J Stroke. 2013;8:124–130. based on a random-effects model, was low. Overall, the included trials were similar regarding their clinical characteristics. Most of 6. Teixeira-Salmela LF, Parreira VF, Britto RR, Brant TC, Ina´ cio EP, Alcaˆntara TO, et al. the trials included participants in the sub-acute phase of Respiratory pressures and thoracoabdominal motion in community-dwelling rehabilitation (four out of five trials), with a mean baseline chronic stroke survivors. Arch Phys Med Rehabil. 2005;86:1974–1978. inspiratory muscle strength of 46 cmH2O (SD 7) and expiratory muscle strength of 59 cmH2O (SD 6), suggesting that most of the 7. Britto RR, Rezende NR, Marinho KC, Torres JL, Parreira VF, Teixeira-Salmela LF. participants could be classified as weak. Although the program Inspiratory muscular training in chronic stroke survivors: a randomized controlled duration varied between trials (mean 4.4 weeks, SD 2.7, range 1 to trial. Arch Phys Med Rehabil. 2011;92:184–190. 8 weeks), the trials had similar session durations (mean 30 minutes, or 50 to 100 repetitions) and session frequencies 8. Lima INDF, Fregonezi GAF, Melo R, Cabral EEA, Aliverti A, Campos TF, et al. Acute (mean 5.0 per week, SD 1.4, range 3 to 7). Another strength of the effects of volume-oriented incentive spirometry on chest wall volumes in patients present review, which is unusual in rehabilitation studies, was that after a stroke. Respir Care. 2014;59:1101–1107. the outcome measures were the same, with respiratory muscle strength always measured via maximal pressures and reported in 9. Messaggi-Sartor M, Guillen-Sola A, Depolo M, Duarte E, Rodrı´guez DA, Barrera MC, cmH2O. Finally, publication bias inherent to systematic reviews et al. Inspiratory and expiratory muscle training in subacute stroke: A randomized was avoided by including studies published in languages other clinical trial. Neurology. 2015;85:564–572. than English.29 10. Queiroz AG, da Silva DD, Amorim R, Lira C, Bassini SR, Uematsu ED. 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Journal of Physiotherapy 62 (2016) 170 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Clinimetrics The Canadian C-Spine Rule Summary Description: The Canadian C-Spine Rule was designed in C-Spine Rule has good-to-excellent inter-rater reliability when 2001 to assist clinicians assess the need for imaging in people who present to the emergency department with a cervical spine applied by physicians (kappa = 0.63), nurses (kappa = 0.80) and injury following blunt trauma. Specifically, this clinical decision paramedics (kappa = 0.93).2,3 The sensitivity of the Canadian rule was developed for use in adults who are alert (score of 15 on the Glasgow Coma Scale), stable and in whom a clinically C-Spine Rule has been reported to range from 90 to 100%, important cervical spine injury is a concern (eg, unstable whereas specificity has ranged from 1 to 77%.4 The large range in fracture, dislocation).1 Instructions and scoring: The Canadian C-Spine Rule is based on three high-risk criteria (age  65 years, specificity reflects the heterogeneity between studies in the dangerous injury mechanism, paresthesia in extremities), five number of people who unnecessarily receive imaging (ie, people low-risk criteria (simple rear-end motor vehicle collision, sitting position in the emergency department, ambulatory at any time, who do not have a serious cervical spine injury but are still delayed onset of neck pain; absence of midline cervical-spine referred for imaging). However, the rule itself errs on the side of tenderness), and the ability of the person to rotate their neck.2 Reliability, validity and sensitivity to change: The Canadian caution, as clinicians will not miss a clinically important cervical spine injury. In the only direct comparison, the Canadian C-Spine Rule was found to have better diagnostic accuracy than the National Emergency X-Radiography Utilization Study (NEXUS) criteria,5 which form another widely used clinical decision rule.4 Commentary this population.11 The Canadian C-Spine Rule identifies age as a high risk factor and mandates imaging in those  65 years, Approximately 2% of people who present to the emergency regardless of what other criteria are met. This would suggest that department will be diagnosed with a clinically important cervical there is an excessive use of imaging in this population and an spine injury following blunt trauma (eg, a fall or motor vehicle additional stepwise decision rule may be beneficial. There is also accident).6–8 Despite the low prevalence, a delayed or missed the need to evaluate the performance of the rule when applied by diagnosis can lead to severe and catastrophic consequences, other health professionals (eg, physiotherapists who assess acute including spinal cord injury and death.9 injuries on the sporting field and in practice). Lastly, to further reduce the rates of imaging and contain costs, there is a need to The Canadian C-Spine Rule is the most rigorously evaluated improve the degree to which the rule is implemented worldwide. clinical decision rule, to date, with which to assess the need for cervical spine imaging in adults who present with cervical spine Provenance: Invited. Not peer reviewed injury following blunt trauma. As such, the Canadian C-Spine Rule is recommended in many international guidelines for routine use Bruno Tirotti Saragiottoa and Zoe A Michaleffa,b in emergency departments because it is highly reliable, valid and aThe George Institute for Global Health, Sydney Medical School, sensitive. The high sensitivity means that clinicians who use the rule in its entirety can be confident that they will not miss a University of Sydney, Sydney, Australia clinically important cervical spine injury. Application of the bArthritis Research UK Primary Care Centre, Research Institute for Canadian C-Spine Rule has been found to reduce the rate of cervical spine imaging by approximately 14%, as it reserves these Primary Care and Health Sciences, Keele University, Keele, investigations for those patients with a higher likelihood of a United Kingdom clinically important cervical spine injury.10 FD]R[IT_$6 eferences The low specificity of the Canadian C-Spine Rule is a reflection of the high false positive rate and means that up to 56% of patients will 1. Stiell IG, et al. JAMA. TD_$7[2IF] 001;286:1841–1848. unnecessarily receive imaging. The Canadian C-Spine Rule therefore 2. Stiell IG, et al. N Engl J Med. DF2T]$I_8[ 003;349:2510–2518. mirrors the aims of the clinician (ie, to not miss a clinically important 3. Stiell IG, et al. CMAJ. 9D$IT[]F_2010;182:1173–1179. cervical spine injury) by recommending imaging in more cases than 4. Michaleff ZA, et al. CMAJ. 2012;184:E867–E876. the actual probability of a person having a serious cervical spine 5. Hoffman JR, et al. Ann Emerg Med. FI$DT_[110] 998;32:461–469. injury. Even with a high false positive rate, the Canadian C-Spine F_1$TDI]6[ . Hasler RM, et al. J Trauma Acute Care Surg. F2[1]0_TDI$ 012;72:975–981. Rule reduces the rate of imaging when compared to routine or 7. Milby AH, et al. Neurosurg Focus. ]F2I$[12_DT 008;25:E10. unstructured physician assessment. 8. Niska R, et al. Natl Health Stat Report. D[IF2T_$]8 010;1–31. 9. Stiell IG, et al. CMAJ. ]F1I[9_TD$ 997;156:1537–1544. There are a number of avenues for further work. Currently, 10. Stiell IG, et al. BMJ. 2009;339:b4146. there is limited evidence as to the diagnostic accuracy of the 11. Ehrlich PF, et al. J Pediatr Surg. 1[D_TIF]2$2 009;44:987–991. Canadian C-Spine Rule when applied to children, with available studies suggesting that the performance of the rule is reduced in http://dx.doi.org/10.1016/j.jphys.2016.04.001 1836-9553/ß 2016 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).