Thesis Abstract and Dissertation Abstracts
Therapeutic Evidence Of Physical Therapy In The Management Of Non-cystic Bronchiectasis: An Update Of Systematic Reviews Of Randomised Controlled Trials
Abstract Category: Science
Course / Degree: Physiotherapy/Master of science
Institution / University: Anglia Ruskin University, United Kingdom
Published in: 2012
The purpose was to update two original systematic reviews, to determine the effect of physical interventions: pulmonary rehabilitation (PR) / intermittent muscle training (IMT) and airway clearance techniques (ACT) on exercise tolerance, sputum weight/volume, dyspnoea and quality of life (QoL) for adults with Bronchiectasis. It also aimed at determining an optimal independent ACT technique. The original review on PR or IMT used 2 abstracts and was updated in 2005 with one research (Bradley, Moran & Greenstone, 2002). While, the review on ACT was performed using articles which mixed participants of chronic obstructive disease (COPD) and bronchiectasis (Jones & Rowe, 2000). A CINAHL, PEDro, AMED, Psych INFO, MEDLINE, EMBASE, and COCHRANE search was done from inception to 2011. Randomised controlled or crossover trials, published in English, with adults diagnosed with stable primary bronchiectasis, comparing PR/IMT of targeted thresholds, but different modes, to sham intervention or placebo were included. Also, articles comparing independent against passive ACTs, and active cycle breathing technique (ACBT) against other independent ACTs were included. 38 of the 8755 articles found met the eligibility criteria, but 18 were duplicates. The updated search revealed 17 additional papers; 8 fulfilled the inclusion criteria: 2 for PR/IMT and 6 for ACT. The results showed improvements in inspiratory muscle strength (Pi max), exercise tolerance (6MWD) and QoL (St George’s respiratory questionnaire, SGRQ) from PR/IMT. ACTs showed improved, but insignificant differences in the volume of sputum expectorated. However, independent ACTs yielded lesser discomfort and higher patient preference. The review had biases of heterogeneity, high dropout rates, insufficient duration, participants, outcome measures and available evidence. Conclusively, the review showed that directed physical intervention is feasible in a home-based setting and effective in the short-term improvement of outcomes in patients with bronchiectasis. Greater effects were observed when interventions were combined or used in patients having Pi max < 60cmH20, with individual preference and self-management as a recurring theme. Nonetheless, the need for robust trials evaluating safety, long-term efficacy, adverse effects, patient preference and cost-effectiveness remains.
Introduction
Bronchiectasis refers to the abnormal, irreversible dilatation of the bronchi caused by damage to the bronchial walls (Barker, 2002). ACTs, PR and IMT constitute the mainstay of physiotherapy management of this condition. The clinical efficacy of these interventions has been validated in similar lung diseases. However, in bronchiectasis, systematic reviews (Jones & Rowe, 2000; Bradley, Moran & Greenstone, 2002) which investigated these effects were either limited by design which mixed the conditions of participants and/or publication resources respectively. Recently, self-administered mechanical devices used as alternatives or adjuncts have been reported to have a greater acceptability, and efficacy, than conventional chest physical therapy (CCPT) in cystic fibrosis patients, but this has not been investigated in patients with bronchiectasis.
Equally, PR has been validated as efficacious in improving the HRQL for patients with COPD, but not bronchiectasis. Whilst a myriad of treatment options potentially exist, explicit scientific treatments for bronchiectasis are unavailable and based on expert opinions or extrapolations made from effective management in COPD and cystic fibrosis not evidenced-based practice (EBP) (Tsang and Bilton, 2009). UK surveys suggest the use of active cycle breathing technique (ACBT) in conjunction with PR in the management of these patients (Bott, et al., 2009). Therefore, this systematic review aimed at updating the available evidence with regards to the efficacy of physiotherapy interventions in clearing bronchial secretions, improving exercise capacity and QoL in patients with bronchiectasis.
Methods
Studies were identified via database searching from inception till 2011, perusing of reference lists of relevant articles, conference materials & airway meetings of abstracts. The following keywords were used: Physiotherapy, Physiotherap*, Physical therap* or training; Exercis*, Exercise rehabilitation or therapy; Pulmonary rehabilitation or Intermittent muscle training; Broncho pulmonary hygiene therapy, Airway* or Tracheobronchial, Chest, Lung*, sputum or “Mucus” clearance; Active cycle breathing techniques or Thoracic* expansion or Positive expiratory pressure (PEP) or Deep breathing technique, combined with bronchiectasis. PEDro was searched using bronchiectasis or kartaganers syndrome. Limitations on publication time lags were not imposed due to the 1800s first literature description of bronchiectasis, ACT and PR.
However, the search process was limited to human, English published literature; screened at title, and/or abstract contents. The eligibility criteria included: 1) randomised or crossover trials on stable primary bronchiectasis; 2) interventions of ACTs: manual (postural drainage, percussion, vibration) and conventional (ACBT, PEP device, flutter, acapella) and targeted threshold of IMT or PR; 3) comparisons of CCPT with independent techniques; ACBT over other independent techniques, or IMT / PR against placebo or sham interventions; 4) Sputum weight/volume, dyspnoea, exercise tolerance, Pi max; pulmonary function and QoL.
Critical review
The methodological quality of individual studies was performed by a sole reviewer, using the Pedro scale (see appendix 1 for attached sample). A total number of 8755 studies were identified from the initial data base search, of which 8686 were excluded at titles unrelated to the clinical question and 31 were excluded at abstracts. Subsequently, a further retrieval and screening of 38 full texts was done of which 18 were repetitions and 10 were excluded that did not attain to the eligibility criteria (see appendix 2 for data).
Narrative Synthesis
PR/IMT versus placebo
Two studies (64 patients) with a mean age range of 50.25-70.45 years compared physical training with no intervention (Liaw, et al., 2011; Newall, et al., 2005). No significant differences were recorded for lung function parameters of V02 peak, SP02, FEV1, FVC or FEV1/FVC and 24-hour sputum volume across both publications. An increase in Pi max, exercise capacity (6MWD) was noted. SGRQ scales were used to assess QoL, with statistical significant differences reported for IMT group and PR+IMT alone.
CCPT versus Independent interventions
2 publications (Paneroni, et al., 2011; Syed, Maiya, and Kumar, 2009) (57 patients, mean age range 45.05-65.15 years) evaluated CCPT over independent ACTs. No significant group differences were noted for FEV1, FVC, wet and dry sputum weights or volume across both studies. VAS scores were used to assess levels of discomfort across both studies. Independent techniques were significantly > CCPT for levels of comfort. Sp02 was constant with improvements in heart rate, sensation of phlegm and dyspnoea which were all clinically insignificant. Adverse but inconsequential effects of dry throat, nausea and / or fatigue were also reported.
ACBT versus other ACTs
4 publications (93 participants) evaluated ACBT with other ACTs (Patterson, et al., 2005; Thompson, et al, 2004; Eaton, et al., 2007; Patterson, Bradley and Elborn, 2004). No significant difference in sputum weight/volume; predicted lung function volumes; Borg scale scores and usefulness was reported between ACBT and flutter or Acapella. ACBT+ Postural drainage was associated with higher levels of discomfort, interference with daily life and time consumption than ACBT or flutter alone. Insignificant differences for acceptability, preference or tolerability was reported across all intervention groups. Although, Thompson, et al. (2004) reported patient preference for flutter > ACBT and insignificant differences for QoL assessed via chronic respiratory disease questionnaire.
Discussion
The review of data showed that IMT and PR are effective in the improvement of Pi max, exercise tolerance and QoL with no effects on pulmonary function variables. The evidence from the studies which evaluated ACTs demonstrated a preference for independent techniques. Also, short-term safety and improvements in the volume of sputum uncorrelated with pulmonary function, irrespective of the mechanism employed was noted. Although, secondary outcomes of respiratory rate, patient preference and comfort levels were higher for independent techniques, the effect of novelty cannot be marginalised.
Implication to practice
The variance in the physical training interventions instituted, suggests the possibility of designing individual components of management to suit the personal needs of patients. Pi max was improved via strength training, suggesting the feasibility of home-based resistive or threshold IMT in this patient cohort. It seems to be more effective however, in patients with Pi max < 60cm H20 or ineffective cough capability. PR can be administered to adults with limited exercise tolerance (Chang, et al., 2008). The adjunctive role of IMT in PR is not clear, although intermediary maintenance effects are possible. Furthermore, the improvement in QoL in intervention groups consisting of IMT may suggest a mediated effect via this intervention. The adverse effects reported suggests the need for prescriptions which allow for adaptive conditioning and modification of exercise interventions during exacerbations (Bradley and Moran, 2006).
This review did not reveal EBP for circumstantial superiority of any ACT over another. ACTs can be recommended early by physiotherapists, with the technique and the frequency of therapy individualised. Independent techniques are effective management stratagems and are feasible for daily, regular use, as determined by patient acceptability and tolerability. Combinations of therapies have been suggested, with a resulting higher volume of expectoration for patients with severe sputum yield. However, as adequate evidence was unavailable, further investigation is warranted (Myers, 2007). The inclination towards the prescription of ACBT in the UK, may per-chance be based on its economic value over other independent techniques, and can be extrapolated to other practice settings across the globe (Patterson, et al., 2007).
Conclusion
The evidence showed an improvement in a number of patient outcomes with bronchiectasis. This may support the inclusion of these management strategies into the care plans of these patient cohorts. IMT / PR improved Pi max, exercise tolerance and QoL. CCPT and independent techniques were equally effective in aiding bronchial clearance, with added benefits were observed when techniques were combined.
In addition, ACBT and similar independent techniques yielded proportional treatment effects of effective sputum clearance, sensation of dyspnoea and phlegm. Compliance and adherence are cornerstones of physiotherapy management and should be addressed in future studies alongside self-management strategies. Finally, awareness of and epidemiological studies on bronchiectasis should be conducted in Africa where a high incidence / prevalence seems to be inferred. Notwithstanding, prescription for patients with bronchiectasis should be run under the auspices of expert-patient / self-management strategies.
Appendix 1: QUALITY APPRAISAL OF A SELECTED STUDY
Study: Liaw, et al., 2011
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Methods |
Randomised controlled trial |
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Participants |
N = 38 (Kaoshiung, China) Age range = 40 - 80 years Mean FEV1 in Intervention group > control |
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Intervention |
8 weeks of home-based Inspiratory muscle training – threshold device Completion of training 28 out of 38 ; No follow-up |
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Outcomes |
10 outcomes - Spiro metric lung function tests, Borg scale, 6MWD, 6Mwork, MIP, MEP, SGRQ, Sp02 |
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Risk of bias |
||
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Item |
Reviewers judgement |
Description |
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Random allocation |
Yes |
Described as randomised |
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Concealed allocation |
No |
Information not available from trial report |
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Baseline comparability |
Yes |
Data for similar groups comparability provided from trial |
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Blinding of subjects |
No |
Information not available from trial report |
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Blinding of therapists |
No |
Information not available from trial report |
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Blinding of assessors |
Yes |
Independent assessors described from trial report |
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Adequate follow-up |
No |
Data for outcome measures of 85% of participants not available from trial report |
|
Analysis by intention-to-treat |
No |
Information on intention-to-treat analysis not explicitly stated in trial report |
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Between-group statistical comparisons |
Yes |
Baseline comparability report provided |
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Measures of variability |
Yes |
Information provided from trial report |
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Eligibility criteria |
Yes |
Information provided from trial report |
|
Ethics |
Yes |
Ethical approval sought / Participant consent |
Appendix 2
Table 1.1 Data extracted from 2 RCTs investigation PR
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TITLE |
POPULATION |
INTERVENTIONS |
OUTCOME MEASURES |
RESULTS |
|
STUDY 1 Liaw, et al., 2011
|
N = 38 Male = 4 Female = 22 n=12 at Mean age = 64.5±10.4 years Kaoshiung, China |
Group 1 (n=19) 8/52 IMT - threshold device was set at 30% Pi max and increased by 2cm H2O by 1/52. Exhalation and inhalation was done with the device inserted into the mouth alongside intermittent rests for 30 minutes /day, 5x a week in a community-based Group 2 (n=19) – Placebo |
10 outcomes - Spiro metric lung function tests, Borg scale, 6 MWD,6Mwork, MIP, MEP, SGRQ, Sp02 20 outcomes - Nil |
Statistically significant differences in respiratory muscle strength, exercise tolerance and HRQL measured via MIP (P=0.004), MEP (P=0.004), 6MWD (P=0.021), 6Mwork (P=0.022) and SGRQ were recorded in the intervention Group Linear regression for age adjustment yielded significant improvement for MIP (P=0.005) and MEP (P=0.038) No significant difference was noted for all outcomes in Group 2
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STUDY 2 Newall, Stockley and Hill, 2005.
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N =32 Male = 6 Female = 26 n=4 at 3/52 Mean age - 56.2 = ±9.8 years Birmingham, UK |
Group 1 (n=11) PR + Sham IMT. Sham IMT – threshold device was fixed at a low and ineffective pressure (7 cm H2O) Group 2 (n=12) PR + Targeted IMT. IMT – threshold device was set at 30% Pi max and increased by 5% by 1/52 until training intensity of 60% Pi max was achieved. 15 minutes of 2x daily exhalation sustained for 6 minutes to RV was followed by rapid breaths to TLC for 2 minutes with device inserted into the mouth Group 3 (n=9) - Control Group 1 and 2 exercise sessions - Two outpatient sessions of 45 minutes - (treadmill walking; cycle ergometry and stair climbing, 15 minutes each), 3 times weekly training at 80% peak HR set via ISWT and Borg scale. One community-based intervention of 45 minutes targeted walking via Borg scale Group 1, 2 and 3 – received 8/52 of educational disease and self-management sessions
|
10 outcomes – Inspiratory muscle pressure (Pi max), peak oxygen uptake (V02), Endurance and maximal exercise capacity (ISWT) 20 outcomes -24 hour sputum volume, maximal and submaximal (endurance) incremental exercise test, Respiratory muscle strength, health status (SGRQ), spirometric Lung function |
Statistically important differences were recorded for respiratory muscle strength (Pi max) in the intervention groups; walking distance between Groups 1 (pGroup 2 (mean distance of 392.8m, p < 0.01) At 3/12, significant improvements in endurance capacity (ISWT) in PR-IMT Group was maintained > control /PR-SHAM Group Statistical improvements in health status of 4 points > minimally clinically important difference (MCID) via SGRQ, were recorded in the PR-IMT Group only No significant difference in lung function measures (V02 peak) and 24 hour sputum volume was noted across all the Groups All outcome measures were insignificant for the control group assessed at 8/52 and 16/52 post study period |
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N= initial participant number; n=drop out number; FVC = forced vital capacity (L); FEV1 = forced expiratory volume in 1 s (L); FEV1/FVC % = ratio of forced vital capacity expressed as percentage; Pi max = maximum inspiratory pressure, cm H2O; PE max = maximum expiratory pressure, cm H2O; FEF25-75%= forced expiratory flow at 25-75% of FVC; TLC = total lung capacity; RV= residual volume; MIP = maximum inspiratory pressure; MEP = maximum expiratory pressure; 6MWD = 6 minute walk distance ; 6Mwork = 6 minute walking work; ISWT = incremental shuttle walking test; V02 peak = peak oxygen uptake; Sp02=oxy-haemoglobin saturation by pulse oximetry |
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Table 1.2: Data extracted from 2 randomised crossover trials investigation independent techniques over CCPT or no intervention
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TITLE |
POPULATION |
INTERVENTIONS |
OUTCOME MEASURES |
RESULTS |
|
STUDY 3 Paneroni, et al., 2011 |
N = 22 Male = 12 Female = 10 Mean age = 64.4 ±8.9 years Respiratory Institute, Italy. |
Group 1 (n=11) IPV day 1 and CPT day 2 Group 2 (n=11) CPT day 1 and IPV day 2 Inpatient intervention was for 30 minutes each consecutively on 2/7 IPV – 2 active cycles of breathing through device with 2 phases of low pressure and high frequency, and another at high pressure and low frequency ended with cough CCPT – forced expiration, postural drainage, percussion and vibration |
10 outcomes - Sputum volume (ml), dry and wet weight (g) 20 outcomes - Sp02, HR, RR and subjective sensation of phlegm and dyspnoea |
No statistical difference in 10 outcomes between IPV and CPT were recorded except for discomfort and RR with IPV significantly > CPT Post-treatment discomfort was 23 ± 17% for IPV versus 40 ± 27% with CPT (P=0.03). RR decreased from 21 ± 4 breaths/min to 19 ± 4 breaths/min (P=0.02), whereas CPT remained the same at 21 ± 4 breaths/min to 21± 5 breaths/min (P=0.58) Dyspnoea improved significantly in IPV with no significant difference between groups HR decreased and sensation of phlegm improved across both groups while Sp02 remained constant but insignificant. Adverse effects of dry throat, nausea and /or fatigue were documented in 27% of patients across both groups but were insignificant to discontinue intervention |
|
STUDY 4 Syed, Maiya, and Kumar, (2009) |
N = 35 Male = 27 Female = 8 Mean age – 45.8± 11.2 years Karnataka, India |
Group 1 (n= 17) CPT day 1, postural drainage (PD) + ACBT DAY 2 Group 2 (n= 18) PD + ACBT day 1, CPT day 2. Inpatient intervention for 20 - 30 minutes each on 2 consecutive days with 12 hours of rest period. CCPT – chest percussions and vibrations in postural drainage position. |
10 outcomes - Wet sputum weight and volume, VAS scores for comfort 20 outcomes - FVC, FEV1, FEV1/FVC |
No significant difference in outcomes between the Groups 1 (P=0.751) or 2 (P=0.630) for sputum weight or volume and FEV1 or FVC FEV1/FVC (% predicted) were statistically significant pre- and post-therapy in both CPT (P=0.032) and ACBT (P=0.000) groups VAS scores for comfort were significant for ACBT (P=0.004) |
|
CPT = conventional chest physiotherapy ; IPV= intrapulmonary percussive ventilation; PEP=positive expiratory pressure; CRDQ = chronic respiratory disease questionnaire; PEFR = peak expiratory flow rate; PaO2 = partial pressure of O2 in arterial blood measured in mmHg; SGRQ = St Georges respiratory questionnaire |
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Table 1.3: Data extracted from 4 randomised crossover trials investigation ACBT against other independent techniques
|
TITLE |
POPULATION |
INTERVENTIONS |
OUTCOME MEASURES |
RESULTS |
|
STUDY 5 Eaton, Young, Zeng and Kolbe, 2007. |
N = 37 Male=13 Female=24 n=1 Mean age 62± 10 years Auckland, New Zealand |
Group 1 (n=12) Flutter – breathing control, 3-s breath hold and exhalation to forced expiratory followed by 2-3 huffs or coughs Group 2 (n=12) ACBT. – Thoracic expansion exercises with breathing control followed by huffs or coughs Group 3 (n=12) ACBT+PD – same as above + PD Outpatient based intervention for 30 minutes, on 3/7 alternate days |
10 outcomes - Wet Sputum volume and weight, Spiro metric lung volumes, Borg dyspnoea score, Pa02, subjective acceptability and tolerability 20 outcomes - Preference |
Significant differences in usefulness (PACBT and Flutter Insignificant differences in usefulness, sputum weights and volume, were noted between ACBT and Flutter ACBT+PD were associated with higher discomfort, interference with daily life and were time consuming than ACBT or Flutter Borg dyspnoea scores, preference, acceptability and tolerability were insignificant across all the groups Other outcomes were insignificant |
|
STUDY 6 Patterson, et al., 2005. |
N = 20 Male = 7 Female = 13 Mean age 58 ± 11 years Belfast, Northern Ireland |
Group 1 (n=10) ACBT – Thoracic expansion exercises with breathing control followed by huffs or coughs Group 2 (n=10) Acapella - 10 breaths of ¾ maximum inspiratory capacity, 2-3s breath hold and exhalation to forced expiratory followed by 2-3 huffs or coughs Outpatient based intervention for 15 minutes each, each performed in postural drainage positions on two consecutive days |
10 outcome - Sputum weight 20 outcome – Sp02, breathlessness, lung function measures |
No significant difference was found between sputum weight expectorated during and 30 minutes after treatment in ACBT or Acapella, mean difference of 0.54g |
|
Study 7 Patterson, Bradley, and Elborn, 2004 |
N = 20 Male = 6 Female = 14 Mean age 54.35 ±14.42 years Belfast, Northern Ireland |
Group 1 (n=10) ACBT + PD + Vibration Group 2 (n=10) TIRE –provides sustained maximum inspiratory pressure during breathing with device in place Outpatient intervention on consecutive 2/7. Single session of ACBT + PD + Vibration or TIRE - same time and ‘normal’ clearance for other session of each day |
10 outcomes - Sputum weight Sp02 2 outcomes - Spiro metric lung function tests, patient preference and perceived effectiveness |
There was no significant difference for all outcomes between groups except for expectorated sputum weight and perceived effectiveness with ACBT+ PD+ Vibration significantly > TIRE |
|
Study 8 Thompson, et al, 2002
|
N =22 Male = 8 Female = 14 n=5 Bristol, UK |
Group 1 ACBT (n=9) Group 2 Flutter device (n=13) Community-based intervention of 8/52- 4/52 for each intervention |
Sputum weight PEFR, CRDQ, Borg scale, Spiro metric lung function tests, subjective patient preference |
No statistical significant difference in any outcome except for patient preference, with flutter > ACBT FEV1 was significant with the flutter device but at a clinically unimportant value |
Dissertation Keywords/Search Tags:
systematic review, RCTs, physical therapy, bronchiectasis
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Submission Details: Dissertation Abstract submitted by Jacqueline Thompson from United Kingdom on 19-Jun-2013 23:43.
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