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Physical training for bronchiectasis (Review)

Bradley JM, Moran F, Greenstone M

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published inThe Cochrane Library

2002, Issue 2

http://www.thecochranelibrary.com

Physical training for bronchiectasis (Review)

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
http://www.thecochranelibrary.com/http://www.thecochranelibrary.com/

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T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 Inspiratory Muscle Training versus Sham or no intervention (change from baseline), Outcome

1 Endurance (metres). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10


2 Incremental shuttle walking test (metres). . . . . . . . . . . . . . . . . . . . . . . . 11

Analysis 1.3. Comparison 1 Inspiratory Muscle Training versus Sham or no intervention (change from baseline), Outcome3 Health Status (CRDQ score). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12


4 Pi Max (cms of water). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Analysis 2.1. Comparison 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results), Outcome 1

Endurance (metres). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14


Incremental shuttle walking test (metres). . . . . . . . . . . . . . . . . . . . . . . . . 15


Health Status (CRDQ score). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Analysis 2.4. Comparison 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results), Outcome 4 Pi

Max (cms of water). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

17WHATS NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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[Intervention Review]

Physical training for bronchiectasis

Judy M Bradley1, Fidelma Moran2 , Michael Greenstone3

1Rehabilitation Sciences Research Institute School, University of Ulster and Belfast City Hospital, Newtownabbey, UK. 2Room 14J07,

School of Health Sciences, University of Ulster, Newtownabbey, UK.3 Castle Hill Hospital, Cottingham, UK

Contact address: Judy M Bradley, Rehabilitation Sciences Research Institute School, University of Ulster and Belfast City Hospital,

University of Ulster, Shore Road, Newtownabbey, Northern Ireland, BT37 0QB, [email protected].

Editorial group:Cochrane Airways Group.

Publication status and date:Edited (no change to conclusions), published in Issue 1, 2009.

Review content assessed as up-to-date: 9 February 2005.

Citation: Bradley JM, Moran F, Greenstone M. Physical training for bronchiectasis.Cochrane Database of Systematic Reviews2002,

Issue 2. Art. No.: CD002166. DOI: 10.1002/14651858.CD002166.


A B S T R A C T

Background

The pathophysiology of bronchiectasis may result in the development of dyspnoea and decreased exercise tolerance, both of which can

impact on a patients quality of life and ability to perform activities of daily living. There is little information regarding the benefits of

physical training in bronchiectasis: however it is probable that thebenefits of physical training in bronchiectasisare at least comparable to

benefits demonstrated in other respiratory conditions. There is also no information regarding the effects of non-adherence to prescribed

physical training in bronchiectasis. However as in patients with COPD non-adherence may contribute to a deterioration in the patients

condition and conceivably the long term prognosis.

Objectives

The objective of this review is to determine whether a prescribed regime of physical training produces improvements or prevents

deterioration in physiological and clinical outcomes in bronchiectasis compared to no physical training.

Search methods

We searched the Cochrane Airways Group trials register and the Cochrane Central Register of Controlled Trials.

Selection criteria

Randomised or quasi randomised controlled trials in whicha prescribed regimen of physical training is compared to no physical training

in patients with bronchiectasis.

Data collection and analysis

We identified three studies. One was did not meet the inclusion criteria and two appeared in abstract form only. More comprehensivedata will be incorporated into this review once data from those two trials are published, and when further data is made available to the

authors of this review. An update search in February 2005 identified one excluded study.

Main results

Results from the two studies published in abstract showed that inspiratory muscle training compared to sham or no inspiratory

muscle training improved endurance exercise capacity: Weighted Mean Difference (WMD) 264 metres (95% CI 16.4 to 512 metres).

Maximum inspiratory pressure (PiMax) improved: WMD 25 cms H20 (95% CI 11.6 to 38.4 cms H2O ) as did quality of life measured

with the CRQ: WMD 12.4 units (95% CI 2.4 to 22.5 units).

1Physical training for bronchiectasis (Review)

mailto:[email protected]:[email protected]

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Authors conclusions

This review only provides evidence of the benefits of inspiratory muscle training and provides no evidence of the effect of other types

of physical training (including pulmonary rehabilitation) in bronchiectasis.

P L A I N L A N G U A G E S U M M A R Y

Physical training for bronchiectasis

A search for controlled trials of physical training in bronchiectasis only identified two early reports (abstracts) including 43 patients in

total. These suggest some benefits of inspiratory muscle training on exercise capacity, quality of life and respiratory muscle function at

eight weeks, but further research is needed to confirm these findings in larger numbers of people with bronchiectasis. Further research

is also needed to assess the benefit of other types of physical training and pulmonary rehabilitation in bronchiectasis.

B A C K G R O U N D

Bronchiectasis can be defined as a disease that results in an ab-

normal dilatation of one or more bronchi. The primary cause of

bronchiectasis is an insult to the respiratory tract e.g. severe pneu-

monia, viral infection or aspiration of a foreign body. Genetic dis-

eases such as cystic fibrosis (CF), primary ciliary dyskinesia (in-

cluding Kartageners syndrome) and immunodeficiency can also

result in bronchiectasis. Any one of these conditions predisposes

the airways to lower respiratory colonisation by bacteria such as

Haemophilus influenzae or Pseudomonas aeruginosa.

Although infection and obstruction are implicated in the devel-opment of bronchiectasis , the inflammatory response may also

be important in disease progression: the hosts response to infec-

tion may fail to completely eradicate the infecting organism and

chronic colonisation is established . A vicious cycle of microbial

colonisation/ infection has been proposed whereby bacteria elabo-

rate substances toxic to the mucociliary escalator and perpetuates

the failure to eliminate the organisms. The inflammatory response

leads to furtherdamage of thebronchial tree andlung parenchyma

and is usually associated with excessive secretions and the devel-

opment of airflow obstruction.

The consequences of this may include the development of chronic

respiratory symptoms including cough, excessive purulent spu-tum, haemoptysis, breathlessness and decreased exercise tolerance.

The causes of breathlessness and decreased exercise tolerance are

multifactorial and may include altered pulmonary mechanics, in-

efficient gas exchange, decreased muscle bulk and confounding

psychological morbidity. All of these factors initiate a cyclical phe-

nomenon whereby decreasedexercisetoleranceleadsto progressive

detraining which in turn results in further reductions in exercise

tolerance.

Physical training is defined as participation in a programme of reg-

ular vigorous physical activity designed to improve physical per-

formance, and/or cardiovascular function and/or muscle strength

(Shepherd 1994). Physical training has been shown to improve

exercise tolerance and reduce symptoms of breathlessness in many

patient populations including CF and chronic obstructive pul-

monary disease (COPD). A meta-analysis of randomised trials

examining the role of physical training in COPD conducted by

Smith 1992, indicated a small non-significant trend in favour of

respiratory muscle training for most outcomes. There is little in-

formation regarding the benefits of physical training in bronchiec-

tasis: however it is probable that the benefits of physical trainingin bronchiectasis are at least comparable to benefits demonstrated

in other respiratory conditions (Morgan 1997). There is also no

information regarding the effects of non-adherence to prescribed

physical training in bronchiectasis. However as in patients with

COPD non-adherence may contribute to a deterioration in the

patients condition and conceivably the long term prognosis.

This review will aim to determine the evidence base benefit for

the use of physical training programmes in the management of

patients with bronchiectasis.

O B J E C T I V E S

The objective of this review is to determine whether a prescribed

regime of physical training in bronchiectasis produces improve-

ments or prevents deterioration in physiological and clinical out-

comes in bronchiectasis compared to no physical training.

M E T H O D S



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Criteria for considering studies for this review

Types of studies

Only randomised or quasi -randomised controlled trials in which

a prescribed regimen of physical training is compared to no phys-ical training in patients with bronchiectasis will be considered for

this review. Single blind and open studies will be considered for

inclusion.

Types of participants

We will include patients (adults and children) with stable

bronchiectasis. Patients with cystic fibrosis will be excluded. Diag-

nosis will be based on symptoms and appropriate imaging (bron-

chography or high resolution CT scanning).

Types of interventionsWe will consider any type of prescribed physical training including

pulmonary rehabilitation. We will record, wherever possible, the

precise nature of the training (intensity, frequency and duration)

will be recorded. We will exclued any studies which do not include

a prescribed physical training component. Important alterations

in patient management such as airway clearance techniques or

medication must be controlled for.

Types of outcome measures

The most appropriate outcome measure in bronchiectasis has not

been defined. The assessment of impairment, disability and hand-

icap is necessary to provide a comprehensive evaluation of treat-ment outcome.

Primary outcomes

Exercise tolerance: Objective change in exercise tolerance (maxi-

mal oxygen uptake (VO2 max), peak oxygen uptake (VO2 peak),

maximal ventilation (Ve max), heart rate, subjective assessment of

dyspnoea) as measured during formalexercisetests or field exercise

tests.

Secondary outcomes

1. Measures of specific indices of respiratory muscle strength:

peak inspiratory pressure (PImax), peak expiratory strength

(PEMax). Other measures of muscle strength, mass, effort and

general fatigue will be included.

2. Pulmonary function tests: forced expiratory volume in one

second (FEV1), forced vital capacity (FVC), forced expiratory

flow at 25 to 75% of FVC (FEF25-75), peak expiratory flow

(PEF), total lung capacity (TLC) and fixed respiratory capacity

(FRC): change in % predicted or and absolute change from

baseline compared to control will be assessed. Peak inspiratory If

other parameters are used, they will be considered.

3. Dyspnoea: All measures of dyspnoea used will be

considered.

4. Quality of life: Change in quality of life as measured bygeneric or disease - specific quality of life instruments, or by

subjective perception of well-being. All quality of life

instruments used will be considered.

5. Weight: Absolute weight change, change in % ideal body

weight, or weight standard deviation score or change in body

composition will be assessed.

6. Expectorated secretions: Dry or wet weight or volume.

7. Changes in physical symptoms such as cough and wheeze

8. Number of acute exacerbations, duration, hospitalisation,

IV antibiotic courses and time off work will be considered.

9. Oxygen saturation measured by pulsed or transcutaneous

oximetry.

10. Compliance with physical training will be recorded indetail.

11. Compliance with other treatment, such as airway clearance

techniques, nutritional regimes if measured. Methods of

assessing compliance will be recorded in detail.

12. Adverse effects including fractures, skeletal muscle injuries

and death will be recorded.

13. Cost evaluation.

If outcomes have been measured more than once in a study, we

will record the outcome measured most distant from the com-

mencement of physical training.

Search methods for identification of studies

We carried out a search using the Cochrane Airways Group trials

register and the Cochrane Central Register of Controlled Trials.

This database is comprised of systematic MEDLINE, CINAHL

and EMBASE searches.

We searched these registers using the search terms;

Bronchiectasis AND training OR physical training OR physical

fitness OR physical activity OR physical rehabilitation OR phys-

ical therapy OR exercise training OR exercise rehabilitation OR

exercise therapy OR exercise OR pulmonary rehabilitation OR

physiotherapy

We searched the reference lists of each RCT for additional stud-

ies. We also contacted authors of RCTs for information on otherpublished and unpublished studies.

Data collection and analysis

Two reviewers (JB, FM) independently selected the trials to be

included in the review using a proforma capturing the main in-



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clusion criteria listed above. Each reviewer assessed the method-

ological quality of each included trial.

The methodological quality of the RCTs was assessed using the

modified version of the five point instrument proposed byJadad

1996and the system for assessing treatment allocation conceal-

ment used by the Cochrane Collaboration.JADAD FIVE POINT SYSTEM:

(1) Was the study described as randomised (1 = yes; 0 = no)?

(2) Was the study described as being double blind (1 = yes; 0 =

no)?

(3) Was there a description of withdrawals and dropouts (1 = yes;

0 = no)?

(4) Was the method of randomisation well described and appro-

priate (1 = yes; 0 = no)?

(5) Was the method of double blinding well described and appro-

priate (1 = yes; 0 = no)?

(6) Deduct 1 point if methods for randomisation or blinding were

inappropriate.

Concealment system:A - adequate concealment

B - uncertain

C - clearly inadequate

We resolved disagreements by consensus.

For binary outcome measures, we sought data on the number of

participants with each outcome event, by allocated treated group,

(irrespective of compliance or subsequent eligibility) to allow an

intention-to-treat analysis. For continuous outcomes, we aimed to

record either mean change from baseline for each group or mean

post treatment / intervention values and the standard deviation

(SD) or standard error (standard error will be converted to SD).

For binary outcomes, we aimed to calculate a pooled estimate of

the treatment effect for each outcome across studies, (the odds ofan outcome amongtreatment allocated patientsto the correspond-

ing odds among controls). For continuous outcomes we aimed to

calculate a pooled estimate of treatment effect by calculating the

weighted mean difference.

R E S U L T S

Description of studies

See: Characteristics of includedstudies; Characteristics of excluded

studies.

Electronic searches yielded a total of 38 references. Three of these

were identified as potentially relevant. One was excluded (Choe

1996), for details see Excluded studies table. The other two ful-

filled the inclusion criteria for the review but have been published

in abstract form only. In spite of efforts to obtain complete data

from these trials none has been made available to the authors of

this review. It is anticipated that more complete data will be avail-

able at a later date and will be incorporated into updated versions

of this review. An update searchconducted in February 2005 iden-

tified one excluded study (Kellett 2005).

Both studies are describedbelow, butwillbe subject to amendment

upon their full journal publication.Newall 2000a was a randomised controlled eight week study.

NIneteen participants were involved (10 in the inspiratory mus-

cle training group, nine in the control group). Inspiratory muscle

training was carried out using a pressure threshold device. The

control group had no intervention. Concealment of allocation was

unclear and no drop outs were reported.

Newall 2000bwas a randomised controlled study, conducted over

an eight week period. 33 patients were randomised to receive either

inspiratory muscle training(using a pressure threshold device) plus

pulmonary rehabilitation (education, exercise training) or sham

inspiratory muscle training plus pulmonary rehabilitation or no

intervention. Twelve participants were in the active inspiratory

muscle training group, 12 in the sham inspiratory muscle traininggroup and nine in the control group. No data was available for the

control group in this study.

Risk of bias in included studies

In the two trials in this review, we ranked the method of con-

cealment unclear (Grade B). Both studies achieved a score of 1/

5 on the Jadad scale however both studies are only available in

abstract form and this score may change when the full text studies

are published. We will, therefore, provide a clearer indication of

study quality when more data becomes available.

Effects of interventions

A limited amount of data was reported in abstract form on 43

participants with bronchiectasis from the two included studies

(Newall 2000a;Newall 2000b). No data was available for the con-

trol group inNewall 2000b, therefore no comparison has been

made between pulmonary rehabilitation and no pulmonary re-

habilitation. There were considerable baseline difference between

groups in the studies. Therefore the results have been presented

using changes from baseline, but the absolute post treatment re-

sults are also shown as a second comparison.

EXERCISE TOLERANCE

The pooled results of the two studies show significant increase

from baseline in the inspiratory muscletraininggroup versussham

or no inspiratory muscle training in endurance (method of as-

sessment not detailed), Weighted Mean Difference (WMD) 264

metres (95% CI 16.4 to 512 metres). Maximal exercise capacity



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(incremental shuttle walking test) did not show a significant in-

crease from baseline, WMD 54 metres (95% CI -34 to 142 me-

tres). The post treatment results showed bigger treatment effects,

but also introduced heterogeneity. The baseline endurance in the

treatment group was 160 m less (500 m versus 661 m) in the

treatment group inNewall 2000aand 328 m more (732 m versus404 m) inNewall 2000b.

QUALITY OF LIFE

The pooled results of the two studies indicate an increase in the

quality of life following treatment compared to baseline in the

inspiratory muscle training group versus sham or no inspiratory

muscletrainingWMD 12.4 units on the CRQ scale (95% CI 2.38

to 22.48). Again the larger treatment effects shown in the post

treatment scores relate to the higher baseline quality of life in the

treatment groups.

PULMONARY FUNCTION

Pooled results from the two trials showed significant increases

in maximal inspiratory pressure (PiMax) from baseline following

treatment compared to baseline in the inspiratory muscle training

group versus sham or no inspiratory muscle training WMD 25

cms of water (95% CI 11.6 to 38.4 cms). Post treatment analysis

showed similar results.

At present there is no evidence from randomised control trials

to indicate whether physical training in bronchiectasis has an ef-

fect on peripheral muscle strength, mass, effort and general fa-

tigue; dyspnoea; weight; expectorated secretions; physical symp-

toms; number of and treatment of acute exacerbations; duration,

hospitalisation, IV antibiotic courses and time off work ; oxygen

saturation of thehaemoglobin of arterial blood (SaO2); bone min-

eral density and diabetes; compliance; nutritional regimes; adverse

effects and cost.

D I S C U S S I O N

Thissystematic review examined the effectiveness of physical train-

ing in the management of bronchiectasis. This was in order to

determine whether a prescribed regimen of physical training in

bronchiectasis produces improvements or prevents deterioration,in physiological and clinical outcomes in bronchiectasis compared

to no physical training.

Despite an exhaustive review of available literature, we only iden-

tified two relevant primary trials. Both of these trials investigated

the efficacy of inspiratory muscle training in bronchiectasis. As

there are only two studies the results should be viewed in the con-

text of possible publication bias.

Neither study was reported to be double blinded however this

quality issue must be considered in the context of the difficulty

of blinding any type of physical training study. Both studies used

random allocation, however neither provideddetailson the specific

procedures used. This maybe dueto thefact that both studies were

reported in abstract form only. In both studies the randomisationused was not successful in ensuring the groups were balanced at

baseline in all measures. These quality issues effect the internal

validity of the studies and justify the low Jadad scores reported.

The primary outcome measure in this review was exercise toler-

ance. Secondary outcome measures included pulmonary function

tests and quality of life. Analyses of the two studies suggest that

there is some evidence of the effect of inspiratory muscle training

on endurance exercise capacity, lung function and quality of life

but didnot show any benefitin terms of maximal exercise capacity.

Baseline differences make it difficult to be sure of the size of the

treatment effect, and the standard deviation of the changes from

baseline is not reported so has been assumed to be similar to the

standard deviation of the post treatment results (this is likely to bea conservative estimate).

A U T H O R S C O N C L U S I O N S

Implications for practice

It has been suggested that the magnitude of improvement from

physical training programmes in patients with bronchiectasis

should at least be comparable to the improvements demonstrated

in otherrespiratory disease populations. Theseclaims arebased pri-

marilyon expert opinion of thebenefits of training in bronchiecta-

sis, albeit supported by a sound physiological rationale. Thisreviewonly provides evidence of the benefits of inspiratory muscle train-

ingand provides no evidence of the effectof other types of physical

training (including pulmonary rehabilitation) in bronchiectasis.

Implications for research

This review has identified that there are no trials assessing the ef-

fect of physical training in bronchiectasis. There is a need for well

designed, adequately powered, randomised controlled clinical tri-

als to assess the net benefit (positive effects and side effects) of

adherence to different forms of prescribed physical training pro-

grammes, in patients with bronchiectasis. As it is likely that the

benefits and side effects of adherence to different types of physical

training differs in patients with mild, moderate and severe disease,

the influence of disease severity should be considered in the de-

sign of any future trial. The full benefit of any prescribed physical

training is unlikely to be demonstrated in programmes that are of

insufficient length or intensity. Therefore any future trial should

be of sufficient duration, intensity and frequency to assess the net

benefit of training on measures of disease impairment, disability

and handicap. Further research shouldalso consider whetherphys-



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ical training programmes delivered within the context of a pul-

monary rehabilitation program offers any additional advantages

to physical training alone.

A C K N O W L E D G E M E N T S

We gratefully thank ClaireAllen for assistancewith the preparation

of the synopsis and Kirsty Olsen who copy edited this review.

R E F E R E N C E S

References to studies included in this review

Newall 2000a{published data only}

Newall C, Henson M, McConnell AK, Stockley RA, Hill

SL. The effect of inspiratory muscle training (IMT) on

pulmonary function, exercise tolerance, and quality of life

in patients with bronchiectasis (BE). European Respiratory

Society. 2000; Vol. August September:1.

Newall 2000b {published data only}

Newall C, Henson M, McConnell AK, Stockley RA, Hill

SL. The effects of pulmonary rehabilitation (PR ) in patients

with bronchiectasis (BE). European Respiratory Society.

2000; Vol. AugustSept:3.

References to studies excluded from this review

Choe 1996 {published data only}

Choe KH Park YJ, et al.The effect of pulmonary

rehabilitation in patients with chronic lung disease.

Tuberculosis and respiratory diseases1996;43(5):73645.

Kellett 2005 {published data only} Kellett F, Redfern J, Niven RMcL. Evaluation of nebulised

hypertonic saline (7%) as an adjunct to physiotherapy in

patients with stable bronchiectasis. Respiratory Medicine

2005;99(1):2731.

Additional references

Jadad 1996

Jadad A, Moore RA, Carroll D, Jenkinson C, Reynolds

JM, Gavaghan DJ, et al.Assessing the quality of reports

of randomised controlled trials: is blinding necessary?.

Controlled Clinical Trials1996;17(1):112.

Morgan 1997

Morgan M, Singh S.Practical Pulmonary Rehabilitation. 1st

Edition. London: Chapman and Hall Medical, 1997.

Revill 1999

Revill SM, Morgan MDL, Singh SJ, Williams J, Hardman

AE. The endurance shuttle walk: A new field test for the

assessment of endurance capacity in chronic obstructive

pulmonary disease. Thorax1999;54(3):21322.

Shepherd 1994

Shephard RJ.Aerobic Fitness and Health. Leeds, England:

Human Kinetic Publishers, 1994.

Smith 1992

Smith K, Cook D, Guyatt G, Madhavan J, Oxman A.Respiratory Muscle Training in Chronic Airflow Limitation:

A Meta-Analysis. American Review of Respiratory Disease

1992;145(3):5339. Indicates the major publication for the study



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C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Newall 2000a

Methods 8 week study; concealment unclear; no dropouts specified; groups not similar at baseline

Participants 19 patients with bronchiectasis (IMT group, n = 10. Mean age 62.4 +/- 16.53); (control group, n = 9.

Mean age 62.8 +/- 11.6)

Interventions 8 weeks IMT using a pressure threshold device

control no intervention

Outcomes Included in this study were PImax; VC; RV; TLC; endurance; ISWT; CRDQ

Notes Jadad = 1

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear Information not available (Cochrane Grade B)

Newall 2000b

Methods 8 week study concealment unclear; no dropouts specified; groups not similar at baseline

Participants 33 patients with bronchiectasis(IMT plus PR: n = 12; mean age 56.8 +/- 7.8 years)

(sham IMT plus PR: n = 12 mean age 63 +/- 8.9)

(control: n = 9 mean age 62 +/- 11.6)

Interventions IMT using a pressure threshold device plus PR (education and exercise training)

sham IMT plus PR

control- no intervention

Outcomes Included in this study were PImax; endurance; ISWT; CRDQ

Notes Jadad = 1

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear Information not available (Cochrane Grade B)

CRDQ: Chronic respiratory disease questionnaire



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IMT: Inspiratory muscle training

ISWT: Incremental shuttle walking test

PImax: Peak inspiratory pressure (cmH2O)

PR: pulmonary rehabilitation (education, exercise training)

RV: Residual Volume (L)

TLC: Total Lung Capacity (L)VC: Vital Capacity (L)

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Choe 1996 Inappropriate patient population (only 1 patient had bronchiectasis) and no randomisation

Kellett 2005 Assessment of the addition of hypertonic saline to breathing technique. In the absence of an inactive control we

excluded the study



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D A T A A N D A N A L Y S E S

Comparison 1. Inspiratory Muscle Training versus Sham or no intervention (change from baseline)

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Endurance (metres) 2 43 Mean Difference (IV, Fixed, 95% CI) 264.21 [16.40, 512.

02]

1.1 Compared to no

intervention

1 19 Mean Difference (IV, Fixed, 95% CI) 204.60 [-374.01,

783.21]

1.2 Compared to sham

(both groups had Pulmonary

Rehabilitation)

1 24 Mean Difference (IV, Fixed, 95% CI) 277.60 [3.36, 551.

84]

2 Incremental shuttle walking test

(metres)

2 43 Mean Difference (IV, Fixed, 95% CI) 54.01 [-33.98, 142.

01]

2.1 Compared to no

intervention


47]



Rehabilitation)


87]

3 Health Status (CRDQ score) 2 43 Mean Difference (IV, Fixed, 95% CI) 12.40 [2.38, 22.43]

3.1 Compared to no

intervention

1 19 Mean Difference (IV, Fixed, 95% CI) 1.90 [-13.52, 17.32]



Rehabilitation)

1 24 Mean Difference (IV, Fixed, 95% CI) 20.1 [6.90, 33.30]

4 Pi Max (cms of water) 2 43 Mean Difference (IV, Fixed, 95% CI) 25.03 [11.63, 38.44]

4.1 Compared to nointervention




Rehabilitation)


Comparison 2. Inspiratory Muscle Training v Sham or no intervention (post treatment results)

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Endurance (metres) 2 43 Mean Difference (IV, Fixed, 95% CI) 502.48 [254.67,

750.30]

1.1 Compared to no

intervention


51]



Rehabilitation)


74]



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2 Incremental shuttle walking test

(metres)


95]

2.1 Compared to no

intervention

1 19 Mean Difference (IV, Fixed, 95% CI) -14.20 [-190.87,

162.47]


(both groups had PulmonaryRehabilitation)

1 24 Mean Difference (IV, Fixed, 95% CI) 202.79 [101.31,

304.27]

3 Health Status (CRDQ score) 2 43 Mean Difference (IV, Fixed, 95% CI) 22.89 [12.87, 32.92]

3.1 Compared to no

intervention




Rehabilitation)


4 Pi Max (cms of water) 2 43 Mean Difference (IV, Fixed, 95% CI) 25.77 [12.36, 39.18]

4.1 Compared to no

intervention

1 19 Mean Difference (IV, Fixed, 95% CI) 24.40 [-1.91, 50.71]



Rehabilitation)


Analysis 1.1. Comparison 1 Inspiratory Muscle Training versus Sham or no intervention (change from

baseline), Outcome 1 Endurance (metres).

Review: Physical training for bronchiectasis

Comparison: 1 Inspiratory Muscle Training versus Sham or no intervention (change from baseline)

Outcome: 1 Endurance (metres)

Study or subgroup IMT ControlMean

Difference WeightMean

Difference

N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Compared to no intervention

Newall 2000a 10 271.4 (651.2) 9 66.8 (634.6) 18.3 % 204.60 [ -374.01, 783.21 ]

Subtotal (95% CI) 10 9 18.3 % 204.60 [ -374.01, 783.21 ]

Heterogeneity: not applicable

Test for overall effect: Z = 0.69 (P = 0.49)

2 Compared to sham (both groups had Pulmonary Rehabilitation)

Newall 2000b 12 678.3 (400.3) 12 400.7 (273.3) 81.7 % 277.60 [ 3.36, 551.84 ]

Subtotal (95% CI) 12 12 81.7 % 277.60 [ 3.36, 551.84 ]



Total (95% CI) 22 21 100.0 % 264.21 [ 16.40, 512.02 ]

Heterogeneity: Chi2 = 0.05, df = 1 (P = 0.82); I2 =0.0%


Test for subgroup differences: Chi2 = 0.05, df = 1 (P = 0.82), I2 =0.0%

-1000 -500 0 500 1000

Favours control Favours IMT



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baseline), Outcome 2 Incremental shuttle walking test (metres).



Outcome: 2 Incremental shuttle walking test (metres)



Difference



Newall 2000a 10 57.8 (162.9) 9 11 (221.9) 24.8 % 46.80 [ -129.87, 223.47 ]

Subtotal (95% CI) 10 9 24.8 % 46.80 [ -129.87, 223.47 ]




Newall 2000b 12 110.89 (134.9) 12 54.5 (118.2) 75.2 % 56.39 [ -45.09, 157.87 ]

Subtotal (95% CI) 12 12 75.2 % 56.39 [ -45.09, 157.87 ]



Total (95% CI) 22 21 100.0 % 54.01 [ -33.98, 142.01 ]




-1000 -500 0 500 1000




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baseline), Outcome 3 Health Status (CRDQ score).



Outcome: 3 Health Status (CRDQ score)



Difference



Newall 2000a 10 7.3 (10.7) 9 5.4 (21.3) 42.3 % 1.90 [ -13.52, 17.32 ]

Subtotal (95% CI) 10 9 42.3 % 1.90 [ -13.52, 17.32 ]




Newall 2000b 12 10.5 (19.5) 12 -9.6 (12.8) 57.7 % 20.10 [ 6.90, 33.30 ]

Subtotal (95% CI) 12 12 57.7 % 20.10 [ 6.90, 33.30 ]



Total (95% CI) 22 21 100.0 % 12.40 [ 2.38, 22.43 ]

Heterogeneity: Chi2 = 3.09, df = 1 (P = 0.08); I2 =68%


Test for subgroup differences: Chi2 = 3.09, df = 1 (P = 0.08), I2 =68%

-100 -50 0 50 100




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baseline), Outcome 4 Pi Max (cms of water).



Outcome: 4 Pi Max (cms of water)



Difference



Newall 2000a 10 30.8 (31.6) 9 -1.6 (26.9) 26.0 % 32.40 [ 6.09, 58.71 ]

Subtotal (95% CI) 10 9 26.0 % 32.40 [ 6.09, 58.71 ]




Newall 2000b 12 28.25 (25.7) 12 5.8 (9.9) 74.0 % 22.45 [ 6.87, 38.03 ]

Subtotal (95% CI) 12 12 74.0 % 22.45 [ 6.87, 38.03 ]



Total (95% CI) 22 21 100.0 % 25.03 [ 11.63, 38.44 ]




-100 -50 0 50 100




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Analysis 2.1. Comparison 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results),

Outcome 1 Endurance (metres).


Comparison: 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results)

Outcome: 1 Endurance (metres)



Difference



Newall 2000a 10 772.1 (651.2) 9 728.2 (634.6) 18.3 % 43.90 [ -534.71, 622.51 ]

Subtotal (95% CI) 10 9 18.3 % 43.90 [ -534.71, 622.51 ]




Newall 2000b 12 1410 (400.3) 12 804.5 (273.3) 81.7 % 605.50 [ 331.26, 879.74 ]

Subtotal (95% CI) 12 12 81.7 % 605.50 [ 331.26, 879.74 ]



Total (95% CI) 22 21 100.0 % 502.48 [ 254.67, 750.30 ]




-1000 -500 0 500 1000




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Outcome 2 Incremental shuttle walking test (metres).



Outcome: 2 Incremental shuttle walking test (metres)



Difference



Newall 2000a 10 448.8 (162.9) 9 463 (221.9) 24.8 % -14.20 [ -190.87, 162.47 ]

Subtotal (95% CI) 10 9 24.8 % -14.20 [ -190.87, 162.47 ]




Newall 2000b 12 579.09 (134.9) 12 376.3 (118.2) 75.2 % 202.79 [ 101.31, 304.27 ]

Subtotal (95% CI) 12 12 75.2 % 202.79 [ 101.31, 304.27 ]



Total (95% CI) 22 21 100.0 % 148.96 [ 60.96, 236.95 ]




-1000 -500 0 500 1000




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Outcome 3 Health Status (CRDQ score).



Outcome: 3 Health Status (CRDQ score)



Difference



Newall 2000a 10 97.2 (10.7) 9 79.5 (21.3) 42.3 % 17.70 [ 2.28, 33.12 ]

Subtotal (95% CI) 10 9 42.3 % 17.70 [ 2.28, 33.12 ]




Newall 2000b 12 101.5 (19.5) 12 74.8 (12.8) 57.7 % 26.70 [ 13.50, 39.90 ]

Subtotal (95% CI) 12 12 57.7 % 26.70 [ 13.50, 39.90 ]



Total (95% CI) 22 21 100.0 % 22.89 [ 12.87, 32.92 ]


Test for overall effect: Z = 4.48 (P < 0.00001)


-100 -50 0 50 100




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Outcome 4 Pi Max (cms of water).



Outcome: 4 Pi Max (cms of water)



Difference



Newall 2000a 10 100 (31.6) 9 75.6 (26.9) 26.0 % 24.40 [ -1.91, 50.71 ]

Subtotal (95% CI) 10 9 26.0 % 24.40 [ -1.91, 50.71 ]




Newall 2000b 12 100.55 (25.7) 12 74.3 (9.9) 74.0 % 26.25 [ 10.67, 41.83 ]

Subtotal (95% CI) 12 12 74.0 % 26.25 [ 10.67, 41.83 ]



Total (95% CI) 22 21 100.0 % 25.77 [ 12.36, 39.18 ]




-100 -50 0 50 100


W H A T S N E W

Last assessed as up-to-date: 9 February 2005.

Date Event Description

30 September 2008 Amended Converted to new review format.



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H I S T O R Y

Protocol first published: Issue 1, 2001

Review first published: Issue 2, 2002

Date Event Description

1 February 2002 New citation required and conclusions have changed Substantive amendment

C O N T R I B U T I O N S O F A U T H O R S

The review was conceived by the Cochrane Airways Group and designed by Dr Judy Bradley and Ms Fidelma Moran. Searches for

relevant studies were conducted by Dr Judy Bradley and Ms Fidelma Moran and by the Cochrane Airways Group. Dr Judy Bradley

and Ms Fidelma Moran screened, appraised and abstracted data for review. Data entry was and analysis was performed by Dr Judy

Bradley and Ms Fidelma Moran with advice from the editor, Dr Mike Greenstone and the Cochrane Airways Group

D E C L A R A T I O N S O F I N T E R E S T

None known.

S O U R C E S O F S U P P O R T

Internal sources

NHS Research and Development, UK.

External sources

Garfield Weston Foundation, UK.

I N D E X T E R M S

Medical Subject Headings (MeSH)

Respiratory Muscles; Bronchiectasis [therapy]; Exercise Therapy [methods]; Physical Endurance



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MeSH check words

Humans



bradley 1996

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