PURPOSEImmobility and pain are modifiable risk factors for development of venous thromboembolism and pulmonary morbidity after major abdominal surgery (MAS). The purpose of this study was to investigate the effect of abdominal incision support with an elasticized abdominal binder on postoperative walk performance (mobility), perceived distress, pain, and pulmonary function in patients following MAS.METHODSSeventy-five patients scheduled to undergo MAS via laparotomy were randomized to experimental (binder) or control (no binder) groups. Sixty (33 male, 27 female; mean age 58±14.9 years) completed the study. Preoperative measurements of 6-minute walk test (6MWT) distance, perceived distress, pain, and pulmonary function were repeated 1, 3, and 5 days after surgery.RESULTSSurgery was associated with marked postoperative reductions (p<0.001) in walk distance (∼75-78%, day 3) and forced vital capacity (35%, all days) for both groups. Improved 6MWT distance by day 5 was greater (p<0.05) for patients wearing a binder (80%) than for the control group (48%). Pain and symptom-associated distress remained unchanged following surgery with binder usage, increasing significantly (p<0.05) only in the no binder group.CONCLUSIONElasticized abdominal binders provide a non-invasive intervention for enhancing recovery of walk performance, controlling pain and distress, and improving patients' experience following MAS.

The updated review of Inspiratory Muscle Training in COPD2Geddes E.L. O'Brien K. Reid D. Brooks D. Crowe J. Inspiratory muscle training in adults with chronic obstructive pulmonary disease: an update of a systematic review.Respir Med. 2008; 102: 1715-1729Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar represents a worthy attempt to update and develop the evidence base for IMT use in the clinical management of COPD. However we are concerned that one of the reviews outcome measures, inspiratory muscle endurance, is an inadequate index of respiratory endurance. We believe this distinction is important as improving endurance capacity should be one of the primary goals of respiratory training. The review identified three different non-invasive techniques for testing endurance, which have also been described in national society guidelines.1American Thoracic Society/European Respiratory Society ATS/ERS statement on respiratory muscle testing.Am J Resp Crit Care Med. 2002; 166: 518-624Crossref PubMed Scopus (1550) Google Scholar These three endurance tests, respiratory muscle endurance time (RMET), inspiratory threshold loading (ITL) and maximal ventilation volume (MVV) are maximal in nature. They require a high degree of co-operation to ensure that the participant's maximum respiratory ability is attained, and as such make it difficult to establish whether it is respiratory impairment or inadequate effort that is responsible for poor test outcome.4Moxham J. Respiratory muscles.in: Hughes J. Pride N. Lung function tests: physiological principles and clinical applications. WB Saunders, China2000: 55-74Google Scholar When completed correctly these maximal tests can only establish the point of respiratory fatigue or exhaustion, which is when a participant can no longer continue. This is not a measure of respiratory endurance. Rather endurance (from the latin duro or durare – to make hard, last out, to survive) is best defined as the ability to resist fatigue or exhaustion (from fatigo or fatigaio – to weary, tire or to be overcome).3Morwood J. Oxford Latin dictionary. Oxford University Press, UK1994Google Scholar Endurance should therefore be viewed as the capability to continue, whereas fatigue represents the point when the ability to endure has failed. The two terms are not synonymous. While a measure of fatigue provides valuable information about an individual's maximum capacity, it does not measure the clinically important ability of the respiratory system to endure sub-maximal loads such as those experienced during the physical activities of daily life. Although they appear related endurance cannot be accurately predicted from estimates of maximal; ventilatory pressure, capacity or strength.1American Thoracic Society/European Respiratory Society ATS/ERS statement on respiratory muscle testing.Am J Resp Crit Care Med. 2002; 166: 518-624Crossref PubMed Scopus (1550) Google Scholar Furthermore when using these non-invasive techniques it is frequently stated that it is endurance of the respiratory/inspiratory/ventilatory muscles that is being measured, which is a misnomer as the direct function of the respiratory muscles can only be truly measured invasively. To better assess respiratory system endurance, constant loading of the respiratory system would be more appropriate since pathologies such as airway narrowing, chest wall restriction, or muscle weakness are constant (in the short term) rather than progressing ‘loads’.5Rohrbach M. Peret C. Kayser B. Boutellier U. Spengler C. Task failure from inspiratory resistive loaded breathing: a role for inspiratory muscle fatigue?.Eur J Appl Physiol. 2003; 90: 405-410Crossref PubMed Scopus (24) Google Scholar It is the consideration of the difference between maximal diagnostic testing and sub-maximal functionality testing of the respiratory system that is pertinent, as both are important and valid. Many studies describe their training intervention as inspiratory/respiratory muscle endurance training but then do not employ a representative measure of endurance to assess this outcome. With the increasing implementation of respiratory muscle training protocols as highlighted in this review, new and standardised tests are urgently needed to quantify the efficacy of interventions that aim to improve respiratory endurance. Inspiratory muscle training in adults with chronic obstructive pulmonary disease: An update of a systematic reviewRespiratory MedicineVol. 102Issue 12PreviewThe purpose was to update an original systematic review to determine the effect of inspiratory muscle training (IMT) on inspiratory muscle strength and endurance, exercise capacity, dyspnea and quality of life for adults with chronic obstructive pulmonary disease (COPD). The original MEDLINE and CINAHL search to August 2003 was updated to January 2007 and EMBASE was searched from inception to January 2007. Randomized controlled trials, published in English, with adults with stable COPD, comparing IMT to sham IMT or no intervention, low versus high intensity IMT, and different modes of IMT were included. Full-Text PDF Open Archive

We appreciate the opportunity to respond to the Letter to the Editor. While endurance tests of the inspiratory muscles have limitations, they are not inadequate. We agree with Drs. Powell and Williams that some of the endurance tests cited in our systematic review require a high degree of cooperation and that it might be difficult to establish whether it is impairment or lack of effort that contributes to a poor outcome. However, patient effort and motivation are key components of motor performance. Considering their role in muscle endurance tests will enhance our understanding of how our evaluative measures relate to improvements in a patient's daily life. Several of the inspiratory muscle endurance tests establish the point that a participant can no longer continue, also termed “task failure.” We prefer not to use the term fatigue because of the broader connotations it implies when used in the context of neuromuscular or cognitive fatigue. In such instances, the participant may be able to perform a task while experiencing various types of fatigue. We do not agree that “…direct function of the respiratory muscles can only be truly measured invasively.” This statement is not supported by the NHLBI Working Group report1NHLBI Workshop summary Respiratory muscle fatigue: report of the respiratory muscle fatigue workshop group.Am Rev Respir Dis. 1990; 142: 474-480Crossref PubMed Scopus (109) Google Scholar nor authors, like those included in our systematic review, who perform clinical research and perceive these tests to be estimates of respiratory muscle endurance. Review of the broader literature on limb muscles demonstrates that many clinical tests of muscle performance are used to estimate muscle endurance and are not restricted to invasive measures.2Bentley D.J. Newell J. Bishop D. Incremental exercise test design and analysis: implications for performance diagnostics in endurance athletes.Sports Med. 2007; 37: 575-586Crossref PubMed Scopus (222) Google Scholar, 3Erlenbusch M. Haub M. Munoz K. MacConnie S. Stillwell B. Effect of high-fat or high-carbohydrate diets on endurance exercise: a meta-analysis.Int J Sport Nutr Exerc Metab. 2005; 15: 1-14PubMed Google Scholar, 4Meyer T. Kindermann M. Kindermann W. Exercise programmes for patients with chronic heart failure.Sports Med. 2004; 34: 939-954Crossref PubMed Scopus (18) Google Scholar The inspiratory muscles in different respiratory conditions may undergo relentless loading, however, these loads are not constant. Levels of ventilation, blood flow distribution, and energy supply will vary throughout the day and lifetime of these individuals dependent on physical demands, progression of disease, and the presence of superimposed acute illness or exacerbation. Without a doubt, the inability to sustain a steady-state submaximal load might be attributed to a different combination of factors than those that limit an incremental, progressive threshold loading test of the respiratory muscles. We are not aware of any data to support the clinical utility of one measure over the other but are aware of the practical considerations of performing tests on patients. It would appear that respiratory muscle tests are selected based on whether they can estimate the desired outcome, are straightforward to perform, are not unduly challenging, and are accessible, reliable, and preferably non-invasive. We agree that endurance testing of the inspiratory muscles should be standardized and that new technologies could provide better information to formulate a diagnosis and exercise prescription. Despite the above-described limitations of the inspiratory muscle endurance tests, our rigorous review showed significant improvements in inspiratory muscle strength, exercise performance, decreased dyspnea and improved quality of life. Given the low-risk nature of this type of training, careful consideration of its potential effectiveness in the management plan of each of our patients is warranted.

PURPOSE To determine the effect of inspiratory muscle training (IMT) (alone or combined with exercise and/or pulmonary rehabilitation) and compare with other rehabilitation interventions among adults with chronic obstructive pulmonary disease (COPD). METHODS We conducted a systematic review, using Cochrane Collaboration protocol. We included randomized controlled trials, published in English, comparing IMT or combined IMT and exercise/pulmonary rehabilitation with other rehabilitation interventions among adults with COPD. Abstracts were reviewed independently by 2 investigators to determine study eligibility up to December 2005. Data were abstracted and methodological quality of included studies was assessed. RESULTS A total of 156 additional articles were retrieved. Two new studies met the inclusion criteria and were included with 16 studies in the original review. Results highlight updated subgroup analyses comparing (1) IMT versus exercise and (2) combined IMT and exercise versus exercise alone. Fourteen meta-analyses were performed for outcomes of inspiratory muscle strength, exercise tolerance, and quality of life. Results showed significant improvements in maximum inspiratory pressure and maximum exercise tidal volume favoring combined IMT and exercise compared with exercise alone. CONCLUSIONS Performing a combination of IMT plus exercise may lead to significant improvements in inspiratory muscle strength and one outcome of exercise tolerance for individuals with COPD.

The purpose of this study was to conduct a systematic review to determine the effect of inspiratory muscle training (IMT) on inspiratory muscle strength and endurance, exercise capacity, dyspnea and quality of life for adults with chronic obstructive pulmonary disease (COPD). A systematic review of the literature was conducted according the Cochrane Collaboration protocol using Medline and CINAHL. Nineteen of 274 extracted articles met the inclusion criteria and addressed comparisons of interest which included: IMT versus sham; IMT versus no intervention; low- versus high-intensity IMT; and two different modes of IMT. Thirteen meta-analyses were reported. Results indicate that targeted resistive or threshold IMT was associated with significant improvements in some outcomes of inspiratory muscle strength (PI(max) (cm H2O)) and endurance (Inspiratory Threshold Loading (kPa)), exercise capacity (Borg Scale for Respiratory Effort (modified Borg scale), Work Rate maximum (Watts)), and dyspnea (Transition Dyspnea Index), whereas IMT without a target or not using threshold training did not show improvement in these variables. There was no conclusive evidence regarding quality of life measures. IMT is effective for adults with COPD when using threshold or targeted devices that control or provide a target for training intensity.

Objective: We performed a systematic review to determine the effect of inspiratory muscle training (IMT) on inspiratory muscle strength and endurance, exercise capacity, dyspnoea and quality of life for adolescents and adults living with cystic fibrosis. Data sources: MEDLINE, EMBASE and CINAHL electronic databases were searched up to January 2008. Review methods: We performed a systematic review using the methodology outlined in the Cochrane Collaboration protocol. Articles were included if: (1) participants were adolescents or adults with cystic fibrosis (>13 years of age); (2) an IMT group was compared to a sham IMT, no intervention or other intervention group; (3) the study used a randomized controlled trial or cross-over design; and (4) it was published in English. Data were abstracted and methodological quality was assessed independently by two reviewers. Results: The search strategy yielded 36 articles, of which two met the inclusion criteria. Both studies used a targeted or threshold device for IMT. Meta-analyses were limited to forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC), which showed no difference in effect between the IMT group and the sham and/or control group. Individual study results were inconclusive for improvement in inspiratory muscle strength. One study demonstrated improvement in inspiratory muscle endurance. Conclusion: The benefit of IMT in adolescents and adults with cystic fibrosis for outcomes of inspiratory muscle function is supported by weak evidence. Its impact on exercise capacity, dyspnoea and quality of life is not clear. Future research should investigate the characteristics of the subgroup of people with cystic fibrosis that might benefit most from IMT.

Purpose: To determine whether aerobic exercise training improves inspiratory muscle strength and/or endurance in adults with stable chronic obstructive pulmonary disease (COPD). Methods: A systematic review was conducted according to the Cochrane Collaboration protocol. MEDLINE, EMBASE, and CINAHL electronic databases were searched to December 2005. Articles were independently reviewed by 2 reviewers to determine inclusion. Criteria included: randomized control trials, adults with stable COPD, comparing aerobic exercise to another comparison group that measured outcomes of inspiratory muscle strength and/or endurance, and published in English. Standardized procedures were used to abstract data from included articles. Methodological quality was assessed. Results: One hundred fifty six (156) articles were retrieved. Nine met inclusion criteria. Participants were predominately male, with moderate to severe COPD and mean age from 49 to 72 years. Meta-analyses were performed for outcomes of inspiratory muscle strength (maximum inspiratory pressure - Pimax) and endurance (respiratory muscle endurance time - RMET). Results showed no effect of aerobic exercise training on Pimax (p=0.55) and RMET (p=0.59) as compared to control. Conclusions: Based on this review, aerobic exercise alone, performed at least 3 times per week for at least 6 weeks in individuals with stable COPD does not improve inspiratory muscle function. If improvement in inspiratory muscle strength or endurance is desired, additional modalities such as inspiratory muscle training could be considered.

Purpose: Atelectasis is frequently observed in acutely ill, intubated patients. One technique for management of the secretion retention is breath stacking, a two-part procedure comprising manual hyperinflation using a resuscitation bag and a one-way valve, followed by a manually assisted cough and suctioning as required. The purpose of this preliminary study was to compare the safety and effectiveness of breath stacking combined with conventional physiotherapy (PT) care (PT composed of modified postural drainage combined with percussions, vibrations and suctioning) compared with PT alone in the management of acute atelectasis. Method: Intubated subjects with acute (, 72 hours) major atelectasis (lobar or greater) were randomized to receive breath stacking plus PT or PT alone twice daily for 3 days. Results: Twenty subjects entered the study. There was no difference between the groups on chest radiograph (p 5 .94) or volume of sputum suctioned. There were no respiratory or cardiac complications. Conclusions: Although this study had less than adequate power, the results demonstrated that breath stacking plus PT was no more effective than conventional PT alone for these patients. Breath stacking was a safe procedure as practised in this study.

Purpose: The objective of this study was to describe the current practice of Canadian physical therapists (PTs) using inspiratory muscle training (IMT) in the management of patients with cervical spinal cord injury (CSCI) or chronic obstructive pulmonary disease (COPD). Method: A postal survey was sent to all Canadian acute-care hospitals (. 250 beds) and to all centres providing rehabilitation for patients with CSCI or COPD. PTs were asked whether they used IMT and, if so, to describe patients for whom IMT was appropriate, as well as the devices and training protocols used. They were asked to list any contraindications to IMT. Results: One hundred nineteen questionnaires were sent to PTs treating patients with CSCI and 145 to PTs treating patients with COPD. The response rates were 70.6 per cent (CSCI) and 65.5 per cent (COPD). The rates of IMT use were 17.4 per cent (CSCI) and 4.7 per cent (COPD). The reasons for non-use included no knowledge about or training in IMT, a lack of resources, patients who were inappropriate for this treatment and no evidence of effectiveness. Conclusions: Few PTs are using IMT for patients with either CSCI or COPD. Little evidence exists of the effectiveness of IMT with CSCI patients, with stronger evidence of effectiveness in patients with COPD. A potentially effective modality for patients with COPD and CSCI, IMT appears to be underused by Canadian PTs.

Objective: To perform a systematic review to determine the effect of inspiratory muscle training (IMT) in adults with cervical spinal cord injury (CSCI). Design: A systematic search of the literature on IMT and CSCI according to the Cochrane Collaboration protocol was performed. We searched electronic databases up to August 2003 including MEDLINE and CINAHL, searched reference lists from pertinent articles and books, made personal contact with authors, and hand searched targeted journals to identify potential studies for inclusion. Study selection: Inclusion criteria for the review included randomized controlled trials published in English comparing IMT with another comparison group among adults with CSCI. Data extraction: Two reviewers abstracted relevant data from included studies. Methodological quality of the studies was assessed using criteria developed by Jadad et al. We also assessed whether the comparison groups were similar at baseline and whether an intention-to-treat analysis was performed. Results: Forty articles were retrieved and three met the inclusion criteria. All studies used inspiratory resistance muscle trainers for at least 15 min, twice daily, five to seven days per week for six to eight weeks. Meta-analysis could not be performed due to differences in study design and outcomes. Only one study reported a positive effect of IMT compared to control for measures of dyspnoea and pulmonary function. Conclusion: Literature on the effect of IMT among adults with CSCI is scarce and an overall effect could not be confirmed.

The purpose of this systematic review was to determine the effect of inspiratory muscle training (IMT) (alone or combined with exercise and/or pulmonary rehabilitation) compared to other rehabilitation interventions such as: exercise, education, other breathing techniques or exercise and/or pulmonary rehabilitation among adults with chronic obstructive pulmonary disease (COPD). A systematic review of the literature on IMT and COPD was conducted according to the Cochrane Collaboration protocol. Inclusion criteria for the review included randomized controlled trials, published in English, comparing IMT or combined IMT and exercise/pulmonary rehabilitation with other rehabilitation interventions such as general exercise, education, other breathing techniques or exercise/pulmonary rehabilitation among adults with COPD. 274 articles were retrieved, and 16 met the inclusion criteria. Seven meta-analyses were performed that compared targeted or threshold IMT to exercise (n = 3) or to education (n = 4). Results showed significant improvements in inspiratory muscle strength and endurance, and in the dyspnea scale on a quality of life measure, for participants in the IMT versus education group. In other instances where meta-analyses could not be performed, a qualitative review was performed. IMT results in improved inspiratory muscle strength and endurance compared to education. Further trials are required to investigate the effect of IMT (or combined IMT) compared to other rehabilitation inventions for outcomes such as dyspnea, exercise tolerance, and quality of life.

Backround. The purpose of the trial was to evaluate the effect on length of stay of individually tailored rehabilitation for clients who were undergoing hip or knee arthroplasty. Method. Clients (n = 133) with complex needs (comorbid conditions or limited social support) were randomly assigned to receive preoperative usual care (UC) or rehabilitation (R). Usual care clients received a single preoperative clinic visit. Rehabilitation clients were individually assessed and received multi disciplinary rehabilitation to optimize functional capacity, education about the in-hospital phase and early discharge planning. All rehabilitation subjects received interdisciplinary counseling/education focused on preparation for discharge home. The intervention for approximately half the rehabilitation clients was a single, cost-effective session, while others received physical conditioning. Results. Clients receiving rehabilitation achieved discharge criteria earlier (R = 5.4, UC = 8 days) and had a shorter actual length of stay (R = 6.5, UC = 10.5 days). Clinical Implications. This preoperative, individually tailored, rehabilitation program reduced length of stay.