Impact of a behavioral-based intervention on inspiratory muscle training prescription by a multidisciplinary team.

INTRODUCTION: Our goal was to compare behavioral- and information-based interventions aimed at increasing prescription of inspiratory muscle training (IMT) for people with chronic obstructive pulmonary disease (COPD) by interdisciplinary teams during pulmonary rehabilitation (PR). METHODS: Six hospital PR programs were randomly assigned to a behavioral- or information-based intervention. Both interventions provided evidence supporting IMT and its prescription details. However, the behavioral-based intervention focused on barriers and challenges to IMT prescription informed by a nationwide survey and the theory of planned behavior (TPB). It included hands-on practice and content, in part, was driven by learners' questions. In contrast, the information-based intervention delivered information in a typical didactic education session followed by a demonstration and question period. It was supplemented with evidence-based research articles. The primary outcome was the change in prescription rate of IMT for COPD patients by determining the difference during the 6 months preceding compared to the 6 months during the interventions. RESULTS: Sixty-one health professionals and 488 COPD outpatients within 6 PR programs participated. No COPD patients were prescribed IMT at any of the sites during the 6-month preintervention phase. The behavioral-based intervention resulted in an IMT prescription rate of 10.2% to people with COPD, whereas the information-based intervention resulted in no IMT prescriptions. DISCUSSION: A behavioral-based intervention that is based on TPB and addresses challenges identified by health professionals is more effective than a traditional lecture approach to increase health professionals' prescription of IMT for patients with COPD.

Annual performance appraisal: one organization's process and retrospective analysis of outcomes.

Performance assessment of personnel is an important component of an organization's quality management program, benefiting the organization, individuals and clients. Performance appraisal is the most common method. This article describes the three-part performance appraisal tool used at the authors' organization, a private inter-professional healthcare agency providing rehabilitation services to clients in the community, and presents the results of a retrospective analysis of the outcomes. Performance appraisals of 13 personnel were randomly selected, representing 39 chart audits and 25 joint client visits. The achievement of mandatory chart audit standards demonstrated 95 ± 7.2% compliance; expected standards showed 96 ± 3.3% compliance. Qualitative findings from the joint visits and interviews showed that therapists enjoyed the process and experience, valued the feedback and appreciated the support they received. Benefits and challenges of the process were identified, resulting in new initiatives being implemented. The authors confirmed that the tool achieves its intended purpose and is relevant in the home care setting.

The effects of a twelve-week home walking program on cardiovascular parameters and fatigue perception of individuals with multiple sclerosis: a pilot study.

PURPOSE: To investigate the effects of a 12-week home walking program on cardiovascular parameters, fatigue perception, and walking distance in persons with multiple sclerosis (MS). METHODS: Twelve ambulatory persons with MS, not currently participating in exercise were randomly assigned to control (C) or experimental groups (EX). Pretest data collection included resting HR, BP, fatigue perception (Fatigue Severity Scale), and 6-minute walk test. EX received a home walking program (30 min, 3 x week, x 12 weeks), using a modification of Karvonen's formula to calculate HR range. A HR monitor was used to adjust walking speed. The C group refrained from any regular exercise. Posttest data were collected at week 12 and analyzed using the Mann-Whitney U Test. RESULTS: No statistically significant differences were noted between groups in any measured parameters; however, walking distance and Physiologic Cost Index did improve in the exercise group. CONCLUSION: No adverse events or increase in fatigue levels related to the exercise intervention were reported in this study. This home walking program may not be of sufficient intensity to elicit significant cardiovascular changes. Abnormal cardiac responses have been documented in this population, which may have affected the results. Clinicians may need to use alternate measures to assess fitness in this population.

Effects of inspiratory muscle training in cystic fibrosis: a systematic review.

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.

Inspiratory muscle training in adults with chronic obstructive pulmonary disease: an update of a systematic review.

The 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. Nineteen of 274 articles in the original search met the inclusion criteria. The updated search revealed 17 additional articles; 6 met the inclusion criteria, all of which compared targeted, threshold or normocapneic hyperventilation IMT to sham IMT. An update of the sub-group analysis comparing IMT versus sham IMT was performed with 10 studies from original review and 6 from the update. Sixteen meta-analyses are reported. Results demonstrated significant improvements in inspiratory muscle strength (PI(max), PI(max) % predicted, peak inspiratory flow rate), inspiratory muscle endurance (RMET, inspiratory threshold loading, MVV), exercise capacity (Ve(max), Borg Score for Respiratory Effort, 6MWT), Transitional Dyspnea Index (focal score, functional impairment, magnitude of task, magnitude of effort), and the Chronic Respiratory Disease Questionnaire (quality of life). Results suggest that targeted, threshold or normocapneic hyperventilation IMT significantly increases inspiratory muscle strength and endurance, improves outcomes of exercise capacity and one measure of quality of life, and decreases dyspnea for adults with stable COPD.

Inspiratory muscle training compared with other rehabilitation interventions in chronic obstructive pulmonary disease: a systematic review update.

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.

Inspiratory muscle training in adults with chronic obstructive pulmonary disease: a systematic review.

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.

Is inspiratory muscle training effective for individuals with cervical spinal cord injury? A qualitative systematic review.

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 IMTcompared 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.

Inspiratory muscle training compared with other rehabilitation interventions in adults with chronic obstructive pulmonary disease: a systematic literature review and meta-analysis.

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.

Ethically-based clinical decision-making in physical therapy: process and issues.

The identification and consideration of relevant ethical issues in clinical decision-making, and the education of health care professionals (HCPs) in these skills are key factors in providing quality health care. This qualitative study explores the way in which physical therapists (PTs) integrate ethical issues into clinical practice decisions and identifies ethical themes used by PTs. A purposive sample of eight PTs was asked to describe a recent ethically-based clinical decision. Transcribed interviews were coded and themes identified related to the following categories: 1) the integration of ethical issues in the clinical decision-making process, 2) patient welfare, 3) professional ethos of the PT, and 4) health care economics and business practices. Participants readily described clinical situations involving ethical issues but rarely identified specific conflicting ethical issues in their description. Ethical dilemmas were more frequently resolved when there were fewer emotional sequelae associated with the dilemma, and the PT had a clear understanding of professional ethos, valued patient autonomy, and explored a variety of alternative actions before implementing one. HCP students need to develop a clear professional ethos and an increased understanding of the economic factors that will present ethical issues in practice.

A systematic process for content review in a problem-based learning curriculum.

The integrative nature of a problem-based curriculum provides unique challenges to the task of maintaining a current curriculum. This paper describes a systematic process for content review in a problem-based curriculum, which utilizes consultation among students, faculty and the clinical community, use of external reviewers and a faculty consensus process. Advantages of the process include increased communication and cooperation among faculty and development of a curriculum that balances the need for preparing students for new evidence-based practice with preparing them for clinical reality.