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Respiratory Management (Rehab Phase)

Systematic Reviews

Seven systematic reviews have examined various interventions that affect respiratory function and management of people with SCI. Interventions examined include respiratory muscle training (RMT), abdominal binding, secretion removal techniques, exercise training, and treatments for acute SCI and sleep disorders. These systematic reviews are outlined in Table 1 below, however, the conclusions and recommendations related to these findings are incorporated in the specific sections later in the chapter that summarize the respective treatments.

Author Year; Country
Research Design
Total Sample Size
Methods Outcome

Berlowitz and Tamplin 2013;
(Tamplin & Berlowitz, 2014)
Reviewed published articles (searches, were not
restricted by date, language, or publication status)
N = 11
Level of evidence:
PEDro scale was used to evaluate studies
Type of study:
11 RCT

Method: Systematically review the effectiveness of RMT on pulmonary function, dyspnea, respiratory complications, respiratory muscle strength, and quality of life for people with cervical SCI. There were no date, language, or publication restrictions. Only randomized controlled trials (RCTs) were included.
Database: Cochrane Injuries and Cochrane Neuromuscular Disease Groups’ Specialized Register of Controlled Trials (CENTRAL) (2012, Issue 1), MEDLINE, EMBASE, CINAHL, ISI Web of Science, PubMed, and clinical trials registries (Australian New Zealand Clinical Trials Registry, Clinical Trials, Controlled Trials metaRegister), and hand searching.
  1. 11 RCTs with 212 participants with cervical SCI were included.
  2. Meta-analysis revealed a statistically significant effect of RMT for 3 outcomes: VC (MD mean and end point 0.4L, 95% CI 0.1 to 0.7), MIP (MD mean end point 10.5 cmH2O, 95% CI 2.8 to 17.8). (Bertlowitz and Tamplin 2013).
  3. Meta-analysis revealed a statistically significant effect of RMT for 2 extended outcomes: MVV (MD mean end point 17.51 L/min, 95% CI 5.20 to 29.81), and IC (MD mean end point 0.35L, 95% CI 0.05 to 0.65) (Tamplin & Berlowitz, 2014).
  4. RMT showed a combined benefit in VC & FVC (MD mean end point 0.41L, 95% CI 0.17 to 0.64) (Tamplin & Berlowitz, 2014)
  5. There was no effect on forced expiratory volume in one second or dyspnoea.
  6. The results from quality of life assessment tools could not be combined from the three studies for meta-analysis
  7. No adverse effects as a results of RMT were identified in cervical SCI.
Wadsworth et al. 2009;
Reviewed published articles from
databases’ inception to March 2008
N = 11
Level of Evidence:
PEDro Scale
Type of study:
5 crossover randomized
1 crossover pseudorandomized
1 crossover
4 within-patient
Methods: Literature search for randomized control and randomized crossover studies reporting the effects of AB in acute or chronic SCI individuals. Interventions included different types of abdominal binding.
Databases: MEDLINE, CINAHL, Cochrane, EMBASE, PEDro.
  1. Some evidence that the use of an abdominal binder improves VC, but decreases FRC when assuming the sitting or tilted position.
  2. AB did not influence total lung capacity.
  3. PEDro mean score of 4.3 / 8.
  4. Available evidence is not yet sufficient to either support or discourage the use of an abdominal binder in this patient population.
Berney et al. 2011;
Reviewed published articles from 1950
to 2008
N = 21
Level of Evidence:
PEDro Scale
Newcastle-Ottawa Scale (NOS) with
nine scored criteria
Type of study:
3 cohort
3 case-control
14 retrospective case series reports.
Methods: Literature search for English articles with quantitative study designs on the effectiveness of treatment strategies for the respiratory management of acute tetraplegia.
Databases: MEDLINE (1950-2008), CINAHL (1982-2008), EMBASE (1980-2008), the Cochrane Library (2008), Web of Science (1900-1914-2008), AHRQ and ICORD
  1. A clinical pathway with a structured respiratory protocol that included a combination of treatment techniques, provided regularly is effective in reducing respiratory complications and cost.
  2. Mortality (ARR = 0.4, 95% confidence interval (CI) 0.18, 0.61), the incidence of respiratory complications and cost.
  3. Overall, study quality was moderate. Further studies using specific interventions that target respiratory complications associated with specific regions of the cervical spine, using more methodologically rigorous designs are required.
Reid et al. 2010;
Reviewed published articles from
databases’ inception to May 2009
N = 24
Level of Evidence:
PEDro Scale – RCTs
Modified Downs and Black – non RCTs
Type of study:
3 prospective controlled
9 pre-post
3 retrospective case reports
7 case reports
Methods: Literature search for English articles assessing physical therapy secretion removal techniques.
Databases: MEDLINE / Pubmed, CINAHL, EMBASE, and PsycINFO.
  1. Level 4/5 evidence supports the use of secretion removal techniques in people with SCI.
  2. Level 2 evidence (from 1 prospective controlled trial) and level 4 evidence (based on 2 pre-post studies) support the effectiveness of abdominal binders for assisted breathing.
  3. Level 1 evidence that respiratory muscle training improves respiratory muscle strength and decreased the number of respiratory infections, both of which infer improved airway clearance.
  4. Level 4 evidence based on 2 pre-post trials and level 5 evidence from 2 case reports support the use of electrical stimulation of the lower thoracic-lumbar spinal cord (T9, T11, and L1) and the abdominal wall muscles to improve expiratory flow rates during cough).
  5. Level 2 (based on 2 prospective controlled trials) and level 4 (based on 1 pre-post trial) evidence support the effectiveness of assisted coughing by manual abdominal compression.
  6. Insufflation combined with manual assisted cough provides the most consistent evidence for improving cough and / or PEFR.
Sheel et al. 2008
Review published articles from 1980 to
N = 13
Level of Evidence:
PEDro scale – RCTs
Modified Downs and Black – non RCTs
Type of study:
3 RCTs
1 pre-post
6 cases series
2 cohort
1 case report
Methods: Literature search for articles assessing exercise training and IMT in individuals for the improved respiratory function of patients with SCI.
Databases: MEDLINE / PubMed, CINAHL, EMBASE, PsycINFO.
  1. There is Level 2 evidence supporting exercise training as an intervention to improve respiratory strength and endurance.
  2. There is Level 4 evidence to support exercise training as an intervention to improve resting and exercising respiratory function in people with SCI.
  3. There is level 4 evidence to support IMT as an intervention to decrease dyspnea and improve cardiovascular function in people with SCI.
Van Houtte, Vanlandewijck, and
Gosselink, 2006;
Reviewed published articles from 1980
to November 2004
N = 21
Level of Evidence:
Modification of the framework for methodological quality developed by Smith et al. and Lotters et al.
– Max score of 40
Type of study:
6 controlled studies
15 non controlled studies
Methods: Literature search for articles assessing the effectiveness of RMT on individuals with SCI.
Databases: MEDLINE (National Library of Medicine, Bethesda, MD, USA) database (from 1980 to November 2004) and relevant references from peer-reviewed articles.
  1. RMT tended to improve expiratory muscle strength, VC and residual volume.
  2. Insufficient data was available to make conclusions concerning the effects on inspiratory muscle strength, respiratory muscle endurance, quality of life, exercise performance and respiratory complications.
Giannoccaro et al. 2013
Reviewed published articles up to October 2012.
N = 113
Level of evidence:
Methodological quality was not assessed
Type of study:
Types of studies included not specified.
Method: Reviewed the prevalence, features and treatment of sleep disorders in SCI. Only studies published in English were included.
Database: PubMed.
  1. Little has been published on the treatment of OSA in patients with SCI, but some SCI patients have been reported to respond to weight reduction, whereas changing sleep position is a more difficult measure to apply to these patients.
  2. Two studies reported poor compliance with CPAP in SCI patients with a significantly lower acceptance rate of 23-30% in higher level complete tetraplegic patients than the 60-80% acceptance described in able-bodied patients. However, data on long-term CPAP in one survey showed that 63% of patients used the treatment regularly.
  3. A recent study reported that despite no significant difference in AHI between people with tetraplegia and able-bodied controls, the abble-bodied people required significantly higher levels of CPAP to control their OSA than patients with tetraplegia, more than two thirds of whom (68.8%) required less than 10 cmH2O of CPAP. This suggests that additional unknown factors may contribute to the high prevalence of OSA in tetraplegia.
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