E. Lynne Geddes

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 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.

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 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.

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.

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.

Moral Development or Moral Decline? A Discussion of Ethics Education for the Health Care Professions.

Ethics education curricula in professional programmes are often confused and ineffective. They focus on traditional conceptions of professional ethics as rules supplementary to the law, and, it is claimed, contribute to tension and conflict in professional relationships, particularly with authority. This paper presents, first, a contemporary conception of the relationship between law and ethics that reinstates morality as a core component; it informs professional ethics and together they contribute to the law. Second, the paper describes the educational philosophy of two programmes in rehabilitation science where the ethics education component is being analyzed. Finally, research, that is currently under way, is described which will demonstrate the different effects of traditional and enhanced ethics education effort upon the moral reasoning processes that students use in reaching moral judgments.

An interprofessional e-learning module on health care ethics

Interprofessional education (IPE) research has found that students are able to increase their understanding of the roles of others and enhance group process skills in blended face-to-face and e-learning courses (Carbonaro et al., 2008; Cooper & Spencer-Dawe, 2006). This is appealing as a challenge with IPE is the difficulty scheduling events in overcrowded curricula. The Institute of Interprofessional Health Sciences Education (IIHSE) is a virtual learning center that overcomes scheduling barriers through asynchronous on-line learning. The IIHSE on-line learning modules were designed to ensure the contextual relevance of learning that is an essential component of IPE (Hammick, Freeth, Koppel, Reeves, & Barr, 2007). The modules incorporate a problem-based learning approach using patient scenarios as a stimulus for learning. Students come together in small groups as an on-line interprofessional team to share learning experiences and make clinical care decisions. A faculty facilitator role models collaborative practice and facilitates interprofessional interactions. The modules are designed for flexible delivery and can be used as a stand alone course, integrated within a course or combined with other modules. This report describes the evaluation of one IIHSE IPE learning module. The over-riding question was do students learn with, from and about each other through participation in an e-learning module on health care ethics?