The impact of home-based physiotherapy interventions on breathlessness during activities of daily living in severe COPD: A systematic review

OBJECTIVES: To conduct a systematic review and meta-analysis to determine the impact of home-based physiotherapy interventions on breathlessness during activities of daily living (ADL) in severe chronic obstructive disease (COPD). DATA SOURCES: The electronic databases AMED, CINAHL, Cochrane Central Register of Controlled Trials, Embase, Medline and Physiotherapy Evidence Database (PEDro) were searched from their inception to Week 20 2008. Bibliographies of all potentially relevant retrieved studies, identified relevant systematic reviews and international guidelines were searched by hand. REVIEW METHODS: Inclusion criteria consisted of individuals over 18 years of age with severe COPD (defined as forced expiratory volume in 1 second <or = 50% predicted) without cardiovascular co-morbidities, home-based interventions and valid, reliable breathlessness ADL outcome measures. The PEDro scale assessed methodological quality. Data extraction included baseline characteristics, treatment intervention, frequency of training, level of supervision, breathlessness ADL outcome measure and results. Where possible, a random-effects meta-analysis was applied to appropriate trial data to produce overall quantitative results. RESULTS: Seven studies, providing nine data sets, met the inclusion criteria. Trial PEDro scores ranged from 4 to 7 out of 10. Studies were homogenous at baseline regarding age and COPD severity, although subjects were predominantly male. Five studies investigated inspiratory or expiratory muscle training, and two studies investigated exercises. Statistically significant breathlessness ADL outcome improvements were reported for all interventions except expiratory muscle training. Five studies demonstrated clinical significance (four for inspiratory muscle training and one for exercise). However, due to heterogeneity among study interventions and outcomes, meta-analysis was only considered clinically appropriate on one occasion to pool three inspiratory muscle training studies in relation to breathlessness score. The random-effects meta-analysis indicated that, on average, inspiratory muscle training improved the breathlessness score significantly by 2.36 (95% confidence interval 0.76 to 3.96) compared with controls. CONCLUSION: Inspiratory muscle training and exercise are home-based physiotherapy interventions that may improve breathlessness during ADL in severe COPD. Administration can only be advocated tentatively in outpatient services and primary care at this stage because further higher quality, more homogeneous research with larger sample sizes is required to substantiate the current findings.