Chest physiotherapy for pneumonia in adults

  • Review
  • Intervention

Authors


Abstract

Background

Despite conflicting evidence, chest physiotherapy has been widely used as an adjunctive treatment for adults with pneumonia.

Objectives

To assess the effectiveness and safety of chest physiotherapy for pneumonia in adults.

Search methods

We searched CENTRAL 2012, Issue 11, MEDLINE (1966 to November week 2, 2012), EMBASE (1974 to November 2012), Physiotherapy Evidence Database (PEDro) (1929 to November 2012), CINAHL (2009 to November 2012) and CBM (1978 to November 2012).

Selection criteria

Randomised controlled trials (RCTs) assessing the efficacy of chest physiotherapy for treating pneumonia in adults.

Data collection and analysis

Two authors independently assessed trial eligibility, extracted data and appraised trial quality. Primary outcomes were mortality and cure rate. We used risk ratios (RR) and mean difference (MD) for individual trial results in the data analysis. We performed meta-analysis and measured all outcomes with 95% confidence intervals (CI).

Main results

Six RCTs (434 participants) appraised four types of chest physiotherapy (conventional chest physiotherapy; osteopathic manipulative treatment (which includes paraspinal inhibition, rib raising and myofascial release); active cycle of breathing techniques (which include active breathing control, thoracic expansion exercises and forced expiration techniques); and positive expiratory pressure).

None of the physiotherapies (versus no physiotherapy or placebo) improved mortality rates of adults with pneumonia.

Conventional chest physiotherapy (versus no physiotherapy), active cycle of breathing techniques (versus no physiotherapy) and osteopathic manipulative treatment (versus placebo) did not increase the cure rate or chest X-ray improvement rate.

Osteopathic manipulative treatment (versus placebo) and positive expiratory pressure (versus no physiotherapy) reduced the mean duration of hospital stay by 2.0 days (mean difference (MD) -2.0 days, 95% CI -3.5 to -0.6) and 1.4 days (MD -1.4 days, 95% CI -2.8 to -0.0), respectively. Conventional chest physiotherapy and active cycle of breathing techniques did not.

Positive expiratory pressure (versus no physiotherapy) reduced fever duration (MD -0.7 day, 95% CI -1.4 to -0.0). Osteopathic manipulative treatment did not.

Osteopathic manipulative treatment (versus placebo) reduced the duration of intravenous (MD -2.1 days, 95% CI -3.4 to -0.9) and total antibiotic treatment (MD -1.9 days, 95% CI -3.1 to -0.7).

Limitations of this review are that the studies addressing osteopathic manipulative treatment were small, and that six published studies which appear to meet the inclusion criteria are awaiting classification.

Authors' conclusions

Based on current limited evidence, chest physiotherapy might not be recommended as routine additional treatment for pneumonia in adults.

Résumé scientifique

Kinésithérapie respiratoire pour la pneumonie chez l'adulte

Contexte

Malgré des preuves contradictoires, la kinésithérapie respiratoire est largement utilisée en tant que traitement complémentaire chez les adultes atteints de pneumonie.

Objectifs

Évaluer l'efficacité et l'innocuité de la kinésithérapie respiratoire pour la pneumonie chez l'adulte.

Stratégie de recherche documentaire

Nous avons effectué des recherches dans CENTRAL 2012, numéro 11, MEDLINE (de 1966 à novembre semaine 2, 2012), EMBASE (de 1974 à novembre 2012), la Physiotherapy Evidence Database (PEDro) (de 1929 à novembre 2012), CINAHL (de 2009 à novembre 2012) et CBM (de 1978 à novembre 2012).

Critères de sélection

Les essais contrôlés randomisés (ECR) évaluant l'efficacité de la kinésithérapie respiratoire pour le traitement de la pneumonie chez l'adulte.

Recueil et analyse des données

Deux auteurs ont indépendamment évalué l'éligibilité des essais, extrait les données et évalué la qualité des essais. Les critères de jugement principaux étaient la mortalité et le taux de guérison. Nous avons utilisé les risques relatifs (RR) et la différence moyenne (DM) pour analyser les résultats des essais individuels. Nous avons effectué une méta-analyse et mesuré tous les critères de jugement avec des intervalles de confiance (IC) à 95 %.

Résultats principaux

Six ECR (434 participants) évaluaient quatre types de kinésithérapies respiratoires (kinésithérapie respiratoire conventionnelle ; traitement par manipulation ostéopathique (qui inclut l'inhibition des muscles paradorsaux, l'élévation des côtes et le relâchement myofascial) ; le cycle actif de techniques respiratoires (qui inclut le contrôle actif de la respiration, les exercices d'expansion thoracique et les techniques d'expiration forcée) ; et la pression expiratoire positive).

Aucune de ces kinésithérapies (par rapport à une absence de kinésithérapie ou à un placebo) n'améliorait les taux de mortalité des adultes atteints de pneumonie.

La kinésithérapie respiratoire conventionnelle (par rapport à une absence de kinésithérapie), le cycle actif de techniques respiratoires (par rapport à une absence de kinésithérapie) et le traitement par manipulation ostéopathique (par rapport à un placebo) n'ont pas augmenté le taux de guérison ou le taux d'amélioration à la radiographie pulmonaire.

Le Traitement par manipulation ostéopathique (par rapport à un placebo) et la pression expiratoire positive (par rapport à une absence de kinésithérapie) réduisaient la durée moyenne du séjour à l'hôpital respectivement de 2,0 jours (différence moyenne (DM) de -2,0 jours, IC à 95%, entre -3,5 et -0,6) et 1,4 jours (DM de -1,4 jours, IC à 95%, entre -2,8 et -0,0),. Ce que ne faisaient ni la kinésithérapie respiratoire conventionnelle ni le cycle actif de techniques respiratoires.

La Pression expiratoire positive (par rapport à une absence de kinésithérapie) réduisait la durée de la fièvre (DM -0,7 jour, IC à 95%, entre -1,4 et -0,0). Mais pas le traitement par manipulation ostéopathique.

Le Traitement par manipulation ostéopathique (par rapport à un placebo) réduisait la durée de l'antibiothérapie par voie intraveineuse (DM de -2,1 jours, IC à 95%, entre -3,4 à -0,9) et la durée totale de l'antibiothérapie (DM -1,9 jours, IC à 95%, entre -3,1 à -0,7).

Les Limitations de cette revue tiennent à ce que les études examinant le traitement par manipulation ostéopathique étaient de petite taille, et que six études publiées qui semblent remplir les critères d'inclusion, sont en attente de classification.

Conclusions des auteurs

Sur la base des preuves actuelles limitées, la kinésithérapie respiratoire ne pourrait pas être recommandée en tant que traitement complémentaire de pratique courante pour la pneumonie chez l'adulte.

Resumo

Fisioterapia respiratória para adultos com pneumonia

Introdução

Apesar das evidências conflitantes, a fisioterapia respiratória tem sido muito utilizada como tratamento adjuvante para adultos com pneumonia.

Objetivos

Avaliar a efetividade e segurança da fisioterapia respiratória para adultos com pneumonia.

Métodos de busca

Nós realizamos as buscas nas seguintes bases de dados: CENTRAL 2012, Edição 11, MEDLINE (1966 à segunda semana de novembro de 2012), EMBASE (1974 a novembro de 2012), Physiotherapy Evidence Database (PEDro) (1929 a novembro de 2012), CINAHL (2009 a novembro de 2012) e CBM (1978 a novembro de 2012).

Critério de seleção

Nós selecionamos ensaios clínicos randomizados (ECR) que avaliaram a eficácia da fisioterapia respiratória no tratamento de adultos com pneumonia.

Coleta dos dados e análises

Dois autores avaliaram de forma independente a elegibilidade e a qualidade dos estudos e extraíram os dados. Os desfechos primários foram mortalidade e taxa de cura. Para a análise dos dados dos estudos individuais, usamos o risco relativo (RR) e diferença de média (MD). Realizamos metanálises e mensuramos todos os desfechos com intervalos de confiança de 95% (95% CI).

Principais resultados

Seis ECR (434 participantes) analisaram quatro tipos de fisioterapia respiratória: fisioterapia respiratória tradicional, manipulação osteopática (que inclui inibição paraespinhal, elevação das costelas e liberação miofascial), técnicas de ciclo ativo da respiração (que incluem controle ativo da respiração, exercícios de expansão torácica e técnicas de expiração forçada) e pressão expiratória positiva.

Nenhum dos tipos de fisioterapia (versus ausência de fisioterapia ou placebo) melhorou a mortalidade de adultos com pneumonia.

A fisioterapia respiratória convencional (versus ausência de fisioterapia), as técnicas de ciclo ativo da respiração (versus ausência de fisioterapia) e a manipulação osteopática (versus placebo) não melhoram a taxa de cura ou as taxas de melhora nas radiografias de tórax.

A manipulação osteopática (versus placebo) e a pressão expiratória positiva (versus ausência de fisioterapia) reduziram o tempo médio de internação hospitalar em 2,0 dias (MD -2,0 dias, 95% CI -3,5 a -0,6) e 1.4 dias (MD -1,4 dias, 95% CI -2,8 a -0,0), respectivamente. A fisioterapia respiratória convencional e técnicas de ciclo ativo da respiração não tiveram esse efeito.

A pressão expiratória positiva (versus ausência de fisioterapia) reduziu a duração de febre (MD -0,7 dias, 95% CI -1,4 a -0,0), mas a manipulação osteopática não teve esse efeito.

A manipulação osteopática (versus placebo) reduziu a duração da antibioticoterapia intravenosa (MD -2.1 dias, 95% CI -3,4 a -0,9) e a duração total do tratamento com antibióticos (MD -1,9 dias, 95% CI -3,1 a -0,7).

As limitações desta revisão incluem o pequeno tamanho amostral dos estudos que analisaram a manipulação osteopática e o fato de que existem seis estudos publicados, que aparentemente preenchem os critérios de inclusão, que ainda estão aguardando classificação.

Conclusão dos autores

Com base nas evidências atuais, que são limitadas, a fisioterapia respiratória pode não ser recomendada de rotina como tratamento adicional em pacientes adultos com pneumonia.

Notas de tradução

Tradução do Centro Cochrane do Brasil (Flávia Maria Ribeiro Vital)

摘要

成人肺炎之胸腔物理治療

背景

即使有矛盾的證據,胸腔物理治療仍然已經廣泛地被使用,做為成人肺炎的輔助治療。

目的

評估成人肺炎物理治療的效益與安全。

搜尋策略

我們搜尋了CENTRAL (2012年,Issue 11)、MEDLINE (1966年至2012年11月第2週)、EMBASE (1974年至2012年11月)、Physiotherapy Evidence Database (PEDro) (1929年至2012年11月)、CINAHL (2009年至2012年11月)以及CBM (1978年至2012年11月)等資料庫。

選擇標準

評估胸腔物理治療對於治療成人肺炎成效的隨機對照試驗(RCTs)。

資料收集與分析

兩位作者獨立地評估試驗的合適性、摘錄資料並評量試驗的品質。 主要結果為死亡率及治癒率。在資料分析中,對於各別試驗的結果我們使用風險率比(RR)及平均差(MD);我們完成了統合分析並測量所有信賴區間(CI)為95%的結果。

主要結果

6個RCTs(434位受試者)評量了4種胸腔物理治療(常規胸腔物理治療;整骨推拿治療(包括脊椎旁抑制、 肋骨抬升與肌筋膜鬆弛);主動的週期呼吸技巧(包括主動的呼吸控制、胸廓擴張訓練與用力呼氣技巧)及正壓呼氣)。

沒有一種物理治療(相較於不施予物理治療或安慰劑)可以改善成人肺炎的死亡率。

常規胸腔物理治療(相較於不施予物理治療)、主動的週期呼吸技巧(相較於不施予物理治療)及整骨推拿治療(相較於安慰劑),皆沒有增加治癒率或胸腔X光的改善率。

整骨推拿治療(相較於安慰劑)與正壓呼氣(相較於不施予物理治療)分別將平均住院期減少了2.0天(平均差(MD) -2.0天, 95% CI -3.5至-0.6)與1.4天(MD -1.4天, 95% CI -2.8至-0.0)。常規胸腔物理治療及主動的週期呼吸技巧則沒有減少。

正壓呼氣(相較於不施予物理治療)縮短了發燒期(MD -0.7天, 95% CI -1.4至-0.0)。整骨推拿治療則沒有縮短。

整骨推拿治療(相較於安慰劑)縮短了靜脈內(MD -2.1天, 95% CI -3.4至-0.9)及整體的抗生素治療期(MD -1.9天, 95% CI -3.1至-0.7)。

本文獻的限制為,整骨推拿治療的研究數量很少,而那6份已發表且似乎符合納入條件的研究仍然在等待分類中。

作者結論

根據目前有限的證據,可能不會建議將胸腔物理治療作為成人肺炎的常規輔助治療。

譯註

翻譯者:臺北醫學大學考科藍臺灣研究中心(Cochrane Taiwan)

本翻譯計畫由臺北醫學大學考科藍臺灣研究中心(Cochrane Taiwan)、台灣實證醫學學會及東亞考科藍聯盟(EACA)統籌執行
聯絡E-mail:cochranetaiwan@tmu.edu.tw

Plain language summary

Chest physiotherapy for pneumonia in adults

Pneumonia is one of the most common health problems affecting all age groups around the world. Antibiotics represent the mainstay of pneumonia treatment, while other therapies are mostly supportive. Chest physiotherapy has been widely used as an adjunctive therapy for pneumonia in adults without any reliable evidence.

Six randomised controlled trials assessing 434 participants were included. The studies appraised four types of chest physiotherapy, namely conventional chest physiotherapy, osteopathic manipulative treatment (including paraspinal inhibition, rib raising, and diaphragmatic or soft myofascial release), active cycle of breathing techniques (including active breathing control, thoracic expansion exercises and forced expiration technique) and positive expiratory pressure. None of these techniques (versus no physiotherapy or placebo therapy) reduce mortality. Among three of the techniques (conventional chest physiotherapy, active cycle of breathing techniques and osteopathic manipulative treatment) there is no evidence to support a better cure rate in comparison with no physiotherapy or placebo therapy. Limited evidence indicates that positive expiratory pressure (versus no physiotherapy) and osteopathic manipulative treatment (versus placebo therapy) can slightly reduce the duration of hospital stay (by 2.02 and 1.4 days, respectively). In addition, positive expiratory pressure (versus no physiotherapy) can slightly reduce the duration of fever by 0.7 day, and osteopathic manipulative treatment (versus placebo therapy) might reduce the duration of antibiotic use by 1.93 days. No severe adverse events were found.

In summary, chest physiotherapy should not be recommended as routine additional treatment for pneumonia in adults. The limitation of our review is that six published studies which appear to meet the inclusion criteria are awaiting classification (five of which are published in Russian).

Résumé simplifié

Kinésithérapie respiratoire pour la pneumonie chez l'adulte

La pneumonie est l'un des problèmes de santé les plus courants qui affecte tous les groupes d'âge partout dans le monde. Les antibiotiques constituent le pilier du traitement de la pneumonie, tandis que d'autres traitements sont principalement de soutien. La kinésithérapie respiratoire est largement utilisée en tant que traitement d'appoint pour la pneumonie chez les adultes sans aucune preuve fiable.

Six essais contrôlés randomisés évaluant 434 participants ont été inclus. Les études évaluaient quatre types de kinésithérapies respiratoires, à savoir la kinésithérapie respiratoire conventionnelle, le traitement par manipulation ostéopathique (y compris l'inhibition des muscles paradorsaux, l'élévation des côtes et le relâchement diaphragmatique ou myofascial doux), le cycle actif de techniques respiratoires (y compris le contrôle actif de la respiration, les exercices d'expansion thoracique et la technique d'expiration forcée) et la pression expiratoire positive. Aucune de ces techniques (par rapport à une absence de kinésithérapie ou à une thérapie placebo) ne réduit la mortalité. Pour trois de ces techniques (la kinésithérapie respiratoire conventionnelle, le cycle actif de techniques respiratoires et le traitement par manipulation ostéopathique) il n'existe aucune preuve en soutien d'un meilleur taux de guérison, en comparaison avec l'absence de kinésithérapie ou à une thérapie placebo. Des preuves limitées indiquent que la pression expiratoire positive (par rapport à une absence de kinésithérapie) et le traitement par manipulation ostéopathique (par rapport à une thérapie placebo) peut réduire légèrement la durée du séjour à l'hôpital (de 2,02 et 1,4 jours, respectivement). En outre, la pression expiratoire positive (par rapport à l' absence de kinésithérapie) peut réduire légèrement la durée de la fièvre de 0,7 jour, et le traitement par manipulation ostéopathique (par rapport à une thérapie placebo) pourrait réduire la durée de l'utilisation d'antibiotiques de 1,93 jours. Aucun événement indésirable grave n'a été trouvé.

En résumé, la kinésithérapie respiratoire ne devrait pas être recommandée en tant que traitement complémentaire de routine pour la pneumonie chez l'adulte. Les limitations de notre revue sont que six études publiées qui semblent remplir les critères d'inclusion, sont en attente de classification (dont cinq ont été publiées en russe).

Notes de traduction

Traduit par: French Cochrane Centre 1st December, 2013
Traduction financée par: Instituts de Recherche en Sant� du Canada, Minist�re de la Sant� et des Services Sociaux du Qu�bec, Fonds de recherche du Qu�bec-Sant� et Institut National d'Excellence en Sant� et en Services Sociaux

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வயது வந்தோரில் ஏற்படும் கபவாதத்திற்கான (நிமோனியா) நெஞ்சு இயன்முறை சிகிச்சை

உலகம் முழுவதிலும், அனைத்து வயது பிரிவினரையும் பாதிக்கும் மிகவும் பொதுவான ஆரோக்கிய பிரச்சினைகளில் ஒன்றாக நிமோனியா விளங்குகிறது. நிமோனியா சிகிச்சையில் நுண்ணுயிர் கொல்லிகள் பிரதானமாக திகழுகின்றன, பிற சிகிச்சை முறைகள் பெரும்பாலும் ஆதரவளிக்கும் சிகிச்சைகளாக செயல்படுகின்றன. வயது வந்தோரில் ஏற்படும் நிமோனியாவிற்கான துணைச்சேர்ம சிகிச்சை முறையாக நெஞ்சு இயன்முறை சிகிச்சை எந்த நம்பகமான ஆதாரங்களும் இல்லாமல் பரவலாக பயன்படுத்தப்படுகிறது.

434 பங்கேற்பாளர்களை மதிப்பிட்ட ஆறு சமவாய்ப்பு கட்டுப்படுத்தப்பட்ட சோதனைகள் சேர்க்கப்பட்டன. நான்கு வகை நெஞ்சு இயன் முறை சிகிச்சை முறைகளான பாரம்பரிய நெஞ்சு இயன்முறை மருத்துவம், ஆஸ்டியோபேதிக் கையாள்கை சிகிச்சை (முதுகு பகுதி தசைப்பிடிப்புகளை ​ மட்டுப்படுத்துதல், விலா எலும்பு உயர்த்துதல், மற்றும் உதரவிதான அல்லது மென்மையான தசை உறைத்திசு விடுவிப்பு உட்பட), தீவிர சுவாச கட்டுப்பாடு சுழற்சி நுட்பங்கள் (தீவிர சுவாச கட்டுப்பாடு, மார்பு விரிவாக்கப் பயிற்சிகள் மற்றும் கட்டாய சுவாச வெளியேற்றும் ​ நுட்பம் உள்ளிட்ட) மற்றும் நேர்மறை வெளிமூச்சு அழுத்தம் ஆகியவற்றை ஆய்வுகள் மதிப்பிட்டன. எந்தவொரு நுட்பங்களும் (இயன்முறை சாரா சிகிச்சைக்கு அல்லது மருந்துப்போலி சிகிச்சைக்கு எதிராக) இறப்பைக் குறைக்கவில்லை. மூன்று வகையான நுட்பங்கள் மத்தியில் (பாரம்பரிய நெஞ்சு இயன் முறை சிகிச்சை, தீவிர சுவாச கட்டுப்பாடு சுழற்சி நுட்பங்கள் மற்றும் ஆஸ்டியோபேதிக் கையாள்கை சிகிச்சை) இயன்முறை சாரா சிகிச்சை அல்லது மருந்துப்போலி சிகிச்சையுடன் ஒப்பிடும் போது அதிக சிறப்பான குணமாக்கும் விகிதத்தை ஆதரிக்க எந்த ஆதாரமும் இல்லை. நேர்மறை வெளிமூச்சு அழுத்தம் (இயன்முறை சாரா சிகிச்சைக்கு எதிராக) மற்றும் ஆஸ்டியோபேதிக் கையாள்கை சிகிச்சை ஆகியவை (மருந்துப்போலி சிகிச்சைக்கு எதிராக) மருத்துவமனையில் தங்கும் காலத்தை சற்றே குறைக்க முடியும் (முறையே, 2.02 மற்றும் 1.4 நாட்கள்) என்று வரையறுக்கப்பட்ட சான்றுகள் காட்டுகிறது. மேலும், நேர்மறை வெளிமூச்சு அழுத்தமானது (இயன்முறை சாரா சிகிச்சைக்கு எதிராக) காய்ச்சலின் கால அளவை 0.7 நாள் என்றளவில் குறைக்க முடியும், ​மற்றும் ஆஸ்டியோபேதிக் கையாள்கை சிகிச்சை (போலி சிகிச்சைக்கு எதிராக) நுண்ணுயிர் கொல்லி​ மருந்துகளின் பயன்பாட்டை 1.93 நாட்கள் என்றளவில் குறைக்கக் கூடும். கடுமையான பாதக நிகழ்வுகள் எதுவும் கண்டுப்பிடிக்கப்படவில்லை.

சுருக்கமாக, வயது வந்தோரில் ஏற்படும் நிமோனியாவிற்கான வழக்கமான கூடுதல் சிகிச்சையாக நெஞ்சு இயன்முறை சிகிச்சை பரிந்துரைக்கப்படக்கூடாது. திறனாய்வின் சேர்கை பண்புகளை சந்தித்த ஆறு வெளியிடப்பட்ட ஆய்வுகள் (ஐந்து ரஷிய மொழியில் வெளியிடப்பட்டவை) வகைப்பாடு செய்ய காத்திருக்கிறது என்பது இந்த திறனாய்வின் வரையறையாகும்.

மொழிபெயர்ப்பு குறிப்புகள்

மொழி பெயர்ப்பாளர்கள்: ப்ளசிங்டா விஜய், சிந்தியா ஸ்வர்ணலதா ஸ்ரீகேசவன், தங்கமணி ராமலிங்கம், ஸ்ரீகேசவன் சபாபதி.

Resumo para leigos

Fisioterapia respiratória para adultos com pneumonia

A pneumonia é um dos problemas de saúde mais comuns que atingem pessoas de qualquer idade, em todo o mundo. Os antibióticos são o principal tratamento da pneumonia, enquanto outros tratamentos geralmente são considerados como auxiliares. A fisioterapia respiratória tem sido muito utilizada como tratamento auxiliar para adultos com pneumonia, porém sem qualquer evidência confiável.

Seis ensaios clínicos randomizados avaliando 434 participantes foram incluídos nesta revisão. Os estudos avaliaram quatro tipos de fisioterapia respiratória, denominadas fisioterapia respiratória convencional, manipulação osteopática (que inclui inibição paraespinhal, elevação das costelas e liberação miofascial ou diafragmática), técnicas de ciclo ativo da respiração (que incluem controle ativo da respiração, exercícios de expansão torácica e técnicas de expiração forçada) e pressão expiratória positiva. Nenhuma dessas técnicas (versus ausência de fisioterapia ou tratamento placebo) reduz a mortalidade. Não há evidência de que três das técnicas (fisioterapia respiratória convencional, manipulação osteopática e técnicas de ciclo ativo da respiração) melhorem a taxa de cura em comparação com ausência de fisioterapia ou tratamento placebo. Existem evidências limitadas de que a pressão expiratória positiva (versus ausência de fisioterapia) e a manipulação osteopática (versus tratamento placebo) podem reduzir significativamente a duração da internação hospitalar (em 2, 02 a 1,4 dias, respectivamente). Adicionalmente, pressão expiratória positiva (versus ausência de fisioterapia) pode reduzir um pouco a duração da febre em 0,7 dias, e a manipulação osteopática (versus tratamento placebo) pode reduzir a duração do uso do antibióticos em 1,93 dias. Não foram identificados eventos adversos graves.

Em resumo, a fisioterapia respiratória não deve ser recomendada como tratamento adjuvante de rotina para adultos com pneumonia. A limitação da nossa revisão é que existem seis estudos publicados que aparentemente preenchem os critérios de inclusão e que estão aguardando classificação (cinco desses estão em russo).

Notas de tradução

Tradução do Centro Cochrane do Brasil (Flávia Maria Ribeiro Vital)

Laički sažetak

Primjena torakalne fizikalne terapije u liječenju upale pluća u odraslih

Upala pluća jedan od najčešćih zdravstvenih problema koji pogađa osobe svih dobnih skupina diljem svijeta. Antibiotici su najvažnija metoda liječenja upale pluća, dok su ostale terapijske metode uglavnom potporne. Fizikalna terapija prsišta (torakalna fizikalna terapija) često se koristi kao dodatna terapija za upalu pluća u odraslih bez pouzdanih dokaza o njenoj učinkovitosti.

U ovaj Cochrane sustavni pregled literature uključeno je 6 randomiziranih kontroliranih pokusa s ukupno 434 ispitanika. Ispitane su četiri vrste torakalne fizikalne terapije: konvencionalna torakalna fizikalna terapija; manipulativna terapija za osteopeniju (koja uključuje paraspinalnu inhibiciju, podizanje rebara i miofascijalnu relaksaciju); ciklus tehnika aktivnog disanja (što uključuje aktivnu kontrolu disanja, vježbe za proširenje prsišta i tehnike prisilnog izdisaja), te vježbe izdisanja pod pozitivnim tlakom. Niti jedna metoda fizikalne torakalne terapije (u usporedbi sa skupinom koja nije provodila terapiju ili je provodila placebo terapiju) nije dovela do povećanja stope smrtnosti. Za tri od četiri odabrane tehnike (konvencionalna torakalna fizikalna terapija; ciklus tehnika aktivnog disanja i manipulativna terapija za osteopeniju) nije dokazana terapijska učinkovitost. Dokazani su ograničeni pozitivni učinci vježbe izdisanja pod pozitivnim tlakom (u odnosu na skupinu u čijem liječenju nije korištena torakalna fizikalna terapija) te manipulativne terapije za osteopeniju (u odnosu na placebo) jer smanjuju duljinu trajanja boravka u bolnici (za 2,02 odnosno 1,4 dana). Također je dokazano da vježbe izdisanja pod pozitivnim tlakom mogu dovesti do blagog smanjenja povišene tjelesne temperature. Isto tako je dokazano da manipulativna terapija za osteopeniju (u odnosu na placebo) može skratiti upotrebu antibiotika za 1,93 dana. Nisu zabilježene značajne nuspojave.

Zaključno, torakalnu fizikalnu terapiju ne bi trebalo preporučiti kao dodatnu rutinsku terapiju za upalu pluća u odraslih. Ograničenje ovog istraživanja je činjenica da šest objavljenih studija koje ispunjavaju kriterije uključivanja još čeka procjenu (od kojih je pet objavljeno na ruskom jeziku).

Bilješke prijevoda

Hrvatski Cochrane
Prevele: Doris Praprotnik i Petra Milić
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr

淺顯易懂的口語結論

成人肺炎之胸腔物理治療

肺炎是影響世界上所有年齡層中,最常見的健康問題之一。抗生素為治療肺炎的主要代表,而其他治療則多為輔助。在沒有任何可靠的證據下,胸腔物理治療已經被廣泛地使用,做為成人肺炎的輔助治療。

收錄了6個評估434位受試者的隨機對照試驗。本研究評量了4種胸腔物理治療:即常規胸腔物理治療、整骨推拿治療(包括脊椎旁抑制、肋骨抬升與橫隔膜或軟肌筋膜鬆弛)、主動的週期呼吸技巧(包括主動的呼吸控制、胸廓擴張訓練與用力呼氣技巧)及正壓呼氣。沒有一種方法(相較於不施予物理治療或安慰劑治療)可以降低死亡率。在3個方法中(常規胸腔物理治療、主動的週期呼吸技巧與整骨推拿治療),沒有證據能支持相較於不施予物理治療或安慰劑治療有較好的治癒率。有限的證據指出,正壓呼氣(相較於不施予物理治療)與整骨推拿治療(相較於安慰劑治療)能稍微縮短住院期(分別為縮短2.02天及1.4天)。另外,正壓呼氣(相較於不施予物理治療)能稍微縮短0.7天的發燒期,而整骨推拿治療(相較於安慰劑治療)也許能減少1.93天的抗生素使用期。沒有發現嚴重的不良事件。

總而言之,不應該建議把胸腔物理治療作為成人肺炎的常規輔助治療。本文獻的限制為,那6份已經發表且似乎符合納入條件的研究,仍然在等待分類當中(其中5份以俄文發表)。

譯註

翻譯者:臺北醫學大學考科藍臺灣研究中心(Cochrane Taiwan)

本翻譯計畫由臺北醫學大學考科藍臺灣研究中心(Cochrane Taiwan)、台灣實證醫學學會及東亞考科藍聯盟(EACA)統籌執行
聯絡E-mail:cochranetaiwan@tmu.edu.tw

Ringkasan bahasa mudah

Fisioterapi dada untuk radang paru-paru untuk orang dewasa

Radang paru-paru adalah masalah kesihatan paling lazim yang mempunyai kesan keatas semua peringkat umur di serata dunia. Antibiotik merupakan rawatan utama bagi radang paru-paru, manakala terapi-terapi lain kebanyakannya adalah rawatan sokongan sahaja. Fisioterapi dada digunakan dengan meluasnya sebagai terapi tambahan untuk radang paru-paru dalam orang dewasa tanpa sebarang bukti yang boleh diyakini.

Enam kajian terkawal secara rawak yang melibatkan 434 peserta telah dinilai. Kajian telah menilai empat jenis fisioterapi dada, iaitu fisioterapi dada konvensional, rawatan manipulasi osteopatik (termasuk perencatan paraspinal, kenaikan tulang rusuk, dan pelepasan diafragma atau 'soft myofascial'), teknik-teknik kitaran pernafasan aktif (termasuk kawalan pernafasan aktif, senaman pengembangan toraks dan teknik penghembusan nafas paksaan) dan tekanan ekspiratori positif. Kesemua teknik-teknik (berbanding tiada fisioterapi atau terapi plasebo) tidak mengurangkan kadar kematian. Dalam kalangan tiga teknik (fisioterapi dada konvensional, teknik kitaran pernafasan aktif dan rawatan manipulasi osteopatik) tidak ada bukti yang menyokong kadar penyembuhan yang lebih baik berbanding dengan tiada fisioterapi ataupun terapi plasebo. Bukti yang terhad menunjukkan tekanan ekspiratori positif (berbanding tiada fisioterapi) dan rawatan manipulasi osteopatik (berbanding terapi plasebo) boleh mengurangkan sedikit tempoh berada di dalam hospital (sebanyak 2.02 dan 1.4 hari, masing-masing). Juga, tekanan ekspiratori positif (berbanding tiada fisioterapi) boleh mengurangkan sedikit tempoh demam sebanyak 0.7 hari, dan rawatan manipulasi osteopatik (berbanding terapi plasebo) mungkin mengurangkan tempoh penggunaan antibiotik sebanyak 1.93 hari. Tiada kejadian yang tidak diingini telah dijumpai.

Ringkasannya, fisioterapi dada tidak harus disyorkan sebagai rawatan tambahan rutin untuk radang paru-paru dalam orang dewasa. Kelemahan kajian kami adalah enam kajian yang telah mempunyai penerbitan yang kelihatan telah memenuhi kriteria kelayakan kemasukan sedang menunggu untuk diklasifikasi (lima di antaranya diterbitkan dalam bahasa Rusia).

Catatan terjemahan

Diterjemahkan Noor Salwah S Omar (Universiti Sains Malaysia). Disunting oleh Tuan Hairulnizam Tuan Kamauzaman (Universiti Sains Malaysia). Untuk sebarang pertanyaan berkaitan terjemahan ini sila hubungi salwah@usm.my.

Background

Description of the condition

Pneumonia is caused most commonly by bacteria but occasionally by viruses, fungi, parasites and other infectious agents. It is the leading cause of death from infectious disease (Niederman 2001). Pneumonias are typically classified as community-acquired pneumonia, hospital-acquired pneumonia (nosocomial pneumonia) and ventilator-associated pneumonia (the most serious form of nosocomial pneumonia, infecting patients who are mechanically ventilated for other reasons). It is estimated that community-acquired pneumonia costs the United States USD 12.2 billion in treatment per year (Colice 2004), with an average mortality rate of 14% (Fine 1990). Nosocomial pneumonia is the second most common nosocomial infection and the leading cause of death from hospital-acquired infection (Bowton 1999).

Description of the intervention

Antibiotics represent the mainstay of pneumonia treatment, while other therapies are mostly supportive. These adjunctive therapies include supplementary oxygen, intravenous hydration and chest physiotherapy (George 1995). Chest physiotherapy is an airway clearance technique that combines manual percussion of the chest wall by a caregiver, strategic positioning of the patient for mucous drainage, and teaching cough and breathing techniques.

Conventional chest physiotherapy includes postural drainage, percussion, chest shaking, huffing and coughing. Recently, several new physiotherapy techniques have been developed, including the active cycle of breathing techniques, positive expiratory pressure and osteopathic manipulative treatment. Active cycle of breathing techniques include active breathing control, thoracic expansion exercises and forced expiration technique, and sometimes postural drainage and chest clapping. Positive expiratory pressure uses devices to provide a positive expiratory pressure of 10 to 25 cmH20 during expiration. It may stabilise airways by keeping them open during expiration, which may facilitate airway clearance. Osteopathic manipulative treatment includes bilateral paraspinal inhibition, bilateral rib raising, diaphragmatic myofascial release and soft myofascial release to the anterior thoracic inlet. It may improve chest wall mobility and enhance exercise tolerance.

How the intervention might work

Chest physiotherapy assists in treating some of the symptoms of respiratory disorders, such as airflow obstruction, alterations in ventilatory pump functions and impaired exercise performance. The aim is to improve the patient's respiratory status and expedite recovery by enhancing airway clearance in lung diseases associated with hypersecretion and reduced airway resistance. Increased airway clearance enhances gas exchange and reduces the work of breathing (Wallis 1999). Chest physiotherapy is best used for patients with copious secretions (more than 30 ml/day) and reduced ability to cough (Cochrane 1977; Graham 1978).

Why it is important to do this review

Chest physiotherapies for cystic fibrosis, acute bronchiolitis and patients undergoing mechanical ventilation have been reviewed (Flenady 2010; Roqué i Figuls 2012; Van der Schans 2009). However, the clinical effectiveness of chest physiotherapy for pneumonia is controversial. Some clinical studies have concluded that chest physiotherapy did not hasten the resolution of pneumonia (Graham 1978) or was not useful (Britton 1983; Britton 1985). Two studies suggested that larger or multi-centre trials were needed to confirm the findings (Ntoumenopoulos 2002; Tydeman 1989). Others concluded that chest physiotherapy had beneficial effects in patients with pulmonary infection (Hanying 2005). However, chest physiotherapy may be ineffective and even harmful. It may cause an increase in oxygen consumption (Horiuchi 1997; Weissman 1991; Weissman 1993), bronchospasm (Campbell 1975), induce hypertension, increase oxygen demand (Horiuchi 1997; Weissman 1993), cause hypoxaemia (Connors 1980; Poelaert 1991) and even lead to rib fractures (Chalumeau 2002).

To our knowledge, no systematic review or meta-analysis of chest physiotherapy for pneumonia has been published. This review aims to systematically review all randomised controlled trials (RCTs) which examine the effectiveness of chest physiotherapy for pneumonia in adults.

Objectives

To assess the effectiveness and safety of chest physiotherapy for pneumonia in adults.

Methods

Criteria for considering studies for this review

Types of studies

We considered all randomised controlled trials (RCTs) assessing the efficacy of chest physiotherapy for adult participants with any type of pneumonia. We included trials which also included other basic respiratory diseases, once pneumonia was diagnosed; we analysed such trials separately. We excluded trials in which physiotherapy was administered for the prevention of pneumonia, as pneumonia could occur in many conditions, such as trauma, cerebral vessels disease and postoperative conditions. We included both published and unpublished trials.

Types of participants

Adult participants (older than 18 years of age) of either gender, with any type of pneumonia. Pneumonia was defined by each original trial author. We included intubated or non-intubated participants.

Types of interventions

Chest physiotherapy of any type was compared with no chest physiotherapy. We included trials using traditional chest physiotherapy. We included trials using mechanical devices which have the same effect as traditional chest physiotherapy. We considered the following methods: postural drainage, chest percussion, vibration, thoracic oscillation, chest shaking, huffing, directed coughing, thoracic expansion, forced exhalation or expiration techniques and manual hyperinflation.

Types of outcome measures

Primary outcomes
  1. Mortality.

  2. Cure rate (the definitions of 'cure' and the 'time to cure' were determined by original trial authors).

Secondary outcomes
  1. Duration of hospital stay (days).

  2. Healing time (days) (subjective or objective assessment of time to complete recovery).

  3. Duration of fever (days) (fever defined as more than 37.5 degrees).

  4. Rate of improvement of chest X-ray (chest X-ray improvement was defined as any improvement on chest X-ray after treatment compared with before treatment. The assessment could be made by radiologists or clinicians).

  5. Duration of antibiotic therapy (days).

  6. Duration of sputum production (days).

  7. In-patient sputum weight.

  8. Duration of leukocytosis (days).

  9. Change in leukocyte count.

  10. Mean leukocyte count.

Adverse events

We defined serious adverse events according to the International Conference on Harmonisation (ICH) Guidelines (ICH 1997) as any event that: leads to death, is life-threatening, requires in-patient hospitalisation or prolongation of existing hospitalisation, results in persistent or significant disability, and any important medical event which may harm the patient or requires intervention to prevent it. All other adverse events were considered non-serious.

Search methods for identification of studies

Electronic searches

For this update we searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2012, Issue 11, part of The Cochrane Library, www.thecochranelibrary.com (accessed 21 November 2012), which contains the Cochrane Acute Respiratory Infections (ARI) Group's Specialised Register, MEDLINE (August 2009 to November week 2, 2012), EMBASE (August 2009 to November 2012), Physiotherapy Evidence Database (PEDro) (August 2009 to November 2012), CINAHL (2009 to November 2012) and CBM (1978 to November 2012). Please see Appendix 1 for details of the previous search.

We used the following search strategy to search CENTRAL and MEDLINE. We combined the MEDLINE search with the Cochrane Highly Sensitive Search Strategy for identifying randomised trials in MEDLINE: sensitivity- and precision-maximising version (2008 revision), Ovid format (Lefebvre 2011). We adapted these search terms to search EMBASE (see Appendix 2), PEDro (see Appendix 3) and CINAHL (see Appendix 4).

MEDLINE (OVID)

1 exp Pneumonia/
2 pneumon*.tw.
3 (bronchopneumon* or pleuropneumon*).tw.
4 Respiratory Tract Infections/
5 (lower respiratory tract infection* or lower respiratory infection* or lrti).tw.
6 (lung adj3 (inflamm* or infect*)).tw.
7 empyema, pleural/ or pleural effusion/ or exp pleurisy/
8 (pleural adj3 (empyema or effusion*)).tw.
9 pleurisy.tw.
10 or/1-9
11 exp Physical Therapy Modalities/
12 (physiotherap* or physical therap* or physical treatment*).tw.
13 Vibration/
14 exp Respiratory Therapy/
15 exp Positive-Pressure Respiration/
16 postural drain*.tw.
17 (patient* adj3 position*).tw.
18 (oscillat* or vibrat* or percuss* or huff*).tw.
19 ((chest or thora*) adj3 (clap* or shak* or compress*)).tw.
20 (forced adj2 (exhal* or expir*)).tw.
21 (cough* adj2 (directed or maneuver* or manoeuver* or techniqu*)).tw.
22 (breath* adj2 (control* or techni* or train* or exercis*)).tw.
23 positive pressure ventilation*.tw.
24 positive expiratory pressure*.tw.
25 electrostimulat*.tw.
26 massag*.tw.
27 ((respirat* or ventilat*) adj2 muscle train*).tw.
28 (osteopath* adj3 (manipulat* or treatment* or therap* or techniq*)).tw.
29 or/11-28
30 10 and 29

Searching other resources

We handsearched related journals. We did not impose any language or publication restrictions.

Data collection and analysis

Selection of studies

Two review authors (XLY, BYW) independently searched the databases. Two review authors (BYW, YPY) independently assessed the titles and abstracts to identify potentially relevant articles. We excluded the trials which failed to meet the inclusion criteria. Differences were resolved by the arbitrator (BRD).

Data extraction and management

Two review authors (XLY, BYW) independently extracted data using a standardised form. A third review author (MY) checked the extracted data. Extracted data included, where possible:

  • description of participants (including age, gender, type of pneumonia);

  • severity of pneumonia;

  • basic conditions and setting;

  • description of intervention (details of chest physiotherapy, including type, frequency, intensity and time);

  • description of control therapy;

  • methodological details (including design and recruitment);

  • method of randomisation;

  • sample size;

  • trial inclusion and exclusion criteria;

  • withdrawals;

  • description of outcomes (including mortality, duration of hospital stay, adverse events, cure, healing time, rate of clearing of X-ray film and duration of fever); and

  • source of funding.

Assessment of risk of bias in included studies

Two review authors (XLY, BYW) independently assessed trial quality based on the generation of the allocation sequence, allocation concealment, blinding and follow-up. Finally, we assessed the risks of bias as follows: A = low risk of bias (all of the criteria met); B = moderate risk of bias (one or more criteria partly met); C = high risk of bias (one or more criteria not met). Differences were resolved by the arbitrator (BRD).

The detailed quality components were as follows.

Generation of the allocation sequence

Adequate: computer-generated random numbers, table of random numbers, or similar.
Unclear: the trial was described as randomised, but the generation of the allocation sequence was not described. Inadequate: the allocation sequence was generated by some rules based on date of admission, record number, date of birth, and so on.

Allocation concealment

Adequate: concealed up to the point of treatment by central randomisation, sealed envelopes or similar.
Unclear: the allocation concealment procedure was not described.
Inadequate: open table of random numbers or similar.

Blinding

Adequate: since the intervention of chest physiotherapy was extremely difficult to mask completely, it was rare to have double-blinding. Hence, we considered single-blinding as adequate.
Unclear: if the method of blinding was not described.
Not performed: if the trial was not blinded.

Follow-up

Adequate: if the numbers and reasons for drop-outs and withdrawals in all intervention groups were described or if it was specified that there were no drop-outs or withdrawals.
Unclear: if the report gave the impression that there had been no drop-outs or withdrawals, but this was not specifically stated.
Inadequate: if the number or reasons for drop-outs and withdrawals were not described.

Measures of treatment effect

We expressed dichotomous data, such as cure rate or mortality, as risk ratios (RR). We expressed continuous data, such as duration of fever, as mean differences (MD). We reported all outcomes with 95% confidence intervals (CIs).

Unit of analysis issues

The unit of analysis was the individual, because all RCTs included in this review were simple parallel-group trials in which participants were randomly allocated to several groups and a single result for each outcome from each individual was collected and analysed. There were no complicated designs, such as cross-over or cluster-randomisation, used in the included RCTs.

Dealing with missing data

We contacted trial authors (by e-mail, letter or fax) to search for additional papers, and to confirm data extraction and obtain missing data.

Assessment of heterogeneity

We assessed heterogeneity in trial results by inspecting the forest plots to detect non-overlapping CIs, applying the Chi2 test with a P value of 0.10 indicating statistical significance, and implementing the I2 statistic (with a value of 50% to denote moderate levels of heterogeneity). In the case of heterogeneity between studies, we made efforts to explore sources of heterogeneity due to various factors, such as type of pneumonia and type of physiotherapy.

Assessment of reporting biases

We could not perform a funnel plot analysis to identify reporting biases because of the small number of included studies.

Data synthesis

We used RevMan (version 5.0) (RevMan 2011) to combine some outcomes. We used a fixed-effect model unless significant heterogeneity was noted; in which case we used a random-effects model. We calculated both the effect sizes and the summary measures with their 95% CIs.

Subgroup analysis and investigation of heterogeneity

We performed a subgroup analysis for different types of chest physiotherapies and outcomes.

Sensitivity analysis

We did not perform a sensitivity analysis in this review.

Results

Description of studies

See the 'Characteristics of included studies' and 'Characteristics of excluded studies' tables.

Results of the search

In this 2012 update we retrieved a total of 835 records from the electronic databases after duplicates had been removed. After screening the titles and abstracts we identified two publications (Dangour 2011; Noll 2008) as potentially eligible, which we retrieved in full text. However, both of them were excluded.

In the 2009 search we retrieved 1329 articles by electronic database searching (383 in MEDLINE, 452 in EMBASE, 105 in CBM, 378 in CENTRAL, six in PEDro and five in the National Research Register). After screening the titles and abstracts we identified 68 trials as potentially relevant, which we retrieved in full text. Among those, six trials (Bjorkqvist 1997; Britton 1985; Graham 1978; Noll 1999; Noll 2000; Tydeman 1989) met the inclusion criteria (see 'Characteristics of included studies' table). Seven trials which appeared to meet the inclusion criteria have not yet been included or excluded in this review, as five of them (Kuznetsov 1976; Kuznetsov 1980a; Kuznetsov 1980b; Sedov 1975; Vorob'ev 1984) are published in Russian, one (Facto 1947) was published in 1947 and we have not yet managed to retrieve the full text, and the seventh trial (Noll) is as yet unpublished.

Included studies

Six trials (Bjorkqvist 1997; Britton 1985; Graham 1978; Noll 1999; Noll 2000; Tydeman 1989) were included in this review, of which three (Graham 1978; Noll 1999; Noll 2000) were conducted in the United States, two (Bjorkqvist 1997; Britton 1985) in Sweden, and one (Tydeman 1989) in the United Kingdom. All of them were randomised, parallel-group controlled trials.

Participants

In total, 434 participants (215 males, 219 females) were involved in the six trials, with 211 participants in the treatment group and 223 participants in the control group. The participants' ages ranged from 15 to 94 years. The included trials involved participants with acute pneumonia. Two trials (Bjorkqvist 1997; Tydeman 1989) included community-acquired pneumonia only, two trials (Noll 1999; Noll 2000) included community-acquired pneumonia, nosocomial pneumonia and nursing home-acquired pneumonia. The remaining two trials (Britton 1985; Graham 1978) did not describe the type of pneumonia. The severity of pneumonia was mild to moderate in two trials (Graham 1978; Tydeman 1989), and not stated in the other four trials (Bjorkqvist 1997; Britton 1985; Noll 1999; Noll 2000). The baseline characteristics of the experiment and control groups of each included trial were comparable.

Interventions

Two trials (Noll 1999; Noll 2000) compared chest physiotherapy and routine treatment to placebo and routine treatment. In the other four trials (Bjorkqvist 1997; Britton 1985; Graham 1978; Tydeman 1989) chest physiotherapy and routine treatment was compared with routine treatment alone. Among these trials, the types of chest physiotherapies were significantly different to each another, including conventional chest physiotherapy, osteopathic manipulative treatment, active cycle of breathing techniques and positive expiratory pressure. Both treatment groups and control groups were given routine treatments such as antibiotics, oxygen therapy and other drug therapies, if necessary.

Outcome measures

The primary outcomes were mortality and cure rate. Mortality could be calculated from data from all included trials. However, cure rate was calculated from five included trials (Britton 1985; Graham 1978; Noll 1999; Noll 2000; Tydeman 1989). The following secondary outcomes were reported in some of the included trials:

Excluded studies

For reasons for excluding studies please see the 'Characteristics of excluded studies' table.

Risk of bias in included studies

The detailed risk of biases and quality of each study are explained in the Characteristics of included studies table. We identified none of the included trials as 'low risk of bias', we assessed three trials (Graham 1978; Noll 1999; Noll 2000) as 'moderate risk of bias', and we assessed three trials (Bjorkqvist 1997; Britton 1985; Tydeman 1989) as 'high risk of bias' (Figure 1; Figure 2). None of the studies were supported by pharmaceutical company funding.

Figure 1.

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Figure 2.

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

Allocation

All six trials explicitly stated that randomisation was used in their studies. However, none mentioned the method of randomisation. Only three studies clearly described the method of allocation concealment (Bjorkqvist 1997; Britton 1985; Graham 1978).

Blinding

Participants and outcome assessors were blinded in two studies (Noll 1999; Noll 2000). In one trial (Britton 1985) only participants were blinded. Two studies (Bjorkqvist 1997; Tydeman 1989) clearly stated that blinding was not conducted. One study (Graham 1978) did not describe whether blinding was used or not.

Incomplete outcome data

Each of the included studies had a statement on drop-outs or withdrawals. Two studies (Noll 1999; Noll 2000) had no drop-outs, and four studies (Bjorkqvist 1997; Britton 1985; Graham 1978; Tydeman 1989) had more than 10% drop-outs. An intention-to-treat (ITT) analysis was not used in these four studies (Bjorkqvist 1997; Britton 1985; Graham 1978; Tydeman 1989).

Selective reporting

There was no evidence of selective outcome reporting.

Other potential sources of bias

One trial (Britton 1985) did not report the standard deviation of duration of hospital stay and fever.

Effects of interventions

Because of the obvious clinical heterogeneity between different chest physiotherapies, we presented the results as comparisons between:

  1. conventional chest physiotherapy plus routine treatment versus routine treatment alone;

  2. active cycle of breathing techniques plus routine treatment versus routine treatment alone;

  3. osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment; and

  4. positive expiratory pressure plus routine treatment versus routine treatment alone.

We only used a placebo with the osteopathic manipulative treatment because in the two trials (Noll 1999; Noll 2000) using this therapy, participants in the control group received standardised light touch treatment as placebo, in addition to the routine treatment. In the remaining trials, participants in the control group received routine treatment alone.

1. Conventional chest physiotherapy plus routine treatment versus routine treatment alone

Two trials (Britton 1985; Graham 1978) including 225 participants, with 110 participants in the treatment group and 115 participants in the control group, appraised the effect of conventional chest physiotherapy.

1.1 Primary outcomes
1.1.1 Mortality

The meta-analysis of the two trials (Britton 1985; Graham 1978) using a fixed-effect model indicated that there was no significant difference between conventional chest physiotherapy plus routine treatment and routine treatment alone (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.15 to 7.13) (Figure 3).

Figure 3.

Forest plot of comparison: 1 Chest physiotherapy plus routine treatment versus routine treatment alone, outcome: 1.1 Mortality.

1.1.2. Cure rate

Among the two included trials (Britton 1985; Graham 1978), all participants were cured in both treatment group and control group in one trial (Britton 1985); the other trial (Graham 1978) reported that cure rates in the treatment group and control group were 59.26% and 70.37%, respectively. However, there was no significant difference between the two groups (RR 0.84, 95% CI 0.57 to 1.25) (Figure 4).

Figure 4.

Forest plot of comparison: 1 Chest physiotherapy plus routine treatment versus routine treatment alone, outcome: 1.2 Cure rate.

1.2 Secondary outcomes
1.2.1 Duration of hospital stay

Meta-analysis could not be performed, as one of the included trials (Britton 1985) did not report the standard deviation of duration of hospital stay. This study (Britton 1985) found that "there was no significant difference between the treatment and control groups" (P value was not available). The other trial (Graham 1978) reached a similar result (mean difference (MD) 0.7 day, 95% CI -1.39 to 2.79).

1.2.2 Duration of fever

One of the included trials (Britton 1985) did not report the standard deviation of duration of fever, therefore meta-analysis could not be carried out. Britton (Britton 1985) found the mean duration of fever in the treatment group and control group was 6.8 and 4.9 days, respectively (P < 0.01). The other trial (Graham 1978) reported the mean duration of fever in treatment group and control group was 2.9 and 2.5 days, respectively. However, there was no statistical significance between the groups (P = 0.64).

1.2.3 Rate of improvement of chest X-ray

Only one trial (Graham 1978) reported this outcome, which indicated that conventional chest physiotherapy had no benefit on improvement of chest X-ray (RR 0.85, 95% CI 0.59 to 1.22).

1.2.4 Healing time

One trial (Britton 1985) reported healing time as a secondary outcome. The mean healing time was 30.6 days in the treatment group, and 31.3 days in the control group. However, it reported "there was no significant difference between groups" (P value was unavailable).

2. Active cycle of breathing techniques plus routine treatment versus routine treatment alone

Only one trial (Tydeman 1989) including 32 participants (12 in the treatment group and 20 in the control group) was included in this review.

2.1 Primary outcomes
2.1.1 Mortality

No participants died during the study period.

2.1.2 Cure rate

The cure rates in the treatment group and the control group were 41.67% and 70.00% respectively, with no statistical significance between groups (RR 0.60, 95% CI 0.29 to 1.23).

2.2 Secondary outcomes
2.2.1 Duration of hospital stay

The duration of hospital stay (mean ± SD) was 6.67 ± 3.26 days in the treatment group, and 5.27 ± 2.26 days in the control group. However, there was no significant difference between groups (MD 1.40 days, 95% CI -0.69 to 3.49).

2.2.2 Rate of improvement of chest X-ray

Active cycle of breathing techniques had no benefit for rate of improvement of chest X-ray (RR 0.60, 95% CI 0.29 to 1.23).

2.2.3 Duration of antibiotic therapy

The duration of antibiotic therapy (mean ± SD) was 15.17 ± 6.70 days in the treatment group, and 15.02 ± 5.53 days in the control group. No significant difference was identified between groups (MD 0.15 day, 95% CI -4.39 to 4.69).

2.2.4 Duration of sputum production

The mean duration of sputum production seemed to be 0.37 days longer in the treatment group than in the control group, but there was no significant difference between groups (MD -0.37, 95% CI -3.74 to 3.00). The subgroup analysis indicated that there were no significant differences in both in-patient and out-patient populations in terms of duration of sputum production (MD 0.83 day, 95% CI -1.57 to 3.23; MD -1.20 days, 95% CI -3.28 to 0.88, respectively).

2.2.5 In-patient sputum weight

Active cycle of breathing techniques did not improve the in-patient sputum weight either (MD 4.9 g, 95% CI -1.82 to 11.62).

3. Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment

We identified two trials (Noll 1999; Noll 2000), involving 79 participants in total, with 39 in the treatment group and 40 in the control group.

3.1 Primary outcomes
3. 1.1 Mortality

Compared with placebo, osteopathic manipulative treatment did not improve mortality (RR 0.27, 95% CI 0.05 to 1.57) (Figure 5).

Figure 5.

Forest plot of comparison: 3 OMT plus routine treatment versus placebo plus routine treatment, outcome: 3.1 Mortality.

3.1.2 Cure rate

Osteopathic manipulative treatment did not increase cure rate in comparison with placebo (RR 1.54, 95% CI 0.97 to 2.46) (Figure 6).

Figure 6.

Forest plot of comparison: 3 OMT plus routine treatment versus placebo plus routine treatment, outcome: 3.2 Cure rate.

3.2 Secondary outcomes
3.2.1 Duration of hospital stay

Osteopathic manipulative treatment, compared with placebo, significantly reduced the mean duration of hospital stay by 2.0 days (weighted mean difference (WMD) -2.0, 95% CI -3.46 to -0.58).

3.2.2 Duration of fever

Only one trial (Noll 1999) with 21 participants assessed this outcome, which suggested that osteopathic manipulative treatment could not decrease the duration of fever in comparison with placebo (MD 0.6 day, 95% CI -1.60 to 2.80).

3.2.3 Rate of improvement of chest X-ray

Two trials (Noll 1999; Noll 2000) appraised this outcome. Pooled data showed that osteopathic manipulative treatment, compared with placebo, had no benefit on improvement of chest X-ray (RR 1.16, 95% CI 0.77 to 1.73).

3.2.4 Duration of antibiotic therapy

Compared with placebo, osteopathic manipulative treatment decreased the mean duration of antibiotic therapy by 1.9 days (MD -1.9, 95% CI -3.12 to -0.74). In addition, the subgroup analysis found that osteopathic manipulative treatment could decrease the mean duration of intravenous antibiotic therapy by 2.1 days (MD -2.1, 95% CI -3.36 to -0.87), but it had no benefit for decreasing the mean duration of oral antibiotic therapy (MD 0.9 day, 95% CI -1.25 to 3.20).

3.2.5 Duration of leukocytosis

Only one trial (Noll 1999) with 21 participants assessed this outcome, and found that osteopathic manipulative treatment did not decrease the mean duration of leukocytosis in comparison with placebo (MD -0.90 day, 95% CI -7.02 to 5.22).

3.2.6 Change in leukocyte count

One trial (Noll 2000) with 58 participants assessed the change in leukocytosis count. There was a significant difference in leukocyte count changes between days one and three (MD 3599.8, 95% CI 1121.22 to 6078.38). However, by day five these differences were no longer statistically significant (MD 2271.5, 95% CI -1287.07 to 5830.07).

3.2.7 Mean leukocyte count

One trial (Noll 2000) also assessed the mean leukocyte count on day three and five after admission, and it identified no significant differences between groups for mean white blood cell count on days three and five (day three: MD 1383, 95% CI -1072 to 3838; day five: MD 1210, 95% CI -1052 to 3472, respectively).

3.2.8 Adverse effects

Only one trial (Noll 2000) reported adverse effects, as transient muscle tenderness emerged after treatment in two individuals during the period of study.

4. Positive expiratory pressure plus routine treatment versus routine treatment alone

One trial (Bjorkqvist 1997) including 98 participants, with 50 in the treatment group and 48 in the control group, focused on this technique.

4.1 Primary outcomes
4. 1.1 Mortality

No participants died during the period of study.

4.1.2 Cure rate

Not reported.

4.2 Secondary outcomes
4.2.1 Duration of hospital stay

Compared with the routine treatment alone, positive expiratory pressure plus routine treatment reduced the mean duration of hospital stay by 1.4 days and there was a significant difference between groups (MD -1.4, 95% CI -2.77 to -0.03).

4.2.2 Duration of fever

Positive expiratory pressure could reduce the mean duration of fever by 0.7 day with a significant difference between groups (MD -0.7, 95% CI -1.36 to -0.04).

4.2.3 Adverse effects

No side effects were found during the study period.

Discussion

Summary of main results

Six randomised controlled trials (RCTs) with 434 participants were included in this review, which appraised four types of chest physiotherapies (i.e. conventional chest physiotherapy, active cycle of breathing techniques, osteopathic manipulative treatment and positive expiratory pressure). None of the techniques were found to improve mortality of pneumonia in adults. Conventional chest physiotherapy, active cycle of breathing techniques and osteopathic manipulative treatment did not increase the cure rate of pneumonia nor the rate of chest X-ray improvement. Osteopathic manipulative treatment and positive expiratory pressure did reduce the mean duration of hospital stay by 2.02 and 1.4 days, respectively, whereas conventional chest physiotherapy and active cycle of breathing techniques did not. Positive expiratory pressure might reduce the duration of fever, while osteopathic manipulative treatment might not. In addition, osteopathic manipulative treatment might have an effect on reducing the duration of intravenous and total antibiotic treatments.

Overall completeness and applicability of evidence

Most of the included RCTs were conducted around 10 to 30 years ago. The main positive conclusions (a decrease in duration of hospital stay, fever and antibiotic treatment) were based on two trials with small sample sizes, conducted more than 10 years ago. There have been advances in chest physiotherapies which have not yet been appraised in randomised controlled trials. The authors of Noll 2008 are conducting a RCT which evaluates the effect of osteopathic manipulative treatment for elderly patients with pneumonia. The results are supposed to offer valuable information for this special population. Moreover, to a large extent, the effects of physiotherapy depend upon the skills of the practitioners. It has been reported that the duration, sessions and quality of chest physiotherapies vary from case to case (Guessous 2008). Misleading results may occur if the treatments are administered by unskilled practitioners. However, information on the experience and training of the physiotherapists who implemented the treatments was not available in most of the included trials. The techniques, the number and duration of sessions and the duration of the intervention period also varied across trials. We therefore recommend that caution is required when interpreting the results of this review and applying them to current practice.

Quality of the evidence

All included studies were of poor to moderate methodological quality. Firstly, although all studies stated that randomisation was used, none mentioned the method of randomisation. Secondly, only two of the six studies (Noll 1999; Noll 2000) were double-blinded trials (in which participants and outcome assessors were blinded), and one (Britton 1985) was a single-blinded trial. Lack of blinding might cause overestimation of the effects. It should be noted that chest physiotherapy was performed by a physiotherapist, so it might be difficult to blind the practitioners. Thirdly, four of the six studies (Bjorkqvist 1997; Britton 1985; Graham 1978; Tydeman 1989) had more than 10% drop-outs, but none used an intention-to-treat (ITT) analysis, which aims to maintain the unbiased group comparison afforded by randomisation and to resolve the problem of non-compliance. Absence of an ITT analysis might lead to potential biases. Finally, the sample sizes of the six trials were too small to permit adequate assessment of this intervention. Moreover, there were challenges in obtaining high-quality evidence for physiotherapy interventions because of the difficulties in blinding the intervention, standardising the method of chest physiotherapy and defining clinically meaningful outcomes.

Potential biases in the review process

Six published studies appeared to meet the inclusion criteria but have not yet been included or excluded. Five papers are published in Russian and one was published in 1947 and we have not yet managed to retrieve a copy of the trial. This is the major limitation in our review and may lead to selective reporting bias. It was impossible to perform a funnel plot analysis to assess potential publication bias because of the limited number of trials for each outcome. Another limitation of our review is that none of the included studies were recent publications; most trials reported on participants treated in the 1980s and 1990s. Moreover, the publication date of the included studies varied from 1978 to 2000, which leads us to consider that definitions of care and cure in the different studies, plus medical management (including the methods of chest physiotherapy) may have differed. For these reasons, clinical heterogeneity was inevitable, although we had performed subgroup analyses on different types of chest physiotherapies and outcomes to minimise the effect of heterogeneity. Clinical heterogeneity might lead to bias if we combined the results of different studies by meta-analysis.

Agreements and disagreements with other studies or reviews

Although chest physiotherapy has been widely used in pneumonia, there is little evidence of any benefit (Guessous 2008). To our knowledge, this is the first systematic review to examine chest physiotherapy for pneumonia in adults. According to our results, chest physiotherapy has no benefit for mortality and cure rate. It can be costly as it requires equipment and experienced respiratory therapists, physiotherapists or clinicians to perform (Guessous 2008). Therefore, we recommend caution when prescribing chest physiotherapy for pneumonia in adults.

Authors' conclusions

Implications for practice

There is limited evidence indicating that osteopathic manipulative treatment and positive expiratory pressure may reduce the mean duration of hospital stay. Osteopathic manipulative treatment could also reduce the duration of antibiotic treatment, while positive expiratory pressure could reduce the duration of fever. However, based on current evidence, chest physiotherapy should not be recommended as a conventional adjunctive treatment for pneumonia in adults.

Implications for research

Further well-designed randomised controlled trials addressing the role of chest physiotherapy for pneumonia in adults may be warranted. The following key points should be considered in the future studies: appropriate sample size with power to detect expected difference, rigorous standardisation of the method of chest physiotherapy, an appropriate comparator therapy, appropriate outcomes (the following categories might be included: mortality, cure rate, improvements in symptoms, improvements in laboratory results, duration of hospital stay, duration of antibiotic or other therapies, and quality of life), and the cost-effectiveness of the therapy.

Acknowledgements

We thank Elizabeth Dooley, the Managing Editor of the ARI Group, for her help with drafting the review; and Sarah Thorning, ARI Group Trials Search Co-ordinator, for her useful comments on the search strategy. We also wish to thank the following people for commenting on the draft review: Sai Janani Sivashankar, George Ntoumenopoulos, Jan Poelaert, Teresa Neeman, and Johannes van der Wouden.

For this 2012 update, we deeply appreciate Sarah Thorning, ARI Group Trials Search Co-ordinator, for her hard work updating database searches.

Data and analyses

Download statistical data

Comparison 1. Chest physiotherapy plus routine treatment versus routine treatment alone
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Mortality2225Risk Ratio (M-H, Fixed, 95% CI)1.03 [0.15, 7.13]
2 Cure rate2225Risk Ratio (M-H, Fixed, 95% CI)0.97 [0.91, 1.04]
3 Duration of hospital stay1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
4 Duration of fever1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
5 Rate of improvement of chest X-ray1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
Analysis 1.1.

Comparison 1 Chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 1 Mortality.

Analysis 1.2.

Comparison 1 Chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 2 Cure rate.

Analysis 1.3.

Comparison 1 Chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 3 Duration of hospital stay.

Analysis 1.4.

Comparison 1 Chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 4 Duration of fever.

Analysis 1.5.

Comparison 1 Chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 5 Rate of improvement of chest X-ray.

Comparison 2. Active cycle of breathing techniques plus routine treatment versus routine treatment alone
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Cure rate1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
2 Duration of hospital stay1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
3 Rate of improvement of chest X-ray1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
4 Duration of antibiotic therapy1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
5 Duration of sputum production1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
5.1 In-patient1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
5.2 Out-patient1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
5.3 Total1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
6 In-patient sputum weight1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
Analysis 2.1.

Comparison 2 Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 1 Cure rate.

Analysis 2.2.

Comparison 2 Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 2 Duration of hospital stay.

Analysis 2.3.

Comparison 2 Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 3 Rate of improvement of chest X-ray.

Analysis 2.4.

Comparison 2 Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 4 Duration of antibiotic therapy.

Analysis 2.5.

Comparison 2 Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 5 Duration of sputum production.

Analysis 2.6.

Comparison 2 Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 6 In-patient sputum weight.

Comparison 3. Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Mortality279Risk Ratio (M-H, Fixed, 95% CI)0.27 [0.05, 1.57]
2 Cure rate279Risk Ratio (M-H, Fixed, 95% CI)1.54 [0.97, 2.46]
3 Duration of hospital stay279Mean Difference (IV, Fixed, 95% CI)-2.02 [-3.46, -0.58]
4 Duration of fever1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
5 Rate of improvement of chest X-ray275Risk Ratio (M-H, Fixed, 95% CI)1.16 [0.77, 1.73]
6 Duration of oral antibiotic therapy279Mean Difference (IV, Random, 95% CI)0.97 [-1.25, 3.20]
7 Duration of intervenous therapy279Mean Difference (IV, Fixed, 95% CI)-2.11 [-3.36, -0.87]
8 Duration of total antibiotic therapy279Mean Difference (IV, Fixed, 95% CI)-1.93 [-3.12, -0.74]
9 Duration of leukocytosis1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
10 Change in leukocyte count1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
10.1 Change between Day 3 and 1 from admission1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
10.2 Change between Day 5 and 1 from admission1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
11 Mean leukocyte count1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
11.1 Day 3 from admission1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
11.2 Day 5 from admission1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
Analysis 3.1.

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 1 Mortality.

Analysis 3.2.

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 2 Cure rate.

Analysis 3.3.

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 3 Duration of hospital stay.

Analysis 3.4.

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 4 Duration of fever.

Analysis 3.5.

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 5 Rate of improvement of chest X-ray.

Analysis 3.6.

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 6 Duration of oral antibiotic therapy.

Analysis 3.7.

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 7 Duration of intervenous therapy.

Analysis 3.8.

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 8 Duration of total antibiotic therapy.

Analysis 3.9.

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 9 Duration of leukocytosis.

Analysis 3.10.

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 10 Change in leukocyte count.

Analysis 3.11.

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 11 Mean leukocyte count.

Comparison 4. Positive expiratory pressure plus routine treatment versus routine treatment alone
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Duration of hospital stay1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
2 Duration of fever1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
Analysis 4.1.

Comparison 4 Positive expiratory pressure plus routine treatment versus routine treatment alone, Outcome 1 Duration of hospital stay.

Analysis 4.2.

Comparison 4 Positive expiratory pressure plus routine treatment versus routine treatment alone, Outcome 2 Duration of fever.

Appendices

Appendix 1. Previous search

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 3), which contains the Cochrane Acute Respiratory Infections (ARI) Group's Specialised Register; MEDLINE (1966 to August Week 1, 2009); EMBASE (1974 to August 2009); CBM (1978 to August 2009); the National Research Register (August 2009); and Physiotherapy Evidence Database (PEDro) (1929 to August 2009).

We used the following search terms in MEDLINE in conjunction with the Cochrane Highly Sensitive Search Strategy for identifying RCTs in MEDLINE (Lefebvre 2008) for identification of randomised clinical trials. We modified these terms as appropriate for other databases.

MEDLINE (OVID)

#1 exp pneumonia/
#2 exp respiratory tract infections/
#3 (pneumonia$ or lung inflammation$ or respiratory tract infection$ or respiratory infection$).mp.
#4 1 or 2 or 3
#5 exp physical therapy modalities/
#6 exp drainage, postural/
#7 exp vibration/
#8 exp positive-pressure respiration/
#9 exp breathing exercises/
#10 exp electric stimulation therapy/
#11 exp massage/
#12 exp musculoskeletal manipulations/
#13 (physical therap$ or physiotherapy$ or physical treatment$ or postural drainag$ or chest clap$ or chest percussion or chest shak$ or oscillati$ or vibration or directed cough$ or forced exhalation or forced expiration or positive pressure ventilation or positive expiratory pressure or breathing exercise$ or diaphragmatic breathing or thoracic expansion exercise$ or breathing train$ or ventilatory muscle train$ or electrostimulation or huff$ or massag$).mp.
#14 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13
#15 4 and 14
#16 randomized controlled trial.pt.
#17 controlled clinical trial.pt.
#18 randomized.ab.
#19 placebo.ab.
#20 randomly.ab.
#21 trial.ab.
#22 groups.ab.
#23 16 or 17 or 18 or 19 or 20 or 21 or 22
#24 15 and 23

See: Appendix 2, Appendix 3 and Appendix 4 for individual search strategies for CBM, EMBASE and PEDro respectively.

CBM search strategy (in Chinese)

#1 pneumonia/exp
#2 "respiratory tract infections"/exp
#3 pneumonia or "respiratory tract infection"
#4 #1 or #2 or #3
#5 "physical therapy modalities"/exp
#6 "drainage, postural"/exp
#7 "positive-pressure respiration"/exp
#8 "breathing exercises"/exp
#9 "electric stimulation therapy"/exp
#10 "massage"/exp
#11 "physical therapy" or "postural drainage" or "chest clap" or "chest percussion" or vibration or "forced exhalation" or "positive pressure ventilation" or "breathing exercise" or "thoracic expansion exercise" or "ventilatory muscle train" or "electrostimulation" or "massage"
#12 #5 or #6 or #7 or #8 or #9 or #10 or #11
#13 #4 and #12

EMBASE search strategy (via EMBASE.COM)

#1 'pneumonia'/exp
#2 'respiratory tract infections'/exp
#3 pneumonia* or lung inflammation* or respiratory tract infection* or respiratory infection*
#4 #1 or #2 or #3
#5 'physical therapy modalities'/exp
#6 'drainage, postural'/exp
#7 'vibration'/exp
#8 'positive-pressure respiration'/exp
#9 'breathing exercises'/exp
#10 'electric stimulation therapy'/exp
#11 'massage'/exp
#12 'musculoskeletal manipulations'/exp
#13 physical therap* or physiotherapy* or physical treatment* or postural drainag* or chest clap* or chest percussion or chest shak* or oscillati* or vibration or directed cough* or forced exhalation or forced expiration or positive pressure ventilation or positive expiratory pressure or breathing exercise* or diaphragmatic breathing or thoracic expansion exercise* or breathing train* or ventilatory muscle train* or electrostimulation or huff* or massag*
#14 #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13
#15 #4 and #14
#16 'randomized controlled trial':it
#17 'controlled clinical trial':it
#18 randomized:ab
#19 placebo:ab
#20 randomly:ab
#21 trial:ab
#22 groups:ab
#23 #16 or #17 or #18 or #19 or #20 or #21 or #22
#24 #15 and #23

PEDro search strategy

#1 pneumonia AND "physical therapy"
#2 "respiratory tract infection" AND "physical therapy"
#3 #1 OR #2

Appendix 2. Embase.com search strategy

#36 #32 AND #35
#35 #33 OR #34
#34 random*:ab,ti OR placebo*:ab,ti OR factorial*:ab,ti OR crossover*:ab,ti OR 'cross over':ab,ti OR 'cross-over':ab,ti OR volunteer*:ab,ti OR assign*:ab,ti OR allocat*:ab,ti OR ((singl* OR doubl*) NEAR/1 blind*):ab,ti
#33 'randomized controlled trial'/exp OR 'single blind procedure'/exp OR 'double blind procedure'/exp OR 'crossover procedure'/exp
#32 #9 AND #31
#31 #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR #30
#30 (osteopath* NEAR/3 (manipulat* OR treatment* OR therap* OR techniq*)):ab,ti
#29 ((respirat* OR ventilat*) NEAR/2 'muscle training'):ab,ti
#28 massag*:ab,ti
#27 electrostimulat*:ab,ti AND [embase]/lim 1947
#26 'positive pressure ventilation':ab,ti OR 'positive expiratory pressure':ab,ti
#25 (breath* NEAR/2 (control* OR techni* OR train* OR exercis*)):ab,ti
#24 (cough* NEAR/2 (directed OR maneuver* OR manoeuver* OR techniq*)):ab,ti
#23 (forced NEAR/2 (exhal* OR expir*)):ab,ti
#22 ((chest OR thora*) NEAR/3 (clap* OR shak* OR compress)):ab,ti
#21 oscillat*:ab,ti OR vibrat*:ab,ti OR percuss*:ab,ti OR huff*:ab,ti
#20 'postural drainage':ab,ti OR (patient* NEAR/3 position*):ab,ti
#19 'manipulative medicine'/exp
#18 'electrostimulation therapy'/de
#17 'massage'/de
#16 'electrostimulation'/de
#15 'breathing exercise'/de
#14 'postural drainage'/de
#13 'positive end expiratory pressure'/de OR 'forced expiration'/de
#12 'vibration'/de OR 'high frequency oscillation'/de OR 'oscillation'/de OR 'whole body vibration'/de
#11 physiotherap*:ab,ti OR 'physio therapy':ab,ti OR (physical NEAR/1 (therap* OR treatment*)):ab,ti
#10 'physiotherapy'/exp
#9 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR # 8197040
#8 (pleural NEAR/2 (effusion OR empyema)):ab,ti OR pleurisy:ab,ti
#7 'pleurisy'/exp
#6 (lung NEAR/2 (inflamm* OR infect*)):ab,ti
#5 (lower NEAR/3 'respiratory tract infection'):ab,ti OR (lower NEAR/3 'respiratory tract infections'):ab,ti OR (lower NEAR/3 'respiratory infection'):ab,ti OR (lower NEAR/3 'respiratory infections'):ab,ti OR lrti:ab,ti
#4 'lower respiratory tract infection'/de
#3 bronchopneumon*:ab,ti OR pleuropneumon*:ab,ti
#2 pneumon*:ab,ti
#1 'pneumonia'/exp

Appendix 3. PEDro search strategy

Abstract and title: pneumonia
Method: clinical trial
New records added since: 6 January 2009

Appendix 4. CINAHL (Ebsco) search strategy

S40 S30 AND S39
S39 S31 OR S32 OR S33 OR S34 OR S35 OR S36 OR S37 OR S38
S38 (MH "Quantitative Studies")
S37 TI placebo* OR AB placebo*
S36 (MH "Placebos")
S35 TI random* OR AB random*
S34 TI ((singl* or doubl* or trebl* or tripl*) W1 (blind* or mask*)) OR AB ((singl* or doubl* or trebl* or tripl*) W1 (blind* or mask*))
S33 TI clinic* W1 trial* OR AB clinic* W1 trial*
S32 PT clinical trial
S31 (MH "Clinical Trials+")
S30 S10 AND S29 S
S29 S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21 OR S22 OR S23 OR S24 OR S25 OR S26 OR S27 OR S28
S28 TI (osteopath* N3 (manipulat* or treatment* or therap* or techni*)) OR AB (osteopath* N3 (manipulat* or treatment* or therap* or techni*))
S27 TI ((respirat* or ventilat*) N2 muscle train*) OR AB ((respirat* or ventilat*) N2 muscle train*)
S26 TI massag* OR AB massag*
S25 TI electrostimulat* OR AB electrostimulat*
S24 TI (positive pressure ventilation* or positive expiratory pressure*) OR AB (positive pressure ventilation* or positive expiratory pressure*)
S23 TI (breath* N2 (control* or techni* or train* or exercis*)) OR AB (breath* N2 (control* or techni* or train* or exercis*))
S22 TI ( cough* N2 (directed or maneuver* or manoeuver* or techni*) ) OR
AB (cough* N2 (directed or maneuver* or manoeuver* or techni*))
S21 TI (forced N2 (exhal* or exhil*)) OR AB (forced N2 (exhal* or exhil*))
S20 TI ((chest* or thora*) N3 (clap* or shak* or compress*)) OR AB ((chest* or thora*) N3 (clap* or shak* or compress*))
S19 TI (oscillat* or vibrat* or percuss* or huff*) OR AB (oscillat* or vibrat* or percuss* or huff*)
S18 TI patient* N3 position* OR AB patient* N3 position*
S17 TI postural drain* OR AB postural drain*
S16 (MH "Drainage, Postural")
S15 (MH "Positive Pressure Ventilation+")
S14 (MH "Respiratory Therapy+")
S13 (MH "Vibration")
S12 TI (physiotherap* or physical therap* or physical treatment*) OR AB (physiotherap* or physical therap* or physical treatment*)
S11 (MH "Physical Therapy+")
S10 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9
S9 TI pleurisy OR AB pleurisy
S8 TI (pleural N3 (empyema or effusion*)) OR AB (pleural N3 (empyema or effusion*))
S7 (MH "Empyema") OR (MH "Pleural Effusion") OR (MH "Pleurisy")
S6 TI (lung* N3 (inflam* or infect*)) OR AB (lung* N3 (inflam* or infect*))
S5 TI (lower respiratory tract infection* or lower respiratory infection* or lrti) OR AB (lower respiratory tract infection* or lower respiratory infection* or lrti)
S4 (MH "Respiratory Tract Infections")
S3 TI (bronchopneumon* or pleuropneumon*) OR AB (bronchopneumon* or pleuropneumon*)
S2 TI pneumon* OR AB pneumon*
S1 (MH "Pneumonia+")

What's new

DateEventDescription
21 November 2012New citation required but conclusions have not changedOur conclusions remain unchanged
21 November 2012New search has been performedSearches conducted. We excluded two new trials in this update (Dangour 2011; Noll 2008)

History

DateEventDescription
21 November 2011New search has been performedSearches conducted
9 September 2010AmendedContact details updated
5 August 2010AmendedContact details updated
12 August 2008AmendedConverted to new review format

Contributions of authors

All authors have contributed to this review.
XL Yin (XLY) and BY Wang (BYW) searched the databases, extracted the data and reformed the tables.
BYW and YP Yan (YPY) screened trials.
M Yang (MY) and YPY appraised the quality of included trials and drafted the full text.
BR Dong (BRD) and TX Wu (TXW) were responsible for editing.
BRD also acted as an arbitrator.
GJ Liu (HGJL) was the consultant for data analysis.

Declarations of interest

None.

Sources of support

Internal sources

  • Chinese Cochrane Center, Chinese Centre of Evidence-Based Medicine, West China Hospital of Sichuan University, China.

External sources

  • No sources of support supplied

Differences between protocol and review

Some secondary outcomes (duration of antibiotic therapy, duration of sputum production, in-patient sputum weight, duration of leukocytosis, change in leukocyte count and mean leukocyte count), which were not included in the protocol, were assessed in the review.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Bjorkqvist 1997

MethodsRandomised, parallel-group trial
Participants

In-patient setting; relevant details of health status of participants; age; sex; country

50 treatment, 48 control

16 to 95 years old (mean 65)

Male/female: 84 /61

Conducted in Sweden

InterventionsThe physiotherapy was positive expiratory pressure (PEP). In this study a bottle containing 10 cm of tap water was used. Patients were asked to sit up with their feet on the floor and blow bubbles at a calm speed into the bottle through a plastic tube (10 mm in diameter) with an air pressure just sufficient to overcome the resistance of the water. This method was used 20 times per hour from 9 am to 8 pm and continued after discharge. This study consisted of three group (A, B, C). Group A was control which underwent early mobilisation and "huffing". Group B members were given the same as A and deep breaths. Group C members were given the same as A and the method of bottle-blowing
Outcomes

Primary outcomes: death

Secondary outcomes: duration of hospital stay (days); fever clearance time; CRP; VC; FEV1; PEF

NotesThe study was supported financially by the Orebro County Council Research Committee and the Orebro Medical Center Research Foundation
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskThe randomised method was not clearly reported
Allocation concealment (selection bias)Low risk"Sealed envelopes" were used
Blinding (performance bias and detection bias)
All outcomes
High riskNo blinding
Incomplete outcome data (attrition bias)
All outcomes
Low risk19 (13%) patients were drop-outs. However, ITT analysis was performed
Selective reporting (reporting bias)Unclear riskInsufficient information
Other biasUnclear riskInsufficient information

Britton 1985

MethodsRandomised, parallel-group, single-blind trial
Participants

In-patient setting; relevant details of health status of participants; age; sex; country

83 treatment, 88 control

15 to 75 years old (control: 47.2, treatment: 47.4)

Male/female: 74/97

Conducted in Sweden

InterventionsThe chest physiotherapy consisted of postural drainage, external help with breathing, percussion and vibration. The placebo was to receive advice on expectoration, deep breathing and how to exercise to avoid thrombosis
Outcomes

Primary outcomes: death; cure rate

Secondary outcomes: duration of hospital stay (days); healing time (days); fever clearance time; FEV1

Notes

The study was approved by the ethical committee of the Karolinska Hospital, Stockholm

Sources of funding were not stated

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskThe randomised method was not clearly reported
Allocation concealment (selection bias)Low risk"Sealed envelopes" were used
Blinding (performance bias and detection bias)
All outcomes
Low riskOutcome assessor was blinded
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskInsufficient information
Selective reporting (reporting bias)Unclear riskInsufficient information
Other biasHigh riskThe standard deviations of duration of hospital stay and fever were not reported

Graham 1978

MethodsRandomised, parallel-group trial
Participants

In-patient setting; relevant details of health status of participants; age; sex; country

27 treatment, 27 control

Age (mean ± SD): control: 63 ± 3 years old, treatment: 61 ± 4 years old

Male/female: control 13/14, treatment 14/13

Conducted in Sweden

InterventionsThe chest physiotherapy consisted of postural drainage, chest percussion and vibration, with encouragement of deep breathing and coughing. This therapy was used concomitantly with intermittent positive pressure breathing every 4 hours during the first 24 hours. Therapy was given for at least 3 days to all the treated participants, with an average duration of 5 days
Outcomes

Primary outcomes: death; cure rate

Secondary outcomes: duration of hospital stay (days); rate of clearing of X-ray film; fever clearance time

Notes

The study was supported by a grant (PHS 17292) to the Vermont Lung Center from the National Heart, Lung, and Blood Institute, National Institutes of Health

Sources of funding not stated

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskThe method of randomisation was not described
Allocation concealment (selection bias)Low risk"Sealed envelopes" were used
Blinding (performance bias and detection bias)
All outcomes
Unclear riskInsufficient information
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskInsufficient information
Selective reporting (reporting bias)Unclear riskInsufficient information
Other biasUnclear riskInsufficient information

Noll 1999

MethodsRandomised, parallel-group, double-blind trial
Participants

In-patient setting; relevant details of health status of participants; age; sex; country

11 in treatment group, 10 in control group

The mean age was 78.7 in the control group, 82.5 in the treatment group

Male/female: control 3/7, treatment 3/8

The trial was conducted in the United States

InterventionsPatients in the treatment group received a standardised osteopathic manipulative treatment protocol treatment consisting of 7 osteopathic manipulative techniques and non-standardised osteopathic manipulative treatments from an osteopathic manipulative treatment specialist, while participants in the control group received a standardised light touch protocol treatment (sham treatment), with care taken not to move myofascial structures or to articulate joints. The session was 10 to 15 minutes, and the frequency of treatment was 2 sessions per day
Outcomes

Primary outcomes: death; cure rate

Secondary outcomes: duration of hospital stay (days); rate of clearing of X-ray film; duration of antibiotic therapy; duration of leukocytosis

Notes
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskThe method of randomisation was not described
Allocation concealment (selection bias)Unclear riskInsufficient information
Blinding (performance bias and detection bias)
All outcomes
Low riskPatients and outcome assessors were blinded
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo drop-outs
Selective reporting (reporting bias)Unclear riskInsufficient information
Other biasUnclear riskInsufficient information

Noll 2000

MethodsRandomised, double-blind, parallel trial
Participants

In-patient setting; relevant details of health status of participants; age; sex; country

28 in treatment group; 30 in control group

Age (mean ± SD): control group: 77.0 ± 17.2 years old; treatment group: 77.7 ± 17.1 years old

Male/female: control group: 16/14; treatment group: 14/14

The trial was conducted in the United States

InterventionsPatients in the treatment group received a standardised osteopathic manipulative treatment protocol treatment consisting of 7 osteopathic manipulative techniques and non-standardised osteopathic manipulative treatments from an osteopathic manipulative treatment specialist, while participants in the control group received a standardised light touch protocol treatment (sham treatment), with care taken not to move myofascial structures or to articulate joints. The session was 10 to 15 minutes, and the frequency of treatment was 2 sessions per day
Outcomes

Primary outcomes: death; cure rate

Secondary outcomes: duration of hospital stay (days); rate of clearing of X-ray film; duration of antibiotic therapy; change in leukocyte count; mean leukocyte count

Notes
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskThe method of randomisation was not described
Allocation concealment (selection bias)Unclear riskInsufficient information
Blinding (performance bias and detection bias)
All outcomes
Low riskPatients and outcome assessors were blinded
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo drop-outs
Selective reporting (reporting bias)Unclear riskInsufficient information
Other biasUnclear riskInsufficient information

Tydeman 1989

  1. a

    CRP: C-reactive protein
    VC: vital capacity
    FEV1: forced expiratory volume in the first second
    ITT: intention-to-treat
    PEF: peak expiratory flow
    OMT: osteopathic manipulative treatment

MethodsRandomised, parallel-group trial
Participants

In-patient setting; relevant details of health status of participants; age; sex; country

12 treatment, 20 control

Age (mean ± SD): control: 36.80 ± 16.91 years old, treatment: 42.08 ± 15.59 years old

Male/female: control 10/10, treatment 9/3

Conducted in UK

InterventionsThe physiotherapy was active cycle of breathing techniques, which consisted of breathing control using the diaphragm; localised expansion exercises; postural drainage; thoracic expansion exercises with vibrations on expiration; percussion. The first 2 methods were continued to discharge and the other methods were used when participants became productive of sputum. The dose of the therapy was dependent on the patient's tolerance and the sputum production
Outcomes

Primary outcomes: death; cure rate

Secondary outcomes: duration of hospital stay (days); rate of clearing of X-ray film; duration of all antibiotic therapy; duration of production of sputum; in-patient sputum weight

NotesThis study was under the funding of Norwich Health Authority and the East Anglian Regional Health Authority Research Committee
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskThe method of randomisation was not described
Allocation concealment (selection bias)Unclear riskInsufficient information
Blinding (performance bias and detection bias)
All outcomes
High riskBlinding was not performed
Incomplete outcome data (attrition bias)
All outcomes
Low riskOnly 4 (11%) patients did not complete the study. Among them, 1 patient died, 2 patients were re-diagnosed as having other disease and 1 patient could not attend sufficient assessments
Selective reporting (reporting bias)Unclear riskInsufficient information
Other biasUnclear riskInsufficient information

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
  1. a

    COPD: chronic obstructive pulmonary disease
    RCT: randomised controlled trial

Barkov 1987Physical agent; no control
Britton 1983aSecondary publications under Britton 1985
Britton 1983bSecondary publications under Britton 1985
Burioka 1998The participants had diffuse panbronchiolitis
Cheng 2004This study was not a RCT or quasi-RCT. It covered mechanical ventilation for patients with acute respiratory failure caused by pneumonia
Choi 2005Study was about mechanical ventilation for patients with pneumonia
Confalonieri 1998aStudy was about respiratory failure caused by pneumonia
Confalonieri 1998bStudy was about respiratory failure caused by pneumonia
Dangour 2011It was a prevention study
Fu 2005In addition to pneumonia, the participants also had asthma, chronic bronchitis or bronchiectasis. Not a RCT or quasi-RCT
Holody 1981In addition to pneumonia, the participants had atelectasis. Not a RCT or quasi-RCT
Jolliet 2001Not a RCT or quasi-RCT
Li 2005Some participants with pneumonia also had congestive heart failure or diabetes mellitus. Not a RCT or quasi-RCT
Mo 2004Some participants with pneumonia also had COPD or asthma. A before-and-after study in the same participants
Noll 2008It was a study protocol
Patman 2009Some participants in the study were less than 18 years old. There was no subgroup analysis for adults provided in the study
Schultz 2006The participants also had asthma, lung cancer, COPD or pulmonary embolism
Wan 2004Participants had lower respiratory tract infections, not only pneumonia. Not a RCT or quasi-RCT
Wang 1997The participants also had chronic bronchitis or acute bronchitis, not only pneumonia. Not a RCT or quasi-RCT
Wu 2005aParticipants had a pulmonary infection, not only pneumonia. Not a RCT or quasi-RCT
Wu 2005bParticipants had a pulmonary infection, not only pneumonia. Not a RCT or quasi-RCT
Wu 2005cParticipants had pneumonia caused by chronic bronchitis. Not a RCT or quasi-RCT
Xia 2005Participants had a pulmonary infection, not only pneumonia. Not a RCT or quasi-RCT
Xu 2004Participants had lower respiratory tract infections, not only pneumonia. Not a RCT or quasi-RCT
Zha 2004The participants had acute lung abscesses. Not a RCT or quasi-RCT
Zhang 2004Participants had pneumonia caused by COPD, not only pneumonia. Not a RCT or quasi-RCT

Characteristics of studies awaiting assessment [ordered by study ID]

Facto 1947

MethodsUnclear
ParticipantsUnclear
InterventionsUnclear
OutcomesUnclear
Notes

Kuznetsov 1976

MethodsUnclear
ParticipantsUnclear
InterventionsUnclear
OutcomesUnclear
Notes

Kuznetsov 1980a

MethodsUnclear
ParticipantsUnclear
InterventionsUnclear
OutcomesUnclear
Notes

Kuznetsov 1980b

MethodsUnclear
ParticipantsUnclear
InterventionsUnclear
OutcomesUnclear
Notes

Sedov 1975

MethodsUnclear
ParticipantsUnclear
InterventionsUnclear
OutcomesUnclear
Notes

Vorob'ev 1984

MethodsUnclear
ParticipantsUnclear
InterventionsUnclear
OutcomesUnclear
Notes

Characteristics of ongoing studies [ordered by study ID]

Noll

  1. a

    IV: intravenous
    WBC: white blood cell

Trial name or titleMulti-Center Osteopathic Pneumonia Study in the Elderly (MOPSE)
MethodsRandomised, double-blind, placebo-controlled trial
Participants

Inclusion criteria:

  • 50 years old or older

  • Patient is hospitalised in an acute care facility

  • Patient must exhibit at least 2 of the classic symptoms of pneumonia, to include:

    • respiration rate greater than or equal to 25 respirations per minute

    • new or increased cough

    • fever greater than or equal to 100.4 degrees F (38 degrees C)

    • pleuritic chest pain

    • worsening of mental or functional status

    • leukocytosis (WBC greater than 12,000 cells per cubic millimetre)

    • new or increased physical findings (rales, wheezing, bronchial breath sounds)

Exclusion criteria:

  • Lung abscess

  • Advancing pulmonary fibrosis

  • Bronchiectasis

  • Pulmonary tuberculosis

  • Lung cancer

  • Metastatic malignancy

  • Uncontrolled metabolic bone disease that places subject at risk of pathologic bone fracture (i.e. Paget's disease or hypoparathyroidism)

  • Acute or unhealed rib or vertebral fracture

  • History of pathologic bone fracture

  • Previous participation in the study

  • Respiratory failure (intubation)

Interventions

The first group: osteopathic manipulative treatment (OMT)

The second group: light touch control

The third group: conventional care only

OutcomesPrimary outcome measures: length of hospital stay, time to clinical stability, rate of symptomatic and functional recovery
Secondary outcome measures: duration of IV and oral antibiotic usage in the hospital, number of complications and deaths secondary to pneumonia, duration and severity of fever, duration and severity of leukocytosis, patient satisfaction
Starting dateMarch 2004
Contact informationNot available
NotesThe trial had been completed when we were drafting this review, however it has not yet been published

Ancillary