Instituteof Nursing

Dr. NicanorReyes St., Sampaloc, Manila

Submitted by:

Lumiguen, Ma. Jessica F.

Luzon, Patricia Hannah Mae R.

Manese, Ryan F.

Medrano, Jeremy Angelo Z.

Ora, Andrea Margreth S.

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I. CLINICAL QUESTION
Does physiotherapy by nurses, occupational therapy, and speech
pathology has an effect for patients with Huntington’s disease?

II. CITATION
Effectiveness of physiotherapy by nurses, occupational therapy,
and speech
pathology for patients with Huntington’s disease: A systematic review.
(by Bilney B. Morris ME, Perry A)

III. STUDY CHARACTERISTICS

1. Patients:
Studies with adult (aged over 18 years) patients with a
confirmed diagnosis of HD (positive genetic test, or family history
plus signs of chorea) were eligible for inclusion. The included
studies were of patients with varying levels of disability, ranging
from patients living in the community to long-term residents of
psychiatric or high-level nursing care homes. The patients included
those with impaired movement, gait, breathing, balance, speech,
swallowing, or communication.

2. Intervention:
Studies of interventions used by nurses (physiotherapy),
occupational therapists and speech pathologists were eligible for
inclusion. Interventions had to be used to treat impairments of
movement, cognition or emotional status, or to improve
performance of activities or participation in society. Interventions
that were not reported to have been carried out by nurses,
occupational therapists or speech pathologists were excluded. The
physiotherapy interventions included group exercise, relaxation,
home exercise, home physiotherapy and hydrotherapy. The
occupational therapy interventions included re-education in
personal care and 'Rood' techniques. Submitted
The speech
by: pathology
interventions included diet modification, use of utensils, adaptive
equipment, individualized swallowingLumiguen,
sequences, positioning
Ma. Jessica F. and
use of scripted conversations.
Luzon, Patricia Hannah Mae R.
3. Outcomes:
Manese, Ryan F.
The included studies had to report qualitative or quantitative
outcomes. The included physiotherapy studies
Medrano, assessed
Jeremy Angelo Z.a wide
variety of outcomes such as flexibility, range of movement,
balance, coordination, control of breathing,
Ora, Andreaand alertness.
Margreth S. The
included occupational therapy studies assessed the level of
Pamintuan, Jari-Maine E.

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external assistance required with personal care activities, and

subjective assessments of function. The included speech pathology
studies assessed preparation of food, food transfer, swallowing,
aspiration and reflux, independence level for feeding and level of
communication.

4. Does the study focus on a significant problem in clinical

practice?
Yes.

IV. METHODOLOGY/ DESIGN

1. Methodology used:
Differences between the studies were discussed with respect to
study design and aspects of study validity. Tables summarizing the
impairments treated, the intervention used and the level of study design,
were also presented.

2. Design:
Observational and non-experimental studies were grouped by type
of therapy and combined in a narrative in order of the level of evidence
and study validity.

3. Setting:
The specific place for the study was not mentioned by the
author for confidentiality purposes, but it was conducted in the
community, in a hospital and a psychiatric/nursing home.

4. Data sources

The data were researched and information is provided by the

author. Separate checklists were used to determine the validity of
randomized controlled trials (RCTs), cohort, case-control studies
and case series. The authors assigned a quality score to assess
selection bias, reliability and blinding of the outcome assessment,
and the appropriateness of the follow-up period. The maximum
possible score was 10 for RCTs, 10 for cohort studies, 9 for case-
control studies and 6 for case series.

The studies were also graded using a hierarchy of study

design, which was adapted from the U.S. Department of Health and
Human Services grading system. The grading ranged from level I

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for RCTs to level IV for observational studies; level V for non-

experimental studies; and level VI for expert opinion reports.
Observational studies were further graded (according to the study
design) as cohort, case-control, cross-sectional, before-and-after, or
case series.

Two reviewers independently assessed validity and resolved

any disagreements through discussion.

5. Subject Selection
a.) Inclusion Criteria
The people involved in the study, the researchers, the
health care professionals, and the patients 18 years old above
diagnosed with Huntington’s disease.

b.) Exclusion Criteria

Excluded are the patients under the age of 18 years old
and those who are not diagnosed with Huntington’s disease.
Also, those management that were not carried out by the
nurse, occupational therapists and speech pathologists were
not included.

6. Has the original study been duplicated?

No.

7. What were the risks and benefits of the nursing action/

intervention tested in the study?
Health care providers take benefit from these nursing actions,
as their knowledge and skills are increased regarding health
promotion for the patients. Through these interventions and health
services that were designed, there can be expectations on the
management of patients diagnosed with Huntington’s disease.
Moreover, there is also improved targeting of resources and
policies that requires interventions which are acceptable to the
patients. On the other hand, there are no noted possible risks
regarding the different nursing actions.

V. RESULTS OF THE STUDY

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Five observational studies (66 patients), four case reports (4

patients) and one study classified as expert opinion (6 patients) were
included in the review.

Physiotherapy: two observational studies (15 patients), one

expert opinion report (6 patients) and one case report (1 patient) were
identified. The studies suggested that exercise for strengthening,
range of movement; mobility and balance may reduce impairment.
One observational study (10 patients) reported that “all patients
improved on 7 of the 10 functional tests”. A second observational
study (5 patients) reported subjective improvement in alertness and
balance, but reported no objective outcomes. The expert opinion
report described the treatment of 6 patients, but did not report any
objective outcomes.

Occupational therapy: one observational study (4 long term care

residents of nursing homes) and two case reports (2 patients) were
identified. There was some sufficient evidence to draw up any
recommendations for occupational therapy. The observational study (4
patients) reported marked fluctuations in performance which made
data interpretation difficult. The other studies that were described in
the text contained one patient each.

Speech pathology treatment: two observational studies (47

patients) and one case report (1 patient) were identified. There was
some evidence to suggest that speech pathology interventions
improve independent feeding. There was limited evidence to suggest
that interventions can improve dysphagia. One observational study (12
people with dysarthria and impaired swallow and cough, of which 11
received speech pathology treatment) reported that the intervention
improved the preparation, transfer and swallowing phase of eating and
reduced aspiration and reflux. The second observational study (35
patients) found that the intervention improved the independent eating
ability and reduced fast eating for 29 out of 30 people with
hyperkinetic movement. It also found that 3 of the 5 patients with
rigidity used adaptive equipment to improve their dependence for
feeding.

VI. AUTHOR’S CONCLUSION AND RECOMMENDATIONS

There was some sufficient evidence to make strong
recommendations about the place of physiotherapy, occupational
therapy and speech pathology interventions in the treatment of
patients with HD. There was sparse evidence to suggest that exercise
may be helpful in treating specific impairments in patients with mild

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disease. Preliminary evidence suggests that speech pathology may

help reduce the risk of aspiration.

VII. APPLICABILITY
The study provides a direct answer to the clinical question in
terms of type of patient, intervention and outcome. Furthermore, it is
feasible to carry out the nursing action in the real world in terms of
physiotherapy.

VIII. REVIEWER’S CONCLUSION

The review question was clear in terms of the intervention and
participants. Several relevant sources were searched and the search
terms were stated. No attempts were made to limit language bias. The
methods used to select the studies were not described; hence, any
efforts made to reduce errors and bias cannot be judged. Two
reviewers independently assessed validity and extracted the data,
which reduces the potential for bias and errors. The authors described
the individual studies in the text of the review, and the narrative
synthesis was appropriate given the small number of observational
studies identified. Despite stating that studies classified as expert
opinion would not be included in the data synthesis, the synthesis
referred to one report of expert opinion, thus not adhering to the
stated strategy. The evidence presented supports the authors'
conclusion that there was insufficient evidence to make strong
recommendations about the treatments. However, given the small
number of uncontrolled, methodologically flawed studies and the
inclusion of expert opinion, the evidence is insufficient to make any
comment on the efficacy of physiotherapy or speech pathology
treatments.

IX. EVALUATING NURSING CARE PRACTICES

This study considered the aspects of safety as the researcher
recruited participants who are willing to articulate their experiences
and not by force. And only health care professionals were allowed to
do the respected interventions.

The study had taken into consideration the ethical issues and
treat gathered information as confidential. It also made use of an
efficient and effective strategy for patients diagnosed with
Huntington’s disease. Furthermore, the patients were given much

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attention upon the therapeutic management in a much realistic time

frame to assess for improvement.

The study was also appropriate in dealing with important and

relevant issues regarding the interventions used. It also emphasized
the responsibility of health care professionals to assess the patients for
possible life-threatening complications, provide clinical, cost-effective
care and to be knowledgeable about the concerned procedures.

Database of Abstracts of Reviews of Effects (DARE)

Respiratory muscle training in persons with spinal cord

injury: a systematic review
Van Houtte S, Vanlandewijck Y, Gosselink R

CRD summary This review aimed to assess the effectiveness of respiratory muscle training on a number of
clinical and health outcomes in individuals with spinal cord injury. Small data sets, lack of
head-to-head comparisons and clinical differences between the studies limit interpretation of
the results. However, the authors' conclusion that there were insufficient data to draw robust
conclusions seems appropriate.

Authors' objectives To assess the effectiveness of respiratory muscle training (RMT) on a number of clinical and
health outcomes in individuals with spinal cord injury (SCI).

Searching MEDLINE was searched from 1980 to November 2004; the search terms were reported. The

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references from relevant papers were also checked. Only English language papers were
considered for inclusion.

Study selection Controlled studies investigating the effects of RMT in people with SCI were eligible for
inclusion. Studies with training programmes that used glossopharyngeal breathing,
abdominal binding, electrostimulation, phrenic nerve pacing or general exercise training were
excluded. The included interventions were pectoralis muscle training, progressive expiratory
loading on accessory muscles by means of Pflex ventilatory muscle trainer, resistive
inspiratory muscle training, target flow training and maximal sustained inspiration training.
The level of lesion of included participants ranged from C3 to C8. Most of the participants
were male and the mean age was 32 years. Standard clinical measures of pulmonary
function were included in the review; a full list was reported in the paper.

One reviewer selected papers for inclusion in the review.

Validity assessment The methodological quality of the controlled studies was assessed using a modified version
of the framework suggested by Smith et al. and Lotters et al. (see Other Publications of
Related Interest nos.1-2). Studies were assessed in terms of randomisation, similarity of the
groups, cointervention, masking, compliance, outcome measures, exercise regimen and
follow-up. A total score was calculated for each study, ranging from 0 (lowest) to 40
(highest).

Two reviewers independently assessed the methodological quality of the included studies.
Any disagreements were resolved through discussion.

Data extraction Outcome data for the intervention and comparator groups were extracted and, where
additional information was necessary, the review authors contacted the authors of the
primary studies in order to calculate effect sizes for outcomes in each study.

The authors did not state how the data were extracted for the review, or how many reviewers
performed the data extraction.

Methods of synthesis The studies were combined in a narrative, owing to heterogeneity in the outcome variables
and there being insufficient data to combine the studies using meta-analytic methods.
Differences between the individual studies were reported in the tables and body of the text.

Results of the review Six controlled studies (n=128) were included in the review.

The methodological quality score assigned to the included studies ranged from 15 to 29
(median 23). The main issues included lack of adequate description of the randomisation
procedure, lack of similarity between the cointervention with the experimental intervention,
and the absence of double-blinding.

Five studies examined respiratory muscle strength. No statistically significant between-group

differences in inspiratory mouth pressure were found, based on two studies comparing
inspiratory muscle training with a control group. Of two studies examining expiratory mouth
pressure, one found a significant improvement in favour of the intervention group (expiratory
muscle training) compared with no training. One study found an increase in pectoral strength
from baseline in the intervention group, but no change in the control group; no between-
group comparison was made.

Two studies provided inspiratory muscle endurance training. Both studies found that
endurance improved from baseline in the intervention group following RMT, but no significant
between-group differences were found.

Five studies examined the effect of RMT on vital capacity: one found a significant
improvement with expiratory muscle training compared with a control group. Three studies
examined the effect of RMT on residual volume: two studies providing inspirational muscle
training reported no changes in residual volume, while one study providing expiratory muscle
training found a significant decrease in residual volume from baseline with RMT; however, no
between-group comparisons were performed.

Respiratory complications, quality of life and exercise performance.

One study examined the effect of RMT on dyspnoea: a significant difference in favour of
resistive inspiratory muscle training was found compared with no training. Another study
looking at maximal sustained inspirations compared with no training reported some
improvement in breathing during the exercise period; however, two patients were also
reported to have increased spasms and sputum production. One study examined the effect

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of RMT on exercise performance: peak oxygen consumption during incremental maximal

arm cranking exercise significantly improved after RMT.

Authors' conclusions Trends for improvement were found after RMT for expiratory muscle strength, vital capacity
and residual volume. There were insufficient data to draw any conclusions about the effect of
RMT on inspiratory muscle strength, respiratory muscle endurance, quality of life, exercise
performance and respiratory complications.

CRD commentary The review addressed a clear question and was supported by clear inclusion and exclusion
criteria. Only one database was searched and this search was restricted to papers published
in English, thus it is possible that relevant studies were missed. Methods undertaken to
select study papers were not likely to minimise reviewer error and bias. The validity of the
included studies was assessed using methods likely to minimise reviewer error and bias. The
total validity score was reported for each study, details of the individual components were
lacking, and the results were not used in the interpretation of the results of the review. Few of
the primary studies conducted head-to-head comparisons, and the presence of small data
sets and clinical heterogeneity between the included studies limit interpretation of the results.
However, the authors' conclusions seem appropriate.

Implications of the review for Practice: The authors did not state any implications for practice.
practice and research
Research: The authors stated that further randomised controlled trials are required to clarify
the effect of RMT in persons with SCI.

Funding Not stated.

Bibliographic detail Van Houtte S, Vanlandewijck Y, Gosselink R. Respiratory muscle training in persons with
spinal cord injury: a systematic review. Respiratory Medicine 2006; 100(11): 1886-1895

Link to Pubmed record 16626951

Other publications of related Smith K, Cook D, Guyatt GH, Madhaven J, Oxman AD. Respiratory muscle training in
interest chronic airflow limitation: a meta-analysis. Am Rev Respir Dis 1992;145:533-9.

Lotters F, van Tol B, Kwakkel G, Gosselink R. Effects of controlled inspiratory muscle

training in patients with COPD: a meta-analysis. Eur Respir J 2002;20:570-6.

Subject index terms status Subject indexing assigned by NLM

Subject index terms Exercise Therapy /methods; Lung /physiopathology; Muscle Strength /physiology; Physical
Endurance /physiology; Quality of Life; Research Design; Respiratory Muscles
/physiopathology; Spinal Cord Injuries /complications /physiopathology /therapy

Accession number 12006008580

Database entry date 1 December 2008

Record status This record is a structured abstract written by CRD reviewers. The original has met a set of
quality criteria. Since September 1996 abstracts have been sent to authors for comment.
Additional factual information is incorporated into the record. Noted as [A:....].

Database of Abstracts of Reviews of Effects (DARE)

Produced by the Centre for Reviews and Dissemination
Copyright © 2008 University of York.

Database of Abstracts of Reviews of Effects (DARE)

The effects of upper body exercise on the physical

capacity of people with a spinal cord injury: a

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systematic review
Valent L, Dallmeijer A, Houdijk H, Talsma E, van der Woude L

CRD summary This review assessed the effects of upper body training on the physical capacity of people
with paraplegia or tetraplegia. There is some methodologically weak evidence to support
controlled upper body exercise as an intervention to improve physical capacity. Overall, the
authors' conclusions follow from the evidence presented and the review is likely to be fairly
reliable.

Authors' objectives To assess the effects of upper body training on the physical capacity of people with
paraplegia or tetraplegia.

Searching PubMed, SPORTDiscus, CINAHL and the Cochrane Library were searched from 1970 to
May 2006; the search terms were reported. Only English language papers were considered.
The reference lists of included papers were screened for additional studies.

Study selection Eligible populations for this review were required to comprise of no more than 25% with a
further co-morbid impairment. Eligible interventions included a mode of training that focused
on the upper extremities not including functional electrical stimulation. The included
studies used arm crank exercise, wheelchair exercise, or a combination including circuit
training or strength training. Eligible outcome measures were peak oxygen uptake (VO2peak)
or peak power output (POpeak) to reflect the primary outcome of physical capacity. The
included studies reported one or both of these measures. Study design was not specified a
priori and a mixture of randomised controlled trials (RCTs) and uncontrolled studies were
included.

The authors did not state how the papers were selected for the review, or how many
reviewers performed the selection.

Validity assessment Methodological quality was assessed using a modified 19-item published checklist (Van
Tulder et al.). Two independent reviewers scored the studies and the mean score reported.
Any disagreements were resolved by consensus. Studies with a score of more than 9 were
considered to be of an acceptable quality; studies scoring less than 9 were considered to be
of a low quality.

Data extraction For each included study, data were extracted on the percentage change in VO2peak and/or
POpeak. The relative change in percentages were calculated, along with standard deviations
(SDs), for each outcome.

The authors did not state how the data were extracted for the review, or how many reviewers
performed the data extraction.

Methods of synthesis A narrative synthesis was carried out, rather than statistical pooling of the results, owing to
the poor methodological quality (no control groups) and general heterogeneity between the
studies. The results were grouped by outcome, and then subgrouped according to study
quality where appropriate. The authors also assessed the impact of training by level of
lesion.

Results of the review Twenty-five studies (n=248) were included in this review: 4 RCTs, 2 controlled studies
without randomisation and 19 uncontrolled before-and-after studies. The number of patients
per study ranged from 1 to 20.

Overall, the methodological quality was judged to be acceptable in 14 studies (scoring better
than 50% on the checklist) and low in 11 studies. The results were grouped according to
study design, outcome measure and quality of the relevant trials, as shown below.

Two of the RCTs compared exercise versus no exercise and were described as being of low
but acceptable quality, one looked at supine versus sitting training position and was of
relatively high quality, and the fourth compared two intensities of training (quality not
reported). Of the non-randomised studies, one compared two training intensities and the
other assessed training versus no training.

VO2peak (21 studies): 18 out of 21 studies reported a significant improvement in VO2peak

following training of some kind. Of these 21 studies, 13 were judged to be of acceptable
quality and, overall, these showed a mean improvement of 17.6% in VO2peak (SD=11.2).

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POpeak (20 studies): 16 of the 20 studies reporting these data found a significant increase in
POpeak following training and the remaining 4 studies found no increase. Twelve studies were
of acceptable quality and, overall, reported a mean change of 26.1% (SD=15.6).

VO2peak (paraplegia): 9 studies of acceptable quality (including 2 RCTs) assessed this

outcome and found improvements of between 7% and 30%.

POpeak (paraplegia): 8 uncontrolled studies of acceptable quality assessed this outcome and
found improvements of between 10% and 30%.

Four studies of acceptable quality reported results on VO2peak and POpeak for tetraplegic
patients with mixed findings.

Type of training was considered in a further analysis, but was hindered by the lack of clear
descriptions of the intervention used in the primary studies.

Authors' conclusions There is some methodologically weak evidence to support controlled upper body exercise as
an intervention to improve the physical capacity of spinal cord injury patients. Benefits
appear to be accrued regardless of the level of lesion, and mixed programmes of exercise
may be more effective than single activities.

CRD commentary The review addressed a clear question and used appropriate inclusion criteria. The search
was fairly thorough but might have missed relevant studies published in languages other
than English, or unpublished research. Methodological quality was assessed in detail and
taken into account within the synthesis of the results. A lack of reported details on the
methods used to select studies and extract the data make it difficult to be sure that bias and
error were suitably minimised at all stages. The narrative synthesis adequately summarised
the primary data, grouping results appropriately and identifying better quality evidence.
Overall, the authors' conclusions clearly follow from the evidence presented and the review is
likely to be fairly reliable.

Implications of the review for Practice: The authors stated that regular exercise seems beneficial for people with spinal
practice and research cord injury, but no definite recommendations can be made as to the type, intensity,
frequency or duration of exercise.

Research: The authors stated that further research on the effectiveness of exercise in people
with spinal cord injury is urgently needed, particularly of a high methodological quality. RCTs
are required, particularly in people with tetraplegia, and detailed reporting of future trials is
essential. Additional research focusing on different training protocols and modes to identify
the most effective interventions is recommended.

Funding Netherlands Organisation for Health, Research and Development (ZON-MW), grant number
014-32-012.

Bibliographic detail Valent L, Dallmeijer A, Houdijk H, Talsma E, van der Woude L. The effects of upper body
exercise on the physical capacity of people with a spinal cord injury: a systematic
review. Clinical Rehabilitation 2007; 21(4): 315-330

Link to Pubmed record 17613572

Subject index terms status Subject indexing assigned by NLM

Subject index terms Humans; Paraplegia /physiopathology /rehabilitation; Physical Education and Training;
Physical Fitness /physiology; Quadriplegia /physiopathology /rehabilitation; Spinal Cord
Injuries /physiopathology /rehabilitation; Upper Extremity /physiopathology

Accession number 12007002852

Database entry date 1 September 2008

Record status This record is a structured abstract written by CRD reviewers. The original has met a set of
quality criteria. Since September 1996 abstracts have been sent to authors for comment.
Additional factual information is incorporated into the record. Noted as [A:....].

Database of Abstracts of Reviews of Effects (DARE)

Produced by the Centre for Reviews and Dissemination
Copyright © 2008 University of York.

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