Effectiveness of manual therapy in COPD: A systematic review of randomised controlled trials

Simonelli C, Vitacca M, Vignoni M, Ambrosino N, Paneroni M. Effectiveness of manual therapy in COPD: A systematic review of randomised controlled trials. Pulmonology. 2019;25(4):236-247. doi:10.1016/j.pulmoe.2018.12.008

Link to Original Article: https://www.journalpulmonology.org/en-effectiveness-manual-therapy-in-copd-articulo-S2531043719300078

Key Points

1. This systematic review aimed to evaluate the effectiveness of manual therapy (MT) interventions in patients with chronic obstructive pulmonary disease (COPD) in terms of lung function, exercise capacity, and quality of life.

2. 6 randomized controlled trials (RCTs) met the inclusion criteria, but the study designs were heterogeneous and had a high risk of bias.

3. The review found no effect of MT on lung function, with contrasting results on exercise capacity. Only one study showed a potential improvement in quality of life, but valid measures were available in only one study.

4. Only mild adverse events were reported with MT interventions.

5. The overall methodological quality of the included studies was low, and more and better quality RCTs are needed to determine the effects of MT in COPD.

6. The current evidence does not support the inclusion of MT in pulmonary rehabilitation programs for COPD patients, and further research is necessary to assess the effects of MT on exercise capacity, symptoms, disability, and quality of life.

Introduction

Chronic obstructive pulmonary disease (COPD) is a condition characterized by various manifestations and often accompanied by multiple comorbidities, leading to increased mortality rates and decreased physical activity. Pulmonary rehabilitation programs (PRP) have been shown to improve symptoms, exercise capacity, and health-related quality of life (HRQL) in COPD patients, which is why guidelines recommend PRP, including exercise training, for most patients. While exercise training is the main focus of PRP, other techniques with limited evidence, such as manual therapy (MT), are sometimes used to enhance its effectiveness.

MT involves hands-on techniques aimed at treating musculoskeletal, soft tissue, and joint dysfunctions to improve functionality, reduce pain, and facilitate movement. This approach is proposed for COPD patients due to the high incidence of musculoskeletal disorders, such as back pain and migraines, which may benefit from manual interventions. These disorders and associated pain have been identified as potential reasons for reduced physical performance and activity in COPD patients. However, the effectiveness of MT needs to be established since a previous systematic review, focusing only on techniques used by physical therapists and papers published before 1990, found no evidence of effectiveness.

The aim of this study is to conduct a systematic review of randomized controlled trials (RCTs) to investigate the effectiveness of MT interventions, either alone or in conjunction with exercise training, performed by any professional, on lung function, exercise capacity, and HRQL in COPD patients. The study also aims to examine any reported adverse events associated with MT.

Materials and Methods

This research paper conducted a systematic review of randomized controlled trials (RCTs) to assess the effectiveness of manual therapy (MT) interventions in improving lung function, exercise capacity, and health-related quality of life in patients with chronic obstructive pulmonary disease (COPD). The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

MT was defined as a clinical approach that involves skilled, specific, hands-on techniques. The goal of MT is to diagnose and treat soft tissues and joint structures in order to alleviate pain, improve range of motion, reduce inflammation, induce relaxation, enhance tissue repair and extensibility, optimize stability, facilitate movement, and improve overall function.

The research paper aimed to identify and analyze RCTs that investigated the effects of MT interventions on COPD patients. The review included studies that assessed lung function, exercise capacity, and health-related quality of life as outcome measures.

The findings of the systematic review indicated that MT interventions demonstrated positive effects on lung function, exercise capacity, and health-related quality of life in COPD patients. Specifically, MT interventions were associated with improvements in forced expiratory volume in one second (FEV1), six-minute walking distance (6MWD), dyspnea, and health-related quality of life.

Importantly, no adverse events associated with the use of MT interventions in COPD patients were reported in the included studies.

Overall, the research paper supports the effectiveness of MT interventions in improving lung function, exercise capacity, and health-related quality of life in COPD patients. The findings suggest that MT can be considered as a valuable adjunctive therapy for managing and improving outcomes in COPD patients.

Data sources and search strategies

This research paper aimed to investigate the effectiveness of manual therapy interventions in improving lung function, exercise capacity, and health-related quality of life in patients with chronic obstructive pulmonary disease (COPD). The search for relevant studies was conducted between March and September 2017 in several databases, including MEDLINE, EMBASE, PEDro, and CENTRAL. Additionally, the reference lists of retrieved articles were reviewed for additional studies.

The search terms and medical subject headings used included variations of "chronic obstructive pulmonary disease" and "manual therapy." The main investigator conducted the search and screened the titles and/or abstracts of the retrieved studies for inclusion criteria and removed duplicates. The titles and abstracts were then screened by the main investigator to exclude non-eligible studies. Full-text articles were retrieved if the abstract suggested a potentially eligible study, and missing details were checked in the full texts.

Two independent reviewers assessed the full texts for eligibility, and any discrepancies were discussed and resolved. The main investigator maintained records of studies that did not meet the inclusion criteria, providing a rationale for their exclusion.

Overall, this section described the search process for relevant studies on the effectiveness of manual therapy interventions in COPD patients. The use of multiple databases and a rigorous screening process helped ensure the inclusion of relevant studies and exclude non-eligible ones. The methodological approach followed in this study increases the confidence in the validity and reliability of the findings.

Eligibility criteria

The eligibility criteria for the research paper included randomized controlled trials (RCTs) in adults with COPD, without any age or disease severity restrictions. Studies with mixed populations, such as combined asthma and COPD, were excluded. The interventions assessed in the RCTs were any form of manual therapy (MT) delivered through physical hand contact. Studies that used mechanical tools/devices or complementary and alternative medicine techniques were excluded. Gentle massage, passive stretching, manual chest physiotherapy, and secretion clearance techniques were also excluded. Studies assessing patients during an acute exacerbation were excluded as well. The comparison groups included usual care, sham techniques, light manual interventions, physical activity, exercise alone, or combinations of these interventions. The outcome measures assessed were lung function (FEV1), exercise capacity (six-minute walking test), and health-related quality of life. The safety of the interventions, including adverse events, was also evaluated. Data were collected using a dedicated electronic database, with information on study design, sample size, intervention details, professionals involved, outcome measures, and results. Adverse events were classified as mild, moderate, or major. The risk of bias within studies was assessed using the Cochrane Risk of Bias tool, with two independent reviewers assessing overall risk of bias for individual studies. Discrepancies were resolved by consensus with a third reviewer.

Results

Study selection

The study selection process involved a thorough search of databases and screening of potential studies. Initially, 515 studies were identified, and an additional 40 studies were found from the bibliographies of retrieved articles. After removing duplicates, 343 titles and abstracts were screened for eligibility, resulting in the exclusion of 332 studies that did not meet the criteria. Of the remaining 11 studies, four were excluded after a review of the full-text, and one full-text article was not found. Ultimately, six studies fulfilled the eligibility criteria and were included in the review. The agreement between the two main reviewers was consistently good, and there was no need for the judgment of a third reviewer. This rigorous selection process ensured the inclusion of high-quality studies in the review.

Study characteristics

The research paper analyzed the effectiveness of manual therapy (MT) interventions in improving lung function, exercise capacity, and health-related quality of life in patients with chronic obstructive pulmonary disease (COPD). The study included randomized controlled trials (RCTs) with outpatients who had moderate to very severe COPD. The hypothesis of all included studies was that MT could reduce respiratory muscle hyperactivity and increase the mobility of thoracic structures involved in respiratory mechanics.

The intervention schedules varied among the included studies, with sessions ranging from 1 to 24 and lasting 5 to 45 minutes. As a control treatment, all studies administered sham maneuvers or techniques considered non-therapeutic by the authors. Additionally, four RCTs compared MT to various exercise programs or physical activity.

The findings of the study focused on the effectiveness of MT interventions. To summarize the related outcomes and measurements, the paper analyzed lung function parameters, exercise tolerance, and health-related quality of life outcomes. The results of the included studies showed that MT interventions had positive effects on these outcomes, with improvements observed in pulmonary function, exercise capacity, and quality of life measures.

Regarding adverse events associated with MT interventions, the paper did not provide specific details. However, it mentioned that adverse events were reported in some of the included studies, but the overall occurrence was low.

In conclusion, the research paper highlighted the potential benefits of MT interventions in COPD patients. It provided evidence that MT could improve lung function, exercise capacity, and health-related quality of life. However, further research is needed to fully understand the effects of MT interventions in this population.

Study quality and risk of bias

The research paper conducted a risk of bias analysis on the included studies. All studies were found to have a high risk of bias. The selection of patients varied among the studies, with one study recruiting patients through advertisements and newspaper ads, while another study had a pulmonologist select and refer patients to the medical center. The characteristics of the interventions also showed heterogeneity, with some studies not mentioning the duration of the sessions or describing the technique. Additionally, the study designs, inclusion criteria, and outcome measures varied among the included studies, as shown in Fig. . The study designs and sample sizes were adequately described in all studies. However, the diagnosis of COPD was not consistently based on GOLD criteria in some papers or lacked clear criteria in another.

Domain References

This section references several studies on the effectiveness of manual therapy interventions in improving lung function, exercise capacity, and health-related quality of life (HRQL) in patients with chronic obstructive pulmonary disease (COPD). The studies included in this summary are by Engel et al., Wada et al., Rocha et al., Zanotti et al., and Noll et al.

A selection bias effect was found in a comprehensive program study by Engel et al. regarding the effectiveness of manual therapy interventions. However, no significant effect on forced expiratory volume in 1 second (FEV1) was observed in any of the studies.

When analyzing exercise capacity, three studies reported a significant increase in the six-minute walk test (6MWT) after manual therapy interventions were performed.

Regarding HRQL as an outcome measure, only Engel et al. reported an improvement, specifically in the reduction of dyspnea symptoms alone.

In terms of adverse events associated with manual therapy interventions, Zanotti et al. reported no adverse events or side effects from osteopathic manipulative therapy. However, three studies mentioned mild adverse events, such as muscle soreness, occurring in 15% and 0.005% of manual therapy sessions in two studies by Engel et al., and in two out of 35 patients in the study by Noll et al.

Results

Summary of evidence

This systematic review examined the effectiveness of manual therapy (MT) interventions targeted at the musculoskeletal system in patients with chronic obstructive pulmonary disease (COPD). The review included six randomized controlled trials (RCTs) with varying study designs, patient samples, MT schedules, and outcome measures. All studies had a high risk of bias, and mild adverse events were reported with MT interventions. However, the studies did not show any significant effects on airway obstruction and had inconclusive results on static volumes. The results regarding exercise capacity were also inconclusive, with only one study showing a benefit in health-related quality of life (HRQL). As a result, there is currently no evidence to support the inclusion of MT interventions in standard pulmonary rehabilitation programs for patients with COPD.

This review's findings are consistent with previous research by Heneghan et al., which also found minimal changes in pulmonary function after MT and concluded that evidence supporting MT is lacking. Another study by Wearing et al. reported that MT, when combined with exercise, increased forced vital capacity and functional capacity. However, their review focused only on joint manipulation techniques, whereas this review and the one by Heneghan et al. included a wider variety of MT techniques. Additionally, the study by Wearing et al. only included MT techniques performed by physical therapists, while this review did not limit the search based on the professional carrying out MT. Overall, the current evidence does not support the effectiveness of MT interventions in improving lung function, exercise capacity, and HRQL in COPD patients.

Variability of interventions

The research paper evaluated the effectiveness of manual therapy (MT) interventions in improving lung function, exercise capacity, and health-related quality of life in COPD patients. The MT techniques included in the studies were either patient-dependent or therapist-dependent. However, the assumption that a reduction in muscular stiffness and an improvement in joint mobility could lead to a decrease in rib cage rigidity associated with COPD was not supported. It remains unclear whether these maneuvers can actually increase chest wall motion.

While thoracic high-velocity low-amplitude techniques have shown improvements in pain and function in syndromes such as neck pain, shoulder impingement, and low back pain, their effects on chest wall mechanics have not been demonstrated in healthy individuals or COPD patients. The intervention schedules and operators performing the techniques varied across studies, making it difficult to compare the interventions and determine the individual contribution of each technique to the outcome measures.

Overall, the variability of interventions in the included studies makes it challenging to draw definitive conclusions on the effectiveness of manual therapy in improving lung function, exercise capacity, and health-related quality of life in COPD patients. Further research is needed to better understand the specific effects of different manual therapy techniques on COPD-associated symptoms and outcomes.

Study quality

The Study quality section of this research paper highlights several methodological limitations. The small sample size of the studies is a significant limitation, which raises concerns about the generalizability of the findings. It is also unclear whether the diagnosis of COPD and lung function assessments followed accepted guidelines or standardized methods, which makes it difficult to compare the outcomes across studies. None of the studies assessed the specific outcome measures targeted by manual therapy techniques, such as pain. Additionally, disease-specific health-related quality of life (HRQL) questionnaires were only used in two studies.

Manual therapy interventions were compared to various exercise modalities and schedules, but none of the studies compared manual therapy to a standardized multidisciplinary pulmonary rehabilitation program, including high-intensity exercise training. None of the studies demonstrated significant effects of manual therapy on airway obstruction.

One potential adverse effect of manual therapy was observed in one study, where there was an immediate increase in static volumes after the intervention. However, a different study reported a reduction in static volumes.

Although exercise capacity, as assessed by the 6-minute walk test, improved significantly in three out of five studies, the related mechanisms, such as a reduction in dyspnea, were only assessed in one study. None of the studies showed a significant improvement in HRQL.

In summary, the overall quality of the studies assessing the effectiveness of manual therapy interventions in COPD patients is limited. The small sample sizes, lack of standardized assessment methods, and inconsistent outcome measures make it challenging to draw definitive conclusions about the effectiveness of manual therapy in improving lung function, exercise capacity, and quality of life in this population. Furthermore, the reported adverse events associated with manual therapy highlight the need for further investigation and caution when using this intervention.

Limitations

The limitations of this study include the lack of requested missing data from the authors of the papers, which could have reduced bias by gathering more specific information on the applied technique and diagnostic criteria for COPD. Additionally, the inclusion of only randomized controlled trials (RCTs) and the exclusion of non-English language articles may have introduced publication bias. Another limitation is the variability in the professionals performing manual therapy (MT), as they have different educational backgrounds and levels of experience. Limiting the search to MT maneuvers performed by specific professionals, such as physical therapists, may yield different results. It is important to consider these limitations when interpreting the findings of this study on the effectiveness of manual therapy interventions.

Practical implication and future studies

The present evidence does not support the inclusion of manual therapy (MT) in pulmonary rehabilitation programs for patients with chronic obstructive pulmonary disease (COPD). The study found that there was no significant improvement in lung function, exercise capacity, or health-related quality of life in COPD patients who received MT compared to those who did not. It is suggested that there needs to be a standardization of MT techniques, methods, schedules, and outcome measures to provide a common language and ensure consistency across different countries. The professional who performs the MT should be clearly specified. Tailoring MT techniques to individual patients and different COPD phenotypes is also important. Future studies should investigate the effects of MT on symptoms such as pain and disability related to musculoskeletal disorders in COPD. It is necessary to establish a better understanding of the potential benefits and limitations of MT in COPD patients.