title: Pulmonary Physical Therapy Techniques to Enhance Survival in Amyotrophic Lateral Sclerosis: A Systematic Review.
abstract: OBJECTIVE
  Respiratory insufficiency is the primary cause of morbidity and mortality in individuals with amyotrophic lateral sclerosis (ALS). Although mechanical interventions are effective in prolonging survival through respiratory support, pulmonary physical therapy interventions are being investigated. The purpose of this systematic review was to examine the effectiveness of pulmonary physical therapy interventions across the progressive stages of ALS.
  
  
  METHODS
  Six databases were searched for articles from inception to December 2014 investigating pulmonary physical therapy interventions in the ALS population. The search strategy followed Cochrane Collaboration guidelines with replication per database. Effect sizes (ES) were calculated for primary outcome measures: forced vital capacity (FVC) and peak cough expiratory flow (PCEF).
  
  
  RESULTS
  Seven studies met inclusion criteria. Four studies used control groups whereas the remainder used repeated measures. With the exception of diaphragmatic breathing, pulmonary physical therapy interventions were effective in improving multiple respiratory outcome measures in this population. Inspiratory muscle training (IMT) was shown to prolong respiratory muscle strength with a strong effect size (ES = 1.48) for FVC. In addition, mean length of survival increased by 12 months. Lung volume recruitment training (LVRT) strongly enhanced immediate cough efficacy with improved FVC (ES = 1.02) and PCEF (ES = 1.82). Manually assisted cough (MAC) only improved PCEF by a small amount (ES = 0.15, bulbar ALS; ES = 0.16, classical ALS groups).
  
  
  CONCLUSIONS
  Specific pulmonary physical therapy interventions (IMT, LVRT, and MAC) have effectiveness in improving respiratory outcome measures and increasing survival. These should be routinely incorporated into the comprehensive management of individuals with ALS. More rigorous methodological investigations should be performed to replicate these findings.Video abstract available with brief technique demonstration of IMT and LVRT (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A136).
authors.affiliation: Department of Rehabilitative Medicine (C.E.M.) and Program in Physical Therapy (C.E.B.), Columbia University Medical Center, New York, New York.
authors.forename: Chelsea E
authors.initials: CE
authors.lastname: Macpherson
authors.forename: Clare C
authors.initials: CC
authors.lastname: Bassile
mesh_terms: D000690:Amyotrophic Lateral Sclerosis / Q000150:complications / Q000401:mortality / Q000534:rehabilitation*; D006801:Humans; D026741:Physical Therapy Modalities; D012131:Respiratory Insufficiency / Q000209:etiology / Q000534:rehabilitation*