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Respiratory muscle training in children and adults with neuromuscular disease

Review question

Does respiratory muscle training have beneficial effects for children and adults with neuromuscular disease?

Background

Neuromuscular disease is a very broad term that covers many diseases that either directly or indirectly affect muscles or nerves. Children and adults with neuromuscular diseases can present with muscle weakness, loss of movement control, and muscle wasting. Some neuromuscular diseases cause weakness of respiratory muscles (diaphragm and accessory muscles of respiration). The decline of respiratory muscle function in these diseases affects activities of daily living and quality of life. Respiratory muscle training could potentially be considered as an extra therapy for people with suspected or confirmed respiratory muscle weakness.

Study characteristics

This review included 11 studies with a total of 250 randomized participants with neuromuscular disease. Six studies included 112 young males (including children) with Duchenne muscular dystrophy, which is an inherited muscle disease. One trial involved 23 adults with other muscle diseases (Becker muscular dystrophy and limb‐girdle muscular dystrophy). Three trials involved 88 people with amyotrophic lateral sclerosis, a progressive condition that affects the nerves controlling movement. One trial involved 27 people with myasthenia gravis, a condition that affects the signals between nerves and muscles.

Key results

The studies showed that respiratory muscle training may result in some improvements in lung function for people with amyotrophic lateral sclerosis and Duchenne muscular dystrophy. However, this finding was not consistent between studies. Physical function and quality of life were only assessed in one amyotrophic lateral sclerosis trial, which indicated that RMT may have no clear effect. One trial reported on adverse events, but the certainty of evidence was too low for conclusions to be drawn. The studies did not report the number of unscheduled hospitalisations for sudden infection or worsening of chronic respiratory failure.

Certainty of the evidence

The certainty of the evidence examined as part of this review was low or very low. Low‐certainty evidence means that our confidence in the effect of respiratory muscle training is limited, and the true effect may be substantially different. When the evidence is of very low‐certainty, the true effect is likely to be substantially different. Given the low or very low‐certainty of the evidence presented in the studies, we believe that there is a need for more well‐conducted studies in order to assess the efficacy of respiratory muscle training in people with NMD.

The evidence is current to November 2018.

Read the full Cochrane Review here

Review question

Is repetitive peripheral magnetic stimulation (rPMS) effective for improving daily activities in people after stroke?

Background

Stroke, the most common cause of disability, occurs when the blood supply to part of the brain is interrupted or reduced. Two types of stroke are known: ischaemic (due to lack of blood flow) and haemorrhagic (due to bleeding). Paralysis of the arm or leg after stroke causes problems with daily activities and functions, including eating, showering, dressing, and walking. People after stroke with hemiparesis require physical rehabilitation, that is, training of upper and lower limbs, exercise focused on activities of daily living, and fitting of appropriate walking aids (e.g. cane). However, effective treatments are currently limited. rPMS is a painless method of stimulation that has been used to try to improve movement in people with brain or nerve disorders.

Search date

The search is current to 7 January 2019.

Study characteristics

This is an update of the review published in 2017. We examined the evidence from four trials of rPMS (three individual RCTs and one cross‐over trial) involving a total of 139 participants. Two studies compared rPMS against 'sham' stimulation (a very weak stimulation or a sound only). Two studies compared rPMS plus rehabilitation versus sham plus rehabilitation.

Key results

We found little evidence for the use of rPMS to improve activities of daily living, muscle strength, upper limb function, and spasticity (unusual stiffness of muscles) in people after stroke. Although one trial reported that rPMS reduced spasticity of the upper limb, the effect was small and remains unclear.

Quality of the evidence

We classified the quality of the evidence as low for improving activities of daily living, mainly because one study had a small sample size.

Authors' conclusions

It remains unclear whether use of rPMS is useful for improving activities of daily living and functional ability in people after stroke. More trials involving larger numbers of participants are needed to determine the effects of rPMS.

Cochrane Review; Results from Four Trials (906 Adults with Diabetes)

Main results Certainty of the evidence from the studies ranged from low to very low, meaning we cannot be confident in the findings. Results were not always completely or clearly reported; the studies had serious limitations, and the results lacked precision. In people with nerve damage due to diabetes, it is uncertain whether ALC reduces pain after 12 months of therapy, compared to placebo. The trials provided little or no information on the effects of ALC on functional impairment, sensory testing, and symptoms. Even when trials provided data, quality of evidence was too low to draw reliable conclusions. Harmful side effects may be no more frequent with ALC than with placebo. The evidence on adverse events from the trial comparing ALC with methylcobalamin was very uncertain. Two of the four studies were funded by a manufacturer of ALC and the other two studies had at least one co‐author who was a consultant for an ALC manufacturer.

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A 52-year-old man presented with a 20-minute history of chest pain radiating to the left shoulder and neck, associated with dyspnea and diaphoresis. He had a history of hypertension, long-term smoking, and a sedentary lifestyle. On physical examination, bibasilar crackles were noted on lung auscultation. An electrocardiogram (ECG) was performed in the primary care setting, and the patient was promptly referred to the emergency department.

A 28-year-old woman presented with a 3-day history of intense pruritus over the lower back. She reported no recent travel or exposure to new environments. She cares for a small kennel with approximately eight dogs rescued from the streets. Physical examination revealed multiple small vesicles, some clustered and others scattered, predominantly involving the lumbar region and the left gluteal area.

A 4-month-old male infant presented with skin lesions localized to the chin for the past 3 days. Physical examination revealed multiple small pustules with surrounding inflammatory signs on the chin, along with a few scattered papules on the chest.

Patient in late teens presenting after a collapse, with no chest pain, no previous cardiac history, and no history of sudden death in family. Are there any features in this EKG that would warrant further work-up or is this just a pediatric EKG?