This paper is a critical evaluation of a meta-analysis titled “Impact of resistance training in subjects with COPD: A systemic review and meta-analysis.” The study was carried out by Wen-hua Liao, Jin-wu Chen, Xin Chen, Lin Lin, Hai-yan Yan, Yu-qi Zhou and Rui Chen. The essay aims at summarizing, appraising, and analyzing the research study. In this paper, I will assess the databases utilized in the analysis, the types of articles used, as well as the timeliness of the write-up. I will also identify the level of evidence of the publication. Finally, I will discuss the contribution that the presentation makes to the nursing scholarship and the implication it has on clinical practice.
Article Summary
The research article reports the findings of a meta-analysis study of trials that evaluated the use of resistance training in the treatment plan of patients with Chronic Obstructive Pulmonary Disease (COPD). The researchers aimed at reviewing and analyzing the effects of resistance training on subjects suffering from COPD.
The study methodology involved a systematic search for randomized controlled trials (RCTs) that included a COPD treatment plan of at least for weeks with resistance training. The scholars looked for these RCTs in online databases like MEDLINE, Cochrane, Elsevier ScienceDirect, Embase, EBM Reviews, and PubMed. The search included articles that were published from the beginning of the year 1980 to October 2013. The selection criteria consisted of patients suffering from stable to severe COPD and no other respiratory disorders, human studies, and RCTs that compared resistance training with no exercise or a combination of strength and endurance exercises. The criteria also included studies with treatment periods of over four weeks, and treatment outcomes that include better quality of life, exercise capacity, dyspnea, pulmonary, and skeletal muscle performance.
The initial search yielded 3562 articles. Out of these, the researchers settled on Eighteen RCTs. The excluded studies did not meet the inclusion for a variety of reasons such as duplication, incomplete data, on-going trials, inhomogenous subjects, inconsistent training programs, differing topics, and treatment durations of less than four weeks among others. The selected studies yielded a pool of 750 participants who were suffering from advanced COPD.
Two independent reviewers extracted data from the RCTs by reported statistics like standard deviation, means, and SE. Each reviewer worked independently. Supplemental data from article authors were reviewed and included in the analysis. The primary outcomes include changes in quality of life and dyspnea while secondary outcomes consist of functional and maximum exercise capacity, FEV, skeletal muscle performance, and adverse effects.
The researchers used the RevMan 5.2 statistical package to analyze their data. They used Fixed effects odd ratios to assess dichotomous outcomes and weighted mean differences (WMDs) to measure continuous results. Heterogeneity was tested by calculating I. In cases where significant heterogeneity was evident the researchers used a random-effects model. They utilized a fixed-effects approach in the analysis of cases that did not show significant heterogeneity.
Using the Chronic Respiratory Disease Questionnaire (CRQ), three studies showed significant improvement of dyspnea in patients who participated in resistance exercises compared to those who did not undertake any training. Although the CRQ score shows no difference in primary outcomes between the subjects who took part in both resistance and endurance training and those who took endurance exercise only, the St George Respiration Questionnaire (SGRQ) indicates improvement in patients who received both exercises. Secondary outcomes such as FEV and skeletal muscle function were enhanced in patient groups that participated in resistance training and the combined activities approach. No adverse events were reported in connection with resistance training.
In light of the above findings, the researchers argue that resistance training has the potential of improving dyspnea and skeletal muscle performance in COPD patients. They concluded that a combination of strength and endurance exercises has positive effects on muscle strength and the quality of life for people suffering from COPD.
Appraisal/ Critique
In the introduction section of the article, the authors have succeeded in conveying the significance of the study. They communicate the relevance of resistance in dealing with exercise intolerance and skeletal muscle dysfunction, which are significant complaints in COPD patients. They also express the goal and aim of the study clearly.
In considering the literature on COPD and training management, the articles makes use of data from as early as 1980 up to the year 2013. The broad scope of information allows the reader to see the steps that have been achieved in dealing with exercise intolerance in COPD. The review includes current articles. Therefore, it makes use of recent scholarship information. As such, the research questions and hypothesis developed by the investigators are theoretically relevant. Although the theoretical framework has been put under introduction, it adequately conveys the significance of the complications (dyspnea, muscular dysfunction) of COPD in patients’ lives, thus, indicating the relevance of the study. Although endurance training is the recommended management practice, the literature review shows that a few scholars have demonstrated that it yields inferior outcomes compared to resistance exercises (Troosters et al., 2010). It also reveals that patients can tolerate resistance exercises better than endurance training because they cause less dyspnea (Gosselink et al., 2011). The studies that have been conducted in the recent past focus on the effect on training resistance training on lung function and skeletal muscle function (Janaudis-Ferreira et al., 2011). However, little has been done to examine the impact of these exercises on other clinically significant outcomes such as exercise capacity, quality of life, and dyspnea. The review is consistent with meta-analyses and RCTs that have been conducted in the recent years (Troosters et al., 2010; Gosselink et al., 2011; Janaudis-Ferreira et al., 2011). Apparently, the authors have succeeded in revealing the gaps in the literature and the intention of their research to fill these gaps and with the bias seen in previous analyses. It is also evident that the scholars analyzed the available literature critically and objectively. However, the literature review fails to show the reader where the investigations were carried out and the specific populations that were used in the trials.
The study design has been structured in a manner that the research question, hypothesis, objectives, and the theoretical framework interrelate, complement each other, and have a recommendable degree of fit. As such, this structure raises my confidence in the evidence yielded, and it strengthens the study.
The meta-analysis includes eighteen RCTs and a sample size of 750 subjects. This number of participants is adequate to give results that apply to a larger population. The study selection criteria allowed the researcher to narrow down their focus on relevant articles in an objective manner thus reducing bias in the inclusion process. The RCTs included in this meta-analysis have similar designs regarding the inclusion and exclusion rules, and there is homogeneity in the clinical characteristics of participants. This aspect of the review strengthens the research study.
The modified Jadad score was useful in appraising the methodological quality of the investigations. By using statistical principles to analyze their data, the investigators succeed in improving the quality of the study evidence by increasing objectivity and control. Also, the size of the pooled subjects makes it possible for the scholars to conduct a dynamic analysis of clinically applicable outcomes resulting from resistance training or the combined approach (resistance plus endurance) to exercises in COPD patients.
The study provides level one evidence because it is a meta-analysis that consists of a sizeable number of Randomized Clinical Trials (RCTs). This classification of proof based on the evidence hierarchy (Boswell & Cannon, 2015).
The study findings indicate that resistance training when offered alone or together with endurance exercises in enhanced skeletal muscle strength, lung performance, and dyspnea scale scores. They also show that resistance training can be easily adapted to clinical practice in the course of pulmonary rehabilitation without the risk of adverse effects.
However, these results should be interpreted with care due to several weaknesses evident in the meta-analysis. Most of the trials in the analysis had a short duration of resistance training treatment. Therefore, it was difficult to examine the long-term effectiveness of the intervention. The outcome data suitable for this review was limited in terms of availability. For instance, the number of studies reporting lung function, CRQ, and SGRQ scores were insufficient. In addition, the trials included in the survey had no sample calculation despite the researchers searching for related articles diligently. The missing sample size computation may be an indication of inadequate sampling, which in turn increases bias. Also, the methodological quality assessment of ten of the included trials yielded low to average results. Despite the weaknesses, the meta-analysis portrays statistical homogeneity and minimal selection bias making it a strong study (Liao, 2015).
Conclusion
The article contributes significantly to the nursing scholarship as it provides evidence on the applicability of resistance training for COPD patient in clinical practice. It shows that this intervention yields better clinical outcomes and improves the quality of life for individuals with advanced COPD. This meta-analysis necessitates the examination of long-term efficiency of resistance training in the study population. There is a need for scholars to carry out trials with an aim of assessing the long-term impacts of resistant training on primary and secondary outcomes of pulmonary rehabilitation.
References
Boswell, C. & Cannon, S. (2015). Introduction to nursing research. Burlington, MA: Jones & Bartlett Publishers
Gosselink, R., De Vos, J., Van den Heuvel, S. P., Segers, J., Decramer, M., & Kwakkel, G. (2011). Impact of inspiratory muscle training in patients with COPD: what is the evidence?. European Respiratory Journal, 37(2), 416-425.
Janaudis-Ferreira, T., Hill, K., Goldstein, R. S., Robles-Ribeiro, P., Beauchamp, M. K., Dolmage, T. E., & Brooks, D. (2011). Resistance arm training in patients with COPD: a randomized controlled trial. CHEST Journal, 139(1), 151-158.
Liao, W. H., Chen, J. W., Chen, X., Lin, L., Yan, H. Y., Zhou, Y. Q., & Chen, R. (2015). Impact of resistance training in subjects with COPD: a systematic review and meta-analysis. Respiratory care, respcare-03598.
Troosters, T., Probst, V. S., Crul, T., Pitta, F., Gayan-Ramirez, G., Decramer, M., & Gosselink, R. (2010). Resistance training prevents deterioration in quadriceps muscle function during acute exacerbations of chronic obstructive pulmonary disease. American journal of respiratory and critical care medicine, 181(10), 1072-1077.
