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(March 2006eDec 2010)

Physiotherapy interventions in the

Cochrane Database of RCTs* PubMed

BTS guidelines on the
management of asthma (2011):
a need for change?



Systematic Reviews
Our search results
Updates to the British Thoracic Society

B: for the Buteyko technique 2004 (breathing

(BTS) asthma guidelines have been recently
highlighted by Turner and colleagues.1 2 To

(no limits)

No recommendation provided exercises)

our concern, the content on physiotherapy


interventions has not been revised or
updated since the 2006 version.

for other breathing exercises

We reviewed the contents of the new BTS
guidelines relevant for physiotherapists. The

and results of our updated search

Level of evidence Content and grades of

timescale for literature search indicates that
the relevant section was last updated in

February 2006, with coverage in Medline

Classified as complementary and alternative medicines/approaches

extending from 1996 to 2005.
Thus, we searched PubMed for English
language papers published between January


2006 and December 2010 and found 32
indexed as randomised controlled trials. In
the Cochrane Database of Systematic

Reviews we found updates or revisions to all

ACPRC, Association of Chartered Physiotherapists in Respiratory Care; BTS, British Thoracic Society; n/p, not provided; RCT, randomised controlled trial.
cited documents, with those updated in 2004
and 2005 and not quoted in the guideline.



A comparison of the contents of the BTS 2011 asthma guidelines and the BTS/ACPRC 2009 guidelines1

A corresponding document, not referred to

and the Buteyko breathing technique

in the BTS guidelines, the joint BTS and the

Breathing exercises including yoga

Manual therapy including massage

yClapping, vibrations, shaking (collectively termed manual therapies) and postural drainage, forced expiratory technique, directed coughing.
Association of Chartered Physiotherapists in
Respiratory Care (ACPRC) Guidelines for
Terminology; intervention (s)

the Physiotherapy Management of the

B; B; A (depending on the outcome Physical exercise training

and spinal manipulation

Adult, Medical, Spontaneously Breathing

Patient, with a section on physiotherapy
interventions in adults with asthma, was
published in Thorax in 2009.3 The authors
BTS 2011

SIGN (Scottish Intercollegiate Guidelines Network) key to evidence statements and grades of recommendations.
searched multiple databases (with date
limits ranging from May 2005 to January
2006) and their recommendations differ, to
some extent, from those provided in the BTS
guidelines. This causes some confusion as to
Insufficient evidence to support

Insufficient evidence to support

measure; recommendation for)

which guidelines should be considered.

A: for breathing exercises

The terminology, levels of evidence and

B (recommendation for)
(e.g. anxiety measures)

grades of recommendations for physio-

Level of evidence Content and grades of

B: for suitable tools

therapy interventions, reported in both


documents, are compared below in the

table 1.
or refute

or refute

According to the BTS asthma guidelines

‘evidence that non-pharmacological
management is effective can be difficult to
obtain and more studies are required’.1
However, this statement seems to be not
zPEP, oscillating positive expiratory pressure devices.

fully relevant in the case of physiotherapy


interventions. Evidence-based practice is


a priority in the development of physio-

Classified as physiotherapy interventions



Inspiratory muscle training in asthma 1

therapy.4 Numerous, increasingly rigorous

*Studies indexed as RCTs in PubMed.

studies have been published since the early

2000s. In 2010, 24 Cochrane reviews on non-
Airway clearance techniques in
Buteyko breathing technique in
Breathing exercises in asthma

medical management of asthma were avail-

Terminology; intervention (s)

Airway clearance adjuncts/

Physical training in asthma

able, including six reviews regarding physical

The updated Cochrane reviews, not

reported in the BTS guideline, do not generally

provide new or changed conclusions;
Table 1

however, it is quite debatable why the updates


have not been provided in the guidelines since

2004. The PubMed search results also suggest

Thorax August 2012 Vol 67 No 8 749


Thorax: first published as 10.1136/thoraxjnl-2011-201418 on 18 December 2011. Downloaded from on 7 December 2018 by guest. Protected by copyright.
the need for updating the guidelines, as the Medicine, Jagiellonian University, School of Medicine, REFERENCES
most recent studies cited in the guidelines are Cracow, Poland 1. British Guideline on the Management of Asthma.
dated for the year 2003. In our view, despite A National Clinical Guideline. British Thoracic Society,
Correspondence to Professor Roman Nowobilski,
the fact that its last searches were conducted Scottish Intercollegiate Guideline Network, June 2008.
Department of Medicine, Institute of Physiotherapy,
up to 2006, the joint BTS/ACPRC 2009 2011.
Faculty of Health Sciences, Jagiellonian University,
index.html (accessed 2 Sep 2011).
guidelines remain in the international Cracow, Poland;
2. Turner S, Paton J, Higgins B, et al. British guidelines
perspective the most reliable document for Competing interests None. on the management of asthma: what’s new for 2011?
asthma physiotherapy practice. Thorax 2011;66:1104e5.
Contributors MP, RN: research work project,
3. Bott J, Blumenthal S, Buxton M, et al; British Thoracic
publication search, writing of the manuscript; TW:
1 2 Society Physiotherapy Guideline Development Group.
Roman Nowobilski, Maciej Plaszewski, research work project; publication search; PG:
Guidelines for the physiotherapy management of the
Tomasz Wloch,3 Piotr Gajewski,4 manuscript compilation AS: research work project,
adult, medical, spontaneously breathing patient. Thorax
Andrzej Szczeklik4 manuscript compilation.
2009;64(Suppl I):i1e51.
1 4. Policy StatementdEvidence Based Practice.
Faculty of Health Sciences, Department of Medicine, Provenance and peer review Not commissioned;
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