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Correspondence |

Grading Recommendations : A Matter of Interpretation FREE TO VIEW

Daniel Langer, MSc, PT; Thierry Troosters, PhD, PT; Marc Decramer, PhD, MD; Rik Gosselink, PhD, PT
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Respiratory Division and Respiratory Rehabilitation Katholieke Universiteit Leuven, Leuven, Belgium

Correspondence to: Daniel Langer, MSc, PT, University Hospital Leuven and Katholieke Universiteit Leuven, Respiratory Division and Respiratory Rehabilitation, Afdeling Pneumologie O&N, 1 BUS 706, Leuven 3000, Belgium; e-mail: Daniel.Langer@faber.kuleuven.be


Chest. 2008;133(3):830. doi:10.1378/chest.07-1970
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To the Editor:

We would like to compliment the authors of the article “Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines” (May 2007)1 for their comprehensive review of the literature and their effort to formulate up-to-date, evidence-based recommendations for clinical practice. However, we have concerns about the grading of recommendations concerning upper extremity training (UET) and inspiratory muscle training (IMT). It is surprising to us that the current recommendations grade the quality of evidence for UET as “high” (A), whereas the quality of evidence for IMT is graded as “moderate” (B). Further, it is unclear to us why (unsupported) UET is strongly recommended (grade 1), whereas the use of IMT is not recommended (grade 1). This would mean that the benefits outweigh the burdens for UET, while the opposite is true for IMT. This is, in our opinion, not a balanced summary of the available evidence.

From the studies quoted in the systematic review, it can be concluded that both UET and IMT specifically improve the strength and endurance of the muscle groups that are trained.1 For both interventions, however, the evidence concerning improvements in health-related quality of life or whole-body functional exercise capacity is either conflicting or absent. In addition, the evidence for both interventions comes from small single-center trials of mostly moderate methodological quality.

Besides the expected benefits and methodological quality of the studies, the burdens of interventions are also taken into account to grade the strengths of recommendations.2 In the systematic review of the literature,1 however, no potential burdens are discussed for either IMT or UET.

Consequently, we feel that IMT and UET should both be recommended with the same strength of grading (1B), since the benefits of both IMT and UET should outweigh the burdens for the patients (grade 1) and recommendations can only be based on qualitatively moderate (B) evidence for both interventions (not on high [A] evidence as the guidelines conclude for UET). IMT should in our opinion be recommended for a selected group of patients, probably those with reduced inspiratory muscle strength who experience symptoms of dyspnea during activities of daily living, while UET should probably be recommended for those patients with reduced upper extremity exercise capacity leading to functional limitations in activities of daily living. We hope that our comments will stimulate a debate on the grading of the strength of the recommendations concerning these two specific aspects of exercise training during pulmonary rehabilitation.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Ries, AL, Bauldoff, GS, Carlin, BW, et al (2007) Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines.Chest131(suppl),4S-42S
 
Guyatt, G, Gutterman, D, Baumann, MH, et al Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians task force.Chest2006;129,174-181
 

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References

Ries, AL, Bauldoff, GS, Carlin, BW, et al (2007) Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines.Chest131(suppl),4S-42S
 
Guyatt, G, Gutterman, D, Baumann, MH, et al Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians task force.Chest2006;129,174-181
 
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