Cough & Secretion Clearance

Postural drainage (v no intervention) on secretion clearance in people with SCI who have respiratory muscle weakness or paralysis

consensus: Strong For Recommendation

Targeted postural drainage should be provided to improve secretion clearance in people with SCI who have respiratory muscle weakness or paralysis.

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	Postural drainage (v no intervention) on secretion clearance in people with SCI who have respiratory muscle weakness or paralysis
P	People with SCI who have respiratory muscle weakness or paralysis	Evidence recommendation No evidence recommendation Reason: No RCTs	Strong opinion statement FOR Targeted postural drainage should be provided to improve secretion clearance in people with SCI who have respiratory muscle weakness or paralysis. Clinical note: Postural drainage (including head down tilt) is usually provided as an adjunct to other respiratory therapies. Head down tilt is contraindicated in conditions that include but are not limited to heart failure, reflux and acute Traumatic Brain Injury with increased/poorly controlled intracranial pressure.
I	Postural drainage
C	No intervention	Consensus-based opinion statement Strong for (85%)
O	Secretion clearance

Manually assisted cough (v no intervention) on secretion clearance in people with SCI who have abdominal muscle weakness or paralysis and an ineffective cough

consensus: Strong For Recommendation

Manually assisted cough should be provided to improve secretion clearance in people with SCI who have abdominal muscle weakness or paralysis and an ineffective cough.

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	Manually assisted cough (v no intervention) on secretion clearance in people with SCI who have abdominal muscle weakness or paralysis and an ineffective cough
P	People with SCI who have abdominal muscle weakness or paralysis and an ineffective cough	Evidence recommendation No evidence recommendation Reason: No RCTs	Strong opinion statement FOR Consensus Statement: Manually assisted cough should be provided to improve secretion clearance in people with SCI who have abdominal muscle weakness or paralysis and an ineffective cough Clinical note: Manually assisted cough is contraindicated in conditions such as recent abdominal trauma. Manually assisted cough should be considered with caution in people with paralytic ileus or rib fractures.
I	Manually assisted cough
C	No intervention	Consensus-based opinion statement Strong for (100%)
O	Secretion clearance

Mechanically assisted cough (Insufflation/exsufflation) (v no intervention) on secretion clearance in people with SCI who have abdominal muscle weakness or paralysis and an ineffective cough

consensus: Strong For Recommendation

Mechanically assisted cough (insufflation-exsufflation) should be provided to improve secretion clearance in people with SCI who have abdominal muscle weakness or paralysis and an ineffective cough.

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	Mechanically assisted cough (insufflation/exsufflation) (v no intervention) on secretion clearance in people with SCI who have abdominal muscle weakness or paralysis and an ineffective cough.
P	People with SCI who have abdominal muscle weakness or paralysis and an ineffective cough.	Evidence recommendation No evidence recommendation Reason: No RCTs	Strong opinion statement FOR Mechanically assisted cough (insufflation-exsufflation) should be provided to improve secretion clearance in people with SCI who have abdominal muscle weakness or paralysis and an ineffective cough. Clinical Note: Contraindications and precautions for the use of positive pressure devices must be considered before prescribing manually assisted cough. For example, positive pressure devices are contraindicated in conditions that include but are not limited to untreated pneumothorax, tracheoesophageal fistula and acute raumatic brain injury with increased/poorly controlled intracranial pressure.
I	Mechanically assisted cough (Insufflation-exsufflation)
C	No intervention	Consensus-based opinion statement Strong for (93%)
O	Secretion clearance

Mechanically assisted cough (Insufflation/exsufflation) plus manually assisted cough (v no intervention) on secretion clearance in people with SCI who have abdominal muscle weakness or paralysis and an ineffective cough.

consensus: Strong For Recommendation

A combination of mechanically assisted cough and manually assisted cough should be provided to improve secretion clearance in people with SCI who have abdominal muscle weakness or paralysis and an ineffective cough.

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	Mechanically assisted cough (Insufflation/exsufflation) plus manually assisted cough (v no intervention) on secretion clearance in people with SCI who have abdominal muscle weakness or paralysis and an ineffective cough.
P	People with SCI who have abdominal muscle weakness or paralysis and an ineffective cough.	Evidence recommendation No evidence recommendation Reason: No RCTs	Strong opinion statement FOR A combination of mechanically assisted cough and manually assisted cough should be provided to improve secretion clearance in people with SCI who have abdominal muscle weakness or paralysis and an ineffective cough. Clinical note: Insufflation-exsufflation and manually assisted cough can be provided independently or in combination for increasing secretion clearance in people with SCI.
I	A combination of mechanically assisted cough (Insufflation-exsufflation) and manually assisted cough
C	No intervention	Consensus-based opinion statement Strong for (100%)
O	Secretion clearance

Percussion and vibration (v no intervention) on secretion clearance in people with SCI who have respiratory muscle weakness

consensus: Weak For Recommendation

Percussion and vibrations may be provided to improve secretion clearance in people with SCI who have respiratory muscle weakness.

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	Percussion and vibration (v no intervention) on secretion clearance in people with SCI who have respiratory muscle weakness
P	People with SCI who have respiratory muscle weakness.	Evidence recommendation No evidence recommendation Reason: No RCTs	Weak opinion statement FOR Consensus Statement: Percussion and vibrations may be provided to improve secretion clearance in people with SCI who have respiratory muscle weakness. Clinical note: Percussion and vibrations are usually provided as an adjunct to other respiratory therapies.
I	Percussion and vibration
C	No intervention	Consensus-based opinion statement Weak for (85%)
O	Secretion clearance

Abdominal FES (v no intervention) on stimulated cough in people with SCI who have abdominal muscle weakness or paralysis

consensus: Weak For Recommendation

Abdominal FES may be provided to improve stimulated cough in people with SCI who have abdominal muscle weakness or paralysis.

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	Abdominal FES (v no intervention) on stimulated cough in people with SCI who have abdominal muscle paralysis or weakness
P	People with SCI who have abdominal muscle paralysis or weakness	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Weak opinion statement FOR Abdominal FES may be provided to improve stimulated cough in people with SCI who have abdominal muscle paralysis or weakness.
I	Abdominal FES
C	No intervention	Consensus-based opinion statement Weak for (92%)
O	Secretion clearance
	SUMMARY	1 RCT (see reference)	Mean difference (95% CI): Peak Expiratory Flow in Litres 0.6 (0.2 to 1.0) Favours abdominal FES
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Serious	Inconsistency Serious	Imprecision Not serious	Indirectness Not serious	Publication bias Serious

ABDOMINAL FES ON PEAK EXPIRATORY FLOW: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

ABDOMINAL FES FOR PEAK EXPIRATORY FLOW: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
CHENG 2006	NMES plus usual care V Usual Care	NMES 30Hz; pulse width 300µs; on/off 4/4s; Intensity 0 to 100mA.	C4-C7 SCI AIS A, B <3 months post injury	13/13	Peak Expiratory Flow (PEF)	Some concerns about Risk of Bias PEDro = 5/10

Abdominal binders (v no intervention) to improve cough in people with SCI who have abdominal muscle weakness or paralysis

consensus: Weak For Recommendation

An abdominal binder may be provided to improve cough in people with SCI who have abdominal muscle weakness or paralysis.

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	Abdominal binders (v no intervention) to improve cough in people with SCI who have abdominal muscle weakness or paralysis.
P	People with SCI who have abdominal muscle weakness or paralysis.	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Weak opinion statement FOR Abdominal binder may be provided to improve cough in people with SCI who have abdominal muscle weakness or paralysis Clinical note: Abdominal binders (to improve cough) are provided in people with abdominal paralysis (partial or full) and may not be suitable for people significant abdominal distension, central adiposity or large abdomens. Abdominal binders may also be provided for purposes other than improving cough.
I	Abdominal FES
C	No intervention	Consensus-based opinion statement Weak for (100%)
O	Secretion clearance
	SUMMARY	1 RCT (see reference)	Mean difference (95% CI): Peak expiratory flow in Litres 0.8 (0.1 to 1.5) Favours abdominal binder
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Serious	Inconsistency Serious	Imprecision Not serious	Indirectness Not serious	Publication bias Serious

ABDOMINAL BINDERS ON COUGH: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

ABDOMINAL BINDERS FOR PEAK EXPIRATORY FLOW: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
WADSWORTH 2012	Sitting with abdominal binder V Sitting without abdominal binder	Elastic binder	C3-T5 AIS A or AIS B SCI Acute	14/14	Peak Expiratory Flow (PEF)	High Risk of Bias PEDro = 4/10

Positive expiratory pressure devices (v no intervention) on secretion clearance in people with SCI who have expiratory muscle weakness

consensus: Weak Against Recommendation

Positive expiratory pressure devices should not be provided to improve secretion clearance in people with SCI who have expiratory muscle weakness.

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	Positive expiratory pressure devices (v no intervention) on secretion clearance in people with SCI who have expiratory muscle weakness
P	People with SCI who have respiratory muscle weakness.	Evidence recommendation No evidence recommendation Reason: Reason: No RCTs	Weak opinion statement AGAINST Positive expiratory pressure devices should not be provided to improve secretion clearance in people with SCI who have expiratory muscle weakness. Clinical note: Positive expiratory pressure techniques include oscillating positive pressure devices.
I	Positive expiratory pressure devices
C	No intervention	Consensus-based opinion statement Weak against (75%)
O	Secretion clearance

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The Australian and New Zealand Physiotherapy Guidelines for people with SCI was funded by icare NSW, National Injury Insurance Scheme Queensland, Transport Accident Commission Victoria, and Lifetime Support Authority South Australia.

Acknowledgement of Country – The Australian and New Zealand Clinical Practice Guidelines team acknowledges the Traditional Custodians of country throughout Australia and their connections to land, sea and community. We pay our respect to their Elders past and present and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

Honouring Te Tiriti – Ethical approval, including Māori consultation through University of Otago, Christchurch, Te Komiti Whakarite (Canterbury District Health Board), and through Māori consultation (Counties Manukau District Health Board) was obtained for Phase 1 of the study. In developing these guidelines, we were committed to meeting our obligations under Te Tiriti and reflect the principles of tino rangatiratanga, equity, active protection, options, and partnership.