Lung Volume & Respiratory Muscle Strength

Respiratory muscle training (v no intervention) on inspiratory respiratory muscle strength in people with SCI who have respiratory muscle weakness

evidence: Weak For Recommendation

Respiratory muscle training may be used to improve respiratory muscle strength in people with SCI who have respiratory muscle weakness.

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	Respiratory muscle training (v no intervention) on respiratory muscle strength in people with SCI who have respiratory muscle weakness
P	People with SCI who have respiratory muscle weakness	Evidence recommendation Weak for (100%)	Weak evidence recommendation FOR Respiratory muscle training may be used to improve respiratory muscle strength in people with SCI who have respiratory muscle weakness. Clinical note: Respiratory muscle training most commonly involves inspiratory muscle training but can also include expiratory muscle training
I	Respiratory muscle training
C	No intervention	Opinion statement No opinion statements
O	Muscle strength (mean inspiratory pressure)
	SUMMARY	10 RCT's (see references)	Mean difference (95% CI): Muscle strength in Mean Inspiratory Pressure -13 (-20 to -8) Favours respiratory muscle training
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Serious	Inconsistency Serious	Imprecision Not serious	Indirectness Not serious	Publication bias Serious

RESPIRATORY MUSCLE TRAINING FOR RESPIRATORY MUSCLE STRENGTH: 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

RESPIRATORY MUSCLE TRAINING FOR RESPIRATORY MUSCLE STRENGTH: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
BOSWELL-RUYS 2020	Resistive Inspiratory muscle training (RMT) V Sham RMT	3-5 sets 12 breaths 2 x day 5 days per week for 6 weeks @ > 30% MIP	C4-C8 SCI AIS A, B, C > 4 weeks post-injury	29/31	Maximal Inspiratory pressure (MIP)	Very low Risk of Bias PEDro = 10/10
Liaw 2000	Inspiratory muscle training (& usual care) V Usual care	15-20 minutes 2 x day; 7 days per week for 6/52	C4-C7 complete SCI < 6 months post-injury	10/10	Maximal Inspiratory pressure (MIP)	High Risk of Bias PEDro = 4/10
LITCHKE 2008	Respiratory resistance training V No intervention	1 set of exercises 2-3 x per day daily for 10 weeks	>80% participants with SCI C5-T12 SCI > 6 months post-injury	4/5	Maximal Inspiratory pressure (MIP)	Some Concerns about Risk of Bias PEDro = 5/10
LITCHKE 2011	Concurrent flow resistance V No intervention	10 breaths 3 different x per day daily for 9 weeks	>80% participants with SCI C5-C7 SCI	5/7	Maximal Inspiratory pressure (MIP)	High Risk of Bias PEDro = 3/10
LOVERIDGE 1989	Concurrent flow resistance V No intervention	85% of sustained inspiratory pressure 2 x day for 15 minutes 5 days per week for 8 weeks	C6-C7 complete SCI >1 year post-injury	6/6	Maximal Inspiratory pressure (MIP)	Some Concerns about Risk of Bias PEDro = 4/10
MUELLER 2013	Inspiratory resistance training V placebo	90 breaths @ > 80% max inspiratory power 4 x per week for 8 weeks	C6-C7 complete SCI >1 year post-injury	8/8	Maximal Inspiratory pressure (MIP)	Some Concerns about Risk of Bias PEDro = 4/10
POSTMA 2014	Resistive Inspiratory muscle training (& usual care) V Usual care	90 breaths @ > 80% max inspiratory power 4 x per week for 8 weeks	T12 and above SCI AIS A-D initial rehab FEV1 <80% predicted	19/21	Maximal Inspiratory pressure (MIP)	High Risk of Bias PEDro = 7/10
ROTH 2010	Expiratory muscle training V Sham	Exp muscle resistive training 10 reps, twice a day, 5 x per week for 6 weeks	T1 and above motor complete SCI	16/13	Maximal Inspiratory pressure (MIP)	High Risk of Bias PEDro = 4/10
SOUMYASHREE 2018	Inspiratory muscle training V Breathing exercises	15 minutes @ 40 MIP 5 x per week for 4 weeks	T1-12 SCI AIS A-D	15/12	Maximal Inspiratory pressure (MIP)	Some Concerns of Risk of bias PEDro = 7/10
WEST 2014	Inspiratory muscle training V Sham	30 breaths at 50-60% Pimax 2 x day 5 days per week for 6 weeks	C5-C7 SCI AIS A or B ≥3 years post-injury	5/5	Maximal Inspiratory pressure (MIP)	High Risk of Bias PEDro = 4/10

Liaw MY, Lin MC, Cheng PT, et al. Resistive inspiratory muscle training: its effectiveness in patients with acute complete cervical cord injury. Archives of Physical Medicine and Rehabilitation 2000 Jun;81(6):752-756.
Litchke L, Lloyd L, Schmidt E, et al. Comparison of two concurrent respiratory resistance devices on pulmonary function and time trial performance of wheelchair athletes. Therapeutic Recreation Journal 2011;45(2):147-159.
Litchke LG, Russian CJ, Lloyd LK, et al. Effects of respiratory resistance training with a concurrent flow device on wheelchair athletes. The Journal of Spinal Cord Medicine 2008;31(1):65-71.
Loveridge B, Badour M, Dubbo H. Ventilatory Muscle Endurance Training in Quadriplegics; effects on breathing pattern. Paraplegia 1989; 27: 329-339.
Mueller G, Hopman MTE and Perret C. Comparison of respiratory muscle training methods in individuals with motor complete tetraplegia. Topics in Spinal Cord Injury Rehabilitation 2012;18(2):118-121.
Postma K, Haisma JA, Hopman MTE, et al. Resistive inspiratory muscle training in people with spinal cord injury during inpatient rehabilitation: a randomized controlled trial. Physical Therapy 2014 ;94(12):1709-1719 2014.
Soumyashree S, Kaur J. Effect of inspiratory muscle training (IMT) on aerobic capacity, respiratory muscle strength and rate of perceived exertion in paraplegics. Journal of spinal cord medicine 2018: 1-7.
West CR, CR, Taylor BJ, Campbell IG, Romer LM. Effects of inspiratory muscle training on exercise responses in Paralympic athletes with cervical spinal cord injury. Scandinavian journal of medicine & science in sports 2014; 24: 764.
Boswell-Ruys CL, Lewis CRH, Wijeysuriya NS, et al. Impact of respiratory muscle training on respiratory muscle strength, respiratory function and quality of life in individuals with tetraplegia: a randomised clinical trial. Thorax 2020;75:279-288.
Roth EJ, Stenson KW, Powley S, Oken J, Primack S, Nussbaum SB, Berkowitz M. Expiratory muscle training in spinal cord injury: a randomized controlled trial. Arch Phys Med Rehabil. 2010 Jun;91(6):857-61.

Abdominal binders in sitting (v no intervention) on lung volumes in people with SCI who have abdominal muscle weakness or paralysis

evidence: Weak For Recommendation

Abdominal binders in sitting may be provided to improve lung volume in people with SCI who have abdominal muscle weakness or paralysis.

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	Abdominal binders in sitting (v no intervention) on lung volumes in people with SCI who have abdominal muscle weakness or paralysis
P	People with SCI who have abdominal muscle weakness or paralysis	Evidence recommendation Weak for (100%)	Weak evidence recommendation FOR Abdominal binders in sitting may be provided to improve lung volume in people with SCI who have abdominal muscle weakness or paralysis. Clinical note: Abdominal binders (to improve lung volumes) are provided in people with respiratory compromise and abdominal muscle paralysis (full or partial). Abdominal binders may not be suitable for people with significant abdominal distension, central adiposity, or large abdomens. Abdominal binders may also be provided for purposes other than improving lung volume.
I	Abdominal binders
C	No abdominal binder	Consensus-based opinion statement No opinion statements
O	Lung volume
	SUMMARY	5 RCTs (see references)	Mean difference (95% CI): Lung volume in litres 0.3 (0.1 to 0.5) Favours abdominal binders
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Very serious	Inconsistency Not serious	Imprecision Not serious	Indirectness Serious	Publication bias Serious

ABDOMINAL BINDERS FOR LUNG VOLUME: 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

Supine (v high sitting) on lung volumes in people with SCI who have abdominal muscle paralysis or weakness.

consensus: Strong For Recommendation

Positioning in supine should be provided (in favour of sitting) to improve lung volumes in people with SCI who have abdominal muscle paralysis or weakness.

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	Supine (v high sitting) on lung volumes in people with SCI who have abdominal muscle paralysis or weakness.
P	People with SCI who have abdominal muscle abdominal muscle paralysis or weakness.	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Strong opinion statement FOR Positioning in supine should be provided (in favour of sitting) to improve lung volumes in people with SCI who have abdominal muscle paralysis or weakness. Clinical note: Supine may not be suitable for people with significant abdominal distension, central adiposity or those with large abdomens and long-standing SCI.
I	Supine
C	High sitting	Consensus-based opinion statement Strong for (85%)
O	Lung volume
	SUMMARY	1 RCT16	Mean difference (95% CI): Lung volume in litres 0.4 (-1.3 to 2.1) Favours supine
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Very serious	Inconsistency Serious	Imprecision Serious	Indirectness Serious	Publication bias Serious

SUPINE (V HIGH SITTING) FOR LUNG VOLUMES: 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

Intermittent application of positive pressure devices (v no intervention) on lung volume in non- ventilated people with SCI who have respiratory muscle weakness

consensus: Strong For Recommendation

Intermittent application of positive pressure devices should be provided to improve lung volume in non-ventilated people with acute SCI who have respiratory muscle weakness. Positive pressure devices include mechanical insufflation, Intermittent Positive Pressure Breathing (IPPB), Continuous Positive Airway Pressure (CPAP) and brief periods of Bilevel Positive Airway Pressure (BiPAP).

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	Intermittent application of positive pressure devices (v no intervention) on lung volume in non- ventilated people with SCI who have respiratory muscle weakness
P	People with SCI who are not ventilated and have respiratory muscle weakness	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Strong opinion statement FOR Intermittent application of positive pressure devices should be provided to improve lung volume in non-ventilated people with SCI who have respiratory muscle weakness. Clinical note: Contraindications and precautions for the use of positive pressure devices must be considered before prescribing these treatments. For example, positive pressure devices are contraindicated in conditions that include but are not limited to untreated pneumothorax, tracheoesophageal fistula and acute traumatic brain injury with increased or poorly controlled intracranial pressure. Positive pressure devices include mechanical insufflation, Intermittent Positive Pressure Breathing (IPPB), Continuous Positive Airway pressure (CPAP) and brief periods of Bilevel Positive Airway Pressure (BiPAP).
I	Intermittent application of positive pressure devices
C	No intervention	Consensus-based opinion statement Strong for (93%)
O	Lung volume (Litres)
	SUMMARY	1 RCT (see reference)	Mean difference (95% CI): Lung volume in litres 0.1 (-0.5 to 0.7) Favours intermittent positive pressure breathing
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Very serious	Inconsistency Serious	Imprecision Serious	Indirectness Serious	Publication bias Serious

INTERMITTENT APPLICATION OF POSITIVE PRESSURE DEVICES ON LUNG VOLUME: 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

Intermittent application of positive pressure (v no intervention) on lung volume in ventilated people with SCI who have respiratory muscle weakness

consensus: Strong For Recommendation

Intermittent application of positive pressure therapy techniques should be used (in consultation with medical staff) for improving lung volume in ventilated people with acute SCI that are medically stable.

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	Intermittent application of positive pressure (v no intervention) on lung volume in ventilated people with SCI who have respiratory muscle weakness
P	People with SCI who are ventilated and have respiratory muscle weakness	Evidence recommendation No evidence recommendation Reason: No RCTs	Strong opinion statement FOR Intermittent application of positive pressure therapy techniques should be used (in consultation with medical staff) for improving lung volume in ventilated people with acute SCI that are medically stable. Clinical note: Positive pressure therapy techniques include ventilator hyper-inflation, mechanical insufflation and manual-hyperinflation. Ventilator hyperinflation is preferred if available. Positive pressure techniques are contraindicated in conditions that include but are not limited to untreated pneumothorax, tracheoesophageal fistula, increased intracranial pressure and facial trauma.
I	Intermittent application of positive pressure therapy techniques
C	No intervention	Consensus-based opinion statement Strong for (100%)
O	Lung volume (Litres)

Deep breathing exercises (v no intervention) on lung volumes in people with SCI who have respiratory muscle weakness

consensus: Weak For Recommendation

Deep breathing exercises may be provided to improve lung volumes in people with SCI.

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	Deep breathing exercises (v no intervention) on lung volumes 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	Strong opinion statement FOR Deep breathing exercises may be provided to improve lung volumes in people with SCI. Clinical note: People with SCI and respiratory muscle weakness should focus on respiratory strength training exercises, rather than deep breathing exercises.
I	Deep breathing exercises
C	No intervention	Consensus-based opinion statement Weak for (100%)
O	Lung volume

Air stacking (v no intervention) on lung volumes in people with SCI who have respiratory muscle weakness

consensus: Weak For Recommendation

Air stacking may be taught to improve lung volume in people with SCI who have respiratory muscle weakness.

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	Air stacking (v no intervention) on lung volumes 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 recommendation due to insufficient or inconclusive evidence.	Weak opinion statement FOR Air stacking may be taught to improve lung volume in people with SCI who have respiratory muscle weakness. Clinical note: Air stacking involves the use of any positive pressure inspiratory device. These should be provided by a mouthpiece and nose peg rather than a face mask because of the risk of pneumothorax if a facemask is provided.
I	Air stacking
C	No intervention	Consensus-based opinion statement Weak for (100%)
O	Lung volume (L)
	SUMMARY	1 RCT (see reference)	Mean difference (95% CI): Lung volume in litres 0 (-0.6 to 0.6) Favours air stacking
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Very Serious	Inconsistency Serious	Imprecision Serious	Indirectness Serious	Publication bias Serious

AIR STACKING ON LUNG VOLUME: 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 (v no intervention) on lung volumes in people with SCI who have respiratory muscle weakness

consensus: No Recommendation

No evidence recommendation or consensus-based opinion statement.
Reason: No consensus could be reached

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	Abdominal FES (v no intervention) on lung volumes 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.	No evidence recommendation or consensus-based opinion statement No recommendation can be made on abdominal FES to improve lung volumes in people with SCI who have abdominal muscle weakness or paralysis.
I	Abdominal FES
C	No intervention	Consensus-based opinion statement No consensus statements Reason: No consensus could be reached
O	Lung volume (Litres)
	SUMMARY	1 RCT23	Mean difference (95% CI): Lung volume in litres 0.4 (-0.1 to 0.8) Favours abdominal FES
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Very serious	Inconsistency No serious	Imprecision Serious	Indirectness No serious	Publication bias Serious

ABDOMINAL FES ON LUNG VOLUME: 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

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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.

ABDOMINAL BINDERS FOR LUNG VOLUME: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
GOLDMAN 1996	Sitting with abdominal binder V Sitting without abdominal binder	Elastic binder	C5-C7 Complete SCI >3 months post injury	7/7	Lung volume Vital Capacity (VC)	High Risk of Bias PEDro = 5/10
BOAVENTURA 2003	Sitting with abdominal binder V Sitting without abdominal binder	Elastic binder	C4-C7 Complete SCI 1 year post injury	10/10	Lung volume Forced Vital Capacity (FVC)	Some Concerns of Risk of bias PEDro = 6/10
BODIN 2005	Sitting with abdominal binder V Sitting without abdominal binder	Elastic binder	C5-C8 SCI At least 1 year post injury	20/20	Lung volume (VC)	High Risk of Bias PEDro = 4/10
HART 2005	Sitting with abdominal binder V Sitting without abdominal binder	Combination elastic and non-elastic binder	C5-T6 AIS A SCI	10/10	Lung volume (FVC)	High Risk of Bias PEDro = 4/10
WADSWORTH 2012	Sitting with abdominal binder V Sitting without abdominal binder	Elastic binder	C3-T5 AIS A or AIS B SCI Acute	14/14	Lung volume (FVC)	High Risk of Bias PEDro = 4/10

INTERMITTENT POSITIVE PRESSURE FOR LUNG VOLUME: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
LAFFONT 2008	Intermittent positive pressure breathing (IPPB) V No intervention	IPPB up to 40cmH20 20mins 2 x per day 5 days per week or 2 months	C5-T6 Complete SCI <6months post injury	14/14	Lung volume (VC)	High Risk of Bias PEDro = 5/10

AIR STACKING FOR LUNG VOLUME: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
JEONG 2015	Air stacking V Incentive spirometry	20 reps air stacking 2 x per day 5 days per week for 6 weeks	tetaplegia	14/12	Lung volume (FVC)	High Risk of Bias PEDro = 6/10

ABDOMINAL FES FOR LUNG VOLUME: 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	Lung volume (FVC)	Some concerns about Risk of Bias PEDro = 5/10