The Short-term in-hospital Pulmonary Rehabilitation versus perioperative Short-term in-hospital Chest Therapy before lung cancer resection: a randomized controlled trial
Main Article Content
Abstract
Objective: The aim of this study is to evaluate the effect of pulmonary resection and perioperative Short-term in-hospital Pulmonary Rehabilitation (SPR) versus perioperative Short-term in-hospital Chest Therapy (SCT) on the functional capacity and postoperative morbidity of patients with poor lung function.
Design: Single-blind randomized control trial.
Setting: Thoracic surgery department at “Santo Spirito” Civil Hospital – Pescara (Italy)
Participants: Patients undergoing elective lung cancer resection (N=30).
Interventions: Patients were randomly assigned to receive daily SPR (pulmonary rehabilitation, self-management and endurance training) versus daily SCT (breathing exercises). Both groups received early postoperative rehabilitation.
Outcome Measures: Pulmonary functional parameters assessed at baseline and prior to surgery (phase 1), hospital length of stay and pulmonary complications assessed after lung cancer resection (phase 2).
Results: Thirty patients were randomly assigned to the SPR arm (15) and SCT arm (15).
During phase 1 evaluation: Forced Vital Capacity (FVC) (p 0,0001); percentage of predicted FVC (p 0,0002); Forced Expiratory Volume in the first second (FEV1) (p 0,0001); percentage of predicted FEV1 (p 0,0001). Percentage of change from baseline to prior to surgery in two groups SPR: FVC (18%); percentage of predicted FVC (20%); FEV1 (29%); percentage of predicted FEV1 (25%). SCT: FVC (10%); percentage of predicted FVC (11%); FEV1 (9%); percentage of predicted FEV1 (9%).
Phase 2: the SPR group SPR group was in a favorable clinical condition compared with the SCT arm and the SPR group had a shorter length of postoperative stay (15 ± 5 vs 17 ±5, respectively).
Conclusions: Despite poor lung function, these findings suggest that a feasible perioperative SPR before lung cancer resection improves preoperative functional capacity and decreases the postoperative respiratory morbidity.
Keywords:
lung cancer, pulmonary rehabilitation, chest therapy
Article Details
How to Cite
BARASSI, Giovanni et al.
The Short-term in-hospital Pulmonary Rehabilitation versus perioperative Short-term in-hospital Chest Therapy before lung cancer resection: a randomized controlled trial.
Medical Research Archives, [S.l.], v. 8, n. 4, apr. 2020.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/2074>. Date accessed: 04 dec. 2024.
doi: https://doi.org/10.18103/mra.v8i4.2074.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C et al , International Agency for Research on Cancer. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11.Lyon, France: 2013. Available from: globocan.iarc.fr (accessed 1 July 2015).
2. Australian Institute of Health and Welfare. Lung cancer in Australia: an overview. Cancer series no. 64. Cat. no. CAN 58. www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737421095&libID= 10737421094.
3. Sisk A, Fonteyn M (2016) Evidence-based Yoga interventions for patients with cancer. Clin J Oncol Nurs 20(2):181–186.
4. Berry MF, Villamizar-Ortiz NR, Tong BC, et al. Pulmonary function tests do not predict pulmonary complications after thoracoscopic lobectomy. Ann Thorac Surg . 2010; 89 (4): 1044 - 1051.
5. Ferguson MK, Siddique J, Karrison T . Modeling major lung resection outcomes using classifi cation trees and multiple imputation techniques. Eur J Cardiothorac Surg . 2008; 34 (5): 1085 - 1089.
6. Licker MJ, Widikker I , Robert J , et al . Operative mortality and respiratory complications after lung resection for cancer: impact of chronic obstructive pulmonary disease and time trends. Ann Thorac Surg . 2006; 81 (5): 1830 - 1837.
7. Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143: e166Se190S.
8. Loganathan RS, Stover DE, Shi W, et al. Prevalence of COPD in women compared to men around the time of diagnosis of primary lung cancer. Chest 2006; 129(5): 1305–1312.
9. Carlotta Mainini, Patrícia FS Rebelo, Roberta Bardelli, Besa Kopliku, Sara Tenconi, Stefania Costi, Claudio Tedeschi1 and Stefania Fugazzaro Perioperative physical exercise interventions for patients undergoing lung cancer surgery: What is the evidence? SAGE Open Medicine Volume 4: 1– 19 © The Author(s) 2016 DOI: 10.1177/2050312116673855.
10. Divisi D, Di Francesco C, Di Leonardo G, et al. Preoperative pulmonary rehabilitation in patients with lung cancer and chronic obstructive pulmonary disease. Eur J Cardiothorac Surg 2013; 43(2): 293–296.
11. Schroedl C and Kalhan R. Incidence, treatment options, and outcomes of lung cancer in patients with chronic obstructive pulmonary disease. Curr Opin Pulm Med 2012; 18(2): 131– 137.
12. Warner DO. Preventing postoperative pulmonary complications: the role of the anesthesiologist. Anesthesiology 2000; 92:1467–72.
13. Cavalheri V, Granger C, Preoperative exercise training for patients with non-small cell lung cancer (Review). Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD012020. DOI: 10.1002/14651858.CD012020.pub2.
14. Endoh H, Tanaka S , Yajima T , et al . Pulmonary function after pulmonary resection by posterior thoracotomy, anterior thoracotomy or video-assisted surgery. Eur J Cardiothorac Surg. 2010; 37 (5): 1209 - 1214.
15. Tung-Chou Li, Ming-Chung Yang, Ailun Heather Tseng, Henry Hsin-Chung Lee Prehabilitation and rehabilitation for surgically treated lung cancer patients. Journal of Cancer Research and Practice 4 (2017) 89e94.
16. Reeve J. Physiotherapy interventions to prevent postoperative pulmonary complications following lung resection. What is the evidence? What is the practice? NZ J Physiother 2008; 36:118–30.
17. Deng GE, Rausch SM, Jones LW, Gulati A, Kumar NB, Greenlee H et al. Complementary therapies and integrative medicine in lung cancer: diagnosis and management of lung cancer, 3rd ed: American Physicians Evidence-Based Clinical Practice Guidelines. Chest 2013; 143: e420S–36S.
18. Crandall K, Maguire R, Campbell A, et al. Exercise intervention for patients surgically treated for Non-Small Cell Lung Cancer (NSCLC): a systematic review. Surg Oncol 2014; 23(1): 17–30.
19. Spruit MA, Singh SJ, Garvey C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013; 188(8): e13–e64.
20. Esra Pehlivan, Akif Turna, Atilla Gurses and Hulya Nilgun Gurses, The Effects of Preoperative Short-term Intense Physical Therapy in Lung Cancer Patients: A Randomized Controlled Trial. Ann Thorac Cardiovasc Surg 2011; 17: 461–468.
21. Marcus Jonsson, Anita Hurtig-Wennlöf, Anders Ahlsson, Mårten Vidlund, Yang Cao, Elisabeth Westerdahl, In-hospital physiotherapy improves physical activity levelafter lung cancer surgery: a randomized controlled trial. Physiotherapy 105 (2019) 434–441.
22. Granger CL, McDonald CF, Berney S, et al. Exercise intervention to improve exercise capacity and health related quality of life for patients with Non-small cell lung cancer: a systematic review. Lung Cancer 2011; 72(2): 139–153.
23. Varela G, Novoa NM, Agostini P, Ballesteros E. Chest physiotherapy in lung resections patients: state of the art. Semin Thorac Cardiovasc Surg 2011;23:297–306.
24. Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicianse vidence-based clinical practice guidelines. Chest. 2013;143: e166Se190S.
25. Licker MJ, Widikker I, Robert J, Frey JG, Spiliopoulos A, Ellenberger C, Schweizer A, Tschopp JM (2006) Operative mortality and respiratory complications after lung resection for cancer: impact of chronic obstructive pulmonary disease and time. Trend Ann Thorac Surg 81(5):1830–1837.
26. Peddle CJ, Jones LW, Eves ND, Reiman T, Sellar CM (2009) Effects of presurgical exercise training on quality of life in patients undergoing lung resection for suspected malignancy: a pilot study. Cancer Nurs 32 (2009):158–165.
27. Karvonen MJ, Kentala A, Mustala O. The effects of training on heart rate: a longitudinal study. Ann Med Exp Biol Fenn 1957; 35: 307-15.
28. Barassi G., Bellomo R. G., Di Iulio A., Lococo A., Porreca A., Di Felice P. A., and Saggini R., Preoperative Rehabilitation in Lung Cancer Patients: Yoga Approach, Adv Exp Med Biol - Clinical and Experimental Biomedicine https://doi.org/10.1007/5584_2018_186.
29. Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J 2005; 26: 319–338.
30. Benzo R, Wigle D, Novotny P, Wetzstein M, Nichols F, Shen RK, Cassivi S, Deschamps C (2012) Preoperative pulmonary rehabilitation before lung cancer resection: results from two randomized studies. Lung Cancer 74 (3):441–445.
31. Agostini P, Cieslik H, Rathinam S, et al. Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors? Thorax. 2010; 65:815e818.
32. Doorenbos A, Given B, Given C, Verbitsky N. Physical functioning: effect of behavioral intervention for symptoms among individuals with cancer. Nurs Res. 2006; 55:161e171.
33. Morano MT, Araujo AS, Nascimento FB, et al. Preoperative pulmonary rehabilitation versus chest physical therapy in patients undergoing lung cancer resection: a pilot randomized controlled trial. Arch Phys Med Rehabil. 2013;94: 53e58.
34. Rodriguez-Larrad A, Lascurain-Aguirrebena I, Abecia-Inchaurregui LC, Seco J. Perioperative physiotherapy in patients undergoing lung cancer resection. Interact Cardiovasc Thorac Surg. 2014; 19:269e281.
35. Sebio Garcia R, Yanez Brage MI, Gimenez Moolhuyzen E, Granger CL, Denehy L. Functional and postoperative outcomes after preoperative exercise training in patients with lung cancer: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2016; 23:486e497.
36. Cesario A, Ferri L, Galetta D, Cardaci V, Biscione G, Pasqua F, Piraino A, Bonassi S, Russo P, Sterzi S, Margaritora S, Granone P. Pre-operative pulmonary rehabilitation and surgery for lung cancer. Lung Cancer 2007; 57:118–199.
37. Bobbio A, Chetta A, Ampollini L, Primomo GL, Internullo E, Carbognani P, Rusca M, Olivieri D. Preoperative pulmonary rehabilitation in patients undergoing lung resection for non-small cell lung cancer. Eur J Cardiothorac Surg 2008; 33:95–98.
38. Sekine Y, Chiyo M, Iwata T, Yasufuku K, Furukawa S, Amada Y, Iyoda A, Shibuya K, Iizasa T, Fujisawa T. Perioperative rehabilitation and physiotherapy for lung cancer patients with chronic obstructive pulmonary disease. Jpn J Thorac Cardiovasc Surg 2005; 53:237–243.
39. Grover P, Varma VD, Pershad D, Verma SK. Role of yoga in the treatment of psychoneuron’s bull. PGI. 1998; 22(2): 68-76.
40. Shankarappa V., Prashanth P., Nachal Annamalai, Varunmalhotra ,The Short Term Effect of Pranayama on the Lung Parameters Journal of Clinical and Diagnostic Research. 2012 February, Vol-6(1): 27-30 27.
41. Apar Avinash Saoji, B.R. Raghavendra, N.K. Manjunath, Effects of yogic breath regulation: A narrative review of scientific evidence. Journal of Ayurveda and Integrative Medicine 10 (2019) 50e58.
42. Jerant A, Franks P, Kravitz RL. Associations between pain control self-efficacy, self-efficacy for communicating with physicians, and subsequent pain severity among cancer patients. Patient Educ Couns.
43. Porter LS, Keefe FJ, Garst J, et al. Caregiver-Assisted Coping Skills Training for Lung Cancer: Results of a Randomized Clinical Trial. J Pain Symptom Manage.
44. van Weert E, Hoekstra-Weebers JE, May AM, et al. The development of an evidence-based physical self-management rehabilitation programme for cancer survivors. Patient Educ Couns. 2008; 71:169–190. [PubMed: 18255249].
45. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977; 84:191–215. [PubMed: 847061.
46. Bodenheimer T, Lorig K, Holman H, et al. Patient self-management of chronic disease in primary care. Jama. 2002; 288:2469–2475. [PubMed: 12435261].
47. Lorig KR, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med. 2003; 26:1–7. [PubMed: 12867348].
48. Paula Agostini, Sally Singh, Incentive spirometry following thoracic surgery: what should we be doing? Physiotherapy 95 (2009) 76–82.
49. Ruben D Restrepo , Richard Wettstein, Leo Wittnebel and Michael Tracy Incentive Spirometry: 2011. RESPIRATORY CARE • OCTOBER 2011 VOL 56 NO 10
50. Parreira V, Tomich GM, Britto RR, Sampaio RF. Assessment of tidal volume and thoracoabdominal motion using flow and volume orientated incentive spirometers in healthy subjects. Braz J Med Biol Res 2005; 38:1105–12.
2. Australian Institute of Health and Welfare. Lung cancer in Australia: an overview. Cancer series no. 64. Cat. no. CAN 58. www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737421095&libID= 10737421094.
3. Sisk A, Fonteyn M (2016) Evidence-based Yoga interventions for patients with cancer. Clin J Oncol Nurs 20(2):181–186.
4. Berry MF, Villamizar-Ortiz NR, Tong BC, et al. Pulmonary function tests do not predict pulmonary complications after thoracoscopic lobectomy. Ann Thorac Surg . 2010; 89 (4): 1044 - 1051.
5. Ferguson MK, Siddique J, Karrison T . Modeling major lung resection outcomes using classifi cation trees and multiple imputation techniques. Eur J Cardiothorac Surg . 2008; 34 (5): 1085 - 1089.
6. Licker MJ, Widikker I , Robert J , et al . Operative mortality and respiratory complications after lung resection for cancer: impact of chronic obstructive pulmonary disease and time trends. Ann Thorac Surg . 2006; 81 (5): 1830 - 1837.
7. Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143: e166Se190S.
8. Loganathan RS, Stover DE, Shi W, et al. Prevalence of COPD in women compared to men around the time of diagnosis of primary lung cancer. Chest 2006; 129(5): 1305–1312.
9. Carlotta Mainini, Patrícia FS Rebelo, Roberta Bardelli, Besa Kopliku, Sara Tenconi, Stefania Costi, Claudio Tedeschi1 and Stefania Fugazzaro Perioperative physical exercise interventions for patients undergoing lung cancer surgery: What is the evidence? SAGE Open Medicine Volume 4: 1– 19 © The Author(s) 2016 DOI: 10.1177/2050312116673855.
10. Divisi D, Di Francesco C, Di Leonardo G, et al. Preoperative pulmonary rehabilitation in patients with lung cancer and chronic obstructive pulmonary disease. Eur J Cardiothorac Surg 2013; 43(2): 293–296.
11. Schroedl C and Kalhan R. Incidence, treatment options, and outcomes of lung cancer in patients with chronic obstructive pulmonary disease. Curr Opin Pulm Med 2012; 18(2): 131– 137.
12. Warner DO. Preventing postoperative pulmonary complications: the role of the anesthesiologist. Anesthesiology 2000; 92:1467–72.
13. Cavalheri V, Granger C, Preoperative exercise training for patients with non-small cell lung cancer (Review). Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD012020. DOI: 10.1002/14651858.CD012020.pub2.
14. Endoh H, Tanaka S , Yajima T , et al . Pulmonary function after pulmonary resection by posterior thoracotomy, anterior thoracotomy or video-assisted surgery. Eur J Cardiothorac Surg. 2010; 37 (5): 1209 - 1214.
15. Tung-Chou Li, Ming-Chung Yang, Ailun Heather Tseng, Henry Hsin-Chung Lee Prehabilitation and rehabilitation for surgically treated lung cancer patients. Journal of Cancer Research and Practice 4 (2017) 89e94.
16. Reeve J. Physiotherapy interventions to prevent postoperative pulmonary complications following lung resection. What is the evidence? What is the practice? NZ J Physiother 2008; 36:118–30.
17. Deng GE, Rausch SM, Jones LW, Gulati A, Kumar NB, Greenlee H et al. Complementary therapies and integrative medicine in lung cancer: diagnosis and management of lung cancer, 3rd ed: American Physicians Evidence-Based Clinical Practice Guidelines. Chest 2013; 143: e420S–36S.
18. Crandall K, Maguire R, Campbell A, et al. Exercise intervention for patients surgically treated for Non-Small Cell Lung Cancer (NSCLC): a systematic review. Surg Oncol 2014; 23(1): 17–30.
19. Spruit MA, Singh SJ, Garvey C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013; 188(8): e13–e64.
20. Esra Pehlivan, Akif Turna, Atilla Gurses and Hulya Nilgun Gurses, The Effects of Preoperative Short-term Intense Physical Therapy in Lung Cancer Patients: A Randomized Controlled Trial. Ann Thorac Cardiovasc Surg 2011; 17: 461–468.
21. Marcus Jonsson, Anita Hurtig-Wennlöf, Anders Ahlsson, Mårten Vidlund, Yang Cao, Elisabeth Westerdahl, In-hospital physiotherapy improves physical activity levelafter lung cancer surgery: a randomized controlled trial. Physiotherapy 105 (2019) 434–441.
22. Granger CL, McDonald CF, Berney S, et al. Exercise intervention to improve exercise capacity and health related quality of life for patients with Non-small cell lung cancer: a systematic review. Lung Cancer 2011; 72(2): 139–153.
23. Varela G, Novoa NM, Agostini P, Ballesteros E. Chest physiotherapy in lung resections patients: state of the art. Semin Thorac Cardiovasc Surg 2011;23:297–306.
24. Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicianse vidence-based clinical practice guidelines. Chest. 2013;143: e166Se190S.
25. Licker MJ, Widikker I, Robert J, Frey JG, Spiliopoulos A, Ellenberger C, Schweizer A, Tschopp JM (2006) Operative mortality and respiratory complications after lung resection for cancer: impact of chronic obstructive pulmonary disease and time. Trend Ann Thorac Surg 81(5):1830–1837.
26. Peddle CJ, Jones LW, Eves ND, Reiman T, Sellar CM (2009) Effects of presurgical exercise training on quality of life in patients undergoing lung resection for suspected malignancy: a pilot study. Cancer Nurs 32 (2009):158–165.
27. Karvonen MJ, Kentala A, Mustala O. The effects of training on heart rate: a longitudinal study. Ann Med Exp Biol Fenn 1957; 35: 307-15.
28. Barassi G., Bellomo R. G., Di Iulio A., Lococo A., Porreca A., Di Felice P. A., and Saggini R., Preoperative Rehabilitation in Lung Cancer Patients: Yoga Approach, Adv Exp Med Biol - Clinical and Experimental Biomedicine https://doi.org/10.1007/5584_2018_186.
29. Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J 2005; 26: 319–338.
30. Benzo R, Wigle D, Novotny P, Wetzstein M, Nichols F, Shen RK, Cassivi S, Deschamps C (2012) Preoperative pulmonary rehabilitation before lung cancer resection: results from two randomized studies. Lung Cancer 74 (3):441–445.
31. Agostini P, Cieslik H, Rathinam S, et al. Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors? Thorax. 2010; 65:815e818.
32. Doorenbos A, Given B, Given C, Verbitsky N. Physical functioning: effect of behavioral intervention for symptoms among individuals with cancer. Nurs Res. 2006; 55:161e171.
33. Morano MT, Araujo AS, Nascimento FB, et al. Preoperative pulmonary rehabilitation versus chest physical therapy in patients undergoing lung cancer resection: a pilot randomized controlled trial. Arch Phys Med Rehabil. 2013;94: 53e58.
34. Rodriguez-Larrad A, Lascurain-Aguirrebena I, Abecia-Inchaurregui LC, Seco J. Perioperative physiotherapy in patients undergoing lung cancer resection. Interact Cardiovasc Thorac Surg. 2014; 19:269e281.
35. Sebio Garcia R, Yanez Brage MI, Gimenez Moolhuyzen E, Granger CL, Denehy L. Functional and postoperative outcomes after preoperative exercise training in patients with lung cancer: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2016; 23:486e497.
36. Cesario A, Ferri L, Galetta D, Cardaci V, Biscione G, Pasqua F, Piraino A, Bonassi S, Russo P, Sterzi S, Margaritora S, Granone P. Pre-operative pulmonary rehabilitation and surgery for lung cancer. Lung Cancer 2007; 57:118–199.
37. Bobbio A, Chetta A, Ampollini L, Primomo GL, Internullo E, Carbognani P, Rusca M, Olivieri D. Preoperative pulmonary rehabilitation in patients undergoing lung resection for non-small cell lung cancer. Eur J Cardiothorac Surg 2008; 33:95–98.
38. Sekine Y, Chiyo M, Iwata T, Yasufuku K, Furukawa S, Amada Y, Iyoda A, Shibuya K, Iizasa T, Fujisawa T. Perioperative rehabilitation and physiotherapy for lung cancer patients with chronic obstructive pulmonary disease. Jpn J Thorac Cardiovasc Surg 2005; 53:237–243.
39. Grover P, Varma VD, Pershad D, Verma SK. Role of yoga in the treatment of psychoneuron’s bull. PGI. 1998; 22(2): 68-76.
40. Shankarappa V., Prashanth P., Nachal Annamalai, Varunmalhotra ,The Short Term Effect of Pranayama on the Lung Parameters Journal of Clinical and Diagnostic Research. 2012 February, Vol-6(1): 27-30 27.
41. Apar Avinash Saoji, B.R. Raghavendra, N.K. Manjunath, Effects of yogic breath regulation: A narrative review of scientific evidence. Journal of Ayurveda and Integrative Medicine 10 (2019) 50e58.
42. Jerant A, Franks P, Kravitz RL. Associations between pain control self-efficacy, self-efficacy for communicating with physicians, and subsequent pain severity among cancer patients. Patient Educ Couns.
43. Porter LS, Keefe FJ, Garst J, et al. Caregiver-Assisted Coping Skills Training for Lung Cancer: Results of a Randomized Clinical Trial. J Pain Symptom Manage.
44. van Weert E, Hoekstra-Weebers JE, May AM, et al. The development of an evidence-based physical self-management rehabilitation programme for cancer survivors. Patient Educ Couns. 2008; 71:169–190. [PubMed: 18255249].
45. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977; 84:191–215. [PubMed: 847061.
46. Bodenheimer T, Lorig K, Holman H, et al. Patient self-management of chronic disease in primary care. Jama. 2002; 288:2469–2475. [PubMed: 12435261].
47. Lorig KR, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med. 2003; 26:1–7. [PubMed: 12867348].
48. Paula Agostini, Sally Singh, Incentive spirometry following thoracic surgery: what should we be doing? Physiotherapy 95 (2009) 76–82.
49. Ruben D Restrepo , Richard Wettstein, Leo Wittnebel and Michael Tracy Incentive Spirometry: 2011. RESPIRATORY CARE • OCTOBER 2011 VOL 56 NO 10
50. Parreira V, Tomich GM, Britto RR, Sampaio RF. Assessment of tidal volume and thoracoabdominal motion using flow and volume orientated incentive spirometers in healthy subjects. Braz J Med Biol Res 2005; 38:1105–12.