1. Hopp, Lisa PhD, RN
  2. Walker, Jane PhD, RN

Article Content


The purpose of this presentation was to describe the process and rigor of systematic review with an example of a systematic review of effectiveness that we recently completed. Participants will use a critical appraisal tool to understand how to assess the transparency and quality of a systematic review of the effectiveness of arm exercise on dyspnea in patients with COPD.



The significance of this presentation is 2-fold. First, the Institute of Medicine has recently called for the United States to greatly increase our capacity to summarize evidence with the process of systematic review. Clinical nurse specialists, in their roles as facilitators of evidence-based practice, are well positioned to assess and conduct systematic reviews. Second, the topic of the review itself is important because dyspnea is a disabling symptom that is particularly troublesome when patients with COPD perform activities of daily living that involve using their arms.



We will describe the process of systematic review, the origins of rigor in systematic review, and the secondary research method of systematic review of effectiveness.



These are the methods of systematic review that we used, and we will illustrate both the process and how to appraise a systematic review, using our review as an example. Participants will have the opportunity to use a standardized appraisal tool to appraise this review. Inclusion criteria: We included any study where the effect of arm exercise could be isolated from other pulmonary rehabilitation strategies like whole-body exercise, lower extremity training, and sham or control interventions. The participants were stable patients with moderate to severe COPD, who were breathing without mechanical ventilation. The methods needed to include a measurement of exercise-related and/or chronic dyspnea. Search strategy: We conducted an exhaustive, comprehensive search of the published and grey literature using a 3-phase approach with no language or year of publication limits. We searched CINAHL and Medline to identify all key words. Subsequently, we used a structured Boolean search of all relevant bibliographic and grey literature databases. Finally, we hand-searched the reference lists of included and other highly relevant, recent articles. Two independent investigators reviewed the search results to make the decision to retrieve studies for critical appraisal. Methodological quality: Two independent reviewers appraised all reports using standardized critical appraisal tools of the Joanna Briggs Institute, specific for the particular research design. There were no disagreements about which studies to include in the review.



Like many systematic reviews of effectiveness, we were unable to conduct a meta-analysis. However, we summarized the extracted data of 5 included randomized controlled trials as follows. The search netted 269 unique reports; we appraised 18 studies and included 5 randomized controlled trials. Eleven studies were excluded because they were of poor methodological quality or because the effect of arm exercise could not be isolated. Two studies were not available from any library source. Arm exercise regimens varied, but most included some type of low-resistance, high-repetition arm lift combinations. No findings could be pooled for meta-analysis. Only 1 study found significant improvements in exercise-related dyspnea, but all studies were underpowered and many had significant dropout rates. These weaknesses may have masked some of the positive effects of arm exercise.



We will illustrate how systematic reviews provide bottom-line clinical and research implications. These are the conclusions of our systematic review: Arm training is theoretically sound, but evidence from these low-powered randomized controlled trials only suggests that it may be effective. If data can be pooled from future studies, this common rehabilitative practice may gain further empirical support (level 2 evidence).


Implications for Practice:

Typically, systematic reviews end with a statement about both practice and research implications. If clinicians integrate arm exercise into a program of pulmonary rehabilitation, 1 study supported simple low-resistance, high-repetition training with arms at the height of the shoulder or above. The intensity and duration of the arm exercises should be increased incrementally to symptom tolerance. Investigators need to plan for intention-to-treat analysis and report data in a manner that will allow meta-analysis.


Section Description

The 2010 National Association of Clinical Nurse Specialists (NACNS) Annual National Conference is planned for Portland, Oregon, on March 3 to 6. More than 375 clinical nurse specialists (CNSs), graduate faculty, nurse administrators, nurse researchers, and graduate students are expected to attend. This year's theme, "CNS as Internal Consultant: Influencing Local to Global Systems," demonstrates the breadth and depth of CNS practice and leadership at multiple levels in organizations and on healthcare.


A total of 142 abstracts were submitted for review, and 58 (not including student posters) were selected for either podium or poster presentations. Again, this year, there is a CNS student poster session; student abstracts will appear in a later issue of the journal. The abstracts addressed CNS practice in all 3 practice domains as described in the Spheres of Influence Framework for CNS Practice. Abstracts emphasized patient safety and quality care outcomes, leadership, CNS education, evidence-based practice, and new ways to shape CNS practice. Topics include CNS work activities incorporated into the 3 Spheres of Influence, the role of the CNS in developing clinical inquiry skills among staff nurses, use of simulation technology, strategies to maintain clinical excellence, the role of the CNS in National Database for Nursing Quality Indicators (NDNQI) activities, and many new and thoughtful ideas to support CNS education, practice, and research. Collectively, the abstracts represent the breadth, depth, and richness of the CNS's contribution to the well-being of individuals, families, and communities, as well as contributing to the advancement of the nursing profession.


The conference abstracts are published to share new knowledge with those unable to attend the conference. As you read each abstract, appreciate the intellectual talent and clinical scholarship of your CNS colleagues who are advancing the practice of nursing and contributing to the health of society through improved outcomes for patients and healthcare organizations. We encourage you to contact individual presenters to network, collaborate, consult, or share your thoughts and ideas on the conference topics.


Watch for next year's call for abstracts and consider submitting for presentation at the next NACNS annual conference scheduled for March 9-12, 2011, in Baltimore, Maryland.