Physiotherapy assessment of breathing pattern disorder: a qualitative evaluation

May combine two claims.

Most post-COVID-19 clinics request a physiotherapy assessment of BPD as a key management step, but diagnosis is hampered by the absence of universally accepted terminology or method of assessment.

“While most post-­ COVID-­ 19 clinics request a physiotherapy assessment of BPD as a key management step, diagnosis is hampered by the absence of universally accepted terminology or method of assessment.”

• cites [11] Connett, 2018, Dysfunctional breathing in children and adults with asthma, Front Pediatr sourcePartly supported

  The Definitions and Terminology section discusses competing terms for dysfunctional breathing, and Diagnostic Considerations says breathing assessments can be difficult. These passages support the general point about diagnostic difficulty, but the paper concerns asthma and does not support the claim that most post-COVID-19 clinics request physiotherapy assessment or that it is a key management step there. (LLM, conf=0.87)

  Experimental — accuracy not yet measured

May combine two claims.

Various assessment tools can be used to assess BPD but many do not capture the core components across all types of presentation.

“Various assessment tools can be used to assess BPD but many do not capture the core components across all types of presentation.”

• cites [13] sourceSupported

May combine two claims.

Some patient-reported outcome measures are not validated in all presentations of BPD (NQ, D-12) or have limited validity (Short Evaluation of Breathing Questionnaire).

“Some patient-­ reported outcome measures are not validated in all presentations of BPD (NQ, 15 D-­ 12 29 ) or have limited validity (Short Evaluation of Breathing Questionniare 30 ).”

• cites [15] sourceNot checked — no full text of the source
• cites [29] sourcePartly supported

  The Methods and Study two validation sections report development in patients with COPD, interstitial lung disease and chronic heart failure, followed by a separate validation study in patients with COPD. This supports a limited validation scope for the D-12, but the paper does not assess presentations of BPD or establish whether the measure has been validated in any of them. The NQ and Short Evaluation of Breathing Questionnaire are attributed to other citations in the sentence. (LLM, conf=0.78)

  Experimental — accuracy not yet measured
• cites [30] Courtney, 2009, Preliminary investigation of a measure of dysfunctional breathing symptoms: the self evaluation of breathing questionnaire (SEBQ), Int J Osteop Med sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Dyspnoea, like pain, has a multidimensional nature containing both sensory and affective components.

“Dyspnoea, like pain, has a multidimensional nature containing both sensory and affective components. 25”

• cites [25] sourcePartly supported

  In “The Language of Dyspnoea” (page not provided), the paper describes dyspnoea as comprising more than one sensation and says its descriptors are influenced by affective components. It does not explicitly characterize sensory and affective components as two dimensions of dyspnoea or compare its structure with pain. (LLM, conf=0.82)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing).

The literature suggests that the diaphragm has a dual role in both respiration and mechanical stabilisation of the spine via increased intra-abdominal pressure.

“The literature suggests that the diaphragm has a dual role in both respiration and mechanical stabilisation of the spine via increased intra-­ abdominal pressure. 36”

• cites [36] sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Prevalence of BPD has been demonstrated in a number of different conditions including asthma, COPD, anxiety, Postural Orthostatic Tachycardia syndrome and post-COVID syndrome, with papers commonly reporting higher breathlessness scores or reduced function/quality of life.

“Prevalence of BPD has been demonstrated in a number of different conditions including patients with asthma, 21 COPD, 22 anxiety, 23 Postural Orthostatic Tachycardia syndrome 24 and in post-­ COVID syndrome 7 with papers commonly reporting higher breathlessness scores or reduced function/quality of life.”

• cites [21] sourceSupported
• cites [22] sourcePartly supported

  Split into 2 atoms — 0 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.

  Experimental — accuracy not yet measured
• cites [7] sourcePartly supported

  Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing).

Fifteen physiotherapists participated in the focus groups.

“Fifteen physiotherapists participated in the FGs.”

May combine two claims.

Focus group participants expressed frustration around the nomenclature of BPD and would value consensus on the meaning of BPD.

“Participants expressed frustration around the nomenclature of BPD and would value consensus on the meaning of BPD.”

Probably not a substantial claim: may not pass S3 (load-bearing).

One hundred and three physiotherapists completed the survey.

“One-­ hundred-­ and-­ three physiotherapists completed the survey.”

Probably not a substantial claim: may not pass S3 (load-bearing).

One of the challenges discussed was undoing the negative assumptions created in the language and explanations of BPD used by clinicians.

“One of the challenges discussed was undoing the negative assumptions created in the language and explanations of BPD used by clinicians.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

There was a strong assumption that the word 'dysfunction' was unpopular with patients.

“There was a strong assumption that the word 'dysfunction' was unpopular with patients.”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing).

The inclusion of the word 'pattern' was felt to be important as it describes objective changes in the patient's presentation.

“The inclusion of the word 'pattern' was felt to be important as it describes objective changes in the patient's presentation.”

May combine two claims.

Differences were noted in cough/throat and voice symptoms in the subjective components and inspiratory and expiratory ratio in the objective components.

“Differences were noted in cough/throat and voice symptoms in the subjective components and inspiratory and expiratory ratio in the objective components.”

Probably not a substantial claim: may not pass S3 (load-bearing).

For some focus group participants, the terminology did not matter, so long as the diagnosis was explained well to the patient.

“For some, the terminology did not matter, so long as the diagnosis was explained well to the patient.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Discussions described the power of the assessment as therapy itself.

“Discussions also described the power of the assessment as therapy itself.”

Probably not a substantial claim: may not pass S3 (load-bearing).

There were some differences of opinion on the importance of, and how to assess or treat, the diaphragm.

“There were some differences of opinion on the importance of, and how to assess or treat, the diaphragm.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Assessment tools were an important component of assessment.

“Assessment tools were an important component of assessment.”

Classified as probably not a substantial claim.

Clinicians emphasised the importance of clear nomenclature.

“Clinicians emphasised the importance of clear nomenclature, although perhaps patients place greater value on the description and validation of their symptoms.”

May combine two claims.

Our study suggests an agreement from clinicians that hyperventilation is not the correct term to define all BPD and that the word 'pattern' is important.

“Our study suggests an agreement from clinicians that hyperventilation is not the correct term to define all BPD and that the word 'pattern' is important.”

Probably not a substantial claim: may not pass S3 (load-bearing).

There was a debate among the experts as to how to assess diaphragm function and its importance as a therapeutic strategy in BPD.

“There was a debate among the experts as to how to assess diaphragm function and its importance as a therapeutic strategy in BPD.”

May combine two claims.

While hands-on assessments were deemed important, participants noted that during such an assessment of breathing, patients often respond differently, altering their breathing pattern.

“While hands on assessments were deemed important, participants noted that during such an assessment of breathing, patients often respond differently, altering their breathing pattern.”

Probably not a substantial claim: may not pass S3 (load-bearing).

This diagnosis validated the condition to the patient.

“Additionally, this diagnosis validated the condition to the patient.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Assessment of BPD with exercise was not thought to be essential for all initial assessments of BPD due to time constraints.

“Assessment of BPD with exercise was not thought to be essential for all initial assessments of BPD due to time constraints.”

May combine two claims.

Patients could have heterogeneous symptoms, some clearly linked to their breathing, but other symptoms lacking such an obvious connection.

“There was also recognition that patients could have heterogeneous symptoms, some clearly linked to their breathing, but other symptoms lacking such an obvious connection.”

Classified as probably not a substantial claim.

The focus group discussion described the importance of assessment in diagnosing BPD, to ensure patients could access the right treatments and services to optimise healthcare and outcomes.

“The FG discussion described the importance of assessment in diagnosing this condition, to ensure patients could access the right treatments and services to optimise healthcare and outcomes.”

May combine two claims.

Despite the Nijmegen Questionnaire not being validated for use in all types of BPD, focus group discussion suggested that the symptoms and scores of patients with BPD could be elevated and that this was a useful tool to identify symptoms.

“Despite the NQ not being validated for use in all types of BPD, FG discussion suggested that the symptoms and scores of patients with BPD could be elevated and that this was a useful tool to identify symptoms.”

• AssumptionRests on an assumption: The Nijmegen Questionnaire is not validated for use in all types of BPD.

Probably not a substantial claim: may not pass S3 (load-bearing).

The relevance of diaphragm assessment in BPD centred on the role of the diaphragm, for which there were differing opinions.

“The relevance of this in assessment, discussed in the FGs, centred on the role of the diaphragm in BPD, for which there were differing opinions.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Some clinicians reported that, with more experience, it was easier to complete an assessment without detailed referral information, although often this was within an MDT/specialist environment where discussion of patients and their symptoms was possible.

“Some clinicians reported that, with more experience, it was easier to complete an assessment without detailed referral information, although often this was within an Multi Disciplinary Team/specialist environment where discussion of patients and their symptoms was possible.”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing). May combine two claims.

These included the possibility of the diaphragm being at a mechanical disadvantage due to tension in other muscles of the abdomen or thorax versus whether the diaphragm is weak causing impaired movement.

“These included the possibility of the diaphragm being at a mechanical disadvantage due to tension in other muscles of the abdomen or thorax versus whether the diaphragm is weak causing impaired movement.”

Classified as probably not a substantial claim.

BPD was different to the physiological breathlessness caused by a gas exchange impairment or a mechanical restriction or obstruction to breathing as in conditions such as COPD or interstitial lung disease.

“BPD was different to the physiological breathlessness caused by a gas exchange impairment or a mechanical restriction or obstruction to breathing asin conditions such as chronic obstructive pulmonary disease (COPD) or interstitial lung disease.”

Classified as probably not a substantial claim. May combine two claims.

Different experiences were reported; for some clinicians, problems with exercise BPD could not be predicted from an assessment at rest, and for others resting BPD treatment was always important as resting breathing pattern optimisation was key prior to exercise assessment.

“Different experiences were reported; for some clinicians, problems with exercise BPD could not be predicted from an assessment at rest, and for others resting BPD treatment was always important as resting breathing pattern optimisation was key prior to exercise assessment.”

Probably not a substantial claim: may not pass S3 (load-bearing).

This corroborates the survey results in relation to optimal length for the initial contact with a patient.

“This corroborates the survey results in relation to optimal length for the initial contact with a patient (see online supplemental files).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Such heterogeneity in presentation made some feel this was an important area to assess, particularly that decreased function and its impact on quality of life was a common report from patients referred with BPD.

“Such heterogeneity in presentation made some feel this was an important area to assess, particularly that decreased function and its impact on quality of life was a common report from patients referred with BPD.”

Probably not a substantial claim: may not pass S3 (load-bearing).

These were aspects of the assessment not covered in the survey.

“These were aspects of the assessment not covered in the survey.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The Breathing Pattern Assessment Tool and Breath Hold were thought to have particular value when the assessor may have less experience and to help quantify improvements after treatments.

“The BPAT and Breath Hold (BH) were thought to have particular value when the assessor may have less experience and to help quantify improvements after treatments.”

May combine two claims.

Often BPD was clearly identified by a clinician in the assessment, but the label of BPD itself meant little to the patient until the symptoms and their potential impact were explained to them.

“Often BPD was clearly identified by a clinician in the assessment, but the label of BPD itself meant little to the patient until the symptoms and their potential impact were explained to them.”

Probably not a substantial claim: may not pass S3 (load-bearing).

There was agreement over the importance of assessing the musculoskeletal system due to the interrelation between breathing, and body tension and movement.

“There was agreement over the importance of assessing the musculoskeletal system due to the interrelation between breathing, and body tension and movement.”

May combine two claims.

Respiratory rate, nose versus mouth breathing, upper chest versus lower chest and whether breathing was erratic or rhythmical had high importance, reflecting survey results.

“Respiratory rate, nose versus mouth breathing, upper chest versus lower chest and whether breathing was erratic or rhythmical had high importance, reflecting survey results.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Clinicians in the focus groups expressed a need for 45-60 minutes for the assessment, with any less potentially ineffective.

“Clinicians in the FG expressed a need for 45-60 min for the assessment, with any less potentially ineffective.”

Classified as probably not a substantial claim.

Increased depth and breadth of experience were keys to increasing both confidence and competence in the assessment of BPD.

“Increased depth and breadth of experience were keys to increasing both confidence and competence in the assessment of BPD.”

Classified as probably not a substantial claim. May combine two claims.

The focus group discussion suggested a juxtaposition between the importance of normalising assessment of breathing pattern as part of all education of breathing, against the idea that a breathing pattern assessment is a specialist skill.

“The FG discussion suggested a juxtaposition between the importance of normalising assessment of breathing pattern as part of all education of breathing, against the idea that a breathing pattern assessment is a specialist skill.”

Probably not a substantial claim: may not pass S3 (load-bearing).

One area of conflict within the focus groups was the perceived role of the diaphragm in BPD and how this might inform both assessment and treatment.

“One area of conflict within the FG was the perceived role of the diaphragm in BPD and how this might inform both assessment and treatment.”

Probably not a substantial claim: may not pass S3 (load-bearing).

There were many opinions shared in the focus groups that alluded to a perception of how a patient may think or feel about a certain aspect of BPD assessment.

“Additionally, there were many opinions shared in the FG that alluded to a perception of how a patient may think or feel about a certain aspect of BPD assessment.”

May combine two claims.

Our study indicates that the assessment tools are somewhat useful but not valued as central to assessment, rather they are complimentary to the expert 'skill and art' of the clinician.

“Our study indicates that the assessment tools are somewhat useful but not valued as central to assessment, rather they are complimentary to the expert 'skill and art' of the clinician.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Focus group discussions describe how other assessment tools including the HiLo assessment, BH and other Musculo-skeletal assessments are well used.

“Additionally, discussions in the FG describe how other assessment tools including the HiLo 33 assessment, BH and other Musculo-­ skeletal assessments are well used.”

• cites [33] Courtney, 2009, Comparison of the manual assessment of respiratory motion (MARM) and the HI lo breathing assessment in determining a simulated breathing pattern, Int J Osteop Med sourceNot checked — no full text of the source

May combine two claims.

Focus group discussions described how the subjective assessment creates opportunities for patients to describe symptoms of BPD in detail and the importance of this in validating the patients' experience of these symptoms.

“FG discussions described how the subjective assessment creates opportunities for patients to describe symptoms of 'BPD' in detail and the importance of this in validating the patients' experience of these symptoms.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

Discussions have also focused on the problems in objective evaluation, but this may not be as important from the patient perspective.

“Moreover, discussions have also focused on the problems in objective evaluation, but this may not be as important from the patient perspective, and, therefore, further understanding is required about patients' experiences of having BPD and the important components of assessment.”

Classified as probably not a substantial claim. May combine two claims.

This inconsistency risked diminishing the importance of the condition, leading to confusion over the diagnosis.

“This inconsistency risked diminishing the importance of the condition, leading to confusion over the diagnosis.”

Probably not a substantial claim: may not pass S2 (checkable).

Clarity in diagnosis, informing consistency in assessment, is fundamental to improving recognition and treatment of BPD.

“Clarity in diagnosis, informing consistency in assessment, is fundamental to improving recognition and treatment of BPD.”

• AssumptionRests on an assumption: BPD is an important condition.

Probably not a substantial claim: may not pass S2 (checkable).

The findings are useful in the planning of education, training, future research and guideline development in BPD assessment.

“The findings are useful in the planning of education, training, future research and guideline development in BPD assessment.”

• AssumptionRests on an assumption: BPD is an important condition.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

BPD is multidimensional, with HVS being just one type of BPD, and different individuals may display different phenotypes.

“The literature supports the idea that BPD is multidimensional, with HVS being just one type of BPD and that different individuals may display different phenotypes. 511 11”

• cites 511 11Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Historically 'hyperventilation syndrome' (HVS) was the most common way of describing BPD.

“Historically 'hyperventilation syndrome' (HVS) was the most common way of describing BPD. 15”

• cites [15] sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

We did not formally include patients as research partners in this aspect of the study.

“We did not formally include patients as research partners in this aspect of the study but recognise the importance of this in future work.”

Probably not a substantial claim: may not pass S3 (load-bearing).

AL participated in the analysis to challenge and further develop interpretation following joint review of transcripts and preliminary themes.

“AL participated in the analysis to challenge and further develop interpretation following joint review of transcripts and preliminary themes.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Patients may place greater value on the description and validation of their symptoms than on clear nomenclature.

“Clinicians emphasised the importance of clear nomenclature, although perhaps patients place greater value on the description and validation of their symptoms.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Participation was voluntary and consent was gained at the start of the survey.

“Participation was voluntary and consent was gained at the start of the survey”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Interviews were transcribed verbatim by LG and transcripts were reviewed by LG and AL.

“Interviews were transcribed verbatim by LG and transcripts were reviewed by LG and AL.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

A convenience sample was the most pragmatic approach.

“A convenience sample was the most pragmatic approach.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Recent Cochrane reviews have called for consistency in terminology.

“Recent Cochrane reviews 6 12 have called for consistency in terminology.”

• cites 6 12Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

The researcher's reflections were also recorded.

“The researcher's reflections were also recorded”

Probably not a substantial claim: may not pass S3 (load-bearing).

The penultimate survey draft was peer reviewed.

“The penultimate survey draft was peer reviewed.”

May combine two claims.

BPD does not always present in the same way, a heterogeneity that may further lead to inconsistent assessment.

“Moreover, BPD does not always present in the same way, a heterogeneity that may further lead to inconsistent assessment.”

• cites [12] Santino, 2020, Breathing exercises for adults with asthma, Cochrane Database Syst Rev sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

All focus group participants received a participant information sheet and gave informed consent.

“All participants received a participant information sheet and gave informed consent.”

May combine two claims.

BPD frequently amplifies other respiratory conditions, increasing the likelihood of excess prescriptions and associated misuse of prescribing budgets.

“Furthermore, BPD frequently amplifies other respiratory conditions, increasing the likelihood of excess prescriptions and associated misuse of prescribing budgets.”

• cites [1] Morgan, 2002, Dysfunctional breathing in asthma: is it common, identifiable and correctable?, ThoraxNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [9] sourceNot checked — no full text of the source

Classified as probably not a substantial claim. May combine two claims.

This was integral to the ability to diagnose BPD and to help the patient understand the role of therapy.

“This was integral to the ability to diagnose 'BPD' and to help the patient understand the role of therapy.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Focus groups were audio-recorded.

“FGs were audio-­ recorded.”

Classified as probably not a substantial claim.

This is the first qualitative study to report clinicians' opinions on the inconsistency in BPD terminology.

“This is the first qualitative study to report clinicians' opinions on this inconsistency.”

Classified as probably not a substantial claim. May combine two claims.

Specialist skills were particularly important in ruling out pathology or physiological explanation of symptoms, ensuring the correct diagnostic label is assigned and other causes of symptoms fully investigated.

“These specialist skills were particularly important in ruling out pathology or physiological explanation of symptoms ensuring the correct diagnostic label is assigned and other causes of symptoms fully investigated.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The survey was piloted by two physiotherapists in a tertiary referral centre.

“The survey was piloted by two physiotherapists in a tertiary referral centre.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

A consistent assessment will help to recognise the disorder and ensure appropriate treatments are offered to patients.

“A consistent assessment will help to recognise the disorder and ensure appropriate treatments are offered to patients.”

• AssumptionRests on an assumption: Limited evidence exists regarding how best to assess and recognise BPD.
• AssumptionRests on an assumption: BPD is an important condition.

Probably not a substantial claim: may not pass S3 (load-bearing).

The role of the diaphragm in BPD is unclear.

“However, its role in BPD is unclear.”

May combine two claims.

Our survey responses from 103 participants are considered generalisable to UK physiotherapy practice, considering there are over 1500 members of the Association of Chartered Physiotherapists in Respiratory Care with only a minority of these members treating patients with BPD regularly.

“Furthermore, our survey responses from 103 participants are considered generalisable to UK physiotherapy practice, considering there are over 1500 members of the Association of Chartered Physiotherapists in Respiratory Care with only a minority of these members treating patients with BPD regularly.”

Classified as probably not a substantial claim.

We did not include patients within the study design.

“However, we did not include patients within the study design, which would be an essential component for future studies.”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

These issues could be impacting on the consistency of assessments and the adequate referral of patients to appropriate services.

“These issues could be impacting on the consistency of assessments and the adequate referral of patients to appropriate services.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Dysfunction of the diaphragm is a well-described phenomenon in pathological disease, including obstructive lung disease where the diaphragm can be put at a mechanical disadvantage and neuromuscular disease when the diaphragm can be weak.

“Dysfunction of the diaphragm is a well-­ described phenomenon in pathological disease, including obstructive lung disease where the diaphragm can be put at a mechanical disadvantage and neuromuscular disease when the diaphragm can be weak. 35”

• cites [35] Maddocks, 2012, COPD-28247-muscle-function-in-copd-a-complex-interplay, Int J COPDNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

This is one of the first qualitative clinician-focused investigations into BPD.

“To our knowledge, this is one of the first qualitative clinician-­ focused investigations into this complex and important condition.”

Classified as probably not a substantial claim. May combine two claims.

Our methodology enabled detailed exploration of the components of assessments and also included the conflicts in the nomenclature used for this condition, and the different thinking around the assessment of the diaphragm.

“Our methodology enabled detailed exploration of the components of assessments and also included the conflicts in the nomenclature used for this condition, and the different thinking around the assessment of the diaphragm.”

Probably not a substantial claim: may not pass S4 (based).

Limited evidence exists regarding how best to assess BPD.

“Limited evidence exists regarding how best to assess BPD.”

Classified as probably not a substantial claim. May combine two claims.

It is unclear how diaphragmatic assessment is currently best performed, whether the diaphragm is at a mechanical disadvantage, or being used excessively to help maintain core control.

“It is unclear how diaphragmatic assessment is currently best performed, whether the diaphragm is at a mechanical disadvantage, or being used excessively to help maintain core control.”

Classified as probably not a substantial claim.

There appear to be limitations to the available assessment tools.

“Although there are some assessment tools available, there appear to be limitations to these, and further work is required to develop our knowledge with these tools to help us have a clear way of evaluating patients consistently and providing them with relevant therapeutic treatments at the earliest opportunity.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The newly developed Breathe-VQ may be useful in assessment of BPD and breathlessness, accounting for vigilance or breathing.

“The newly developed Breathe-­ VQ may be useful in such assessment accounting for vigilance or breathing. 28”

• cites [28] Steinmann J , Lewis A , Ellmers T . Validating the breathing vigilance questionnaire for use in dysfunctional breathing. medRxiv.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

This dual function must involve coordination of the diaphragm and other muscles surrounding the abdominal cavity and may compromise the respiratory motion of the rib cage and abdomen.

“This dual function must involve coordination of the diaphragm and other muscles surrounding the abdominal cavity and may compromise the respiratory motion of the rib cage and abdomen. 37”

• cites [37] Hodges, 2000, Changes in intra-abdominal pressure during postural and respiratory activation of the human diaphragm, J Appl Physiol sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

These components, included in the BPAT, may support why there has been good clinical uptake of this tool.

“These components, included in the BPAT, may support why there has been good clinical uptake of this tool.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

Recognition of different types of BPD may have importance to help ensure that the correct types of intervention are chosen.

“Although not discussed in the FGs, recognition of different types of BPD may have importance to help ensure that the correct types of intervention are chosen. 38”

• cites [38] Courtney, 2009, The functions of breathing and its dysfunctions and their relationship to breathing therapy, Int J Osteop Med sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

The results emphasise the importance of a consistent approach to both terminology and assessment of BPD.

“The results emphasise the importance of a consistent approach to both terminology and assessment of this condition.”

May combine two claims.

Objective assessment tools lack sufficient evidence (BH and BPAT) or are perceived to be too complex for general use (Manual Assessment of Respiratory Motion).

“Objective assessment tools lack sufficient evidence (BH 31 and BPAT 14 ) or are perceived to be too complex for general use (Manual Assessment of Respiratory Motion 32 ).”

• cites [31] sourceNot checked — no full text of the source
• cites [14] sourceNot checked — no full text of the source
• cites [32] sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Those who completed the survey were more likely to have expert experience and may not be reflective of the views of more junior staff.

“We also acknowledge a potential responder bias, in that those who completed the survey were more likely to have expert experience and may not be reflective of the views of more junior staff.”

Classified as probably not a substantial claim.

We provide practical recommendations for the essential components to include in physiotherapy BPD assessment as summarised from the results in table 2.

“We also provide practical recommendations for the essential components to include in physiotherapy BPD assessment as summarised from the results in table 2.”

Probably not a substantial claim: may not pass S4 (based).

The literature describing BPD assessment suggests it lacks standardisation.

“The literature describing BPD assessment suggests it lacks standardisation.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The affective component of dyspnoea has been regarded as a non-specific unpleasant or distressing experience and is thought to be more commonly experienced in medically unexplained shortness of breath, which may represent patients with BPD.

“The affective component has been regarded as a non-­ specific unpleasant or distressing experience of dyspnoea and is thought to be more commonly experienced in medically unexplained shortness of breath, 26 which may represent patients with BPD.”

• cites [26] sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

Our research combined online survey results and focus group data to explore BPD assessment from clinical experts in the field.

“Our research combined online survey results and FG data to explore BPD assessment from clinical experts in the field.”

• AssumptionRests on an assumption: The survey and focus group participants were clinical experts in BPD.

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Much of the literature has described the importance of improving the consistency of assessment, and this paper offers unique insights into physiotherapists' experiences of BPD assessment processes.

“Much of the literature has described the importance of improving the consistency of assessment and this paper offers unique insights into physiotherapists' experiences of BPD assessment processes.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

These techniques may add additional value to an assessment, including having value for the patient to use in self-assessment during remote or virtual assessments.

“These techniques may add additional value to an assessment, including having value for the patient to use in self-­ assessment during remote or virtual assessments which has had increased focus during the COVID-­ 19 pandemic. 34”

• cites [34] Bondarenko, 2021, Reliability of the breathing pattern assessment tool for in-person or remote assessment in people with asthma, Clin Exp Allergy sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

There is limited understanding as to how BPD and breathlessness interlink.

“However, there is limited understanding as to how BPD and breathlessness interlink.”