*3.3. Risk of Bias Assessment*

Thirteen studies [22–29,34,37,40,42,43] that used an appropriate random sequence generation method such as random number tables were evaluated as having a low risk of selection bias, and three studies [21,32,37] that properly concealed allocation using an opaque sealed envelope were also evaluated as having a low risk of selection bias. Three studies [34,36,37] that reported that the practitioners who were not blinded were at high risk of performance bias, and one study [42] that reported that both participants and personnel were blinded was evaluated as having a low risk of performance bias. Five studies [20,21,36,37,42] reporting blindness of outcome assessors were evaluated as having a low risk of detection bias. Three studies [32,39,43] that performed per-protocol analysis without specifying the reason for dropout were evaluated as having a high risk of attrition bias. Three studies [18,39,43] did not report raw data, and four studies [23,24,41,46] that did not report pulmonary function-related outcomes were evaluated as having a high risk of reporting bias. One study [28] without baseline characteristic data and one study [34] with cross-over design was evaluated as having a high risk of other potential biases (Figure 2). *Healthcare* **2021**, *9*, x 11 of 18

**Figure 2.** Risk of bias for all included studies. Low, unclear, and high risk, respectively, are represented with the following symbols: "+", "?", and "−". difference in FEV1 (MD 0.05 L, 95% CI from −0.24 to 0.34) and FEV1/FVC (MD 0.84%, 95% **Figure 2.** Risk of bias for all included studies. Low, unclear, and high risk, respectively, are represented with the following symbols: "+", "?", and "−".

Manipulation showed no differences compared with sham in lung functions (FEV1: MD 0.23 L, 95% CI from −0.12 to 0.58; FVC: MD −0.02 L, 95% CI from −0.57 to 0.53; FEV1/FVC: MD 3.01%, 95% CI from −6.90 to 12.92), exercise capacity (6MWD: MD 64.80 m, 95% CI from −12.94 to 142.54), and incidence of AE (RR 0.50, 95% CI: from 0.11 to 2.38). Additional massage significantly improved FEV1/FVC (MD 20.00%, 95% CI from 15.46 to 24.54) and total effective rate (TER) calculated using the severity of respiratory symptoms (RR 1.17, 95% CI from 1.00 to 1.38), compared with ROC alone. However, there were no differences between them in the FEV1 (MD 0.68 L, 95% CI from −0.62 to 1.99), 6MWD (MD 56.20 m, 95% CI from −8.18 to 120.58), and incidence of AE (RR 8.89, 95% CI from 0.48 to 165.55). When comparing additional acupressure with ROC alone, although there was no


**Table 1.**Characteristics of included studies using Western manual

 therapy.


**Table 1.** *Cont.*


**Table 2.**

Characteristics

 of included

 studies using Eastern manual

 therapy.


**Table 2.** *Cont.*


**Table 2.** *Cont.*

medical research council dyspnea scale; NR—not recorded; pv—predicted value; SGRQ—St. George respiratory questionnaire; TER—total effective rate; 6MWD—6 min walking

distance.
