# The Effectiveness of Pump Techniques and Compages: A Systematic Review
## 4 Discussion
On the other hand, these studies respected designs similar to common clinical practice, in which pump techniques are frequently adjunct to other therapeutic procedures, through the integration of different manual techniques [30]. Significant differences also appeared in sessions' numbers, treatment length, and duration of each session: all these parameters seem to have been chosen arbitrarily. There is therefore a specific difficulty in measuring the single effects of the pump techniques with pragmatic studies, since they are usually applied within a multimodal program. Singular studies seem to suggest a certain effectiveness of pump techniques in reducing pain and improving lung function in surgical and pulmonary diseases patients when compared to standard rehabilitation, and in reducing the length of hospitalization when compared to standard care. Only one study [47] showed worse results after having undergone thoracic pump with activation, compared to sham treatment. This specific pump technique, by facilitating the inspiration phase, may increase the residual volume and decrease the expiratory flow in old people with airflow obstruction. No significant difference emerged when pump techniques were compared with light touch, and hematite exams results on healthy subjects were contradictory. The pompages techniques, alone or combined with exercise, seem effective in improving walking capacity in pulmonary disease and balance in knee osteoarthritis, nevertheless no significant difference emerged adding pompages techniques to stretching and exercise or sham tension-type headache program. No serious adverse effect related to the application of pump techniques was reported in the selected studies. These results must be taken with great caution, due to the heterogeneity of the studies and the small samples. The RoB and the quality of evidence assessment confirmed several limitations of the included studies. A major strength of our study is an extensive search using many databases and careful consideration of all published reviews and guidelines on this topic. The selection and qualitative assessment were conducted independently by two authors. Only studies using explicit criteria for Population, Intervention, Comparison, and Outcome (PICO) were included, while studies with important missing data were excluded, minimizing the reference bias. Studies in all languages, from every country and for any year of publication were searched, thereby reducing publication bias. Nevertheless, no study showed some evidence that favored controls, and we do not exclude the possibility that other negative studies were not published. Most of the included studies did not have a published protocol, and thus it is difficult to assess reporting bias. The most important limitation of this review is related to the differences among studies related to populations, interventions and outcome measures, which did not allow us to perform a quantitative synthesis. Seven studies came from the same author, so we cannot exclude a publication bias. Even after attempting to contact authors, we were not able to retrieve five studies (detailed in Supplement 2), and some data from other studies were not found, forcing the elimination of them. In the absence of any previous systematic reviews on this topic, we could not compare our results with other ones. Only an indirect comparison was made with a recent systematic review that challenged the validity of treating spinal dysfunctions with spinal manipulative therapy (manipulation, mobilization or traction) to obtain physiological effects [62]. The results of this systematic review may be interesting for clinical practice, because the use of pump techniques and pompages and outcome measures concerning pain, physical activity, and pulmonary function are common in clinical settings. The quality of RCTs in this field should be significantly improved to reduce bias in future systematic reviews, especially by better standardization of techniques and dosages.