Supplementary Material for: Enhancing Cough Capacity: The Unseen Benefits of Active Passive Lower-Limb Training in Patients with Tracheostomy—A Randomized Controlled Trial

Background: Decannulation challenges post-tracheostomy are often due to reduced cough efficacy, with active-passive lower-limb training being a commonly used but understudied rehabilitative approach. Objective: To evaluate the efficacy of active-passive lower-limb training, potentially enhancing diaphragm engagement, in improving cough capacity for tracheostomized patients with CNS injuries. Methods: A total of 36 patients were enrolled in this study and stratified into three groups (n=12) for a 14-day intervention assessment. Utilizing a randomized crossover design combine with a control group. In intervention groups, participants were allocated to one of two intervention sequences: (1) the CA sequence, which involved an initial phase of active–passive lower-limb training followed by an additional physiotherapy (PT) course; or (2) the AC sequence, which applied these interventions in the reverse order. A standard care control group (Con) was monitored for an equivalent duration. Assessments were conducted on days 1, 7, and 14. Primary and secondary outcomes included peak cough flow (PCF), Glasgow Coma Scale score, and ultrasound-derived measurements of cough-related respiratory muscle thickness. Results: All groups showed significantly improved PCF post-intervention (p=0.011, 0.007, 0.007). Active-passive lower-limb training led to a greater PCF increase compared to additional PT or standard care (p=0.011). Both interventions increased parasternal intercostal muscle thickness (p<0.05). Conclusions: Active-passive lower-limb training significantly improved cough capacity in tracheostomized patients with CNS injuries, being as effective as additional PT and potentially reducing staffing needs. This intervention is a promising approach to enhance cough effectiveness in tracheostomy patients.