Effectiveness of pulmonary rehabilitation programmes and/or respiratory muscle training in patients with post-COVID conditions: a systematic review.

BACKGROUND: The term "post-COVID-19 condition" refers to the symptomatology that appears between four to twelve weeks after Covid-19 infection. These symptoms can persist for weeks or even months, significantly diminishing the quality of life for affected individuals. The primary objective of this study was to assess the effectiveness of pulmonary rehabilitation programs and/or respiratory muscle training on respiratory sequelae in patients with post-COVID condition. METHODS: The literature search was conducted in the following databases: PubMed, PEDro, Embase, Cochrane, Scopus, and Web of Science. Randomized clinical trials were included in which participants were aged 18 years or older. Articles were excluded if at least one of the therapies did not involve pulmonary rehabilitation or respiratory muscle training, if the participants were COVID positive, if studies lacked results, and finally, if interventions were conducted without supervision or at home. This review only encompasses supervised non-virtual interventions. This study adheres to the PRISMA statement and has been registered in the PROSPERO database (CRD42023433843). RESULTS: The outcomes obtained in the included studies are assessed across the following variables: Exercise capacity using the 6-minute walk test, Dyspnea, fatigue, Pulmonary function, Maximum inspiratory pressure, and Quality of life. CONCLUSION: Despite the absence of a specific treatment at present, it was evident from this review that a well-structured pulmonary rehabilitation program that incorporates both aerobic and muscular strength exercises along with techniques and inspiratory muscle exercises was the most effective form of treatment.

Future Directions for Respiratory Muscle Training in Neuromuscular Disorders: A Scoping Review.

BACKGROUND: Respiratory muscle training (RMT) aims to improve inspiratory and/or expiratory muscle function in neuromuscular disorders (NMDs). A comprehensive overview of the available literature is lacking. This scoping review explores methodological characteristics, (adverse) effects, and adherence of RMT studies in NMDs. Moreover, it identifies limitations and research gaps in the literature and provides future research directions. SUMMARY: Eligible studies were identified using MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials databases. Three reviewers independently selected articles. Inclusion criteria were English language, original research articles on RMT using a device, patients with an NMD, and pulmonary function tests or respiratory muscle strength as outcome measures. We included NMDs with slow, intermediate and fast progression. Exclusion criteria were critically ill patients, weaning from mechanical ventilation, other neurological disorders, and RMT combined with non-respiratory interventions. One reviewer extracted the data on patients' characteristics, methodological characteristics, results of outcome measures, adverse events, and patient adherence. Forty-five studies were identified. We found a large diversity in study designs and training protocols. The effects of RMT on respiratory muscle strength and/or endurance are variable. Patient adherence was high and no serious adverse events were reported. KEY MESSAGES: The diversity in studies across the available literature precludes definitive conclusions regarding the effects of RMT on respiratory muscle function and clinically relevant outcomes in NMDs. Therefore, well-powered and -designed studies that focus on clinically relevant outcomes and assess whether RMT can improve or offset deterioration of respiratory muscle weakness in NMDs are needed.

Effects of different inspiratory muscle training protocols on functional exercise capacity and respiratory and peripheral muscle strength in patients with chronic kidney disease: a randomized study.

BACKGROUND: Pathological changes were observed in the diaphragm due to abnormal renal function in chronic kidney disease (CKD). Inspiratory muscle training (IMT) has been suggested for patients with CKD; however, the most appropriate intensity for IMT has not been determined. Therefore, this study aimed to investigate the effects of different IMT protocols on respiratory muscle strength, quadriceps femoris muscle strength (QMS), handgrip muscle strength (HGS), functional exercise capacity, quality of life (QoL), pulmonary function, dyspnoea, fatigue, balance, and physical activity (PA) levels in patients with CKD. METHODS: This randomized, controlled, single-blind study included 47 patients and they were divided into three groups: Group 1 (n = 15, IMT with 10% maximal inspiratory pressure (MIP)), Group 2 (n = 16, IMT with 30% MIP), and Group 3(n = 16; IMT with 60% MIP). MIP, maximal expiratory pressure (MEP), 6-min walking test (6-MWT), QMS, HGS, QoL, pulmonary function, dyspnoea, fatigue, balance, and PA levels were assessed before and after eight weeks of IMT. RESULTS: Increases in MIP, %MIP, 6-MWT distance, and %6-MWT were significantly higher in Groups 2 and 3 than in Group 1 after IMT (p < 0.05). MEP, %MEP, FEF25-75%, QMS, HGS, and QoL significantly increased; dyspnoea and fatigue decreased in all groups (p < 0.05). FVC, PEF, and PA improved only in Group 2, and balance improved in Groups 1 and 2 (p < 0.05). CONCLUSIONS: IMT with 30% and 60% MIP similarly improves inspiratory muscle strength and functional exercise capacity. IMT with 30% is more effective in increasing PA. IMT is a beneficial method to enhance peripheral and expiratory muscle strength, respiratory function, QoL and balance, and reduce dyspnoea and fatigue. IMT with %30 could be an option for patients with CKD who do not tolerate higher intensities. TRIAL REGISTRATION: This study was retrospectively registered (NCT06401135, 06/05/2024).

The effect of respiratory muscle training on children and adolescents with cystic fibrosis: a systematic review and meta-analysis.

BACKGROUND: Cystic fibrosis is a chronic genetic disease that can affect the function of the respiratory system. Previous reviews of the effects of respiratory muscle training in people with cystic fibrosis are uncertain and do not consider the effect of age on disease progression. This systematic review aims to determine the effectiveness of respiratory muscle training in the clinical outcomes of children and adolescents with cystic fibrosis. METHODS: Up to July 2023, electronic databases and clinical trial registries were searched. Controlled clinical trials comparing respiratory muscle training with sham intervention or no intervention in children and adolescents with cystic fibrosis. The primary outcomes were respiratory muscle strength, respiratory muscle endurance, lung function, and cough. Secondary outcomes included exercise capacity, quality of life and adverse events. Two review authors independently extracted data and assessed study quality using the Cochrane Risk of Bias Tool 2. The certainty of the evidence was assessed according to the GRADE approach. Meta-analyses where possible; otherwise, take a qualitative approach. RESULTS: Six studies with a total of 151 participants met the inclusion criteria for this review. Two of the six included studies were published in abstract form only, limiting the available information. Four studies were parallel studies and two were cross-over designs. There were significant differences in the methods and quality of the methodology included in the studies. The pooled data showed no difference in respiratory muscle strength, lung function, and exercise capacity between the treatment and control groups. However, subgroup analyses suggest that inspiratory muscle training is beneficial in increasing maximal inspiratory pressure, and qualitative analyses suggest that respiratory muscle training may benefit respiratory muscle endurance without any adverse effects. CONCLUSIONS: This systematic review and meta-analysis indicate that although the level of evidence indicating the benefits of respiratory muscle training is low, its clinical significance suggests that we further study the methodological quality to determine the effectiveness of training. TRIAL REGISTRATION: The protocol for this review was recorded in the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42023441829.

"Effects of threshold respiratory muscle training on respiratory muscle strength, pulmonary function and exercise endurance after stroke: a meta-analysis".

BACKGROUND: Most studies on improvements in respiratory muscle strength, activities of daily living (ADL) and quality of life (QoL) in stroke patients receiving threshold respiratory muscle training (TRMT) have small sample sizes, and some studies have contradictory results. OBJECTIVES: To evaluate the effectiveness of TRMT on respiratory muscle strength, pulmonary function and exercise endurance in stroke patients. MATERIALS AND METHODS: PubMed, Cochrane Library, Physical Therapy Evidence Database (PEDro), Embase (via OVID) and Web of Science databases were searched for randomized controlled trial (RCT) from inception to January 17, 2024. The primary outcome was maximum inspiratory pressure (MIP) or maximum expiratory pressure (MEP). Secondary outcomes included pulmonary function measured by forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1) and peak expiratory flow (PEF), and exercise endurance measured by 6-minute walk test (6MWT). RESULTS: A total of eight randomized controlled trials(RCTs), including 305 persons, were included in this study. The training time ranged from 3 weeks to 10 weeks. Among them, the intervention group in 4 studies used inspiratory muscle training, and the other 4 studies used inspiratory muscle training and expiratory muscle training. For the primary outcome, TRMT significantly improved MIP (mean=14.68 cmH2O, 95 %CI=2.28 to 27.09 cmH2O, P=0.02) and MEP (mean=9.37 cmH2O, 95 %CI=2.89 to 15.84 cmH2O, P=0.005) in stroke patients. Regarding the secondary outcomes, TRMT improved FVC, FEV1 and 6MWT (P<0.05) but did not significantly improve PEF. CONCLUSION: TRMT improved inspiratory muscle strength and expiratory muscle strength, improved exercise endurance, and improved FVC and FEV1 of pulmonary function but did not significantly improve PEF.

Respiratory Muscle Training and Its Impact on Balance and Gait in Patients with Severe COPD.

Background and Objectives: Improving extrapulmonary symptoms in COPD through respiratory muscle training can help alleviate the burden of respiratory symptoms, reduce fatigue, and improve exercise capacity in patients with COPD. This, in turn, can enhance physical activity, balance, and gait, ultimately improving the overall quality of life for individuals with COPD. This study aimed to investigate the effects of respiratory muscle training on balance and gait in patients with moderate to severe COPD. Materials and Methods: We included 65 patients with moderate to severe COPD randomly assigned to either the pulmonary rehabilitation protocol group (PR) or the pulmonary rehabilitation and inspiratory muscle training group (PR + IMT) for three weeks. Patients performed a spirometry, maximal inspiratory and expiratory pressure (MIP/MEP), 6 min walking test (6MWT), activities-specific balance confidence (ABC) scale questionnaire, Berg Balance Scale (BBS), timed up and go test (TUG), and single-leg stance test (SLS). Results: Rehabilitation had a notable impact on MIP in Group 2 (PR + IMT), with a highly significant difference between pre- and post-rehabilitation distributions (p < 0.0001). At the same time, Group 1 (PR-only) showed no significant changes (p = 0.27). In Group 1 (Control), pre- and post-rehabilitation comparisons reveal slight non-significant changes for SLS EO (p = 0.16), ABC (p = 0.07), TUG (p = 0.06), and BBS (p = 0.13). In contrast, in Group 2 (Cases), there are significant improvements in all variables after rehabilitation compared to the pre-rehabilitation values: SLS EO (p < 0.0001), ABC (p < 0.0001), TUG (p < 0.0001), and BBS (p < 0.0001). Conclusions: Our research demonstrated that respiratory muscle training significantly positively impacts balance and gait performance among patients with moderate to severe COPD compared to a control group.

Inspiratory muscle training for mechanically ventilated patients in the intensive care unit: Obstacles and facilitators for implementation. A mixed method quality improvement study.

BACKGROUND: Mechanically ventilated patients are at risk of developing inspiratory muscle weakness (IMW), which is associated with failure to wean and poor outcomes. Inspiratory muscle training (IMT) is a recommended intervention during and after extubation but has not been widely adopted in Dutch intensive care units (ICUs). OBJECTIVES: The objective of this study was to explore the potential, barriers, and facilitators for implementing IMT as treatment modality for mechanically ventilated patients. METHODS: This mixed-method, proof-of-concept study was conducted in a large academic hospital in the Netherlands. An evidence-based protocol for assessing IMW and training was applied to patients ventilated for ≥24 h in the ICU during an 8-month period in 2021. Quantitative data on completed measurements and interventions during and after ICU-stay were collected retrospectively and were analysed descriptively. Qualitative data were collected through semistructured interviews with physiotherapists executing the new protocol. Interview data were transcribed and thematically analysed. FINDINGS: Of the 301 screened patients, 11.6% (n = 35) met the inclusion criteria. Measurements were possible in 94.3% of the participants, and IMW was found in 78.8% of the participants. Ninety-six percent started training in the ICU, and 88.5% continued training after transfer to the ward. Follow-up measurements were achieved in 73.1% of the patients with respiratory muscle weakness. Twelve therapists were interviewed, of whom 41.7% regularly worked in the ICU. When exploring reasons for protocol deviation, three themes emerged: "professional barriers", "external factors", and "patient barriers". CONCLUSIONS: Implementation of measurements of and interventions for IMW showed to be challenging in this single centre study. Clinicians' willingness to change their handling was related to beliefs regarding usefulness, effectiveness, and availability of time and material. We recommend that hospitals aiming to implement IMT during or after ventilator weaning consider these professional and organisational barriers for implementation of novel, evidence-based interventions into daily clinical practice.

Respiratory muscle training for obstructive sleep apnea: Systematic review and meta-analysis.

Obstructive sleep apnea is the most common sleep disorder. This review aims to evaluate the effectiveness and safety of respiratory muscle training in the treatment of patients with obstructive sleep apnea. The study protocol was registered in Prospero Platform (CRD42018096980). We performed searches in the main databases: Medical Literature Analysis and Retrieval System Online (MEDLINE) via Pubmed; Excerpta Medica dataBASE (Embase) via Elsevier; Cochrane Central Register of Controlled Trials (CENTRAL) via Cochrane Library; Latin American and Caribbean Literature on Health Sciences (LILACS) through the Portal of the Virtual Health Library and Physiotherapy Evidence Database (PEDro) for all randomised-controlled trials published before July 2022. The randomised-controlled trials were assessed for risk of bias and certainty of evidence. Thirteen randomised-controlled trials were included. All studies had an overall high risk of bias. Inspiratory muscle training probably improves systolic blood pressure and sleepiness when compared with sham. However, inspiratory muscle training probably does not improve diastolic blood pressure and maximum expiratory pressure, and may not be superior to sham for apnea-hypopnea index, forced expiratory volume in 1 s, forced vital capacity, sleep quality and quality of life. In addition, it is uncertain whether there is any effect of inspiratory muscle training on maximum inspiratory pressure and physical capacity. Inspiratory muscle training may also improve maximum inspiratory pressure and maximum expiratory pressure compared with oropharyngeal exercises. However, it may not be superior for apnea-hypopnea index, sleep quality, sleepiness, quality of life and functional capacity. When associated with physical exercise, inspiratory muscle training may not be superior to physical exercise alone for maximum inspiratory pressure, maximum expiratory pressure, systolic and diastolic blood pressure, and functional capacity. At the same time, when associated with cardiac rehabilitation exercises, inspiratory muscle training may reduce apnea-hypopnea index, improve inspiratory muscle strength, sleepiness and sleep quality compared with cardiac rehabilitation alone. However, it may not be superior for improving quality of life. Regarding expiratory muscle training, it may improve expiratory muscle strength and sleep quality, but not sleepiness when compared with sham. The evidence on the effects of expiratory muscle training in apnea-hypopnea index is very uncertain.

The rationale of applying inspiratory/expiratory muscle training within the same respiratory cycle in children with bronchial asthma: a placebo-controlled randomized clinical investigation.

OBJECTIVE: Even though positive implications of inspiratory muscle training (In-MT) have been established in children and adolescents with bronchial asthma (C/AwBA), the role of combined inspiratory and expiratory muscle training (Ex-MT) within the same respiratory cycle (In/Ex-SC) is still unknown. This study was, therefore, set out to explore the effect of In/Ex-SC on respiratory muscle strength, pulmonary functions, and control of asthma symptoms in C/AwBA. METHODS: This was a placebo-controlled randomized clinical investigation that included 51 C/AwBA (12-18 years). Participants were assigned randomly into three groups: Placebo, In-MT only, or combined In/Ex-SC training (n = 17, each group). The training was conducted for ∼35 min, thrice/week over 12 weeks. The maximal inspiratory (IPmax) and expiratory (EPmax) pressure (indicating the strength of the inspiratory and expiratory muscles, respectively), pulmonary functions [forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and FEV1/FVC index], and asthma control test (ACT) were assessed before and after the intervention. RESULTS: The In/Ex-SC yielded larger increases in IPmax and EPmax than either the Placebo training (P=.031 and P=.009 respectively) or the In-MT (P=.029 and P=.032 respectively). Further, In/Ex-SC produced favorable improvement in FEV1, FVC, and FEV1/FVC compared to the Placebo training (P=.001, P=.004, and P=.0005 respectively) or In-MT (P=.038, P=.037, and P=.025 respectively) training. Furthermore, In/Ex-SC led to better control of asthma symptoms than the Placebo (P<.001) or In-MT (P=.002) training. CONCLUSION: This study provides evidence that combined In/Ex-SC can considerably improve respiratory muscle strength, enhance pulmonary function, and promote control over asthma symptoms in C/AwBA.

The use of respiratory muscle training in patients with pulmonary dysfunction, internal diseases or central nervous system disorders: a systematic review with meta-analysis.

OBJECTIVE: The aim of this systematic review with meta-analysis was to evaluate the effectiveness of RMT in internal and central nervous system disorders, on pulmonary function, exercise capacity and quality of life. METHODS: The inclusion criteria were (1) publications designed as Randomized Controlled Trial (RCT), with (2) participants being adults with pulmonary dysfunction caused by an internal disease or central nervous system disorder, (3) an intervention defined as RMT (either IMT or EMT) and (4) with the assessment of exercise capacity, respiratory function and quality of life. For the methodological quality assessment of risk of bias, likewise statistical analysis and meta-analysis the RevMan version 5.3 software and the Cochrane Risk of Bias Tool were used. Two authors independently analysed the following databases for relevant research articles: PubMed, Scopus, Cochrane Library, Web of Science, and Embase. RESULTS: From a total of 2200 records, the systematic review includes 29 RCT with an overall sample size of 1155 patients. Results suggest that patients with internal and central nervous system disorders who underwent RMT had better quality of life and improved significantly their performance in exercise capacity and in respiratory function assessed with FVC and MIP when compared to control conditions (i.e. no intervention, sham training, placebo or conventional treatments). CONCLUSION: Respiratory muscle training seems to be more effective than control conditions (i.e. no intervention, sham training, placebo or conventional treatment), in patients with pulmonary dysfunction due to internal and central nervous system disorders, for quality of life, exercise capacity and respiratory function assessed with MIP and FVC, but not with FEV1.

Effect of respiratory muscle training in patients with chronic kidney disease: A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: This systematic review and meta-analysis aimed to evaluate the effect of respiratory muscle training on respiratory muscle strength, lung function, cardiopulmonary fitness, and quality of life for chronic kidney disease patients. METHODS: PubMed, Embase, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials published randomized controlled trials that evaluated the effect of respiratory muscle training for chronic kidney disease patients from inception to December 2021, and rerun on September 2022. The quality of included studies was evaluated according to the Cochrane Collaboration's risk of bias tool-2. The outcomes were analyzed as mean differences with a fixed/random effect model. The strength of evidence was evaluated with the Grading of Recommendation, Assessment, Development, and Evaluation approach. RESULTS: Eleven randomized controlled trials were included. All but two of the studies were in hemodialysis patients. The follow-up time range was 4 to 12 weeks. Compared to controls, respiratory muscle training significantly improved maximal expiratory pressure (mean difference = 17.36, p = 0.013), maximal inspiratory pressure (mean difference = 18.26, p = 0.002), forced expiratory volume at 1 second (mean difference = 0.20, p= 0.020), forced vital capacity (mean difference = 0.26, p = 0.008), but not for 6-minute walk test (mean difference = 39.85, p= 0.138). CONCLUSIONS: As a non-pharmacological therapy, respiratory muscle training can effectively improve maximal expiratory pressure, maximal inspiratory pressure, forced expiratory volume at 1 second, and forced vital capacity in patients with chronic kidney disease and is safe for such populations.

Effectiveness of Respiratory Muscle Training in Adults With Pulmonary Hypertension. A Systematic Review and Meta-Analysis.

BACKGROUND: Patients with pulmonary hypertension (PH) may have impaired exercise capacity and quality of life; this may possibly be due to the early onset of dyspnoea associated with respiratory muscle weakness. Respiratory muscle training could improve the condition of these patients, so this study aimed to determine, through a systematic review and meta-analysis, the effectiveness of respiratory muscle training in adult patients with PH. METHODS: Medline, Embase, CENTRAL, clinical trial registries databases, and grey literature and reference lists of reviews related to the objective were searched up to March 2022. Controlled clinical trials comparing the effectiveness of respiratory muscle training with sham or no intervention in adults with PH were included. Records were independently screened by two authors. The primary outcomes were maximal and functional exercise capacity, quality of life, and dyspnoea. The secondary outcomes were respiratory muscle strength, physical activity, lung function, and adverse events. Two authors independently extracted data and the study quality was assessed using the Cochrane risk-of-bias tool 2 (RoB 2). The certainty of the evidence was assessed according to the GRADE approach. RESULTS: A total of 5,524 records were screened, and seven randomised clinical trials (RCTs) (257 participants) were included. It was uncertain whether inspiratory muscle training (IMT), compared with sham IMT or no intervention, increased the distance walked in the 6-minute walk test (6MWT) (MD, 39 m; 95% CI, 20.72-57.39; I2=27%; four RCTs; very low certainty of evidence) and slightly decreased the perceived sensation of dyspnoea (MD, 0.5 points on the mMRC scale; 95% CI, -0.87 to -0.13; I2=0%; two RCTs; very low certainty of evidence). In addition, it was uncertain whether IMT had no effect on the emotional (SMD, -0.34; 95% CI, -1.06 to 0.38; I2=64%; three RCTs; very low certainty of evidence) and physical (SMD, 0.06; 95% CI, -0.41 to 0.52; I2=16%; three RCTs; very low certainty of evidence) component of quality of life. CONCLUSIONS: It is uncertain whether IMT increases functional exercise capacity and slightly decreases the sensation of dyspnoea. In addition, it is uncertain whether IMT does not affect the quality of life. More RCTs and with a better methodological design are needed to increase the certainty of the evidence and determine the real effect of this intervention.

Comparing two types of loading during inspiratory muscle training in patients with weaning difficulties: An exploratory study.

BACKGROUND: Inspiratory muscle training improves respiratory muscle function and may improve weaning outcomes in patients with weaning difficulties. Compared to the commonly used pressure threshold loading, tapered flow resistive loading better accommodates pressure-volume relationships of the respiratory muscles, which might help to facilitate application of external loads and optimise training responses. OBJECTIVE: The objective of this study was to compare acute breathing pattern responses and perceived symptoms during an inspiratory muscle training session performed against identical external loading provided as pressure threshold loading or as tapered flow resistive loading. We hypothesised that for a given loading, tapered flow resistive loading would allow larger volume expansion and higher inspiratory flow responses and consequently higher external work of breathing and power than pressure threshold loading and that subsequently patients perceived fewer symptoms during tapered flow resistive loading than during pressure threshold loading. METHODS: In this exploratory study, 21 patients (maximal inspiratory pressure: 35 ± 14 cmH2O and vital capacity:0.85 L±0.37 L) performed two training sessions against external loads equalling 42 ± 15% of maximal inspiratory pressure provided either as pressure threshold loading or as tapered flow resistive loading. During these training sessions, breath-by-breath data of breathing parameters were collected, and patients rated their perceived breathing effort, dyspnoea, and unpleasantness. RESULTS: Compared to pressure threshold loading, tapered flow resistive loading allowed significantly larger volume expansion (0.53 ± 0.28 L versus 0.41 ± 0.20 L, p < 0.01) and inspiratory flow responses (0.43 ± 0.20 L/s versus 0.33 ± 0.16 L/s, p = 0.01). Tapered flow resistive loading was perceived as less unpleasant (3.1 ± 1.9 versus 3.8 ± 2.4, p = 0.048). No significant differences in breathing effort, dyspnoea, work of breathing, and power were observed. CONCLUSIONS: For a given loading, inspiratory muscle training with tapered flow resistive loading allowed larger volume expansion and higher inspiratory flow responses than pressure threshold loading, which led patients to perceive tapered flow resistive loading as less unpleasant. This might help us to facilitate early implementation of inspiratory muscle training in patients with weaning difficulties. CLINICAL TRIAL REGISTRATION NUMBER: Clinicaltrials.gov identifier: NCT03240263.

Effectiveness of Device-Guided Breathing in Chronic Coronary Syndrome: A Randomized Controlled Study.

Background: Chronic coronary syndrome (CCS) is one of the most life-restricting coronary artery diseases, and symptom relief is the main goal in CCS patients who suffer from angina. Objectives: To assess the potential benefits of device-guided breathing in CCS patients with angina in this randomized, controlled, single-blinded study. Methods: Fifty-one patients with CCS received device-guided breathing for 7 days/8 weeks. Exercise capacity [exercise stress test], cardiac function [transthoracic echocardiography], and angina severity [Canadian Cardiovascular Society Classification] were evaluated initially and after the training. Device-guided breathing was performed at the lowest resistance of the device (POWERbreathe® Classic LR) for the control group (n = 17). The low load training group (LLTG; n = 18) and high load training group (HLTG; n = 16) were trained at 30% and 50% of maximal inspiratory pressure. Baseline characteristics were compared using one-way ANOVA and Kruskal-Wallis test. Categorical data were compared using the chi-square test. ANCOVA was performed to compare changes between three groups. A p value < 0.05 was considered statistically significant. Results: Metabolic equivalent values were significantly improved in both HLTG and LLTG groups (p < 0.001, p = 0.003). The Duke treadmill score significantly improved and shifted to low-risk both in the HLTG (p < 0.001) and LLTG (p < 0.001) groups. Angina severity significantly alleviated after the training in both HLTG and LLTG groups (p < 0.001, p = 0.002). Conclusions: An 8-week long program of short-term respiratory muscle training provided positive gains in exercise capacity and angina severity in CCS patients with angina. The effects of long-term training programs on CCS patients should be investigated clinically because of the possibility of helping to decrease the need for invasive treatments.

Walking training augments the effects of expiratory muscle training in Parkinson's disease.

OBJECTIVES: To investigate the effects of walking training combined with respiratory muscle training (RMT) on pulmonary function, respiratory muscle strength, and functional exercise capacity in patients with Parkinson's disease. MATERIALS & METHODS: Thirty patients with Parkinson's disease were included in the study. Patients were randomly divided into two groups: the walking and RMT group (W + RMT, n = 15) and the RMT (n = 15) group. Spirometry, respiratory muscle strength, and a 6-min walking test were measured before and after the eighth week of the study. RMT was performed using inspiratory and expiratory threshold loading methods. Walking training intensity was adjusted according to the 6-min walking test. Patients performed 15 min of inspiratory muscle training and 15 min of expiratory muscle training in both groups, and 15 min of walking training in the W + RMT group in addition to RMT, twice per day, 5 days/week, for a total of 8 weeks at home. Training intensity was adjusted once per week for the groups at the hospital. RESULTS: Respiratory muscle strength and 6-min walking distance were significantly increased (p = .001), and UPDRS-III scores were significantly improved (W + RMT: p = .008 and RMT: p = .01) in the two groups. The increase in maximal expiratory pressure was significantly higher in the W + RMT group than in the RMT group (p = .007). CONCLUSION: Walking training increases the effect of expiratory muscle training in patients with Parkinson's disease.

Association Between Inspiratory Muscle Function and Balance Ability in Older People: A Pooled Data Analysis Before and After Inspiratory Muscle Training.

Inspiratory muscle training (IMT) improved balance ability and respiratory muscle function in healthy older adults. The current study is a retrospective analysis to explore the relationship between inspiratory muscle function, balance ability, and adaptation to IMT. All participants (total = 129; IMT = 60; age range = 65-85 years) performed inspiratory and balance assessments, including the mini-balance evaluation system test, maximal inspiratory pressure, and peak inspiratory flow tests. Baseline inspiratory muscle function was positively related to balance ability (p < .05), and IMT-induced improvements in inspiratory function (23.3% in maximal inspiratory pressure, 8.0% in peak inspiratory flow rate, 14.9% in maximal peak inspiratory power) were related to improvements in balance (10.6% in mini-balance evaluation system test), with the greatest improvements (17.0%) observed in the oldest participants (76-85 years old, p < .05). In conclusion, with or without IMT, positive associations between inspiratory function and balance ability exist, with greater improvements in inspiratory muscle function related to greater improvements in balance ability.

Multidomain Frailty as a Therapeutic Target in Elderly Patients with Heart Failure.

Heart failure and frailty share aging as a strong risk factor. The prevalence of frailty has been shown to be particularly high in elderly patients with heart failure. Moreover, it is important not to confine frailty to physical aspects. Rather, it should be considered to consist of multiple domains, including physical disability, psychiatric disorders, cognitive impairment, depression, and social disconnection. Development of interventions that can improve frailty domains are not well established, although observational studies have evaluated the association of various frailty domains and their prognostic impact. Some interventions, including resistance exercise, functional exercise, and respiratory muscle training have been demonstrated to hold potential for improving physical frailty. In terms of cognitive dysfunction, previous studies have demonstrated that exercise therapy is also effective for cognitive dysfunction. The social domain of frailty is one of the least investigated domains, particularly in patients with heart failure. However, heart failure is also strongly associated with physical frailty and cognitive impairment and has a poor prognosis in old patients. The prevalence of social frailty in elderly patients who need hospitalization due to heart failure is higher than previously thought. Very few studies have tested interventions targeting social frailty. Frailty and heart failure affect each other, and both are becoming increasingly important in society. In this article, we review the physical, cognitive, and social domains of frailty and the possible interventions to improve them in patients with heart failure.

Physical activity and nutrition guidelines to help with the fight against COVID-19.

As the world is witnessing the epidemic of coronavirus disease 2019, emerging genetics and clinical pieces of evidence suggest a similar immunopathology to those of severe acute respiratory syndrome and Middle East respiratory syndrome. Staying at home to prevent the spread of the virus and consequently being largely inactive is associated with unintended consequences. These can actually enhance the infection risk and exacerbate poor health conditions including impaired immune function. Physical activity is a feasible way of improving health, particularly physical and mental health in a time of social isolation. However, people with certain health conditions in these circumstances may need a special physical activity programme in addition to any exercise they may already be performing via online programmes. This review aims to provide practical guidelines during the COVID-19 quarantine period. We suggest performing aerobic, resistance training, respiratory muscle training and yoga in the healthy, and in those with upper respiratory tract illness, patients with lower respiratory tract illness should be restricted to respiratory muscle training and yoga. In addition, vitamins D and C, omega-3 fatty acids, and regular consumption of fruit and vegetables might be considered as nutritional aids to support the immune system in those affected by COVID-19.

Effects of Inspiratory Muscle Training and Early Mobilization on Weaning of Mechanical Ventilation: A Systematic Review and Network Meta-analysis.

OBJECTIVE: To compare the effectiveness and rank order of physical therapy interventions, including conventional physical therapy (CPT), inspiratory muscle training (IMT), and early mobilization (EM) on mechanical ventilation (MV) duration and weaning duration. DATA SOURCES: PubMed, The Cochrane Library, Scopus, and CINAHL complete electronic databases were searched through August 2019. STUDY SELECTION: Randomized controlled trials (RCTs) investigating the effect of IMT, EM, or CPT on MV duration and the weaning duration in patients with MV were included. Studies that were determined to meet the eligibility criteria by 2 independent authors were included. A total of 6498 relevant studies were identified in the search, and 18 RCTs (934 participants) were included in the final analysis. DATA EXTRACTION: Data were extracted independently by 2 authors and assessed the study quality by the Cochrane risk-of-bias tool. The primary outcomes were MV duration and weaning duration. DATA SYNTHESIS: Various interventions of physical therapy were identified in the eligible studies, including IMT, IMT+CPT, EM, EM+CPT, and CPT. The data analysis demonstrated that compared with CPT, IMT+CPT significantly reduced the weaning duration (mean difference; 95% confidence interval) (-2.60; -4.76 to -0.45) and EM significantly reduced the MV duration (-2.01; -3.81 to -0.22). IMT+CPT and EM had the highest effectiveness in reducing the weaning duration and MV duration, respectively. CONCLUSION: IMT or EM should be recommended for improving the weaning outcomes in mechanically ventilated patients. However, an interpretation with caution is required due to the heterogeneity.

Effects of Expiratory Muscle Training and Air Stacking on Peak Cough Flow in Individuals with Parkinson's Disease.

The purpose of this study was to investigate the effects of air stacking (AS) and an expiratory muscle training (EMT) program to increase voluntary and reflex peak cough flow (PCF) in individuals with Parkinson's disease. Participants were allocated to the control (n = 11), EMT (n = 11), or EMT + AS group (n = 11). All groups performed EMT (5 sets of 5 repetitions), 6 times a week for 2 months. The control group used a fixed resistance, EMT plus AS and EMT groups used a progressively increased resistance. The EMT plus AS group additionally performed 10 series of three to four lung insufflations using a manual resuscitator bag. Voluntary and reflex PCF, maximum expiratory pressure, and slow vital capacity were assessed before and after training. EMT plus AS was more beneficial than EMT alone for improving reflex and voluntary PCF. The effect of the EMT plus AS was greater for reflex PCF than for voluntary PCF.