Inspiratory muscle training improves breathing pattern during exercise in COPD patients (letter).

The addition of IMT to a PR programme for selected COPD patients changes breathing pattern during exercise

Efficacy of a Novel Method for Inspiratory Muscle Training in People With Chronic Obstructive Pulmonary Disease.

Most inspiratory muscle training (IMT) interventions in patients with chronic obstructive pulmonary disease (COPD) have been implemented as fully supervised daily training for 30 minutes with controlled training loads using mechanical threshold loading (MTL) devices. Recently, an electronic tapered flow resistive loading (TFRL) device was introduced that has a different loading profile and stores training data during IMT sessions

Randomised controlled trial of adjunctive inspiratory muscle training for patients with COPD.

BACKGROUND: This study aimed to investigate whether adjunctive inspiratory muscle training (IMT) can enhance the well-established benefits of pulmonary rehabilitation (PR) in patients with COPD. METHODS: 219 patients with COPD (FEV1: 42%±16% predicted) with inspiratory muscle weakness (PImax: 51±15 cm H2O) were randomised into an intervention group (IMT+PR; n=110) or a control group (Sham-IMT+PR; n=109) in this double-blind, multicentre randomised controlled trial between February 2012 and October 2016 (ClinicalTrials.gov NCT01397396). Improvement in 6 min walking distance (6MWD) was a priori defined as the primary outcome. Prespecified secondary outcomes included respiratory muscle function and endurance cycling time. FINDINGS: No significant differences between the intervention group (n=89) and the control group (n=85) in improvements in 6MWD were observed (0.3 m, 95% CI -13 to 14, p=0.967). Patients who completed assessments in the intervention group achieved larger gains in inspiratory muscle strength (effect size: 1.07, p<0.001) and endurance (effect size: 0.79, p<0.001) than patients in the control group. 75 s additional improvement in endurance cycling time (95% CI 1 to 149, p=0.048) and significant reductions in Borg dyspnoea score at isotime during the cycling test (95% CI -1.5 to -0.01, p=0.049) were observed in the intervention group. INTERPRETATION: Improvements in respiratory muscle function after adjunctive IMT did not translate into additional improvements in 6MWD (primary outcome). Additional gains in endurance time and reductions in symptoms of dyspnoea were observed during an endurance cycling test (secondary outcome) TRIAL REGISTRATION NUMBER: NCT01397396; Results

Inspiratory muscle training affects proprioceptive use and low back pain.

We have shown that individuals with recurrent nonspecific low back pain (LBP) and healthy individuals breathing against an inspiratory load decrease their reliance on back proprioceptive signals in upright standing. Because individuals with LBP show greater susceptibility to diaphragm fatigue, it is reasonable to hypothesize that LBP, diaphragm dysfunction, and proprioceptive use may be interrelated. The purpose of this study was to investigate whether inspiratory muscle training (IMT) affects proprioceptive use during postural control in individuals with LBP

Inspiration for the Future: The Role of Inspiratory Muscle Training in Cystic Fibrosis

Cystic fibrosis (CF) is an inherited, multi-system, life-limiting disease characterized by a progressive decline in lung function, which accounts for the majority of CF-related morbidity and mortality. Inspiratory muscle training (IMT) has been proposed as a rehabilitative strategy to treat respiratory impairments associated with CF. However, despite evidence of therapeutic benefits in healthy and other clinical populations, the routine application of IMT in CF can neither be supported nor refuted due to the paucity of methodologically rigorous research. Specifically, the interpretation of available studies regarding the efficacy of IMT in CF is hampered by methodological threats to internal and external validity. As such, it is important to highlight the inherent risk of bias that differences in patient characteristics, IMT protocols, and outcome measurements present when synthesizing this literature prior to making final clinical judgments. Future studies are required to identify the characteristics of individuals who may respond to IMT and determine whether the controlled application of IMT can elicit meaningful improvements in physiological and patient-centered clinical outcomes. Given the equivocal evidence regarding its efficacy, IMT should be utilized on a case-by-case basis with sound clinical reasoning, rather than simply dismissed, until a rigorous evidence-based consensus has been reached

Identificación de equipos y procedimientos utilizados por fisioterapeutas brasileños para pruebas de endurance muscular inspiratoria

A avaliação da função dos músculos inspiratórios por meio do teste de endurance muscular inspiratória (EMI), definida como a capacidade de sustentação dessa tarefa ao longo do tempo, atualmente apresenta ampla variedade de instrumentos e procedimentos para sua mensuração. Este estudo teve como objetivo identificar os diferentes equipamentos, procedimentos e forma de avaliação dos testes de EMI entre fisioterapeutas brasileiros. É um estudo transversal realizado por meio de questionário enviado por correio eletrônico individualmente a cada participante. Cento e treze fisioterapeutas de diferentes regiões do país, grande parte com atuação conjunta na clínica e na docência (52,1%), responderam realizar poucas vezes a medida de EMI (48,7%). O manovacuômetro aneroide foi o aparelho mais utilizado por 42,5% dos profissionais. O clipe nasal e o bocal tubular de plástico rígido ou papel foram os acessórios mais utilizados durante o teste, correspondendo a 51,8% e 33%, respectivamente. O teste de ventilação voluntária máxima foi o mais utilizado para avaliação da endurance inspiratória, relatado por 23% dos respondentes. O teste de carga constante para avaliação da endurance foi adotado por 51,2% dos fisioterapeutas, sendo que 54,9% associaram comandos verbais à demonstração para explicação do teste. A interpretação dos valores aferidos era feita através de valores de referência por 25,7% dos entrevistados. Identificou-se que os fisioterapeutas brasileiros entrevistados não apresentaram a mesma conduta para os testes de EMI. No entanto os equipamentos, procedimentos e a forma de avaliação são utilizados com base nas diretrizes sobre o tema e de acordo com a disponibilidade de recursos do serviço.La evaluación de la función de los músculos inspiratorios a través del entrenamiento muscular inspiratorio (EMI), definida como la capacidad de sustentación de esta tarea a lo largo del tiempo, actualmente presenta una amplia variedad de instrumentos y procedimientos para su medición. Este estudio tuvo como objetivo identificar los diferentes equipos, procedimientos y forma de evaluación de las pruebas de EMI entre fisioterapeutas brasileños. Es un estudio transversal realizado por medio de un cuestionario enviado por correo electrónico a cada participante. Ciento trece fisioterapeutas de diferentes regiones del país, que en gran parte actúan a la vez en la clínica y en la enseñanza (52,1%), dijeron realizar pocas veces la medida de EMI (48,7%). El manovacuómetro aneroide fue el aparato más utilizado por el 42,5% de los profesionales. El clip nasal y la boquilla tubular de plástico rígido o papel fueron los accesorios más utilizados durante la prueba, correspondiendo al 51,8% y al 33%, respectivamente. La prueba de ventilación voluntaria máxima fue la más utilizada para la evaluación de la resistencia respiratoria, reportada por el 23% de los entrevistados. La prueba de carga constante para la evaluación de la resistencia se adoptó por el 51,2% de los fisioterapeutas, siendo que el 54,9% asoció comandos verbales a la demostración para la explicación de la prueba. La interpretación de los valores evaluados se hacía a través de valores de referencia por el 25,7% de los entrevistados. Se identificó que los fisioterapeutas brasileños entrevistados no presentaron la misma conducta para las pruebas de EMI. Sin embargo, los equipos, procedimientos y la forma de evaluación se utilizan con base en las directrices sobre el tema y de acuerdo con la disponibilidad de recursos del servicio.The assessment of inspiratory muscles through the inspiratory muscle endurance test (IME), defined as the ability to support this task over time, currently presents wide range of instruments and procedures for its measurement. This study aimed to identify the different equipment, procedures and assessments of IME tests among Brazilian physical therapists. It is a cross-sectional study carried out through a questionnaire sent individually by electronic mail to each participant. One hundred and thirteen physical therapists from different regions of the country, many practicing in the clinic and in the teaching field (52.1%), said they measured IME a few times (48.7%). The aneroid manovacuometer was used by 42.5% of the professionals. The nose clip and the hard plastic or paper tubular incentive spirometer were the most used accessories during the test, corresponding to 51.8% and 33%, respectively. The maximum voluntary ventilation test was used to assess the inspiratory endurance, reported by 23% of the respondents. The constant load test for endurance assessment was adopted by 51.2% of the physical therapists, and 54.9% associated verbal commands with the demonstration for the test application. The interpretation of the measured values was made with reference values by 25.7% of respondents. We identified that Brazilian physical therapists interviewed did not show the same conduct for IME tests. However, the equipment, procedures and assessment form are used based on the guidelines on the subject and according to the availability of resources of the service

Inspiratory muscle training in patients with chronic obstructive pulmonary disease (COPD)

An important clinical manifestation of chronic obstructive pulmonary disease (COPD) is impaired exercise capacity due to dyspnea and limb muscle weakness. Respiratory muscle dysfunction is also frequently observed in patients with COPD and is related to dyspnea and exercise limitation. Inspiratory muscle training (IMT) has been applied during pulmonary rehabilitation in COPD patients. However, even after decades of research the role of the respiratory muscles in the rehabilitation program of these patients remains controversial. It is still unclear whether the addition of IMT to a general exercise training program can lead to additional gains in clinically relevant outcomes. This has been attributed to methodological shortcomings and considerable heterogeneity among the several small, single center clinical studies that have been performed and published so far. From meta-analysis it was concluded that IMT might be most effective in patients with pronounced inspiratory muscle weakness. In this PhD project, we investigated a newly developed device for IMT that provides a tapered flow resistive loading (TFRL) and allows for controlling training quality during the IMT sessions. We observed significantly larger increases in inspiratory muscle strength and endurance, as well as changes in breathing pattern during endurance loaded breathing tasks after TFRL-IMT in comparison to the conventionally applied mechanical threshold loading IMT. We also found that patients participating in a combined general exercise training and IMT intervention achieved favorable changes in breathing pattern (breathing deeper and slower) during exercise in comparison with patients participating in rehabilitation without added IMT. The additional benefits of IMT as an adjunct to a general exercise training program on outcomes beyond respiratory muscle dysfunction in patients with COPD were examined in a large multicenter randomized double-blind controlled trial. Superior improvements in inspiratory muscle function did not translate into additional improvements in 6 minute walking distance. However, a larger improvement was observed in endurance cycling time, as well as reductions in dyspnea symptoms at iso-time during the cycling test. The training quality indices (both external work and power achieved during the IMT sessions) and training intensity (and not compliance) were significantly related to improvements in inspiratory muscle strength which in turn was related to improvements in endurance cycling time. We also reviewed potential physiological mechanisms explaining effects of IMT on exercise capacity and dyspnea in patients with COPD and have identified areas in which further research would be warranted. This fundamental knowledge will be a guideline incorporating inspiratory muscle training into evidence-based treatment recommendations for clinical practice and will provide insights for future research on inspiratory muscle training in patients suffering from respiratory muscle dysfunction.TABLE OF CONTENTS Chapter 1 General introduction and rationale 13 1.1 General introduction 15 1.2 Introduction to the presented chapters and objectives of the studies 23 1.3 References 27 Chapter 2 Efficacy of a novel method for inspiratory muscle training in people with chronic obstructive pulmonary disease 31 2.1 Abstract 33 2.2 Introduction 34 2.3 Materials and methods 35 2.4 Results 41 2.5 Discussion 44 2.6 References 48 Chapter 3 Inspiratory muscle training improves breathing pattern during exercise in COPD patients 51 3.1 Abstract 53 3.2 Introduction 54 3.3 Materials and methods 55 3.4 Results 57 3.5 Discussion 62 3.6 References 65 Chapter 4 Chapter 4.1: Inspiratory muscle training protocol for patients with chronic obstructive pulmonary disease (IMTCO study): a multicentre randomised controlled trial 67 4.1.1 Abstract 69 4.1.2 Article summary 70 4.1.3 Introduction 71 4.1.4 Materials and methods 72 4.1.5 Discussion 80 4.1.6 References 81 Chapter 4.2: A multicentre, randomised, double-blind, controlled trial of adjunctive inspiratory muscle training for patients with chronic obstructive pulmonary disease (IMTCO) 85 4.2.1 Abstract 87 4.2.2 Introduction 88 4.2.3 Materials and methods 89 4.2.4 Results 91 4.2.5 Discussion 98 4.2.6 References 103 4.2.7 Data supplement 106 Chapter 5 Respiratory muscle function and exercise limitation in patients with chronic obstructive pulmonary disease (COPD) : A Review 109 5.1 Abstract 111 5.2 Introduction 112 5.3 Load-capacity balance of the respiratory muscles, dyspnea, and exercise limitation in COPD patients 113 5.4 Therapeutic approaches to decrease the load on the respiratory muscles and to improve respiratory muscle capacity 121 5.5 Potential physiological mechanisms explaining effects of improvements in respiratory muscle function on exercise capacity and dyspnea 124 5.6 References 129 Chapter 6 General discussion, future directions and conclusions 139 6.1 General discussion and future directions 141 6.2 General conclusions 152 6.3 References 154 Summary 157 Samenvatting 161 Bijstellingen 165 Short curriculum vitae 169 Publications 173nrpages: 177status: publishe

Inspiratory muscle training protocol for patients with chronic obstructive pulmonary disease (IMTCO study): a multicentre randomised controlled trial

Contains fulltext : 118667.pdf (publisher's version ) (Open Access)INTRODUCTION: Inspiratory muscle training (IMT) has been applied during pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD). However, it remains unclear if the addition of IMT to a general exercise training programme leads to additional clinically relevant improvements in patients with COPD. In this study, we will investigate whether the addition of IMT to a general exercise training programme improves 6 min walking distance, health-related quality of life, daily physical activity and inspiratory muscle function in patients with COPD with inspiratory muscle weakness. METHODS AND ANALYSIS: Patients with COPD (n=170) with inspiratory muscle weakness (Pi,max /=50% of their Pi,max), whereas the placebo group (n=85) will undertake IMT at a low training intensity (</=10% of Pi,max). Total daily IMT time for both groups will be 21 min (6 cycles of 30 breaths). Improvement in the 6 min walking distance will be the primary outcome. Inspiratory muscle function, health-related quality of life and daily physical activity will be assessed as secondary outcomes. ETHICS AND DISSEMINATION: Ethics approval has been obtained from relevant centre committees and the study has been registered in a publicly accessible clinical trial database. The results will be easily interpretable and should immediately be communicated to healthcare providers, patients and the general public. RESULTS: This can be incorporated into evidence-based treatment recommendations for clinical practice. CLINICALTRIALSGOV: NCT01397396

Measurement validity of an electronic inspiratory loading device during a loaded breathing task in patients with COPD

We studied the validity of a recently introduced, handheld, electronic loading device in providing automatically processed information on external inspiratory work, power and breathing pattern during loaded breathing tasks in patients with COPD. Thirty-five patients with moderate to severe COPD performed an endurance breathing task against a fixed resistive inspiratory load that corresponded to 55 ± 13% of their maximal inspiratory pressure. Flow and pressure signals during this task were sampled and processed at 500 Hz by the handheld loading device and at 100 Hz with an external, laboratory system that provided the "gold standard" reference data. Intra Class Correlations between methods were 0.97 for average mean inspiratory power, 0.98 for average mean pressure, 0.98 for average duty cycle, and 0.99 for total work (all p < 0.0001). We conclude that the handheld device provides automatically processed and valid estimates of physical units of energy during loaded breathing tasks. This enables health care providers to quantify the load on inspiratory muscles during these tests in daily clinical practice.publisher: Elsevier articletitle: Measurement validity of an electronic inspiratory loading device during a loaded breathing task in patients with COPD journaltitle: Respiratory Medicine articlelink: http://dx.doi.org/10.1016/j.rmed.2013.01.020 content_type: article copyright: Copyright © 2013 Elsevier Ltd.status: publishe

Respiratory muscle function and exercise limitation in patients with chronic obstructive pulmonary disease: a review

Introduction: Respiratory muscle dysfunction is common and contributes to dyspnea and exercise limitation in patients with chronic obstructive pulmonary disease (COPD). Improving dynamic function of respiratory muscles during exercise might help to reduce symptoms and improve exercise capacity. Areas covered: The aims of this review are to 1) summarize physiological mechanisms linking respiratory muscle dysfunction to dyspnea and exercise limitation; 2) provide an overview of available therapeutic approaches to better maintain load-capacity balance of respiratory muscles during exercise; and 3) to summarize current knowledge on potential mechanisms explaining effects of interventions aimed at optimizing dynamic respiratory muscle function with a special focus on inspiratory muscle training. Expert commentary: Several mechanisms which are potentially linking improvements in dynamic respiratory muscle function to symptomatic and functional benefits have not been studied so far in COPD patients. Examples of underexplored areas include the study of neural processes related to the relief of acute dyspnea and the competition between respiratory and peripheral muscles for limited energy supplies during exercise. Novel methodologies are available to non-invasively study these mechanisms. Better insights into the consequences of dynamic respiratory muscle dysfunction will hopefully contribute to further refine and individualize therapeutic approaches in patients with COPD. © 2017 Informa UK Limited, trading as Taylor &amp; Francis Group