BREATHS: A Knowledge Translation Framework for Optimizing Inspiratory Muscle Training in Physical Therapy Practice
Main Article Content
Abstract
There is an overwhelming body of evidence that supports the efficacy of inspiratory muscle training in improving strength of the inspiratory muscles and activity performance in a variety of patient populations. Essential to the utilization of this abundant body of evidence is knowledge translation, a concept that emphasizes the translation of global knowledge to application that can be effectively integrated into clinical practice. To this effect, this perspective paper aims to provide physical therapists with explicit ways to apply and integrate the evidence related to inspiratory muscle training into clinical practice by proposing a novel 7-step BREATHS framework. This framework discusses the Biomechanics of breathing, Resources and devices available for inspiratory muscle assessment and treatment, Examination of inspiratory muscle strength, Assessment of outcome measures, Treatment considerations in strengthening inspiratory muscles, Holistic health impact through inspiratory muscle training, and Safety considerations for clinicians to consider across the continuum of care. This framework is designed to upskill physical therapists and other health care providers with a contemporary model to deliver safe, effective, and evidence-informed inspiratory muscle training for various patients and clients. The paper elucidates the underpinnings of each aspect of the BREATHS framework and its application to practice, enabling clinicians to better appreciate the power of inspiratory muscle training in maximizing overall health and wellness in their patients and clients.
Article Details
How to Cite
ANDERSON, Jennifer; PRILUCK, Deborah; DIAS, Konrad J..
BREATHS: A Knowledge Translation Framework for Optimizing Inspiratory Muscle Training in Physical Therapy Practice.
Medical Research Archives, [S.l.], v. 13, n. 6, june 2025.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6591>. Date accessed: 15 july 2025.
doi: https://doi.org/10.18103/mra.v13i6.6591.
Section
Review Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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2. American Physical Therapy Association. Physical Therapist Practice and the Movement System | APTA.; 2015. Accessed May 8, 2025. https://www.apta.org/patient-care/interventions/movement-system-management/movement-system-white-paper#
3. Poddighe D, Van Hollebeke M, Rodrigues A, et al. Respiratory muscle dysfunction in acute and chronic respiratory failure: how to diagnose and how to treat? European Respiratory Review. 2024;33(174):240150. doi:10.1183/16000617.0150-2024
4. Smith JR, Taylor BJ. Inspiratory muscle weakness in cardiovascular diseases: Implications for cardiac rehabilitation. Prog Cardiovasc Dis. 2022;70:49-57. doi:10.1016/j.pcad.2021.10.002
5. Huang MH, Fry D, Doyle L, et al. Effects of inspiratory muscle training in advanced multiple sclerosis. Mult Scler Relat Disord. 2020;37. doi:10.1016/j.msard.2019.101492
6. Inzelberg R, Peleg N, Nisipeanu P, Magadle R, Carasso RL, Weiner P. Inspiratory muscle training and the perception of dyspnea in Parkinson’s disease. Canadian Journal of Neurological Sciences. 2005;32(2):213-217. doi:10.1017/S0317167100003991,
7. Martin-Sanchez C, Barbero-Iglesias FJ, Amor-Esteban V, Martin-Sanchez M, Martin-Nogueras AM. Benefits of inspiratory muscle training therapy in institutionalized adult people with cerebral palsy: A double-blind randomized controlled trial. Brain Behav. 2024;14(9). doi:10.1002/BRB3.70044,
8. Beaumont M, Forget P, Couturaud F, Reychler G. Effects of inspiratory muscle training in COPD patients: A systematic review and meta-analysis. Clinical Respiratory Journal. 2018;12(7):2178-2188. doi:10.1111/CRJ.12905,
9. Azambuja ADCM, De Oliveira LZ, Sbruzzi G. Inspiratory Muscle Training in Patients with Heart Failure: What Is New? Systematic Review and Meta-Analysis. Phys Ther. 2020;100(12):2099-2109. doi:10.1093/PTJ/PZAA171
10. Zhang X, Zheng Y, Dang Y, et al. Can inspiratory muscle training benefit patients after stroke? A systematic review and meta-analysis of randomized controlled trials. Clin Rehabil. 2020;34(7):866-876. doi:10.1177/0269215520926227,
11. Watson K, Egerton T, Sheers N, et al. Respiratory muscle training in neuromuscular disease: a systematic review and meta-analysis. European Respiratory Review. 2022;31(166). doi:10.1183/16000617.0065-2022,
12. Fabero-Garrido R, del Corral T, Angulo-Díaz-Parreño S, et al. Respiratory muscle training improves exercise tolerance and respiratory muscle function/structure post-stroke at short term: A systematic review and meta-analysis. Ann Phys Rehabil Med. 2022;65(5). doi:10.1016/j.rehab.2021.101596
13. Laveneziana P, Albuquerque A, Aliverti A, et al. ERS statement on respiratory muscle testing at rest and during exercise. European Respiratory Journal. 2019;53(6). doi:10.1183/13993003.01214-2018,
14. Adler D, Janssens JP. The pathophysiology of respiratory failure: Control of breathing, respiratory load, and muscle capacity. Respiration. 2019;97(2):93-104. doi:10.1159/000494063,
15. Severin R, Franz CK, Farr E, et al. The effects of COVID-19 on respiratory muscle performance: making the case for respiratory muscle testing and training. European Respiratory Review. 2022;31(166). doi:10.1183/16000617.0006-2022,
16. Huber JE, Chandrasekaran B, Wolstencroft JJ. Changes to Respiratory Mechanisms during Speech as a Result of Different Cues to Increase Loudness. J Appl Physiol (1985). 2005;98(6):2177. doi:10.1152/JAPPLPHYSIOL.01239.2004
17. Janssens L, Brumagne S, Polspoel K, Troosters T, McConnell A. The effect of inspiratory muscles fatigue on postural control in people with and without recurrent low back pain. Spine (Phila Pa 1976). 2010;35(10):1088-1094. doi:10.1097/BRS.0B013E3181BEE5C3,
18. Costa R, Almeida N, Ribeiro F. Body position influences the maximum inspiratory and expiratory mouth pressures of young healthy subjects. Physiotherapy. 2015;101(2):239-241. doi:10.1016/J.PHYSIO.2014.08.002
19. Lista-Paz A, Langer D, Barral-Fernández M, et al. Maximal Respiratory Pressure Reference Equations in Healthy Adults and Cut-off Points for Defining Respiratory Muscle Weakness. Arch Bronconeumol. 2023;59(12):813-820. doi:10.1016/j.arbres.2023.08.016
20. Vargus-Adams JN, Majnemer A. International Classification of Functioning, Disability and Health (ICF) as a framework for change: Revolutionizing rehabilitation. J Child Neurol. 2014;29(8):1030-1035. doi:10.1177/0883073814533595,
21. Ahmadnezhad L, Yalfani A, Borujeni BG. Inspiratory muscle training in rehabilitation of low back pain: A randomized controlled trial. J Sport Rehabil. 2020;29(8):1151-1158. doi:10.1123/JSR.2019-0231,
22. Charususin N, Gosselink R, Decramer M, et al. Randomised controlled trial of adjunctive inspiratory muscle training for patients with COPD. Thorax. 2018;73(10):942-950. doi:10.1136/THORAXJNL-2017-211417,
23. Craighead DH, Heinbockel TC, Freeberg KA, et al. Time-efficient inspiratory muscle strength training lowers blood pressure and improves endothelial function, no bioavailability, and oxidative stress in midlife/older adults with above-normal blood pressure. J Am Heart Assoc. 2021;10(13). doi:10.1161/JAHA.121.020980,
24. Abidi S, Ghram A, Ahmaidi S, Ben Saad H, Chlif M. Effects of Inspiratory Muscle Training on Stress Urinary Incontinence in North African Women: A Randomized Controlled Trial. Int Urogynecol J. 2024;35(10). doi:10.1007/S00192-024-05921-1,
25. Chang YC, Chang HY, Ho CC, et al. Effects of 4-week inspiratory muscle training on sport performance in college 800-meter track runners. Medicina (Lithuania). 2021;57(1):1-8. doi:10.3390/MEDICINA57010072,
26. Bosnak-Guclu M, Arikan H, Savci S, et al. Effects of inspiratory muscle training in patients with heart failure. Respir Med. 2011;105(11):1671-1681. doi:10.1016/J.RMED.2011.05.001,
27. Doğan YE, Yıldırım MA, Öneş K, Kütük B, Ata İ, Karacan İ. The optimal treatment duration for inspiratory muscle strengthening exercises in stroke patients: a double-blinded randomized controlled trial. Top Stroke Rehabil. Published online 2024. doi:10.1080/10749357.2024.2423591,
28. Soumyashree S, Kaur J. Effect of inspiratory muscle training (IMT) on aerobic capacity, respiratory muscle strength and rate of perceived exertion in paraplegics. Journal of Spinal Cord Medicine. 2020;43(1):53-59. doi:10.1080/10790268.2018.1462618,
29. Dahhak A, Devoogdt N, Langer D. Adjunctive Inspiratory Muscle Training During a Rehabilitation Program in Patients with Breast Cancer: An Exploratory Double-Blind, Randomized, Controlled Pilot Study. Arch Rehabil Res Clin Transl. 2022;4(2). doi:10.1016/j.arrct.2022.100196
30. Barğı G, Güçlü MB, Arıbaş Z, Akı ŞZ, Sucak GT. Inspiratory muscle training in allogeneic hematopoietic stem cell transplantation recipients: a randomized controlled trial. Supportive Care in Cancer. 2016;24(2):647-659. doi:10.1007/S00520-015-2825-3,
31. Palau P, Domínguez E, Gonzalez C, et al. Effect of a home-based inspiratory muscle training programme on functional capacity in postdischarged patients with long COVID: The InsCOVID trial. BMJ Open Respir Res. 2022;9(1). doi:10.1136/BMJRESP-2022-001439,
32. Abodonya AM, Abdelbasset WK, Awad EA, Elalfy IE, Salem HA, Elsayed SH. Inspiratory muscle training for recovered COVID-19 patients after weaning from mechanical ventilation: A pilot control clinical study. Medicine. 2021;100(13):e25339. doi:10.1097/MD.0000000000025339
33. Palau P, Domínguez E, Ló pez L, et al. Inspiratory Muscle Training and Functional Electrical Stimulation for Treatment of Heart Failure With Preserved Ejection Fraction: The TRAINING-HF Trial. Rev Esp Cardiol. 2019;72(4):288-297. doi:10.1016/j.rec.2018.09.004
34. Shoemaker MJ, Dias KJ, Lefebvre KM, Heick JD, Collins SM. Physical Therapist Clinical Practice Guideline for the Management of Individuals with Heart Failure. Phys Ther. Published online 2020. doi:10.1093/ptj/pzz127
35. Dietsch AM, Krishnamurthy R, Young K, Barlowa SM. Instrumental assessment of aero-resistive expiratory muscle strength rehabilitation devices. Journal of Speech, Language, and Hearing Research. 2024;67(3):729-739. doi:10.1044/2023_JSLHR-23-00381,
36. Lee CT, Chien JY, Hsu MJ, Wu HD, Wang LY. Inspiratory muscle activation during inspiratory muscle training in patients with COPD. Respir Med. 2021;190. doi:10.1016/j.rmed.2021.106676
37. Kim SH, Shin MJ, Lee JM, Huh S, Shin YB. Effects of a new respiratory muscle training device in community-dwelling elderly men: an open-label, randomized, non-inferiority trial. BMC Geriatr. 2022;22(1). doi:10.1186/S12877-022-02828-8,
38. Sørensen D, Christensen ME. Behavioural modes of adherence to inspiratory muscle training in people with chronic obstructive pulmonary disease: a grounded theory study. Disabil Rehabil. 2019;41(9):1071-1078. doi:10.1080/09638288.2017.1422032,
39. Palermo AE, Butler JE, Boswell-Ruys CL. Comparison of two inspiratory muscle training protocols in people with spinal cord injury: a secondary analysis. Spinal Cord Ser Cases. 2023;9(1). doi:10.1038/S41394-023-00594-2,
40. Garber CE, Blissmer B, Deschenes MR, et al. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334-1359. doi:10.1249/MSS.0B013E318213FEFB,
41. Shei RJ, Paris HL, Sogard AS, Mickleborough TD. Time to Move Beyond a “One-Size Fits All” Approach to Inspiratory Muscle Training. Front Physiol. 2022;12. doi:10.3389/FPHYS.2021.766346,
42. Dsouza FV, Amaravadi SK, Samuel SR, Raghavan H, Ravishankar N. Effectiveness of Inspiratory Muscle Training on Respiratory Muscle Strength in Patients Undergoing Cardiac Surgeries: A Systematic Review With Meta-Analysis. Ann Rehabil Med. 2021;45(4):264-273. doi:10.5535/ARM.21027,
43. Bissett BM, Wang J, Neeman T, Leditschke IA, Boots R, Paratz J. Which ICU patients benefit most from inspiratory muscle training? Retrospective analysis of a randomized trial. Physiother Theory Pract. 2020;36(12):1316-1321. doi:10.1080/09593985.2019.1571144,
44. Tinetti M, Huang A, Molnar F. The Geriatrics 5M’s: A New Way of Communicating What We Do. J Am Geriatr Soc. 2017;65(9):2115-2115. doi:10.1111/JGS.14979
45. Rozek-Piechura K, Kurzaj M, Okrzymowska P, Kucharski W, Stodółka J, Maćkała K. Influence of Inspiratory Muscle Training of Various Intensities on the Physical Performance of Long-Distance Runners. J Hum Kinet. 2020;75(1):127-137. doi:10.2478/HUKIN-2020-0031,
46. Fernández-Lázaro D, Gallego-Gallego D, Corchete LA, et al. Inspiratory muscle training program using the powerbreath®: Does it have ergogenic potential for respiratory and/or athletic performance? a systematic review with meta-analysis. Int J Environ Res Public Health. 2021;18(13). doi:10.3390/IJERPH18136703,
47. Nickels M, Erwin K, McMurray G, et al. Feasibility, safety, and patient acceptability of electronic inspiratory muscle training in patients who require prolonged mechanical ventilation in the intensive care unit: A dual-centre observational study. Australian Critical Care. 2024;37(3):448-454. doi:10.1016/j.aucc.2023.04.008
48. Luo Z, Qian H, Zhang X, Wang Y, Wang J, Yu P. Effectiveness and safety of inspiratory muscle training in patients with pulmonary hypertension: A systematic review and meta-analysis. Front Cardiovasc Med. 2022;9. doi:10.3389/FCVM.2022.999422,
49. McDonald T, Stiller K. Inspiratory muscle training is feasible and safe for patients with acute spinal cord injury. Journal of Spinal Cord Medicine. 2019;42(2):220-227. doi:10.1080/10790268.2018.1432307,
50. Cahalin LP, Arena R, Guazzi M, et al. Inspiratory muscle training in heart disease and heart failure: A review of the literature with a focus on method of training and outcomes. Expert Rev Cardiovasc Ther. 2013;11(2):161-177. doi:10.1586/ERC.12.191,
51. Alpert MA. Beneficial Effects of Inspiratory Muscle Training in Patients With Pulmonary Arterial Hypertension. American Journal of Cardiology. 2023;203:526-527. doi:10.1016/j.amjcard.2023.07.129
2. American Physical Therapy Association. Physical Therapist Practice and the Movement System | APTA.; 2015. Accessed May 8, 2025. https://www.apta.org/patient-care/interventions/movement-system-management/movement-system-white-paper#
3. Poddighe D, Van Hollebeke M, Rodrigues A, et al. Respiratory muscle dysfunction in acute and chronic respiratory failure: how to diagnose and how to treat? European Respiratory Review. 2024;33(174):240150. doi:10.1183/16000617.0150-2024
4. Smith JR, Taylor BJ. Inspiratory muscle weakness in cardiovascular diseases: Implications for cardiac rehabilitation. Prog Cardiovasc Dis. 2022;70:49-57. doi:10.1016/j.pcad.2021.10.002
5. Huang MH, Fry D, Doyle L, et al. Effects of inspiratory muscle training in advanced multiple sclerosis. Mult Scler Relat Disord. 2020;37. doi:10.1016/j.msard.2019.101492
6. Inzelberg R, Peleg N, Nisipeanu P, Magadle R, Carasso RL, Weiner P. Inspiratory muscle training and the perception of dyspnea in Parkinson’s disease. Canadian Journal of Neurological Sciences. 2005;32(2):213-217. doi:10.1017/S0317167100003991,
7. Martin-Sanchez C, Barbero-Iglesias FJ, Amor-Esteban V, Martin-Sanchez M, Martin-Nogueras AM. Benefits of inspiratory muscle training therapy in institutionalized adult people with cerebral palsy: A double-blind randomized controlled trial. Brain Behav. 2024;14(9). doi:10.1002/BRB3.70044,
8. Beaumont M, Forget P, Couturaud F, Reychler G. Effects of inspiratory muscle training in COPD patients: A systematic review and meta-analysis. Clinical Respiratory Journal. 2018;12(7):2178-2188. doi:10.1111/CRJ.12905,
9. Azambuja ADCM, De Oliveira LZ, Sbruzzi G. Inspiratory Muscle Training in Patients with Heart Failure: What Is New? Systematic Review and Meta-Analysis. Phys Ther. 2020;100(12):2099-2109. doi:10.1093/PTJ/PZAA171
10. Zhang X, Zheng Y, Dang Y, et al. Can inspiratory muscle training benefit patients after stroke? A systematic review and meta-analysis of randomized controlled trials. Clin Rehabil. 2020;34(7):866-876. doi:10.1177/0269215520926227,
11. Watson K, Egerton T, Sheers N, et al. Respiratory muscle training in neuromuscular disease: a systematic review and meta-analysis. European Respiratory Review. 2022;31(166). doi:10.1183/16000617.0065-2022,
12. Fabero-Garrido R, del Corral T, Angulo-Díaz-Parreño S, et al. Respiratory muscle training improves exercise tolerance and respiratory muscle function/structure post-stroke at short term: A systematic review and meta-analysis. Ann Phys Rehabil Med. 2022;65(5). doi:10.1016/j.rehab.2021.101596
13. Laveneziana P, Albuquerque A, Aliverti A, et al. ERS statement on respiratory muscle testing at rest and during exercise. European Respiratory Journal. 2019;53(6). doi:10.1183/13993003.01214-2018,
14. Adler D, Janssens JP. The pathophysiology of respiratory failure: Control of breathing, respiratory load, and muscle capacity. Respiration. 2019;97(2):93-104. doi:10.1159/000494063,
15. Severin R, Franz CK, Farr E, et al. The effects of COVID-19 on respiratory muscle performance: making the case for respiratory muscle testing and training. European Respiratory Review. 2022;31(166). doi:10.1183/16000617.0006-2022,
16. Huber JE, Chandrasekaran B, Wolstencroft JJ. Changes to Respiratory Mechanisms during Speech as a Result of Different Cues to Increase Loudness. J Appl Physiol (1985). 2005;98(6):2177. doi:10.1152/JAPPLPHYSIOL.01239.2004
17. Janssens L, Brumagne S, Polspoel K, Troosters T, McConnell A. The effect of inspiratory muscles fatigue on postural control in people with and without recurrent low back pain. Spine (Phila Pa 1976). 2010;35(10):1088-1094. doi:10.1097/BRS.0B013E3181BEE5C3,
18. Costa R, Almeida N, Ribeiro F. Body position influences the maximum inspiratory and expiratory mouth pressures of young healthy subjects. Physiotherapy. 2015;101(2):239-241. doi:10.1016/J.PHYSIO.2014.08.002
19. Lista-Paz A, Langer D, Barral-Fernández M, et al. Maximal Respiratory Pressure Reference Equations in Healthy Adults and Cut-off Points for Defining Respiratory Muscle Weakness. Arch Bronconeumol. 2023;59(12):813-820. doi:10.1016/j.arbres.2023.08.016
20. Vargus-Adams JN, Majnemer A. International Classification of Functioning, Disability and Health (ICF) as a framework for change: Revolutionizing rehabilitation. J Child Neurol. 2014;29(8):1030-1035. doi:10.1177/0883073814533595,
21. Ahmadnezhad L, Yalfani A, Borujeni BG. Inspiratory muscle training in rehabilitation of low back pain: A randomized controlled trial. J Sport Rehabil. 2020;29(8):1151-1158. doi:10.1123/JSR.2019-0231,
22. Charususin N, Gosselink R, Decramer M, et al. Randomised controlled trial of adjunctive inspiratory muscle training for patients with COPD. Thorax. 2018;73(10):942-950. doi:10.1136/THORAXJNL-2017-211417,
23. Craighead DH, Heinbockel TC, Freeberg KA, et al. Time-efficient inspiratory muscle strength training lowers blood pressure and improves endothelial function, no bioavailability, and oxidative stress in midlife/older adults with above-normal blood pressure. J Am Heart Assoc. 2021;10(13). doi:10.1161/JAHA.121.020980,
24. Abidi S, Ghram A, Ahmaidi S, Ben Saad H, Chlif M. Effects of Inspiratory Muscle Training on Stress Urinary Incontinence in North African Women: A Randomized Controlled Trial. Int Urogynecol J. 2024;35(10). doi:10.1007/S00192-024-05921-1,
25. Chang YC, Chang HY, Ho CC, et al. Effects of 4-week inspiratory muscle training on sport performance in college 800-meter track runners. Medicina (Lithuania). 2021;57(1):1-8. doi:10.3390/MEDICINA57010072,
26. Bosnak-Guclu M, Arikan H, Savci S, et al. Effects of inspiratory muscle training in patients with heart failure. Respir Med. 2011;105(11):1671-1681. doi:10.1016/J.RMED.2011.05.001,
27. Doğan YE, Yıldırım MA, Öneş K, Kütük B, Ata İ, Karacan İ. The optimal treatment duration for inspiratory muscle strengthening exercises in stroke patients: a double-blinded randomized controlled trial. Top Stroke Rehabil. Published online 2024. doi:10.1080/10749357.2024.2423591,
28. Soumyashree S, Kaur J. Effect of inspiratory muscle training (IMT) on aerobic capacity, respiratory muscle strength and rate of perceived exertion in paraplegics. Journal of Spinal Cord Medicine. 2020;43(1):53-59. doi:10.1080/10790268.2018.1462618,
29. Dahhak A, Devoogdt N, Langer D. Adjunctive Inspiratory Muscle Training During a Rehabilitation Program in Patients with Breast Cancer: An Exploratory Double-Blind, Randomized, Controlled Pilot Study. Arch Rehabil Res Clin Transl. 2022;4(2). doi:10.1016/j.arrct.2022.100196
30. Barğı G, Güçlü MB, Arıbaş Z, Akı ŞZ, Sucak GT. Inspiratory muscle training in allogeneic hematopoietic stem cell transplantation recipients: a randomized controlled trial. Supportive Care in Cancer. 2016;24(2):647-659. doi:10.1007/S00520-015-2825-3,
31. Palau P, Domínguez E, Gonzalez C, et al. Effect of a home-based inspiratory muscle training programme on functional capacity in postdischarged patients with long COVID: The InsCOVID trial. BMJ Open Respir Res. 2022;9(1). doi:10.1136/BMJRESP-2022-001439,
32. Abodonya AM, Abdelbasset WK, Awad EA, Elalfy IE, Salem HA, Elsayed SH. Inspiratory muscle training for recovered COVID-19 patients after weaning from mechanical ventilation: A pilot control clinical study. Medicine. 2021;100(13):e25339. doi:10.1097/MD.0000000000025339
33. Palau P, Domínguez E, Ló pez L, et al. Inspiratory Muscle Training and Functional Electrical Stimulation for Treatment of Heart Failure With Preserved Ejection Fraction: The TRAINING-HF Trial. Rev Esp Cardiol. 2019;72(4):288-297. doi:10.1016/j.rec.2018.09.004
34. Shoemaker MJ, Dias KJ, Lefebvre KM, Heick JD, Collins SM. Physical Therapist Clinical Practice Guideline for the Management of Individuals with Heart Failure. Phys Ther. Published online 2020. doi:10.1093/ptj/pzz127
35. Dietsch AM, Krishnamurthy R, Young K, Barlowa SM. Instrumental assessment of aero-resistive expiratory muscle strength rehabilitation devices. Journal of Speech, Language, and Hearing Research. 2024;67(3):729-739. doi:10.1044/2023_JSLHR-23-00381,
36. Lee CT, Chien JY, Hsu MJ, Wu HD, Wang LY. Inspiratory muscle activation during inspiratory muscle training in patients with COPD. Respir Med. 2021;190. doi:10.1016/j.rmed.2021.106676
37. Kim SH, Shin MJ, Lee JM, Huh S, Shin YB. Effects of a new respiratory muscle training device in community-dwelling elderly men: an open-label, randomized, non-inferiority trial. BMC Geriatr. 2022;22(1). doi:10.1186/S12877-022-02828-8,
38. Sørensen D, Christensen ME. Behavioural modes of adherence to inspiratory muscle training in people with chronic obstructive pulmonary disease: a grounded theory study. Disabil Rehabil. 2019;41(9):1071-1078. doi:10.1080/09638288.2017.1422032,
39. Palermo AE, Butler JE, Boswell-Ruys CL. Comparison of two inspiratory muscle training protocols in people with spinal cord injury: a secondary analysis. Spinal Cord Ser Cases. 2023;9(1). doi:10.1038/S41394-023-00594-2,
40. Garber CE, Blissmer B, Deschenes MR, et al. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334-1359. doi:10.1249/MSS.0B013E318213FEFB,
41. Shei RJ, Paris HL, Sogard AS, Mickleborough TD. Time to Move Beyond a “One-Size Fits All” Approach to Inspiratory Muscle Training. Front Physiol. 2022;12. doi:10.3389/FPHYS.2021.766346,
42. Dsouza FV, Amaravadi SK, Samuel SR, Raghavan H, Ravishankar N. Effectiveness of Inspiratory Muscle Training on Respiratory Muscle Strength in Patients Undergoing Cardiac Surgeries: A Systematic Review With Meta-Analysis. Ann Rehabil Med. 2021;45(4):264-273. doi:10.5535/ARM.21027,
43. Bissett BM, Wang J, Neeman T, Leditschke IA, Boots R, Paratz J. Which ICU patients benefit most from inspiratory muscle training? Retrospective analysis of a randomized trial. Physiother Theory Pract. 2020;36(12):1316-1321. doi:10.1080/09593985.2019.1571144,
44. Tinetti M, Huang A, Molnar F. The Geriatrics 5M’s: A New Way of Communicating What We Do. J Am Geriatr Soc. 2017;65(9):2115-2115. doi:10.1111/JGS.14979
45. Rozek-Piechura K, Kurzaj M, Okrzymowska P, Kucharski W, Stodółka J, Maćkała K. Influence of Inspiratory Muscle Training of Various Intensities on the Physical Performance of Long-Distance Runners. J Hum Kinet. 2020;75(1):127-137. doi:10.2478/HUKIN-2020-0031,
46. Fernández-Lázaro D, Gallego-Gallego D, Corchete LA, et al. Inspiratory muscle training program using the powerbreath®: Does it have ergogenic potential for respiratory and/or athletic performance? a systematic review with meta-analysis. Int J Environ Res Public Health. 2021;18(13). doi:10.3390/IJERPH18136703,
47. Nickels M, Erwin K, McMurray G, et al. Feasibility, safety, and patient acceptability of electronic inspiratory muscle training in patients who require prolonged mechanical ventilation in the intensive care unit: A dual-centre observational study. Australian Critical Care. 2024;37(3):448-454. doi:10.1016/j.aucc.2023.04.008
48. Luo Z, Qian H, Zhang X, Wang Y, Wang J, Yu P. Effectiveness and safety of inspiratory muscle training in patients with pulmonary hypertension: A systematic review and meta-analysis. Front Cardiovasc Med. 2022;9. doi:10.3389/FCVM.2022.999422,
49. McDonald T, Stiller K. Inspiratory muscle training is feasible and safe for patients with acute spinal cord injury. Journal of Spinal Cord Medicine. 2019;42(2):220-227. doi:10.1080/10790268.2018.1432307,
50. Cahalin LP, Arena R, Guazzi M, et al. Inspiratory muscle training in heart disease and heart failure: A review of the literature with a focus on method of training and outcomes. Expert Rev Cardiovasc Ther. 2013;11(2):161-177. doi:10.1586/ERC.12.191,
51. Alpert MA. Beneficial Effects of Inspiratory Muscle Training in Patients With Pulmonary Arterial Hypertension. American Journal of Cardiology. 2023;203:526-527. doi:10.1016/j.amjcard.2023.07.129