Inspiratory Muscle Training in Patients with Chronic Obstructive Pulmonary Disease (COPD) as Part of a Respiratory Rehabilitation Program Implementation of Mechanical Devices: A Systematic Review

Effects of respiratory muscular training in post-covid-19 patients: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Post-Covid-19 syndrome is defined as non-self-sustaining signs and/or symptoms lasting more than 12 weeks, occurring during or after a Covid-19 infection. The primary outcome was the analysis of the respiratory muscle training (RMT) result in respiratory muscle strength, (maximum inspiratory pressure (MIP) e maximum expiratory pressure (MEP)); and the secondary results were the analysis of lung function, dyspnea, quality of life (QoL), fatigue and functional performance.

METHODS

The PICO description for this research was: P: patients diagnosed with post-Covid-19; I: RMT; C: Sham or simulated inspiratory or expiratory muscle training and usual care; O: MIP, MEP, Lung Function, level of dyspnea, QoL and functional performance. On January 15, 2024, the following databases were consulted: PubMed, Lilacs, Cochrane Library, PEDro and EMBASE. Randomized clinical trials were included without restrictions on year of publication or language. The data selection and extraction steps were carried out by two independent reviewers.

RESULTS

The search in the databases resulted in a total of 14,216 studies, and after the eligibility process, 7 studies were included with a sample of 527 patients. The MIP results suffered a statistically significant increase, that is, the RMT was favorable to improve the MIP (MD = 29.55cmH2O IC 95%: 7.56cmH2O to 51.54cmH2O, p = 0,00001). For the MEP outcome, the results were statistically significant in favor of RMT (MD = 10.93cmH2O CI 95%: 3.65cmH2O to 18.21cmH2O, p = 0.00001). We also noticed a significant improvement for the group that received the RMT in the distance covered in the 6-Minute Walk Test (6MWT) MD = 40.70 m CI 95%: 18.23 m to 65.17 m%, p = 0.01).

CONCLUSION

We noticed that RMT is being used in patients with respiratory diseases, including post-Covid-19. Our systematic review observed that this training provides an increase in inspiratory and expiratory muscle strength, a reduction in dyspnea levels, and an increase in the distance covered in the 6MWT and improved QoL in post-covid patients after intervention.

Longitudinal Changes in Maximal Forced Inspiratory Flow and Clinical Outcomes in Patients With COPD

BACKGROUND

COPD primarily impairs expiratory flow due to progressive airflow obstruction and reduced lung elasticity. Increasing evidence underlines the importance of inspiratory flow as a biomarker for selecting inhaler devices and providing ancillary aerodynamic information.

RESEARCH QUESTION

Does the longitudinal changes in maximum forced inspiratory flow (FIFmax) influence acute exacerbations and lung function decline in patients with COPD?

STUDY DESIGN AND METHODS

This longitudinal study evaluated FIFmax in patients with COPD over a 7-year period from 2004 to 2020. Eligible patients were categorized into 2 groups based on FIFmax trajectory: the increased FIFmax group and the decreased FIFmax group. The study assessed the annual rate of acute exacerbations and the annual decline rate of FEV1. Subgroup analyses were conducted based on treatment status, with a focus on inhaled therapy and inhaler device usage.

RESULTS

Among the eligible 956 patients with COPD, 56.5% belonged to the increased FIFmax group. After propensity score matching, the increased FIFmax group experienced lower rates of severe exacerbations (0.16 per year vs 0.25 per year, P = .017) and a slower decline in FEV1 (0 [interquartile range, -51 to 71] mL/y vs -43 [interquartile range, -119 to 6] mL/y; P < .001) compared with the decreased FIFmax group. These associations were particularly prominent in patients using specific inhaler therapies such as dry powder inhalers.

INTERPRETATION

This study showed that the longitudinal changes in FIFmax are associated with clinical outcomes in patients with COPD. Patients with increased FIFmax experienced a lower rate of severe exacerbations and a slower decline in lung function. These findings suggest the potential benefits of optimizing inspiratory flow in COPD management, although further studies are needed to confirm these observations due to potential confounding factors.

"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.

A preliminary study on the respiratory benefits of adaptive video gaming in individuals with cervical spinal cord injuries

PURPOSE

The purpose of this study was to collect preliminary data to assess whether participation in adaptive video gaming using a pneumatic sip-and-puff video game controller may provide respiratory or health benefits for individuals with cervical-level spinal cord injuries.

METHODS

A survey was anonymously distributed to potential participants and consisted of four sections: (1) General Information, (2) Gaming Habits, (3) Respiratory Quality of Life, and (4) Impact of Adaptive Video Gaming on Respiratory Health.

RESULTS

The study included 124 individuals with cervical-level spinal cord injuries. Participants had primarily positive self-rated health and good respiratory quality of life. Nearly half of the participants (47.6%) Agreed or Strongly Agreed that their breathing control has improved after using their sip-and-puff gaming controller and 45.2% Agreed or Strongly Agreed that their respiratory health has improved. Individuals who Agreed or Strongly Agreed that adaptive video gaming has improved their breathing control also reported a significantly higher level of exertion while gaming compared to those who did not Agree or Strongly Agree (p = 0.00029).

CONCLUSIONS

It is possible that there are respiratory benefits of using sip-and-puff video game controllers for individuals with cervical spinal cord injuries. The benefits reported by users were found to be dependent on their level of exertion while playing video games. Further exploration in this area is needed due to the positive benefits reported by participants.

Qualitative interviews of patients with COPD and muscle weakness enrolled in a clinical trial evaluating a new anabolic treatment: patient perspectives of disease experience, trial participation and outcome assessments

BACKGROUND

Chronic obstructive pulmonary disease (COPD) and muscle weakness can cause impaired physical function, significantly impacting patients' health-related quality of life (HRQoL). Loss of muscle strength is usually assessed through clinical and performance outcome (PerfO) assessments, which consists of tasks performed in a standardized manner, providing evidence of a patient's functional ability. However, evidence documenting the patient experience of COPD and muscle weakness is limited.

METHODS

This two-stage qualitative study used semi-structured interviews in patients aged 45-80 years with COPD (post-bronchodilator forced expiratory volume in 1s [FEV1]/forced vital capacity ratio < 0.70, and FEV1% predicted of 30-80%) and muscle weakness. In Stage 1, 30-minute concept elicitation interviews were conducted with participants recruited across three US sites to explore impacts on physical functioning and activities of daily living. In Stage 2, interviews were performed with participants exiting a Phase IIa trial investigating the efficacy of a selective androgen receptor modulator (GSK2881078) on leg strength, whereby PerfOs were used to evaluate strength and physical functioning endpoints. These participants completed either 60-minute in-depth (n = 32) or 15-minute confirmatory (n = 35) interviews exploring trial experience, completion of outcome measures, disease experience and treatment satisfaction.

RESULTS

In Stage 1 (n = 20), most participants described their muscles as weak (83.3%). Difficulties with walking (100%) and lifting heavy objects (90%) were reported. In Stage 2, 60-minute interviews, all participants (n = 32) reported a positive trial experience. Most participants reported that the home exercise program was easy to fit into daily life (77.8%), the PROactive daily diary was easy to complete (100%) and wearable sensors were easy to use (65.6%). However, technical issues were reported (71%), and few participants (19.4%) found physical assessments easy to complete. Improvements in muscle strength and functional limitations were reported by most participants. The shorter 15-minute confirmatory interviews (n = 35) supported the in-depth interview results.

CONCLUSION

The qualitative interviews generated in-depth evidence of key concepts relevant to patients with COPD and muscle weakness and support the assessments of patient strength and physical function as outcome measures in this population in future studies.

TRIAL NUMBER

GSK Stage 1: 206869; Stage 2: 200182, NCT03359473; Registered December 2, 2017, https://clinicaltrials.gov/ct2/show/NCT03359473 .

Rehabilitation training enhanced the therapeutic effect of calycosin on neurological function recovery of rats following spinal cord injury

BACKGROUND

Calycosin (CA), a flavonoids component, has demonstrated potential neuroprotection effects by inhibiting oxidative stress in spinal cord injury (SCI) models. This study aims to investigate the impact of combined rehabilitation training (RT) and calycosin therapy on neurological function following SCI, primarily by assessing changes in motor function recovery, neuronal survival, neuronal oxidative stress levels, and neural proliferation, in order to provide novel insights for the treatment of SCI.

MATERIALS AND METHODS

The SCI model was constructed by compressing the spinal cord using vascular clamps. Calycosin was injected intraperitoneally into the SCI model rats, and a group of 5 rats underwent RT. The motor function of rats after SCI was evaluated using the Basso Beattle Bresnaha (BBB) score and the inclined plate test. Histopathological changes were evaluated by NeuN immunohistochemistry, HE and Nissl staining. Apoptosis was detected by TUNEL staining. The antioxidant effect of combined treatment was assessed by measuring changes in oxidative stress markers after SCI. Western blot analysis was conducted to examine changes in Hsp90-Akt/ASK1-p38 pathway-related proteins. Finally, cell proliferation was detected by BrdU and Ki67 assays.

RESULTS

RT significantly improved the BBB score and angle of incline promoted by calycosin, resulting in enhanced motor function recovery in rats with SCI. Combining rehabilitation training with calycosin has a positive effect on morphological recovery. Similarly, combined RT enhanced the Nissl and NeuN staining signals of spinal cord neurons increased by calycosin, thereby increasing the number of neurons. TUNEL staining results indicated that calycosin treatment reduced the apoptosis signal in SCI, and the addition of RT further reduced the apoptosis. Moreover, RT combined with calycosin reduced oxidative stress by increasing SOD and GSH levels, while decreasing MDA, NO, ROS, and LDH expressions compared to the calycosin alone. RT slightly enhanced the effect of calycosin in activating Hsp90 and Akt and inhibiting the activation of ASK1 and p38, leading to enhanced inhibition of oxidative stress by calycosin. Additionally, the proliferation indexes (Ki67 and BrdU) assays showed that calycosin treatment alone increased both, whereas the combination treatment further promoted cell proliferation.

CONCLUSION

Our research findings demonstrate that rehabilitation training enhances the ability of calycosin to reduce oxidative stress, resulting in a decrease in neuronal apoptosis and an increase in proliferation, ultimately promoting neuronal survival.

Effects of usual yoga practice on the diaphragmatic contractility: A cross-sectional controlled study

Objectives

The aim of this study is to observe and compare the effects of regular yoga practice on the main inspiratory muscle, the diaphragm, by analyzing its thickness, excursion, velocity and contraction time, using ultrasound.

Design

A Cross-Sectional Controlled Study.

Participants

80 healthy subjects (40 habitual yoga practitioners and 40 non-practitioners), without previous respiratory pathology participated in this study. During maximum diaphragmatic breathing, the diaphragmatic thickness (at rest and after maximum inspiration), excursion, velocity and contraction time were measured by ultrasound.

Results

in the experimental group, practicing yoga, statistically significant differences (p < 0.001) were observed compared to the control group, not practicing, in the thickness of the diaphragm at rest (0.26 ± 0.02 vs 0.22 ± 0.01 cm); the diaphragmatic thickness in maximum inspiration (0.34 ± 0.03 vs 0.28 ± 0.03 cm); contraction velocity (1.54 ± 0.54 vs 2.23 ± 0.86 cm/s), contraction time (3.28 ± 0.45 vs 2.58 ± 0.49 s) and Borg scale of perceived exertion (1.05 ± 1.6 vs 1.70 ± 1.34), p = 0.05. However, the diaphragmatic excursion was greater in the control group (5.45 ± 1.42 vs 4.87 ± 1.33 cm) with no statistically significant differences (p = 0.06).

Conclusions

the regular practice of yoga improves the parameters of diaphragm thickness, speed and contraction time measured in ultrasound and the sensation of perceived exertion during a maximum inspiration. So it can be considered as another method for training the inspiratory muscles in clinical practice.

The effects of inspiratory muscle training on balance and functional mobility: a systematic review

INTRODUCTION

Inspiratory muscle training (IMT) has been widely used in both healthy and diseased populations especially in older adults, and its effects have been proven not only on inspiratory muscle strength but also on dyspnea, exercise capacity, quality of life, and other health parameters.

AIM

This study aims to review the effects of IMT on balance and functional ability of healthy and diseased populations.

METHODS

A systematic literature search was conducted on MEDLINE, EMBASE, AMED, and Cochrane Central Register of Controlled Trials (CENTRAL). Randomized control trials having participants > 18 years of age and having balance and functional mobility as primary or secondary outcomes were included. Two independent reviewers screened studies against the eligibility criteria, extracted the data, and assessed the quality of evidence. The protocol was prospectively registered on PROSPERO: CRD42021261652.

RESULTS

Ten studies were included in the review out of which eight had balance and six had functional mobility as an outcome measure. There was a significant improvement in balance of the participants after treatment with IMT, however the effect on functional mobility was inconclusive.

CONCLUSION

The review provided evidence of improvement in balance and functional mobility following inspiratory muscle training in both healthy and diseased adults. Future studies should be conducted to determine the optimal protocol and dosage of treatment.

The Effectiveness of Home-Based Inspiratory Muscle Training on Small Airway Function and Disease-Associated Symptoms in Patients with Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is characterized by persistent airflow limitations, occurring mainly in the small airways. Weakness in the respiratory muscles contributes to dyspnea and a decreased exercise capacity in COPD patients. This study aimed to investigate the effectiveness of home-based inspiratory muscle training (IMT) on small airway function and symptoms in COPD patients. This research adopted a non-randomized controlled-study quasi-experimental design. The IMT program consisted of two 15 min sessions·d-1, 5 d·wk-1, with 40% of the maximal inspiratory pressure (PImax) on each participant's assessment results and lasted for 12 weeks. Small airway function was assessed using plethysmography at baseline and after 12 weeks. The modified British Medical Research Council (mMRC), COPD assessment test (CAT), PImax, and 6 min walking distance (6MWD) were recorded at baseline as well as four, eight, and twelve weeks. Twenty-three participants with at least moderate COPD were enrolled in IMT (n = 16) or in the control group (n = 7) in this study. The study participants were mostly male (82.6%), and the average age was 68.29 ± 10.87 years, with a mean body mass index (BMI) of 23.54 ± 4.79. After 12 weeks, the ratios of the first second of forced expiration to the forced vital capacity (FEV1/FVC%) (B coefficient [95% Wald confidence interval] of 5.21 [0.46 to 9.96], p = 0.032), forced expiratory flow (FEF25-75%) (0.20 [0.04 to 0.35] L/s, p = 0.012), and FEF50% (0.26 [0.08 to 0.43] L/s, p = 0.004) in the IMT group were significantly better than in the control group. The IMT group showed significantly lower CAT scores at week 8 (-5.50 [-10.31 to -0.695] scores, p = 0.025) than the control group. The mMRC grade, CAT score, PImax, and 6MWD were significantly improved compared to their values at baseline in the IMT group. Home-based IMT effectively improved post-bronchodilator small airway function and disease-associated symptoms in COPD patients.

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Is Frailty Diagnosis Important in Patients with COPD? A Narrative Review of the Literature

Frailty is prevalent in older adults and is related to a worsening functionality, quality of life, and health outcomes. Though there is an increasing interest in this field, the relationship between frailty and worsening COPD outcomes remains unknown. A narrative review of the literature with studies published between 2018 and 2022 was carried out to address three questions: the prevalence of frailty and other geriatric syndromes in COPD patients, the link between frailty and worsening health outcomes in COPD patients, and the non-pharmacological interventions performed in order to reverse frailty in these patients. A total of 25 articles were selected. Frailty prevalence ranged from 6% and 85.9%, depending on the COPD severity and the frailty measurement tool used. Frailty in COPD patients was related to a high prevalence of geriatric syndromes and to a high incidence of adverse events such as exacerbations, admissions, readmissions, and mortality. One study showed improvements in functionality after physical intervention. In conclusion, the prevalence of frailty is associated with a high incidence of geriatric syndromes and adverse events in COPD patients. The use of frailty screenings and a comprehensive geriatric assessment of COPD patients is advisable in order to detect associated problems and to establish individualized approaches for better outcomes.

Closing the Gap between Inpatient and Outpatient Settings: Integrating Pulmonary Rehabilitation and Technological Advances in the Comprehensive Management of Frail Patients

Pulmonary rehabilitation (PR) is a well-established intervention supported by strong evidence that is used to treat patients affected by chronic respiratory diseases. However, several barriers still affect its spreading in rehabilitation clinical practices. Although chronic respiratory diseases are common age-related disorders, there is still a gap of knowledge regarding the implementation of sustainable strategies integrating PR in the rehabilitation management of frail patients at high risk of respiratory complications. Therefore, in the present study, we characterized the effects of PR in frail patients, highlighting the evidence supporting its role in improving the complex rehabilitative management of these patients. Moreover, we propose a novel organizational model promoting PR programs for frail patients in both inpatient and outpatient settings. Our model emphasizes the role of interdisciplinary care, specifically tailored to patients and environmental characteristics. In this scenario, cutting-edge technology and telemedicine solutions might be implemented as safe and sustainable strategies filling the gap between inpatient and outpatient settings. Future research should focus on large-scale sustainable interventions to improve the quality of life and global health of frail patients. Moreover, evidence-based therapeutic paths should be promoted and taught in training courses promoting multiprofessional PR knowledge to increase awareness and better address its delivery in frail patients.