Effects of Respiratory Muscle Training on Respiratory Function, Respiratory Muscle Strength, and Exercise Tolerance in Patients Poststroke: A Systematic Review With Meta-Analysis

doi:10.1016/j.apmr.2016.04.018

Archives of Physical Medicine and Rehabilitation

Volume 97, Issue 11, November 2016, Pages 1994-2001

https://doi.org/10.1016/j.apmr.2016.04.018 Get rights and content

Abstract

Objective

To examine the effects of respiratory muscle training on respiratory function, respiratory muscle strength, and exercise tolerance in patients poststroke.

Data Sources

We searched MEDLINE, Cochrane Library, Embase, SciELO, Physiotherapy Evidence Database (PEDro), and CINAHL (from the earliest date available to November 2015) for trials.

Study Selection

Randomized controlled trials (RCTs) that examined the effects of respiratory muscle training versus nonrespiratory muscle training in patients poststroke. Two reviewers selected studies independently.

Data Extraction

Extracted data from the published RCTs. Study quality was evaluated using the PEDro Scale. Weighted mean differences (WMDs), standard mean differences (SMDs), and 95% confidence intervals (CIs) were calculated.

Data Synthesis

Eight studies met the study criteria. Respiratory muscle training improved maximal inspiratory pressure WMDs (7.5; 95% CI, 2.7–12.4), forced vital capacity SMDs (2.0; 95% CI, 0.6–3.4), forced expiratory volume at 1 second SMDs (1.2; 95% CI, 0.6–1.9), and exercise tolerance SMDs (0.7; 95% CI, 0.2–1.2). No serious adverse events were reported.

Conclusions

Respiratory muscle training should be considered an effective method of improving respiratory function, inspiratory muscle strength, and exercise tolerance in patients poststroke. Further research is needed to determine optimum dosages and duration of effect.

Section snippets

Methods

This meta-analysis was completed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.¹²

Description of selected studies

The initial search led to the identification of 309 abstracts, 19 of which were considered potentially relevant and were retrieved for detailed analysis. Seven studies met the eligibility criteria. Figure 1 shows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of studies in this review.

The remaining 7 articles18, 19, 20, 21, 22, 23, 24 were fully analyzed, approved by both reviewers, and had their data extracted. Each of the articles was scored using the

Discussion

The main results of our systematic review indicate that respiratory muscle training is effective in increasing MIP, respiratory function, and exercise tolerance in patients poststroke. These findings highlight the importance of including respiratory muscle assessment as part of the evaluation and selection of patients who might benefit from respiratory muscle training.

This systematic review with meta-analysis is important because it analyzes respiratory muscle training as a potential coadjuvant

Conclusions

Taking into account the available studies, this systematic review with meta-analysis showed that respiratory muscle training should be considered an efficient method of improving MIP, respiratory function, and exercise tolerance in patients poststroke. More well-designed RCTs are necessary to determine the most appropriate methods (device, intensity, frequency, and duration) to optimally tailor the respiratory training to the particular characteristics of a patient subgroup or individual

Supplier

a.
Review Manager Version 5.3; The Cochrane Collaboration.

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Cited by (43)

Respiratory muscle training improves exercise tolerance and respiratory muscle function/structure post-stroke at short term: A systematic review and meta-analysis
2022, Annals of Physical and Rehabilitation Medicine
Citation Excerpt :
This result agrees with those of other meta-analyses [17–19] and disagrees with another review [53]. The effect size is similar to previous meta-analyses [17,18] but not superior, perhaps because the evidence for physical improvements in both reviews came from one study with poor quality, which demonstrates our concerns about inadequate reporting and the nature and dose of RMT [44]. We could differentiate between the effects of IMT and EMT, reporting that IMT alone can be an effective intervention for improving exercise tolerance, as the Zhang et al. [19] review also reported.
Previous reviews relating to the effects of respiratory muscle training (RMT) after stroke tend to focus on only one type of training (inspiratory or expiratory muscles) and most based the results on poor-quality studies (PEDro score ≤4).
With this systematic review and meta-analysis, we aimed to determine the effects of RMT (inspiratory or expiratory muscle training, or mixed) on exercise tolerance, respiratory muscle function and pulmonary function and also the effects depending on the type of training performed at short- and medium-term in post-stroke.
Databases searched were MEDLINE, PEDro, CINAHL, EMBASE and Web of Science up to the end of April 2020. The quality and risk of bias for each included study was examined by the PEDro scale (including only high-quality studies) and Cochrane Risk of Bias tool.
Nine studies (463 patients) were included. The meta-analysis showed a significant increase in exercise tolerance [4 studies; n = 111; standardized mean difference [SMD] = 0.65 (95% confidence interval 0.27–1.04)]; inspiratory muscle strength [9 studies; n = 344; SMD = 0.65 (0.17–1.13)]; inspiratory muscle endurance [3 studies; n = 81; SMD = 1.19 (0.71–1.66)]; diaphragm thickness [3 studies; n = 79; SMD = 0.9 (0.43–1.37)]; and peak expiratory flow [3 studies; n = 84; SMD = 0.55 (0.03–1.08)] in the short-term. There were no benefits on expiratory muscle strength and pulmonary function variables (forced expiratory volume in 1 s) in the short-term.
The meta-analysis provided moderate-quality evidence that RMT improves exercise tolerance, diaphragm thickness and pulmonary function (i.e., peak expiratory flow) and low-quality evidence for the effects on inspiratory muscle strength and endurance in stroke survivors in the short-term. None of these effects are retained in the medium-term. Combined inspiratory and expiratory muscle training seems to promote greater respiratory changes than inspiratory muscle training alone.
Respiratory Muscle Training Improves Strength and Decreases the Risk of Respiratory Complications in Stroke Survivors: A Systematic Review and Meta-analysis
2020, Archives of Physical Medicine and Rehabilitation
To evaluate the effects of respiratory muscle training in a population of stroke patients.
The following databases were searched for clinical trials through December 2019: PubMed, EMBASE, Cochrane Library, CINAHL, and China National Knowledge Infrastructure.
Randomized controlled trials (N=9) published in English met the inclusion criteria.
Data were extracted and assessed for accuracy by 2 reviewers. Any disagreements were resolved after discussions with an independent third reviewer. The quality of the included randomized controlled trials was assessed using the Cochrane bias tool.
The meta-analysis showed increased maximal inspiratory pressure (standardized mean difference [SMD], 0.88; 95% confidence interval [CI], 0.62-1.15; P<.001; 12-wk follow-up period: SMD, 0.94; 95% CI, 0.42-1.45; P<.001), maximal expiratory pressure (SMD, 0.83; 95% CI, 0.15-1.52; P=.017; 12-wk follow-up period: SMD, 0.99; 95% CI, 0.47-1.51; P<.001), forced expiratory volume in 1 second (SMD, 1.41; 95% CI, 0.57-2.24; P=.001), forced vital capacity (SMD, 1.36; 95% CI, 0.55-2.16; P<.001), peak expiratory flow (SMD, 0.74; 95% CI, 0.16-1.32; P=.013), 6-minute walk test (SMD, 0.67; 95% CI, 0.11-1.23; P=.020), and decreased respiratory complications (odds ratio, 0.55; 95% CI, 0.30-1.00; P=.050) compared with no respiratory intervention or a sham intervention.
Respiratory muscle training improved poststroke muscle strength and the benefits were carried over for up to 12 weeks, including improved lung function, walking capacity, and a reduced risk of respiratory impediments.
Effectiveness of expiratory muscle strength training on expiratory strength, pulmonary function and cough in the adult population: a systematic review
2020, Physiotherapy (United Kingdom)
Citation Excerpt :
Certainly changes to lung tissue in chronic diseases such as MS are known to impair lung compliance to a greater extent than skeletal muscle weakness [8]. One recent systematic review has suggested combined expiratory and inspiratory training may have a greater impact on pulmonary function by enhancing inspiratory reserve volume and elastic recoil, and generating significant improvements in FEV1 [44]. The potential to overestimate the current treatment effect, due to the small number of eligible studies, small sample sizes, variation in age, population and intervention design, must be considered when interpreting the present results.
Respiratory muscle strength declines in certain disease states, leading to impaired cough, reduced airway clearance and an increased risk of aspiration pneumonia. Respiratory muscle training may therefore reduce this risk.
To assess current evidence of expiratory muscle strength training (EMST) on maximum expiratory pressure, cough flow and spirometry.
Databases including CINAHL, Medline, Science Direct and PEDRo were searched.
Randomised controlled trials investigating expiratory muscle strength training on maximum expiratory pressure, pulmonary function or cough in any adult population, published before December 2017.
Data were extracted to a trial description form and study quality evaluated by two reviewers. Meta-analysis was performed with calculation of mean differences and 95% confidence intervals.
Nine studies met inclusion criteria and ranged in size from 12 to 42 participants. Trials investigated EMST in healthy adults (2), multiple sclerosis (3), COPD (2), acute stroke (1) and spinal cord injury (1). Overall, EMST improved maximum expiratory pressure (15.95 cmH₂O; 95% CI: 7.77 to 24.12; P < 0.01) with no significant impact on cough flow (4.63 L/minute; 95%CI −27.48 to 36.74; P = 0.78), forced vital capacity (−0.16 L; 95%CI −0.35 to 0.02; P = 0.09) or forced expiratory volume in 1 second (−0.09 L; 95%CI −0.10 to −0.08; P < 0.001) vs control or sham training.
Meta-analysis indicated a small significant increase in maximum expiratory pressure following EMST. Improvements in maximum expiratory pressure did not lead to improvements in cough or pulmonary function.
Variations in protocol design and population limited the overall effect size.
Systematic Review Registration PROSPERO CRD42018104190.
Effects of non-invasive brain stimulation on freezing of gait in parkinsonism: A systematic review with meta-analysis
2019, Parkinsonism and Related Disorders
Citation Excerpt :
The PEDro Scale assesses the methodological quality of a study based on important criteria (e.g., concealed allocation, intention-to-treat analysis, adequacy of follow-up). These characteristics make the PEDro Scale a useful tool for assessing the quality of rehabilitation trials [20,21]. Methodological quality was independently assessed by two researchers.
To investigate the effect of non-invasive brain stimulation (NIBS), including repetitive transcranial magnetic stimulation and transcranial direct current stimulation, on freezing of gait (FOG) in parkinsonism.
The PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Physiotherapy Evidence Database (PEDro) databases were searched up to October 2018 for articles published in English or Korean. Quality assessment was performed using the PEDro scale. Studies with random allocation and pre-intervention and post-intervention assessments for FOG were included, and the standardized mean differences for each outcome were calculated.
Seven studies including 102 participants were included in the final analysis. The meta-analysis showed a significant improvement in freezing of gait questionnaire (FOG-Q) scores (SMD = 0.28; 95% CI, 0.01 to 0.55) and turning time (SMD = 0.30; 95% CI, 0.02 to 0.58). When analyzing only participants with Parkinson's disease, the effect size according to the FOG-Q score was greater (SMD = 0.57; 95% CI, 0.15 to 0.98) and the United Parkinson's disease rating scale-III score was significantly improved after NIBS (SMD = 0.43; 95% CI, 0.01 to 0.86). Both motor and frontal cortex stimulation didn't reveal significant improvement for FOG, but, the effect size of motor cortex stimulation (SMD = 0.35; 95% CI, −0.06 to 0.76) was almost double compared with that of frontal cortex stimulation (SMD = 0.19; 95% CI, −0.26 to 0.63).
NIBS showed a beneficial effect on FOG in parkinsonism, and the effects were more prominent in Parkinson's disease. Further studies are needed to determine the optimal protocol and elucidate effects according to the intervention and disease type.
Comparative analysis of maximal respiratory pressures with the reference values of a healthy adult population
2019, Fisioterapia
La determinación de las presiones respiratorias máximas es un procedimiento no invasivo de gran utilidad clínica para la evaluación de la fuerza de los músculos respiratorios. El objetivo es analizar en qué medida las ecuaciones predictivas existentes para población española, se ajustan a los valores observados de presión inspiratoria y espiratoria máximas (PEM y PIM) en una muestra de sujetos adultos sanos.
Estudio descriptivo observacional de corte transversal en el que se reclutaron 63 sujetos sanos mediante muestreo probabilístico aleatorizado simple entre la comunidad universitaria de la Universidade da Coruña. Las presiones respiratorias máximas se efectuaron con un transductor de presiones conectado a una boquilla de submarinista, siguiendo las recomendaciones de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR). Se compararon los resultados con las ecuaciones de Morales de 1997.
Se presentan los datos de 24 mujeres y 39 hombres (45,94 ± 16,71 años). Existe una diferencia estadísticamente significativa en las mujeres de -19,08 ± 23,57 cmH₂O y de -28,13 ± 29,93 cmH₂O para la PIM y la PEM, respectivamente, entre el valor observado y el valor predicho. Asimismo, en el caso de los hombres se observó una diferencia estadísticamente significativa de -25,18 ± 24,31 cmH₂O para la PIM y de -39,53 ± 44,38 cmH₂O para la PEM.
Las ecuaciones predictivas disponibles para las presiones respiratorias máximas sobreestiman considerablemente los valores alcanzados de la PIM y la PEM. Los resultados del presente estudio ponen de manifiesto la necesidad de realizar nuevas ecuaciones de referencia a través de un estudio multicéntrico representativo de toda la población española.
The determination of maximal respiratory pressures is a non-invasive process of high clinical value for assessing respiratory muscle strength. The aim is to analyse to what extent the existing predictive equations for the Spanish population are adjusted to the maximal inspiratory and expiratory pressures (MIP and MEP) values observed in a sample of healthy adult subjects.
A cross-sectional study was conducted on a sample of 63 healthy subjects recruited from the A Coruña University community using a simple random probabilistic method. Maximal respiratory pressures were performed using a pressure transducer connected to a scuba mouthpiece according to the standards of Spanish Society of Pulmonology and Thoracic Surgery (SEPAR). The results were compared with predictive equations proposed by Morales in 1997.
The study included the results from 24 females and 39 males (45.94 ± 16.71 years). Females showed a statically significant difference between the observed and predictive values, with -19.08 ± 23.57 cmH₂O and -28.13 ± 29.93 cmH₂O for MIP and MEP. A statistically significant difference was also observed for males with -25.18 ± 24.31 cmH₂O for MIP and -39.53 ± 44.38 cmH₂O for MEP.
Predictive equations to calculate the theoretical values of maximal respiratory pressures in a healthy Spanish adult population overestimate considerably the real values of MIP and MEP. The results of this study highlight the need to create new reference equations by conducting a multicentre study representative of the entire Spanish population.
The effects of respiratory muscle training on respiratory function and functional capacity in patients with early stroke: a meta-analysis
2024, European Review of Aging and Physical Activity

View all citing articles on Scopus

: Disclosures: none.

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Review article (meta-analysis)Effects of Respiratory Muscle Training on Respiratory Function, Respiratory Muscle Strength, and Exercise Tolerance in Patients Poststroke: A Systematic Review With Meta-Analysis

Abstract

Objective

Data Sources

Study Selection

Data Extraction

Data Synthesis

Conclusions

Section snippets

Methods

Description of selected studies

Discussion

Conclusions

Supplier

Arch Phys Med Rehabil

J Clin Epidemiol

Arch Phys Med Rehabil

Chest

Arch Phys Med Rehabil

J Am Coll Cardiol

Reliability of muscle strength assessment in chronic post-stroke hemiparesis: a systematic review and meta-analysis

Top Stroke Rehabil

Determinants of maximal inspiratory pressure. The Baltimore Longitudinal Study of Aging

Am J Respir Crit Care Med

Chest wall kinematics in patients with hemiplegia

Am J Respir Crit Care Med

Strength of the respiratory and lower limb muscles and functional capacity in chronic stroke survivors with different physical activity levels

Braz J Phys Ther

Acute ischaemic hemispheric stroke is associated with impairment of reflex in addition to voluntary cough

Eur Respir J

Transcranial magnetic stimulation study of expiratory muscle weakness in acute ischemic stroke

Neurology

Comparative lung function performance of stroke survivors and age-matched and sex-matched controls

Physiother Res Int

Inspiratory muscle training for the recovery of function after stroke (review)

Cochrane Database Syst Rev

Respiratory muscle strength and training in stroke and neurology: a systematic review

Int J Stroke

Systematic review of inspiratory muscle training after cerebrovascular accident

Respir Care

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

BMJ

Cochrane handbook for systematic reviews of interventions 4.2.6

Scales to assess the quality of randomized controlled trials: a systematic review

Phys Ther

Reliability of the PEDro scale for rating of quality randomized controlled trials

Phys Ther

Measuring inconsistency in meta-analyses

BMJ

Effects of the combination of respiratory muscle training and abdominal drawing-in maneuver on respiratory muscle activity in patients with post-stroke hemiplegia: a pilot randomized controlled trial

Top Stroke Rehabil

Review article (meta-analysis)
Effects of Respiratory Muscle Training on Respiratory Function, Respiratory Muscle Strength, and Exercise Tolerance in Patients Poststroke: A Systematic Review With Meta-Analysis