Inspiratory Muscle Training

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Title: Effect of inspiratory muscle training intensities on pulmonary function and work capacity in
people who are healthy: a randomized controlled trial
Author(s): Stephanie J. Enright and Viswanath B. Unnithan
Source: Physical Therapy. 91.6 (June 2011): p894.
Document Type: Report
DOI: http://dx.doi.org.db08.linccweb.org/10.2522/ptj.20090413
Copyright : COPYRIGHT 2011 American Physical Therapy Association, Inc.
http://ptjournal.apta.org/site/subscriptions/
Abstract:
Background. Inspiratory muscle training (IMT) has been shown to improve inspiratory muscle function, lung volumes
(vital capacity [VC] and total lung capacity [TLC]), work capacity, and power output in people who are healthy; however,
no data exist that demonstrate the effect of varying intensities of IMT to produce these outcomes.
Objectives. The purpose of this study was to evaluate the impact of IMT at varying intensities on inspiratory muscle
function, VC, TLC, work capacity, and power output in people who are healthy.
Design. This was a randomized controlled trial.
Setting. The study was conducted in a clinical laboratory.
Participants. Forty people who were healthy (mean age=21.7 years) were randomly assigned to 4 groups of 10
individuals.
Interventions. Three of the groups completed an 8-week program of IMT set at 80%, 60%, and 40% of sustained
maximum inspiratory effort. Training was performed 3 days per week, with 24 hours separating training sessions. A
control group did not participate in any form of training.
Measurements. Baseline and posttraining measurements of body composition, VC, TLC, inspiratory muscle function
(including maximum inspiratory pressure [MIP] and sustained maximum inspiratory pressure [SMIP]), work capacity
(minutes of exercise), and power output were obtained.
Results. The participants in the 80%, 60%, and 40% training groups demonstrated significant increases in MIP and SMIP,
whereas those in the 80% and 60% training groups had increased work capacity and power output. Only the 80% group
improved their VC and TLC. The control group demonstrated no change in any outcome measures.
Limitations. This study may have been underpowered to demonstrate improved work capacity and power output in
individuals who trained at 40% of sustained maximum inspiratory effort.
Conclusion. High-intensity IMT set at 80% of maximal effort resulted in increased MIP and SMIP, lung volumes, work
capacity, and power output in individuals who were healthy, whereas IMT at 60% of maximal effort increased work
capacity and power output only. Inspiratory muscle training intensities lower than 40% of maximal effort do not translate
into quantitative functional outcomes.
Full Text:
In people who are healthy, the inability to sustain high levels of ventilation has been established to be a factor in limiting
maximal aerobic capacity. (1-3) Although previous studies have shown that the pulmonary system is unaffected by
whole-body exercise, (4,5) evidence now suggests that a regimen of high-intensity inspiratory muscle training (IMT)
without the addition of systemic exercise may result in quantitative outcomes. These outcomes include increased lung
volumes, diaphragm thickness, and work capacity in people who are healthy and moderately trained (6) and in improved
running performance (7,8) and recovery time during sprint activity. (9) In addition, inspiratory resistive loading has been
shown to enhance cycling capacity (10) and swimming performance (11) and improve respiratory muscle function in
wheelchair athletes. (12) These functional improvements have been associated with decreased blood lactate
concentrations during wholebody exercise in highly trained individuals. (13)
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The inspiratory muscles are morphologically and functionally skeletal muscles and, therefore, should respond to training
in the same way as would any locomotor muscle if an appropriate physiological load is applied. (14) However,
controversy exists regarding the mode and intensity of training required to result in improvements in specific indexes of
pulmonary function and work capacity. Generally, training theory suggests that gains in inspiratory muscle strength
(force-generating capacity) can be achieved at intensities of 80% to 90% of maximum inspiratory pressure (MIP).
Strength-endurance gains (maximal effective force that can be maintained) can be achieved at 60% to 80% of MIP, and
gains in endurance (the ability to continue a dynamic task for a prolonged period) can be achieved at approximately 60%
of peak pressure, which equates to high-intensity training regimens used in systemic exercise. (15) However, earlier
studies have suggested that quantitative improvements in work capacity following IMT regimens can occur with
intensities as low as 40% of peak pressure. (16,17) Recent published data using intensities of 80% of peak pressure have
shown an increase in lung volumes (vital capacity [VC] and total lung capacity [TLC]), diaphragm thickness, and work
capacity in patients with cystic fibrosis (18) and in people who are healthy. (6,7) However, the effect specifically of lower
intensities of IMT in people who are healthy is yet to be determined. Therefore, the primary objective of this investigation
was to determine the optimal training intensity required to improve quantitative outcomes (ie, lung volumes, work
capacity, power output, and inspiratory pressures) in people who are healthy.
Method
Design Overview
This was a randomized controlled study in which 40 people were allocated to 4 groups. Three training groups comprising
of 10 participants in each group (n=30) were required to complete an 8-week supervised program of IMT in which the
training intensity was set at 80%, 60%, or 40% of each participant's sustained maximal inspiratory effort. The participants
performed no other forms of exercise training during the study period. A fourth group of individuals did not participate in
any form of training and acted as a control group (n=10). At the initial screening visits, body composition, pulmonary
function, and physical activity status were determined. (19) In addition, measurements of inspiratory muscle function,
work capacity, and power output were taken in all participants (Tab. 1). These measurements (excluding body
composition) were repeated at the end of the 8-week training period and were obtained by independent laboratory-based
data collectors who were blinded to the group allocation.
[FIGURE 1 OMITTED]
Setting and Participants
This study was conducted in a university-based human movement laboratory. Forty moderately trained university students
of both sexes (20 male, 20 female) who were healthy volunteered to take part in this investigation. Each participant's level
of physical activity was assessed by questionnaire, (19) and an individual was defined as being recreationally active by
participating in at least 4 hours per week of sporting activity that was of sufficient intensity to elevate his or her heart rate
to within 80% of the age-predicted maximum. The mean age of the participants was 21.7 years (SD =4.0). All
participants were nonsmokers and had no evidence of pulmonary pathology (eg, asthma) or any known metabolic or
endocrine disorder. All participants were informed of the nature of the study and gave full written consent prior to the
study. The flow diagram in Figure 1 contains details of participant eligibility, randomization, and study design.
Randomization and Interventions
This was a single-center controlled study in which the participants were allocated to 4 groups using random number
tables. (20) Prior to the study, all participants' stature (in centimeters) and weight (in kilograms) were determined using a
stadiometer (600-2,100-mm model, * accurate to 1.5 mm) and an electronic beam scale (Inscale electro scale, model
MRP2OOP, ([dagger]) accurate to 0.1 kg), respectively. Participants were measured wearing lightweight clothing and no
shoes. Percentage of body fat was estimated using skinfold calipers (0- to 48-mm model *) at 4 sites: biceps, triceps,
subscapular region, and supra-iliac crest. Three measurements for each site were taken, with the mean used for body fat
determination. (21)
Body fat measurements were calculated according to the equations of Grant et al (22) using different formulas based on
sex (Appendix).
Lung Function Measurements
Vital capacity, expiratory reserve volume (ERV), functional residual capacity (FRC), TLC, and residual volume (RV) were
calculated as per British Thoracic Society standards (23) using the helium dilution technique (Vitalograph ([double
dagger])). All participants were asked to refrain from vigorous exercise for at least 24 hours prior to the tests. During all
measurements, participants were seated and a single experienced technician obtained recordings. All lung function
measurements were expressed in liters and as percentage of the predicted value for age, height, and sex. (24)
[FIGURE 2 OMITTED]
Assessment of Physical Activity Status
The level of physical activity was assessed before and after IMT using a recall questionnaire. (19) Activity scores were
calculated over a 24-hour period and expressed in metabolic equivalents (1 MET=3.5 mL[O.sub.2]/kg/min or the resting
energy expenditure in one person). Following the completion of the recall questionnaire, all participants were encouraged
not to change their physical activity patterns during the study period.
Inspiratory Muscle Function
Each participant's MIP and sustained maximum inspiratory pressure (SMIP) were determined using an electronic
manometer and computer connected by serial interface to a laptop computer. This setup had been programmed with a
specifically designed computer software package (Respiratory Trainer, model 2 [RT2 device] ([section])). The
manometer had a fixed leak via a 2-mm-diameter aperture to prevent glottal closure during the inspiratory maneuver. (25)
This feature set a maximum flow of 450 mL/s and allowed continuous measurement of pressure over a full range of lung
volumes, from RV to TLC, until no further pressure could be generated. This pressure was recorded over time by a
computer.
The MIP was the maximum pressure (cm [H.sub.2]0) developed in the first second of inspiration and represented a
measure of inspiratory muscle strength. The SMIP represented the integrated area under the pressure-time curve,
measured in pressure-time units (PTUs) (Fig. 2). (26) All data were stored on the computer database for later retrieval and
analysis.
Assessment of Work Capacity
At the time of scheduling, all participants were instructed to avoid caffeine and refrain from eating and participating in
vigorous activity for at least 3 hours before the test. A progressive, incremental exercise test was performed on an
electronically braked cycle ergometer (Excalibur Sport([parallel])) to measure work capacity as described by Godfrey and
Mearns. (27) Participants began pedaling with no added resistance and at 1-minute intervals at a self-selected pace.
Resistance was added in increments by the technician administering the test and was adjusted for each participant
depending on his or her height, with 15-W increments for those participants shorter than 125 cm, 20 W for those 125 to
149 cm tall, and 25 W for those at or above 150 cm. The participants were instructed to continue until they could no
longer pedal due to volitional exhaustion. All participants, therefore, exercised to a self-determined maximum. Work
capacity was defined as the duration of exercise achieved (in minutes), and power output was defined as the energy
expended (in watts) at the end of the protocol. Accuracy of the incremental load was achieved by using microprocessors,
which checked the actual workload 5 times per second. The system also contained a feedback mechanism that eliminated
the influence of temperature, thereby guaranteeing accuracy of workload up to 1,000 W. The incremental loads for each
participant were calculated, and the workload was programmed manually into the system using the Excalibur Work-Load
Programmer([parallel]) according to the manufacturer's instructions. At each work level, heart rate (measured with a
Polar RS100 Heart Rate Monitor, model RS800sd (#)) and ratings of perceived exertion (measured using a modified 0-10
Borg scale) (28) were recorded to assess the perceived exercise intensity.
Sample Size Determination and Reliability of the Main Outcome Measures
The reproducibility of the principal outcome variables was determined in 10 individuals who were healthy on consecutive
days using methods and an experimental protocol identical to those used in the present study. An adequate sample size
was found to be at least 9 individuals in the experimental group at [alpha]=.05 and 1 - [beta]= 90%. Recently published
observations from our laboratory (29) have demonstrated reproducibility coefficients of .87 for measurements of MIP and
.99 for SMIP.
IMT Protocol
A pressure manometer and specifically designed computer software (RT2 device ([section])) were used in the training
program. Training was performed 3 times weekly on nonconsecutive days (with at least 24 hours separating training
sessions) over 9 weeks, although inspiratory pressure data were not collected until the second week of training to allow
the participants to become familiar with the training equipment and protocol.
For each of the training groups, 3 SMIPs were recorded at the commencement of each training session, and the highest
sustainable profile was selected automatically and redrawn by the computer as a training template equal to 80%, 60%, or
40% of the maximum pressure profile. This profile was determined by manipulation of the computer software prior to the
study and remained constant throughout the training period. Therefore, subsequently at each training session, each
participant was re-tested to determine his or her maximal effort, and the computer software was adjusted according to the
required training intensity. Inspiratory training maneuvers were repeated using a regimen of 6 repetitions performed within
each of the training groups at 80%, 60%, or 40%
of the SMIP. Thus, the participants were required to complete a total of 36 repetitions at each training session. During
each set, the rest time between repetitions was progressively reduced from 60 to 45, 30, 15, 10, and 5 seconds, as this
method has been shown to recruit a larger proportion of muscle fibers and, thus, a larger pool of fibers are trained for
subsequent lower but potentially fatiguing loads. (30) During the training sessions, the accumulated area under the
pressure-time curve was calculated and used as a measure of inspiratory muscle endurance. All training sessions were
conducted in a quiet room with no distractions, and the same instructions were given to all participants, thereby ensuring
that they were being motivated in a consistent manner during the training period.
Data Analysis
Between-group baseline characteristics (eg, age), anthropometric data (mass, stature, body fat, and body mass index
[BMI]), lung function data (VC, FRC, TLC, and RV), inspiratory pressure data (MIP and SMIP), work capacity, and
power output were compared with a 1-way analysis of variance (ANOVA). Prior to all analyses, normality of the data was
assessed by the one-sample Kolmogorov-Smirnov test. A 2-way repeated-measures ANOVA was used to identify
differences before and after training between and within groups for inspiratory pressure data, lung function, work
capacity, and power output. For all significant data, unplanned, pair-wise multiple comparisons were made using the
Tukey critical difference test. Differences were considered to be significant at P<.05. All statistical calculations were
performed using SPSS, version 16. **
Role of Funding Source
The Physiotherapy Research Foundation provided funding to purchase the IMT equipment used in this study.
Results
Study Group Characteristics: Baseline Analysis
All participants had complete data sets of baseline and posttraining measurements of lung function and inspiratory
pressure data, including MIP and SMIP. In addition, Borg scale scores, work capacity, power output, and peak heart rate
(bpm) were obtained in both training and control groups. There were no differences in age, mass, stature, body
composition (BMI and percentage of fat), and physical activity status among the groups at baseline. In addition, there
were no differences in the dependent variables of inspiratory pressure, lung volumes (VC and TLC), power output, and
peak heart rate among the groups (Tab. 1).
Effects of IMT on MIP and SMIP
There was 100% adherence to the IMT protocols by all participants in the 3 training groups. Following 8 weeks of IMT,
an increase in MIP was observed in the groups who trained at 80%, 60%, and 40% of their maximum sustained
inspiratory effort. The 80% training group increased MIP from a mean of 68 to 163 cm [H.sub.2]O, and the 60% training
group MIP increased MIP from a mean of 73 to 127 cm [H.sub.2]O, representing an increase of approximately 50% for
both these training intensities. In the 40% training group, MIP increased with less magnitude (from 76 to 91 cm
[H.sub.2]O) compared with the 80% and 60% training groups. The SMIP values also improved in all of the training
groups in a similar magnitude to MIP. The 80% training group increased SMIP from a mean of 528 to 1,176 PTUs. The
SMIP values increased from 635 to 884 PTUs in the 60% training group and from 544 to 619 PTUs in the 40% training
group. There was no change in the control group over time in either MIP or SMIP, resulting in a different group effect
following training (Tab. 2).
Effects of IMT on Lung Function
There were no changes in lung volumes in the 60% or 40% training groups or the control group. However, VC increased
in the 80% training group from a mean of 3.4 to 3.8 L, and TLC increased in this training group from a mean of 5.1 to
5.4 L, representing a 7% increase in these variables from pretraining levels. Furthermore, both VC and TLC were different
among the groups over time, resulting in a difference in the groups following training. No significant changes occurred in
either VC or TLC in any of the other training groups or in the control group (Tab. 2).
Effects of IMT on Work Capacity and Power Output
There were no significant changes in either Borg scale scores or peak heart rate following IMT in any of the training
groups or the control group, although significant improvements in work capacity occurred in the 80% and 60% training
groups. There was an improvement in the duration of exercise from a mean of 5.0 to 6.2 minutes in the 80% training
group. In addition, power output increased from a mean of 125 to 155 W from pretraining levels in the 80% training
group. In the 60% training group, the duration of exercise increased from a mean of 5.4 to 6.8 minutes, and power output
increased from a mean of 135 to 170 W. No significant change in either work capacity or power output was observed in
the 40% training group or the control group over time. There was, therefore, a difference in work capacity and power
output between the 3 training groups following IMT and the control group from baseline values (Tab. 3).
Discussion
This study demonstrated that IMT improved inspiratory muscle strength (measured as the MIP) and endurance
(measured as the accumulated SMIP achieved during the training protocol). These changes in inspiratory pressures were
achieved in all participants who underwent an 8-week period of training at 80%, 60%, or 40% of each individual's MIP,
with no changes in these indexes in the participants who acted as a control group. However, quantitative improvements in
lung volumes, work capacity, and power output were evident in the 80% training group, whereas the 60% training group
improved work capacity and power output only. No improvements in lung volumes, work capacity, or power output were
evident in the 40% training group. These data are in agreement with previous research, where lung volumes and work
capacity were shown to increase in people who were healthy (6) and in age-matched individuals with cystic fibrosis (18)
who utilized an 8-week, high-intensity inspiratory training protocol. In addition, these data suggest that improvements in
volitional tests of inspiratory muscle function alone, which may be evident following IMT, do not necessarily translate
into quantitative improvements in pulmonary function or work capacity. (31)
There is now considerable evidence that IMT improves pulmonary function, (6) exercise performance, (7-12) and
recovery times following sprint performance in healthy athletic populations. (9) These outcomes have been achieved using
a variety of training methods, including 4 weeks of isocapnic hypernea, (7) 6 weeks of volitional hypernea, (13) and 6
weeks of using a respiratory resistance (threshold) device equivalent to 50% MIP. (9,11) The functional improvements in
work capacity and power output in the participants who trained at 60% and 80% of MIP are in agreement with the
findings of these earlier investigations. However, in the present investigation, only participants in the 80% training group
achieved improvements in lung volumes.
In accordance with the early work of Belman and Shadmehr, (32) and in contrast to the use of a threshold-loading device,
the present study used a pressure-flow-based training program. This program is designed to increase both pressure
generation and inspiratory flow throughout the training maneuver and as an outcome of training. The training intervention
in this study was successful in achieving a sustained training intensity, which is principle consistent with the overload
principle. (14) However, during IMT regimens, the effect of a learning response cannot be ignored. Analysis of the MIP
and SMIP data for all of the training groups indicated a learning response in the first few weeks of training despite a 1-
week habituation period. This learned response could be attributable to an improved neuromuscular recruitment pattern,
which is a well-described mechanism for early improvements in strength training, and may partially explain the large
magnitude of change in MIP and SMIP over the 8-week training period. (33) However, the participants in the group that
trained at 80% of MIP increased their VC and TLC, which indicates an increased ability of the inspiratory muscles to
expand the thorax following training. The increase in these lung volumes also may result from a greater contribution of the
upper thorax and neck muscles to the inspired volume after training. (6,18)
These findings of increases in VC and TLC are in agreement with the findings
of an earlier study by Leith and Bradley.34 Their participants trained for a 5-week period for gains ha either endurance (4
participants performed voluntary normocarbic hyperpnea to exhaustion) or strength (4 participants performed repeated
static maximum inspiratory and expiratory maneuvers against obstructed airways). Although this study (34) was designed
to demonstrate how ventilatory muscle strength or endurance can be increased by appropriate ventilatory muscle training
programs, increases ha VC and TLC of 4% were observed only in the participants who trained for strength at an
appropriate intensity. The finding of no increase ha lung volumes ha the participants who trained for endurance only (at an
intensity of approximately 20%) is ha agreement with the findings of previous studies where a similar training intensity
failed to elicit changes in lung volumes in people who were healthy (6) or in patients with cystic fibrosis. (18)
In conjunction with the improvements in lung volumes in the group who trained at 80% of SMIP, there also were
increases in work capacity and power output as assessed by cycle ergometry. (27) These increases also were evident in
the group that trained at 60% of SMIP. The nonsignificant change ha Borg scale scores before and after the IMT protocol
ha both training groups may reflect the participants' ability to sustain a higher workload without an increase in
breathlessness. However, it has been established that respiratory muscle fatigue occurs during exercise at an intensity of
at least 85% of maximal oxygen consumption (35-39) and has been shown to impair exercise performance. (36) This
impairment ha exercise capacity has been attributed to possible limb muscle vasoconstriction and reduction ha limb blood
flow elicited by a metaboreflex originating in the diaphragm, causing systemic vasoconstriction during periods of
inspiratory muscle fatigue. (2,38,39)
The participants included in this study were healthy and recreationally active and, therefore, should have been able to
cycle for a relatively long duration tmtil the onset of leg fatigue. However, they achieved only approximately 75% of
predicted peak heart rate (200 - age) and achieved only approximately 5 to 6 minutes of exercise. According to the
American College of Sports Medicine, (40) the protocol used achieved only a measure of work capacity rather than a
measure of aerobic exercise capacity, which may have been attributable to lack of motivation by the participants during
the exercise test. However, despite this lack of adherence to the protocol as described in this study, (27) these findings
further add strength to the rationale for IMT, particularly in patients with inspiratory muscle weakness or fatigue.
Accepting the limitations of cycle ergometry without the analysis of expired gas analysis to measure functional
improvements following IMT, the impact of this regimen of IMT on the improved work capacity and power output
suggests that IMT may improve functional capacity in people who are healthy.
Studies of IMT have remained controversial due to the inadequacy of some study designs. For example, some studies
have omitted control groups, (16,32) thus preventing the efficacy of IMT from being fully identified. The criteria for
methodological quality established by Smith et al, (41) namely, the use of random sampling, comparable groups,
comparable co-intervention, and standardization of testing techniques, were all observed in the present study.
Consequently, the true efficacy of IMT could be judged. In addition to the attention to study design, the training program
used in this study utilized a technique of incremental loading of the inspiratory muscles where the workload was fixed and
reassessed at each training session. This technique was achieved by selecting the best of 3 maximum sustained inspiratory
efforts at the commencement of each training session in each participant to maintain overload. The program also required
the participants to work through their full inspiratory volume from RV to TLC, thereby maintaining consistency with the
volume at which the training was applied. Furthermore, the use of computer software to run the training program
maintained consistency of effort and loading, with the additional advantage of accurate recordings of training levels that
were independent of observer input, allowing checks on adherence to the training process.
Unlike previous investigations, (6,18,42,43) however, this study failed to evaluate the effects on functional capacity of
IMT with intensities below 40% of SMIP. It was considered justified to exclude these training groups, as suboptimal
training loads of 20% (6,18) and 10% (42,43) have failed to elicit changes in any quantitative functional outcomes other
than changes in indexes of inspiratory muscle function. This finding has been evident both in patients with chronic
obstructive pulmonary disease (42) and in people who are healthy. (43) However, although this study failed to
demonstrate changes in work capacity and power output in the group who trained at 40% of SMIP, it may be possible
that this study was underpowered to detect changes in functional capacity in this group of participants. Indeed, it may be
possible that intensities of 50% of SMIP or even lower may improve exercise capacity, as the sample size calculation for
the present investigation was based upon previous studies that used diaphragm thickness and inspiratory pressure data as
outcomes for sample size estimation.6,18 This contention is supported by earlier studies16,17 that demonstrated modest
improvements in work capacity, albeit in participants with impaired exercise capacity due to chronic obstructive
pulmonary disease.
In conclusion, this study showed that improvements in volitional tests of muscle function alone may not be adequate
evidence that IMT is effective. (31) However, this study showed that if substantial pressures are generated during a
regimen of high-intensity IMT, significant improvements in lung volumes, work capacity, and power output may be
achieved in people who are healthy.
The Bottom Line
What do we already know about this topic?
Inspiratory muscle training has been shown to improve inspiratory muscle function, lung volumes, and physical work
capacity in people with chronic lung disease and in people who are healthy; however, the optimal training intensity to
produce these outcomes is unclear.
What new information does this study offer?
Inspiratory muscle training at low, moderate, or high intensities (40%, 60%, and 80% of sustained maximal inspiratory
effort) is beneficial in improving inspiratory muscle function, and training at moderate or high intensities improves
physical work capacity. Only high-intensity training (80%) also provides gains in lung volume.
If you're a patient, what might these findings mean for you?
Improvements in tests of inspiratory muscle function alone may not be adequate evidence that inspiratory muscle training
is effective; however, if substantial pressures are generated during inspiratory muscle training, significant improvements
in your lung volume and physical work capacity may be achieved.
Appendix.
Formulas for Calculation of Body Mass Index and Percentage of Body Fat
Formula for the calculation of body mass index:
kg/[m.sup.2]
Formulas for the assessment of percentage of body fat:
For men: [35.055 log (sum of 4-site skinfold thickness [mm])] - 32.175 / [1.1715 - (0.0779 log [sum of 4-site skinfold
thickness])] x 10
For women: [29.025 log (sum of 4-site skinfold thickness [mm])] - 15.255 / [1.1339 - (0.0645 log [sum of 4-site skinfold
thickness (mm)])] x 100
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performance to exhaustion. Appl Physiol Nutr Metab. 2008;33:671-681.
* Holtain Ltd, Crosswell, Crymych, Swansea, SA41 3UF United Kingdom.
** SPSS Inc, 233 Wacker Dr, Chicago, IL 60606.
([dagger]) Inscale Measurement Technology Ltd, 7 Heron Close, St-Leonards-on Sea, East Sussex TN38 8DX, United
Kingdom.
resolver.linccweb.org:9003/FLCC0800?url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&ctx_enc=info:ofi/enc:UTF-8&ctx_ver=Z39.88-2004&rfr_id=info:… 10/16
([double dagger]) PK Morgan Ltd, Rainham, Kent KF62 5MD, United Kingdom.
([section]) DeVilhiss UK Ltd, Sunrise Business Park, High Street, Wollaston, Stourbridge, West Midlands DY8 4PS,
United Kingdom.
([parallel]) Medical Graphics Corp, 350 Oak Grove Pkwy, St Paul, MN 55127.
(#) Polar RS Sports, 4802 Glenwood Rd, Brooklyn, NY 11234.
S.J. Enright, MSc, MPhil, PhD, MCSP, PGCert HE, is Senior Lecturer, Wales College of Medicine, Biology, Life and
Health Sciences, Cardiff University, Heath Park, Cardiff CF14 4XN, United Kingdom. Address all correspondence to Dr
Enright at: enrights@cardiff.ac.uk.
V.B. Unnithan, PhD, FACSM, is Professor of Paediatric Exercise Physiology, Centre for Sport, Health and Exercise
Research, Staffordshire University, Stoke-on-Trent, United Kingdom.
[Enright SJ, Unnithan VB. Effect of inspiratory muscle training intensities on pulmonary function and work capacity in
people who are healthy: a randomized controlled trial. Phys Ther. 2011;91:894-905.]
Dr Enright provided the concept and research design, data collection and analysis, project management, fund
procurement, participant recruitment, facilities and equipment, consultation and institutional liaisons, and preparation of the
manuscript for publication. Dr Unnithan provided original concept/idea/research design, writing, data analysis, and
consultation (including review of the manuscript before submission).
This study was approved by the School of Healthcare Studies Research and Development Ethics Committee at Cardiff
University.
A platform presentation of this study was given at the 19th Annual Congress of the European Respiratory Society;
September 1 3, 2009; Vienna, Austria.
This study was supported by the Physiotherapy Research Foundation.
This study is registered with the ISRCTN: no. 26277638.
This article was submitted December 15, 2009, and was accepted February 18, 2011.
DOI: 10.2522/ptj.20090413
Table 1.
Baseline Measures of Anthropometric Data, Pulmonary Function,
Inspiratory Muscle Function, and Work Capacity (a)
Measure Group 1 Group 2
Sex, male/female 4/6 5/5

Age (y) 21.0 (18.1-24.0) 21.7 (19.1-24.3)
Stature (cm) 168 (163-170) 171 (168-174)
Mass (kg) 59.9 (57.8-62.0) 54.9 (52.6-57.2)
PAS (MET) 39 (36-42) 43 (39-47)
Body fat (%) 23.0 (22.1-23.9) 20.6 (19.5-21.7)
BMI (kg/[m.sup.2]) 21.3 (21.0-21.6) 18.8 (18.4-19.2)
VC (L) (c) 3.4 (3.1-3.8) 3.6 (3.3-3.9)
RV (L) (c) 1.6 (1.2-2.1) 1.7 (1.3-2.1)
TLC (L) (c) 5.1 (4.6-5.6) 5.3 (4.9-5.7)
FRC (L) (c) 2.7 (2.4-3.1) 2.8 (2.3-3.2)
MIP (cm [H.sub.2]O) 68 (56-80) 73 (58-88)
SMIP (PTU) 528 (469-628) 635 (481-807)
Borg scale score 8.2 (7.9-8.5) 8.6 (8.2-9.0)
Work capacity (min) 5.0 (4.2-5.8) 5.4 (4.3-6.5)
Power output (W) 245 (202-289) 260 (219-300)
Peak heart rate (bpm) 143 (112-174) 146 (101-191)
Measure Group 3 Group 4
Sex, male/female 6/4 5/5

Age (y) 22.8 (20.0-25.6) 21.3 (19.8-22.8)
Stature (cm) 168 (166-170) 170 (166-174)
Mass (kg) 56.5 (53.9-59.1) 58.3 (53.4-59.6)
PAS (MET) 42 (40-44) 44 (39-49)
Body fat (%) 22.1 (21.3-22.9) 23.7 (23.1-24.3)
BMI (kg/[m.sup.2]) 19.5 (19.2-19.7) 20.2 (20.0-20.4)
VC (L) (c) 3.6 (3.3-3.9) 3.6 (3.4-3.8)
RV (L) (c) 1.6 (1.1-2.2) 1.7 (1.2-2.2)
TLC (L) (c) 4.9 (4.5-5.3) 5.1 (4.7-5.4)
FRC (L) (c) 2.6 (2.2-3.0) 2.9 (2.5-3.3)
MIP (cm [H.sub.2]O) 76 (61-91) 68 (54-82)
SMIP (PTU) 544 (408-681) 415 (386-543)
Borg scale score 7.6 (7.2-8.0) 7.9 (7.6-8.2)
Work capacity (min) 4.5 (4.211.7) 4.4 (4.111.7)
Power output (W) 240 (204-276) 220 (188-252)
Peak heart rate (bpm) 150 (118-182) 148 (98-198)
Between-Subjects
Measure P Value (b)
Sex, male/female NS
Age (y) NS
Stature (cm) NS
Mass (kg) NS
PAS (MET) NS
Body fat (%) NS
BMI (kg/[m.sup.2]) NS
VC (L) (c) NS
RV (L) (c) NS
TLC (L) (c) NS
FRC (L) (c) NS
MIP (cm [H.sub.2]O) NS
SMIP (PTU) NS
Borg scale score NS
Work capacity (min) NS
Power output (W) NS
Peak heart rate (bpm) NS
(a) All values are means with confidence intervals shown in

parentheses. Group 1 =participants who trained at 80% of sustained
maximum inspiratory effort, group 2=participants who trained at 60%
of sustained maximum inspiratory effort, group 3=participants who
trained at 40% of sustained maximum inspiratory effort, group
4=participants who did not receive any form of training and served as
a control group. PAS=physical activity status, MET=metabolic
equivalent, BMI=body mass index, VC=vital capacity, RV=residual
volume, TLC=total lung capacity, FRC=functional residual capacity,
MIP=maximum inspiratory pressure, SMIP=sustained maximum inspiratory
pressure, PTU=pressure-time unit, NS=no significant difference.
(b) All statistical analyses were performed using 1-way analysis of

variance.
(c) All lung volumes are expressed as liters (body temperature and
pressure saturated).
Table 2.
Group Comparisons for Lung Volumes and Inspiratory Muscle Function
Before and After Training Intervention (a)
Measure Before Training After Training P
VC (L) (c)
Group 1 3.4 (3.1-3.8) 3.8 (3.3-4.2) <.01

Group 2 3.6 (3.3-3.9) 3.7 (3.5-3.9) NS
Group 3 3.6 (3.3-3.9) 3.6 (3.4-3.8) NS
Group 4 3.6 (3.4-3.8) 3.6 (3.3-3.9) NS
TLC (L) (c)
Group 1 5.1 (4.6-5.6) 5.4 (4.8-5.7) <.01

Group 2 5.3 (4.9-5.7) 5.4 (5.0-5.9) NS
Group 3 4.9 (4.5-5.3) 4.9 (4.6-5.2) NS
Group 4 5.1 (4.7-5.4) 5.1 (4.6-5.5) NS
FRC (L) (c)
Group 1 2.7 (2.4-3.1) 2.8 (2.4-3.2) NS

Group 2 2.8 (2.3-3.2) 2.8 (2.3-3.1) NS
Group 3 2.6 (2.2-3.0) 2.6 (2.1-3.1) NS
Group 4 2.9 (2.5-3.3) 2.9 (2.1-3.3) NS
RV (L) (c)
Group 1 1.6 (1.2-2.1) 1.5 (1.1-2.0) NS

Group 2 1.7 (1.3-2.1) 1.7 (1.4-2.1) NS
Group 3 1.6 (1.1-2.2) 1.6 (1.1-2.2) NS
Group 4 1.7 (1.2-2.2) 1.6 (1.1-2.1) NS
MIP (cm [H.sub.2]O)
Group 1 68 (56-80) 163 (143-182) <.001

Group 2 73 (58-88) 127 (111-142) <001
Group 3 76 (61-91) 91 (74-107) <.001
Group 4 68 (54-82) 67 (51-84) NS
SMIP (PTU)
Group 1 528 (469-628) 1,176 (942-1,410) <.001

Group 2 635 (481-807) 884 (729-1,040) <.001
Group 3 544 (408-681) 619 (501-737) <.01
Group 4 415 (386-543) 406 (3291139) NS
Interaction
Measure (Group x Time) (b)
VC (L) (c)
Group 1 <.05 (A), *

Group 2
Group 3
Group 4
TLC (L) (c)

Group 1 <.05 (A), *

Group 2 NS
Group 3 NS
Group 4 NS
FRC (L) (c)
Group 1 NS
Group 2 NS
Group 3 NS
Group 4 NS
RV (L) (c)
Group 1 NS
Group 2 NS
Group 3 NS
Group 4 NS
MIP (cm [H.sub.2]O)
Group 1 <.05 (B),**

Group 2 <.05 (C)
Group 3 <.05 (C)
Group 4 NS
SMIP (PTU)
Group 1 <.05 (D), **

Group 2 <.05 (C)
Group 3 <.05 (C)
Group 4 NS

parentheses. Group 1 = participants who trained at 80% of sustained
maximum inspiratory effort, sustained maximum group 2=participants who
trained at 60% of sustained maximum inspiratory effort, group
3=participants who trained at 40% of inspiratory effort, group
4=participants who did not receive any form of training and served as
a control group. VC=vital capacity, TLC=total lung capacity,
FRC=functional residual capacity, RV=residual volume, MIP=maximum
inspiratory pressure, SMIP=sustained maximum inspiratory pressure,
PTU=pressure time unit, NS=no significant difference. Alpha level was
set at P<.05.
(b) All statistical analyses were performed using analysis of

variance; where significant differences were identified, the Tukey
critical difference test was performed. Interaction effects were
detailed as: (A)=significant improvements in group 1, with no
significant changes in groups 2, 3, and 4, from before training to
after training; (B)=significant improvements in group 1, with no
significant differences in group 4, from before training to after
training; (C)=significant improvements in group 2, with no significant
changes in group 4, from before training to after training;
(D)=significant improvements in group 3, with no significant changes in
group 4, from before training to after training. * Significant
between-group effects occurred, with group having higher values
following training than groups 2, 3, and 4 (P<.05), but with no
significant between-group differences in VC and TLC in groups 2, 3,
and 4. ** Significant between-group effects in MIP and SMIP following
training occurred among groups 1, 2, 3, and 4; group 1 had higher
values than groups 2, 3, and 4 (P<.05), with significant differences
also occurring among groups 2, 3, and 4 (P<.05).
Table 3.
Group Comparisons for Peak Work Capacity Before and After Training
Intervention (a)
Measure Before Training Before Training P
Borg scale scores
Group 1 8.2 (7.9-8.5) 7.4 (7.0-7.8) NS

Group 2 8.6 (8.2-9.0) 7.5 (7.1-7.9) NS
Group 3 7.6 (7.2-8.0) 7.4 (6.9-7.9) NS
Group 4 7.9 (7.6-8.2) 7.7 (7.4-8.0) NS
Work capacity (min)
Group 1 5.0 (4.2-5.8) 6.2 (4.9-7.4) <.01

Group 2 5.4 (4.3-6.5) 6.8 (5.4-8.1) <.01
Group 3 4.5 (4.2-4.7) 4.9 (4.6-5.2) NS
Group 4 4.4 (4.1-4.7) 4.2 (4.0-4.4) NS
Power output (W)
Group 1 125 (112-138) 155 (143-156) <.01

Group 2 135 (126-144) 170 (159-181) <.01
Group 3 112 (104-120) 122 (113-131) NS
Group 4 110 (98-122) 105 (93-117) NS
Peak heart rate (bpm)
Group 1 143 (112-174) 149 (110-188) NS

Group 2 146 (101-191) 150 (121-179) NS
Group 3 150 (118-182) 155 (121-191) NS
Group 4 148 (98-198) 154 (126-182) NS
Interaction
Measure (Group x Time) (b)
Borg scale scores
Group 1 NS
Group 2 NS
Group 3 NS
Group 4 NS
Work capacity (min)
Group 1 <.05 (A), *

Group 2 NS
Group 3 NS
Group 4 NS
Power output (W)
Group 1 <.05 (A), *

Group 2 NS
Group 3 NS
Group 4 NS
Peak heart rate (bpm)
Group 1 NS
Group 2 NS
Group 3 NS
Group 4 NS

parentheses. Group 1=participants who trained at 80% of sustained
maximum inspiratory effort, group 2=participants who trained at 60% of
sustained maximum inspiratory effort, group 3=participants who trained
at 40% of sustained maximum inspiratory effort, group 4=participants
who did not receive any form of training and served as a control
group. NS=no significant difference. Alpha level was set at P<.05.
(b) All statistical analyses were performed using 2-way repeated-

measures analysis of variance; where significant differences were
identified, the Tukey critical difference test was performed.
Interaction effects were detailed as: A=significant improvements in
group 1, with no significant changes in groups 2, 3, and 4, from
before training to after training. * Significant between-group effects
occurred, with groups 1 and 2 having higher values following training
than groups 3 and 4 (P<.05) and with significant between-group
differences in work capacity and power output in groups 3 and 4. Group
1 had significantly higher values of work capacity and power output
than groups 2, 3, and 4.
Enright, Stephanie J.^Unnithan, Viswanath B.
Source Citation (MLA 7th Edition)

Enright, Stephanie J., and Viswanath B. Unnithan. "Effect of inspiratory muscle training intensities on pulmonary function
and work capacity in people who are healthy: a randomized controlled trial." Physical Therapy June 2011: 894+. Academic
OneFile. Web. 28 Oct. 2013.
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Inspiratory Muscle Training

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10/28/13 LINCCWeb SFX Services

Design. This was a randomized controlled trial.

Setting. The study was conducted in a clinical laboratory.

Setting and Participants

Randomization and Interventions

Lung Function Measurements

Assessment of Physical Activity Status

Inspiratory Muscle Function

Assessment of Work Capacity

Sample Size Determination and Reliability of the Main Outcome Measures

Role of Funding Source

Study Group Characteristics: Baseline Analysis

Effects of IMT on MIP and SMIP

Effects of IMT on Lung Function

Effects of IMT on Work Capacity and Power Output

The Bottom Line

What do we already know about this topic?

What new information does this study offer?

If you're a patient, what might these findings mean for you?

Formula for the calculation of body mass index:

Formulas for the assessment of percentage of body fat:

* Holtain Ltd, Crosswell, Crymych, Swansea, SA41 3UF United Kingdom.

** SPSS Inc, 233 Wacker Dr, Chicago, IL 60606.

(#) Polar RS Sports, 4802 Glenwood Rd, Brooklyn, NY 11234.

This study was supported by the Physiotherapy Research Foundation.

This study is registered with the ISRCTN: no. 26277638.

Measure Group 1 Group 2

Sex, male/female 4/6 5/5

Measure Group 3 Group 4

Sex, male/female 6/4 5/5

(a) All values are means with confidence intervals shown in

(b) All statistical analyses were performed using 1-way analysis of

Measure Before Training After Training P

Group 1 3.4 (3.1-3.8) 3.8 (3.3-4.2) <.01

TLC (L) (c)

Group 1 5.1 (4.6-5.6) 5.4 (4.8-5.7) <.01

FRC (L) (c)

Group 1 2.7 (2.4-3.1) 2.8 (2.4-3.2) NS

Group 1 1.6 (1.2-2.1) 1.5 (1.1-2.0) NS

MIP (cm [H.sub.2]O)

Group 1 68 (56-80) 163 (143-182) <.001

Group 1 528 (469-628) 1,176 (942-1,410) <.001

Group 1 <.05 (A), *

TLC (L) (c)

Group 1 <.05 (A), *

FRC (L) (c)

MIP (cm [H.sub.2]O)

Group 1 <.05 (B),**

Group 1 <.05 (D), **

(a) All values are means with confidence intervals shown in

(b) All statistical analyses were performed using analysis of

Measure Before Training Before Training P

Borg scale scores

Group 1 8.2 (7.9-8.5) 7.4 (7.0-7.8) NS

Work capacity (min)

Group 1 5.0 (4.2-5.8) 6.2 (4.9-7.4) <.01

Power output (W)

Group 1 125 (112-138) 155 (143-156) <.01

Peak heart rate (bpm)

Group 1 143 (112-174) 149 (110-188) NS

Borg scale scores

Work capacity (min)

Group 1 <.05 (A), *

Power output (W)