Inspiratory Muscle Training

As expected, the loss of inspiratory muscle function is related to the level of injury as illustrated in Figure 3. Dyspnea, defined as a subjective report of breathlessness or shortness of breath, is common in people with SCI and is greatest in people with tetraplegia (Ayas et al. 1999). Approximately two-thirds of the prevalence of dyspnea in this group is attributed to the inspiratory muscle loss (Spungen et al. 1997). Improved inspiratory muscle strength and endurance could potentially improve cough and maximal exercise ventilation in addition to decreasing dyspnea. The inspiratory muscles can be trained similar to the limb muscles with inexpensive devices that increase the resistive or threshold inspiratory load on the inspiratory muscles (Reid et al. 2004). Table 9 outlines common measures that are indicative of respiratory muscle strength and endurance. In neuromuscular disorders like SCI, maximal lung volumes that measure IC also can reflect increased inspiratory muscle strength.

Commercially available hand-held devices can be used for inspiratory muscle training. The three main types of devices are the resistive and threshold trainers (Figure 3) and isocapneic hyperpnea (see Reid et al. 2004 for details of these training techniques). These devices have a one-way valve that closes during inspiration so that the subject must breathe against a load. The resistive trainer imposes a load through a small diameter hole whereas the threshold trainer imposes a load via a spring loaded valve. Isocapneic hypernea imposes loading in a very different manner. The participant targets a prescribed ventilation that require higher inspiratory and expiratory flows. A bag attached to the device is adjusted to match the amount of rebreathing in order to maintain isocapnea i.e. a normal end-tidal CO₂level. For all of the devices, the one-way valve opens during expiration such that no load is imposed during the expiratory phase of respiration. Evidence showing decreased dyspnea and improved strength and endurance after IMT is well documented in people with other health conditions such as chronic obstructive pulmonary disease (COPD) (Reid et al. 2004; Geddes et al. 2005).

Figure 3. Inspiratory Muscle Trainers

Threshold trainer: has an adjustable spring-loaded valve that imposes the inspiratory load. The inspiratory load can be increased by winding the spring more tightly. Advantage of this trainer is that the same load is imposed on the inspiratory muscles regardless of breathing pattern.
Threshold and P-Flex trainers available from Respironics HealthScan Inc., 41 Canfield Rd., Cedar Grove, NJ7, 0009-1201. 1-800-962-1266.

Resistive trainer: has holes of different diameters.  The inspiratory load can be increased by setting the dial to holes of lesser diameter. Disadvantage of this trainer is that the subject can reduce the inspiratory load by breathing more slowly.  If this device is used for training, a target must be used. Various targets have been designed that set a breathing rate (flow and/or inspiratory pressure) for the subject.

Isocapneic Hypernea Trainer: has a rebreathing bag that can be adjusted to ensure that the person’s CO₂ level is maintained within a physiologic range. A target is provided for the person to increase the level of ventilation to a training intensity. This device enables training at low loads but much higher inspiratory and expiratory flow such that the inspiratory and expiratory muscles training at higher speeds of contraction. In contrast, the threshold and resistive trainers, place high loads while the speed of contraction is relatively low.
SpiroTiger™ trainer available from FaCT Canada Consulting Ltd. 1215 Cariboo Hwy N Quesnel, BC V2J 2Y3 Canada1-877-322-8348

Discussion

Two RCTs provide level 1a evidence (Mueller et al. 2012, 2013; Van Houtte et al. 2008) that inspiratory resistive and normocapneic hypernea training, respectively, significantly increases inspiratory muscle strength. A case report provides level 5 evidence that threshold IMT improved inspiratory muscle strength and decreases the number of respiratory infections (Ehrlich et al. 1999). One RCT (Tamplin et al. 2013) provides level 1 evidence that group singing exercises 3 times weekly for 12 weeks significantly improves phonation, and projected speech intensity.

Earlier reports were not comparable and could not be combined in a meta-analysis (Brooks et al. 2005) because of research design, heterogeneity of subject characteristics or differences in training techniques. Several previous studies that used an RCT design incorporated with suboptimal IMT protocol. In particular, several used an inspiratory resistive device with no target to control for decreasing resistance with slower flows so the training methods may have induced an alteration in breathing pattern towards slower inspiratory flows rather than a training response against higher inspiratory pressures. The few studies that utilized a RCT design also showed improvement in both control (or sham) and training groups. Comparable improvement in measures of inspiratory muscle and lung function in the control and IMT groups may reflect learning of testing maneuvers, benefit from other rehabilitation or lifestyle activities, and/or natural progression of improvement after SCI.

The single subject report by Ehrlich et al. (1999), utilized the threshold trainer, which imposes a constant inspiratory load regardless of breathing pattern. Given that threshold IMT has consistently shown improvements in inspiratory muscle strength and endurance in people with chronic obstructive pulmonary disease, this technique warrants a larger RCT to determine its benefit for people after SCI.

The RCT by Van Houtte et al. (2008) and case report by Ehrlich et al. (1999) provides level 5 evidence that respiratory muscle training has the potential to dramatically reduce respiratory infections.

Future research to determine a potential treatment effect of IMT after SCI, should utilize: 1) larger samples; 2) a research design that controls for the influence of learning or recovery from SCI on IMT outcome measures of inspiratory muscle strength and endurance, and dyspnea; 3) optimal training techniques of threshold loading, targeted resistive devices, or normocapnic hyperpnea; 4) outcomes of inspiratory muscle strength and endurance; dyspnea; quality of life; daily function; 5) a comparison of the effectiveness of IMT relative to or as an adjunct to other rehabilitation interventions. Of equal importance, overly aggressive prescription of IMT has the potential to fatigue and injure the inspiratory muscles, which can increase the person’s predisposition to respiratory compromise. The article by Reid et al. (2004) provides a table that outlines parameters to monitor during IMT in order to avoid untoward responses such as muscle fatigue and hypercapnia. Parameters include: intensity of load, mode of load, duration, frequency and length of training to ensure adequate training protocol; blood pressure, heart rate, respiratory rate, other signs and symptoms of respiratory distress or inability to tolerate exercise load as signs of exercise intolerance; discoordinate chest wall movement, excessive dyspnea during training, long lasting complaints of fatigue after training sessions to avoid inspiratory muscle fatigue; signs of delayed-onset muscle soreness, reduced strength and endurance to avoid muscle injury; and end-tidal CO₂, SpO₂ and signs of headache, confusion to avoid hypercapnea (Reid et al. 2004). Van Houtte et al. (2008) provided 48 hours rest after their participants were unable to tolerate an overly intense workload.

For inspiratory muscle training to improve ventilation, decrease dyspnea, and to improve daily function after SCI, parameters to optimize IMT are only available for people with other respiratory conditions. For people with chronic obstructive pulmonary disease, the optimal IMT protocol should utilize threshold or targeted resistive trainers, at an intensity of 30-70% of MIP, for a duration up to 30 minutes per session, performed continuously or in intervals, 4-6 days/week and be continued indefinitely (Geddes et al. 2006). Progression of intensity (MIP) should not exceed 5% per week.

Conclusion

There is level 1b evidence based on 2 RCTs (Van Houtte et al. 2008; Postma et al. 2014), level 2 evidence based on 5 RCTs (Mueller et al. 2012, 2013; Loveridge et al. 1989; Liaw et al. 2000; Derrickson et al. 1992; West et al. 2014), level 3 evidence from 2 studies (Aslan et al. 2016 and Fischer et al. 2014), and level 4 evidence from several pre-post and case studies to support IMT as an intervention that will improve inspiratory muscle strength and might decrease dyspnea and respiratory infections in some people with SCI.