Inspiratory muscle training

1. Introduction

Version followed: inspiratory muscle training (IMT) as described in respiratory-physiotherapy practice for COPD (Hill, Cecins, Eastwood and Jenkins 2010 practical guide for clinicians, based on a threshold device), the manufacturer's user instructions for a spring-loaded threshold trainer (POWERbreathe Classic), the 2023 Cochrane review on IMT in COPD (Ammous et al.), and the guideline positions of the 2013 ATS/ERS pulmonary rehabilitation statement and the 2013 British Thoracic Society (BTS) pulmonary rehabilitation guideline. Heart failure and athlete applications follow the reviews by Sadek et al. and HajGhanbari et al. This guide is written for the psychotherapist; it gives no training loads, percentages, breath counts, session frequencies or progression schedules. [source: Hill et al. 2010; POWERbreathe Classic user guide; Ammous et al. 2023 via AAFP; Spruit et al. 2013; McConnell & Gosselink letter quoting BTS 2013]

What it is. IMT is a physical training method in which a person breathes in through a hand-held device that makes inhaling harder, so that the diaphragm and rib-cage muscles work against a load; breathing out is left unrestricted. In threshold devices, a spring-loaded one-way valve opens only when the person inhales with enough force, and the load is set on a numbered scale. Resistive (flow-dependent) devices, which make inhaling harder through a narrowed opening, also exist [uncertain: not verified]. Electronic trainers exist as well; the UK primary-care respiratory literature names POWERbreathe and Respironics among IMT devices. [source: POWERbreathe Classic user guide; Hollier 2019]

How change is thought to happen. IMT works like strength training for other muscles: repeated breathing against a load is meant to make the inspiratory muscles stronger and more enduring. Inspiratory muscle weakness is common in COPD and is linked to breathlessness and reduced exercise capacity. Stronger inspiratory muscles are expected to make breathing feel easier and to ease breathlessness. [source: Hill et al. 2010; Hollier 2019] It is not a relaxation, mindfulness or slow-breathing method. The inhalation is fast and forceful, so it should not be confused with the paced-breathing techniques a psychotherapist may teach (see the Breathwork family tabs). [source: POWERbreathe Classic user guide] [synthesis]

Who delivers it. In clinical populations, IMT is assessed for, issued and supervised by respiratory physiotherapists or other trained rehabilitation clinicians. It is often provided alongside or after pulmonary rehabilitation (PR), where funded. [source: Hollier 2019; Hill et al. 2010] Devices are also sold directly to the public and to athletes. Under-16s should train only with adult supervision, and the device is not suitable for children under 7. [source: POWERbreathe Classic user guide] A psychotherapist does not prescribe, load or progress IMT. Their role is screening and referral; working with breathlessness, panic and fear of exertion; supporting adherence; and passing on any adverse effects the client reports. [synthesis]

Evidence status (brief).

COPD, IMT alone versus control or sham (Cochrane 2023: 55 RCTs, 2,467 participants overall). Dyspnoea improved, at very low certainty. Six-minute walk distance improved and COPD Assessment Test symptom scores fell, both at moderate certainty. [source: Ammous et al. 2023 via AAFP]
COPD, IMT added to PR. The same review found little or no difference in dyspnoea, exercise capacity or quality of life compared with PR alone. Its limitations included high risk of bias, heterogeneous protocols and adverse effects not being reported. [source: Ammous et al. 2023 via AAFP]
Guidelines. The BTS 2013 guideline does not recommend IMT "as a routine adjunct to pulmonary rehabilitation". [source: McConnell & Gosselink letter quoting BTS 2013] The ATS/ERS 2013 statement says that IMT given as an adjunct to whole-body exercise training improves inspiratory muscle strength and endurance but not dyspnoea or maximal exercise capacity. [source: Spruit et al. 2013 executive summary] UK respiratory physiotherapy commentary describes IMT as helping to maintain PR gains but "not a substitute" for PR. [source: Hollier 2019]
Chronic heart failure. A meta-analysis of 7 small RCTs (203 patients) reports improved inspiratory muscle strength, walking distance and dyspnoea, limited by the small number of heterogeneous studies. [source: Sadek et al., Eur J Prev Cardiol] Positions in cardiology guidelines: [uncertain: not verified].
Athletes. A meta-analysis of 21 RCTs reports better time-trial and endurance performance after respiratory muscle training. Small samples and varied protocols limit the conclusions. [source: HajGhanbari et al. 2013]
Dyspnoea-related fear. One small sham-controlled RCT in COPD (40 participants) reports larger reductions in dyspnoea-related kinesiophobia (fear of movement), anxiety and depression scores after IMT than after sham. This is a single trial and has not been replicated in the sources reviewed here. [source: Saka et al. 2021]
IMT is not a treatment for any disease in its own right. It never replaces prescribed medicines, oxygen, PR or medical review, and clients should be told not to change medication or treatment without their doctor. [source: POWERbreathe Classic user guide; Hollier 2019]

2. Framework

IMT does not have psychotherapy phases. The framework below describes the clinical pathway as published, with the psychotherapist's points of contact marked [synthesis].

Stage A: Identification and referral. Goal: to identify people who may benefit. Hill et al. propose IMT particularly for people with COPD who cannot fully take part in whole-body exercise, for example because of severe musculoskeletal problems. Others take it up after PR to help maintain gains. [source: Hill et al. 2010; Hollier 2019] Psychotherapist's role: notice clients whose breathlessness, fear of exertion or avoidance of activity is limiting therapy or life. Encourage them to ask their respiratory team, GP or cardiologist whether PR or IMT is appropriate, rather than buying a device unsupervised. [synthesis] Move on when the client has a referral, or has had a clinician's decision.

Stage B: Clinical assessment and screening (physiotherapist or clinician). Goal: to establish suitability, a baseline and safety. Clinicians measure maximum inspiratory pressure (PImax). They also assess breathlessness, health-related quality of life and exercise capacity, and screen for exclusions such as pneumothorax risk or the risk of spontaneous rib fracture. [source: Hill et al. 2010] The contraindications and cautions are listed in section 4.1. Move on when the clinician clears the client for training.

Stage C: Supervised initiation. Goal: correct technique and safe tolerance. Hill et al. recommend supervision, including monitoring oxygen saturation during the first session. Patients should be warned that transient muscle soreness is a normal response to unfamiliar muscle work. [source: Hill et al. 2010] The manufacturer's technique is described in section 4.2. Move on when the clinician is satisfied with technique and saturation.

Stage D: Training period and progression (clinician-led). Goal: progressive strengthening. The clinician sets the training load, frequency, duration and progression, and progresses training as symptoms allow. Trials and device manuals specify these parameters, but they are deliberately not reproduced here. [source: Hill et al. 2010; POWERbreathe Classic user guide; Sadek et al.] Psychotherapist's role: adherence support, work on breathlessness-related anxiety, and monitoring and passing on adverse effects. [synthesis] Moving between loads is the clinician's decision alone.

Stage E: Review and maintenance. Goal: to re-measure outcomes (PImax, breathlessness, quality of life, exercise capacity) and decide whether to continue, maintain or stop. [source: Hill et al. 2010] Psychotherapist's role: help the client consolidate what changed in their beliefs about breathlessness and keep up activity. [synthesis]

Format. The device is used individually at home after supervised teaching, sometimes alongside group PR. [source: Hollier 2019; Hill et al. 2010] Trial programmes ran for weeks to months, but session counts are not given here. [source: Sadek et al.] The psychotherapist's work is usually a small number of focused sessions within ongoing therapy, or joint work with a PR team that includes psychologists or behavioural specialists. [source: Spruit et al. 2013] [synthesis]

3. Guiding principles

Clinician-prescribed, clinician-progressed. Load, frequency and progression belong to the physiotherapist or clinician. Never suggest loads, settings or schedules, even if the client asks. [source: Hill et al. 2010] [synthesis]
Screen before anyone trains. Contraindications concern the lungs, ears, ribs, heart and abdomen (section 4.1). Ask about them and route the client to medical clearance if any apply. [source: POWERbreathe Classic user guide; Hollier 2019]
Adjunct, not substitute. IMT does not replace PR, medication, oxygen or medical review. Frame it as one part of the respiratory team's plan. [source: Hollier 2019; McConnell & Gosselink letter quoting BTS 2013]
Accurate expectations. Evidence for IMT on its own in COPD is moderate for exercise capacity and very low for dyspnoea. It adds little to PR. Do not promise less breathlessness, cure or less anxiety. [source: Ammous et al. 2023 via AAFP; Saka et al. 2021] [synthesis]
Breathlessness is multidimensional. Anxiety and depression are common in people referred to PR and can affect outcomes, and PR teams may include psychologists. Psychological work sits alongside the physical training. [source: Spruit et al. 2013]
Behaviour change needs more than information. The ATS/ERS statement says a purely didactic approach is likely to be insufficient. Use collaborative, self-efficacy-building methods for adherence. [source: Spruit et al. 2013]
Distinguish effortful training from calming breathing. IMT inhalation is fast and forceful. Keep it separate from slow or paced breathing used to manage anxiety, so the client does not use IMT as a panic strategy or paced breathing as a strength exercise. [synthesis]
Stop signals override goals. Pain, persistent ear discomfort, dizziness, falling oxygen saturation or worsening heart-failure symptoms mean stop and contact the clinician. [source: POWERbreathe Classic user guide; Hollier 2019]
Hygiene and ownership. Each person has their own device, cleaned regularly and never shared, including with family members. [source: POWERbreathe Classic user guide]
Stay within your competence and profession's code. A psychotherapist does not touch the client to cue breathing and does not teach device technique. Where the psychotherapist is also a registered physiotherapist, practise within that profession's rules and keep the two roles clearly separate. [synthesis]

4. Intervention inventory

This section has two parts. Items 4.1 and 4.2 describe what the respiratory clinician does, so that the psychotherapist can screen, prepare and recognise problems. Items 4.3 to 4.12 are the psychotherapist's own interventions. Most of those are [synthesis], because the IMT sources reviewed here describe no psychotherapy procedures. They are built on the principles in section 3.

4.1 Contraindication and caution screen (before any referral or self-purchase)

Purpose: to make sure a client who is considering IMT, or already using a device, has been checked against the published contraindications and cautions. Use it when IMT comes up, and especially when a client has bought a device without clinical input.
Contraindications and cautions as sources state them. These lists are from the manufacturer's user guide (POWERbreathe Classic), UK respiratory physiotherapy (Hollier 2019; DeMars), and Hill et al. 2010.
- Do not use: with a ruptured eardrum or any other ear condition; with a markedly raised left ventricular end-diastolic volume or pressure; if heart-failure signs or symptoms worsen after training; with current or likely costochondritis; during a cold, sinusitis or respiratory infection (until it clears); or after a traumatic pneumothorax or broken rib until fully recovered. [source: POWERbreathe Classic user guide]
- Consult a doctor first if any of these apply: a history of spontaneous pneumothorax; pulmonary hypertension; large bullae on chest X-ray; marked osteoporosis with a history of rib fracture; oxygen saturation falling below 94% during or after training; recent abdominal surgery or an abdominal hernia; or any uncertainty about suitability. [source: POWERbreathe Classic user guide]
- Asthma with low symptom perception, frequent severe exacerbations or an abnormally low perception of breathlessness is listed as unsuitable or as needing caution. [source: POWERbreathe Classic user guide; Hollier 2019; DeMars]
- Clinical exclusions include risk of pneumothorax or of spontaneous rib fracture. [source: Hill et al. 2010] Osteoporosis is described as a precaution rather than an absolute contraindication. Desaturation during training and active ear or sinus problems call for care. [source: DeMars]
- Where IMT is combined with other airway devices, epilepsy, pulmonary embolism, oesophageal varices, rib fractures and pregnancy are also listed. [source: Hollier 2019] Specific IMT guidance on epilepsy, pregnancy, glaucoma or psychosis: [uncertain: not verified]. Treat any of these as a reason for medical clearance. [synthesis]
Steps (psychotherapist):
1. Ask whether a respiratory or cardiac clinician has recommended the device and set it up.
2. Ask plainly about each area: ears, lungs (collapsed lung, bullae, current infection), ribs and bones, heart (heart failure, pulmonary hypertension), recent abdominal surgery or hernia, asthma control, and whether anyone has measured their oxygen levels while training.
3. If any item applies, or the client is unsure, advise them to pause device use and check with the prescribing clinician or GP before going on. Record that advice.
4. Remind the client never to change medicines, inhalers or oxygen because of IMT. [source: POWERbreathe Classic user guide]
Example language (illustrative): "Before we talk about how the trainer fits with our work, I'd like to run through a few health questions the device makers and physiotherapists ask about. Have you ever had a collapsed lung, an ear problem or a cracked rib? Has anyone checked your oxygen levels while you use it?"
Watch for: a client who downplays symptoms so they can keep training; health anxiety that turns the screen into a source of fear. If this happens, keep the questions factual and brief, and hand the decision to the clinician. Also watch for the client who has bought a device after seeing it promoted for anxiety or "breath control". The device was not designed for that use. [synthesis]

4.2 Supervised device training as clinicians and manufacturers describe it (for recognition, not for delivery by the psychotherapist)

Purpose: so the psychotherapist knows what correct use looks like and can spot distress or misuse. The psychotherapist does not teach this.
What the clinician does: measures PImax and baseline breathlessness, quality of life and exercise capacity. The clinician then sets the load, supervises the first sessions (including oxygen saturation monitoring), progresses training as symptoms allow, and warns the client about transient muscle soreness. [source: Hill et al. 2010]
Technique the manufacturer describes, paraphrased: sit or stand upright and relaxed, and seal the lips around the mouthpiece; a nose clip is optional. Breathe out as fully as possible. Then take a fast, forceful breath in while straightening the back and expanding the chest. Let the breath out slowly and passively, with the shoulders relaxed, and pause until the urge to breathe returns. Do not pant. If light-headed or dizzy, slow down and pause at the end of a breath until the urge to breathe comes back. Stop at once and see a doctor if there is pain. Ear discomfort, especially during a cold, usually reflects poor pressure equalisation and needs medical advice if it persists. The guide specifies breath counts, frequency and load progression; these are not reproduced here. [source: POWERbreathe Classic user guide]
Hygiene: clean the device regularly because it is exposed to saliva, dry and store it as directed, and never share it. [source: POWERbreathe Classic user guide]
Example language (illustrative): "Your physio will set the trainer and check how you're doing with it. What I can help with is how breathing hard against it feels for you, and what goes through your mind while you do it."
Watch for: panting or rapid repeated breaths; dizziness, tingling or light-headedness (possible over-breathing); pain; ear symptoms; the client setting a higher load than prescribed or training through warning signs; and training while driving, in or near water, or in any setting where a dizzy spell or faint would be dangerous. These are reasons to pause and contact the clinician. [source: POWERbreathe Classic user guide] [synthesis]

4.3 Referral and collaborative-care liaison

Purpose: to link the client with a respiratory physiotherapy, PR or cardiac rehabilitation team, and to coordinate psychological and physical work. PR teams may include psychologists and behavioural specialists. [source: Spruit et al. 2013]
Steps:
1. With consent, write or speak to the GP, respiratory team or cardiac team. Describe how breathlessness and fear of exertion affect the client, and ask whether PR, IMT or another intervention is appropriate.
2. Share relevant psychological information with consent: panic, anxiety, depression, trauma linked to breathlessness (for example a past intensive-care admission), and avoidance.
3. Agree who does what. The clinician manages the device and loads; you manage anxiety, mood and motivation. Agree how adverse effects will be passed on.
4. Ask for the clinician's stop rules so you can reinforce them.
Example language (illustrative): "I'd like to let your respiratory team know how much the fear of getting breathless is holding you back, so they can take that into account. Is that all right with you, and is there anything you'd rather I didn't include?"
Watch for: the client being referred for a device instead of PR when PR is what is indicated; mixed messages between professionals; and you being drawn into giving physical advice. [source: Hollier 2019] [synthesis]

4.4 Psychoeducation: what IMT is and is not

Purpose: to set accurate expectations and keep IMT separate from anxiety-management breathing.
Steps:
1. Explain that IMT is strength training for the breathing-in muscles, delivered and progressed by a physiotherapist.
2. Summarise the evidence honestly. On its own in COPD it helps walking distance and symptom scores. It may ease breathlessness, but that evidence is weak. It adds little on top of full PR. [source: Ammous et al. 2023 via AAFP]
3. Make it clear that IMT is not a calming technique. Slow, gentle breathing for anxiety is a different skill. If paced breathing is part of your therapy, teach it separately (see the Breathwork family tabs). [synthesis]
4. Make it clear that IMT does not replace medicines, oxygen or PR. [source: POWERbreathe Classic user guide; Hollier 2019]
Example language (illustrative): "Think of the trainer as a gym for the muscles you breathe in with. It's meant to feel like effort. It isn't a relaxation exercise, and it doesn't replace your inhalers or rehab."
Watch for: magical expectations ("this will fix my anxiety"); disappointment if breathlessness changes little; and using the device during panic. [synthesis]

4.5 Assessing and formulating breathlessness-related anxiety

Purpose: to understand how breathlessness, fear, avoidance and deconditioning interact for this client. Anxiety and depression are common in people referred to PR and can affect outcomes. [source: Spruit et al. 2013] In the trial by Saka et al., all participants showed dyspnoea-related kinesiophobia on the Breathlessness Beliefs Questionnaire. [source: Saka et al. 2021]
Steps:
1. Map a recent episode: the trigger (exertion, stairs, a cold), the sensations, the thoughts ("I'll suffocate"), the emotions, the behaviours (stopping, avoiding, calling for help, using an inhaler) and the after-effects.
2. Ask what the client believes breathlessness means, and what they avoid because of it.
3. Screen for panic disorder, health anxiety, depression and trauma linked to breathing events, using validated measures within your scope. Questionnaires such as the Hospital Anxiety and Depression Scale and the Breathlessness Beliefs Questionnaire were used in the IMT trial above. [source: Saka et al. 2021] Describe licensed instruments; do not reproduce their items. Where a breathing-pattern disorder or hyperventilation is suspected, screening tools such as the Nijmegen Questionnaire are used in respiratory physiotherapy [uncertain: not verified]. Refer for physiotherapy assessment rather than diagnosing it yourself. [synthesis]
4. Draw a shared cycle: breathlessness, then fear, then avoidance, then deconditioning, then more breathlessness. Mark where physical training, including IMT and PR, and psychological work each act.
Example language (illustrative): "So when you feel your chest tighten on the stairs, the thought that comes is 'I can't get enough air', and then you stop and sit down. Over months you've done less and less. Shall we sketch that loop together?"
Watch for: red-flag physical symptoms that should go to the medical team, such as new chest pain, worsening swelling or a sudden change in breathlessness; and blaming psychology for breathlessness that has a physical cause. [synthesis]

4.6 Preparing for the sensations of loaded breathing

Purpose: to reduce anticipatory anxiety about breathing against resistance. Loaded inhalation deliberately produces effort and some breathlessness, which can resemble feared sensations. [source: POWERbreathe Classic user guide] [synthesis]
Steps (all synthesis):
1. Before the first supervised session, ask what the client expects to feel and fear. Common answers are suffocation, "lungs bursting", or being unable to get the next breath.
2. Describe the expected sensations in neutral terms: effort in the chest and neck, breathing out feeling easy, possible muscle soreness afterwards (which Hill et al. describe as normal), and a brief light-headedness if the client breathes too fast. [source: Hill et al. 2010; POWERbreathe Classic user guide]
3. Separate expected effort from stop signals: pain, persistent ear discomfort, dizziness that does not settle after slowing down, falling oxygen saturation, or worsening heart-failure symptoms. [source: POWERbreathe Classic user guide; Hollier 2019]
4. Agree on a plan for the first session. The client tells the physiotherapist about their anxiety and agrees a signal to pause with them. The client notices thoughts during training and brings them to the next psychotherapy session.
5. Do not use the device as a home interoceptive-exposure tool. Any exposure to breathlessness sensations belongs within a medically cleared, clinician-agreed plan. [synthesis]
Example language (illustrative): "You'll probably feel your breathing muscles working hard, a bit like lifting something heavy. That's the training doing its job. Pain, ear trouble or feeling faint are different. Those mean stop and tell your physio."
Watch for: the client reading normal effort as danger, or ignoring real stop signals to prove courage. Is it working? The client attends the first session and reports manageable anxiety. [synthesis]

4.7 Responding to breathlessness or panic during or after training

Purpose: to give the client a safe, consistent response when training triggers fear or panic.
Steps:
1. Stop using the device. Follow the manufacturer's advice for light-headedness: slow down and pause after the breath out until the urge to breathe returns. [source: POWERbreathe Classic user guide]
2. Then use the coping strategy already agreed in therapy, for example a recovery position, gentle breathing at rest, or a coping statement. Where paced breathing is used, teach it as a separate skill following its own published pattern (see the Breathwork family tabs). [synthesis]
3. Use the clinician's breathlessness action plan and reliever medication exactly as prescribed. Never change them. [source: POWERbreathe Classic user guide]
4. Seek medical help according to the medical action plan when symptoms are severe, new or not settling, such as chest pain, marked worsening of breathlessness, or fainting. [synthesis]
5. Afterwards, review the episode in session: what was feared, what happened, and what the client learned.
6. CBT for panic includes a debate about whether calming breathing helps or works as a safety behaviour that maintains fear. The literature on this was not reviewed for this guide [uncertain: not verified]. In practice, frame recovery breathing as one coping option, not a rescue the client must have, and review whether it is becoming an avoidance ritual. [synthesis]
Example language (illustrative): "If it tips into panic, put the trainer down and let the breath out slowly. Then do what we practised. Your trainer will wait. Afterwards we'll look at what your mind told you in that moment."
Watch for: repeated panic linked to training, which should be passed on to the physiotherapist, who may adjust the plan; tingling, cramping hands or dizziness suggesting over-breathing; and the client stopping training altogether after one frightening episode. [synthesis]

4.8 Adherence support

Purpose: home IMT depends on regular self-practice, and a purely didactic approach is likely to be insufficient for behaviour change. [source: Spruit et al. 2013] The ATS/ERS statement links collaborative self-management with self-efficacy. [source: Spruit et al. 2013]
Steps (synthesis):
1. Explore ambivalence with a motivational-interviewing stance: ask what matters to the client (for example walking to the shops or playing with grandchildren) and how training relates to it.
2. Help the client build the clinician's prescribed routine into daily life using implementation intentions, for example "after breakfast, at the table". Do not change the prescription itself.
3. Problem-solve barriers: forgetting, embarrassment, colds (pause until symptoms clear, as the guide says), soreness, low mood, device cleaning, and travel. [source: POWERbreathe Classic user guide]
4. Encourage any log the clinician asks for, and taking it to reviews.
5. Reinforce PR attendance; IMT is not a substitute for it. [source: Hollier 2019]
Example language (illustrative): "You said walking to your daughter's house is what you're aiming for. Where in your day could the training your physio set fit most easily?"
Watch for: perfectionism or overtraining (doing more than prescribed), all-or-nothing dropout after a missed day, and depression undermining practice. Is it working? Steady practice as prescribed, attendance at reviews, and the client talking about training in their own terms. [synthesis]

4.9 Monitoring and passing on adverse effects

Purpose: the Cochrane review notes that trials did not report adverse effects, so careful clinical vigilance matters. [source: Ammous et al. 2023 via AAFP]
Steps:
1. At each contact during the training period, ask briefly about pain, ear discomfort, dizziness, rib or chest-wall pain, worsening breathlessness or swelling, and any change in heart-failure symptoms. [source: POWERbreathe Classic user guide; Hollier 2019]
2. If any is present, advise the client to pause and contact the prescribing clinician. With consent, tell the clinician yourself if the risk warrants it.
3. Record what was reported and what advice you gave.
Example language (illustrative): "Any pain, ear trouble or dizziness with the trainer since we last met? If so, let's get your physio to check before you carry on."
Watch for: symptoms attributed to anxiety that may be physical, and the reverse. When in doubt, refer it on. [synthesis]

4.10 Working with mood, beliefs and self-efficacy

Purpose: the trial by Saka et al. reports reductions in anxiety, depression and dyspnoea-related fear of movement alongside IMT. Psychological work can build on any physical gains, though a single small trial does not establish this effect. [source: Saka et al. 2021] [synthesis]
Steps (synthesis): Elicit and test catastrophic beliefs about breathlessness, using evidence from the client's own training and activity. Link small physical gains to revised beliefs ("I can tolerate this sensation"). Plan graded return to valued activities within the medical team's limits. Address grief, shame and the loss of role that come with chronic lung or heart disease.
Example language (illustrative): "Three months ago you were sure breathing hard meant danger. What has the training taught you about that?"
Watch for: overgeneralising ("I'm cured, so I can stop my rehab"); deterioration in the underlying illness, which can be mistaken for therapy failure; and existential distress in advanced disease. Offer palliative-care links where the client's team indicates. [synthesis]

4.11 Athletes and performance contexts

Purpose: athletes may use IMT to improve performance. A meta-analysis reports benefits in time trials and endurance, with caveats. [source: HajGhanbari et al. 2013]
Steps (synthesis): If a client uses IMT for sport, check that they have been screened (section 4.1), have their own device, and train under a coach or sport physiotherapist. Work on performance anxiety, perfectionism and overtraining separately. Be alert to disordered eating or compulsive exercise patterns.
Example language (illustrative): "Who set up your breathing-trainer programme? I'm more interested in what happens in your head on the start line."
Watch for: competitive escalation of loads, training while ill, and secrecy about symptoms. [synthesis]

4.12 Review, maintenance and ending

Purpose: to consolidate change and hand ongoing physical care back to the respiratory or cardiac team.
Steps: Align with the clinician's re-measurement of PImax, breathlessness, quality of life and exercise capacity. [source: Hill et al. 2010] In psychotherapy, review the breathlessness-fear cycle, what has changed, relapse signs (a return of avoidance, or panic after an exacerbation), and the plan after a cold or hospital admission. That plan is to restart only on the clinician's advice. [source: POWERbreathe Classic user guide] [synthesis]
Example language (illustrative): "Your physio will decide whether you carry on with the trainer. Let's write down what you'll do if the fear creeps back after your next chest infection."
Watch for: fear returning after exacerbations, and stopping maintenance activity once therapy ends. [synthesis]

5. Handling problems

The IMT sources reviewed here cover physical stop signs and device problems. They do not cover psychological difficulties, so the guidance below on those is [synthesis] unless a source is given.

Client asks you for a load, setting or schedule. Decline clearly and refer them to the physiotherapist. Explain that loads are set from measured inspiratory strength and the person's symptoms. [source: Hill et al. 2010] Language (illustrative): "That's your physio's call. It depends on measurements I don't take. Let's make a note to ask them at your next appointment."
Self-purchased device, no clinical input. Run the screen in section 4.1, recommend clinical assessment, and point out that people with lung or heart disease should check with their doctor before using the device. [source: POWERbreathe Classic user guide] [synthesis]
Pain, ear discomfort, dizziness or desaturation. Stop, and contact the clinician. Pain needs medical advice. Persistent ear discomfort needs a doctor. Saturation below 94% is a reason for medical review. [source: POWERbreathe Classic user guide; Hollier 2019]
Worsening heart-failure symptoms (more breathlessness, swelling, fatigue) after training. Stop and refer urgently to the cardiac team. Worsening heart failure is listed as a contraindication. [source: POWERbreathe Classic user guide; Hollier 2019]
Cold, sinusitis or chest infection. Pause training until symptoms clear, as the manufacturer advises, and then follow the clinician's advice on restarting. Plan in advance with the client so a pause does not become dropout. [source: POWERbreathe Classic user guide] [synthesis]
Panic triggered by loaded breathing. Follow section 4.7. Tell the physiotherapist, who may adapt the plan. Then work on the feared interpretation in session. Do not push the client to "face it" with the device outside the clinician's plan. [synthesis]
Over-breathing, tingling or light-headedness. Follow the manufacturer's advice: slow down and pause after the breath out. If symptoms persist, the client stops and seeks clinical review. Never train while driving, in or near water, or anywhere a faint would be dangerous. [source: POWERbreathe Classic user guide] [synthesis]
Non-adherence. Explore it without blame. Check whether the cause is practical (forgetting, soreness, colds), emotional (fear, low mood) or a matter of belief ("it's pointless"). Respond with the methods in section 4.8. If adherence stays poor, tell the clinician. The evidence that IMT adds to PR is limited, so a joint decision to focus on PR may be appropriate. [source: Ammous et al. 2023 via AAFP; Spruit et al. 2013] [synthesis]
Overtraining or compulsive use. Typical signs are training beyond the prescription, training through symptoms, or perfectionism about the training log. Explore what the extra training does for the client emotionally, reinforce the clinician's limits, and look for broader compulsive-exercise or health-anxiety patterns. [synthesis]
Disappointment with results. Revisit honest expectations. Gains are modest, and evidence for benefit on breathlessness is weak. Shift the focus to valued activity and to what can still change psychologically. [source: Ammous et al. 2023 via AAFP] [synthesis]
Stuck client: avoidance persists despite stronger muscles. Re-formulate. The fear may now be held in place by beliefs, safety behaviours or trauma (for example memories of intensive care). Use standard CBT or trauma-focused work within your competence, and agree on graded activity with the medical team. [synthesis]
Rupture: the client feels you are blaming anxiety for a physical illness. Validate the physical reality of the disease and the expertise of the medical team. Restate your role as helping with the fear and the impact of breathlessness, not explaining it away. [synthesis]
Conflicting professional advice. With consent, contact the prescribing clinician directly. Do not put the client in the middle. [synthesis]
Under-16s. Only with adult supervision and clinical advice. The device is not suitable under 7. Involve parents or carers, and follow safeguarding procedures. [source: POWERbreathe Classic user guide] [synthesis]
Infection control in shared settings (groups, families). Each person has their own device, which is never shared, including with family members. [source: POWERbreathe Classic user guide]

Sources

Web sources:

Publications cited:

Ammous O, Feki W, Lotfi T, et al. (2023). Inspiratory muscle training, with or without concomitant pulmonary rehabilitation, for chronic obstructive pulmonary disease (COPD). Cochrane Database of Systematic Reviews, CD013778.
Hill K, Cecins NM, Eastwood PR, Jenkins SC (2010). Inspiratory muscle training for patients with chronic obstructive pulmonary disease: a practical guide for clinicians. Archives of Physical Medicine and Rehabilitation, 91(9), 1466–1470.
Spruit MA, Singh SJ, Garvey C, et al. (2013). An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. American Journal of Respiratory and Critical Care Medicine, 188, e11–e40.
British Thoracic Society (2013). Guideline on pulmonary rehabilitation in adults. Cited here through the McConnell & Gosselink letter; the full guideline citation is [uncertain: not verified].
HajGhanbari B, Yamabayashi C, Buna TR, et al. (2013). Effects of respiratory muscle training on performance in athletes: a systematic review with meta-analyses. Journal of Strength and Conditioning Research, 27(6), 1643–1663.
Sadek Z, Salami A, Joumaa WH, Awada C, Ahmaidi S, Ramadan W. Best mode of inspiratory muscle training in heart failure patients: a systematic review and meta-analysis. European Journal of Preventive Cardiology, 25(16), 1691 [uncertain: year and volume not verified].
Saka S, Gürses HN, Bayram M (2021). Effect of inspiratory muscle training on dyspnea-related kinesiophobia in chronic obstructive pulmonary disease: a randomized controlled trial. Complementary Therapies in Clinical Practice, 44, 101418.

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