{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,24]],"date-time":"2026-07-24T11:02:03Z","timestamp":1784890923726,"version":"3.55.0"},"update-to":[{"DOI":"10.12688\/f1000research.175598.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T00:00:00Z","timestamp":1777939200000}},{"DOI":"10.12688\/f1000research.175598.2","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T00:00:00Z","timestamp":1777939200000}}],"reference-count":32,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T00:00:00Z","timestamp":1777939200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["f1000research.com"],"crossmark-restriction":false},"short-container-title":["F1000Res"],"abstract":"<ns5:p>\n                    Background Pulmonary rehabilitation (PR) is an established intervention for COPD, but the added value of inspiratory muscle training (IMT) within PR remains uncertain. This systematic review examined whether IMT plus PR provides benefits beyond PR alone in adults with moderate to severe COPD. Methods PubMed, ScienceDirect, Cochrane Library, and Web of Science were searched from inception to January 2023. Randomized controlled trials (RCTs) comparing IMT+PR with PR alone in adults with moderate to severe COPD were included. Primary outcomes were inspiratory muscle strength (PImax), dyspnea, health related quality of life (HRQoL), exercise capacity [six minute walk test (6MWT)], and pulmonary function tests (PFTs). Risk of bias was assessed using the Cochrane RoB 2.0 tool. Results Nine RCTs (n=295) met the inclusion criteria. IMT+PR improved PImax in 6\/9 studies, with gains of 5.2 to 22.9 cmH\n                    <ns5:sub>2<\/ns5:sub>\n                    O. Dyspnea improved in 6\/8 studies, often exceeding the minimal clinically important difference (MCID). HRQoL improved in all studies assessing this outcome (6\/6), although superiority of IMT+PR over PR or control conditions was not consistently demonstrated. Exercise capacity findings were mixed, with significant within-group 6MWT gains in 4 of 7 studies but inconsistent between-group differences. PFTs (FEV\n                    <ns5:sub>1<\/ns5:sub>\n                    , FVC) were generally unchanged, while limited data from single-center trials suggest reductions in dynamic hyperinflation and small increases in inspiratory capacity. Conclusion Adding IMT to PR meaningfully improves PImax and HRQoL in moderate to severe COPD, with frequent but less consistent benefits for dyspnea and 6MWT performance and minimal effect on spirometry. IMT may be most appropriate for patients with inspiratory muscle weakness (PImax &lt;60 cmH\n                    <ns5:sub>2<\/ns5:sub>\n                    O or &lt;50% predicted). Further RCTs should define optimal IMT protocols and clarify which COPD phenotypes derive the greatest benefit.\n                  <\/ns5:p>","DOI":"10.12688\/f1000research.175598.3","type":"journal-article","created":{"date-parts":[[2026,5,27]],"date-time":"2026-05-27T07:59:15Z","timestamp":1779868755000},"page":"19","update-policy":"https:\/\/doi.org\/10.12688\/f1000research.crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Inspiratory Muscle Training plus Pulmonary Rehabilitation versus Rehabilitation alone in COPD A Systematic Review of Randomized Controlled Trials"],"prefix":"10.12688","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0009-0006-4196-3454","authenticated-orcid":false,"given":"Fahad","family":"Algharbi","sequence":"first","affiliation":[{"name":"Department of Physiotherapy Dammam Eastern Province Imam Abdulrahman Bin Faisal University"},{"name":"Royal Commission Health Services program Al Jubail Eastern Province Royal Commission for Jubail and Yanbu"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shibili","family":"Nuhmani","sequence":"additional","affiliation":[{"name":"Department of Physiotherapy Dammam Eastern Province Imam Abdulrahman Bin Faisal University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammed","family":"Asiri","sequence":"additional","affiliation":[{"name":"Department of Physiotherapy Dammam Eastern Province Imam Abdulrahman Bin Faisal University"},{"name":"Department of Respiratory Therapy Kharj Maternity and Children Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4878-5025","authenticated-orcid":false,"given":"Alsayed","family":"Shanb","sequence":"additional","affiliation":[{"name":"Department of Physiotherapy Dammam Eastern Province Imam Abdulrahman Bin Faisal University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammed","family":"Al-Subaiei","sequence":"additional","affiliation":[{"name":"Department of Physiotherapy Dammam Eastern Province Imam Abdulrahman Bin Faisal University"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2560","published-online":{"date-parts":[[2026,5,5]]},"reference":[{"key":"ref1","first-page":"223-229","article-title":"Assessment of the Effects of Inspiratory Muscle Training (IMT) and Aerobic Training on the Quality of Life of Patients with Chronic Obstructive Pulmonary Disease.","volume":"18","author":"A Abedi Yekta","year":"2019 Mar","journal-title":"Tanaffos."},{"key":"ref2","doi-asserted-by":"publisher","DOI":"10.6084\/m9.figshare.30957968","article-title":"Extended dataset for \u201cInspiratory Muscle Training plus Pulmonary Rehabilitation versus Rehabilitation alone in COPD: A Systematic Review of Randomized Controlled Trials\u201d.","author":"F Algharbi","year":"2025","journal-title":"Figshare. 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Med (Lausanne)."}],"container-title":["F1000Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/f1000research.com\/articles\/15-19\/v3\/xml","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/f1000research.com\/articles\/15-19\/v3\/pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/f1000research.com\/articles\/15-19\/v3\/iparadigms","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,24]],"date-time":"2026-07-24T10:24:10Z","timestamp":1784888650000},"score":1,"resource":{"primary":{"URL":"https:\/\/f1000research.com\/articles\/15-19\/v3"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,5]]},"references-count":32,"URL":"https:\/\/doi.org\/10.12688\/f1000research.175598.3","relation":{"has-version":[{"id-type":"doi","id":"10.12688\/f1000research.175598.2","asserted-by":"subject"},{"id-type":"doi","id":"10.12688\/f1000research.175598.1","asserted-by":"subject"}],"has-review":[{"id-type":"doi","id":"10.5256\/f1000research.200338.r481839","asserted-by":"subject"},{"id-type":"doi","id":"10.5256\/f1000research.200338.r498181","asserted-by":"subject"},{"id-type":"doi","id":"10.5256\/f1000research.200338.r481839","asserted-by":"object"},{"id-type":"doi","id":"10.5256\/f1000research.200338.r498181","asserted-by":"object"}]},"ISSN":["2046-1402"],"issn-type":[{"value":"2046-1402","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,5]]},"assertion":[{"value":"Indexed","URL":"https:\/\/f1000research.com\/articles\/15-19\/v3#article-reports","order":0,"name":"referee-status","label":"Referee status","group":{"name":"current-referee-status","label":"Current Referee Status"}},{"value":"10.5256\/f1000research.193598.r452337, Noppawan Charususin, Thammasat University, Bangkok, Bangkok, 25 Feb 2026, version 1, 1 approved with reservations","URL":"https:\/\/f1000research.com\/articles\/15-19\/v1#referee-response-452337","order":0,"name":"referee-response-452337","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Fahad Algharbi<\/b>; \n<i>Posted: 03 Mar 2026<\/i>; Thank you for your careful review and thoughtful feedback; we greatly appreciate your insights and time.  Answer 1: Thank you for this important point. We agree that the Cochrane review by Ammous et al. is the highest-level synthesis on IMT in COPD, both as a stand-alone intervention and when combined with PR, and we wish to clarify the distinct and complementary rationale for our review.&nbsp;  While the Cochrane review evaluates two broad questions together (IMT alone and IMT plus PR) the key operational decision in clinical services is specifically whether adding IMT to an established PR pathway is worth the additional time, equipment, supervision, and adherence burden; our review isolates this integration question entirely, synthesizing outcomes and protocols exclusively in the context where PR is already being delivered, which is the precise scenario clinicians and rehabilitation programs face.&nbsp; Second, the Cochrane authors themselves explicitly acknowledge that a larger effect in people with inspiratory muscle weakness and with longer training durations remains to be confirmed, and that future research should focus on people with weakened breathing muscles; our review was designed to respond to this exact gap by extracting trial-level details that matter for service delivery ( baseline PImax, intensity progression, duration, device type, and supervision ) and by examining whether clinically meaningful signals appear stronger in more impaired patients and longer programs, thereby providing an implementation-oriented synthesis that directly addresses the uncertainty Cochrane identified rather than simply replicating its conclusions.&nbsp;  Also, the Ammous et al., 2023 review applied strict methodological exclusions, removing trials that used resistive devices without a controlled breathing pattern or with training loads below 30% of PImax; while methodologically rigorous, this means that many protocols actually used in PR settings ( particularly in frailer patients or early training phases ) are not represented in the Cochrane evidence base, and our broader, PR-embedded protocol mapping provides practical insight into what appears effective, tolerable, and deliverable across the range of real-world rehabilitation pathways.&nbsp;  Lastly, and perhaps most importantly, while Cochrane reports that PR plus IMT probably increases PImax without reaching their cited MCID of 17.2 cmH\u2082O, and that effects on 6MWD and HRQoL versus PR alone are uncertain or small at the pooled level, our review complements this by translating study-level findings into clinically interpretable ranges, demonstrating individual trial PImax gains of 5.2 to 22.9 cmH\u2082O, identifying that 100% of studies assessing HRQoL across multiple instruments \u201cSF-36, CCQ, ABC, and BBS\u201d reported statistically significant improvements that the SGRQ-focused Cochrane meta-analysis does not capture, highlighting where within-group changes exceed established MCID thresholds for 6MWT and dyspnea, and identifying the ceiling-effect pattern in patients with preserved baseline inspiratory strength that the Cochrane subgroup analysis could not resolve, all of which translate the existing evidence into a format directly applicable to patient selection and clinical decision-making in ways that a pooled mean difference structurally cannot.  Answer 2: The review was registered in PROSPERO (ID: CRD420251251860), and the manuscript has been updated accordingly.","URL":"https:\/\/f1000research.com\/articles\/15-19\/v3#referee-comment-15580","order":1,"name":"referee-comment-15580","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.200338.r481839, Patsaki Irini, University of West Attica, Egaleo, 27 May 2026, version 3, indexed","URL":"https:\/\/f1000research.com\/articles\/15-19\/v3#referee-response-481839","order":2,"name":"referee-response-481839","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.200338.r498181, Ivanizia S. Silva, Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, 24 Jul 2026, version 3, indexed","URL":"https:\/\/f1000research.com\/articles\/15-19\/v3#referee-response-498181","order":3,"name":"referee-response-498181","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"The author(s) declared that no grants were involved in supporting this work","order":4,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}