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Effect of Respiratory Muscle Training on Exercise Performance in Healthy Individuals: A Systematic Review and Meta-Analysis
Open accessAbstract
Objectives Two distinct types of specific respiratory muscle training (RMT), i.e. respiratory muscle strength (resistive/threshold) and endurance (hyperpnoea) training, have been established to improve the endurance performance of healthy individuals. We performed a systematic review and meta-analysis in order to determine the factors that affect the change in endurance performance after RMT in healthy subjects. Data sources A computerized search was performed without language restriction in MEDLINE, EMBASE and CINAHL and references of original studies and reviews were searched for further relevant studies. Review methods RMT studies with healthy individuals assessing changes in endurance exercise performance by maximal tests (constant load, time trial, intermittent incremental, conventional [non-intermittent] incremental) were screened and abstracted by two independent investigators. A multiple linear regression model was used to identify effects of subjects' fitness, type of RMT (inspiratory or combined inspiratory/expiratory muscle strength training, respiratory muscle endurance training), type of exercise test, test duration and type of sport (rowing, running, swimming, cycling) on changes in performance after RMT. In addition, a meta-analysis was performed to determine the effect of RMT on endurance performance in those studies providing the necessary data. Results The multiple linear regression analysis including 46 original studies revealed that less fit subjects benefit more from RMT than highly trained athletes (6.0% per 10 mL · kg⁻¹ · min⁻¹ decrease in maximal oxygen uptake, 95% confidence interval [CI] 1.8, 10.2%; p = 0.005) and that improvements do not differ significantly between inspiratory muscle strength and respiratory muscle endurance training (p = 0.208), while combined inspiratory and expiratory muscle strength training seems to be superior in improving performance, although based on only 6 studies (+12.8% compared with inspiratory muscle strength training, 95% CI 3.6, 22.0%; p = 0.006). Furthermore, constant load tests (+16%, 95% CI 10.2, 22.9%) and intermittent incremental tests (+18.5%, 95% CI 10.8, 26.3%) detect changes in endurance performance better than conventional incremental tests (both p < 0.001) with no difference between time trials and conventional incremental tests (p = 0.286). With increasing test duration, improvements in performance are greater (+0.4% per minute test duration, 95% CI 0.1, 0.6%; p = 0.011) and the type of sport does not influence the magnitude of improvements (all p > 0.05). The meta-analysis, performed on eight controlled trials revealed a significant improvement in performance after RMT, which was detected by constant load tests, time trials and intermittent incremental tests, but not by conventional incremental tests. Conclusion RMT improves endurance exercise performance in healthy individuals with greater improvements in less fit individuals and in sports of longer durations. The two most common types of RMT (inspiratory muscle strength and respiratory muscle endurance training) do not differ significantly in their effect, while combined inspiratory/expiratory strength training might be superior. Improvements are similar between different types of sports. Changes in performance can be detected by constant load tests, time trials and intermittent incremental tests only. Thus, all types of RMT can be used to improve exercise performance in healthy subjects but care must be taken regarding the test used to investigate the improvements.
Overview
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TL;DR
In healthy individuals, respiratory muscle training (RMT) improves endurance exercise performance, with larger gains in less fit subjects and longer-duration tests; effects are similar across sports and between inspiratory strength and endurance training, while combined inspiratory/expiratory strength training may be superior. RMT effects are detected by constant-load, time-trial, and intermittent incremental tests but not by conventional incremental tests.
Key findings
- In the multiple linear regression model including 46 original studies, less fit subjects benefited more from RMT: 6.0% per 10 mL·kg⁻¹·min⁻¹ decrease in maximal oxygen uptake (95% CI 1.8–10.2%; p = 0.005). Combined inspiratory and expiratory muscle strength training (RMST.INEX) improved performance more than inspiratory muscle strength training (RMST.IN) by +12.8% (95% CI 3.6–22.0%; p = 0.006; based on 6 studies), while RMET and RMST.IN did not differ significantly (p = 0.208).
- Constant load tests (+16.5%, 95% CI 10.2–22.8%; p < 0.001) and intermittent incremental tests (+18.5%, 95% CI 10.8–26.3%; p < 0.001) detected changes better than conventional incremental tests; time trials did not differ significantly from conventional incremental tests (p = 0.286). Improvements were greater with increasing test duration (+0.4% per minute, 95% CI 0.1–0.6%; p = 0.011), and type of sport did not influence the magnitude of improvement (all p > 0.05).
- The meta-analysis of 8 controlled trials found a significant overall improvement after RMT (standardised mean difference [SMD] 1.11, 95% CI 0.61–1.61; p < 0.001; I² = 71%). Subgroup analyses were significant for constant load tests (SMD 0.66, 95% CI 0.20–1.12; p = 0.005), time trials (SMD 1.85, 95% CI 0.88–2.82; p < 0.001), and intermittent incremental tests (SMD 2.95, 95% CI 1.12–4.80; p = 0.002), but not conventional incremental tests (SMD 0.30, 95% CI −0.20–0.79; p = 0.30). Overall improvement for RMT over control was 11%, with subgroup differences of 21% for constant load tests, 2% for time trials, 13% for intermittent incremental tests, and 7% for conventional incremental tests.
Methods
- Systematic review and meta-analysis of original studies assessing RMT (respiratory muscle strength training or respiratory muscle endurance training) on endurance performance in healthy humans. Searches were performed in MEDLINE, EMBASE, and CINAHL up to 31 October 2011 without language restriction; 49 studies were selected, and 46 were included in the multiple linear regression model after excluding 3 for missing test duration.
- Eligible exercise tests were constant load tests, time trials, intermittent incremental tests, or conventional (non-intermittent) incremental tests. The main outcome was relative change in endurance performance (test duration or maximal distance for fixed-duration time trials).
- A multiple linear regression model using generalised estimating equations (exchangeable correlation structure) included fitness, type of training (RMST.IN, RMST.INEX, RMET), type of test, test duration, and type of sport. A separate meta-analysis was performed on controlled trials with sham-training or no-training control groups and sufficient data, using a random effects model, I² statistics for heterogeneity, and a funnel plot for publication bias.
Limitations
- The paper states that training duration/intensity, exercise test intensity, and respiratory sensation variables were not included in the regression model to prevent collinearity or because too many studies lacked data; the funnel plot showed potential publication bias, with missing small studies with negative outcomes; and the meta-analysis included only 8 controlled trials. The authors also note that RMST.INEX evidence came from only 6 studies by 3 research groups, with physical improvements from one group using constant load tests only, so direct comparisons are needed.
- The text makes evident additional constraints: methodological quality was low (median 29%, range 14–86%), only 43% of studies had a sham-training group, and the meta-analysis studies were not fully representative of the regression-model studies (average change +15% vs +5%, p = 0.002; average fitness 2.6 vs 3.1, p = 0.065). Heterogeneity was moderate to substantial (I² = 71% overall; 78.3% for test-type comparison).
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“the type of sport does not influence the magnitude of improvements (all p > 0.05)”
- Also stated in: § Linear regression model · plain
“improvements are independent of exercise modality”
- Also stated in: § Abstract · plain
“Improvements are similar between different types of sports.”
§ Effect of respiratory muscle training on exercise performance in healthy individuals: a systematic review and meta-analysis > Abstract
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- Also stated in: § Linear regression model · plain
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In the paper
“improvements do not differ significantly between inspiratory muscle strength and respiratory muscle endurance training (p = 0.208)”
- Also stated in: § Linear regression model · plain
“effects of RMET and RMST.IN are similar”
- Also stated in: § Influence of type of RMT on improvements in exercise performance · plain
“The multiple regression analysis revealed that RMST.IN and RMET did not differ in their effect on improving exercise performance.”
§ Effect of respiratory muscle training on exercise performance in healthy individuals: a systematic review and meta-analysis > Abstract
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- Also stated in: § Linear regression model · plain
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In the paper
“Study quality did not correlate with the main outcome, i.e. with the relative change in performance.”
§ Effect of respiratory muscle training on exercise performance in healthy individuals: a systematic review and meta-analysis > Trial flow and study characteristics
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In the paper
“constant load tests (+16%, 95% CI 10.2, 22.9%) and intermittent incremental tests (+18.5%,95% CI 10.8, 26.3%) detect changes in endurance performance better than conventional incremental tests (both p < 0.001)”
- Also stated in: § Linear regression model · plain
“improvements in performance are greater in CLTs and IITs than in ITs”
§ Effect of respiratory muscle training on exercise performance in healthy individuals: a systematic review and meta-analysis > Abstract
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In the paper
“while it was not correlated with age (r = -0.018,p = 0.882)”
§ Effect of respiratory muscle training on exercise performance in healthy individuals: a systematic review and meta-analysis > Effect of subjects' fitness on improvements in exercise performance
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Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
In the citing paper
“The effects of RMET seem to be greatest for sustained endurance efforts at intensities of 65–85% of peak aerobic power (Morgan et al., 1987; Spengler and Boutellier, 2000; Illi et al., 2012; Shei, 2018).”
From Sex-Specific Effects of Respiratory Muscle Endurance Training on Cycling Time Trial Performance in Normoxia and Hypoxia (2021) · cites this paper as Illi et al., 2012
In the citing paper
“Their analysis suggested that the presence and type of such a control group did not make a difference.”
From Sex-Specific Effects of Respiratory Muscle Endurance Training on Cycling Time Trial Performance in Normoxia and Hypoxia (2021) · cites this paper as Illi et al. (2012)
In the citing paper
“In normoxia, respiratory muscle training (RMT) delays diaphragm fatigue and can improve the performance of endurance exercise (Boutellier, 1998; Spengler and Boutellier, 2000; Sheel, 2002; Illi et al., 2012; HajGhanbari et al., 2013; Segizbaeva et al., 2014; Shei, 2018).”
From Sex-Specific Effects of Respiratory Muscle Endurance Training on Cycling Time Trial Performance in Normoxia and Hypoxia (2021) · cites this paper as Illi et al., 2012
In the citing paper
“The lack of changes in running or cycling performance is at odds with two meta-analysis suggesting enhancements in time-trial performance following RMT4,5, but in line with other studies which also found no ergogenic effects of RMT in the absence38,39 or presence of sham or control groups40,41.”
From Similar effects on exercise performance following different respiratory muscle training programs in healthy young men (2023) · cites this paper as [4]
In the citing paper
“Both respiratory muscle endurance training (RMET) and inspiratory resistive training (IMT) seem to increase whole-body exercise performance, but direct comparisons between the two are scarce.”
From Similar effects on exercise performance following different respiratory muscle training programs in healthy young men (2023) · cites this paper as [4]
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In the paper
§ Effect of respiratory muscle training on exercise performance in healthy individuals: a systematic review and meta-analysis > Effect of type of exercise test and test duration on the improvement in exercise performance
“These authors used a protocol resulting in much shorter test durations (4.4 to 4.5 min) than the suggested 8-12 min required for max 2, O V determination.[107]”
§ Effect of respiratory muscle training on exercise performance in healthy individuals: a systematic review and meta-analysis > 43%
“IT 80% (cycle) = 5.0 min IT 60% (cycle) = 5.4 min IT 40% (cycle) = 4.5 min”
Citations
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Respiratory muscle work compromises leg blood flow during maximal exercise
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Optimizing the exercise protocol for cardiopulmonary assessment
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Wenger, H. A., & Bell, G. J. (1986) · Sports Medicine · doi:10.2165/00007256-198603050-00004 · Cited by 529
Predicted normal values for maximal respiratory pressures in caucasian adults and children.
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Hodges, P. W., & Gandevia, S. C. (2000) · Journal of Applied Physiology · doi:10.1152/jappl.2000.89.3.967 · Cited by 493
Cited by
Human Physiology in an Aquatic Environment
Pendergast, D. R., Moon, R. E., Krasney, J. J., Held, H. E., & Zamparo, P. (2015) · Comprehensive physiology · doi:10.1002/cphy.c140018 · Cited by 217
de Menezes, K. K. P., Nascimento, L. R., Ada, L., Polese, J. C., Avelino, P. R., & Teixeira‐Salmela, L. F. (2016) · Journal of physiotherapy · doi:10.1016/j.jphys.2016.05.014 · Cited by 153
Langer, D., Charususin, N., Jácome, C. I. O., Hoffman, M., MCCONNELL, A. K., Decramer, M., & Gosselink, R. (2015) · Physical Therapy · doi:10.2522/ptj.20140245 · Cited by 136
de Souza, H. C. D., Rocha, T. D. D. S., Pessoa, M. F., Rattes, C., Brandão, D. C., Fregonezi, G., Campos, S. L., Aliverti, A., & Dornelas, A. (2014) · The Journals of Gerontology Series A · doi:10.1093/gerona/glu182 · Cited by 135
Inspiratory muscle training for asthma
Silva, I. S., Fregonezi, G., Dias, F. A., Ribeiro, C. T., Guerra, R. O., & Ferreira, G. M. (2013) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd003792.pub2 · Cited by 125
Metadata
- Authors
- Illi, S. K., Held, U., Frank, I., & Spengler, C. M.
- Affiliations
- ETH Zurich (CH)
- University of Zurich (CH)
- Corresponding author
- Spengler, Christina M.
- Venue
- Sports Medicine
- Published
- 2012-08
- Volume
- 42
- Issue
- 8
- Pages
- 707-724
- ISSN
- 0112-1642 (ISSN-L)
- 1179-2035
- OpenAlex
- W1585284281
- Semantic Scholar
- 401359051f423b12ba33ef9c6499c2009cf30be0
- Cited by
- 411
- References
- 112
- Citations by year
- 2026: 58 · 2025: 40 · 2024: 37 · 2023: 39 · 2022: 38 · 2021: 27 · 2020: 30 · 2019: 36 · 2018: 22 · 2017: 14 · 2016: 19 · 2015: 15 · 2014: 16 · 2013: 14 · 2012: 6
- FWCI
- 1.80
- Type
- journal article
- Language
- en
- Open access
- green
- www.zora.uzh.ch
- Licence
- other-oa
- www.springer.com/tdm (tdm)
- Locations
- Sports Medicine (publishedVersion)
- PubMed (publishedVersion)
- Zurich Open Repository and Archive (University of Zurich) (acceptedVersion, other-oa)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion, other-oa)
- Zurich Open Repository and Archive (University of Zurich)
- Funders
- National Science Foundation
- Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung (3200B0, 116777)
- Bundesamt für Sport
- Topics
- Health Sciences › Medicine › Physiology (medical) › Cardiovascular and exercise physiology
- Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports Performance and Training
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Respiratory Support and Mechanisms
- Keywords
- respiratory muscle training, endurance performance, inspiratory muscle strength training, expiratory muscle strength training, respiratory muscle endurance training, VO2max, test length, training status, healthy individuals, rowing, running, swimming, cycling, time trial, incremental test, constant load test
- MeSH terms
- Breathing Exercises, Humans, Oxygen Consumption, Physical Endurance, Respiratory Muscles, Linear Models, Databases, Bibliographic, Muscle Strength, Athletic Performance
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