International Journal of Orthopaedic and Trauma Nursing 58 (2025) 101193

Contents lists available at ScienceDirect

International Journal of Orthopaedic and Trauma Nursing

journal homepage: www.elsevier.com/locate/ijotn

Review article

Inspiratory muscle training: A theoretical framework for its selected

application in orthopaedic enhancing recovery pathways
Francesco V. Ferraro a , Rania Edris b , Thomas W. Wainwright c,d,e,*
a
School of Sports and Exercise Science, College of Science and Engineering, University of Derby, Derby, United Kingdom
b
School of Science, College of Science and Engineering, University of Derby, Derby, United Kingdom
c
Orthopaedic Research Institute, Bournemouth University, Bournemouth, United Kingdom
d
Physiotherapy Department, University Hospitals Dorset NHS Foundation Trust, Bournemouth, United Kingdom
e
Rehabilitation Department, Lanzhou University, Lanzhou, China

A R T I C L E I N F O A B S T R A C T

Keywords: This paper explores a theoretical framework for integrating Inspiratory Muscle Training (IMT) into enhanced
Respiratory muscle training recovery pathways, emphasising its potential role in mitigating respiratory decline, reducing hospital stays, and
Pulmonary rehabilitation improving functional mobility for selected patients. IMT has shown benefits in high-risk surgical populations,
Prehabilitation
including those with chronic respiratory conditions, obesity, obstructive sleep apnea, and frailty. Standardised
Rehabilitation
Orthopaedic
screening protocols involving respiratory muscle function tests are recommended to identify suitable candidates,
with structured IMT programs ideally commencing 6–8 weeks before surgery. Implementing IMT within an
enhanced recovery pathway may enhance the ability for early mobilisation, improve oxygenation, and support
the functional recovery of patients. While IMT has demonstrated efficacy in various surgical populations, its
specific benefits to orthopaedic patients require further consideration and investigation. Indeed, future research
should focus on optimising IMT protocols and assessing patient outcomes in the short-term (e.g. length of stay
and complications), and the medium-term (e.g. return to activities of daily living). By incorporating IMT into
prehabilitation and rehabilitation protocols, we propose that healthcare systems may be able to improve surgical
outcomes and patients’ well-being while reducing postoperative complications and healthcare burden for at-risk
patients.

1. Introduction £30–£150 depending on features), and adaptability across different pa­

tient populations. Advances in IMT technology have evolved from sim­
Respiratory Muscle Training (RMT) encompasses a range of in­ ple analogic devices to digital and app-based solutions that offer real-
terventions designed to strengthen the muscles involved in breathing. time feedback and personalised progression (Stavrou et al., 2021).
Originally developed for athletes and healthy individuals to enhance IMT interventions generally fall into three main modalities: normo­
respiratory function and performance (Sapienza et al., 2011; Kowalski capnic hyperpnea, which involves near-maximal ventilation for a
et al., 2022), RMT has since expanded into clinical applications, sustained period (Hill et al., 2010); flow resistive loading, where
particularly in populations with compromised respiratory function. resistance is manipulated through variable-diameter orifices
Based on the targeted muscle groups, RMT can be categorised into (Mickleborough et al., 2010); and pressure threshold loading, which
Expiratory Muscle Training (EMT), which focuses on the Rectus and utilises a valve mechanism to generate a set inspiratory resistance (Silva
Transversus Abdominis, External and Internal Obliques (Laciuga et al., et al., 2013). Of these, pressure threshold loading has demonstrated
2014), Inspiratory Muscle Training (IMT) when focuses on the Dia­ the most consistent benefits across a range of conditions and re­
phragm and External intercostal (Rodrigues and McConnell, 2024), or a mains the most widely applied method in both research and clinical
combination of both (HajGhanbari et al., 2013). practice (McConnell and Romer, 2004; Romer and McConnell, 2003;
Among these, IMT has gained increasing attention over the past three Paiva et al., 2015).
decades due to its feasibility, low cost (e.g. devices often range from Within the context of enhanced recovery pathways, the potential

* Corresponding author. Orthopaedic Research Institute, Bournemouth University, Bournemouth, United Kingdom.
E-mail address: [email protected] (T.W. Wainwright).

https://doi.org/10.1016/j.ijotn.2025.101193
Received 11 March 2025; Received in revised form 6 May 2025; Accepted 19 May 2025
Available online 22 May 2025
1878-1241/© 2025 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
F.V. Ferraro et al. International Journal of Orthopaedic and Trauma Nursing 58 (2025) 101193

role of IMT in orthopaedic patients remains largely unexplored. While an evident gap in research concerning IMT application in obese popu­
most patients undergoing orthopaedic surgery may not require targeted lation undergoing orthopaedic surgery but based on other applications
respiratory training, certain at-risk populations, such as those with of IMT in other clinical areas, it is possible to conceive that IMT might
pre-existing respiratory impairments, obesity, frailty, or prolonged diminish the length of stay and reduce mortality in the obese population
immobilisation, may benefit from structured IMT interventions before undergoing arthroplasty.
and after surgery. As enhanced recovery pathways continue to evolve
towards more personalised recovery pathways, it is worth consid­ 2.1.3. Obstructive sleep apnea (OSA)
ering whether IMT could serve as an additional optimisation tool for Another common condition in elective orthopaedic surgery is
selected at-risk patients. Obstructive Sleep Apnea (OSA). A study by Finkel et al. screened 2877
This article explores the theoretical framework for IMT in ortho­ elective surgery patients and found that 23.7 % were at high risk for
paedic enhanced recovery pathways, examining its potential benefits, OSA, with 81 % of these cases previously undiagnosed (Porhomayon
relevant patient populations, optimal timing (preoperative vs. post­ et al., 2011). Additionally, it has been shown that OSA is frequently
operative), and proposed implementation strategies. Additionally, we undiagnosed in surgical populations, and its presence is associated with
discuss existing research gaps and highlight future directions for inte­ increased perioperative complications (Adesanya et al., 2010). For this
grating IMT into clinical practice. condition, several reviews reported the effects of IMT. In particular, de
Sousa et al. discussed how IMT in association with cardiac rehabilitation
2. Discussion exercises reduces apnea-hypopnea index and improves inspiratory
muscle strength, sleepiness and sleep quality compared with cardiac
2.1. Patients potentially at-risk of impaired respiratory function and rehabilitation alone (Silva de Sousa et al., 2024). Similarly, Dar et al. and
complications Torres Castro et al. reported that IMT alone significantly improves
inspiratory muscle strength, sleep quality, daytime sleepiness and lung
2.1.1. Chronic Obstructive Pulmonary Disease function in OSA. However, there is still debate on the effects of IMT on
Patients with Chronic Obstructive Pulmonary Disease (COPD) lung function (i.e., Forced Vital Capacity and Forced Expiratory Volume
experience breathing difficulties and obstruction due to airflow in­ in 1 s) (Torres-Castro et al., 2022; Dar et al., 2022). Although there is no
flammatory responses, increased mucus production and emphysematous research on the uses of IMT in OSA orthopaedic patients, it is possible
destruction of the gas-exchanging surface of the lung (Hogg and Timens, that incorporating IMT into the preoperative regimen may be advanta­
2009). This condition is more common in males and smokers, with a geous. Indeed, strengthening respiratory muscles could potentially
reported incidence rate of September 8, 1000 person-year (Terzikhan reduce perioperative respiratory complications and enhance post­
et al., 2016). In orthopaedic surgery, it has been reported that patients operative recovery.
with COPD undergoing revision of total knee arthroplasty (TKA) have a
higher incidence of postoperative complications compared to non-COPD 2.1.4. Older patients
patients (Gu et al., 2018). Other authors have highlighted that COPD Apart from the existing complications mentioned above, it is possible
patients undergoing TKA have a higher in-hospital mortality rate (0.1 %) to highlight orthopaedic patients who, without existing complications,
compared to non-COPD patients (0.03 %) and that they also tend to can be considered at high risk of respiratory complications, and IMT
experience longer hospital stays and increased treatment costs (Albagly might be used to mitigate the risks. According to the WHO, in 2020, the
et al., 2024; Shin et al., 2023). Several studies have shown that IMT has a number of people aged 60 years and older outnumber children younger
benefit in COPD populations. Gosselink demonstrated that IMT signifi­ than 5 years, and the proportion of the world’s population over 60 will
cantly improved respiratory muscle strength and endurance, resulting in nearly double in the next 20 years (WorldHealthOrganization, 2024).
reductions of dyspnoea and improvement in functional exercise capacity According to NHS England, between April 2018 and March 2019, 93.8 %
and quality of life (Gosselink et al., 2011). Similar results were reported of 81,130 hip replacements were in patients 50+ years old, with 51.9 %
by Figueiredo and Beaumont, who demonstrated improvements in over 70. The highest incidence was in ages 75–79 (323.1 per 100,000
inspiratory muscle strength, functional capacity, and pulmonary func­ females, 551.9 per 100,000 males). For 93,911 knee replacements, 97.4
tion but with no agreement on significant changes in dyspnea and % were in patients 50+ years old, with 51.8 % over 70. The peak
quality of life (Figueiredo et al., 2020; Beaumont et al., 2018). occurrence was in ages 75–79 (883.4 per 100,000 females, 760.4 per
100,000 males) (Digital, 2019). A condition that might affect the out­
2.1.2. Obesity comes of the operation and that is associated with physiological age
Obesity is a condition known to be associated with osteoarthritis and changes is senile emphysema.
poor metabolic health status (Horan, 2006). In 2021, the Health Survey This condition is characterised by the enlargement of airspaces
for England (HSE) reported that 25 % of men and 26 % of women were without significant destruction of alveolar walls and decreased elastic
classified as obese (Digital, 2021). This condition is common in knee recoil (Dyer, 2012). Although not directly pathological, the condition
arthroplasty, where a recent figure showed 63 % of patients were clas­ can affect people’s physical capacity and even lead to COPD (Janssens
sified as obese, with a mean Body Mass Index (BMI) of 37.5 kg/m2, with et al., 1999). In the past decade, many studies have highlighted the
potentially higher length of stay and mortality risks (Hennrikus et al., benefit of IMT in older adults, particularly in people over 75, where the
2021; Carender et al., 2022). Obesity can affect the respiratory system improvements in respiratory muscle strength, mobility and balance
and may lead to decreased lung volumes and compliance, causing a seem to be highly significant than in adults between 65 and 75 years old
higher risk of pulmonary complications, such as hypoventilation and (Ferraro et al., 2021). Recently, a systematic review showed how IMT
atelectasis (Carron et al., 2020). A recent systematic review and significantly positively affects balance and overall mobility in healthy
meta-analysis showed that IMT improved physical capacity measured and frailer older adults (Sheraz et al., 2023), indicating that the inter­
with 6 min walk test and inspiratory muscle strength obtained with vention is feasible also for frailer populations. Similarly, patients with
maximal inspiratory pressure but had no effects on lung function, BMI poor baseline will benefit from IMT intervention, particularly in
and metabolic parameters in obese populations (Caicedo-Trujillo et al., mobility and respiratory muscle strength. This is likely due to the
2023). Similar results were also reported in other metabolic conditions adaptive training principle, as it has been shown in healthy athletes as
where IMT has excellent results in improving physical capacity and well as ill conditions (HajGhanbari et al., 2013; Vorona et al., 2018).
inspiratory muscle strength (Sheraz et al., 2024) with significant in­
creases in inspiratory muscle strength with obese women undergoing 2.1.5. Smoking and vaping
open bariatric surgery (Barbalho-Moulim et al., 2011). However, there is Smoking is known to reduce lung function and can lead to

2
F.V. Ferraro et al. International Journal of Orthopaedic and Trauma Nursing 58 (2025) 101193

comorbidities during major operations (Alsanad et al., 2025). Similar delayed respiratory recovery or complication may be present. In each
vaping has been associated with increased airway resistance, breathing condition, IMT has been proposed to enhance respiratory function,
difficulties, and transient inflammation (Honeycutt et al., 2022) and it mobility, balance, and length of stay outcomes. However, it is yet to be
can potentially lead to healing complications affecting the physiological confirmed whether at-risk patients should be identified and treated
cardiovascular responses (Warner et al., 2020). The WHO reported that before, after, or at both time points in their intra-operative pathway.
smokers are more likely to experience postoperative issues such as This will vary on whether the operation is elective or following trauma,
impaired heart and lung function, infections, and delayed or impaired but for elective patients, it is important to calculate the patient’s risks for
wound healing (Organization, 2020). Smokers undergoing knee complications or delayed recovery at multiple timepoints and then
arthroplasty had a higher incidence of lower respiratory tract infections implement the best treatments (such as IMT for respiratory recovery and
(4.2 %) compared to non-smokers (2.7 %). Additionally, smokers complications) for resolving that risk (Briguglio and Wainwright, 2022).
exhibited increased usage of pain medications post-surgery and higher Pre-rehabilitation is becoming extremely common in non-traumatic
mortality rates within one year (Pandit et al., 2018). Similarly, research surgery as a multidisciplinary approach aimed at enhancing a pa­
on total hip arthroplasty patients revealed that smokers had an elevated tient’s functional capacity and reducing postoperative complications
risk of complications such as lower respiratory tract infections, before medical interventions (Fleurent-Grégoire et al., 2024). Two pilot
myocardial infarction, and cerebrovascular events compared to studies, one with major abdominal surgery patients and the other with
non-smokers and ex-smokers. Notably, ex-smokers demonstrated patients undergoing esophagectomy, showed that preoperative IMT
reduced risks, highlighting the benefits of smoking cessation prior to improved postoperative respiratory muscle function (Kulkarni et al.,
surgery (Matharu et al., 2019). While these studies provide valuable 2010; Dettling et al., 2013). Similar results were also reported by other
insights, specific research focusing on the effects of IMT in smokers or authors with potential benefits in diminishing pneumonia and atelec­
ex-smokers with reduced lung function is limited. Given the established tasis and increasing mobility post-operatively (Karanfil and Møller,
benefits of IMT in improving respiratory muscle strength and lung 2018; Guinan et al., 2019). Regarding postoperative IMT application,
function in other populations, it is plausible that smokers or ex-smokers Azambuja et al., in a recent systematic review, reported that rehabili­
with compromised pulmonary function may also benefit from such tative IMT increases maximal inspiratory pressure, 6 min walk test,
training (McConnell, 2013). However, further targeted research is maximum oxygen consumption and quality of life in patients with heart
necessary to confirm the efficacy and optimal protocols of IMT in this failure (Azambuja et al., 2020). Similar results were noticed in a more
specific group. recent review where rehabilitative IMT with adult patients undergoing
cardiac surgeries improved PeakVO2, 6 min walking test, maximal
2.1.6. Patients undergoing major orthopaedic surgeries inspiratory pressure, quality of life, postoperative pulmonary compli­
Although the application of IMT has not been explored in elective cations and spirometry outcomes (Starko et al., 2024). It is possible to
and trauma orthopaedic surgeries, it is possible to speculate on its deduce that IMT can be used as a pre- and post-operative intervention in
benefits for at-risk patients undergoing major orthopaedic surgery based orthopaedic surgery, Fig. 1; however, future research should investigate
on data from other surgical specialties. Katsura et al. completed a the impact of the intervention on rehabilitative outcomes.
Cochrane review to assess the effectiveness of preoperative IMT on
postoperative pulmonary complications in adults undergoing cardiac or 3. Theoretical framework
major surgery, and they reported that preoperative IMT reduces post­
operative atelectasis, pneumonia and length of hospital stay (Katsura Given the applications of IMT and clinical results across different
et al., 2015). The benefit of these abdominal and thoracic procedures is contexts discussed, we may summarise that IMT can be associated with
interesting, given the previously shown effect of IMT on spinal condi­ four main clinical benefits: i) improvement in respiratory muscle
tions several studies have reported how IMT can diminish low back pain strength and function – due to the conditioning effect of the intervention
and improve mobility in healthy and abdominal pathological conditions itself, which focuses on inspiratory muscle strength exercises; ii)
(Borujeni and Yalfani, 2019; Ahmadnezhad et al., 2020). These results improvement in quality of life, due to patients feeling better (measured
suggest that IMT may be a useful adjunct for patients at-risk undergoing via QoL dedicated questionnaires (Yekta et al., 2019)) and more active
procedures such as major spine surgery, where multi-level fusion pro­ post-intervention; iii) improvement in functional mobility (e.g., 6 min
cedures are completed for degenerative spine conditions. walking tests); iv) improvement in dynamic balance (e.g., mini-BEST).
Another aspect that has been well explored is the positive association Refer to Fig. 2.
between improvement in inspiratory muscle strength and improvement It is possible to highlight three main theories to explain these results.
in dynamic balance (e.g., walking). This is important, given the known First, the diaphragm plays a dual role in respiration and core stabilisa­
increased fall risk in the early recovery stages after TJA or surgery for tion by modulating intra-abdominal pressure (IAP), which is essential
fractured neck of femur. Recent studies have shown how older pop­ for postural control and balance. Hence, stronger inspiratory muscles
ulations (65+) and care-home dwellers reported significant improve­ contribute to better IAP control, resulting in high core management and
ment in dynamic balance measured with the mini-BEST test following 8 better mobility (Hodges and Gandevia, 2000; Papalia et al., 2020). A
consecutive weeks of IMT (Ferraro et al., 2019, 2020). Similar im­ second theory is that IMT provides patients with less perceived exertion,
provements have been noticed in older diabetes population (SHERAZ and as a consequence, it enhances gait endurance and walking perfor­
et al., 2024a, SHERAZ et al., 2024b), where an IMT intervention has mance (e.g., 6 min walking test) (Fabero-Garrido et al., 2022; Shoe­
improved an initial lack of balance. More recently, IMT has been asso­ maker et al., 2009). A third and final theory is that IMT produces a
ciated with other forms of balance training, such as Tai Chi, where im­ positive effect on the metaboreflex, which results in increased
provements in balance were also associated with higher improvements endurance-based activities (McConnell and Romer, 2004; Illi et al.,
in overall mobility (Ferraro et al., 2025). Hence, it is possible to conceive 2012). An agreement has not been reached regarding the mechanisms
that integrating IMT in major orthopaedic surgery and TJA as a pre and that link improvement in inspiratory muscle strength with mobility and
post rehabilitation intervention may help to increase balance and balance outcomes hence, it is possible to conclude that a combination of
mobility for certain groups of patients, leading to better post-operative all these elements plays a role as mobility and balance are considered
outcomes. multimodal tasks that require holistic approaches (Pollock et al., 2000).

2.1.7. Pre and post rehabilitation 4. Specific benefits of IMT in orthopaedics

The previous sections discuss the proposed applications of IMT for
different types of orthopaedic patients and surgery where the risk of TJA are among the most common elective orthopaedic procedures,

3
F.V. Ferraro et al. International Journal of Orthopaedic and Trauma Nursing 58 (2025) 101193

restriction (Karcz and Papadakos, 2013) have reduced since the intro­
duction of enhanced recovery pathways but remain a preventable
complication of surgery. When they occur, PPCs, such as atelectasis and
pneumonia, significantly impact patient outcomes, leading to increased
hospital stays, healthcare costs, and higher postoperative morbidity
(Fernandez-Bustamante et al., 2017). Specific patient populations,
including older adults and individuals with pre-existing respiratory
conditions such as COPD, obesity, and OSA, are particularly vulnerable
to these complications, and as such, they could potentially benefit from
targeted interventions to optimise respiratory function and accelerate
recovery (Caicedo-Trujillo et al., 2023; Torres-Castro et al., 2022;
Krause-Sorio et al., 2021).
IMT can be a promising intervention to enhance recovery in ortho­
paedic surgery through its ability to strengthen respiratory muscles,
improve lung function pre- and postoperatively, and enhance functional
mobility. Evidence suggests that IMT can reduce the length of hospital
stay, lower the incidence of PPCs, and contribute to improved post-
surgical outcomes (Kendall et al., 2018; Ge et al., 2018). Additionally,
preoperative IMT has demonstrated effectiveness in enhancing respira­
tory endurance and strength, thus reducing postoperative respiratory
decline (Katsura et al., 2015). Furthermore, IMT has been shown to be
particularly beneficial in reducing PPCs in surgical populations, with
notable improvements in inspiratory strength, oxygenation, and func­
tional exercise capacity (Silva de Sousa et al., 2024). In order to realise
these benefits, a structured IMT program should ideally commence four
to six-eight weeks before surgery (Fig. 2), employing threshold-loading
devices to optimise inspiratory muscle strength and reduce post­
operative complications (Paiva et al., 2015). Whilst postoperatively,
IMT should be integrated into rehabilitation protocols to support res­
piratory recovery, facilitate early mobilisation, balance and counteract
respiratory muscle weakness.

5. Challenges in implementing IMT in ERAS pathways

Despite the promising benefits of IMT, there are significant limita­

tions to its implementation in orthopaedic enhanced recovery pathways.
One major challenge is the lack of standardised IMT protocols. The
literature shows considerable heterogeneity in IMT regimen design
training intensities ranging roughly from 30 % to 80 % of a patient’s
maximal inspiratory pressure (MIP), frequencies from once daily to
several times per week, and program durations from a few weeks up to
3–6 months in different studies (Katsura et al., 2015; Starko et al., 2024).
Such variability in intensity, duration and patient selection criteria re­
Fig. 1. An older patient uses an Inspiratory Muscle Training device to train
flects an absence of consensus on the optimal IMT protocol for surgical
their inspiratory muscle strength.
patients. This lack of homogeneity makes it difficult to establish
best-practice guidelines, as outcomes are hard to compare across studies.
aiming to restore physiological function in patients with advanced
However, based on previous literature and expected outcomes, a pre­
osteoarthritis or joint degeneration (Seidlitz and Kip, 2018). Despite the
liminary recommended protocol is reported in Table 1.
widely recognised success of TJA, post-arthroplasty recovery for some
Workflow integration into the perioperative pathway is also chal­
patients continues to be sub-optimal, particularly in terms of reduced
lenging, as the prehabilitation window may be too short for patients to
functional mobility, increased risk of falls, and social isolation, which
complete a meaningful IMT course (see Table 2). Adding IMT sessions
may prolong rehabilitation and delays the return to daily activities
requires coordination across multidisciplinary teams. Studies report
(Changjun et al., 2023; Chen et al., 2019; Choi et al., 2022).
organisational barriers such as scheduling constraints and poor inte­
Studies have shown that a notable percentage of patients continue to
gration into the patient pathway. Perioperative staff also need training
experience long-term discomfort following TKA (Edwards et al., 2022),
in IMT techniques and devices, which is not routinely part of ortho­
which can affect health-related quality of life, leading to functional
paedic ERAS protocols. Without dedicated training and buy-in from
limitations, depression, anxiety, and sleep problems (Wylde et al.,
clinicians, IMT can be inconsistently delivered (Briguglio and Wain­
2018). While THA is generally associated with improved mobility, it
wright, 2022).
similarly presents significant postoperative mobility challenges that
Patient adherence to IMT regimens is a well-recognised issue. Even
impact recovery and overall patient well-being (Luo et al., 2024). These
when an IMT program is offered, keeping patients engaged and
limitations affect patients’ independence and increase fall risk, which
compliant throughout the pre- and postoperative period is difficult as
prolongs rehabilitation, particularly in older adults or those with
patients who might be skeptical about the benefits of IMT or do not feel
pre-existing comorbidities (Olsen et al., 2024; Cole et al., 2022; Edwards
an immediate need for it are less likely to commit to the training
et al., 2022; Seidlitz and Kip, 2018).
(Azambuja et al., 2020). Finally, implementing a new prehabilitation
Postoperative pulmonary complications (PPCs), as a consequence of
intervention requires institutional support in terms of funding,
anaesthesia, prolonged immobility, and pain-related respiratory
personnel, and infrastructure (Davis et al., 2022). Even though an IMT

4
F.V. Ferraro et al. International Journal of Orthopaedic and Trauma Nursing 58 (2025) 101193

Fig. 2. Infographic summarising the definition of Inspiratory Muscle Training, the recommended training protocol and the conditions discussed in the manuscript.
+
COPD = Chronic Obstructive Pulmonary Disease, *Including multi-level spinal and prolonged procedures.

Table 1
– Examples of Inspiratory Muscle Training protocol to be used in orthopaedic surgery.
Phase Setting Frequency Intensity Progression Supervision

Pre-operative Phase Home 1–2x/day, 50 % of the Increasing resistance when patients can achieve Weekly physio check-in
2–4 weeks before 15 min measured MIP more than 30 breaths
surgery
Days 1–5 post-op Hospital/ 1- 2x/day, 30 % of pre-op MIP Increasing resistance when patients can achieve Physiotherapist supervised whilst in
Home 15 min more than 30 breaths hospital.
Days 6–14 post- Home 2x/day, 40–50 % of updated Increasing resistance when patients can achieve Patient logs, effort and symptoms; weekly
discharge 15 min MIP more than 30 breaths remote check-ins
Weeks 3–ongoing Home 2x/day, 60–70 % of MIP Aim to reach maximum resistance within eight None needed
15 min consecutive weeks of training

A protocol of Inspiratory Muscle Training for orthopaedic surgery has not been developed yet; however, it is possible to create a protocol based on previous findings.
Modified from Ferraro et al. (2025); McConnell (2013). MIP = Maximal Inspiratory Pressure; min = minutes.
As an example - The above Inspiratory Muscle Training protocol could be applied to the surgical pathway for the below patient.
Patient profile:Mrs X is a 74-year-old female scheduled for an elective total hip replacement (THR) due to severe osteoarthritis. Her medical history includes
well-controlled COPD (GOLD Stage II), obesity (BMI 36), and reduced mobility due to her hip joint pain. Pulmonary function tests reveal a XX (low-normal for age and
sex). She is an ex-smoker and lives independently but reports struggling with prolonged exertion and stair-climbing.
Preoperative Screening and MDT Planning:Following her pre-operative assessment, Mrs X is identified as potentially at risk of postoperative pulmonary compli­
cations (PPCs) and impaired cardio-respiratory capacity. The preoperative team (which may include physiotherapist, nurse specialist, and respiratory therapist)
recommend an Inspiratory Muscle Training (IMT) program integrated into her enhanced recovery pathway.

device for an individual patient is relatively inexpensive, running a 6. Conclusive summary of clinical recommendations
program at scale entails costs for equipment procurement, staff training,
and potentially extending preoperative services. A qualitative study of a To optimise surgical outcomes and reduce postoperative complica­
multimodal prehabilitation program noted that staff shortages and lack tions, we propose that IMT could be systematically integrated into
of organisational capacity were major barriers to prehabilitation enhanced recovery pathways for at-risk patients through a screening
implementation (Fuchs et al., 2024). Indeed, inconsistent availability of process (e.g. respiratory muscle function tests such as maximal inspi­
IMT across institutions reflects these systemic issues, highlighting the ratory pressure) and tailored intervention protocols (such as four to six-
need for greater investment and structural support. eight weeks of training). We propose that by IMT may be a useful
adjunct to enhanced recovery pathways in order to help promote early
mobilisation, reduce pulmonary complications, and improve overall
balance, mobility and quality of life for patients with impaired

5
F.V. Ferraro et al. International Journal of Orthopaedic and Trauma Nursing 58 (2025) 101193

Table 2 undergoing open bariatric surgery: respiratory muscle strength, lung volumes, and
– Comparison between Inspiratory Muscle Training’s known benefits and its diaphragmatic excursion. Clinics (São Paulo) 66, 1721–1727.
Beaumont, M., Forget, P., Couturaud, F., Reychler, G., 2018. Effects of inspiratory muscle
expected benefits in the orthopaedic surgery population. training in COPD patients: a systematic review and meta-analysis. The clinical
IMT Known Benefits IMT Expected Benefits in the Orthopaedic respiratory journal 12, 2178–2188.
surgery population Borujeni, B.G., Yalfani, A., 2019. Reduction of postural sway in athletes with chronic low
back pain through eight weeks of inspiratory muscle training: a randomized
• Improves respiratory muscle • Enhances post-arthroplasty recovery by controlled trial. Clin. BioMech. 69, 215–220.
strength and function improving respiratory endurance Briguglio, M., Wainwright, T.W., 2022. Nutritional and physical prehabilitation in
• Enhances lung function and • Reduces postoperative pulmonary elective orthopedic surgery: rationale and proposal for implementation. Therapeut.
oxygenation complications in TKA and THA patients Clin. Risk Manag. 21–30.
• Reduces postoperative pulmonary • Facilitates early mobilisation and Caicedo-Trujillo, S., Torres-Castro, R., Vasconcello-Castillo, L., Solis-Navarro, L.,
complications (e.g., atelectasis, rehabilitation effectiveness Sanchez-Ramirez, D., Núñez-Cortés, R., Vera-Uribe, R., Muñoz-Muñoz, I., Barros-
pneumonia) • Improves functional mobility, Poblete, M., Romero, J.E., 2023. Inspiratory muscle training in patients with obesity:
a systematic review and meta-analysis. Front. Med. 10, 1284689.
• Improves functional mobility (e.g., potentially accelerating return to daily
Carender, C.N., Glass, N.A., Demik, D.E., Elkins, J.M., Brown, T.S., Bedard, N.A., 2022.
6-min walk test) activities
Projected prevalence of obesity in primary total knee arthroplasty: how big will the
• Enhances balance and reduces fall • Reduces fall risk, particularly in older problem get? J. Arthroplast. 37, 1289–1295.
risk adults undergoing joint replacement Carron, M., Safaee Fakhr, B., Ieppariello, G., Foletto, M., 2020. Perioperative care of the
• Reduces perceived exertion and • May alleviate postoperative fatigue and obese patient. Journal of British Surgery 107, e39–e55.
improves exercise tolerance improve patient-reported outcomes Changjun, C., Jingkun, L., Yun, Y., Yingguang, W., Yanjun, R., Debo, Z., Kaining, Z.,
• Improves quality of life and reduces • Supports patients with pre-existing res­ Pengde, K., 2023. Enhanced recovery after total joint arthroplasty (TJA): a
fatigue piratory conditions, improving surgical contemporary systematic review of clinical outcomes and usage of key elements.
• Supports recovery in high-risk pop­ outcomes Orthop. Surg. 15, 1228–1240.
ulations (e.g., COPD, obesity, OSA) • Reduces hospital stay duration by Chen, S.K., Voaklander, D., Perry, D., Jones, C.A., 2019. Falls and fear of falling in older
• Reduces hospital length of stay and enhancing recovery efficiency adults with total joint arthroplasty: a scoping review. BMC Muscoskelet. Disord. 20,
healthcare burden • May mitigate the impact of prolonged 1–8.
• Can be integrated into immobilisation on respiratory function Choi, Y.S., Kim, T.W., Chang, M.J., Kang, S.-B., Chang, C.B., 2022. Enhanced recovery
after surgery for major orthopedic surgery: a narrative review. Knee surgery &
prehabilitation and rehabilitation • Contributes to a holistic recovery
related research 34, 8.
programs approach by addressing both physical
Cole, S., Kolovos, S., Soni, A., Delmestri, A., Sanchez-Santos, M.T., Judge, A., Arden, N.
and respiratory health
K., Beswick, A.D., Wylde, V., Gooberman-Hill, R., 2022. Progression of chronic pain
and associated health-related quality of life and healthcare resource use over 5 years
after total knee replacement: evidence from a cohort study. BMJ Open 12, e058044.
respiratory function. A multidisciplinary approach involving surgeons, Dar, J.A., Mujaddadi, A., Moiz, J.A., 2022. Effects of inspiratory muscle training in
anaesthetists, nurses, and respiratory therapists is essential for success­ patients with obstructive sleep apnoea syndrome: a systematic review and meta-
analysis. Sleep Science 15, 480–489.
ful integration. Future research should focus on refining IMT protocols, Davis, J.F., van Rooijen, S.J., Grimmett, C., West, M.A., Campbell, A.M., Awasthi, R.,
assessing long-term benefits, and validating its role in orthopaedic sur­ Slooter, G.D., Grocott, M.P., Carli, F., Jack, S., 2022. From theory to practice: an
gical pathways. In conclusion, IMT may be a useful intervention to add international approach to establishing prehabilitation programmes. Current
Anesthesiology Reports 12, 129–137.
to orthopaedic enhanced recovery pathways, given its proven evidence Dettling, D.S., van der Schaaf, M., Blom, R.L., Nollet, F., Busch, O.R., van Berge
base in other areas, low cost, and potential to help accelerate recovery Henegouwen, M.I., 2013. Feasibility and effectiveness of pre-operative inspiratory
and reduce complications for those patients at a higher risk of muscle training in patients undergoing oesophagectomy: a pilot study. Physiother.
Res. Int. 18, 16–26.
respiratory-related complications.
Digital, N., 2021. Health Survey for England 2021: overweight and obesity. https://
digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-eng
CRediT authorship contribution statement land/2021/part-2-overweight-and-obesity.
Digital, N.H.S., 2019. Patient-Reported Outcome Measures (PROMs): Finalised Hip &
Knee Replacements (April 2018 - March 2019). NHS Digital.
Francesco V. Ferraro: Writing – review & editing, Writing – original Dyer, C., 2012. The interaction of ageing and lung disease. Chron. Respir. Dis. 9, 63–67.
draft, Visualization, Conceptualization. Rania Edris: Writing – review & Edwards, R.R., Campbell, C., Schreiber, K.L., Meints, S., Lazaridou, A., Martel, M.O.,
editing, Writing – original draft. Thomas W. Wainwright: Writing – Cornelius, M., Xu, X., Jamison, R.N., Katz, J.N., 2022. Multimodal prediction of pain
and functional outcomes 6 months following total knee replacement: a prospective
review & editing, Writing – original draft, Conceptualization. cohort study. BMC Muscoskelet. Disord. 23, 302.
Fabero-Garrido, R., Del Corral, T., Angulo-Díaz-Parreño, S., Plaza-Manzano, G., Martín-
Declaration of competing interest Casas, P., Cleland, J.A., Fernandez-DE-Las-Penas, C., López-DE-Uralde-Villanueva, I.,
2022. Respiratory muscle training improves exercise tolerance and respiratory
muscle function/structure post-stroke at short term: a systematic review and meta-
The authors declare the following financial interests/personal re­ analysis. Annals of Physical and Rehabilitation Medicine 65, 101596.
lationships which may be considered as potential competing interests: Fernandez-Bustamante, A., Frendl, G., Sprung, J., Kor, D.J., Subramaniam, B., Ruiz, R.
M., Lee, J.-W., Henderson, W.G., Moss, A., Mehdiratta, N., 2017. Postoperative
Guest Editor for VSI - Enhanced Recovery Pathways in Orthopaedic and pulmonary complications, early mortality, and hospital stay following
Trauma Care (TWW) If there are other authors, they declare that they noncardiothoracic surgery: a multicenter study by the perioperative research
have no known competing financial interests or personal relationships network investigators. JAMA Surg. 152, 157–166.
Ferraro, F.V., Gavin, J.P., Wainwright, T., Mcconnell, A., 2019. The effects of 8 weeks of
that could have appeared to influence the work reported in this paper. inspiratory muscle training on the balance of healthy older adults: a randomized,
double-blind, placebo-controlled study. Physiological reports 7, e14076.
References Ferraro, F.V., Gavin, J.P., Wainwright, T.W., Mcconnell, A.K., 2020. Comparison of
balance changes after inspiratory muscle or Otago exercise training. PLoS One 15,
e0227379.
Adesanya, A.O., Lee, W., Greilich, N.B., Joshi, G.P., 2010. Perioperative management of
Ferraro, F.V., Gavin, J.P., Wainwright, T.W., Mcconnell, A.K., 2021. Association between
obstructive sleep apnea. Chest (Am. Coll. Chest Physicians) 138, 1489–1498.
inspiratory muscle function and balance ability in older people: a pooled data
Ahmadnezhad, L., Yalfani, A., Borujeni, B.G., 2020. Inspiratory muscle training in
analysis before and after inspiratory muscle training. J. Aging Phys. Activ 30,
rehabilitation of low back pain: a randomized controlled trial. J. Sport Rehabil. 29,
421–433.
1151–1158.
Ferraro, F.V., Zhou, Y., Roldan, A., Edris, R., 2025. Multimodal respiratory muscle
Albagly, A., Kobo, O., Yonai, Y., Berkovich, Y., Steinfeld, Y., 2024. COPD patient’s
training and Tai Chi intervention with healthy older adults: a double-blind
outcomes following total knee arthroplasty—an analysis of the national inpatients
randomised placebo control trial. J. Bodyw. Mov. 42, 527–534.
sampling (2016–2020). J. Clin. Med. 13, 5578.
Figueiredo, R.I., Azambuja, A.M., Cureau, F.V., Sbruzzi, G., 2020. Inspiratory muscle
Alsanad, M., Aljanoubi, M., Alenezi, F.K., Farley, A., Naidu, B., Yeung, J., 2025.
training in COPD. Respir. Care 65, 1189–1201.
Preoperative smoking cessation interventions: a systematic review and meta-
Fleurent-Grégoire, C., Burgess, N., Mcisaac, D.I., Chevalier, S., Fiore, J.R.J.F., Carli, F.,
analysis. Perioper. Med. 14, 5.
Levett, D., Moore, J., Grocott, M.P., Copeland, R., 2024. Towards a common
Azambuja, A.D.C.M., DE Oliveira, L.Z., Sbruzzi, G., 2020. Inspiratory muscle training in
definition of surgical prehabilitation: a scoping review of randomised trials. British
patients with heart failure: what is new? Systematic review and meta-analysis. Phys.
journal of anaesthesia.
Ther. 100, 2099–2109.
Fuchs, T.I., Pfab, C., Kiselev, J., Schaller, S.J., Spies, C., Rombey, T., 2024. Barriers and
Barbalho-Moulim, M.C., Miguel, G.P.S., Forti, E.M.P., Do Amaral Campos, F., Costa, D.,
facilitators to the implementation of prehabilitation for elderly frail patients prior to
2011. Effects of preoperative inspiratory muscle training in obese women

6
F.V. Ferraro et al. International Journal of Orthopaedic and Trauma Nursing 58 (2025) 101193

elective surgery: a qualitative study with healthcare professionals. BMC Health Serv. years after total knee arthroplasty: a prospective observational study. BMC
Res. 24, 536. Muscoskelet. Disord. 25, 22.
Ge, X., Wang, W., Hou, L., Yang, K., Fa, X., 2018. Inspiratory muscle training is Organization, W.H., 2020. Smoking Greatly Increases Risk of Complications after
associated with decreased postoperative pulmonary complications: evidence from Surgery. World Health Organization website. November, 9.
randomized trials. J. Thorac. Cardiovasc. Surg. 156, 1290–1300 e5. Paiva, D.N., Assmann, L.B., Bordin, D.F., Gass, R., Jost, R.T., Bernardo-Filho, M.,
Gosselink, R., DE Vos, J., van Den Heuvel, S., Segers, J., Decramer, M., Kwakkel, G., França, R.A., Cardoso, D.M., 2015. Inspiratory muscle training with threshold or
2011. Impact of inspiratory muscle training in patients with COPD: what is the incentive spirometry: which is the most effective? Rev. Port. Pneumol. 21, 76–81.
evidence? Eur. Respir. J. 37, 416–425. Pandit, H., Mouchti, S., Matharu, G., Delmestri, A., Murray, D., Judge, A., 2018. The
Gu, A., Wei, C., Maybee, C.M., Sobrio, S.A., Abdel, M.P., Sculco, P.K., 2018. The impact effect of smoking on postoperative complications and PATIENT-REPORTED
of chronic obstructive pulmonary disease on postoperative outcomes in patients outcomes following primary knee arthroplasty. Orthopaedic proceedings. Bone Joint
undergoing revision total knee arthroplasty. J. Arthroplast. 33, 2956–2960. Lett. 46, 46.
Guinan, E., Forde, C., O’Neill, L., Gannon, J., Doyle, S., Valkenet, K., Trappenburg, J., Papalia, G.F., Papalia, R., Diaz Balzani, L.A., Torre, G., Zampogna, B., Vasta, S.,
van Hillegersberg, R., Ravi, N., Hussey, J., 2019. Effect of preoperative inspiratory Fossati, C., Alifano, A.M., Denaro, V., 2020. The effects of physical exercise on
muscle training on physical functioning following esophagectomy. Dis. Esophagus balance and prevention of falls in older people: a systematic review and meta-
32, doy091. analysis. J. Clin. Med. 9, 2595.
Hajghanbari, B., Yamabayashi, C., Buna, T.R., Coelho, J.D., Freedman, K.D., Morton, T. Pollock, A.S., Durward, B.R., Rowe, P.J., Paul, J.P., 2000. What is balance? Clin. Rehabil.
A., Palmer, S.A., Toy, M.A., Walsh, C., Sheel, A.W., 2013. Effects of respiratory 14, 402–406.
muscle training on performance in athletes: a systematic review with meta-analyses. Porhomayon, J., el-Solh, A., Chhangani, S., Nader, N.D., 2011. The management of
J. Strength Condit Res. 27, 1643–1663. surgical patients with obstructive sleep apnea. Lung 189, 359–367.
Hennrikus, M., Hennrikus, W.P., Lehman, E., Skolka, M., Hennrikus, E., 2021. The Rodrigues, G.D., Mcconnell, A.K., 2024. The Misuse of Respiratory Resistive Loading
obesity paradox and orthopedic surgery. Medicine 100, e26936. during Aerobic Exercises: Revisiting Mechanisms of “Standalone” Inspiratory Muscle
Hill, K., Cecins, N.M., Eastwood, P.R., Jenkins, S.C., 2010. Inspiratory muscle training for Training. American Physiological Society, Rockville, MD.
patients with chronic obstructive pulmonary disease: a practical guide for clinicians. Romer, L.M., Mcconnell, A.K., 2003. Specificity and reversibility of inspiratory muscle
Arch. Phys. Med. Rehabil. 91, 1466–1470. training. Med. Sci. Sports Exerc. 35, 237–244.
Hodges, P.W., Gandevia, S.C., 2000. Activation of the human diaphragm during a Sapienza, C., Troche, M., Pitts, T., Davenport, P., 2011. Respiratory strength training:
repetitive postural task. J. Physiol. 522, 165–175. concept and intervention outcomes. Seminars in Speech and Language. © Thieme
Hogg, J.C., Timens, W., 2009. The pathology of chronic obstructive pulmonary disease. Medical Publishers, pp. 21–30.
Annu. Rev. Pathol. 4, 435–459. Seidlitz, C., Kip, M., 2018. Introduction to the indications and procedures. White Paper
Honeycutt, L., Huerne, K., Miller, A., Wennberg, E., Filion, K.B., Grad, R., Gershon, A.S., on Joint Replacement: Status of Hip and Knee Arthroplasty Care in Germany,
Ells, C., Gore, G., Benedetti, A., 2022. A systematic review of the effects of e-cigarette pp. 1–14.
use on lung function. NPJ primary care respiratory medicine 32, 45. Sheraz, S., Ferraro, F.V., Siddiqui, F.A., Tariq, H., Anthony Faghy, M., Malik, A.N., 2023.
Horan, F., 2006. Obesity and joint replacement. The Journal of Bone & Joint Surgery The effects of inspiratory muscle training on balance and functional mobility: a
British 88, 1269–1271. systematic review. PGM (Postgrad. Med.).
Illi, S.K., Held, U., Frank, I., Spengler, C.M., 2012. Effect of respiratory muscle training on Sheraz, S., Malik, A.N., Ferraro, F.V., Siddiqi, F.A., 2024. Multifactorial inspiratory
exercise performance in healthy individuals: a systematic review and meta-analysis. muscle training and its impact on respiratory and functional parameters of patients
Sports Med. 42, 707–724. with diabetic polyneuropathy—a Randomized Controlled Trial. Physiother. Res. Int.
Janssens, J.-P., Pache, J.-C., Nicod, L., 1999. Physiological changes in respiratory 29, e2127.
function associated with ageing. Eur. Respir. J. 13, 197–205. Shin, K.-H., Kim, J.-U., Jang, I.-T., Han, S.-B., Kim, S.-B., 2023. Impact of Chronic
Karanfil, E.T., Møller, A.M., 2018. Preoperative inspiratory muscle training prevents Obstructive Pulmonary Disease on outcomes after total joint arthroplasty: a Meta-
pulmonary complications after cardiac surgery–a systematic review. Dan Med J 65, analysis and systematic review. Indian J. Orthop. 57, 211–226.
A5450. Shoemaker, M.J., Donker, S., Lapoe, A., 2009. Systematic review: inspiratory muscle
Karcz, M., Papadakos, P.J., 2013. Respiratory complications in the postanesthesia care training in patients with chronic obstructive pulmonary disease: the state of the
unit: a review of pathophysiological mechanisms. Can. J. Respir. Ther.: CJRT= evidence. Cardiopulm. Phys. Ther. J. 20, 5–15.
Revue canadienne de la therapie respiratoire: RCTR 49, 21. Silva DE Sousa, A., Pereira Da Rocha, A., Brandão Tavares, D.R., Frazão Okazaki, J.É., DE
Katsura, M., Kuriyama, A., Takeshima, T., Fukuhara, S., Furukawa, T.A., 2015. Andrade Santana, M.V., Fernandes Moça Trevisani, V., Pereira Nunes Pinto, A.C.,
Preoperative inspiratory muscle training for postoperative pulmonary complications 2024. Respiratory muscle training for obstructive sleep apnea: systematic review and
in adults undergoing cardiac and major abdominal surgery. Cochrane Database Syst. meta-analysis. J. Sleep Res. 33, e13941.
Rev. Silva, I.S., Fregonezi, G.A., Dias, F.A., Ribeiro, C.T., Guerra, R.O., Ferreira, G.M., 2013.
Kendall, F., Oliveira, J., Peleteiro, B., Pinho, P., Bastos, P.T., 2018. Inspiratory muscle Inspiratory muscle training for asthma. Cochrane Database Syst. Rev.
training is effective to reduce postoperative pulmonary complications and length of Starko, G., Müller, D., Lipka, A., Feiereisen, P., Corbellini, C., Abreu, R.M.D., 2024.
hospital stay: a systematic review and meta-analysis. Disabil. Rehabil. 40, 864–882. Effects of respiratory muscle training pre-and post-cardiac surgery in adults: a
Kowalski, T., Granda, D., Klusiewicz, A., 2022. Practical application of respiratory scoping review. J. Cardiovasc. Dev. Dis. 11, 351.
muscle training in endurance sports. Strength Condit. J. 10, 1519. Stavrou, V.T., Tourlakopoulos, K.N., Daniil, Z., Gourgoulianis, K.I., 2021. Respiratory
Krause-Sorio, B., An, E., Aguila, A.P., Martinez, F., Aysola, R.S., Macey, P.M., 2021. muscle strength: new technology for easy assessment. Cureus 13.
Inspiratory muscle training for obstructive sleep apnea: protocol development and Terzikhan, N., Verhamme, K.M., Hofman, A., Stricker, B.H., Brusselle, G.G., Lahousse, L.,
feasibility of home practice by sedentary adults. Front. Physiol. 12, 737493. 2016. Prevalence and incidence of COPD in smokers and non-smokers: the
Kulkarni, S., Fletcher, E., Mcconnell, A., Poskitt, K., Whyman, M., 2010. Pre-operative Rotterdam Study. Eur. J. Epidemiol. 31, 785–792.
inspiratory muscle training preserves postoperative inspiratory muscle strength Torres-Castro, R., Solis-Navarro, L., Puppo, H., Alcaraz-Serrano, V., Vasconcello-
following major abdominal surgery–a randomised pilot study. Ann. R. Coll. Surg. Castillo, L., Vilaró, J., Vera-Uribe, R., 2022. Respiratory muscle training in patients
Engl. 92, 700–705. with obstructive sleep apnoea: a systematic review and meta-analysis. Clocks & sleep
Laciuga, H., Rosenbek, J.C., Davenport, P.W., Sapienza, C.M., 2014. Functional outcomes 4, 219–229.
associated with expiratory muscle strength training: narrative review. J. Rehabil. Vorona, S., Sabatini, U., al-Maqbali, S., Bertoni, M., Dres, M., Bissett, B., van Haren, F.,
Res. Dev. 51. Martin, A.D., Urrea, C., Brace, D., 2018. Inspiratory muscle rehabilitation in
Luo, D., Fan, Z., Yin, W., 2024. Chronic post-surgical pain after total knee arthroplasty: a critically ill adults. A systematic review and meta-analysis. Annals of the American
narrative review. Perioper. Med. 13, 108. Thoracic Society 15, 735–744.
Matharu, G., Mouchti, S., Twigg, S., Delmestri, A., Murray, D., Judge, A., Pandit, H., Warner, D.O., Preston, P., Subramanyam, R., Kathuria, H., Hollingsworth, H., 2020.
2019. The effect of smoking on outcomes following primary total HIP arthroplasty: a Smoking or Vaping: Perioperative Management. UpToDate. UpToDate Inc, Waltham,
POPULATION-BASED cohort study of 60 812 patients. Orthopaedic proceedings. MA.
Bone Joint Lett. 13, 13. WORLDHEALTHORGANIZATION, 2024. Ageing and health. https://www.who.int/
Mcconnell, A., 2013. Respiratory Muscle Training: Theory and Practice. Elsevier Health news-room/fact-sheets/detail/ageing-and-health.
Sciences. Wylde, V., Beswick, A., Bruce, J., Blom, A., Howells, N., Gooberman-Hill, R., 2018.
Mcconnell, A., Romer, L., 2004. Respiratory muscle training in healthy humans: Chronic pain after total knee arthroplasty. EFORT Open Rev. 3, 461–470.
resolving the controversy. Int. J. Sports Med. 25, 284–293. Yekta, A.H.A., Esfahani, M.P., Salehi, S., Hassabi, M., Khosravi, S., Kharabian, S.,
Mickleborough, T., Nichols, T., Lindley, M., Chatham, K., Ionescu, A., 2010. Inspiratory Sohrabi, M.R., Mafi, A.A., Rezaei, S., 2019. Assessment of the effects of inspiratory
flow resistive loading improves respiratory muscle function and endurance capacity muscle training (IMT) and aerobic training on the quality of life of patients with
in recreational runners. Scand. J. Med. Sci. Sports 20, 458–468. chronic obstructive pulmonary disease. Tanaffos 18, 223.
Olsen, U., Sellevold, V.B., Gay, C.L., Aamodt, A., Lerdal, A., Hagen, M., Dihle, A.,
Lindberg, M.F., 2024. Factors associated with pain and functional impairment five