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. 2025 Jul 9:12:1621375.
doi: 10.3389/fmed.2025.1621375. eCollection 2025.

Effects of pulmonary rehabilitation combined with inspiratory muscle training on lung function and exercise capacity in older patients with COPD: a systematic review and meta-analysis

Jun Xie #  1 , Yang Zhu #  2 , Ya Wang  3 , Yunjun Mo  1 , Xiaohui Shi  1 , Wen-Ming Liang  4 , Fei-Fei Ren  5 , Zhenmin Bai  2 , Feng Nie  1
Affiliations

Effects of pulmonary rehabilitation combined with inspiratory muscle training on lung function and exercise capacity in older patients with COPD: a systematic review and meta-analysis

Jun Xie et al. Front Med (Lausanne). .

Abstract

Background: Pulmonary rehabilitation is central to COPD management, with inspiratory muscle training (IMT) as a key component. However, evidence is inconsistent on whether combining PR with IMT offers added benefits for older COPD patients.

Objective: To evaluate the comparative effects of PR combined with IMT versus PR alone on key outcomes in older COPD patients, including quality of life [St. George's Respiratory Questionnaire (SGRQ)], exercise tolerance [6-min walk distance (6MWD)], respiratory muscle strength [maximal inspiratory pressure (PImax)], and pulmonary function metrics (FEV1, FEV1%).

Methods: A systematic search of PubMed, EMBASE, Web of Science, and the Cochrane Library (January 2005-January 2025) identified randomized controlled trials (RCTs) meeting criteria: (1) participants were ≥ 55 years old with GOLD stage II-IV COPD; (2) interventions compared PR combined with IMT versus PR alone; (3) outcomes included PImax, FEV1, FEV1%, SGRQ, and 6MWD. Non-English and animal studies were excluded. Risk of bias was assessed using Cochrane RoB 2.0, and the certainty of evidence was evaluated via the GRADEpro 3.6.1.

Results: Nine RCTs (582 patients) were included. Compared with PR alone, PR combined with IMT did not improve 6MWD (SMD = 0.15, 95% CI: -0.11-0.42; low-quality evidence) or SGRQ scores (SMD = -0.19, 95% CI: -0.38-0.01, low-quality evidence). PImax improved moderately (SMD = 0.78, 95% CI: 0.44-1.13, I2 = 48.7%, low-quality evidence). FEV1 and FEV1% trended upward (SMD = 0.50 and 0.58, respectively) but showed high heterogeneity (FEV1: I2 = 72.9%, p = 0.025, very low-quality evidence; FEV1%: I2 = 75.6%, p = 0.006, low-quality evidence), precluding significance. Subgroup analyses showed significant PImax improvements in interventions lasting ≥ 12 weeks (SMD = 0.866, 95% CI: 0.579-1.153; I2 = 0%) or with weekly cumulative durations ≥ 180 min (SMD = 0.922, 95% CI: 0.666-1.177; I2 = 0%), with no 6MWD benefits in any subgroup.

Conclusion: Low-quality evidence indicates that PR combined with IMT improves respiratory muscle strength (PImax) in older COPD patients versus PR alone, with no significant benefit for exercise capacity (6MWD) or lung function. For older COPD patients, ≥ 12-week PR combined with IMT interventions (sessions > 60 min; weekly duration ≥ 180 min) may enhance PImax.

Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251010168, CRD420251010168.

Keywords: COPD; exercise capacity; inspiratory muscle training; pulmonary function; pulmonary rehabilitation.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Flowchart of study identification process. Starts with 2,166 records from databases and registers. 766 records are removed before screening. 1,400 records are screened; 1,361 reports excluded for study design. Out of 39 reports sought for retrieval, 3 are not retrieved. 36 reports are assessed for eligibility, and 27 are excluded for various reasons. Finally, 9 studies are included.
FIGURE 1
PRISMA flowchart of study selection.
Quality assessment of studies with risk of bias summary and a bar chart. The top table shows studies with bias levels: low risk (green plus), some concerns (yellow question mark), and high risk (red minus) across various domains. The chart below shows bias percentages: green for low risk, yellow for some concerns, and red for high risk across different domains.
FIGURE 2
Bias risk assessment.
Forest plot showing standardized mean differences with 95% confidence intervals for several studies: Tounsi (2021), Beaumont (2018), Tout (2013), Charususin (2018), Dellweg (2017), Mador (2005), Magadle (2007), and Wang (2017). Each study's weight is indicated, with a summary diamond representing overall effect at 0.15 [-0.11, 0.42]. Weights use random effects analysis.
FIGURE 3
Effect of PR combined with IMT on 6MWD in older COPD patients.
Forest plot showing the standardized mean differences (SMD) with 95% confidence intervals (CI) for six studies on the left. The studies are Charusssin (2018), Dellweg (2017), Mador (2005), Magadle (2007), Tounsi (2021), and Wang (2017). The plot includes weights for each study, with an overall SMD of 0.78 (0.44, 1.13). The heterogeneity is indicated by I-squared at 48.7% with a p-value of 0.083.
FIGURE 4
Effect of PR combined with IMT on PImax in older COPD patients.
Forest plot showing results from three studies: Majewska (2016), Tout (2013), and Wang (2017). Each study's line indicates the standard mean difference (SMD) with a 95% confidence interval (CI). Combined SMD is 0.50 (CI -0.37 to 1.36). The plot notes weights from random effects analysis, with an overall I-squared of 72.9% and p-value of 0.025. The vertical line represents no effect at zero.
FIGURE 5
Effect of PR combined with IMT on FEV1 in older COPD patients.
Forest plot showing the standardized mean difference (SMD) and 95% confidence intervals (CI) for four studies: M. Majewska (2016), Dellweg (2017), Wang (2017), and Magadle (2007). SMD values range from -0.12 to 1.46. The overall effect size is 0.58 with a CI of -0.15 to 1.31. Weights are indicated next to each study, with a total weight of 100 percent. The plot notes an I-squared statistic of 75.6 percent and a p-value of 0.006, suggesting random effects analysis.
FIGURE 6
Effect of PR combined with IMT on FEV1% in older COPD patients.
Forest plot showing studies by Majewska (2016), Beaumont (2018), Magadice (2007), Tout (2013), and Wang (2017), with standardized mean differences (SMD) and 95% confidence intervals. Study weights and overall effect size of -0.11 with I-squared = 0%, p = 0.707, are included. Dashed line at zero indicates no effect. Weights are from random effects analysis.
FIGURE 7
Effect of PR combined with IMT on SGRQ in older COPD patients.
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