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Inspiratory Muscle Training

Author: SCIRE Community Team | Reviewer: Shannon Sproule | Published: 21 November 2017 | Updated: ~

Inspiratory muscle training is a treatment used to help with breathing and coughing after spinal cord injury (SCI). This page introduces inspiratory muscle training and its use after SCI.

Key Points

  • People with thoracic and cervical SCI may experience problems with breathing caused by weakness or paralysis of some of the breathing muscles.
  • Inspiratory muscle training involves breathing exercises using simple equipment to strengthen the muscles used to breathe in.
  • There are three types of devices that can be used during training: resistive trainers, threshold trainers, and isocapneic hyperpneic trainers.
  • Studies have shown that inspiratory muscle training increases the strength and endurance of the inspiratory muscles in people with SCI.

Cartoon of inhaler and head

Inspiratory muscle training describes a number of different techniques in which simple equipment is used to strengthen the muscles used to breathe in (inspire). The equipment is used to make breathing in more challenging. This causes the breathing muscles to work harder, so that they can adapt and become stronger with training.

Speak with a health provider before using inspiratory muscle training to make sure it is safe and suitable for you and to learn how to use the equipment correctly.

Inspiratory muscle training is done using a device that makes breathing in more challenging. The device has some type of mechanism that creates resistance when the person breathes in, but allows breathing out to occur freely. There are several different types of inspiratory muscle training devices:

  • Resistive trainers are the simplest trainers. They have a range of small diameter holes, which the person breathes in through. The smaller the hole, the greater the challenge is. The drawback of these trainers is that the resistance changes if you breathe in quickly or slowly.
  • Threshold trainers have a spring-loaded valve that provides resistance. The valve can be adjusted for difficulty level. These trainers provide the same resistance if you breathe in quickly or slowly.
  • Isocapneic hyperpnea involves a more complex device that allows breathing to be done at lower levels of resistance and higher flow rates. This device uses a rebreathing bag that helps maintain carbon dioxide levels in a normal range. This device uses targets to increase the intensity of breathing to a training level.


Different types of inspiratory muscle trainers – Top: threshold trainer; bottom: resistive trainer.2

Your health provider will assist you with selecting an appropriate trainer and supervise your early training. The device is held to the mouth with a clip over the nose. Some people with reduced hand movement will need someone to position and hold the trainer during each training session. Alternatively, tilting the chair backwards or using a stand to hold the trainer may assist with positioning the mouthpiece independently.

Inspiratory muscle training involves regular sessions of breathing exercises consisting of a set number of breaths and sets. Sessions often last around 30 minutes and are done 2 to 3 times per day. However, the ideal protocol for inspiratory muscle training for people with SCI is not yet known.

Inspiratory muscle training is usually done for at least 6 weeks to allow enough time for the muscles to become stronger and adapt to training. Like other exercise, training should be continued regularly for strength to be maintained.

Silhouette of the respiratory system

Cervical and thoracic spinal cord injuries can cause paralysis or weakness of muscles of the neck, chest, and abdomen that are important for breathing and coughing. This can cause breathing problems that can contribute to shortness of breath, fatigue, and a need for mechanical ventilation.

Depending on the level of injury of the SCI, some of the muscles of breathing may still be able to be controlled. In some cases, strengthening these muscles can help to compensate for weakness in other muscles and improve breathing ability.

Inspiratory muscle training is used to strengthen the muscles that can be controlled to improve independent breathing ability. It may also be used to help prevent medical complications related to breathing and coughing problems, such as lung infections like pneumonia.

Who benefits from inspiratory muscle training?

Every person is unique, and how much inspiratory muscle training will benefit any individual depends on the characteristics of their SCI and their unique life circumstances. That being said, in general, inspiratory muscle training is considered most beneficial for people with injuries in the mid-cervical to mid-thoracic spinal cord. These types of injuries tend to have breathing problems that could benefit from inspiratory muscle training and also have muscles available to train. People with upper cervical SCI usually have greater impairment of the breathing muscles that often requires more extensive breathing support instead, such as ongoing mechanical ventilation.

There are certain situations where extra attention is needed to determine whether inspiratory muscle training is appropriate and safe. Consult a qualified health provider for further safety information.

Restrictions of precautions for using inspiratory muscle training may include:

cartoon of a man inhaling from a puffer

  • Unstable asthma
  • Previous collapsed lung (pneumothorax) not caused by a traumatic injury
  • Unhealed collapsed lung (pneumothorax) caused by a traumatic injury
  • Presence of air bubbles near the membranes lining the lungs
  • A low tolerance for shortness of breath
  • A ruptured eardrum or other ear conditions

Inspiratory muscle training is generally safe when used appropriately (see above for a list of situations in which inspiratory muscle training may not be safe). However, it is important to seek advice from a health provider to determine if this treatment is the best option for you.

Some possible risks and side effects of using inspiratory muscle training may include:cartoon of a man holding his chest distraught

  • Coughing
  • If breathing is done too rapidly, it could cause hyperventilation, leading to lightheadedness, dizziness, or fainting
  • Muscle tiredness or soreness
  • Increased muscle spasms

silhouette showing back and vertebrae with lighting bolts beside it

Several research studies have shown that inspiratory muscle training helps to improve breathing after spinal cord injury. Inspiratory muscle training was found to improve the strength and endurance of the breathing muscles. As well, it may reduce shortness of breath and chest infections in some people with SCI. These findings are supported by moderate evidence from five studies and weak evidence from six studies.

Research on whether inspiratory muscle training is effective in helping with speaking and coughing and what its long-term effects are is currently lacking.

Breathing difficulties are common among people with thoracic and cervical injuries. Inspiratory muscle training is a safe treatment option for increasing strength of breathing muscles to aid breathing. The research evidence suggests inspiratory muscle training is effective in increasing strength and endurance of the breathing muscles after SCI. It is important to discuss treatment options with your health providers to find out which treatments are suitable for you.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Parts of this page have been adapted from the SCIRE Project (Professional) “Respiratory Management” Chapter:

Sheel AW, Reid WD, Townson AF, Ayas N (2014). Respiratory Management Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors.

Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p. 1-54. Available from: 


Evidence for “How effective is inspiratory muscle training for people with SCI?” is based on the following studies:

[1] Van Houtte S, Vanlandewijck Y, Kiekens C, Spengler CM, Gosselink R. Patients with acute spinal cord injury benefit from normocapnic hyperpnoea training. J Rehabil Med 2008; 40: 119-125.

[2] Mueller G, Hopman MTE, and Perret C. Comparison of respiratory muscle training methods in individuals with motor complete tetraplegia. Top Spinal Cord Inj Rehabil 2012; 18(2): 118-121.

[3] Mueller G, Hopman MTE, and Perret C. Comparison of respiratory muscle training methods in individuals with motor and sensory complete tetraplegia: a randomized controlled trial. J Rehabil Med 2013; 45: 248-253.

[4] Loveridge B, Badour M, Dubo H. Ventilatory muscle endurance training in quadriplegia: effects on breathing pattern. Paraplegia 1989; 27: 329-339.

[5] Liaw M-Y, Lin M-C, Cheng P-T, Wong M-K A, Tang F-T. Resistive inspiratory muscle training: its effectiveness in patients with acute complete cervical injury. Arch Phys Med Rehabil 2000; 81: 752-756.

[6] Derrickson J, Ciesla N, Simpson N, Imle PC. A comparison of two breathing exercise programs for patients with quadriplegia. Physical Therapy 1992; 72: 763-769.

[7] Tamplin J, Baker FA, Grocke D, Brazzale DJ, Pretto JJ, Ruehland WR, Buttifant M, Brown DJ and Berlowitz DJ. Effect of singing on respiratory function, voice and mood after quadriplegia: a randomized controlled trial. Arch Phys Med Rehabil 2013; 94: 426-434.

[8] Litchke LG, Lloyd LK, Schmidt EA, Russian CJ, and Reardon RF. Effects of concurrent respiratory resistance training on health-related quality of life in wheelchair rugby athletes: a pilot study. Top Spinal Cord Inj Rehabil 2012; 18(3): 264-272.

[9] Ehrlich M, Manns PJ, Poulin C. Respiratory training for a person with C3-C4 tetraplegia. Aust J Physiother 1999; 45(4): 301-307.

[10] Uijl SG, Houtman S, Folgering HT, Hopman MT. Training of the respiratory muscles in individuals with tetraplegia. Spinal Cord 1999; 37: 575-9.

[11] Rutchik A, Weissman AR, Almenoff PL, Spungen AM, Bauman WA, Grimm DR. Resistive IMT in subjects with chronic spinal cord injury. Arch Phys Med Rehabil 1998; 79: 293-297.

[12] Hornstein S, Ledsome JR. Ventilatory muscle training in acute quadriplegia. Physiotherapy Canada 1986; 38: 145-149.

[13] Gross D, Ladd HW, Riley EJ, Macklem PT, Grassino A. The effect of training on strength and endurance of the diaphragm in quadriplegia. Am J Med 1980; 68: 27-35.

Other references:

Postma K, Haisma JA, Hopman M, Bergen MP, Stam HJ, Bussmann JB. Resistive inspiratory muscle training in people with spinal cord injury during inpatient rehabilitation: a randomized controlled trial. Phys Ther 2014; 94(12): 1709-1719.

McConnell A. Respiratory muscle training: theory and practice. London: Churchill Livingston; 2013. Chapter 6, Implementing respiratory muscle training; p.149-173.

Berlowitz DJ, Tamplin J. Respiratory muscle training for cervical spinal cord injury. Cochrane Database of Syst Rev 2013, 7: CD008507.

Spungen AM, Grimm DR, Lesser M, Bauman WA, Almenoff PL. Self-reported prevalence of pulmonary symptoms in subjects with spinal cord injury. Spinal Cord 1997; 35: 652-657,

Reid WD, Geddes EL, Brooks D, O’Brien K, Crowe J. Inspiratory muscle training in chronic obstructive pulmonary disease. Special Series on Skeletal Muscle Training. Physiotherapy Canada 2004; 56:128-142.

Geddes EL, Reid WD, Brooks D, Crowe J, O’Brien K. A Primer on Inspiratory Muscle Trainers. Buyers Guide for the European Respiratory Society 2006.

Geddes EL, Reid WD, Crowe J., O’Brien K, Brooks D. Inspiratory muscle training in adults with chronic obstructive pulmonary disease: A systematic review. Respir Med 2005; 99: 1440-1458.

Sheel AW, Reid WD, Townson AF, Ayas NT, Konnyu KJ. Effects of exercise training and inspiratory muscle training in spinal cord injury: a systematic review. J Spinal Cord Med 2008; 31(5): 500-8.

Image Credits

  1. asthma ©Delwar Hossain, CC BY 3.0 US
  2. Image by SCIRE Community Team
  3. respiratory organ ©ProSymbols, CC BY 3.0 US
  4. inhalation ©Priyanka, CC BY 3.0 US
  5. hiccup ©Priyanka, CC BY 3.0 US
  6. Back Pain ©Matt Wasser, CC BY 3.0 US


Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.