***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Aim The aim of the present study was to compare threshold inspiratory muscle training ( IMT ) and expiratory muscle training ( EMT ) in elderly male patients with moderate degree of COPD . Material s and methods Forty male patients with moderate degree of COPD were recruited for this study . They were r and omly divided into two groups : the IMT group who received inspiratory training with an intensity ranging from 15 % to 60 % of their maximal inspiratory pressure , and the EMT group who received expiratory training with an equal intensity which was adjusted according to the maximal expiratory pressure . Both groups received training three times per week for 2 months , in addition to their prescribed medications . Results Both IMT and EMT groups showed a significant improvement in forced vital capacity , forced expiratory volume in the first second , forced expiratory volume in the first second% from the predicted values , and forced vital capacity% from the predicted value , with no difference between the groups . Both types of training result ed in a significant improvement in blood gases ( SaO2 % , PaO2 , PaCO2 , and HCO3 ) , with the inspiratory muscle group showing the best results . Both groups showed a significant improvement in the 6-min walking distance : an increase of about 25 % in the inspiratory muscle group and about 2.5 % in the expiratory muscle group . Conclusion Both IMT and EMT must be implemented in pulmonary rehabilitation programs in order to achieve improvements in pulmonary function test , respiratory muscle strength , blood oxygenation , and 6-min walking distance OBJECTIVE To determine the effects of a short- duration , combined ( inspiratory and expiratory ) , progressive resistance respiratory muscle training ( RMT ) protocol on respiratory muscle strength , fatigue , health-related quality of life , and functional performance in individuals with mild-to-moderate multiple sclerosis ( MS ) . DESIGN Quasi-experimental before-after trial . SETTING University rehabilitation research laboratory . PARTICIPANTS Volunteers with MS ( N=21 ) were divided into 2 groups : RMT ( n=11 ; 9 women , 2 men ; mean age ± SD , 50.9 ± 5.7y , mean Exp and ed Disability Status Scale score ± SD , 3.2 ± 1.9 ) and a control group that did not train ( n=10 ; 7 women , 3 men ; mean age ± SD , 56.2 ± 8.8y , mean Exp and ed Disability Status Scale score ± SD , 4.4 ± 2.1 ) . Exp and ed Disability Status Scale scores ranged from 1 to ≤6.5 . No patients withdrew from the study . INTERVENTION Training was a 5-week combined progressive resistance RMT program , 3d/wk , 30 minutes per session . MAIN OUTCOME MEASURES The primary outcome measures were maximal inspiratory pressure and expiratory pressure and the Modified Fatigue Impact Scale . All subjects completed secondary measures of pulmonary function , the six-minute walk test , the timed stair climb , the Multiple Sclerosis Self-Efficacy Scale , the Medical Outcomes Study 36-Item Short-Form Health Survey , and the Physical Activity Disability Scale . RESULTS Maximal inspiratory pressure and expiratory pressure ( mean ± SD ) increased 35 % ± 22 % ( P<.001 ) and 26 % ± 17 % ( P<.001 ) , respectively , whereas no changes were noted in the control group ( 12 % ± 23 % and -4 % ± 17 % ,  respectively ) . RMT improved fatigue ( Modified Fatigue Impact Scale , P<.029 ) , with no change or worsening in the control group . No changes were noted in the six-minute walk test , stair climb , Multiple Sclerosis Self-Efficacy Scale , or Physical Activity Disability Scale in the RMT group . The control group had decreases in emotional well-being and general health ( Medical Outcomes Study 36-Item Short-Form Health Survey ) . CONCLUSIONS A short- duration , combined RMT program improved inspiratory and expiratory muscle strength and reduced fatigue in patients with mild to moderate MS Objective : Dysphagia is the main cause of aspiration pneumonia and death in Parkinson disease ( PD ) with no established restorative behavioral treatment to date . Reduced swallow safety may be related to decreased elevation and excursion of the hyolaryngeal complex . Increased submental muscle force generation has been associated with expiratory muscle strength training ( EMST ) and subsequent increases in hyolaryngeal complex movement provide a strong rationale for its use as a dysphagia treatment . The current study 's objective was to test the treatment outcome of a 4-week device-driven EMST program on swallow safety and define the physiologic mechanisms through measures of swallow timing and hyoid displacement . Methods : This was a r and omized , blinded , sham-controlled EMST trial performed at an academic center . Sixty participants with PD completed EMST , 4 weeks , 5 days per week , for 20 minutes per day , using a calibrated or sham , h and held device . Measures of swallow function including judgments of swallow safety ( penetration – aspiration [ PA ] scale scores ) , swallow timing , and hyoid movement were made from videofluoroscopic images . Results : No pretreatment group differences existed . The active treatment ( EMST ) group demonstrated improved swallow safety compared to the sham group as evidence d by improved PA scores . The EMST group demonstrated improvement of hyolaryngeal function during swallowing , findings not evident for the sham group . Conclusions : EMST may be a restorative treatment for dysphagia in those with PD . The mechanism may be explained by improved hyolaryngeal complex movement . Classification of evidence : This intervention study provides Class I evidence that swallow safety as defined by PA score improved post EMST BACKGROUND Pulmonary and respiratory muscle function impairment are common in patients with Parkinson 's disease ( PD ) .  Inspiratory muscle training may improve strength , dyspnea and functional capacity in healthy subjects and in those with chronic obstructive pulmonary disease . This study investigated the effect of specific inspiratory muscle training ( SIMT ) on pulmonary functions , inspiratory muscle performance , dyspnea and quality of life , in patients with PD . PATIENTS AND METHODS Twenty patients with PD ( stage II and III Hoehn and Yahr scale ) were recruited for the study and were divided into two groups : ( a ) ten patients who received SIMT and ( b ) ten patients who received sham training , for three months . Pulmonary functions , the respiratory muscle strength and endurance , the perception of dyspnea ( POD ) and the quality of life were studied before and within one week after the training period . All subjects trained daily , six times a week , each session consisting of 1/2 hour , for 12 weeks . RESULTS Following the training period , there was a significant improvement , in the training group but not in the control group , in the following parameters : inspiratory muscle strength , ( PImax , increased from 62.0 + /- 8.2 to 78.0 + /- 7.5 cm of H2O ( p < 0.05 ) , inspiratory muscle endurance ( increased from 20.0 + /- 2.8 to 29.0 + /- 3.0 cm of H2O ( p < 0.05 ) , and the POD ( decreased from 17.9 + /- 3.2 to 14.0 + /- 2.4 units ( p < 0.05 ) . There was a close correlation between the increase in the inspiratory muscle performance and the decrease in the POD . CONCLUSIONS The inspiratory muscle performance may be improved by SIMT in patients with PD . This improvement is associated with a significant decrease in their POD BACKGROUND Recently , resistance expiratory muscle strength training ( EMST ) has been reported as a remedial treatment for dysphagia . OBJECTIVE To investigate the effect of resistance EMST on the swallowing function in stroke patients with oropharyngeal dysphagia . METHODS Forty-two stroke patients with dysphagia were r and omly assigned to two groups : an experimental group ( n = 13 ) and a placebo group ( n = 13 ) . The experimental group performed EMST using a portable EMST device , while the placebo group performed EMST using a sham EMST device with no loading . The intervention was performed 5 days per week for 4weeks , in five sets of 5 breaths through the device for a total of 25 breaths per day . Both groups underwent conventional dysphagia treatment for 30 minutes/day , 5 days/week , for 4 weeks . Videofluoroscopic dysphagia scale ( VDS ) and penetration-aspiration scale ( PAS ) based on a videofluoroscopic swallowing study ( VFSS ) were assessed to analyze the oropharyngeal swallowing function . RESULTS The experimental group showed more improvement in pharyngeal phase of the VDS ( p = 0.018 and 0.006 , respectively ) and PAS compared to the placebo group ( p = 0.014 ) . CONCLUSIONS We suggest that EMST could improve the effects of dysphagia observed in post-stroke elderly patients based on swallowing function Objective : To compare the effects of an inspiratory versus and expiratory muscle-training program on voluntary and reflex peak cough flow in patients with Parkinson disease . Design : A r and omized controlled study . Setting : Home-based training program . Participants : In all , 40 participants with diagnosis of Parkinson ’s disease were initially recruited in the study and r and omly allocated to three study groups . Of them , 31 participants completed the study protocol ( control group , n = 10 ; inspiratory training group , n = 11 ; and expiratory training group , n = 10 ) Intervention : The inspiratory and expiratory group performed a home-based inspiratory and expiratory muscle-training program , respectively ( five sets of five repetitions ) . Both groups trained six times a week for two months using a progressively increased resistance . The control group performed expiratory muscle training using the same protocol and a fixed resistance . Main measures : Spirometric indices , maximum inspiratory pressure , maximum expiratory pressure , and peak cough flow during voluntary and reflex cough were assessed before and at two months after training . Results : The magnitude of increase in maximum expiratory pressure ( d = 1.40 ) and voluntary peak cough flow ( d = 0.89 ) was greater for the expiratory muscle-training group in comparison to the control group . Reflex peak cough flow had a moderate effect ( d = 0.27 ) in the expiratory group in comparison to the control group . Slow vital capacity ( d = 0.13 ) and forced vital capacity ( d = 0.02 ) had trivial effects in the expiratory versus the control group . Conclusions : Two months of expiratory muscle-training program was more beneficial than inspiratory muscle-training program for improving maximum expiratory pressure and voluntary peak cough flow in patients with Parkinson ’s disease Expiratory muscle strength training ( EMST ) involves forcible blowing as a means of generating high expiratory pressure , against adjustable resistance . EMST has recently been introduced as a potential treatment for dysphagia . This study was performed to investigate the effects of EMST on the activity of suprahyoid muscles , aspiration and dietary stages in stroke patients with dysphagia . Twenty-seven stroke patients with dysphagia were r and omly divided into two groups . The experimental group performed EMST with a 70 % threshold value of maximal expiratory pressure , using an EMST device , 5 days a week for 4 weeks . The placebo group trained with a sham device . The EMST regime involved 5 sets of 5 breaths through the EMST device for a total of 25 breaths per day . Activity in the suprahyoid muscle group was measured using  surface electromyography  ( sEMG ) . Further , the penetration-aspiration scale ( PAS ) was used to assess the results of the videofluoroscopic swallowing study ( VFSS ) . In addition , dietary stages were evaluated using the Functional Oral Intake Scale ( FOIS ) . The experimental group exhibited improved suprahyoid muscle group activity and PAS results , when compared to the placebo group . Following intervention , statistical analysis indicated significant differences in measured suprahyoid muscle activity ( P = 0·01 ) , liquid PAS outcomes ( P = 0·03 ) and FOIS results ( P = 0·06 ) , but not semisolid type PAS outcomes ( P = 0·32 ) , between the groups . This study confirms EMST as an effective treatment for the development of suprahyoid muscle activity in stroke patients with dysphagia . Additionally , improvements in aspiration and penetration outcomes were observed BACKGROUND AND PURPOSE Assessment of the quality of r and omized controlled trials ( RCTs ) is common practice in systematic review s. However , the reliability of data obtained with most quality assessment scales has not been established . This report describes 2 studies design ed to investigate the reliability of data obtained with the Physiotherapy Evidence Data base ( PEDro ) scale developed to rate the quality of RCTs evaluating physical therapist interventions . METHOD In the first study , 11 raters independently rated 25 RCTs r and omly selected from the PEDro data base . In the second study , 2 raters rated 120 RCTs r and omly selected from the PEDro data base , and disagreements were resolved by a third rater ; this generated a set of individual rater and consensus ratings . The process was repeated by independent raters to create a second set of individual and consensus ratings . Reliability of ratings of PEDro scale items was calculated using multirater kappas , and reliability of the total ( summed ) score was calculated using intraclass correlation coefficients ( ICC [ 1,1 ] ) . RESULTS The kappa value for each of the 11 items ranged from.36 to.80 for individual assessors and from.50 to.79 
    Output:
    
Conclusions : Respiratory muscle training may be an effective alternative for improving respiratory muscle strength , swallowing function and phonatory parameters in subjects with Parkinson ’s disease .