***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 
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    Input: Background : It has been previously shown that the inspiratory muscles of patients with congestive heart failure ( CHF ) are weaker than those of normal persons . This weakness may contribute to the dyspnea and limit exercise capacity in these patients . The respiratory muscles can be trained for both strength and endurance Background In congestive heart failure ( CHF ) , the prognostic significance of impaired respiratory muscle strength has not been established . Methods and Results Maximal inspiratory pressure ( Pimax )  was prospect ively determined in 244 consecutive patients ( 207 men ) with CHF ( ischemic , n=75 ; idiopathic dilated cardiomyopathy , n=169 ; age , 54±11 years ; left ventricular ejection fraction [ LVEF ] , 22±10 % )  . Pimax was lower in the 244 patients with CHF than in 25 control subjects ( 7.6±3.3 versus 10.5±3.7 kPa;P = 0.001 ) . The 57 patients ( 23 % ) who died during follow-up ( 23±16 months ; range , 1 to 48 months ) had an even more reduced Pimax ( 6.3±3.2 versus 8.1±3.2 kPa in survivors;P = 0.001 ) . Kaplan-Meier survival curves differentiated between patients subdivided according to quartiles for Pimax ( P = 0.014 ) . Pimax was a strong risk predictor in both univariate ( P = 0.001 ) and multivariate Cox proportional hazard analyses ( P = 0.03 ) ; multivariate analyses also included NYHA functional class , LVEF , peak oxygen consumption ( peak ˙Vo2 ) , and norepinephrine plasma concentration . The areas under the receiver-operating characteristic curves for prediction of 1-year survival were comparable for Pimax and peak ˙Vo2 ( area under the curve [ AUC ] , 0.68 versus 0.73;P = 0.28 ) , and they improved with the triple combination of Pimax , peak ˙Vo2 , and LVEF ( AUC , 0.82;P = 0.004 compared with AUC of Pimax ) . Conclusions In patients with CHF  , inspiratory muscle strength is reduced and emerges as a novel , independent predictor of prognosis . Because testing for Pimax is simple in clinical practice , it might serve as an additional factor to improve risk stratification and patient selection for cardiac transplantation Most systematic review s rely substantially on the assessment of the method ological quality of the individual trials . The aim of this study was to obtain consensus among experts about a set of generic core items for quality assessment of r and omized clinical trials ( RCTs ) . The invited participants were experts in the field of quality assessment of RCTs . The initial item pool contained all items from existing criteria lists . Subsequently , we reduced the number of items by using the Delphi consensus technique . Each Delphi round comprised a question naire , an analysis , and a feedback report . The feedback report included staff team decisions made on the basis of the analysis and their justification . A total of 33 international experts agreed to participate , of whom 21 completed all question naires . The initial item pool of 206 items was reduced to 9 items in three Delphi rounds . The final criteria list ( the Delphi list ) was satisfactory to all participants . It is a starting point on the way to a minimum reference st and ard for RCTs on many different research topics . This list is not intended to replace , but rather to be used alongside , existing criteria lists Background Inspiratory and peripheral muscle training improves muscle strength , exercise tolerance , and quality of life in patients with chronic heart failure ( HF ) . However , studies investigating different workloads for these exercise modalities are still lacking . Objective To examine the effects of low and moderate intensities on muscle strength , functional capacity , and quality of life . Design A r and omized controlled trial . Methods Thirty-five patients with stable HF ( aged > 18 years , NYHA II/III , LVEF < 40 % ) were r and omized to : non-exercise control group  ( n = 9 ) , low-intensity training group ( LIPRT , n = 13 , 15 % maximal inspiratory workload , and 0.5 kg of peripheral muscle workload ) or moderate-intensity training group ( MIPRT , n = 13 , 30 % maximal inspiratory workload and 50 % of one maximum repetition of peripheral muscle workload ) . The outcomes were : respiratory and peripheral muscle strength , pulmonary function , exercise tolerance by the 6-minute walk test , symptoms based on the NYHA functional class , and quality of life using the Minnesota Living with Heart Failure Question naire . Results All groups showed similar quality -of-life improvements . Low and moderate intensities training programs improved inspiratory muscle strength , peripheral muscle strength , and walking distance . However , only moderate intensity improved expiratory muscle strength and NYHA functional class in HF patients . Conclusions The low-intensity inspiratory and peripheral resistance muscle training improved inspiratory and peripheral muscle strength and walking distance , demonstrating that LIPRT is an efficient rehabilitation method for debilitated HF patients . In addition , the moderate-intensity resistance training also improved expiratory muscle strength and NYHA functional class in HF patients OBJECTIVES This study sought to evaluate the effects of inspiratory muscle training in inspiratory muscle strength , as well as in functional capacity , ventilatory responses to exercise , recovery oxygen uptake kinetics , and quality of life in patients with chronic heart failure ( CHF ) and inspiratory muscle weakness . BACKGROUND Patients with CHF may have reduced strength and endurance in inspiratory muscles , which may contribute to exercise intolerance and is associated with a poor prognosis . METHODS Thirty-two patients with CHF and weakness of inspiratory muscles ( maximal inspiratory pressure [ Pi(max ) ] < 70 % of predicted ) were r and omly assigned to a 12-week program of inspiratory muscle training ( IMT , 16 patients ) or to a placebo-inspiratory muscle training ( P-IMT , 16 patients ) . The following measures were obtained before and after the program : Pi(max ) at rest and 10 min after maximal exercise ; peak oxygen uptake , circulatory power , ventilatory oscillations , and oxygen kinetics during early recovery ( VO2/t-slope ) ; 6-min walk test ; and quality of life scores . RESULTS The IMT result ed in a 115 % increment Pi(max ) , 17 % increase in peak oxygen uptake , and 19 % increase in the 6-min walk distance . Likewise , circulatory power increased and ventilatory oscillations were reduced . The VO2/t-slope was improved during the recovery period , and quality of life scores improved . CONCLUSIONS In patients with CHF and inspiratory muscle weakness , IMT results in marked improvement in inspiratory muscle strength , as well as improvement in functional capacity , ventilatory response to exercise , recovery oxygen uptake kinetics , and quality of life 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 for consensus ratings generated by groups of 2 or 3 raters . The ICC for the total score was.56 ( 95 % confidence interval=.47-.65 ) for ratings by individuals , and the ICC for consensus ratings was.68 ( 95 % confidence interval=.57-.76 ) . DISCUSSION AND CONCLUSION The reliability of ratings of PEDro scale items varied from " fair " to " substantial , " and the reliability of the total PEDro score was " fair " to " good . AIMS The purpose of this study was to evaluate the effectiveness , feasibility , and safety of a 4-week high-intensity inspiratory muscle training ( hi-IMT ) in patients with chronic heart failure ( CHF ) . METHODS AND RESULTS A double-blind r and omized clinical trial was carried out in 22 patients with CHF . Participants were assigned to the hi-IMT or sham-IMT group . The trainer device was a prototype of the Orygen-Dual Valve . The training workloads were adjusted weekly at the inspiratory pressure which allowed the performance of 10 consecutive maximal repetitions ( 10RM ) . Main outcomes were strength and endurance of the respiratory muscles assessed by maximal respiratory pressures ( PImax and PEmax ) and a 10RM manoeuvre , respectively . Twenty-one patients presented impairment in  respiratory muscle strength and endurance .  Patients in the hi-IMT group showed a significant improvement in both strength and endurance : inspiratory muscle strength in the intervention group increased 57.2 % compared with 25.9 % in the control group ( P = 0.001 ) . The percentage change in endurance was 72.7 % for the hi-IMT group compared with 18.2 % in the sham-IMT group ( P < 0.001 ) . No adverse effects occurred during the intervention . CONCLUSION A 4-week hi-IMT with the use of the Orygen-Dual Valve is shown to be an effective , feasible , and safe tool to improve weakness and fatigue of the inspiratory muscles . The key point of this study is to discuss immediate practical implication s in terms of respiratory muscle dysfunction postulated as a potential prognostic factor and as an additional therapeutic target . TRIALS REGISTRATION NCT01606553 Background The benefits of inspiratory muscle training ( IMT ) in patients with chronic heart failure ( CHF ) have been inadequately studied . Design and methods Using a prospect i ve , age and sex-matched controlled study , we investigated 35 patients with moderate to severe CHF ( NYHA class II – III and left ventricular ejection fraction 24.4 ± 1.3 % [ mean ± SEM ] ) . An incremental respiratory endurance test using a fixed respiratory workload was provided by software with an electronic mouth pressure manometer interfaced with a computer . The training group ( n = 20 ) exercised at 60 % of individual sustained maximal inspiratory pressure ( SMIP ) and the control group ( n = 15 ) at 15 % of SMIP . All patients exercised three times weekly for 10 weeks . Pulmonary function , exercise capacity , dyspnea and quality of life were assessed , pre- and post-training . Results The training group significantly increased both maximum inspiratory pressure ( Pimax ) , ( 111 ± 6.8 versus 83 ± 5.7cmH2O , P<0.001 ) , and SMIP ( 527822 ± 51358 versus 367360 ± 41111 cmH2O/sec × 10 - 1 , P < 0.001 ) . Peak VO2 increased after training ( 17.8 ± 1.2 versus 15.4 ± 0.9 ml/kg/min , P < 0.005 ) , as did the six-minute walking distance ( 433 ± 16 versus 367 ± 22 meters , P < 0.001 ) . Perceived dyspnea assessed using the Borg scale was reduced for both the treadmill ( 12.7 ± 0.57 versus 14.2 ± 0.48 , P < 0.005 ) and the walking ( 9 ± 0.48 versus 10.5 ± 0.67 , P < 0.005 ) exercise tests and the quality of life score was also improved ( 21.1 ± 3.5 versus 25.2 ± 4 , P < 0.01 ) . Resting heart rate was significantly reduced with training ( 77 ± 3.3 versus 80 ± 3beats/min , P < 0.05 ) . The control group significantly increased Pimax ( 86.6 ± 6.3 versus 78.4 ± 6.9cmH2O , P < 0.05 ) , but decreased SMIP ( 274972 ± 32399 versus 204661 ± 37184cmH2O/sec × 101 , P < 0.005 ) . No other significant effect on exercise capacity , heart rate , dyspnea , or quality of life was observed in this group . Conclusion Inspiratory muscle training using an incremental endurance test , successfully increases both inspiratory strength and endurance , alleviates dyspnea and improves functional status in CHF 
    Output:
    
Conclusion : HIIMT seems to be a useful strategy for improving exercise capacity and inspiratory muscle strength in HFrEF patients