human
***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: Objective : To identify factors associated with tolerance and survival after noninvasive positive-pressure ventilation ( NIPPV ) and to investigate the influence of NIPPV on lung function in patients with ALS . Methods : NIPPV was offered to 71 patients with ALS in accordance with currently published guidelines . Effects of NIPPV on lung function and factors influencing tolerance and survival after NIPPV were studied . Results : Forty-four patients ( 61.9 % ; 95 % CI : 50.6 to 73.2 ) tolerated NIPPV ( NIPPV use ≥4 h/day ) and 27 ( 38.1 % ; 95 % CI : 26.8 to 49.4 ) were intolerant ( NIPPV use < 4 h/day ) . Patients with mild or moderate bulbar symptoms were more likely to tolerate NIPPV than those with severe impairment ( odds ratio = 6.09 , 95 % CI : 1.18 to 31.52 , p = 0.031 ) . After NIPPV introduction , a slower decline in forced vital capacity ( FVC ) was observed in tolerant vs intolerant patients ( p = 0.002 ) . The slope of FVC decline after NIPPV initiation ( risk ratio [ RR ] : 0.78 , 95 % CI : 0.65 to 0.94 , p = 0.01 ) together with NIPPV tolerance ( RR : 0.32 , 95 % CI : 0.13 to 0.78 , p = 0.013 ) were the only independent predictors of survival in the overall group of patients . In multivariate analysis , body mass index was the most powerful predictor of longer survival  after NIPPV in tolerant patients ( RR : 0.77 , 95 % CI : 0.61 to 0.96 , p = 0.022 ) . Conclusion : Survival  after noninvasive ventilation was independently related to ventilatory use ( ≥4 h/day ) and to the modifications of forced vital capacity decline after treatment initiation . The severity of bulbar impairment and the nutritional status of the ALS patients at the introduction of ventilation may predict tolerance and survival Adults and children with neuromuscular disease exhibit weak cough and are susceptible to recurrent chest infections , a major cause of morbidity and mortality . Mechanical insufflation/exsufflation may improve cough efficacy by increasing peak cough flow . It was hypothesised that mechanical insufflation/exsufflation would produce a greater increase in peak cough flow than other modes of cough augmentation . The acceptability of these interventions was also compared . Twenty-two patients aged 10–56 yrs ( median 21 yrs ) with neuromuscular disease and 19 age-matched controls were studied .  Spirometry was performed and respiratory muscle strength measured . Peak cough flow was recorded during maximal unassisted coughs , followed in r and om order by coughs assisted by physiotherapy , noninvasive ventilation , insufflation and exsufflation , and exsufflation alone . Subjects rated strength of cough , distress and comfort on a visual analogue scale . In the neuromuscular disease group , mean±sd forced expiratory volume in one second was 0.8±0.6 L·s−1 , forced vital capacity 0.9±0.8 L , maximum inspiratory pressure 25±16 cmH2O , maximum expiratory pressure 26±22 cmH2O and unassisted peak cough flow 169±90 L·min−1 . The greatest increase in peak cough flow was observed with mechanical insufflation/exsufflation at 235±111 L·min−1 ( p<0.01 ) . All techniques showed similar patient acceptability . Mechanical insufflation/exsufflation produces a greater increase in peak cough flow than other st and ard cough augmentation techniques in adults and children with neuromuscular disease 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 OBJECTIVE To compare the effects of expiratory muscle training and sham training on respiratory muscle strength in patients with multiple sclerosis ( MS ) . DESIGN A r and omized control trial ; subjects were r and omly assigned to either expiratory muscle training or sham training . SETTING Training and measurement of respiratory muscle pressures were conducted in patients ' homes . Weekly home visits were conducted to assure compliance with the training protocol s and to obtain measurements . PATIENTS Twenty subjects with clinical ly definite MS and decreased expiratory muscle strength entered the study ; 10 subjects completed 3 months of expiratory training using a threshold training device and 5 subjects completed 3 months of sham training using the same device but without an expiratory training threshold load . MEASUREMENT Respiratory muscle strength was assessed at baseline and after 1 , 2 , and 3 months of training ; maximal inspiratory and expiratory pressures were used as measures of respiratory muscle strength . RESULTS There was a significant increase in expiratory muscle strength after 3 months of training when the expiratory training group was compared to the sham group ( p = .003 ) ; no significant change in inspiratory muscle strength was observed . CONCLUSIONS The results of this pilot study suggest that the strength of the expiratory muscles of persons with MS can be increased through respiratory muscle training targeted to the expiratory muscles . Further research is indicated to determine if increasing the strength of the expiratory muscles in MS has an effect on clinical outcomes in this patient population Respiratory impairment , due to respiratory muscle weakness , is a major cause of morbidity and mortality in patients with amyotrophic lateral sclerosis/motor neuron disease ( ALS/MND ) . Threshold loading may strengthen the inspiratory muscles and thereby improve patient prognosis . A phase II , double-blind , r and omized-controlled trial was undertaken to determine whether a 12-week inspiratory muscle training programme attenuated the decline in respiratory function and inspiratory muscle strength in patients with ALS/MND . Nine patients were r and omized to inspiratory muscle training and 10 to sham training . Primary endpoints were respiratory function ( forced vital capacity , vital capacity ) , lung volumes and inspiratory muscle strength . Patients were assessed before , during and immediately after a 12-week training period , and at eight weeks follow-up . While improvements in inspiratory muscle strength were observed in both treatment arms , there was a non-significant increase in maximum inspiratory pressure of 6.1 % in the experimental group compared to controls ( st and ard error of mean , 6.93 % ; 95 % confidence interval −8.58 −20.79 ; p=0.39 ) . The gains in inspiratory muscle strength were partially reversed during a period of training cessation . In conclusion , inspiratory muscle training may potentially strengthen the inspiratory muscles and slow the decline in respiratory function in patients with ALS/MND Respiratory complications are common in patients with amyotrophic lateral sclerosis ( ALS ) with respiratory failure representing the most common cause of death . Ineffective airway clearance result ant from deficient cough frequently contributes to these abnormalities . We sought to evaluate the effectiveness of high frequency chest wall oscillation ( HFCWO ) administered through the Vest ™ Airway Clearance System when added to st and ard care in preventing pulmonary complications and prolonging the time to death in patients with ALS . This is a single center study performed at the Penn State Milton S. Hershey Medical Center ( HMC ) . Nine patients with a diagnosis of ALS and concurrently receiving non‐invasive ventilatory support with bi‐level positive airway pressure ( BiPAP ) were recruited from the outpatient clinic at HMC . Four patients were r and omized to receive st and ard care and five patients to receive st and ard care plus the addition of HFCWO administered twice‐daily for 15 min duration . Longitudinal assessment s of oxyhemoglobin saturation , forced vital capacity ( FVC ) , and adverse events were obtained until time of death . Pulmonary complications of atelectasis , pneumonia , hospitalization for a respiratory‐related abnormality , and tracheostomy with mechanical ventilation were monitored throughout the study duration . No differences were observed between treatment groups in relation to the rate of decline in FVC . The addition of HFCWO airway clearance failed to improve time to death compared to st and ard treatment alone ( 340 days + /− 247 vs. 470 days + /− 241 ; p = 0.26 ) . The r and om allocation of HFCWO airway clearance to patients with ALS concomitantly receiving BiPAP failed to attain any significant clinical benefits in relation to either loss of lung function or mortality . This study does not exclude the potential benefit of HFCWO in select patients with ALS who have coexistent pulmonary diseases , pre‐existent mucus‐related pulmonary complications , or less severe levels of respiratory muscle weakness STUDY OBJECTIVES To analyze the physiologic effects and tolerance of mechanical insufflation-exsufflation ( MI-E ) for patients with chronic ventilatory failure of various etiologies . DESIGN Prospect i ve clinical trial . SETTING Rehabilitation unit of a university hospital . PATIENTS OR PARTICIPANTS Thirteen patients with amyotrophic lateral sclerosis ( ALS ) , 9 patients with severe COPD , and 7 patients with other neuromuscular disorders ( oNMDs ) with chronic airway secretion encumbrance and decreases in oxyhemoglobin saturation ( Spo(2 ) ) . INTERVENTIONS Pressures of MI-E of 15 cm H(2)O , 30 cm H(2)O , and 40 cm H(2)O were cycled to each patient , with 3 s for insufflation and 4 s for exsufflation . One application was six cycles at each pressure for a total of three applications . MEASUREMENTS AND RESULTS We continuously evaluated respiratory inductance plethysmography ( RIP ) and Spo(2 ) during every application . Peak cough flow ( PCF ) and dyspnea ( Borg Scale ) were also measured before the first and after the last application . The technique was well tolerated in all patient groups . Median Spo(2 ) improved significantly ( p < 0.005 ) in all patient groups . Median PCF improved significantly ( p < 0.005 ) in the ALS and oNMD groups from 170 to 200 L/min and from 180 to 220 L/min , respectively , and dyspnea improved significantly in the patients with oNMDs and patients with COPD from 3 to 1 and from 2 to 0.75 , respectively . Breathing pattern characteristics ( RIP ) did not deteriorate after MI-E in any patient groups . Inspiratory flow limitation significantly decreased at the highest MI-E pressures for the ALS group . CONCLUSIONS Our results confirm good tolerance and physiologic improvement in patients with restrictive disease and in patients with obstructive disease , suggesting that MI-E may be a potential complement to noninvasive ventilation for a wide variety of patient groups Background and Purpose Physical deconditioning is involved in the impaired exercise tolerance of patients with multiple sclerosis ( MS ) , but data on the effects of aerobic training ( AT ) in this population are scanty . The purpose of this study was to compare the effects of an 8-week AT program on exercise capacity — in terms of walking capacity and maximum exercise tolerance , as well as its effects on fatigue and health-related quality of life — as compared with neurological rehabilitation ( NR ) in subjects with MS . Subjects and Methods Nineteen subjects ( 14 female , 5 male ; mean age [X̄±SD]=41±8 years ) with mild to moderate disability secondary to MS participated in a r and omized crossover controlled study . Eleven subjects ( 8 female , 3 male ; mean age [X̄±SD]=44±6 years ) completed the study . 
    Output:
    
agent
***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: Objective : To identify factors associated with tolerance and survival after noninvasive positive-pressure ventilation ( NIPPV ) and to investigate the influence of NIPPV on lung function in patients with ALS . Methods : NIPPV was offered to 71 patients with ALS in accordance with currently published guidelines . Effects of NIPPV on lung function and factors influencing tolerance and survival after NIPPV were studied . Results : Forty-four patients ( 61.9 % ; 95 % CI : 50.6 to 73.2 ) tolerated NIPPV ( NIPPV use ≥4 h/day ) and 27 ( 38.1 % ; 95 % CI : 26.8 to 49.4 ) were intolerant ( NIPPV use < 4 h/day ) . Patients with mild or moderate bulbar symptoms were more likely to tolerate NIPPV than those with severe impairment ( odds ratio = 6.09 , 95 % CI : 1.18 to 31.52 , p = 0.031 ) . After NIPPV introduction , a slower decline in forced vital capacity ( FVC ) was observed in tolerant vs intolerant patients ( p = 0.002 ) . The slope of FVC decline after NIPPV initiation ( risk ratio [ RR ] : 0.78 , 95 % CI : 0.65 to 0.94 , p = 0.01 ) together with NIPPV tolerance ( RR : 0.32 , 95 % CI : 0.13 to 0.78 , p = 0.013 ) were the only independent predictors of survival in the overall group of patients . In multivariate analysis , body mass index was the most powerful predictor of longer survival  after NIPPV in tolerant patients ( RR : 0.77 , 95 % CI : 0.61 to 0.96 , p = 0.022 ) . Conclusion : Survival  after noninvasive ventilation was independently related to ventilatory use ( ≥4 h/day ) and to the modifications of forced vital capacity decline after treatment initiation . The severity of bulbar impairment and the nutritional status of the ALS patients at the introduction of ventilation may predict tolerance and survival Adults and children with neuromuscular disease exhibit weak cough and are susceptible to recurrent chest infections , a major cause of morbidity and mortality . Mechanical insufflation/exsufflation may improve cough efficacy by increasing peak cough flow . It was hypothesised that mechanical insufflation/exsufflation would produce a greater increase in peak cough flow than other modes of cough augmentation . The acceptability of these interventions was also compared . Twenty-two patients aged 10–56 yrs ( median 21 yrs ) with neuromuscular disease and 19 age-matched controls were studied .  Spirometry was performed and respiratory muscle strength measured . Peak cough flow was recorded during maximal unassisted coughs , followed in r and om order by coughs assisted by physiotherapy , noninvasive ventilation , insufflation and exsufflation , and exsufflation alone . Subjects rated strength of cough , distress and comfort on a visual analogue scale . In the neuromuscular disease group , mean±sd forced expiratory volume in one second was 0.8±0.6 L·s−1 , forced vital capacity 0.9±0.8 L , maximum inspiratory pressure 25±16 cmH2O , maximum expiratory pressure 26±22 cmH2O and unassisted peak cough flow 169±90 L·min−1 . The greatest increase in peak cough flow was observed with mechanical insufflation/exsufflation at 235±111 L·min−1 ( p<0.01 ) . All techniques showed similar patient acceptability . Mechanical insufflation/exsufflation produces a greater increase in peak cough flow than other st and ard cough augmentation techniques in adults and children with neuromuscular disease 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 OBJECTIVE To compare the effects of expiratory muscle training and sham training on respiratory muscle strength in patients with multiple sclerosis ( MS ) . DESIGN A r and omized control trial ; subjects were r and omly assigned to either expiratory muscle training or sham training . SETTING Training and measurement of respiratory muscle pressures were conducted in patients ' homes . Weekly home visits were conducted to assure compliance with the training protocol s and to obtain measurements . PATIENTS Twenty subjects with clinical ly definite MS and decreased expiratory muscle strength entered the study ; 10 subjects completed 3 months of expiratory training using a threshold training device and 5 subjects completed 3 months of sham training using the same device but without an expiratory training threshold load . MEASUREMENT Respiratory muscle strength was assessed at baseline and after 1 , 2 , and 3 months of training ; maximal inspiratory and expiratory pressures were used as measures of respiratory muscle strength . RESULTS There was a significant increase in expiratory muscle strength after 3 months of training when the expiratory training group was compared to the sham group ( p = .003 ) ; no significant change in inspiratory muscle strength was observed . CONCLUSIONS The results of this pilot study suggest that the strength of the expiratory muscles of persons with MS can be increased through respiratory muscle training targeted to the expiratory muscles . Further research is indicated to determine if increasing the strength of the expiratory muscles in MS has an effect on clinical outcomes in this patient population Respiratory impairment , due to respiratory muscle weakness , is a major cause of morbidity and mortality in patients with amyotrophic lateral sclerosis/motor neuron disease ( ALS/MND ) . Threshold loading may strengthen the inspiratory muscles and thereby improve patient prognosis . A phase II , double-blind , r and omized-controlled trial was undertaken to determine whether a 12-week inspiratory muscle training programme attenuated the decline in respiratory function and inspiratory muscle strength in patients with ALS/MND . Nine patients were r and omized to inspiratory muscle training and 10 to sham training . Primary endpoints were respiratory function ( forced vital capacity , vital capacity ) , lung volumes and inspiratory muscle strength . Patients were assessed before , during and immediately after a 12-week training period , and at eight weeks follow-up . While improvements in inspiratory muscle strength were observed in both treatment arms , there was a non-significant increase in maximum inspiratory pressure of 6.1 % in the experimental group compared to controls ( st and ard error of mean , 6.93 % ; 95 % confidence interval −8.58 −20.79 ; p=0.39 ) . The gains in inspiratory muscle strength were partially reversed during a period of training cessation . In conclusion , inspiratory muscle training may potentially strengthen the inspiratory muscles and slow the decline in respiratory function in patients with ALS/MND Respiratory complications are common in patients with amyotrophic lateral sclerosis ( ALS ) with respiratory failure representing the most common cause of death . Ineffective airway clearance result ant from deficient cough frequently contributes to these abnormalities . We sought to evaluate the effectiveness of high frequency chest wall oscillation ( HFCWO ) administered through the Vest ™ Airway Clearance System when added to st and ard care in preventing pulmonary complications and prolonging the time to death in patients with ALS . This is a single center study performed at the Penn State Milton S. Hershey Medical Center ( HMC ) . Nine patients with a diagnosis of ALS and concurrently receiving non‐invasive ventilatory support with bi‐level positive airway pressure ( BiPAP ) were recruited from the outpatient clinic at HMC . Four patients were r and omized to receive st and ard care and five patients to receive st and ard care plus the addition of HFCWO administered twice‐daily for 15 min duration . Longitudinal assessment s of oxyhemoglobin saturation , forced vital capacity ( FVC ) , and adverse events were obtained until time of death . Pulmonary complications of atelectasis , pneumonia , hospitalization for a respiratory‐related abnormality , and tracheostomy with mechanical ventilation were monitored throughout the study duration . No differences were observed between treatment groups in relation to the rate of decline in FVC . The addition of HFCWO airway clearance failed to improve time to death compared to st and ard treatment alone ( 340 days + /− 247 vs. 470 days + /− 241 ; p = 0.26 ) . The r and om allocation of HFCWO airway clearance to patients with ALS concomitantly receiving BiPAP failed to attain any significant clinical benefits in relation to either loss of lung function or mortality . This study does not exclude the potential benefit of HFCWO in select patients with ALS who have coexistent pulmonary diseases , pre‐existent mucus‐related pulmonary complications , or less severe levels of respiratory muscle weakness STUDY OBJECTIVES To analyze the physiologic effects and tolerance of mechanical insufflation-exsufflation ( MI-E ) for patients with chronic ventilatory failure of various etiologies . DESIGN Prospect i ve clinical trial . SETTING Rehabilitation unit of a university hospital . PATIENTS OR PARTICIPANTS Thirteen patients with amyotrophic lateral sclerosis ( ALS ) , 9 patients with severe COPD , and 7 patients with other neuromuscular disorders ( oNMDs ) with chronic airway secretion encumbrance and decreases in oxyhemoglobin saturation ( Spo(2 ) ) . INTERVENTIONS Pressures of MI-E of 15 cm H(2)O , 30 cm H(2)O , and 40 cm H(2)O were cycled to each patient , with 3 s for insufflation and 4 s for exsufflation . One application was six cycles at each pressure for a total of three applications . MEASUREMENTS AND RESULTS We continuously evaluated respiratory inductance plethysmography ( RIP ) and Spo(2 ) during every application . Peak cough flow ( PCF ) and dyspnea ( Borg Scale ) were also measured before the first and after the last application . The technique was well tolerated in all patient groups . Median Spo(2 ) improved significantly ( p < 0.005 ) in all patient groups . Median PCF improved significantly ( p < 0.005 ) in the ALS and oNMD groups from 170 to 200 L/min and from 180 to 220 L/min , respectively , and dyspnea improved significantly in the patients with oNMDs and patients with COPD from 3 to 1 and from 2 to 0.75 , respectively . Breathing pattern characteristics ( RIP ) did not deteriorate after MI-E in any patient groups . Inspiratory flow limitation significantly decreased at the highest MI-E pressures for the ALS group . CONCLUSIONS Our results confirm good tolerance and physiologic improvement in patients with restrictive disease and in patients with obstructive disease , suggesting that MI-E may be a potential complement to noninvasive ventilation for a wide variety of patient groups Background and Purpose Physical deconditioning is involved in the impaired exercise tolerance of patients with multiple sclerosis ( MS ) , but data on the effects of aerobic training ( AT ) in this population are scanty . The purpose of this study was to compare the effects of an 8-week AT program on exercise capacity — in terms of walking capacity and maximum exercise tolerance , as well as its effects on fatigue and health-related quality of life — as compared with neurological rehabilitation ( NR ) in subjects with MS . Subjects and Methods Nineteen subjects ( 14 female , 5 male ; mean age [X̄±SD]=41±8 years ) with mild to moderate disability secondary to MS participated in a r and omized crossover controlled study . Eleven subjects ( 8 female , 3 male ; mean age [X̄±SD]=44±6 years ) completed the study . 
    Output:
    