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Inspiratory muscle training in COPD: can data finally beat emotion?
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  • Published on:
    Science is the great antidote to the poison of enthusiasm and superstition
    • Michael I Polkey, co-author of the original MS Royal brompton & Harefield NHS Trust
    • Other Contributors:
      • Nicolino Ambrosino, co-author of the original MS

    To the Editor

    Science is the great antidote to the poison of enthusiasm and superstition

    We thank Langer and colleagues for their interest in our editorial. In many ways the title they have chosen for their response confirms our thesis. ‘Absence of evidence’ may not be ‘Evidence of absence’ but it is ……………….. Absence of evidence . Our contention overall is that the relentless search for benefit despite the recently reported negative trials is driven by emotion rather than data.
    Whilst physiological arguments are of interest to physiologists, there remains no convincing evidence in our view either that respiratory muscle fatigue is present in patients with COPD, or that it contributes to exercise limitation. The various suggestions they make in the hope of eliciting a ‘positive result’ for IMT (e.g. changing outcome measure, patient selection) are credible research suggestions and we would not oppose interested investigators pursuing research in this arena, but this does not alter our contention that IMT has no place in current clinical practice.
    Clinically their argument is that IMT alone is beneficial in COPD. We think this argument is specious (irrespective of whether it is correct); pulmonary rehabilitation, in part thanks to the Leuven group, has one of the strongest evidence bases for any therapy in COPD. Therefore the idea that one might drop PR in order to do IMT instead is not one we believe should be taken into the clinical arena....

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    Conflict of Interest:
    None declared.
  • Published on:
    Absence of evidence is not evidence of absence! Lessons from recent trials of adjunctive IMT in COPD and recommendations for further research: careful selection of candidates, controlling interventions and choosing the most adequate outcomes.
    • Daniel Langer, Assistant Professor, Physiotherapist KU Leuven, Department of Rehabilitation Sciences
    • Other Contributors:
      • Rik Gosselink, Full Professor, Physiotherapist
      • Ghislaine Gayan-Ramirez, Full professor

    We support the view of Drs. Polkey and Ambrosino that recommendations for clinical practice should not be based on either positive or negative preoccupation concerning the potential effectiveness of a treatment but rather on an impartial evaluation of the available data. In their editorial entitled ‘Inspiratory Muscle Training in COPD: can data finally beat emotion’ they unfortunately provide a fairly one-sided evaluation of this treatment, based on an incomplete and largely outdated review of the available evidence1. It is unfortunate that they neglect a major part of available data, which could contribute to a more balanced and fair discussion about this intervention. We therefore deemed it necessary to add this missing evidence along with our own interpretation of recent findings to the discussion.
    Complexity of studying add-on interventions to pulmonary rehabilitation
    Based on the results from three recent multicentre trials2-4, Polkey and Ambrosino exclude a role for adjunctive IMT in the rehabilitation of patients with COPD. As emphasized in a previous opinion piece by Dr. Ambrosino5, it is important to distinguish between studies that evaluate the effects of inspiratory muscle training (IMT) as a standalone intervention (i.e. in comparison to no intervention or a sham control intervention) and studies on the effects of IMT added to a pulmonary rehabilitation program (PRP).
    Concerning the first comparison, there is a large amount of data available s...

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    Conflict of Interest:
    None declared.