Thoracotomy often causes respiratory muscle injury, reduced chest wall expansion, decreased lung volume, and limited shoulder range of motion (ROM). Respiratory muscle-stretching exercises (RMSE) have been proposed to enhance chest expansion and facilitate recovery. This aimed to compare the effects of RMSE combined with conventional physical therapy versus conventional therapy alone in patients undergoing elective thoracotomy. A single-center randomized controlled trial was conducted at Songklanagarind Hospital, Thailand, between August 2013 and December 2019. Twenty-eight patients scheduled for elective thoracotomy were recruited, and 23 (mean age 47.1 ± 15.2 years; 18 males, 5 females) completed the trials. Participants were randomized to an intervention group (RMSE plus conventional therapy, n = 12) or a control group (conventional therapy only, n = 11). RMSE consisted of four stretching exercises performed twice daily for eight days. Primary outcomes were middle and lower chest expansion (MCE, LCE), slow vital capacity (SVC), and shoulder flexion and abduction ROM, assessed preoperatively, on postoperative day 2, and day 8. Both groups demonstrated significant within-group improvement between days 2 and 8. In the intervention group, MCE increased by 1.46cm (95%CI: -2.5 to -0.87), LCE by 1.75cm (95%CI: -2.42 to -1.08), SVC by 438 mL (95%CI: -761 to -115), shoulder flexion by 48.3°, and abduction by 38.8° (95%CI: -57.2 to -20.4). Similar improvements were observed in the control group: MCE 1.18cm (95%CI: -1.76 to -0.61), LCE 1.27cm (95%CI: -1.91 to -0.65), SVC 347 mL (95%CI: -690 to -4), shoulder flexion 35.4° (95%CI: -50.6 to -20.2), and abduction 35.7° (95%CI: -54.0 to -17.4). Between-group comparisons showed no significant differences for any outcome (all Group x Time, p-value > 0.05). Respiratory muscle-stretching exercise combined with conventional therapy facilitated significant recovery in chest wall mobility, lung volume, and shoulder motion after thoracotomy. However, these benefits were not significantly greater than those achieved with conventional therapy alone. Clinically, Respiratory muscle-stretching exercise is feasible, safe, and may be considered as an adjunct to standard care. TCTR20140224004.

The RESISTANT study (Respiratory Muscle Training in Patients with Spinal Muscular Atrophy): results of a randomized controlled trial.

Phase angle on bioelectrical impedance analysis and chronic obstructive pulmonary disease-related pathophysiology in smokers.

INTRODUCTION Postoperative fatigue is a major complication after surgery. It is one of the most distressing problems reported by patients and also thought to be the main contributor to delayed recovery after surgery. This is especially important for older patients who are often suffering from frailty characterised by a decreased physiological reserve. Surgical stress and the associated acute inflammatory response may be the driver of this fatigue by inducing acquired postoperative muscle weakness leading to impaired functional recovery. Corticosteroids are known to dampen this peri-operative stress response. Therefore, this study will investigate whether muscle weakness and, consequently, fatigue and delayed recovery after surgery can be ameliorated by administering methylprednisolone. METHODS AND ANALYSIS The CORTERAS trial is a large monocentric, parallel-group, double-blind, randomised controlled trial comparing the administration of 250 mg of methylprednisolone or a placebo in adults 60 years or older and scheduled for major elective surgery. In on-pump cardiac surgical procedures, a repeat dose of 250 mg will be given on initiation of cardiac bypass to correct for dilution. The primary outcome is the percentage change of handgrip strength on day 1 after surgery. Secondary outcomes encompass peripheral limb muscle strength, normalised peripheral limb muscle strength, fatigue, early quality of recovery, respiratory muscle strength, pain scores, postoperative nausea and vomiting (PONV), quality of life and markers of inflammation. The sample size has been calculated as a total of 674 patients receiving the study intervention and reaching the primary endpoint. Randomisation is performed at the patient level using computer-generated block assignments. Stratification is based on type of surgery, sex (male or female), age (60 to 70 years or older than 70 years) and BMI (≤30 or >30 kg m−2). Patients and outcome assessors are blinded to the intervention assignment. Assessments are conducted pre-operatively, immediately postoperatively, during the hospital stay (postoperative days 1, 3 and 5), and on day 28 postoperatively. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Independent Ethics Committee at Ziekenhuis Oost-Limburg in Genk, under protocol version 2.0 (1 November 2021), reference number Z-202170. The study has been registered at ClinicalTrials.gov (NCT05220319) on 31 January 2022 and the first patient was included on 6 February 2022. Trial results will be presented at national and international academic conferences, and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT05220319

ObjectiveThis study conducted a thorough review and meta-analysis to examine how respiratory muscle training (RMT) affects lung function recovery in individuals with spinal cord injury (SCI).MethodsWe conducted a systematic review of Randomized Controlled Trials (RCTs) examining the effects of RMT on lung function in patients with SCI. The search included databases such as PubMed, Embase, The Cochrane Library, Scopus, and Web of Science up to October 2025. The experimental group received RMT as the main intervention, while the control group received either no treatment, a placebo, or conventional rehabilitation. Outcome measures included Forced Expiratory Volume in the first second (FEV1), Forced Vital Capacity (FVC), Maximum Inspiratory Pressure (MIP), Maximum Expiratory Pressure (MEP), Peak Expiratory Flow (PEF), Minute Ventilation Volume (MVV), Total Lung Capacity (TLC), Inspiratory Capacity (IC), and Vital Capacity (VC). Two reviewers independently screened, extracted data, and assessed bias. Meta-analysis was conducted using RevMan 5.3 software, and the quality of included studies was evaluated using the Cochrane bias risk assessment tool and the Physical Therapy Evidence Database scale. The reporting of this study followed the PRISMA guidelines and was registered with PROSPERO (ID: CRD42024627736).ResultsIn this meta-analysis, 25 RCTs were included, comprising a total of 679 patients. The meta-analysis showed that compared with conventional rehabilitation, respiratory muscle training significantly improved FEV1 (p < 0.0001), FVC (p = 0.0001), MIP (p < 0.00001), MEP (p = 0.0004), PEF (p < 0.00001), MVV (p < 0.0001), TLC (p = 0.05), VC (p = 0.04), and their differences were statistically significant. However, IC (p = 0.40) was not statistically significant. Subgroup analyses showed that resistive training and surface electromyography biofeedback training were effective for improving FEV1 and FVC, while threshold training significantly improved MVV.ConclusionThis meta-analysis provides strong evidence that RMT is an effective intervention for enhancing respiratory muscle strength and key parameters of pulmonary function in individuals with SCI. Further research with robust methodologies and extensive sample sizes is needed to validate this finding.

The importance of quantifying training loads and applying exercise principles in respiratory muscle training studies

In recent years, respiratory muscle training and neurostimulation have emerged as strategies to prevent or reverse respiratory muscle weakness. This review evaluates the latest evidence for respiratory muscle training and neurostimulation as targeted interventions. Inspiratory muscle training (IMT) improves physiological parameters including maximal inspiratory and expiratory pressures, peak expiratory flow, and diaphragm thickness, though clinical trials have not consistently shown benefits in weaning success, ventilator duration, or survival. Evidence for expiratory muscle training (EMT) in ICU patients is scarce, but combined IMT and EMT may improve outcomes. Neurostimulation of the diaphragm and expiratory muscles has advanced from feasibility to early clinical trials. Diaphragm neurostimulation has been demonstrated to improve diaphragm strength and weaning success. Preliminary experimental evidence suggests that diaphragm neurostimulation may also influence lung mechanics, haemodynamics, and brain function. Respiratory muscle training and neurostimulation may attenuate critical illness-associated respiratory muscle weakness. While IMT improves physiological parameters, consistent clinical benefits have not yet been demonstrated. Neurostimulation represents a promising intervention, but further research is required to establish its impact on clinically relevant outcomes and to exclude potential harms when applied in the early phase of critical illness.

Background: Amyotrophic lateral sclerosis (ALS) is a fatal heterogeneous neurodegenerative disease characterized by the degeneration of both upper and lower motor neurons and spinal cord. Measurement of respiratory muscle strength has been shown to be an important assessment in the decision-making process and can be assessed by maximum inspiratory (PImax) and expiratory pressures (PEmax), sniff nasal inspiratory (SNIP) and expiratory (SNEP) pressures. Body position appears to have a significant effect on respiratory muscle strength. The aim of this study was to observe the difference in peak values of SNIP and SNEP of the respiratory muscles measured in 2 different positions (seated and supine with 45° elevation) in subjects with ALS and a group of matched healthy subjects. Methods: This is a case-control study of subjects with ALS and healthy subjects. Spirometry and surface electromyography (EMG) of the sternocleidomastoid, scalene, rectus abdominis, and external oblique muscles were assessed during PImax and PEmax maneuvers in the seated position, and SNIP and SNEP in the seated and supine positions at 45° elevation (randomized). Results: SNEP values in the 45° elevation were lower than in the sitting position in ALS (70.3 ± 26.7 vs 57.3 ± 22.8 cm H2O, P = .041). SNIP and SNEP were lower in ALS in the 45° elevation compared with healthy subjects (69.1 ± 27.2 vs 95.5 ± 23.5 cm H2O; 57.3 ± 22.5 vs 92.7 ± 26.4 cm H2O, P = .041). In subjects with ALS, baseline electromyographic activity of the sternocleidomastoid muscle at rest was higher than in healthy subjects in both positions (P = .041). No significant differences in electrical activity were found for other variables and measurements. Conclusions: In ALS, nasal pressure may be affected by reduced diaphragm and abdominal muscle effectiveness in the supine position. The sternocleidomastoid muscle showed increased electrical activity in the supine position with 45° elevation compared with controls, which may indicate muscle weakness.

Background: Malnutrition is a serious problem in patients with COPD, it interferes with normal skeletal muscle function, with reduced muscle mass and decreased respiratory muscle strength and endurance. The purpose of the study was to determine the incidence of malnutrition based on BMI and SGA in patients with stable chronic obstructive pulmonary disease at the Prof. Dr. Chairuddin P. Lubis Medan Teaching Hospital. Method: The research design is an observational analytic, from November 2023 to March 2024. The study population was COPD patients who sought treatment at the Pulmonary Polyclinic at RSCPL with a total sample using the consecutive sampling method of 91 people Assessment of BMI by measuring TB and BW of patients when they came and assessment of SGA with a questionnaire Data processing using SPSS using descriptive statistics by displaying the IMT and SGA frequency distribution tables. Result: The results of this study found that most patients were categorized as underweight, namely 28 patients (30.8%). The majority of SGA classification as underweight/moderate nutrition "SGA B", namely 50 patients or (54.9%). Conclusion: We found that the Subjective Global Assessment (SGA) questionnaire is very influential in detecting patients with COPD who are malnourished to reduce respiratory muscle decline, and relapse of exacerbations.

Mechanical ventilation provides life-saving support to patients with respiratory failure, but inadequately tailored settings can lead to respiratory muscle dysfunction and poor patient outcomes. Surface electromyography (sEMG) offers a non-invasive modality to monitor respiratory muscle function. However, variability in acquisition setups limits the comparability of study findings and hinders broad clinical implementation.Therefore, we systematically appraised setup rationales and reporting quality in respiratory sEMG literature. The MEDLINE ALL, Embase, and Web of Science databases were systematically searched on 19 September 2024 for studies reporting original respiratory sEMG data in adults during spontaneous breathing. sEMG methodology was extracted in accordance with the reporting guidelines of the International Society of Electrophysiology and Kinesiology and analyzed by target muscle and medical domain. 240 out of 402 unique articles were included. The diaphragm was the most studied respiratory muscle (61%) with 48 unique setups out of 160 descriptions. Diaphragm setups with small inter-electrode distances (IEDs) were most common (n = 138, 86%). Large IED setups were predominantly applied in ICU (n = 8, 36%) and COPD (n = 5, 23%) populations. Setups for non-diaphragmatic respiratory muscles typically featured one or two dominant positions grounded in methodological studies. Reporting quality was low with a median of 5 out of 10 recommended items documented. This review reveals substantial diversity of diaphragm sEMG setups, reflecting differences in clinical contexts and study populations. The setups for extra-diaphragmatic muscles were more consistent and methodologically grounded. Muscle- and context-specific guidelines are essential to improve consistency and support clinical implementation of respiratory sEMG.

To investigate the effectiveness of a virtual reality-based rehabilitation (VRBR) program in individuals with Adolescent Idiopathic Scoliosis (AIS) who have undergone posterior fusion surgery (PSF). A total of 28 AIS patients who had undergone PSF surgery were included in the study. Participants were randomly assigned to either the VRBR group (n = 14) or the Control group (n = 14). The VRBR group received a rehabilitation program using the Kinect Xbox 360 for 30min, twice a week, over a period of 6 weeks. The Control group was prescribed a comparable set of exercises to be performed as a home-based program over the same duration. Spinal mobility was assessed using the Modified Schober Test, and respiratory muscle strength was measured with a portable Micro RPM device. Physical activity levels were monitored using a pedometer, kinesiophobia was evaluated using the Tampa Scale for Kinesiophobia (TSK), quality of life was assessed via the Scoliosis Research Society-22 Questionnaire (SRS-22), and spinal balance was evaluated using full-spine radiographs (orthoroentgenograms). In the VRBR group, statistically significant improvements were observed in spinal mobility, MIP, MEP, physical activity level, TSK, and SRS-22 scores (p < 0.0001), as well as in coronal balance parameters including CSVL-C7PL (p = 0.041), sagittal vertical axis (SVA) (p = 0.01), and pelvic tilt (p < 0.0001) when compared to baseline. In contrast, no statistically significant improvements were found in any of the assessed parameters within the Control group (p > 0.05). Between-group comparisons revealed statistically significant improvements in favor of the VRBR group in spinal mobility (p = 0.048), MIP (p = 0.029), and physical activity levels (p < 0.01). The findings suggest that VR-based rehabilitation contributes positively to postoperative outcomes in AIS, with notable advantages in terms of spinal mobility, respiratory function, and physical activity.

This paper explores the integration of newer technologies like artificial intelligence (AI) in respiratory muscle training (RMT) and real-time biomechanical analysis to enhance swimming performance and respiratory efficiency. Combining AI-driven personalized training protocols with biomechanical feedback aims to improve inspiratory muscle strength, optimize breathing patterns, and refine stroke mechanics. This interdisciplinary approach leverages machine learning, motion capture, and physiological monitoring in aquatic sports. Results from experimental trials with swimmers demonstrate significant improvements in respiratory performance and swimming efficiency. The findings highlight AI's potential to revolutionize training strategies, offering data-driven customization to boost athletic outcomes

A 62-year-old female was referred to the acute medical unit with a history of progressively worsening mobility, shortness of breath and leg swelling over the last few months. Initial investigations revealed hypoxia with features of decompensated heart failure (HF) and a significantly elevated troponin. The patient developed a rapidly progressive type two respiratory failure (T2RF) over 24 hours requiring non-invasive ventilation (NIV). There was evidence of marked proximal and respiratory muscle weakness and following investigation the patient was diagnosed with anti-signal-recognition-particle immune mediated necrotising myopathy (SRP-IMNM) with myocardial and respiratory involvement. Following the introduction of high dose corticosteroid and further immunosuppression, the patient was discharged well and has had persistent improvement over the subsequent year.

Primary ciliary dyskinesia (PCD) is a rare disorder characterized by defective motile cilia, impairing airway mucociliary clearance. Children with PCD (cwPCD) may exhibit distinctions in exercise responses compared to healthy peers (HP). We aimed to compare physiological responses to cardiopulmonary exercise testing (CPET), incremental shuttle walk test (ISWT), and 6-min walk test (6MWT) in cwPCD and HP and investigate the associations between clinical parameters. Twenty-three cwPCD and 23 HP were included. Pulmonary function and respiratory muscle strength were assessed. All participants performed CPET, ISWT, and 6MWT. Heart rate (HR), blood pressure (BP), oxygen saturation (SpO2), anddyspnea and fatigue (modified Borg Scale) were assessed before and after tests. In cwPCD, CPET and ISWT revealed similar HR, SpO2, systolic BP, dyspnea, and fatigue responses (p > 0.05), while 6MWT elicited lower responses in these parameters (p < 0.05). cwPCD had lower ∆HR (p = 0.003), peak oxygen uptake (peak ) (p = 0.048), relative peak (p = 0.041), and higher minute ventilation/carbon dioxide production (V̇E/ ) at anaerobic threshold (p = 0.047) compared to HP. Peak correlated with ISWT distance (ISWD) (r = 0.592) and 6MWT distance(6MWD)(r = 0.601) in cwPCD and HP(r = 0.648, r = 0.507, respectively)(p < 0.05). Regression equations were developed: relative peakV̇O₂(mL/min/kg) = - 25.630 + 0.083 × 6MWD(m)[F(1-21) = 7.719, p = 0.011, R2 = 0.269] and relative peak (mL/min/kg) = 1.922 + 0.032 × ISWD(m)[F(1-21) = 11.790, p = 0.002, R2 = 0.329). CPET and ISWT evoke comparable responses, while 6MWT results in lower physiological responses. However, 6MWT remains useful, given its association with peak . ThecwPCD have an altered control and early CO2 increase with exercise, greater ventilatory inefficiency, and chronotropic impairment. Compared to field tests, CPET can be more helpful for determining ventilatory inefficiency and chronotropic impairment in PCD. NCT05712798 (Registration Date: 26.01.2023).

IntroductionChronic obstructive pulmonary disease (COPD) is characterized by respiratory muscle weakness, hyperinflation, and systemic inflammation, leading to impaired pulmonary function and quality of life. Respiratory muscle training (RMT) may strengthen the inspiratory and expiratory muscles, improve pulmonary function, reduce dyspnea, and enhance functional outcomes. This study assessed the impact of concurrent RMT on respiratory muscle strength, spirometry, dyspnea, and quality of life in patients with COPD.Materials and MethodsThis was a single-cohort pre/post-intervention study initially recruiting 43 patients with COPD to participate in an 8-week RMT program using a threshold pressure device. Both inspiratory and expiratory training were performed using a PowerLung device with adjustable resistance. Training consisted of three sets of ten breaths twice daily for each mode, and participants were instructed to increase resistance incrementally when the load became easy. Assessments included spirometry, maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), COPD Assessment Test (CAT), Medical Research Council (MRC) Breathlessness Scale, and Airways Questionnaire 20 (AQ20). Data were collected at baseline and post-intervention and analyzed using paired t-tests and Wilcoxon signed-rank tests, stratified by GOLD category.ResultsTwenty-seven participants completed the study. Statistically significant improvements were observed in MIP (mean increase 14.1 cm H₂O, p < .001), MEP (mean increase 20.1 cm H₂O, p < .001), CAT (mean decrease 2.92, p = .020), and AQ20 (mean decrease 1.67, p = .005). FEV₁ improved modestly but did not reach statistical significance (mean increase 0.0367 L, p = .064). The GOLD distribution included eight participants in GOLD 2, 12 in GOLD 3, and seven in GOLD 4. Improvements in MIP and MEP were statistically significant within all GOLD categories. A clinically meaningful increase in FEV₁ (≥ 60 mL) was observed in participants in GOLD 3 and 4 stages, though not statistically significant. Correlations between muscle strength improvements and symptom scores were moderate to strong.DiscussionConcurrent RMT improves respiratory muscle strength and quality of life in patients with COPD, with the greatest benefits observed in advanced disease stages. Enhanced respiratory muscle efficiency may reduce dyspnea and promote exercise tolerance.ConclusionRMT is a promising intervention for COPD management that offers improved respiratory muscle strength and quality of life. Future studies should explore the long-term effects and optimize protocols for broader implementation.

What is the effect of measurable respiratory muscle training on respiratory muscle strength in mechanically ventilated adults in intensive care units? A systematic review and meta-analysis.

IntroductionGlobally, millions of abdominal surgeries are performed annually, placing a substantial burden on public health systems worldwide. Postoperative pulmonary complications (PPCs) are common negative consequences after major abdominal surgery that can worsen recovery outcomes. Although the effect of prehabilitation has been frequently investigated in this population, the feasibility and efficacy of delivering a supervised, intensive exercise programme within a limited preoperative period remain underexplored.This randomised controlled trial (RCT) aims to evaluate the effectiveness of the SUPERvised PREhabilitation with Personalised, Aerobic training, Respiratory muscle training and patient EDucation (SUPER-PREPARED) multi-model to reduce the incidence of PPCs among the population undergoing abdominal surgery.Methods and analysisThe SUPER-PREPARED trial will be a single-centre, prospective, two-arm RCT. A total of 120 participants will be recruited and randomly allocated to either the SUPER-PREPARED group or the usual care group. The primary outcome is the incidence of PPCs, assessed at specific time points (1 day before discharge and 1 month, 6 months and 1 year after surgery). The secondary outcomes include patient-centred measures (functional capacity, quality of life), clinical measures (respiratory muscle function, pulmonary function) and postoperative recovery metrics (postoperative intestinal ventilation timing, length of intensive care unit (ICU) stay, length of postoperative hospital stay, postoperative hospitalisation expenses and readmission rate). The detailed criteria defining PPCs and the schedule of the study are displayed in tables. Data analysis will be independently conducted by two experienced clinicians via the per-protocol analysis.Ethics and disseminationThis study will be conducted in strict accordance with the Declaration of Helsinki (2024). The protocol was approved by the Ethics Committee on Biomedical Research, West China Hospital of Sichuan University (2024 nianshen No. 2049). The final results will be disseminated by peer-reviewed journals and presentations at academic conferences.Trial registration numberChiCTR2500102615.

Sarcopenia as a treatable trait in COPD: From mechanisms to management.

Abstract Introduction We present the case of a 46-year old male who unfortunately developed progressive multifocal leukoencephalopathy following administration of rituximab for polymyositis /systemic sclerosis overlap syndrome. Case description He was originally felt to have a diagnosis of systemic sclerosis with interstitial lung disease. This was managed with oral steroids and mycophenolate mofetil (MMF). His symptoms progressed despite immunosuppression; manifesting as significant shortness of breath and acute proximal muscle weakness. Therefore various investigations were performed demonstrating various abnormalities; including a creatine kinase level of 7653, ALT of 222 and a CRP of 29. A CTPA was performed which revealed no cause for his deterioration in symptoms. Subsequent MRI of his thighs demonstrated appearances consistent with patchy moderate bilateral girdle myositis extending into the thighs bilaterally. Due to his marked symptoms and evidence of active severe myositis his prednisolone dose was increased and the decision was made to alter his immunosuppression, discontinuing the MMF for rituximab. Approximately 3 weeks following his first rituximab infusion he became unwell with acute confusion. This was accompanied by a sore nose with crusting and raised inflammatory markers, with a CRP value of 143. He was found to have selective IgA deficiency prior to commencing the rituximab and therefore he was treated for a sinus infection with augmentin. His CRP subsequently normalised, however his symptoms progressed leading to an acute hospital admission. Assessment revealed that he was increasingly confused and ataxic. A CT head was arranged demonstrating abnormal subcortical low density within the left frontal lobe and medially within the right fronto-temporal regions. Subsequent imaging with an MRI head revealed abnormal signal within the medial occipital and parietal lobes bilaterally. His symptoms progressed and over time he went on to develop a right sided hemiparesis. Repeated imaging of his brain was arranged demonstrating progression of the changes in the subcortical and deep white matter of the cerebral hemispheres with some new lesions in the periventricular white matter. He also underwent a lumbar puncture with CSF analysis essentially unremarkable other than a raised protein level and detection of the John Cunningham Virus. He was transferred under the care of the neurologist to a tertiary centre for consideration of plasma exchange. Unfortunately, there was no clinical improvement despite treatment. The patient sadly passed away shortly following transfer. Discussion The use of immunosuppressive biological agents have been reported as a possible risk factor for developing progressive multifocal leukoencephalopathy (PML). This is a rare, often fatal demyelinating disease of the central nervous system caused by the John Cunningham virus. The development of PML in patients receiving rituximab in the oncology setting is well-described, particularly in those with underlying non-Hodgkin lymphoma or chronic lymphocytic leukaemia.1 However, it is thought that these diseases in themselves are independent risk factors for developing PML. Development of PML in the context of treating rheumatoid arthritis with rituximab is very rare with a reported incidence of 2.56 cases per 100,000 patients.2 The literature demonstrates that the disease is more likely to occur in those with pre-existing risk factors for PML independent of rituximab treatment, such as Sjogren’s syndrome, a history of malignancy, prior and concomitant therapy with disease modifying anti-rheumatic drugs and treatment with ≥ 2 prior TNF inhibitors.3 In patients treated with rituximab for rheumatoid arthritis, the estimated incidence of PML has remained stable and low since 2009 despite its increasing use. There has been no documented pattern of latency from the time of rituximab initiation to PML development and no association of developing PML with the number of rituximab courses given. 4 Key learning points PML should always be investigated as a potential diagnosis in patients treated with rituximab for underlying autoimmune disease when they present with new onset neurological symptoms. Should PML be considered as a diagnosis, further dosing of immunosuppressive therapy, including rituximab, should be discontinued until PML has been excluded. Routine JCV antibody testing for virus exposure is not approved, nor warranted, for patients with rheumatoid arthritis due to the rarity of PML in these populations. To date, JCV antibody testing for PML is only done in those receiving natalizumab in the context of treating multiple sclerosis as the incidence of PML is sufficiently high enough to warrant risk stratification (1in 1000 patients).5

Effects of inspiratory muscle training on balance, trunk control, fear of falling, respiratory function, and quality of life in people with multiple sclerosis: a randomized controlled trial.