Respiratory muscle training improves respiratory function and reduces pneumonia risk in subacute strokeRespiratory muscle training improves outcomes for patients after stroke

ObjectiveTo systematically evaluate the effects of respiratory muscle training on respiratory function, functional outcomes, and pulmonary complications in patients with subacute stroke.MethodWe systematically searched PubMed, EMBASE, Cochrane Library, Web of Science, Scopus, and ClinicalTrials.gov up to August 12, 2026 for randomized controlled trials (RCTs). Pooled estimates were calculated using Hartung-Knapp-adjusted random-effects models. Two reviewers independently screened, extracted data, and assessed risk of bias (ROB2). Sensitivity and publication bias were evaluated via leave-one-out and trim-and-fill analyses.ResultsEleven RCTs (Final analysis sample:737 patients) were included. Respiratory muscle training significantly improved six-minute walk distance (mean difference [MD] = 34.09 m, 95% confidence interval [CI] 9.71–58.47), forced expiratory volume in one second (MD = 0.32 L, 95% CI 0.16–0.49), forced vital capacity (MD = 0.31 L, 95% CI 0.20–0.41), maximum inspiratory pressure (MD = 14.16 cmH₂O, 95% CI 6.93–21.38), and Trunk Impairment Scale scores (MD = 2.27, 95% CI 1.12–3.43). Respiratory muscle training also reduced pneumonia incidence (risk ratio = 0.41, 95% CI 0.24–0.72). Heterogeneity was substantial for maximum inspiratory pressure (I2 = 89.9%), moderate-to-high for forced expiratory volume in one second (I2 = 62.4%), and moderate for Trunk Impairment Scale scores (I2 = 56.0%); forced vital capacity showed no heterogeneity (I2 = 0%). Sensitivity analyses indicated that the six-minute walk test and Trunk Impairment Scale findings were sensitive to individual trials, whereas forced expiratory volume in one second, forced vital capacity, and maximum inspiratory pressure estimates remained statistically significant after leave-one-out analyses. Egger’s test for maximum inspiratory pressure was not significant (p = 0.097), but trim-and-fill analysis suggested potential missing studies for forced expiratory volume in one second, forced vital capacity, and maximum inspiratory pressure.ConclusionIn patients with subacute stroke, respiratory muscle training is associated with improvements in respiratory function and functional outcomes and with a reduced risk of pneumonia. However, some pooled estimates were sensitive to individual trials and the evidence remains limited by heterogeneity, indicating a need for further large randomized trials.Systematic review registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD420261482562, Identifier, CRD420261482562.