Multifactorial Inspiratory Muscle Training in Diabetic Population: A Qualitative Study

Multifactorial Inspiratory Muscle Training in Diabetic Population: A Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Multifactorial Inspiratory Muscle Training in Diabetic Population: A Qualitative Study Suman Sheraz, Arshad Nawaz Malik, Francesco Vincenzo Ferraro, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4726704/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The aim of this descriptive qualitative study was to explore the patient’s perspective of multifactorial home-based Inspiratory Muscle Training (IMT) combined with group-based Otago Exercise Program (OEP) to bridge the gap of the experiences and perceptions of diabetes polyneuropathy patients regarding home-based multifactorial IMT intervention. Individual semi-structured interviews were conducted with 12 patients using thematic analysis. The patients’ interviews were transcribed verbatim in Urdu, translated into English, and then coded into relevant themes. Three key themes emerged, including perception regarding quality of life, facilitators, and barriers to intervention. The patients reported improvement in their quality of life perceived through improvement in their physical and mental health as well as their functional independence. While improvement in shortness of breath and walking capacity, discomfort, initial difficulty in usage and distraction in the home environment were the key barriers. A multifactorial IMT intervention was perceived to have positive effects on the physical, mental, and emotional health of diabetes patients. These findings highlight the importance of multifactorial IMT interventions and suggest tailoring interventions and physical therapies to address the barriers and facilitators to enhance the likelihood of successful training outcomes. Health sciences/Endocrinology Health sciences/Health care Type 2 Diabetes Mellitus Patient’s Perceptions Qualitative Quality of life Figures Figure 1 Introduction Patients’ perspectives on Diabetes Mellitus (DM), highlights the fears of patients concerning fatigue, generalized body pains, troublesome excessive urination, and dread of experiencing complications if they do not adhere to medical treatment ( 1 ). Current physical therapy goals for management of DM are targeted towards prevention of complications, which occur more often with uncontrolled blood glucose levels ( 2 , 3 ). As reported in NICE guidelines, multiple management strategies are used to control glycemic index, manage co-morbidities & complications ( 4 – 6 ). The American College of Sports Medicine (ACSM) and the Centers for Disease Control and Prevention (CDC) suggested at least 30 minutes of moderate-intensity physical activity (PA) on most days of the week for adequate glycemic management ( 7 ). Multiple exercise training protocols, including aerobic, resistance ( 7 ), high-intensity interval training ( 7 ), Tai Chi ( 8 ) and calisthenics ( 9 ) are currently being used for a range of effects in diabetic patients. A recent systematic review (2023) suggested that Inspiratory Muscle Training (IMT) defined as a therapeutic technique to improve the strength of respiratory muscle ( 10 ) is an effective intervention especially when in addition to other exercise forms specific to need of the patients ( 11 ). The IMT has been used with COPD ( 12 ), heart failure ( 13 ) and stroke ( 14 ) and currently considered for its effects on balance with elderly ( 15 ), stroke ( 16 ) heart failure ( 17 ) and in DM (under review). However, there is an evident research gap in terms of patient’s perception of this training. The patient’s view, with this easy-to-perform home-based intervention will provide a real-world perspective and will help the health care practitioners to adapt strategies based on the individualized needs and preferences of patients improving the care quality ( 18 ). The current study aims to report patients’ perspectives on a multifactorial exercise program designed to improve balance, diminish fear of falls, and increase functional mobility in patients with DM ( 19 ). Results A total of twelve patients with diabetic polyneuropathy (seven men and five women, of age ranging between 50–66 years) were interviewed in the study. For all the patients, the disease was diagnosed for more than 8 years, and all the patients had moderate to severe levels of diabetic polyneuropathy (mTCNS score ranging from 9–12). The demographic and clinical characteristics of the patients are mentioned in Table 1 . Table 1 Demographic and clinical characteristics of patients. Age (years) Gender (M/F) BMI (kg/m 2 ) Duration of diagnosis (years) Treatment (Medicines / Insulin / Both) mTCNS score P1 56 M 30.1 12 Insulin 10 P2 56 F 34.9 8 Medicines 12 P3 65 M 28.3 9 Medicines 10 P4 52 F 26.7 8 Both 9 P5 53 F 29.5 11 Medicines 9 P6 66 M 26.8 9 Insulin 12 P7 60 M 31.6 8 Both 12 P8 56 M 22.3 14 Insulin 9 P9 55 M 29.4 16 Insulin 10 P10 63 M 25.1 14 Insulin 11 P11 50 F 32.2 8 Medicines 10 P12 55 F 25.9 12 Medicines 9 BMI: Body Mass Index, mTCNS: Modified Toronto Clinical Neuropathy Scoring System Three key themes were identified after data analysis: (a) Perception of quality of life (b) Facilitators and (c) Barriers to home-based multifactorial IMT. The quotations from the data are highlighted below with the description of each theme. Detailed description of themes. Sub themes and codes are given in Table 2 . Table 2 Themes, sub themes and codes related to patients’ perception of multifactorial IMT. Theme Sub-themes Codes Improvement in QOL Experienced better breathing control • Decreased SOB during activity • Level of dyspnea reduced Generalized improvement in physical health • Improved walking capacity • Decreased level of fatigue • Feeling of relaxation • Better sleep • Functional independence Reduced physical discomfort • Decreased muscle pain and stiffness • Reduced muscle aching Facilitators User friendly regimen • Safe and Easy to use. • Needs minimal supervision. • Easy customization of intervention • Easy incorporation in daily routine • Saves travel time. • Flexible schedule Reduced Health care cost • Saves travel cost. • Saves per session cost. • Reduced financial burden Improved physical autonomy • Independence • Empowerment • Self-sufficiency • Increased confidence • Family support Barriers Device Related barriers • COVID apprehension • Uncomfortable nose piece • Feeling of nausea with mouthpiece • Exertional • Ringing in ears in initial sessions Issues with home-based treatment • Environmental distractions • Reduced commitment to exercise • Safety concerns • Technical issues • Self-discipline • Lack of supervision • Limited feedback Lack of social communication • Limited/No social interaction • Isolation • Lack of time / other responsibilities Overall, the patients were satisfied with this home-based multifactorial intervention. However, they highlighted a few limitations, which can improve the level of satisfaction. Themes and sub-themes are highlighted in Fig. 1 . Theme 1: Improvement in Quality of Life All patients reported improvements in quality of life after 12 weeks of multifactorial IMT intervention performed at home. The patients noted a substantial decrease in the level of dyspnea and reduced shortness of breath on activities that previously provoked the dyspnea. “One of the major benefits of these exercises is improvement in my shortness of breath. Previously, I experienced shortness of breath whenever I used to climb stairs and do speedy walk but recently, when my mother was admitted in hospital, I walked a lot more than usual but didn’t experience shortness of breath.” (P6, M, 66years) They also reported that the comprehensive rehabilitation approach (i.e., IMT + OEP) improved their walking speed, reduced dyspnea and fatigue thereby improving functional independence. This not only improved their physical function but also helped in improvement of mental well-being through relaxation attainment and improved quality of sleep. “I feel better and more confident as this combination of exercises has not only reduced shortness of breath but also improved my physical health because I no more experience day to day discomfort and sleep better now.” (P1, M, 56years) “I used to feel exhausted all the time but now I feel myself as more energetic, independent, and more confident knowing how to control of my breath.” (P8, M, 56years) There was also a generalized improvement in the physical health and well-being of patients. The patients reported decreased muscle tension and stiffness which previously used to make them struggle all day thereby relieving the muscles aches. “The muscle tightness that previously used to stay with me all the time and drain me has now run away. These exercises have given me a major relief in terms of improved mobility.” (P10, M, 63years) “The day when I exercise is spent very well, but when I didn’t do exercise, the whole day spent too lazy, and I didn’t feel mentally relaxed.” (P2, F, 56years) Theme 2: Facilitators to multifactorial IMT The patients were satisfied with the home-based intervention as it was a combination of user-friendly and easy to use device based IMT training accompanied by set of easy to perform OEP for balance and strength training. “The exercises are easy to perform at home where the environment is comfortable for me as I no longer must wait in the department for my turn as I used to do earlier. This saves time and unnecessary fatigue and exertion.” (P9, M, 55years) The training diaries were maintained and weekly monitored to check adherence to the protocol and the participants having adherence rate < 80% were considered as drop out from study. “I have weekly supervised session with my therapist which gives me confident that I am on track and keeps me motivated for the session throughout the week.” (P11, F, 50years) The training was not only easy to perform and requiring minimal supervision, but also reduced the health care cost associated with the supervised training sessions. It indirectly reduced the travelling and session cost thereby reducing the financial burden on the patients. “I no longer need to schedule my exercise sessions as per my son’s schedule of night shifts.” (P5, F, 53years) Another facilitator of this intervention was the reduced health care cost associated with less frequent hospital visits saving their travel cost as well as cost of treatment sessions. “I experienced a significant relief in terms of cost after starting this home-based treatment. (P3, M, 65years) Multifactorial IMT also improved the physical autonomy of the patients. The empowerment and independence the patient perceived, attaining with the intervention, reduced the dependency on care givers and made them accountable and self-sufficient. “I feel more empowered as I can progress at my own pace. Now, I can try more challenging exercises and move forward when me and my therapist feel ready for it.” (P2, F, 56years) Theme 3: Barriers to multifactorial IMT Although the adherence to the intervention was good and patients felt improvement in symptoms as well as quality of life with this home-based intervention, still there were a few barriers highlighted by the patients. The most important being the initial difficulty in usage with device-based treatment because of the uncomfortable nose clip and feeling of nausea and ringing of ears. This difficulty got settled as the patients became accustomed to this training. “Initially, I felt a constant beep in my ears and head, and then felt dizziness but with time it got easier.” (P7, M, 60years) “When I started doing IMT, it felt like there was something in my ear and at times I felt nauseous also, but later, this feeling reduced and I got able to complete the required number of breaths easily.” (P12, F, 55years) There was apprehension of patients related to COVID also which settled down with time. “Yes, I have to acknowledge my initial fears and concerns regarding COVID 19, when I understand the importance and need of treatment but the fear of contracting COVID with this breathing device was constantly in my mind.” (P3, M, 65years) Patients reported it to be somewhat difficult to go for a home-based treatment as there is distraction in home environment and it needs to be highly self-directed, motivated, and self-disciplined to continue with the treatment at home which becomes quite difficult at times. “Before starting treatment, I was quite happy with the idea of home-based treatment performing exercises in the comfort of my own home at my own schedule but with time I realized the challenges of home-based sessions, I had to find ways to overcome distractions and staying motivated.” (P12, F, 55years) A few patients need monitoring and guidance to deal with safety and technical issues. Another challenge reported by the patients is the limited feedback on their performance as the patients underwent only one supervised session per week. “Although I have been guided properly, still I am a bit uncertain regarding what I am performing and miss the immediate supervision by my therapist, whose motivation kept my moral high.” (P4, F, 52years) The patients also used to miss the social interaction with other patients at the hospital set-up. “Though, I am satisfied with this home-based approach, however, sometimes I find myself missing the social interaction with the fellow patients who were going through similar experiences.” (P6, M, 66years) Another challenge of this intervention as reported by patients was the lack of time and other responsibilities also made them forget the sessions. “It was quite demanding at times, and I faced this challenge of balancing multiple responsibilities and managing time for the exercise session. I do recognize the importance of sessions but finding time for them was quite tough.” (P11, F, 50years) Discussion The study explored the patient’s perspective of 12 weeks of multifactorial IMT intervention. The major themes identified were improvement in the quality of life, facilitators, and barriers to the home-based multifactorial IMT, highlighting not only the positive impact of intervention but also the challenges faced during intervention. Our results show patients’ perceived quality of life improved physically, mentally, and emotionally via the reduction in dyspnea levels, improved functional independence, better sleep and decreased fatigue. These improvements are consistent with the improvements observed with IMT in patients with COVID-19 ( 29 ) and advanced lung disease ( 30 ). A thematic synthesis highlighting the nine domains of quality of life important to older adults, including autonomy, role and activity, health perception, relationships, attitude and adaptation, emotional comfort, spirituality, home and neighborhood, and financial security ( 31 ). Out of these, almost all domains were improved after intervention in this qualitative study except for relationships and home & neighborhood. A higher level of self-efficacy was reported by diabetes patients in current study, like reported for COPD patients who reported higher self-efficacy with IMT as compared to pulmonary rehabilitation ( 32 ). Overall, the diabetic patients had a positive perception and experience of this intervention, like the patients who underwent mobile health intervention ( 33 ). However, the mobile health intervention patients faced the financial burden as a barrier compared to patients who underwent multifactorial IMT where financial cost was reduced ( 33 ). The positive impact of this multifactorial intervention is not only attributed to IMT but also the OEP. This exercise program, based on easy-to-perform exercises, from a physical therapist’s perspective, improved physical functioning, promoted relaxation, improved self-efficacy, and increased confidence ( 34 ). As reported, multifactorial intervention is perceived to be a feasible and effective strategy to improve the quality of life of diabetes patients. The patients perceived it to be a user-friendly regimen that is safe and easy to perform, requires minimal supervision and can be easily incorporated into the patient’s routine. This is similar results as those of a scoping review done on the use of non-medical devices for chronic breathlessness that showed similar patient-perceived facilitators like ease of use and comfort using the devices ( 35 ). This finding also supports the usage of this intervention because in previous studies, lack of space / room for exercise was considered as a barrier to physical activity ( 36 ). The patients also reported it as a budget-friendly intervention as it can save the travel and per-session costs. As per the patient’s perception, the multifactorial IMT intervention also improved the physical autonomy of the patients, making them more empowered, independent, self-sufficient, and confident. The patients recovering from COVID-19 also regained their confidence and positivity and felt improvement physically, emotionally as well as cognitively ( 29 ). Home-based multifactorial IMT was found to be acceptable for diabetes patients except for the few challenges related to home-based treatment and device-related barriers. Despite the ease of technique, the patients reported initial difficulty in performing IMT, which was resolved later. The patients in the current study reported ringing of ears, dizziness, uncomfortable nose clip and nauseous feeling when they started doing IMT; however, in another study, the patients reported feeling thirsty while performing it on initial days ( 32 ). Neck pain in patients with arthritis and recurrent infections was also reported as a physical limitation to perform IMT ( 32 ). The patients, when asked about how to improve the quality of intervention, expressed that nothing needed to be done as these difficulties were faced only initially, and it got better with time and practice. In conclusion, this study is among the first studies to look at Multifactorial IMT from a patient’s perspective and has proven the substantial effect of the intervention on the lives of the patients with diabetes. Being home-based, the patients perceived the intervention as a convenient and accessible solution, particularly with transport/ travelling issues. The patients considered it important as it can reduce healthcare costs and, at the same time, enhance their quality of life and contribute to better community health outcomes. The importance of this patient-centered approach lies in its contribution to improved health outcomes, quality of life, healthcare cost reduction, better community health and long-term well-being of patients ( 37 , 38 ). Future studies need to investigate the perspectives of physical therapists and healthcare providers for improving adherence and overcoming the challenges as described by these patients. Methods Research Design and Methods The current study utilizes qualitative research methods to explore the perception of patients towards home-based multifactorial IMT. Semi structured, interviews were conducted among patients with DM, using an interview guide having an open-ended questioning approach. The Consolidated criteria for reporting qualitative research (COREQ) was used to ensure detailed and comprehensive reporting ( 20 ). All the experiments were performed in accordance with relevant guidelines. Sample size: The data was collected from 12 patients with DM (who underwent the multifactorial intervention) till saturation of data. The patients were recruited from December 2022 till March 2023. Participants: Participants who were > 50 years of age and have participated in 12 weeks of multifactorial IMT were selected through non-probability purposive sampling. The patients were having polyneuropathy confirmed by the modified Toronto Clinical Neuropathy Score (mTCNS). Those patients who were not able to communicate in Urdu were not interviewed. Ethical considerations: This study was approved by the ethical committee of Riphah International University, Islamabad, Pakistan (Ref # Riphah/RCRS/REC/13564). Written informed consent was taken from all the patients prior to the data collection. Multifactorial IMT intervention: The home-based multifactorial IMT is comprised of 12 weeks of an established protocol of IMT along with Otago Exercise Program (OEP) and standardized protocol for patients with diabetes as per recommendation of ACSM for 12 weeks (under review). The record for adherence to the treatment protocol was maintained through a training diary which was monitored weekly and the patients with < 80% adherence rate were considered as drop out. Data Collection Procedure: The participants were briefed about the study and a preferred time for an individual semi-structured interview was taken from the patients. The interviews were conducted from 12 patients and data was collected till the point of saturation after which no further new information was being added ( 21 ). The interview-based meeting was audio recorded after getting permission from the patients. An interview guide was prepared prior to data collection through contribution of all authors and piloted on two patients before conducting interviews with the patients. The questions uncovered the experience and perception with IMT, perceived effect of training and the challenges or factors enhancing exercise performance. All interviews were conducted by one female interviewer (SS) having experience in conducting interviews. The interviews lasted for approximately 30min (range 20min – 40min). All interviews were conducted in Pakistan Railway General Hospital following intervention, in local language (Urdu) and were recorded and transcribed verbatim for the analysis. Data Availability Statement: The datasets used and analyzed during the current study is available from the corresponding author on reasonable request. Data Analysis Procedure: The interviews from the patients were transcribed verbatim by one author (SS), rechecked for accuracy, and were then analyzed following principles of reflexive thematic analysis ( 22 , 23 ). The process involved deep immersion in data followed by a rigorous and systematic process to generate themes ( 22 ). All the interviews were conducted by the primary data analyst (SS) who not only conducted all the interviews but also supervised the 12-week intervention. She recorded her opinions, thoughts and reflections of the patients and their engagement in intervention through an informal observation and was therefore deeply immersed in data over prolonged period utilizing the opportunity for strong rapport building with the patients. This reflective process enabled SS to acknowledge her biases regarding the intervention based on her role and prior knowledge. She drew on these reflections informing discussion about the data with other members involved in analysis which enhanced the rigor of the analysis process. SS thoroughly read and re-read the transcribed data to become familiar with the data, identify patterns to gain an insight of every patient’s perception and experience with intervention. She then developed an initial list of codes thereby organizing the data and later collating the codes she developed sub-themes and eventually themes from it ( 24 ). Another author (ANM) did cross examination of the data by reverse tracing of verbatim quotations back to the transcripts to ensure that the developed themes were grounded in original data. ( 25 ). Ascertaining methodological rigor, themes and quotations were then reviewed by another author (FAS) to validate their significance and offer an alternative interpretation of data. ( 26 , 27 ). This process continued through multiple iterations until an acceptable consensus was reached by the research group. The interpretation and analysis of the data thereby involved the inclusion of multiple perspectives, that encompassed the viewpoints of both participants and analysts. The data was translated into English after the analysis and careful selection of quotes from local language (Urdu). To ensure translation validity when translating complex constructs, the authors consulted with each other and with a professional English translator ( 28 ). Conclusion The study revealed consistent themes regarding the patient’s perspective of home-based multifactorial IMT, such as improvement in QOL, facilitators and barriers to the treatment. The study highlights the effect of intervention from the patients’ view, leading to patient-centered care and improved healthcare practices that ultimately contribute to the quality of care provided to the patients. The patients experienced a profound enhancement in their quality-of-life following intervention and reported noticeable perceived improvement in their general physical health. Improved physical autonomy, user friendly intervention requiring only minimal supervision, reduced health care cost and easy incorporation in patient’s routine were the perceived facilitators, whereas device related barriers, distraction within home environment, self-regulation and discipline and no social interaction were the perceived barriers identified that should be worked upon to facilitate incorporation of this multifactorial intervention in the patient’s routine. The patients find multifactorial IMT to be an effective and user-friendly approach to aid in the rehabilitation of patients with diabetes. The study findings can be explored further in future from the therapist/care-giver point of view to refine and improve exercise recommendations for patients with diabetes. Limitations: The results of the study should be interpreted in the context of a few limitations. A potential limitation of this study is that the interviews were conducted by the same researcher who administered the intervention. Though efforts were made to minimize researcher bias, the dual role of the researcher could introduce a degree of subjectivity in the data. The individual interviews reflect individual experiences, thoughts, and perceptions of patients, but it may undermine the group interaction and the chances of gaining insight into the cause of individual differences that could have been attained with a focus group. Also, the study lacked a detailed record of the life activities of the patients during the intervention, especially their activity level and level of life stressors during the intervention. Declarations Author Contribution Conceptualization, A.N.M. and S.S.; Methodology, F.A.S and S.S.; Data collection and analysis,S.S., A.N.M., F.V.F and F.A.S.; writing—original draft preparation, S.S. and F.V.F.; writing—review and editing, A.N.M., F.A.S and F.V.F.; visualization, F.V.F. and S.S.; supervision, F.V.F. and A.N.M.; Project administration, A.N.M and S.S. All authors have read and agreed to the submitted version of the manuscript. Acknowledgement The authors would like to extend our deepest gratitude to all the patients who generously dedicated their time and trust to participate in this study, making a significant contribution to the advancement of medical knowledge in this field. Data Availability The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. References Widyahening IS, Hashmi FK, Soewondo P, Bukhsh A, Chan KG, Goh BH, et al. Type 2 Diabetes Patients’ Perspectives, Experiences, and Barriers Toward Diabetes-Related Self-Care: A Qualitative Study From Pakistan. 2020 [cited 2023 Sep 29];11:534873. Available from: www.frontiersin.org Harris-Hayes M, Schootman M, Schootman JC, Hastings MK. The Role of Physical Therapists in Fighting the Type 2 Diabetes Epidemic. J Orthop Sports Phys Ther [Internet]. 2020 Jan 1 [cited 2023 Jul 31];50(1):5. Available from: /pmc/articles/PMC7069691/ Thent ZC, Das S, Henry LJ. Role of Exercise in the Management of Diabetes Mellitus: the Global Scenario. 2013 [cited 2023 Jul 31]; Available from: www.plosone.org Asfaw MS, Kassahun Dagne W. Physical activity can improve diabetes patients' glucose control; A systematic review and meta-analysis. 2017 [cited 2023 Jul 31]; Available from: https://doi.org/10.1016/j.heliyon.2022.e12267 Shah SZA, Karam JA, Zeb A, Ullah R, Shah A, Haq IU, et al. Movement is Improvement: The Therapeutic Effects of Exercise and General Physical Activity on Glycemic Control in Patients with Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Diabetes Therapy [Internet]. 2021 Mar 1 [cited 2023 Jul 31];12(3):707–32. Available from: https://link.springer.com/article/10.1007/s13300-021-01005-1 Recommendations | Type 2 diabetes in adults: management | Guidance | NICE. Crossman EL. Physical Activity in Patients With Type 2 Diabetes Mellitus: Updated Consensus Statement From the ACSM. Am Fam Physician [Internet]. 2023 Jan [cited 2023 May 8];107(1):103–4. Available from: https://www.aafp.org/pubs/afp/issues/2023/0100/practice-guidelines-physical-activity-diabetes.html Zhou Z, Zhou R, Li K, Zhu Y, Zhang Z, Luo Y, et al. Effects of tai chi on physiology, balance and quality of life in patients with type 2 diabetes: A systematic review and meta-analysis. J Rehabil Med [Internet]. 2019 [cited 2023 Jul 24];51(6):405–17. Available from: https://pubmed.ncbi.nlm.nih.gov/30968941/ Kong N, Yang G, Wang L, Li Y. CALISTHENICS EXERCISES TO INTERVENE IN OBESITY AND DIABETES IN MIDDLE-AGED PEOPLE. Rev Bras Med Esporte [Internet]. [cited 2023 Sep 5];28(2):2022. Available from: http://dx.doi.org/10.1590/1517-8692202228022021_0457 Soumyashree S, Kaur J. Effect of inspiratory muscle training (IMT) on aerobic capacity, respiratory muscle strength and rate of perceived exertion in paraplegics. Arruda NS de, Peixoto N de M, Callegaro CC, Trevisan ME, Jaenisch RB. Effects of Inspiratory Muscle Training in Type 2 Diabetes: A Systematic Review. Braz J Cardiovasc Surg [Internet]. 2023 Jul 4;38(4):e20220366. Available from: http://www.ncbi.nlm.nih.gov/pubmed/37403864 Buran Cirak Y, Yilmaz Yelvar GD, Durustkan Elbasi N. Effectiveness of 12-week inspiratory muscle training with manual therapy in patients with COPD: A randomized controlled study. Clin Respir J [Internet]. 2022 Apr 1 [cited 2023 Jul 31];16(4):317–28. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/crj.13486 Sadek Z, Salami A, Youness M, Awada C, Hamade M, Joumaa WH, et al. A randomized controlled trial of high-intensity interval training and inspiratory muscle training for chronic heart failure patients with inspiratory muscle weakness. Chronic Illn. 2022 Mar 1;18(1):140–54. Zhang W, Pan H, Zong Y, Wang J, Xie Q. Respiratory Muscle Training Reduces Respiratory Complications and Improves Swallowing Function After Stroke: A Systematic Review and Meta-Analysis Archives of Physical Medicine and Rehabilitation. China National Knowledge Infrastructure Archives of Physical Medicine and Rehabilitation [Internet]. 2022 [cited 2023 Sep 5];103:1179–91. Available from: https://doi.org/10.1016/j.apmr.2021.10.020 Sheraz S, Ferraro FV, Siddiqui FA, Tariq H, Faghy MA, Malik AN. The effects of inspiratory muscle training on balance and functional mobility: a systematic review. https://doi.org/101080/0032548120232253136 [Internet]. 2023 Aug 31 [cited 2023 Sep 5]; Available from: https://www.tandfonline.com/doi/abs/10.1080/00325481.2023.2253136 Aydoğan Arslan S, Uğurlu K, Sakizli Erdal E, Keskin ED, Demirgüç A. Effects of Inspiratory Muscle Training on Respiratory Muscle Strength, Trunk Control, Balance and Functional Capacity in Stroke Patients: A single-blinded randomized controlled study. https://doi.org/101080/1074935720201871282 [Internet]. 2021 [cited 2023 Jul 31];29(1):40–8. Available from: https://www.tandfonline.com/doi/abs/10.1080/10749357.2020.1871282 Bosnak-Guclu M, Arikan H, Savci S, Inal-Ince D, Tulumen E, Aytemir K, et al. Effects of inspiratory muscle training in patients with heart failure. Respir Med. 2011 Nov 1;105(11):1671–81. Bombard Y, Ross Baker G, Orlando E, Fancott C, Bhatia P, Casalino S, et al. Engaging patients to improve quality of care: a systematic review. [cited 2023 Oct 5]; Available from: https://doi.org/10.1186/s13012-018-0784-z Genç FZ, Bilgili N. The effect of Otago exercises on fear of falling, balance, empowerment and functional mobility in the older people: Randomized controlled trial. Int J Nurs Pract. 2023; Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007;19(6). Mwita KM. Factors influencing data saturation in qualitative studies. International Journal of Research in Business and Social Science (2147- 4478) [Internet]. 2022 Jun 5 [cited 2023 Oct 7];11(4):414–20. Available from: https://www.ssbfnet.com/ojs/index.php/ijrbs/article/view/1776 Braun V, Clarke V. Reflecting on reflexive thematic analysis. Vol. 11, Qualitative Research in Sport, Exercise and Health. 2019. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol [Internet]. 2006 [cited 2023 Sep 11];3(2):77–101. Available from: https://www.tandfonline.com/action/journalInformation?journalCode=uqrp20 Fereday J, Muir-Cochrane E. Demonstrating Rigor Using Thematic Analysis: A Hybrid Approach of Inductive and Deductive Coding and Theme Development. Int J Qual Methods. 2006;5(1). Tobin GA, Begley CM. Methodological rigour within a qualitative framework. J Adv Nurs. 2004;48(4). MacKintosh KA, Knowles ZR, Ridgers ND, Fairclough SJ. Using formative research to develop CHANGE!: A curriculum-based physical activity promoting intervention. BMC Public Health. 2011;11. Boddy LM, Knowles ZR, Davies IG, Warburton GL, MacKintosh KA, Houghton L, et al. Using formative research to develop the healthy eating component of the CHANGE! school-based curriculum intervention. BMC Public Health. 2012;12(1). van Nes F, Abma T, Jonsson H, Deeg D. Language differences in qualitative research: Is meaning lost in translation? Eur J Ageing. 2010;7(4). Shelley J, Hudson J, Mackintosh KA, Saynor ZL, Duckers J, Lewis K, et al. Perceptions of inspiratory muscle training in adults recovering from COVID-19. PLoS One. 2022;17(11 November). Hoffman M, Assis MG, Augusto VM, Silveira BMF, Parreira VF. The effects of inspiratory muscle training based on the perceptions of patients with advanced lung disease: a qualitative study. Braz J Phys Ther. 2018;22(3). Van Leeuwenid KM, Van Loon MS, Van Nes FA, Bosmans JE, De Vetid HCW, Ket JCF, et al. What does quality of life mean to older adults? A thematic synthesis. 2019 [cited 2023 Oct 6]; Available from: https://doi.org/10.1371/journal.pone.0213263 O’connor C, Lawson R, Waterhouse J, Mills GH. Is inspiratory muscle training (IMT) an acceptable treatment option for people with chronic obstructive pulmonary disease (COPD) who have declined pulmonary rehabilitation (PR) and can IMT enhance PR uptake? A single-group prepost feasibility study in a home-based setting. [cited 2023 Sep 13]; Available from: http://bmjopen.bmj.com/ Yasmin F, Ali L, Banu B, Rasul FB, Sauerborn R, Souares A. Understanding patients’ experience living with diabetes type 2 and effective disease management: a qualitative study following a mobile health intervention in Bangladesh. [cited 2023 Oct 6]; Available from: https://doi.org/10.1186/s12913-019-4811-9 Cederbom S, Bjerk M, Bergland A. A qualitative study exploring physical therapists’ views on the Otago Exercise Programme for fall prevention: a stepping stone to “age in place” and to give faith in the future. Physiother Theory Pract. 2022;38(1). Prihartadi AS, Licastro GI, Johnson MJ, Luckett T, Pearson M, Swan F. Non-medical devices for the management of chronic breathlessness: A scoping review of device use, barriers and facilitators for patients, carers and clinicians. 2021 [cited 2023 Oct 6]; Available from: http://dx. Shi C, Zhu H, Liu J, Zhou J, Tang W. Barriers to Self-Management of Type 2 Diabetes During COVID-19 Medical Isolation: A Qualitative Study. 2020 [cited 2023 Oct 7]; Available from: http://doi.org/10.2147/DMSO.S268481 Grover S, Fitzpatrick A, Azim FT, Ariza-Vega P, Bellwood P, Burns J, et al. Defining and implementing patient-centered care: An umbrella review ☆. 2021 [cited 2023 Oct 7]; Available from: https://doi.org/10.1016/j.pec.2021.11.004 Hutting N, Caneiro JP, Ong’wen C M, Miciak M, Roberts L. Patient-centered care in musculoskeletal practice: Key elements to support clinicians to focus on the person. 2021 [cited 2023 Oct 7]; Available from: http://creativecommons.org/licenses/by/4.0/ Additional Declarations No competing interests reported. Supplementary Files COREQchecklist.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4726704","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":342531537,"identity":"ca9a86c7-edd8-43db-8b8b-fbd2f12a3b73","order_by":0,"name":"Suman Sheraz","email":"data:image/png;base64,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","orcid":"","institution":"Riphah International University","correspondingAuthor":true,"prefix":"","firstName":"Suman","middleName":"","lastName":"Sheraz","suffix":""},{"id":342531538,"identity":"ca62861b-64fa-400f-824c-49e3172c017a","order_by":1,"name":"Arshad Nawaz Malik","email":"","orcid":"","institution":"Riphah International University","correspondingAuthor":false,"prefix":"","firstName":"Arshad","middleName":"Nawaz","lastName":"Malik","suffix":""},{"id":342531539,"identity":"5a92dba5-b9dd-4d45-b7b6-f7870549af3c","order_by":2,"name":"Francesco Vincenzo Ferraro","email":"","orcid":"","institution":"University of Derby","correspondingAuthor":false,"prefix":"","firstName":"Francesco","middleName":"Vincenzo","lastName":"Ferraro","suffix":""},{"id":342531540,"identity":"cfae1420-e3fb-4ff4-ba5c-b995e3ec97b4","order_by":3,"name":"Furqan Ahmed Siddiqi","email":"","orcid":"","institution":"=Foundation University, Foundation University","correspondingAuthor":false,"prefix":"","firstName":"Furqan","middleName":"Ahmed","lastName":"Siddiqi","suffix":""}],"badges":[],"createdAt":"2024-07-11 20:38:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4726704/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4726704/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63369447,"identity":"2458dfaf-d547-4ed0-b90b-3b57fc6a7c5c","added_by":"auto","created_at":"2024-08-27 11:44:13","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":157980,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTheme chart showing themes and sub themes related to the patient’s perspective of using multifactorial IMT\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4726704/v1/8e7ee981fd4de0cba745f39d.jpg"},{"id":68142976,"identity":"421e3454-2f0e-47bf-b670-406e865942e0","added_by":"auto","created_at":"2024-11-04 05:24:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":684229,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4726704/v1/55dfdbe7-eb0c-4d2b-8beb-2fdae439de79.pdf"},{"id":63370637,"identity":"935c53a2-4cf6-4358-a08a-9629eb9a984e","added_by":"auto","created_at":"2024-08-27 11:52:13","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":495088,"visible":true,"origin":"","legend":"","description":"","filename":"COREQchecklist.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4726704/v1/33444cbfc42169d636b6f8b5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Multifactorial Inspiratory Muscle Training in Diabetic Population: A Qualitative Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePatients\u0026rsquo; perspectives on Diabetes Mellitus (DM), highlights the fears of patients concerning fatigue, generalized body pains, troublesome excessive urination, and dread of experiencing complications if they do not adhere to medical treatment (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Current physical therapy goals for management of DM are targeted towards prevention of complications, which occur more often with uncontrolled blood glucose levels (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). As reported in NICE guidelines, multiple management strategies are used to control glycemic index, manage co-morbidities \u0026amp; complications (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe American College of Sports Medicine (ACSM) and the Centers for Disease Control and Prevention (CDC) suggested at least 30 minutes of moderate-intensity physical activity (PA) on most days of the week for adequate glycemic management (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Multiple exercise training protocols, including aerobic, resistance (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), high-intensity interval training (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), Tai Chi (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) and calisthenics (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) are currently being used for a range of effects in diabetic patients. A recent systematic review (2023) suggested that Inspiratory Muscle Training (IMT) defined as a therapeutic technique to improve the strength of respiratory muscle (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) is an effective intervention especially when in addition to other exercise forms specific to need of the patients (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe IMT has been used with COPD (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), heart failure (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) and stroke (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) and currently considered for its effects on balance with elderly (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), stroke (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) heart failure (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) and in DM (under review). However, there is an evident research gap in terms of patient\u0026rsquo;s perception of this training. The patient\u0026rsquo;s view, with this easy-to-perform home-based intervention will provide a real-world perspective and will help the health care practitioners to adapt strategies based on the individualized needs and preferences of patients improving the care quality (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe current study aims to report patients\u0026rsquo; perspectives on a multifactorial exercise program designed to improve balance, diminish fear of falls, and increase functional mobility in patients with DM (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of twelve patients with diabetic polyneuropathy (seven men and five women, of age ranging between 50\u0026ndash;66 years) were interviewed in the study. For all the patients, the disease was diagnosed for more than 8 years, and all the patients had moderate to severe levels of diabetic polyneuropathy (mTCNS score ranging from 9\u0026ndash;12). The demographic and clinical characteristics of the patients are mentioned in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and clinical characteristics of patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003e(years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003cp\u003e(M/F)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003cp\u003e(kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDuration of diagnosis\u003c/p\u003e \u003cp\u003e(years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003cp\u003e(Medicines / Insulin / Both)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003emTCNS\u003c/p\u003e \u003cp\u003escore\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInsulin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMedicines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMedicines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMedicines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInsulin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInsulin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInsulin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInsulin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMedicines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMedicines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eBMI: Body Mass Index, mTCNS: Modified Toronto Clinical Neuropathy Scoring System\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThree key themes were identified after data analysis: (a) Perception of quality of life (b) Facilitators and (c) Barriers to home-based multifactorial IMT. The quotations from the data are highlighted below with the description of each theme. Detailed description of themes. Sub themes and codes are given in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes, sub themes and codes related to patients\u0026rsquo; perception of multifactorial IMT.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-themes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCodes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eImprovement in QOL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperienced better breathing control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Decreased SOB during activity\u003c/p\u003e \u003cp\u003e\u0026bull; Level of dyspnea reduced\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneralized improvement in physical health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Improved walking capacity\u003c/p\u003e \u003cp\u003e\u0026bull; Decreased level of fatigue\u003c/p\u003e \u003cp\u003e\u0026bull; Feeling of relaxation\u003c/p\u003e \u003cp\u003e\u0026bull; Better sleep\u003c/p\u003e \u003cp\u003e\u0026bull; Functional independence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReduced physical discomfort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Decreased muscle pain and stiffness\u003c/p\u003e \u003cp\u003e\u0026bull; Reduced muscle aching\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eFacilitators\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUser friendly regimen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Safe and Easy to use.\u003c/p\u003e \u003cp\u003e\u0026bull; Needs minimal supervision.\u003c/p\u003e \u003cp\u003e\u0026bull; Easy customization of intervention\u003c/p\u003e \u003cp\u003e\u0026bull; Easy incorporation in daily routine\u003c/p\u003e \u003cp\u003e\u0026bull; Saves travel time.\u003c/p\u003e \u003cp\u003e\u0026bull; Flexible schedule\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReduced Health care cost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Saves travel cost.\u003c/p\u003e \u003cp\u003e\u0026bull; Saves per session cost.\u003c/p\u003e \u003cp\u003e\u0026bull; Reduced financial burden\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImproved physical autonomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Independence\u003c/p\u003e \u003cp\u003e\u0026bull; Empowerment\u003c/p\u003e \u003cp\u003e\u0026bull; Self-sufficiency\u003c/p\u003e \u003cp\u003e\u0026bull; Increased confidence\u003c/p\u003e \u003cp\u003e\u0026bull; Family support\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eBarriers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDevice Related barriers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; COVID apprehension\u003c/p\u003e \u003cp\u003e\u0026bull; Uncomfortable nose piece\u003c/p\u003e \u003cp\u003e\u0026bull; Feeling of nausea with mouthpiece\u003c/p\u003e \u003cp\u003e\u0026bull; Exertional\u003c/p\u003e \u003cp\u003e\u0026bull; Ringing in ears in initial sessions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIssues with home-based treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Environmental distractions\u003c/p\u003e \u003cp\u003e\u0026bull; Reduced commitment to exercise\u003c/p\u003e \u003cp\u003e\u0026bull; Safety concerns\u003c/p\u003e \u003cp\u003e\u0026bull; Technical issues\u003c/p\u003e \u003cp\u003e\u0026bull; Self-discipline\u003c/p\u003e \u003cp\u003e\u0026bull; Lack of supervision\u003c/p\u003e \u003cp\u003e\u0026bull; Limited feedback\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLack of social communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Limited/No social interaction\u003c/p\u003e \u003cp\u003e\u0026bull; Isolation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Lack of time / other responsibilities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOverall, the patients were satisfied with this home-based multifactorial intervention. However, they highlighted a few limitations, which can improve the level of satisfaction. Themes and sub-themes are highlighted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Improvement in Quality of Life\u003c/h2\u003e \u003cp\u003eAll patients reported improvements in quality of life after 12 weeks of multifactorial IMT intervention performed at home. The patients noted a substantial decrease in the level of dyspnea and reduced shortness of breath on activities that previously provoked the dyspnea.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;One of the major benefits of these exercises is improvement in my shortness of breath. Previously, I experienced shortness of breath whenever I used to climb stairs and do speedy walk but recently, when my mother was admitted in hospital, I walked a lot more than usual but didn\u0026rsquo;t experience shortness of breath.\u0026rdquo; (P6, M, 66years)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThey also reported that the comprehensive rehabilitation approach (i.e., IMT\u0026thinsp;+\u0026thinsp;OEP) improved their walking speed, reduced dyspnea and fatigue thereby improving functional independence. This not only improved their physical function but also helped in improvement of mental well-being through relaxation attainment and improved quality of sleep.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I feel better and more confident as this combination of exercises has not only reduced shortness of breath but also improved my physical health because I no more experience day to day discomfort and sleep better now.\u0026rdquo; (P1, M, 56years)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I used to feel exhausted all the time but now I feel myself as more energetic, independent, and more confident knowing how to control of my breath.\u0026rdquo; (P8, M, 56years)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThere was also a generalized improvement in the physical health and well-being of patients. The patients reported decreased muscle tension and stiffness which previously used to make them struggle all day thereby relieving the muscles aches.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The muscle tightness that previously used to stay with me all the time and drain me has now run away. These exercises have given me a major relief in terms of improved mobility.\u0026rdquo; (P10, M, 63years)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The day when I exercise is spent very well, but when I didn\u0026rsquo;t do exercise, the whole day spent too lazy, and I didn\u0026rsquo;t feel mentally relaxed.\u0026rdquo; (P2, F, 56years)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Facilitators to multifactorial IMT\u003c/h2\u003e \u003cp\u003eThe patients were satisfied with the home-based intervention as it was a combination of user-friendly and easy to use device based IMT training accompanied by set of easy to perform OEP for balance and strength training.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The exercises are easy to perform at home where the environment is comfortable for me as I no longer must wait in the department for my turn as I used to do earlier. This saves time and unnecessary fatigue and exertion.\u0026rdquo; (P9, M, 55years)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe training diaries were maintained and weekly monitored to check adherence to the protocol and the participants having adherence rate\u0026thinsp;\u0026lt;\u0026thinsp;80% were considered as drop out from study.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I have weekly supervised session with my therapist which gives me confident that I am on track and keeps me motivated for the session throughout the week.\u0026rdquo; (P11, F, 50years)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe training was not only easy to perform and requiring minimal supervision, but also reduced the health care cost associated with the supervised training sessions. It indirectly reduced the travelling and session cost thereby reducing the financial burden on the patients.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I no longer need to schedule my exercise sessions as per my son\u0026rsquo;s schedule of night shifts.\u0026rdquo; (P5, F, 53years)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAnother facilitator of this intervention was the reduced health care cost associated with less frequent hospital visits saving their travel cost as well as cost of treatment sessions.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I experienced a significant relief in terms of cost after starting this home-based treatment. (P3, M, 65years)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eMultifactorial IMT also improved the physical autonomy of the patients. The empowerment and independence the patient perceived, attaining with the intervention, reduced the dependency on care givers and made them accountable and self-sufficient.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I feel more empowered as I can progress at my own pace. Now, I can try more challenging exercises and move forward when me and my therapist feel ready for it.\u0026rdquo; (P2, F, 56years)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Barriers to multifactorial IMT\u003c/h2\u003e \u003cp\u003eAlthough the adherence to the intervention was good and patients felt improvement in symptoms as well as quality of life with this home-based intervention, still there were a few barriers highlighted by the patients. The most important being the initial difficulty in usage with device-based treatment because of the uncomfortable nose clip and feeling of nausea and ringing of ears. This difficulty got settled as the patients became accustomed to this training.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Initially, I felt a constant beep in my ears and head, and then felt dizziness but with time it got easier.\u0026rdquo; (P7, M, 60years)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When I started doing IMT, it felt like there was something in my ear and at times I felt nauseous also, but later, this feeling reduced and I got able to complete the required number of breaths easily.\u0026rdquo; (P12, F, 55years)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThere was apprehension of patients related to COVID also which settled down with time.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Yes, I have to acknowledge my initial fears and concerns regarding COVID 19, when I understand the importance and need of treatment but the fear of contracting COVID with this breathing device was constantly in my mind.\u0026rdquo; (P3, M, 65years)\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePatients reported it to be somewhat difficult to go for a home-based treatment as there is distraction in home environment and it needs to be highly self-directed, motivated, and self-disciplined to continue with the treatment at home which becomes quite difficult at times.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Before starting treatment, I was quite happy with the idea of home-based treatment performing exercises in the comfort of my own home at my own schedule but with time I realized the challenges of home-based sessions, I had to find ways to overcome distractions and staying motivated.\u0026rdquo; (P12, F, 55years)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eA few patients need monitoring and guidance to deal with safety and technical issues. Another challenge reported by the patients is the limited feedback on their performance as the patients underwent only one supervised session per week.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Although I have been guided properly, still I am a bit uncertain regarding what I am performing and miss the immediate supervision by my therapist, whose motivation kept my moral high.\u0026rdquo; (P4, F, 52years)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe patients also used to miss the social interaction with other patients at the hospital set-up.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Though, I am satisfied with this home-based approach, however, sometimes I find myself missing the social interaction with the fellow patients who were going through similar experiences.\u0026rdquo; (P6, M, 66years)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAnother challenge of this intervention as reported by patients was the lack of time and other responsibilities also made them forget the sessions.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It was quite demanding at times, and I faced this challenge of balancing multiple responsibilities and managing time for the exercise session. I do recognize the importance of sessions but finding time for them was quite tough.\u0026rdquo; (P11, F, 50years)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study explored the patient\u0026rsquo;s perspective of 12 weeks of multifactorial IMT intervention. The major themes identified were improvement in the quality of life, facilitators, and barriers to the home-based multifactorial IMT, highlighting not only the positive impact of intervention but also the challenges faced during intervention.\u003c/p\u003e \u003cp\u003eOur results show patients\u0026rsquo; perceived quality of life improved physically, mentally, and emotionally via the reduction in dyspnea levels, improved functional independence, better sleep and decreased fatigue. These improvements are consistent with the improvements observed with IMT in patients with COVID-19 (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) and advanced lung disease (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA thematic synthesis highlighting the nine domains of quality of life important to older adults, including autonomy, role and activity, health perception, relationships, attitude and adaptation, emotional comfort, spirituality, home and neighborhood, and financial security (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Out of these, almost all domains were improved after intervention in this qualitative study except for relationships and home \u0026amp; neighborhood.\u003c/p\u003e \u003cp\u003eA higher level of self-efficacy was reported by diabetes patients in current study, like reported for COPD patients who reported higher self-efficacy with IMT as compared to pulmonary rehabilitation (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOverall, the diabetic patients had a positive perception and experience of this intervention, like the patients who underwent mobile health intervention (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). However, the mobile health intervention patients faced the financial burden as a barrier compared to patients who underwent multifactorial IMT where financial cost was reduced (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). The positive impact of this multifactorial intervention is not only attributed to IMT but also the OEP. This exercise program, based on easy-to-perform exercises, from a physical therapist\u0026rsquo;s perspective, improved physical functioning, promoted relaxation, improved self-efficacy, and increased confidence (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs reported, multifactorial intervention is perceived to be a feasible and effective strategy to improve the quality of life of diabetes patients. The patients perceived it to be a user-friendly regimen that is safe and easy to perform, requires minimal supervision and can be easily incorporated into the patient\u0026rsquo;s routine. This is similar results as those of a scoping review done on the use of non-medical devices for chronic breathlessness that showed similar patient-perceived facilitators like ease of use and comfort using the devices (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). This finding also supports the usage of this intervention because in previous studies, lack of space / room for exercise was considered as a barrier to physical activity (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe patients also reported it as a budget-friendly intervention as it can save the travel and per-session costs. As per the patient\u0026rsquo;s perception, the multifactorial IMT intervention also improved the physical autonomy of the patients, making them more empowered, independent, self-sufficient, and confident. The patients recovering from COVID-19 also regained their confidence and positivity and felt improvement physically, emotionally as well as cognitively (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHome-based multifactorial IMT was found to be acceptable for diabetes patients except for the few challenges related to home-based treatment and device-related barriers. Despite the ease of technique, the patients reported initial difficulty in performing IMT, which was resolved later. The patients in the current study reported ringing of ears, dizziness, uncomfortable nose clip and nauseous feeling when they started doing IMT; however, in another study, the patients reported feeling thirsty while performing it on initial days (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Neck pain in patients with arthritis and recurrent infections was also reported as a physical limitation to perform IMT (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The patients, when asked about how to improve the quality of intervention, expressed that nothing needed to be done as these difficulties were faced only initially, and it got better with time and practice.\u003c/p\u003e \u003cp\u003eIn conclusion, this study is among the first studies to look at Multifactorial IMT from a patient\u0026rsquo;s perspective and has proven the substantial effect of the intervention on the lives of the patients with diabetes. Being home-based, the patients perceived the intervention as a convenient and accessible solution, particularly with transport/ travelling issues. The patients considered it important as it can reduce healthcare costs and, at the same time, enhance their quality of life and contribute to better community health outcomes. The importance of this patient-centered approach lies in its contribution to improved health outcomes, quality of life, healthcare cost reduction, better community health and long-term well-being of patients (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFuture studies need to investigate the perspectives of physical therapists and healthcare providers for improving adherence and overcoming the challenges as described by these patients.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eResearch Design and Methods\u003c/h2\u003e \u003cp\u003eThe current study utilizes qualitative research methods to explore the perception of patients towards home-based multifactorial IMT. Semi structured, interviews were conducted among patients with DM, using an interview guide having an open-ended questioning approach. The Consolidated criteria for reporting qualitative research (COREQ) was used to ensure detailed and comprehensive reporting (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). All the experiments were performed in accordance with relevant guidelines.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSample size:\u003c/h2\u003e \u003cp\u003eThe data was collected from 12 patients with DM (who underwent the multifactorial intervention) till saturation of data. The patients were recruited from December 2022 till March 2023.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eParticipants:\u003c/h2\u003e \u003cp\u003eParticipants who were \u0026gt;\u0026thinsp;50 years of age and have participated in 12 weeks of multifactorial IMT were selected through non-probability purposive sampling. The patients were having polyneuropathy confirmed by the modified Toronto Clinical Neuropathy Score (mTCNS). Those patients who were not able to communicate in Urdu were not interviewed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations:\u003c/h2\u003e \u003cp\u003e This study was approved by the ethical committee of Riphah International University, Islamabad, Pakistan (Ref # Riphah/RCRS/REC/13564). Written informed consent was taken from all the patients prior to the data collection.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eMultifactorial IMT intervention:\u003c/h2\u003e \u003cp\u003eThe home-based multifactorial IMT is comprised of 12 weeks of an established protocol of IMT along with Otago Exercise Program (OEP) and standardized protocol for patients with diabetes as per recommendation of ACSM for 12 weeks (under review). The record for adherence to the treatment protocol was maintained through a training diary which was monitored weekly and the patients with \u0026lt;\u0026thinsp;80% adherence rate were considered as drop out.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eData Collection Procedure:\u003c/h2\u003e \u003cp\u003e The participants were briefed about the study and a preferred time for an individual semi-structured interview was taken from the patients. The interviews were conducted from 12 patients and data was collected till the point of saturation after which no further new information was being added (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The interview-based meeting was audio recorded after getting permission from the patients. An interview guide was prepared prior to data collection through contribution of all authors and piloted on two patients before conducting interviews with the patients. The questions uncovered the experience and perception with IMT, perceived effect of training and the challenges or factors enhancing exercise performance. All interviews were conducted by one female interviewer (SS) having experience in conducting interviews. The interviews lasted for approximately 30min (range 20min \u0026ndash; 40min). All interviews were conducted in Pakistan Railway General Hospital following intervention, in local language (Urdu) and were recorded and transcribed verbatim for the analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eData Availability Statement:\u003c/h2\u003e \u003cp\u003eThe datasets used and analyzed during the current study is available from the corresponding author on reasonable request.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis Procedure:\u003c/h2\u003e \u003cp\u003eThe interviews from the patients were transcribed verbatim by one author (SS), rechecked for accuracy, and were then analyzed following principles of reflexive thematic analysis (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The process involved deep immersion in data followed by a rigorous and systematic process to generate themes (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). All the interviews were conducted by the primary data analyst (SS) who not only conducted all the interviews but also supervised the 12-week intervention. She recorded her opinions, thoughts and reflections of the patients and their engagement in intervention through an informal observation and was therefore deeply immersed in data over prolonged period utilizing the opportunity for strong rapport building with the patients. This reflective process enabled SS to acknowledge her biases regarding the intervention based on her role and prior knowledge. She drew on these reflections informing discussion about the data with other members involved in analysis which enhanced the rigor of the analysis process.\u003c/p\u003e \u003cp\u003eSS thoroughly read and re-read the transcribed data to become familiar with the data, identify patterns to gain an insight of every patient\u0026rsquo;s perception and experience with intervention. She then developed an initial list of codes thereby organizing the data and later collating the codes she developed sub-themes and eventually themes from it (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Another author (ANM) did cross examination of the data by reverse tracing of verbatim quotations back to the transcripts to ensure that the developed themes were grounded in original data. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Ascertaining methodological rigor, themes and quotations were then reviewed by another author (FAS) to validate their significance and offer an alternative interpretation of data. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). This process continued through multiple iterations until an acceptable consensus was reached by the research group. The interpretation and analysis of the data thereby involved the inclusion of multiple perspectives, that encompassed the viewpoints of both participants and analysts. The data was translated into English after the analysis and careful selection of quotes from local language (Urdu). To ensure translation validity when translating complex constructs, the authors consulted with each other and with a professional English translator (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study revealed consistent themes regarding the patient\u0026rsquo;s perspective of home-based multifactorial IMT, such as improvement in QOL, facilitators and barriers to the treatment. The study highlights the effect of intervention from the patients\u0026rsquo; view, leading to patient-centered care and improved healthcare practices that ultimately contribute to the quality of care provided to the patients.\u003c/p\u003e \u003cp\u003eThe patients experienced a profound enhancement in their quality-of-life following intervention and reported noticeable perceived improvement in their general physical health. Improved physical autonomy, user friendly intervention requiring only minimal supervision, reduced health care cost and easy incorporation in patient\u0026rsquo;s routine were the perceived facilitators, whereas device related barriers, distraction within home environment, self-regulation and discipline and no social interaction were the perceived barriers identified that should be worked upon to facilitate incorporation of this multifactorial intervention in the patient\u0026rsquo;s routine. The patients find multifactorial IMT to be an effective and user-friendly approach to aid in the rehabilitation of patients with diabetes. The study findings can be explored further in future from the therapist/care-giver point of view to refine and improve exercise recommendations for patients with diabetes.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLimitations:\u003c/h2\u003e \u003cp\u003eThe results of the study should be interpreted in the context of a few limitations. A potential limitation of this study is that the interviews were conducted by the same researcher who administered the intervention. Though efforts were made to minimize researcher bias, the dual role of the researcher could introduce a degree of subjectivity in the data. The individual interviews reflect individual experiences, thoughts, and perceptions of patients, but it may undermine the group interaction and the chances of gaining insight into the cause of individual differences that could have been attained with a focus group. Also, the study lacked a detailed record of the life activities of the patients during the intervention, especially their activity level and level of life stressors during the intervention.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization, A.N.M. and S.S.; Methodology, F.A.S and S.S.; Data collection and analysis,S.S., A.N.M., F.V.F and F.A.S.; writing\u0026mdash;original draft preparation, S.S. and F.V.F.; writing\u0026mdash;review and editing, A.N.M., F.A.S and F.V.F.; visualization, F.V.F. and S.S.; supervision, F.V.F. and A.N.M.; Project administration, A.N.M and S.S. All authors have read and agreed to the submitted version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to extend our deepest gratitude to all the patients who generously dedicated their time and trust to participate in this study, making a significant contribution to the advancement of medical knowledge in this field.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWidyahening IS, Hashmi FK, Soewondo P, Bukhsh A, Chan KG, Goh BH, et al. Type 2 Diabetes Patients\u0026rsquo; Perspectives, Experiences, and Barriers Toward Diabetes-Related Self-Care: A Qualitative Study From Pakistan. 2020 [cited 2023 Sep 29];11:534873. Available from: www.frontiersin.org\u003c/li\u003e\n\u003cli\u003eHarris-Hayes M, Schootman M, Schootman JC, Hastings MK. The Role of Physical Therapists in Fighting the Type 2 Diabetes Epidemic. J Orthop Sports Phys Ther [Internet]. 2020 Jan 1 [cited 2023 Jul 31];50(1):5. Available from: /pmc/articles/PMC7069691/\u003c/li\u003e\n\u003cli\u003eThent ZC, Das S, Henry LJ. Role of Exercise in the Management of Diabetes Mellitus: the Global Scenario. 2013 [cited 2023 Jul 31]; Available from: www.plosone.org\u003c/li\u003e\n\u003cli\u003eAsfaw MS, Kassahun Dagne W. Physical activity can improve diabetes patients\u0026amp;#x0027; glucose control; A systematic review and meta-analysis. 2017 [cited 2023 Jul 31]; Available from: https://doi.org/10.1016/j.heliyon.2022.e12267\u003c/li\u003e\n\u003cli\u003eShah SZA, Karam JA, Zeb A, Ullah R, Shah A, Haq IU, et al. Movement is Improvement: The Therapeutic Effects of Exercise and General Physical Activity on Glycemic Control in Patients with Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Diabetes Therapy [Internet]. 2021 Mar 1 [cited 2023 Jul 31];12(3):707\u0026ndash;32. Available from: https://link.springer.com/article/10.1007/s13300-021-01005-1\u003c/li\u003e\n\u003cli\u003eRecommendations | Type 2 diabetes in adults: management | Guidance | NICE. \u003c/li\u003e\n\u003cli\u003eCrossman EL. Physical Activity in Patients With Type 2 Diabetes Mellitus: Updated Consensus Statement From the ACSM. Am Fam Physician [Internet]. 2023 Jan [cited 2023 May 8];107(1):103\u0026ndash;4. Available from: https://www.aafp.org/pubs/afp/issues/2023/0100/practice-guidelines-physical-activity-diabetes.html\u003c/li\u003e\n\u003cli\u003eZhou Z, Zhou R, Li K, Zhu Y, Zhang Z, Luo Y, et al. Effects of tai chi on physiology, balance and quality of life in patients with type 2 diabetes: A systematic review and meta-analysis. J Rehabil Med [Internet]. 2019 [cited 2023 Jul 24];51(6):405\u0026ndash;17. Available from: https://pubmed.ncbi.nlm.nih.gov/30968941/\u003c/li\u003e\n\u003cli\u003eKong N, Yang G, Wang L, Li Y. CALISTHENICS EXERCISES TO INTERVENE IN OBESITY AND DIABETES IN MIDDLE-AGED PEOPLE. Rev Bras Med Esporte [Internet]. [cited 2023 Sep 5];28(2):2022. Available from: http://dx.doi.org/10.1590/1517-8692202228022021_0457\u003c/li\u003e\n\u003cli\u003eSoumyashree S, Kaur J. Effect of inspiratory muscle training (IMT) on aerobic capacity, respiratory muscle strength and rate of perceived exertion in paraplegics. \u003c/li\u003e\n\u003cli\u003eArruda NS de, Peixoto N de M, Callegaro CC, Trevisan ME, Jaenisch RB. Effects of Inspiratory Muscle Training in Type 2 Diabetes: A Systematic Review. Braz J Cardiovasc Surg [Internet]. 2023 Jul 4;38(4):e20220366. Available from: http://www.ncbi.nlm.nih.gov/pubmed/37403864\u003c/li\u003e\n\u003cli\u003eBuran Cirak Y, Yilmaz Yelvar GD, Durustkan Elbasi N. Effectiveness of 12-week inspiratory muscle training with manual therapy in patients with COPD: A randomized controlled study. Clin Respir J [Internet]. 2022 Apr 1 [cited 2023 Jul 31];16(4):317\u0026ndash;28. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/crj.13486\u003c/li\u003e\n\u003cli\u003eSadek Z, Salami A, Youness M, Awada C, Hamade M, Joumaa WH, et al. A randomized controlled trial of high-intensity interval training and inspiratory muscle training for chronic heart failure patients with inspiratory muscle weakness. Chronic Illn. 2022 Mar 1;18(1):140\u0026ndash;54. \u003c/li\u003e\n\u003cli\u003eZhang W, Pan H, Zong Y, Wang J, Xie Q. Respiratory Muscle Training Reduces Respiratory Complications and Improves Swallowing Function After Stroke: A Systematic Review and Meta-Analysis Archives of Physical Medicine and Rehabilitation. China National Knowledge Infrastructure Archives of Physical Medicine and Rehabilitation [Internet]. 2022 [cited 2023 Sep 5];103:1179\u0026ndash;91. Available from: https://doi.org/10.1016/j.apmr.2021.10.020\u003c/li\u003e\n\u003cli\u003eSheraz S, Ferraro FV, Siddiqui FA, Tariq H, Faghy MA, Malik AN. The effects of inspiratory muscle training on balance and functional mobility: a systematic review. https://doi.org/101080/0032548120232253136 [Internet]. 2023 Aug 31 [cited 2023 Sep 5]; Available from: https://www.tandfonline.com/doi/abs/10.1080/00325481.2023.2253136\u003c/li\u003e\n\u003cli\u003eAydoğan Arslan S, Uğurlu K, Sakizli Erdal E, Keskin ED, Demirg\u0026uuml;\u0026ccedil; A. Effects of Inspiratory Muscle Training on Respiratory Muscle Strength, Trunk Control, Balance and Functional Capacity in Stroke Patients: A single-blinded randomized controlled study. https://doi.org/101080/1074935720201871282 [Internet]. 2021 [cited 2023 Jul 31];29(1):40\u0026ndash;8. Available from: https://www.tandfonline.com/doi/abs/10.1080/10749357.2020.1871282\u003c/li\u003e\n\u003cli\u003eBosnak-Guclu M, Arikan H, Savci S, Inal-Ince D, Tulumen E, Aytemir K, et al. Effects of inspiratory muscle training in patients with heart failure. Respir Med. 2011 Nov 1;105(11):1671\u0026ndash;81. \u003c/li\u003e\n\u003cli\u003eBombard Y, Ross Baker G, Orlando E, Fancott C, Bhatia P, Casalino S, et al. Engaging patients to improve quality of care: a systematic review. [cited 2023 Oct 5]; Available from: https://doi.org/10.1186/s13012-018-0784-z\u003c/li\u003e\n\u003cli\u003eGen\u0026ccedil; FZ, Bilgili N. The effect of Otago exercises on fear of falling, balance, empowerment and functional mobility in the older people: Randomized controlled trial. Int J Nurs Pract. 2023; \u003c/li\u003e\n\u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007;19(6). \u003c/li\u003e\n\u003cli\u003eMwita KM. Factors influencing data saturation in qualitative studies. International Journal of Research in Business and Social Science (2147- 4478) [Internet]. 2022 Jun 5 [cited 2023 Oct 7];11(4):414\u0026ndash;20. Available from: https://www.ssbfnet.com/ojs/index.php/ijrbs/article/view/1776\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Reflecting on reflexive thematic analysis. Vol. 11, Qualitative Research in Sport, Exercise and Health. 2019. \u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol [Internet]. 2006 [cited 2023 Sep 11];3(2):77\u0026ndash;101. Available from: https://www.tandfonline.com/action/journalInformation?journalCode=uqrp20\u003c/li\u003e\n\u003cli\u003eFereday J, Muir-Cochrane E. Demonstrating Rigor Using Thematic Analysis: A Hybrid Approach of Inductive and Deductive Coding and Theme Development. Int J Qual Methods. 2006;5(1). \u003c/li\u003e\n\u003cli\u003eTobin GA, Begley CM. Methodological rigour within a qualitative framework. J Adv Nurs. 2004;48(4). \u003c/li\u003e\n\u003cli\u003eMacKintosh KA, Knowles ZR, Ridgers ND, Fairclough SJ. Using formative research to develop CHANGE!: A curriculum-based physical activity promoting intervention. BMC Public Health. 2011;11. \u003c/li\u003e\n\u003cli\u003eBoddy LM, Knowles ZR, Davies IG, Warburton GL, MacKintosh KA, Houghton L, et al. Using formative research to develop the healthy eating component of the CHANGE! school-based curriculum intervention. BMC Public Health. 2012;12(1). \u003c/li\u003e\n\u003cli\u003evan Nes F, Abma T, Jonsson H, Deeg D. Language differences in qualitative research: Is meaning lost in translation? Eur J Ageing. 2010;7(4). \u003c/li\u003e\n\u003cli\u003eShelley J, Hudson J, Mackintosh KA, Saynor ZL, Duckers J, Lewis K, et al. Perceptions of inspiratory muscle training in adults recovering from COVID-19. PLoS One. 2022;17(11 November). \u003c/li\u003e\n\u003cli\u003eHoffman M, Assis MG, Augusto VM, Silveira BMF, Parreira VF. The effects of inspiratory muscle training based on the perceptions of patients with advanced lung disease: a qualitative study. Braz J Phys Ther. 2018;22(3). \u003c/li\u003e\n\u003cli\u003eVan Leeuwenid KM, Van Loon MS, Van Nes FA, Bosmans JE, De Vetid HCW, Ket JCF, et al. What does quality of life mean to older adults? A thematic synthesis. 2019 [cited 2023 Oct 6]; Available from: https://doi.org/10.1371/journal.pone.0213263\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;connor C, Lawson R, Waterhouse J, Mills GH. Is inspiratory muscle training (IMT) an acceptable treatment option for people with chronic obstructive pulmonary disease (COPD) who have declined pulmonary rehabilitation (PR) and can IMT enhance PR uptake? A single-group prepost feasibility study in a home-based setting. [cited 2023 Sep 13]; Available from: http://bmjopen.bmj.com/\u003c/li\u003e\n\u003cli\u003eYasmin F, Ali L, Banu B, Rasul FB, Sauerborn R, Souares A. Understanding patients\u0026rsquo; experience living with diabetes type 2 and effective disease management: a qualitative study following a mobile health intervention in Bangladesh. [cited 2023 Oct 6]; Available from: https://doi.org/10.1186/s12913-019-4811-9\u003c/li\u003e\n\u003cli\u003eCederbom S, Bjerk M, Bergland A. A qualitative study exploring physical therapists\u0026rsquo; views on the Otago Exercise Programme for fall prevention: a stepping stone to \u0026ldquo;age in place\u0026rdquo; and to give faith in the future. Physiother Theory Pract. 2022;38(1). \u003c/li\u003e\n\u003cli\u003ePrihartadi AS, Licastro GI, Johnson MJ, Luckett T, Pearson M, Swan F. Non-medical devices for the management of chronic breathlessness: A scoping review of device use, barriers and facilitators for patients, carers and clinicians. 2021 [cited 2023 Oct 6]; Available from: http://dx.\u003c/li\u003e\n\u003cli\u003eShi C, Zhu H, Liu J, Zhou J, Tang W. Barriers to Self-Management of Type 2 Diabetes During COVID-19 Medical Isolation: A Qualitative Study. 2020 [cited 2023 Oct 7]; Available from: http://doi.org/10.2147/DMSO.S268481\u003c/li\u003e\n\u003cli\u003eGrover S, Fitzpatrick A, Azim FT, Ariza-Vega P, Bellwood P, Burns J, et al. Defining and implementing patient-centered care: An umbrella review ☆. 2021 [cited 2023 Oct 7]; Available from: https://doi.org/10.1016/j.pec.2021.11.004\u003c/li\u003e\n\u003cli\u003eHutting N, Caneiro JP, Ong\u0026rsquo;wen C M, Miciak M, Roberts L. Patient-centered care in musculoskeletal practice: Key elements to support clinicians to focus on the person. 2021 [cited 2023 Oct 7]; Available from: http://creativecommons.org/licenses/by/4.0/\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Type 2 Diabetes Mellitus, Patient’s Perceptions, Qualitative, Quality of life","lastPublishedDoi":"10.21203/rs.3.rs-4726704/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4726704/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe aim of this descriptive qualitative study was to explore the patient\u0026rsquo;s perspective of multifactorial home-based Inspiratory Muscle Training (IMT) combined with group-based Otago Exercise Program (OEP) to bridge the gap of the experiences and perceptions of diabetes polyneuropathy patients regarding home-based multifactorial IMT intervention. Individual semi-structured interviews were conducted with 12 patients using thematic analysis. The patients\u0026rsquo; interviews were transcribed verbatim in Urdu, translated into English, and then coded into relevant themes. Three key themes emerged, including perception regarding quality of life, facilitators, and barriers to intervention. The patients reported improvement in their quality of life perceived through improvement in their physical and mental health as well as their functional independence. While improvement in shortness of breath and walking capacity, discomfort, initial difficulty in usage and distraction in the home environment were the key barriers. A multifactorial IMT intervention was perceived to have positive effects on the physical, mental, and emotional health of diabetes patients. These findings highlight the importance of multifactorial IMT interventions and suggest tailoring interventions and physical therapies to address the barriers and facilitators to enhance the likelihood of successful training outcomes.\u003c/p\u003e","manuscriptTitle":"Multifactorial Inspiratory Muscle Training in Diabetic Population: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-27 11:44:08","doi":"10.21203/rs.3.rs-4726704/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"30256835-3d3c-4316-a426-c6ebfd4c6ace","owner":[],"postedDate":"August 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":36286427,"name":"Health sciences/Endocrinology"},{"id":36286428,"name":"Health sciences/Health care"}],"tags":[],"updatedAt":"2024-11-04T05:24:19+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-27 11:44:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4726704","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4726704","identity":"rs-4726704","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}