Fry 2007.

Methods	Randomized controlled trial
Participants	N = 46 (23/23) randomized, N = 41 (20/21) analyzed Inclusion criteria: aged > 18 years, ambulatory, clinically diagnosed MS Exclusion criteria: acute respiratory infection, oral temperature > 100ºF, unstable physical conditions not related to MS, current smoking history Experimental group (N = 20): EDSS, mean ± SD: 3.96 ± 1.80 Age, mean ± SD: 50 ± 9.1 years Women: 91% MS type (%): RR 52; SP 16; PP 21; PR 11 Time since diagnosis: — Control group (N = 21): EDSS, mean ± SD: 3.36 ± 1.47 Age, mean ± SD: 46.2 ± 9.4 years Women: 74% MS type (%): RR 72; SP 18; PP 5; PR 5 Time since diagnosis: — Country: USA
Interventions	Experimental group: Home‐based inspiratory muscle training with a threshold inspiratory muscle trainer device Duration: 3 months Frequency: 2 sessions daily Repetitions and sets: 3 sets of 15 repetitions Resistance and progression: initial resistance (H2O) IMT set on 30% of pretest PImax; weekly progression based on baseline MIP, Borg 6‐20 RPE, and symptoms Control group: No treatment, called at 4, 8 and 10 weeks to control for complications and for changes in level of physical activity.
Outcomes	PImax, predicted PImax (%), PEmax, predicted PEmax (%), MVV, predicted MVV (%), FSS, FVC, predicted FVC (%), FEV1, predicted FEV1 (%), FEV1/FVC, predicted FEV1/FVC (%), FEF 25‐75%, predicted FEF 25‐75%, VC, predicted VC (%), impaired ventilatory muscle strength inspiratory, impaired ventilatory muscle strength expiratory, pulmonary disorder classification, FSS
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	Quote p 163: "participants were randomly placed into a home exercise I group or C group by date of enrolment in the study."
Allocation concealment (selection bias)	Unclear risk	No information
Blinding of participants and personnel (performance bias) All outcomes	High risk	No information Comment: blinding participants and personnel not possible
Blinding of outcome assessment (detection bias) All outcomes	Low risk	Quote p 163: "The investigator who conducted the pre‐pulmonary and post‐pulmonary function tests was blinded to group assignment."
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	Quote p 163: "Of the 46 subjects who participated in the pre‐test session, two withdrew due to illness unrelated to a neurological exacerbation and three subjects no longer wished to participate in the study." Comment: unclear which participants withdrew from which group and why.
Selective reporting (reporting bias)	Unclear risk	No published study protocol available Comment: relevant outcomes, but not all (e.g., QoL, basic ADLs, cough efficacy), were reported.