International Journal of Sports Physiology and Performance, 2022, 17, 343-349

https://doi.org/10.1123/ijspp.2021-0119
© 2022 Human Kinetics, Inc ORIGINAL INVESTIGATION

Effect of Moderate- or High-Intensity Inspiratory Muscle Strength

Training on Maximal Inspiratory Mouth Pressure and Swimming
Performance in Highly Trained Competitive Swimmers
Toshiyuki Ohya, Kenta Kusanagi, Jun Koizumi, Ryosuke Ando,
Keisho Katayama, and Yasuhiro Suzuki

Purpose: Inspiratory muscle strength training (IMST) can improve exercise performance. Increased maximal inspiratory
mouth pressure (MIP) could be beneficial for swimmers to enhance their performance. This study aimed to clarify the effect
of high-intensity IMST for 6 weeks on MIP and swimming performance in highly trained competitive swimmers. Methods:
Thirty male highly trained competitive swimmers were assigned to high-intensity IMST (HI; n = 10), moderate-intensity
IMST (MOD; n = 10), and control (n = 10) groups. The 6-week IMST intervention comprised twice daily sessions for 6 d/wk
at inspiratory pressure threshold loads equivalent to 75% MIP (HI) and 50% MIP (MOD). Before and after the intervention,
MIP and swimming performance were assessed. Swimming performance was evaluated in free and controlled frequency
breathing 100-m freestyle swimming time trials in a 25-m pool. For controlled frequency breathing, participants took 1
breath every 6 strokes. Results: The MIP values after 2 and 6 weeks of IMST in the HI and MOD groups were significantly
higher than those before IMST (P = .0001). The magnitudes of the MIP increases after 6 weeks of IMST did not differ
between the HI (13.4% [8.7%]) and MOD (13.1% [10.1%]) groups (P = .44). The 100-m freestyle swimming times under
the controlled frequency condition were significantly shorter after IMST than those before IMST in both the HI (P = .046)
and MOD (P = .042) groups. Conclusions: Inspiratory pressure threshold load equivalent to 50% MIP could be sufficient to
improve MIP and swimming performance under the controlled frequency breathing condition in highly trained competitive
swimmers.

Keywords: respiratory muscle, pimax, pulmonary function, diaphragm

Swimmers are required to precisely coordinate their frequency
of breathing and tidal volume with stroke mechanics, resulting in a
different breathing pattern to that seen in land-based exercise.1 In
addition, coupled with the increased hydrostatic pressure on the
chest and the potential effect of body position on breathing, these
factors, individually and collectively, are likely to increase the load
on the respiratory system.2 Thus, inspiratory muscle fatigue (IMF)
may occur during swimming. Indeed, Brown and Kilding3 dem-
onstrated that maximal inspiratory mouth pressure (MIP), com-
monly used to infer inspiratory muscle strength, decreased
immediately after a 100-m front crawl swim, indicating the devel-
opment of IMF. This IMF appears to be based on increased
inspiratory muscle work combined with competition from the
locomotor muscles of the limbs for blood flow (ie, oxygen trans-
port).4,5 Hence, IMF would limit swimming performance.6,7
Respiratory muscle training attenuates IMF and can improve
exercise performance.8–10 One of the reasonable mechanisms
postulated to explain the improved exercise performance after
inspiratory muscle strength training (IMST) is a decrease in the
rating of perceived breathlessness.8,11,12 Volianitis et al10 suggested
that rowing performance improvements after IMST were
Ohya and Kusanagi are with the School of Health and Sport Sciences, and
Koizumi, the Graduate School of Health and Sport Sciences, Chukyo University,
Aichi, Japan. Ando and Suzuki are with the Dept of Sports Research, Japan Inst
of Sports Sciences, Tokyo, Japan; Suzuki is also with the Center for General
Education, Tokyo Keizai University, Tokyo, Japan. Katayama is with the
Research Center of Health, Physical Fitness and Sports, Nagoya University,
Aichi, Japan. Ohya (tohya@sass.chukyo-u.ac.jp) is corresponding author.
accompanied by decreases in IMF and perception of breathless-
ness. Kilding et al13 revealed that 100- and 200-m swimming
performances improved and were concomitant with the increased
MIP after 6 weeks of IMST. The IMST was associated with marked
reduction in perceived exertion over a range of swim speeds.13
Thus, increased MIP could be beneficial for swimmers to enhance
their performance.
The swimmers who participated in the research by Kilding
et al13 were not highly trained competitive swimmers. Therefore,
the effect of IMST on swimming performance in highly trained
competitive swimmers remains unclear. The demands of swim-
ming train the inspiratory muscles by chest wall loading
imposed by water pressure.11 Therefore, highly trained swim-
mers may be near a plateau with regard to their respiratory
muscle function and, thus, find it difficult to make further gains
in MIP after addition of respiratory muscle training.8 Although
IMST is typically performed at 50% MIP in athletes,8,10,13,14
high-intensity IMST is needed for highly trained competitive
swimmers to enhance their inspiratory muscle strength and swim
performance.
The purpose of this study was to clarify the effect of high-
intensity IMST for 6 weeks on MIP and swimming performance in
highly trained competitive swimmers. Based on the aforemen-
tioned considerations, we hypothesized that high-intensity IMST
would lead to greater swimming performance with MIP improve-
ment than moderate-intensity IMST in highly trained competitive
swimmers. To test this hypothesis, we evaluated swimming per-
formance and MIP after 6 weeks of IMST. We set the IMST
intensities at 50% MIP and 75% MIP.
343
344 Ohya et al
Methods
Participants
Thirty male highly trained competitive college swimmers partici-
pated in the study. All of the participants were part of a collegiate
swimming club and had participated in interscholastic and/or
intercollegiate athletic competitions at least at once. The character-
istics of the participants are shown in Table 1. The participants
comprised 8 sprint (specialty event, 50 or 100 m), 14 middle-
distance (specialty event, 100 or 200 m), and 8 long-distance
(specialty event, over 400 m) swimmers. The Fédération Inter-
nationale de Natation Amateur points shown reflect the specialty
events for the swimmers. The weekly swimming training typically
involved 8 sessions per week (40 km/wk) with 4 dryland or
resistance training sessions per week. All participants provided
written consent to participate in the study after receiving informa-
tion on the purpose of the study, the procedure, and the possible
risks. The study was approved by the Human Subjects Committee
at Chukyo University.
Experimental Overview
The participants were divided into matched groups according to
their baseline MIP measurements, free breathing, and controlled
frequency breathing 100-m freestyle swimming times before
IMST, and Fédération Internationale de Natation Amateur points,
and randomly assigned to the high-intensity IMST (HI), moderate-
intensity IMST (MOD), and control groups. The HI and MOD
groups performed IMST for 6 weeks, comprising twice daily
sessions for 6 days per week in addition to daily swimming and
dryland training. The control group performed only daily swim-
ming and dryland training. Before the IMST intervention, the
participants visited the laboratory 4 times. At the first visit, they
completed an assessment of pulmonary function and were famil-
iarized with the MIP measurements. On the second and third visits,
MIP measurements were performed. On the fourth visit, swimming
performance tests were conducted. These procedures were repeated
after 6 weeks of IMST in all participants.
IMST
The IMST protocol consisted of 30 breaths per session using a
POWERbreath IM trainer (IMT Technologies Ltd, Birmingham,
UK) with an inspiratory pressure threshold load equivalent to 50%
MIP in weeks 1 and 2 for both the HI and MOD groups for
familiarization. From weeks 3 to 6, an inspiratory pressure thresh-
old load equivalent to 75% MIP in the HI group or 50% MIP in the
MOD group was applied. Based on data showing that accessory
inspiratory muscles dramatically contributed to inspiration >60%
MIP, especially >75% MIP,15 we set an inspiratory pressure
Table 1 Characteristics of the Participants Before the IMST Intervention
HI group (n = 10)
Age, y 20 (1)
Height, cm 175.4 (4.4)
Weight, kg 69.1 (4.6)
FINA points 800 (53)
Abbreviations: CON, control (daily swimming and dryland training only); FINA, Fédération Internationale de Natation Amateur; HI, high-intensity IMST;
IMST, inspiratory muscle strength training; MOD, moderate-intensity IMST. Note: Data are expressed as mean (SD). No significant differences were observed among
the groups.
IJSPP Vol. 17, No. 3, 2022
threshold load equivalent to 75% MIP in the HI group. Both
groups performed IMST for 6 weeks as twice daily sessions for
6 days per week. MIP was assessed every week in both groups to
maintain the same relative training intensity. IMST was performed
before or after daily swimming and dryland training. Swimming
and dryland training volume and intensity did not differ among the
groups during the experimental period.
MIP Measurements
The MIP was assessed according to the guidelines of the American
Thoracic Society/European Respiratory Society (2002)16 using a
portable autospirometer (AS-507; Minato Medical Science, Osaka,
Japan) with a handheld mouth pressure meter (AAM377; Minato
Medical Science). All measurements were taken while the parti-
cipants were sitting with their nose occluded. The participants were
instructed to breathe out to residual volume and then inhale as hard
and as quickly as possible to total lung capacity and sustain this
inspiration for at least 1 second. Measurements were repeated until
a minimum of 5 and maximum of 7 technically satisfactory
measurements were obtained. The greatest of 3 measurements
with <10% between-measurement variability was defined as the
maximum.17
Swimming Performance Tests
Swimming performance was evaluated as the time taken to
complete free breathing and controlled frequency breathing
100-m freestyle swimming time trials in a 25-m indoor swimming
pool. For the controlled frequency breathing condition, all parti-
cipants were given specific instructions to take 1 breath every 6
strokes. Controlled frequency breathing swimming is often used
during daily training by swimmers.18 The reason for choosing the
test was to assess the impact of IMST on swimming performance
by improving breath holding during swimming. The breathing
condition was randomly assigned. Participants performed each
test alone. Swimming times were measured by stopwatch, and all
tests were measured by the same investigator. Each test was
preceded by the participant’s self-chosen warm-up. Participants
were requested to perform the same warm-up before and after
IMST intervention.
Pulmonary Function Measurements
Pulmonary function was assessed using a portable autospirometer
(AS-507; Minato Medical Science)19 to determine vital capacity
(VC) and maximal voluntary ventilation for 12 seconds. All
measurements were performed according to published guide-
lines.20 The VC measurement was repeated 3 times, and the largest
value was selected. Maximal voluntary ventilation for 12 seconds
was measured twice, and the higher value was accepted.
MOD group (n = 10) CON group (n = 10)
19 (1) 19 (1)
173.5 (6.4) 174.4 (4.0)
68.9 (7.5) 69.0 (7.8)
785 (53) 762 (45)

Statistical Analysis
Values are expressed as mean (SD). All statistical analyses were
performed using SPSS for Windows software (version 23.0; IBM
Corp, Armonk, NY). Comparisons of anthropometric and physio-
logical characteristics among the groups were analyzed by 1-way
analysis of variance. The Bonferroni test was used to compare
differences among the groups. Changes in MIP during IMST among
the groups (group × training phase [before and after 2 and 6 weeks of
IMST]) were analyzed by 2-way analysis of variance with repeated
measures. Changes in swimming performance time and pulmonary
function during IMST among the groups (group × training phase
[before and after 6 weeks of IMST]) were also analyzed by 2-way
analysis of variance with repeated measures. The Bonferroni test was
used to compare differences among the groups and training phases.
Values of P < .05 were considered significant. Sample size was
calculated based on changes in MIP after the IMST intervention.13,21
Based on an alpha of .05 and a statistical power (1-β) of 0.9, at least 5
participants were required in each group. Two participants in the HI
group dropped out during IMST and were excluded from the
analyses.
Results
MIP
Figure 1 shows the MIP values before and after 2 and 6 weeks of
IMST. There was a significant interaction (group × training phase)
for MIP (P = .0001). The MIP values after 2 and 6 weeks of IMST
in the HI and MOD groups were significantly higher than those
before IMST intervention (P = .0001). The magnitudes of the
increased MIP after 6 weeks of IMST did not differ between
Figure 1 — MIP values before and after 2 and 6 weeks of inspiratory
muscle strength training intervention (filled circles: high-intensity group,
n = 8; unfilled triangles: moderate-intensity group, n = 10; and unfilled
squares: control group, n = 10). MIP indicates maximal inspiratory mouth
pressure. Data are expressed as mean (SD). *P < .05 versus control;
†P < .05 versus before.
IJSPP Vol. 17, No. 3, 2022
Inspiratory Muscle Training in Elite Swimmers 345
the HI (13.4% [8.7%]) and MOD (13.1% [10.1%]) groups
(P = .44). The MIP after 6 weeks of IMST in the MOD group
was significantly higher than that in the control group (P = .044).
Swimming Performance Tests
Figures 2 and 3 show the individual and mean 100-m freestyle
swimming times under the free breathing and controlled frequency
breathing conditions before and after IMST intervention, respec-
tively. There was no significant interaction (group × training phase)
(P = .72) or improvement before and after IMST intervention in the
mean 100-m freestyle swimming times under the free breathing
condition in all groups (P = .073). Although there was no signifi-
cant interaction (group × training phase) (P = .904), the 100-m
freestyle swimming times under the controlled frequency breathing
condition after IMST intervention were significantly shorter than
those before IMST intervention in the HI (P = .046) and MOD
(P = .042) groups.
Pulmonary Function
Table 2 shows the pulmonary function before and after the IMST
intervention. There were no significant differences in VC and
maximal voluntary ventilation for 12 seconds before and after
the intervention in all groups.
Discussion
The major findings of the study were (1) MIP increased signifi-
cantly after 6 weeks of IMST in the HI and MOD groups, but the
magnitudes of the increases in MIP did not differ between the HI
and MOD groups and (2) the 100-m freestyle swimming times after
IMST intervention did not change under the free breathing condi-
tion in either group, but were significantly shorter under the
controlled frequency breathing condition in both groups.
The MIP values after IMST intervention were significantly
higher than those before IMST intervention in the 2 IMST groups
(Figure 1). These results demonstrate that 6 weeks of IMST
improved inspiratory muscle strength in highly trained competitive
swimmers regardless of IMST intensity. The magnitudes of the
MIP increases after 6 weeks of IMST were 13.4% (8.7%) in the HI
group and 13.1% (10.1%) in the MOD group. These findings are
similar to those reported by Kilding et al,13 who found that IMST,
comprising 30 breaths per session at inspiratory pressure threshold
load equivalent to 50% MIP, substantially improved MIP by 9.1%
after 6 weeks of IMST in competitive swimmers. Taken together, 6
weeks of IMST can lead to MIP improvement in highly trained
competitive swimmers.
Considering the increased hydrostatic pressure on the chest
and the potential effect of body position on breathing, these factors,
individually and collectively, are likely to result in increased load
on the respiratory system during swimming training.2 Therefore,
highly trained swimmers place a burden on their respiratory system
by daily swimming training and, thus, find it difficult to make
further gains in MIP after additional IMST compared with terres-
trial athletes. The demands of swimming train the inspiratory
muscles by chest wall loading imposed by water pressure.11 Highly
trained swimmers may be close to their plateau with regard to
respiratory muscle function and, consequently, find it difficult to
further enhance their MIP after addition of IMST for 6 weeks.8 We
hypothesized that high-intensity IMST would lead to greater
swimming performance with MIP improvement than moderate-
Figure 2 — The 100-m freestyle swimming times under the free breathing condition before and after 6 weeks of inspiratory muscle strength training
intervention (A, filled circles: high-intensity group, n = 8; B, unfilled triangles: moderate-intensity group, n = 10; C, unfilled squares: control group,
n = 10; D, mean values).

Figure 3 — The 100-m freestyle swimming times under the controlled frequency breathing condition before and after 6 weeks of inspiratory muscle
strength training intervention (A, filled circles: high-intensity group, n = 8; B, unfilled triangles: moderate-intensity group, n = 10; C, unfilled squares:
control group, n = 10; D, mean values). †P < .05 versus before.

346 IJSPP Vol. 17, No. 3, 2022


Table 2 Pulmonary Function Before and After 6 Weeks of IMST
HI group (n = 8)
Before After
VC, L 5.79 (0.53) 5.70 (0.54)
MVV12, L 190 (40) 182 (44)
Abbreviations: CON, control; HI, high-intensity IMST; IMST, inspiratory muscle strength training; MOD, moderate-intensity IMST; MVV12, maximal voluntary
ventilation for 12 s; VC, vital capacity. Note: Data are expressed as mean (SD). No significant differences were observed among the groups.
intensity IMST in highly trained competitive swimmers. Thus, we
set the IMST intensities at 50% MIP and 75% MIP. Although we
hypothesized that MIP would show greater improvement in the HI
group compared with the MOD group after IMST intervention, no
additional effect was evident when IMST was performed under the
high-intensity load condition, specifically inspiratory pressure
threshold load equivalent to 75% MIP.
Only a few studies have investigated high-intensity respira-
tory muscle training.22,23 Sperlich et al23 reported no effects on
respiratory muscle strength and pulmonary parameters (MIP,
maximal expiratory mouth pressure, and VC) in healthy partici-
pants after 6-week high-intensity inspiratory muscle training
consisting of 30 breaths per session at inspiratory pressure
threshold load equivalent to 90% MIP. Meanwhile, Micklebor-
ough et al22 revealed that MIP was significantly increased in
recreational road runners after 6-week high-intensity IMST com-
prising inspiratory pressure threshold load equivalent to 80%
MIP. We set the inspiratory pressure threshold load to 75% MIP
in the HI group because Ando et al24 and Chino et al15 demon-
strated that accessory inspiratory muscle dramatically contributed
to higher inspiratory mouth pressure, especially 75% MIP.
Although the effect of high-intensity IMST on MIP remains
unclear, this study demonstrated that inspiratory pressure thresh-
old load equivalent to 50% MIP was sufficient to improve MIP in
highly trained competitive swimmers.
High-intensity training loads have been used for whole-body
strength training in athletes. Meta-analysis data showed that 80% of
1-repetition maximum with loads corresponding to 8 to 12 repeti-
tions produced large effect sizes for whole-body strength increases
in trained athletes.25,26 The number of repetitions was set at 30 in
the present study despite the inspiratory pressure threshold load
equivalent to 75% MIP. One of the reasons why the magnitude of
the MIP increases after IMST intervention did not differ between
the 2 conditions is that the later inspirations for IMST in each
training session may not have been performed successfully in the
HI group. When IMST has a high inspiratory pressure threshold
load, it may be better to reduce the number of repetitions and set an
interval per training session.
The 100-m freestyle swimming times under the free breathing
condition after IMST intervention showed no significant improve-
ment in all groups (Figure 2). These results are inconsistent with the
findings of Kilding et al,13 who reported that 6 weeks of inspiratory
muscle training had positive effects on swimming performance in
club-level trained swimmers. The swimmers who participated in
the research by Kilding et al13 had 100-m swimming times before
IMST intervention of approximately 63 seconds, whereas the
swimmers in this study had times of approximately 53 seconds
before IMST intervention. Mickleborough et al27,28 suggested that
subelite adult swimmers, who had a markedly lower training
volume and intensity compared with elite swimmers, did receive
IJSPP Vol. 17, No. 3, 2022
Inspiratory Muscle Training in Elite Swimmers 347
MOD group (n = 10) CON group (n = 10)
Before After Before After
5.92 (0.89) 5.81 (0.87) 5.76 (0.58) 5.71 (0.68)
185 (31) 183 (30) 193 (35) 188 (41)
additional benefits from combining flow resistive inspiratory mus-
cle training and swim training. One of the reasons for the lack of
effect on swimming performance in this study could be the
difference in competition level. The highly trained competitive
swimmers in this study had low trainability, and MIP improvement
did not affect their 100-m freestyle swimming performance.
Several studies reported that respiratory muscle training atten-
uated IMF and improved exercise performance.8–10 One of the
reasonable mechanisms postulated to explain the improved exer-
cise performance after IMST is a decrease in the rating of perceived
breathlessness.8,11,12 Although our results cannot determine
whether IMST improved the rating of perceived breathlessness
during 100-m freestyle swimming, we speculate that IMST atten-
uated the rating of perceived breathlessness during 100-m freestyle
swimming because the magnitude of the increased MIP was similar
to that in Kilding et al.13 The present findings suggest that IMST
improves MIP but fails to enhance 100-m freestyle swimming
performance in highly trained competitive swimmers.
Meanwhile, the 100-m freestyle swimming times under the
controlled frequency breathing condition after IMST intervention
were significantly shorter than those before IMST intervention in
the HI and MOD groups (Figure 3). The participants were able to
breathe every 6 strokes under the controlled frequency breathing
condition, and it was speculated that the magnitude of the rating of
perceived breathlessness was higher than that under the free
breathing condition. Shei29 pointed out that improved inspiratory
muscle strength allows swimmers to complete breath holds during
a swim test at a lower intensity relative to the maximal inspiratory
pressure generating capacity. Attenuated rating of perceived
breathlessness may enhance swimming performance in severe
breath conditions, such as the controlled frequency breathing
condition employed in this study.
Another possible reason for the improved performance under
the controlled frequency breathing condition is increased tidal
volume. Wylegala et al30 reported that resistance respiratory
muscle training improved underwater swimming time concomitant
with an increase in MIP. Breathing frequency during underwater
endurance swimming decreased and tidal volume increased after
resistance respiratory muscle training.30 There was also a reduction
in oxygen uptake requirement during underwater swimming.30
Vašíčková et al31 revealed that 4 weeks of respiratory muscle
training had a positive effect on underwater swimming perfor-
mance, measured as the maximal length of underwater swimming
that swimmers were able to swim with 1 inspiration. The mecha-
nism for the improved performance under the controlled frequency
breathing condition in this study remains unclear, and further
research is needed to clarify this mechanism.
The reason for choosing the 100-m freestyle swimming test
under the controlled frequency breathing condition was to assess the
impact of IMST on swimming performance by improved breath
348 Ohya et al
holding during swimming. There are 3 main components of drag or
resistance that act on swimmers as they move through the water:
friction (or skin), form, and wave drag.32 The coordination of the
rotational breathing movement could impact the magnitude of the net
drag force fluctuations.33 Lerda and Cardelli34 reported that increased
skill level was associated with smaller average breathing frequency
throughout a men’s 100-m freestyle race because taking fewer breaths
improved the body balance and propulsion. Swimmers must choose
the most effective tradeoff between the need for oxygen and the need
to move forward more efficiently by breathing less often. If attenuated
rating of perceived breathlessness in swimmers can improve MIP and
reduce their inspiration frequency during swimming for strategic gain,
their 100-m freestyle swimming times may improve.
This study had several limitations. First, the study did not
have a sham controlled design. We could not create a sham group
because of the highly trained competitive swimmers who par-
ticipated in the study. Essentially, we could not instruct highly
trained competitive swimmers to perform ineffective IMST.
However, we consider that the major findings of the study
were not affected by the lack of a sham group because the
main purpose of the study was to determine the effect of
high-intensity IMST on MIP and swimming performance com-
pared with moderate-intensity IMST. Second, the study did not
have a double-blind design. However, the participants in the
study had high motivation for swimming performance tests, even
in the control group. We, therefore, believe that the major
findings of the study were not significantly influenced by the
lack of a double-blind design. Our study design is quite similar to
the study by Kilding et al,13 which also lacked a double-blind
design, and we feel that comparisons of our data with these
previously reported data are valuable. Finally, the present study
included a variety of disciplines. Although 100-m freestyle
swimming was often used during daily training in this collegiate
swimming club regardless of the main distance, swimmers who
did not have 100-m freestyle as their main distance may not have
been familiar with the 100-m freestyle swimming performance
tests. The swimming performance may have clearer if we had
only recruited swimmers who specialized in 100-m freestyle
swimming for this study.
Practical Application
This study demonstrated that 6 weeks of IMST enhanced MIP
and 100-m freestyle swimming performance under the con-
trolled frequency breathing condition in highly trained competi-
tive swimmers. Although the mechanism for the enhanced
swimming performance remains unclear, we speculate that
IMST attenuates the rating of perceived breathlessness during
swimming. IMST at inspiratory pressure threshold load equiva-
lent to 50% MIP for 6 weeks, comprising twice daily sessions for
6 days per week, can enhance MIP in highly trained competitive
swimmers. Based on our findings, swimmers and coaches should
choose to prescribe IMST in an effort to enhance swimming
performance and MIP.
Conclusion
This study showed that MIP was increased after 6 weeks of IMST
under moderate (50% MIP) and high (75% MIP) load conditions in
highly trained competitive swimmers with improved 100-m free-
style swimming times under the controlled frequency breathing
IJSPP Vol. 17, No. 3, 2022
condition. The magnitudes of the increases in MIP and swimming
performance improvement did not differ between the 2 load
conditions. These results suggest that inspiratory pressure thresh-
old load equivalent to 50% MIP is sufficient to improve MIP and
swimming performance under the controlled frequency breathing
condition in highly trained competitive swimmers with no addi-
tional effects when IMST is performed under high load conditions.
Acknowledgments
The authors thank Alison Sherwin, PhD, from Edanz Group (https://
jp.edanz.com/ac) for editing a draft of this manuscript.
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