Expiratory Muscle Strength Training

Expiratory Muscle Strength Training

Dysphagia Management in Acute Care

Effects on Expiratory Muscle Strength & Endurance

Respiratory Training Devices

Threshold PEP-Phillips

10 units per case

$21.95 Each

20 levels of resistance

EMST 150:

48 Units: $2,039

$49.99 Each

Settings from 30 ml H2O

to 150 ml H20

• Weiner et al.
• 21% increase in max expiratory pressure in pt's with COPD
• Increase in expiratory muscle endurance
• 19% increase in distance walked
• Improvements in respiratory strength benefit multiple areas of activity
• Saleem et al.
• 158% increase in in PE max from baseline in individual w/ Parkinson's Disease following 20 week program
• Following 4 weeks detraining only 16% drop was observed

Acapella- Vibratory PEP Device

$54.00 Each

2 levels of resistance available

Separate Devices

Helps to break up secretions

Lower resistance level for high level of debility

The Breather

Case of 10: $33.75 ea

$40.75 Each

4 Levels Expiratory Resistance

5 Levels Insp. Resistance

Constant resistance provided during expiration

Background

Training Protocol

Effects on Cough and Swallow

• No standardized protocol currently exists
• Most experimental protocols range from 4-8 weeks. However, one 20 wk protocol was identified
• 1-6 days/week, 1x to 3x daily
• Sessions of 10-30 minutes
• Threshold ranges between 25% and 80% of PE Max
• Load increase of 5% to 10% per cycle

• EMST can be summarized as a respiratory/swallowing exercise that utilizes progressive resistance to maximize gains
• Swallowing is submaximal activity: utilizing effort far below max force of associated musculature
• In order to increase force of musculature involved, physiological load must exceed typical demand
• Most swallowing exercises are unable to utilize quantifiable or progressive resistance
• IOPI & EMST are current exemptions
• Pt's exhale into a 1 way pressure release valve w/ an adjustable threshold
• Improves swallow "through afferent stimulation to brain stem swallowing centers through peripheral sensory receptors in the tongue and oropharynx and by by strengthening oropharyngeal, laryngeal, and supralaryngeal muscles involved in swallowing" (Kim & Sapienza, 2005)

(Burkhead, Sapienza, & Rosenbek, 2007)

• With improved cough function, incidence of pneumonia decreased
• Kojima et al. demonstrated improved cough function following EMST training by increased sputum weight
• Chiara et al.: Participants w/ MS expressed positive improvements in cough and secretion management
• Troche et al. used VFSS to investigate changes in swallow in pt's with PD
• Participants had significantly decreased peneration/aspiration scores
• Improvements were observed in hyolaryngeal movement

(Laciuga, Rosenbek, Davenport, & Sapienza, 2014)

Effects on Speech

Increases in Suprahyoid Muscle Activity at 25% and 75% of Max Expiratory Pressure

Indications and Contraindications

References

• Jones et al.
• Participants with Lance-Adams Syndrome demonstrated increased max phonation time, intelligibility, and communication effectiveness survey scores following EMST treatment
• Chiara et al.
• Participants with Multiple Sclerosis had improvements in sustained vowel prolongation, words per minute
• Changes in Dysarthria were not significant

• EMST has been established as a safe treatment in individuals with COPD, MS, PD, healthy persons, and professional voice users
• The maker's of EMST 150 suggest that until intrathoracic and intracranial pressures are further examined pt's with acute cardiovascular concerns and CVA may not be candidates (emst150.com, 2014)
• No adverse effects have been observed with EMST in populations studied
• Pressures developed with respiratory training are lower than those produced by bowel movements or coughs
• Laciuga et al. tested cardiovascular response to EMST in healthy individuals
• No significant changes in blood pressure, heart rate, or SpO2 were observed
• Anecdotal: In pt w/ impaired respiratory status, SpO2 was observed to drop significantly following minimal EMST training
• A pilot study by Kulnik, Rafferty, Birring, Moxham, and Kalra is currently investigating EMST training in Acute stroke related to reduced pneumonia incidence

Burkhead, L. M., Sapienza, C. M., & Rosenbek, J. C. (2007).

Strength-training exercise in dysphagia rehabilitation: principles, procedures, and directions for future research. Dysphagia, 22(3), 251-265.

Chiara, T., Martin, A. D., Davenport, P. W., & Bolser, D. C. (2006).

Expiratory muscle strength training in persons with multiple sclerosis having mild to moderate disability: effect on maximal expiratory pressure, pulmonary function, and maximal voluntary cough. Archives of physical medicine and rehabilitation, 87(4), 468-473.

Jones, H. N., Donovan, N. J., Sapienza, C. M., Shrivastav, R., Fernandez, H. H., & Rosenbek, J.

C. (2006). Expiratory muscle strength training in the treatment of mixed dysarthria in a patient with Lance-Adams syndrome. JOURNAL OF MEDICAL SPEECH LANGUAGE PATHOLOGY, 14(3), 207.

Kojima, H., Yamada, T., Takeda, M., Itou, Y., Yoshida, M., & Kimura, M. (2006).

Effectiveness of cough exercise and expiratory muscle training: a meta-analysis. Journal of Physical Therapy Science, 18(1), 5-10.

Kulnik, S. T., Rafferty, G. F., Birring, S. S., Moxham, J., & Kalra, L. (2014).

A pilot study of respiratory muscle training to improve cough effectiveness and reduce the incidence of pneumonia in acute stroke: study protocol for a randomized controlled trial. Trials, 15(1), 123.

Laciuga H., Davenport P., Sapienza C. (2012). The acute effects of a single session of

expiratory muscle strength training on blood pressure, heart rate, and oxygen saturation in healthy adults. Front. Physio. 3:48 10.3389/fphys.2012.00048

Saleem AF, Sapienza CM, Okun MS. Respiratory muscle strength training: Treatment and response

duration in a patient with early idiopathic Parkinson’s disease. NeuroRehabilitation. 2005;20(4):323–33.

Troche M., Okun M., Rosenbek J., Musson N., Sapienza C. (2009).

Swallow outcomes following intervention with expiratory muscle strength training (Emst) in Parkinson’s disease: results of a randomized clinical trial. Dysphagia 24, 455–456

Weiner P, Magadle R, Beckerman M, Weiner M, Berar-Yanay N. Comparison of specific expiratory,

inspiratory, and combined muscle training programs in COPD. Chest. 2003;124(4):1357–64.

(Burkhead, Sapienza, & Rosenbek, 2007)