Expiratory Muscle Strength Training Research Articles

Body Mass Index and Thoracic Expansion in Post-COVID Dyspnea: A Secondary Analysis.

Dyspnea secondary to lung impairment can persist following the acute phase of COVID-19. Thoracic expansion measurements have been used as a diagnostic tool to evaluate chest wall mobility, respiratory function, and the effects of respiratory muscle strength training. Changes in chest wall mobility may occur because of altered chest biomechanics in individuals with respiratory diseases and an elevated body mass index (BMI). The purpose of this secondary analysis was to evaluate whether BMI influences thoracic expansion or forced expiratory volume over 1 second (FEV1) in individuals with persistent dyspnea following COVID-19. This study assessed the relationship between BMI and thoracic expansion, pulmonary symptoms, and exercise capacity following a home-based pulmonary rehabilitation intervention. A secondary data analysis was conducted with a sample of 19 adults with persistent dyspnea following COVID-19 infection who participated in a 12-week, home-based pulmonary rehabilitation study. Participants received expiratory muscle strength training devices and were instructed to perform pulmonary rehabilitation exercises three times per week over the study period. Pulmonary function, pulmonary symptoms, exercise capacity, and BMI measurements were collected. For analysis, study participants were divided into obese (BMI > 30 kg/m2) or nonobese (BMI < 30 kg/m2) categories. Correlations using the change scores from baseline to 12 weeks between thoracic expansion, FEV1, pulmonary symptoms, and exercise capacity were assessed. In addition, the minimal detectable change (MDC) in thoracic expansion was explored. Thoracic expansion was significantly improved after 12 weeks of training (p = .012) in the nonobese group. There was a significant correlation between the change in walking distance and pulmonary symptoms (r = -.738, p < .001) and in thoracic expansion (r = .544, p = .020), and walking distance, when controlling for BMI, but no change in FEV1. Average MDC was 1.28 for inspiration and 0.91 for expiration. Measurements of thoracic expansion were significantly lower in post-COVID individuals with an increased BMI. Individuals with persistent dyspnea and a higher BMI may require additional measures to increase chest mobility or to detect pulmonary changes following COVID-19.

Instrumental Assessment of Aero-Resistive Expiratory Muscle Strength Rehabilitation Devices.

Expiratory muscle strength training (EMST) is increasingly being used to treat voice, cough, and swallowing deficits in a wide range of conditions. However, a multitude of aero-resistive EMST models are commercially available, and the absence of side-by-side comparative data interferes with clinicians' ability to assess which model is best suited to a particular client's needs. The primary aim of this research was to test and compare the pressure and flow parameters of six currently available EMST models to help inform clinical decision making. We identified and tested five devices of each of six different EMST models to generate benchmark data for minimum trigger pressures across settings. The reliability was tested within each device and between five devices of the same model across settings using coefficient of variation. All six models required higher pressures to initiate flow at the highest setting compared to the lowest setting, as expected. Detailed descriptive statistics for each model/setting combination include average flow-triggering pressure for each model/setting and the variability across trials within a device and across devices of the same model. From these, ranked order of the least to most stable EMST model was derived. Systematic testing of several commercially available expiratory resistance training devices yielded clinical benchmarks and reliability data to aid clinicians in selecting an appropriate therapy device and regimen for a client based on their available airflow and air pressure as well as reliability of the device. These findings allow clinicians to directly compare key parameters across EMST devices.

Effect of Expiratory Muscle Strength Training on the Performance of Professional Male Trumpet Players.

Many trumpet players use breathing training devices in addition to their daily practice routine. Playing a brass instrument requires, besides many other skills, a controlled air stream to generate the necessary air pressures. On the trumpet, high intraoral pressures are needed, especially during high and loud notes. Therefore, it is not uncommon in trumpet pedagogy to teach that the use of breathing training devices enhances physical strength so that the required pressures can be produced with less effort. However, to date, no systematic assessment of the use of breathing training devices among trumpet players exists and their effect on playing performance is still unclear. In this a pre-post, within-subject repeated measure study, we investigated the influence of a 5-week expiratory muscle strength training (EMST) upon trumpet performance. Twenty-four male professional trumpet players were allocated to either a control or intervention group. The intervention group (n =13) trained with an EMST device against a set resistance of 55% of their maximum expiratory pressure (MEP) for 5 weeks on 5 days per week. The control group (n =11) did no intervention. All participants underwent the same measures (MEP and rate of perceived exertion [RPE]) and played the same tasks (maximum long note, maximum high note, maximum dynamics and phrasing in high register) prior to and after the 5 weeks. After EMST, MEP increased significantly (13%, p = 0.049) in the intervention group, whereas no significant change was found in the control group. Performance parameters did not change in either of the groups, also after EMST. Despite the increase in MEP, we found no evidence that EMST has an influence on trumpet performance. We conclude that EMST seems unnecessary for the enhancement of trumpet playing, at least in a population of male professionals who already demonstrate excellent respiratory condition and control.

Maximal Expiratory Pressure and Its Link With Cough Airflow Before and After Expiratory Muscle Strength Training in Parkinson's Disease

Purpose: Expiratory muscle strength training (EMST) improves maximal expiratory pressure (MEP), and several researchers have reported improvements to voluntary cough airflow in people with Parkinson's disease (PD). However, the link between the change in MEP and cough and whether patient-specific factors impact the training response is not well understood. Therefore, study aims were to examine (a) the relationship between MEP and cough pre- and post-EMST, (b) the associations between the change in MEP and change in cough, and (c) if patient-specific factors predict the change MEP. Method: This is a secondary analysis of data from 30 people with PD who completed MEP and voluntary and reflex cough testing via spirometry pre– and post–5 weeks of EMST. Pearson's r correlations were used for Aims 1 and 2. Multivariable linear regression was used for Aim 3. Results: Pre-EMST correlations between MEP and cough as well as correlations between the change in MEP and change in cough were nonsignificant. Post-EMST, MEP was correlated with voluntary cough expired volume (CEV, r = .58 , p &lt; .001), peak expiratory flow rate (PEFR, r = .56 , p = .001), and cough volume acceleration ( r = .47 , p = .009 ) , as well as reflex CEV ( r = .5, p = .005). Patient-specific factors did not predict the change in MEP. Conclusions: This study showed that there was a larger correlation between expiratory muscle strength and cough airflow post-EMST than pre-EMST for voluntary and reflex cough in PD; however, the correlation between the change was small. Future research is needed to identify additional physiologic changes that are impacting cough airflow after EMST. Supplemental Material: https://doi.org/10.23641/asha.24602565

Effectiveness of Expiratory Muscle Strength Training on Dysphagia Risk in Pre-Frail Elderly

Pre-frail dan frail elderly are susceptible to dysphagia. Dysphagia leads to vulnerability to aspiration pneumonia, undernutrition, and dehydration, which negatively affect physical condition and quality of life. Expiratory muscle strength training (EMST) is an intervention for dysphagia. However, the effects of EMST on pre-frail elderly are still unclear. This study aimed to investigate effectiveness of expiratory muscle training on dysphagia risk of pre-frail elderly. The study design was a randomized clinical trial. Twenty-four pre-frail elderly at Rindang Asih I and II Elderly Social Service Institution randomly assigned into experimental group (n=12) or control group (n=12). The experimental group received expiratory muscle training using PEP Threshold® device 5 times per week for 6 weeks. Both of group also received typical multicomponent exercise for elderly 3 times per week for 6 weeks. Outcome measure was risk of dysphagia assessed using Swallowing Disturbance Questionnaire (SDQ). The intra-group analysis showed significant differences pre- and post-intervention in experimental group but not in control group (p&lt;0,001 and p=0,107, respectively). Inter-group analysis showed significant differences between experimental and control group post-intervention (p&lt;0,001). This finding indicate that expiratory muscle training effective on reducing dysphagia risk in pre-frail elderly.

Effect of expiratory muscle strength training on voice and speech: An exploratory study in persons with Parkinson’s disease or multiple sclerosis

Purpose This study explored how respiration, voice, and speech were affected following expiratory muscle strength training (EMST) and maintenance training in persons with Parkinson’s disease (PD) or multiple sclerosis (MS). Method Nine participants with PD and six with MS participated in a randomised study, where the effects of EMST, sham, and maintenance treatment were investigated. Outcome measures included maximum expiratory pressure (MEP); maximum phonation time (MPT); intelligibility; verbal diadochokinesis (DDK); speech rate; a self-report form on voice, speech, and communication; and open questions about how the participants experienced the intervention. Group comparisons were performed within and between groups. Result The PD and the MS groups both improved significantly in MEP, and this improvement remained after 3 months of maintenance EMST. An improvement was also seen in DDK. Post-EMST, 33% of the PD group and 80% of the MS group reported a positive effect on communication. Conclusion The results of this study support previous evidence that EMST has positive effects on expiratory pressure in persons with PD or MS, but its effect on voice and speech remains unclear. Since subjective reports of the intervention and effects on communication were predominantly positive, further research is needed on larger groups to explore appropriate outcome measures.

Improvement in Swallowing Function in Patients with Previous Irradiation for Nasopharyngeal Carcinoma by Expiratory Muscle Strength Training.

Dysphagia and chronic aspiration are common post-irradiation complications in nasopharyngeal carcinoma (NPC) survivors. Expiratory Muscle Strength Training (EMST) is a simple device-driven exercise therapy for swallowing training. This study investigates the effectiveness of EMST in a group of post-irradiated NPC patients. This prospective cohort, including twelve patients with previous irradiation for NPC and with swallowing disturbance, was performed between 2019 and 2021 in a single institution. Patients were trained with EMST for 8weeks. Non-parametric analyses examined effects of EMST on primary outcome, maximum expiratory pressure. Secondary outcomes were measured with Penetration-aspiration scale, Yale pharyngeal residue severity rating scale (YPRSRS) by flexible endoscopic evaluation of swallowing, and Eating Assessment Tool (EAT-10) and M.D. Anderson Dysphagia Inventory questionnaire. Twelve patients, with a mean (SD) age of 64.3 (8.2) were recruited. There was no patient dropout with 88.9% overall compliance of training. Maximum expiratory pressure improved by 41% (median 94.5 to 133.5 cmH2O, p = 0.003). There was reduction in Penetration-aspiration scale with thin liquid (median 4 to 3, p = 0.026), and in YPRSRS at pyriform fossa with mildly thick liquid (p = 0.021) and at vallecula with thin liquid (p = 0.034), mildly thick liquid (p = 0.014) and pureed meat congee (p = 0.016). Questionnaire scores did not significantly change statistically. EMST is an easy-to-use and effective exercise therapy to improve airway safety and swallowing function in post-irradiated NPC survivors.

Expiratory Muscle Strength Training in Multiple System Atrophy: A Pilot Study.

The effects of expiratory muscle strength training (EMST) has not yet been investigated in MSA patients. The primary objective was to test the effects of EMST on expiratory muscle strength and voluntary peak cough flow (vPCF) in patients with multiple system atrophy (MSA). The secondary objective was to assess the suitability of the pulmonary dysfunction index as a tool for identifying MSA patients with expiratory muscle weakness and reduced voluntary peak cough flow. This was an open label, non-controlled study, with an 8-week intensive home-based EMST protocol. The outcome measures included: maximal expiratory pressure (MEP) and vPCF. The sensitivity and specificity of the index of pulmonary dysfunction in the respiratory diagnostic process were assessed using receiver operating characteristic (ROC) analysis. Fifteen MSA patients were enrolled in the study. Twelve MSA patients completed the training period. After the training period, MEP significantly increased (P = 0.006). Differences in vPCF were not significant (P = 0.845). ROC analysis indicated that the overall respiratory diagnostic accuracy of the index of pulmonary dysfunction had an outstanding capability to detect patients at risk of less effective coughing and an acceptable capability of detecting patients with decreased expiratory muscle strength. These findings indicate non-significant differences in vPCF after 8 weeks of EMST. The index of pulmonary dysfunction appears to be a promising prognostic screening tool for identifying altered cough efficacy in MSA patients. Test cut-offs may be used to select an appropriate respiratory physiotherapy technique.

Home-Based Pilot Pulmonary Program for Dyspneic Patients Post-COVID-19.

It is estimated that at least 10% of people who have had COVID-19 will experience ongoing symptoms such as shortness of breath, fatigue, and cognitive disturbances. Pulmonary exercise has demonstrated improved dyspnea outcomes in other respiratory conditions. Thus, the purpose of this study was to assess the efficacy of a home-based pulmonary rehabilitation program in post-COVID-19 survivors who continue to experience dyspnea. This was a longitudinal, single group pilot study in which 19 patients received a home-based expiratory muscle strength training program over 12 weeks. Outcomes measured at baseline, 6 weeks, and 12 weeks included pulmonary symptoms, functional performance, thoracic expansion, forced expiratory volume, and expiratory resistance measures. Significant improvements were found in pulmonary symptoms (p < .001), functional performance (p = .014), and progressive expiratory resistance capabilities (p < .001). A home-based pulmonary program may be an inexpensive strategy for post-COVID-19 survivors who continue to experience dyspnea.

Rehabilitation of Airway Protection in Individuals With Movement Disorders: A Telehealth Feasibility Study.

Airway protective deficits (swallowing and cough) greatly reduce health and quality of life and are a pervasive consequence of neurodegenerative movement disorders. Expiratory muscle strength training (EMST) and cough skill training (CST) are two treatment approaches to improve airway protection; however, many patients are unable to access these treatments. Telehealth may improve access to care, but it remains unknown whether these treatments are feasible and efficacious via telehealth. This study aimed to determine the practical feasibility and preliminary treatment effect of EMST and CST via telehealth. Twenty participants with movement disorders completed 4 weeks of EMST and 2 weeks of CST, including two clinician-directed treatment sessions via telehealth and 3 days of home practice per week. Feasibility was calculated for each treatment. Practical feasibility was defined as completing treatment (EMST or CST) and obtaining the relevant outcome measures-a proxy of maximum expiratory pressure (pMEP) for EMST and peak expiratory flow rate (PEFR) for CST-within a 30-min session/period. Session factors that may have influenced feasibility were examined. Preliminary treatment effect was defined as changes in pMEP and PEFR. Time taken to obtain pMEP and complete EMST was 17.48 min, and time taken to obtain PEFR and complete CST was 17.69 min. pMEP, single voluntary cough PEFR, and sequential voluntary cough PEFR increased from pre- to posttreatment. Findings suggest that the delivery of EMST and CST is feasible via telehealth and yield improvements to pMEP and PEFR. This has important implications for expanding service delivery of airway protective interventions and reducing health care disparities in people with neurodegenerative movement disorders. https://doi.org/10.23641/asha.21357669.

"Effects of an Expiratory Muscle Strength Training Method on Young Individuals and its Clinical Use"

"Effects of an Expiratory Muscle Strength Training Method on Young Individuals and its Clinical Use"

Expiratory Muscle Strength Training for Drooling in Adults with Parkinson’s Disease

One of the most debilitating symptoms of advanced Parkinson’s disease is drooling. Currently, the main treatment that is offered for drooling is botulinum toxin injections to the saliva glands which have a number of side effects and do not treat the causes of drooling, such as impaired swallowing and lip closure. This study explored the effect of an alternative therapy approach for drooling that aimed at improving the swallow, expiratory muscle strength training (EMST). Sixteen participants received EMST over a 6- to 8-week period. Measurements were taken pre- and post-training for drooling (Sialorrhea Clinical Scale for Parkinson’s Disease; SCS-PD), swallowing, lip strength and peak cough flow. Measures of drooling, swallowing and peak cough flow were stable over pre-training assessments and improved following training (p < 0.01). The most conservative estimate of the within-group change for SCS-PD was − 2.50 (95% confidence interval − 3.22 to − 1.22). No adverse effects were reported and participants gave high satisfaction ratings for the training. A programme of EMST offers promise as a therapy to reduce drooling for people with Parkinson’s disease. Adequately powered randomised controlled trials of EMST are now needed.

Possible Rehabilitation Procedures to Treat Sarcopenic Dysphagia.

Sarcopenic dysphagia requires the presence of both dysphagia and generalized sarcopenia. The causes of dysphagia, except for sarcopenia, are excluded. The treatment for sarcopenic dysphagia includes resistance training along with nutritional support; however, whether rehabilitation procedures are useful remains unclear. In this narrative review, we present possible rehabilitation procedures as a resistance training for managing sarcopenic dysphagia, including Shaker exercise, Mendelsohn maneuver, tongue-hold swallow exercise, jaw-opening exercise, swallow resistance exercise, lingual exercise, expiratory muscle strength training, neuromuscular electrical stimulation, and repetitive peripheral magnetic stimulation. We hope that some procedures mentioned in this article or new methods will be effective to treat sarcopenic dysphagia.

Behavioural Interventions in People with Oropharyngeal Dysphagia: A Systematic Review and Meta-Analysis of Randomised Clinical Trials.

Objective: To determine the effects of behavioural interventions in people with oropharyngeal dysphagia. Methods: Systematic literature searches were conducted to retrieve randomized controlled trials in four different databases (CINAHL, Embase, PsycINFO, and PubMed). The methodological quality of eligible articles was assessed using the Revised Cochrane risk-of-bias tool for randomised trials (RoB 2), after which meta-analyses were performed using a random-effects model. Results: A total of 37 studies were included. Overall, a significant, large pre-post interventions effect size was found. To compare different types of interventions, all behavioural interventions and conventional dysphagia treatment comparison groups were categorised into compensatory, rehabilitative, and combined compensatory and rehabilitative interventions. Overall, significant treatment effects were identified favouring behavioural interventions. In particular, large effect sizes were found when comparing rehabilitative interventions with no dysphagia treatment, and combined interventions with compensatory conventional dysphagia treatment. When comparing selected interventions versus conventional dysphagia treatment, significant, large effect sizes were found in favour of Shaker exercise, chin tuck against resistance exercise, and expiratory muscle strength training. Conclusions: Behavioural interventions show promising effects in people with oropharyngeal dysphagia. However, due to high heterogeneity between studies, generalisations of meta-analyses need to be interpreted with care.

Effectiveness of Interventions for Dysphagia in Parkinson Disease: A Systematic Review.

Purpose:Dysphagia is a common sequela of Parkinson disease (PD) and is associated with malnutrition, aspiration pneumonia, and mortality. This review article synthesized evidence regarding the effectiveness of interventions for dysphagia in PD.Method:Electronic searches were conducted in Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and speechBITE. Of the 2,015 articles identified, 26 met eligibility criteria: interventional or observational studies with at least five or more participants evaluating dysphagia interventions in adults with PD-related dysphagia, with outcomes measured using videofluoroscopic swallowing study (VFSS), fiberoptic endoscopic evaluation of swallowing (FEES), or electromyography (EMG). Risk of bias (RoB) was evaluated using the Evidence Project tool and predetermined criteria regarding the rigor of swallowing outcome measures.Results:Interventions were classified as follows: pharmacological (n = 11), neurostimulation (n = 8), and behavioral (n = 7). Primary outcome measures varied across studies, including swallowing timing, safety, and efficiency, and were measured using VFSS (n = 17), FEES (n = 6), and EMG (n = 4). Critical appraisal of study findings for RoB, methodological rigor, and transparency showed the majority of studies failed to adequately describe contrast media used, signal acquisition settings, and rater blinding to time point. Low certainty evidence generally suggested improved swallow timing with exercises with biofeedback and deep brain stimulation (DBS), improved safety with DBS and expiratory muscle strength training, and improved efficiency with the Lee Silverman Voice Treatment and levodopa.Conclusions:Studies with lower RoB and greater experimental rigor showed potential benefit in improving swallowing efficiency but not safety. Further research investigating discrete changes in swallowing pathophysiology post-intervention is warranted to guide dysphagia management in PD.Supplemental Material: https://doi.org/10.23641/asha.17132162

Clinical Practice Patterns of Speech-Language Pathologists Delivering Dysphagia Services to Persons with COPD: Analysis of Survey Outcomes.

Swallowing impairments co-occur with chronic obstructive pulmonary disease (COPD) leading to aspiration, disease exacerbations, and malnutrition. This pilot survey study aimed to identify current clinical practice patterns for swallowing evaluation and treatment in persons with COPD. A 35-question Qualtrics survey was deployed to medical speech-language pathology (SLP) social media sites and professional boards; flyers were distributed at a professional conference. Forty-eight SLPs completed the study. SLPs routinely include a clinical swallow examination (96%), videofluoroscopic swallowing study (79%), adjunctive respiratory measures (respiratory rate [83%], and pulse oximetry [67%], respiratory-swallow pattern [77%]) but less frequently include fiberoptic endoscopic evaluation of swallowing (23%). Self-reported advanced clinical experience and expert respiratory analysis skills were associated with adjunctive respiratory measure (respiratory rate, pulse oximetry) inclusion during assessment. Compensatory strategy training (77%) is a preferred treatment for dysphagia in COPD; however, respiratory-swallow pattern training and expiratory muscle strength training are increasing in use. SLPs self-report a comprehensive, individualized patient-centered care approach with inclusion of adjunctive respiratory-focused methods in dysphagia evaluation and treatment practice in persons with COPD. Advances in the identification of the integral role of respiratory function in swallowing integrity may be translating to clinical practice methods for dysphagia management in persons with COPD.

Multisite Implementation of the VA Intensive Dysphagia Treatment Program

<h3>Research Objectives</h3> To examine the effectiveness of a multimodal implementation strategy to improve patient care and adherence related to swallowing disorders by measuring adherence to recommended treatment protocols. <h3>Design</h3> Retrospective analysis of data entered by speech-language pathologists (SLPs) collected through a quality improvement program. <h3>Setting</h3> VA Primary Care Facilities. <h3>Participants</h3> 29 SLPs across 15 national VA facilities390 patients followed through a dysphagia treatment program. <h3>Interventions</h3> SLPs participated in a guided implementation process over 5 years consisting of a dedicated program manager, routine site calls to address implementation barriers, and a web-based centralized database allowing local data entry (VA REDCap).Patient participants were followed through an intensive dysphagia swallowing treatment program utilizing evidence-based Interventions: Lingual strengthening (LS) and expiratory muscle strength training (EMST). Patients received regular follow-up with SLPs who reported patient adherence to the recommended follow-up timeline. <h3>Main Outcome Measures</h3> SLP adherence was determined by number of visits entered in REDCap per patient as a percentage of prescribed number of visits for the given protocol.Patients were considered adherent if they 1) completed at least 2 follow-up appointments per their prescribed protocol and 2) completed a final visit at the end of the full exercise program (8 weeks for LS, 6 weeks for EMST). These criteria were used to calculate number of patients who were "adherent" versus "non-adherent". <h3>Results</h3> Since 2013, 390 patients have participated in the IDT program (338 LS, 52 EMST). Patient adherence was 64% (63% LS, 68% EMST). SLPs entered data for 85% of prescribed visits (84% LS, 87% EMST). Barriers to adherence noted during site calls included time required for data entry and inconsistent/inadequate staffing for follow-up visits. <h3>Conclusions</h3> These findings highlight an effective multimodal implementation strategy for investigators or healthcare systems interested in standardizing intensive dysphagia treatment across multiple sites. Overall, patient adherence levels regardless of therapy approach were higher than those reported in prior studies of adherence to dysphagia therapy. Future research will focus on developing behavioral or systems-based interventions targeting barriers underlying the remaining adherence gaps. <h3>Author(s) Disclosures</h3> No disclosures.

Severely disabled multiple sclerosis patients can achieve the performance of healthy subjects after expiratory muscle strength training

BackgroundThe efficacy of expiratory muscle strength training (EMST) in patients with multiple sclerosis (MS) is controversial. The current study's primary objective was to test the effects of a progressive and intensive 12 week home based EMST program on expiratory muscle strength and voluntary cough strength. The secondary objective was to determine the retention of EMST benefits. MethodsThirty-five severely disabled MS patients (relapsing-remitting MS, n = 15; primary progressive MS, n = 5; secondary progressive MS, n = 15) with Expanded Disability Status Scale (EDSS) 5.0 − 7.0 were included in the study. Within 36 weeks, patients completed 12 weeks of a non-training period, 12 weeks of EMST and 12 weeks of a detraining period. Maximal expiratory pressure (PEmax) and voluntary peak cough flow (vPCF) were assessed 4 times: at week 0 (baseline), week 12 (pre-training), week 24 (post-training), and week 36 (post-detraining). MS patients included in the study were compared to age- and sex-matched healthy subjects. In the healthy controls, the PEmax and vPCF were assessed once to obtain normative data. ResultsTwenty-six patients completed the training period (mean age 52.7 ± 10.2, EDSS 5.9 ± 0.6) and were compared to 26 sex- and age-matched healthy subjects (mean age 53.5 ± 5.8). Patients with MS had a lower PEmax (p = 0.002) and vPCF (p = 0.022) at baseline than the healthy control group. In training period, the PEmax and vPCF increased (p = 0.0000; effect size: d = 0.94 and p = 0.0036; d = 0.57 respectively) in comparison with the non-training period (p = 0.0692; d = -0.36 and p = 0.5810; d = 0.11 respectively). Following the 12 weeks detraining period, the PEmax and vPCF declined but remained 16.7% and 5.5% respectively above the pre-training values. No differences were observed in the PEmax and vPCF between the MS group at the post-training and post-detraining timepoint and the healthy control group normative values. ConclusionsEMST improves expiratory muscle strength and voluntary cough strength in severely disabled MS patients.

Expiratory Muscle Strength Training in Patients with Parkinson's Disease: A Pilot Study of Mobile Monitoring Application.

Expiratory muscle strength training (EMST) studies have reported significant improvements in maximum expiratory strength, cough efficacy, and swallowing function in patients with Parkinson's disease (PD).1 Currently, EMST is usually performed in short and intensive training periods.1 However, information about detraining outcomes highlights the need for the development of long-term maintenance home-based programs to sustain training gains following intensive periods of EMST, especially considering the progressive nature of PD.2 Nevertheless, low long-term adherence to home exercise is an important issue in many patient groups and may compromise treatment outcomes.3 Therefore, we developed a mobile phone-based visual feedback (MPVF) application to keep patients motivated to continue EMST following intensive periods of training. With the help of a specially developed algorithm, the application can evaluate real-time data using a microphone attached to an expiratory handheld device (Fig. 1). Supplement S1 provides detailed information about the algorithm. The first step in the research process of examining whether the feedback application is effective in long-term EMST adherence is to find out whether a MPVF application is suitable for patients with PD who may experience difficulties in using a smartphone due to motor and cognitive problems related to age and PD itself. Therefore, we conducted a pilot study to investigate the usability of MPVF in EMST in patients with PD. A total of 12 patients (Table S1) with PD performed an intensive home-based EMST with MPVF for 2 weeks. Peak cough flow, maximum expiratory pressure, and maximum inspiratory pressure were measured. The usability of the MPVF was also assessed using a semistructured interview. Supplement S2 provides detailed information about the methods. The median of adherence for completing the prescribed exercises in the training period was 90.5% (between 174 and 431 completed EMST maneuvers). A total of 2 weeks of intensive EMST were sufficient to significantly improve the participants' maximum expiratory pressure and voluntary peak cough flow (Table S2). The improvement is quantitatively comparable with the results of other intensive EMST studies with longer durations, for example.4, 5 When interpreting such rapid improvement, the impact of visual feedback should be considered. It can be assumed that visual feedback increased training effort compared with regular training without immediate control. All participants appreciated EMST with MPVF (12/12). They found it motivating (11/12), comprehensible (11/12), and user friendly (10/12). Even participants (n = 3) with mild cognitive impairment (Montreal Cognitive Assessment scores 24–25) who coincidentally had no previous experience with smartphones were able to use the application without difficulties or help from another person. With respect to the suggestions for improvement from a semistructured interview, the patients might be divided into 2 groups. The first group proposed simplifying the application as much as possible. The second group preferred more advanced options of presenting training data, such as in overview graphs and charts. To meet the needs of both groups, the application should be able to work in basic and advanced modes in the future. These findings indicate that EMST coupled with MPVF is feasible and potentially useful in patients with PD. We thank Tomas Sieger, PhD, from the Czech Technical University in Prague for his advice on the method of instantaneous sound level calculation. We also thank Ota Gal, PhD, from the Department of Neurology and Centre of Clinical Neuroscience, General University Hospital in Prague for manuscript review and critique. (1) Research Project: A. Conception, B. Organization, C. Execution; (2) Statistical Analysis: A. Design, B. Execution, C. Review and Critique; (3) Manuscript Preparation: A. Writing of the First Draft, B. Review and Critique. M.S.: 1A, 1B, 1C, 2A, 2B, 2C, 3A R. Korteová: 1A, 1B, 1C, 2C R. Kliment: 1A, 3A R.J.: 3B E.R.: 1A, 2C, 3B M.H.: 1A, 3B This study was approved by the Ethics Committee of the General University Hospital in Prague (No. 1613/19 S-IV). All participants signed an informed consent. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines. This work was supported by The EU Joint Programme–Neurodegenerative Disease Research 8F19003iCARE-PD and Ministry of Health of the Czech Republic Grants No NV19-04-00233 and NU20-04-0337. The authors declare that there are no conflicts of interest relevant to this work. The authors declare that there are no additional disclosures to report. Supplement S1 The MPVF algorithm. Supplement S2 The methods. Table S1 Demographic and clinical characteristics. Table S2 Median and interquartile range (IQR) of maximum respiratory pressure and voluntary cough values across pre- and posttesting time points. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Using Ultrasound to Document the Effects of Expiratory Muscle Strength Training (EMST) on the Geniohyoid Muscle.

Expiratory muscle strength training (EMST) is an exercise program designed to strengthen the muscles of expiration by increasing expiratory load during breathing exercises using either resistive or pressure threshold devices. Previous research has shown that EMST may increase submental suprahyoid muscle activity as measured with surface electromyography. The impact of EMST on submental muscles is of interest to those who treat dysphagia. The purpose of this study was to determine whether the cross-sectional area of the geniohyoid muscle changes as observed with ultrasound during a 5-week EMST program performed at 75% of maximum expiratory strength using the EMST150 device in healthy adults. Ten healthy adults participated in the 5-week program. Maximum expiratory pressure (MEP) and cross-sectional area of the geniohyoid muscle were measured weekly. Geniohyoid cross-sectional area was measured from ultrasound images recorded in the coronal plane. Repeated Measures ANOVA was used to determine whether there were significant changes among the dependent variables over the study period. Both MEP and geniohyoid area increased significantly in response to a 5-week program of EMST. EMST in healthy adults is effective at strengthening the geniohyoid muscle as reflected by significantly increased cross-sectional area measured with B-mode ultrasound. This is the first study to document weekly change in muscle morphology as a result of EMST. Increasing geniohyoid muscle mass and consequent strength through a program of EMST may be beneficial for persons with pharyngeal stage dysphagia resulting from reduced hyolaryngeal elevation, reduced laryngeal closure, or reduced UES opening.