Breathing Untrained Trained Support Diaphragm Healthy Unhealthy

Intervention Proof of Concept

Respiratory Muscle Strength Training Since about 1999 PD SCI MS Children Elderly Spinal Muscle Atrophy Bilateral Paralysis ALS Paradoxical VF Dysfunction Safety COPD

Pressure, Flow, Voice

Intervention What is it? What is it not? Who can it be used with? Outcomes: Case, Group, and Randomized trials CoMorbidities Protocol Maintenance

Respiratory Muscle Strength Training (RMST) The process of building strength within muscle groups Two Types: Inspiratory Muscle Strength Training (IMST) Diaphragm External intercostals Expiratory muscle strength training (EMST) Abdominals Internal intercostals

Question: Which Direction? Problem? Purpose? Desired Outcome? MIP or MEP?

Overload & Specificity Training must“overload” the system/muscle type Low Load Overload

Result: Adaptations Neural adaptations (6-8 weeks) Strength Time Neural adaptations (6-8 weeks) Myogenic adaptations (+ 5 weeks) Neural adaptations Hypertrophy Strength Progress (Modified from Sale, 1988)

Multiple Functions have Been Studied

What is a RMST? General “breathing exercisers” Resistive trainers – is there a difference? Pressure threshold trainers

EMST? Pressure‑threshold device 4 week program 5 days per week 25 breaths per day Load set at 75% of MEP Describe the program – how you use the device etc. Calibrated deivce consisting of a mouthpiece with a one-way spring-loaded valve against adjustable spring. As long as the threshold pressure is maintained, as air flows through the device. Does not allow for modification of flow rate. Although it primary targ et of this exercise is the expiratory muscles – other biomechanical events spedific to swallow have been observed. Expiratory pressure threshold training: Pressure‑threshold device Calibrated, one way, spring-loaded valve Not resistance training (physiological load calibrated and imposed) Target muscles: expiratory (abdominals) and supralaryngeal

What is the setting? Adjustable Valve Mouthpiece Loaded Spring

Provides specific, constant, pressure load (spring loaded valve 0-150 cm/H20)

Recommendations for Training (EMST) Presentation Information Recommendations for Training (EMST) Twice daily exercise in all studies Daily or every other day Most studies used an overload principle Specificity of training observed with some carry-over noted 5 weeks to 3 months of training resulted in increased respiratory muscle strength The same exercise principles that are true of exercise with limb muscles are true of muscles of respiration. CONFIDENTIAL 15

Time to Do Your Training

Time to Train Training manual included Video online Very simple to use Very instrumental feeling