1. ISHA Membership Campaign
Post cards are available at the Registration Table!
Prizes awarded to top recruiters!
This slide is for conference presenters who are already ISHA members.
You are NOT required to show this slide or discuss this topic during your presentation! We have provided it for those who would like to promote the Membership Campaign before or after their session. If you choose to use this slide, we have included some sample verbiage below. Do not feel obligated to read it to your audience verbatim! You can say whatever you feel comfortable saying as you promote ISHA membership – speaking from the heart is always best! We thank you for any and all efforts to help us with this campaign. Again, you are NOT required to mention the Membership Campaign as part of your presentation, but if you choose to do so, we hope you’ll find this slide and the accompanying sample verbiage helpful. If you have questions, please contact Beth Browning, ISHA VP of Marketing at or (317)
After you’ve been introduced by the moderator, you can begin your presentation by showing this slide and saying something like…
(SAMPLE VERBIAGE) “Welcome everyone! I would like to start my presentation by encouraging you to become an ISHA member. If you are already a member, I encourage you to recruit your colleagues and friends to become members too. Unfortunately, ISHA membership has dwindled in recent years and we now have a mere 25% of all licensed SLPs and AUDs in Indiana who belong to this organization! That is shocking and sad! ISHA exists because of its members. Without sufficient membership, they cannot advocate for our professions at the state level. This is critical because ASHA cannot fight our state battles for us! There are bills being proposed at the State Capitol all the time that could potentially affect our profession – either directly or indirectly – and we must have a unified voice to protect our professional integrity! Remember several years ago when school psychologists didn’t want SLPs to use certain assessment protocols – even ones authored by SLPs?! ISHA fought that and won! What about when OTs wanted to provide swallowing services, which is outside of their scope of practice? ISHA fought that and won too! What about the unreasonably high caseload sizes we have right now which are affecting the schools’ ability to hire SLPs? This is something our membership has been begging for, but ISHA cannot put up a fight with only 25% of licensed professionals maintaining membership! There are many reasons to join ISHA beyond legislative advocacy such as lifelong professional networks, continuing education opportunities, and public awareness of how we make a difference in people’s lives. If you haven’t already, please grab some post cards at the Registration Table to help us recruit more ISHA members. These are not designed for mailing but for sharing, one-on-one, with your colleagues and friends. Prizes are being awarded to the top recruiters, but the best prize is knowing that you are helping secure the future of our professions in the state of Indiana. Thank you.”
Legislative Advocacy!
Professional Networks!
Continuing Education!
Public Awareness!

2. Respiratory Muscle Strength Training: EMST vs. IMST
Rebecca Miles Risser, M.M.,M.A., CCC-SLP
Co-President, Indiana Voice & Dysphagia Network
Director of Speech Pathology, Voice Specialist
The Voice Clinic of Indiana
1185 W Carmel Drive, Suite D1-A
Carmel, IN

3. The exchange of oxygen from the environment for carbon dioxide from the body’s cells.
What is Respiration?

4. Respiratory Tract

5. Muscles of Inhalation

6. Muscles of Exhalation

7. Atmospheric Pressure always = 0. Alveolar Pressure (air within alveoli) . Al. pressure < At. pressure = inhalation. Al. pressure > At. pressure = exhalation.

8. Alveolar pressure can be changed by two forces: Passive and Active Respiratory Movement
Passive Respiratory Force
Elastic Properties of Respiratory System
Expiration may be active or passive
Active Respiratory Force
Contraction of respiratory muscles
INSPIRATION IS ALWAYS ACTIVE
Insp: Diaphragm, external intercostals increase lung volume.
Active Exp: any muscle that actively pulls chest wall down that adds to passive recoil– abdominal muscles, internal intercostals.

9. Respiratory Muscle Weakness in our patients.
We have two obligations to our dyspneic patients:
The importance of their understanding of known disease on upper or lower respiratory function.
Make sure causative factors - i.e. heart disease, lung disease – have been ruled out.
Low muscle tone (i.e. spinal cord injury and neuromuscular degenerative diseases) may result in disability to generate enough muscular force to create subglottic pressure (i.e: active expiratory pressure) to create volume or vary frequency in the voice.

10. Upper vs. Lower Respiratory Function
Upper Respiratory:
VCD/EILO
AdSD
MTD
Static laryngeal conditions (bilateral ad. paralysis, web, arytenoid dislocation)
Lower Respiratory:
Asthma, COPD, RAD
Must be under the care of Pulmonology, etc.

11. What’s the goal of RMST? Goal:
Increase the force generating capacity of the inspiratory or expiratory muscles.
Improve the function of respiratory muscles through specific, though not task specific, exercise.

12. How does this work? Muscle Overload High frequency, High resistance.
70-75% of either Maximum Expiratory Pressure (MEP) or Maximum Inspiratory Pressure (MIP)
25 x daily
Typically, sustained for 1-2 seconds each trial.
Overall, typically less intrathoracic, intracranial pressure than produced during bowel movement.

13. What changed? NEURAL CHANGES MYOGENIC CHANGES
Peripheral – level of the motor unit
Central – level of spinal cord or brainstem (sensory nerves)
Cortical – cortical map area (synapses, etc.)
MYOGENIC CHANGES
Muscular hypertrophy
Fiber type changes

14. Neural changes Neural changes occur earlier than muscular changes.
Endurance training results in increased blood flow and angiogenesis with the motor cortex.
Increased muscle activation
Cortical mapping adaptations in sensory nerves, cortical thickness, and angiogenesis.

15. Myogenic changes Increase in oxidative capacity in trained muscles
(Oxidative capacity refers to the muscle’s maximal capacity to use oxygen in microliters of O2 per gram per hour.)
Skeletal muscles (all respiratory muscles) are made of both slow twitch or fast twitch muscle fibers.
Slow: slow to contract but very resistant to fatigue. (i.e. posture)
Fast: fast to contract with great force, but prone to fatigue (i.e. cough).
All muscles have a combination, depending on function.
RMST stimulates fast twitch resulting in muscular enlargement or “hypertrophy”.

16. Increases as a result of RMST
Expiratory:
Increases in MEP “significantly” within 2 weeks of training.
MEP increases of up to 50% or more at 4 weeks of training.
Inspiratory:
MIP also increased, similarly to MEP.
Also, synergy noted between training inspiratory muscle strength and PCA.
Results: very small changes in glottic opening, but BIG changes in the sensation of SOB/obstruction.

17. “Detraining” Detraining:
Skeletal muscle size will return to pre-training levels within 1 month of exercise cessation.
HOWEVER, respiratory muscle gains remain significantly higher than pre-training levels up to 8 weeks after training cessation.

18. candidates for RMST

19. Research into populations that benefit
Healthy Athletes
Professional Voice Users
COPD
Asthma
Aging
Arthritis
Cardio Pulmonary Disease
CHF
Diaphragmatic Paralysis MS
Post polio syndrome
Spinal cord injury
Ventilator dependent
Dysphagia
Presbyphonia
Parkinson’s Disease
Bilateral VF Paralysis
VCD/ELIO
Obesity
Myasthenia Gravis
ALS
Cystic Fibrosis
Duchenne Muscular Dystrophy
Myotonic Dystrophy
Instrumentalists
Singers

20. Breathing RMST has shown
significant and progressive improvements in MIP and MEP
reduction in the perception of dyspnea.

21. Cough
Weakness in forced inhalatory or forced expiratory muscles reduce ability to build up necessary air pressures and velocity.
Increased MIP increases lung volume.
Increased MEP increases high velocity of expiratory flow.

22. Swallow Improved cough to reduce aspirated materials
Improved pharyngeal swallow
Increased submental muscle force generation, so therefore, increased hyolaryngeal complex movement (airway protection, UES opening)

23. Speech Increases subglottic pressure
Increases synergy between diaphragm and PCA
“THINK LOUD, THINK SHOUT” – Loud voicing stimulates improved articulation, and other muscles controlling speech in some neurogenic populations.

24. RMST by diagnostics IMST EMST General Exercise COPD Singers
Diaphragmatic Paralysis
Navy Divers
Obesity
Young and healthy
Upper Airway Limitation (PVFM/VCD/EILO)
Sedentary Elderly
ALS
Spinal cord injury
Myasthenia Gravis MS
Cystic Fibrosis
Myotonic Dystrophy
Duchenne Muscular Dystrophy PD
Cardiopulmonary Disease
Pompe Syndrome
Military Personnel
Spinal Cord Injury
Professional Voice Users
Asthma
Instrumentalists

25. Evaluation MicroRPM Respiratory Pressure Level Meter

26. Norms: Inspiratory Strength
Wilson, Cooke, Edwards, & Spiro (1984)
Men: 106 cm H20
Women: 73 cm H20
Boys: 75 cm H20
Girls: 63 cm H20

27. Norms: Expiratory Strength
Wilson, Cooke, Edwards, & Spiro (1984
Men: 148 cm H20
Women: 93 cm H20
Boys: 96 cm H20
Girls: 80 cm H20

28. Respironics (could be good for deconditioned patients
Respiratory Trainers
IMST
Powerbreathe
IMST
Respironics (could be good for deconditioned patients

29. Respiratory Trainers
Both IMST & EMST
Powerlung
EMST
EMST-150

30. The Indiana Voice and Dysphagia Network
Fall Meeting: September , The Performing Arts Center, Carmel

31. Come see us at The Voice Clinic of Indiana!