The Safety, Tolerability, and Impact of Respiratory–Swallow Coordination Training and Expiratory Muscle Strength Training on Pulmonary, Cough, and Swallow Function Surrogates in Amyotrophic Lateral Sclerosis

Purpose This feasibility study examined the safety, tolerability, and impact of expiratory muscle strength training (EMST) combined with respiratory–swallow coordination training (RST) in comparison to EMST alone, and no treatment on pulmonary function, cough function, surrogates of swallow function, and diaphragm thickness in a pre–post small case series of people with amyotrophic lateral sclerosis (ALS). Method This prospective, nonrandomized, delayed intervention case series consisted of six people with ALS: three patients assigned to EMST + RST, two patients assigned to EMST only, and one patient who received no intervention. Patients undergoing treatment underwent a 5-week no-treatment lead-in period before undergoing their respective 5 weeks of treatment with an optional maintenance period for an additional 5 weeks ( n = 4). Primary outcome measures included pulmonary function measurements, scores on the Eating Assessment Tool-10 and Swallowing Related Quality of Life, and diaphragm thickness. Results Descriptive statistics were used to describe outcome measures and individual patient performance. Results revealed that EMST + RST was a safe and well-tolerated intervention, and that both respiratory interventions led to maintenance and improvement of some outcome measures in most patients within this small case series. Conclusion This exploratory study provides preliminary support regarding the tolerability and efficacy of a combined respiratory intervention in a small case series of people with ALS.

Expiratory Muscle Strength Training in patients After Total Laryngectomy; A Feasibility Pilot Study

Objectives: Expiratory muscle strength training (EMST) is a threshold based device-driven treatment for improving expiratory pressure. EMST proved to be effective in different patient groups to improve cough function. To date, EMST has not been tested in the total laryngectomy population (TL). Methods: This prospective, randomized case-series study examined feasibility, safety, and compliance of EMST in a group of TL participants and its effects on pulmonary function, physical exertion, fatigue, and vocal functioning. Ten TL participants were included in the study to perform a 4 till 8 weeks of EMST. Objective and subjective outcome measures included manometry, spirometry, cardio pulmonary exercise testing (CPET), voice recordings, and patient reported outcome measures. Group means were reported and estimates of the effect are shown with a 95% confidence interval, using single sample t-tests. Results: Nine participants completed the full study protocol. Compliance to the training program was high. All were able to perform the training, although it requires adjustments of the device and skills of the participants. Maximum expiratory pressure (MEP) and vocal functioning in loudness improved over time. After EMST no changes were seen in other objective and subjective outcomes. Conclusions: EMST appears to be feasible and safe after total laryngectomy. MEP improved over time but no improvement in the clinically relevant outcome measures were seen in this sample of relatively fit participants. Further investigation of the training in a larger group of participants who report specifically pulmonary complaints is recommended to investigate if the increase in MEP results in clinical benefits. Level of Evidence: 4

Effects of Expiratory Muscle Strength Training on Videofluoroscopic Measures of Swallowing: A Systematic Review

Purpose Expiratory muscle strength training (EMST) is increasingly utilized in dysphagia rehabilitation; however, little is known about the effects of this approach on swallowing function or physiology. We conducted a systematic review to appraise and synthesize evidence regarding the effects of EMST on videofluoroscopic measures of swallowing in individuals with medical diagnoses, in which dysphagia is a concern. Method A literature search was conducted according to Cochrane guidelines. Of 292 nonduplicate articles, 11 were judged to be relevant for review. These underwent detailed review for study quality, risk of bias evaluation, and synthesis of swallowing outcomes. Results The selected articles described EMST in a variety of patient populations using either the EMST150 or the Phillips Threshold positive expiratory pressure device. The typical protocol involved five sets of five breaths through the device (25 breaths/day), 5 days per week for 4 weeks. Exercise loads were set between 50% and 75% depending on the population, and treatment was typically supervised by a clinician weekly. The Penetration–Aspiration Scale was the most commonly reported videofluoroscopic outcome measure. Conclusions differed as to whether or not swallowing improved following a course of EMST. Differences in videofluoroscopy protocols, methods of summarizing participant performance, and statistical approaches across studies meant that meta-analysis of swallowing outcomes could not be completed. Conclusion This review failed to find clear evidence regarding the effects of EMST on videofluoroscopic measures of swallowing. Heterogeneity in the etiologies and baseline severity of dysphagia across studies and in the methods used to measure swallowing outcomes was a particular barrier to data synthesis.