Respiratory Muscle Strength Training (RMST) Notes

Respiratory Muscle Strength Training (RMST)

Introduction

  • Professor Meslanik and Stacy Castle presented on RMST at Dijeshia.
  • Professor Meslanik needed a respiratory muscle strength trainer.
  • RMST can lead to amazing outcomes.

Rationale and Evidence

  • The presentation will cover the rationale and evidence-based data for RMST.
  • Nugitia donates respiratory muscle strength trainers for conferences.
  • RMST is not a one-size-fits-all approach; it is important to determine indications and contraindications based on the individual and their specific diagnosis.

Indications and Contraindications

  • RMST with ALS patient: Probably not.

  • RMST with Parkinson's patient: Probably OK.

    • Personal data collection needed because it's very person-specific.

    • ALS: Focus on conservation of energy and compensation (not really appropriate).

    • Parkinson's: Focus on intention (neurologically shifts the brain); Speak Out therapy may be better.

      • Speak Out rationale = Intention.
      • ALS rationale = conservation of energy and compensation for what you don't have.

Breathing

  • Inspiration = Inhalation

  • Expiration = Exhalation

  • Diaphragmatic Breathing.

    • How to teach diaphragmatic breathing.

      • Biggest trick for teaching people to diaphragmatically breathe is as hard if you don't know how to do it.
      • Contract abdominal muscles in and out to feel the movement.
      • Breathe in and stick stomach out; breathe out and pull everything in.

    • Diaphragmatic Breathing Importance.

      • Most singers have muscle tension dysphonia because they're getting all their energy from up here when they talk and are not utilizing diaphragmatic breathing.
      • Most of us talk a combination.
      • When you're a lecturer or use your voice as a singer, you want to be employing diaphragmatic breathing methods.
      • What we don't wanna be doing as a speaker is tensing this stuff. We really do wanna be trying to breathe a little deeper, so…

Common Sense and Learning

  • Higher education studies show that giving students the test first helps them learn better (Doctor Hernandez principle).

Definition and Rationale for RMST

  • Respiratory Muscle Strength Training (RMST) is a treatment strategy aimed at strengthening the muscles of respiration by increasing their force-generating capacity.

  • Helps people with:

    • Dysphagia

    • Dystonia

    • Dyspnea (disordered breathing)

    • Cough strength is imperative for clearing secretions.

      • Dystussia (cough)

  • Instrumentalists, professional voice users, and athletes can also benefit.

  • SLPs maximize swallow, voice, and cough (SVC) abilities, resulting in better voicing and swallowing.

Resistance-Based vs. Pressure Threshold-Based RMST Devices

  • Resistance-based devices target respiration by adjusting the size of an orifice (hole).

    • Smaller diameter opposes more resistance, requiring increased respiratory muscle force.

  • Pressure threshold-based devices use a calibrated device with a spring-loaded valve and adjustable external dial.

    • EMST 150 by Aspire is an example.

Examples of Devices

  • Resistance-based:

    • The Breather
    • Power Lung (less common)
    • Power Breathe (mostly in the UK)

  • The Breather is preferred because it targets both expiration and inspiration and is more cost-effective.

The Breather

  • First drug-free, evidence-based respiratory muscle training device.
  • Designed for patients with COPD, CHF, dysphagia, stroke, hypertension, Parkinson's, and neuromuscular disease.
  • Improves respiratory muscle weakness, dyspnea, quality of life, and speech/swallow performance.
  • Invented by Peggy Nicholson in 1980.
  • New model redesigned for patients with poor hand strength.
  • Inspiratory and expiratory dials range from -50 cm to +55 cm of water pressure.
  • High patient compliance due to felt quality of life improvements.
  • Evidence-based results include increased MIP/MEP, improved oxygen saturation, reduced hyperinflation.
  • MIP/MEP = Max pressure in/ Max pressure out.
  • Improves pharyngeal function for speech and swallowing.
  • Improves delivery and distribution of inhaled medication.
  • Leads to faster weaning from mechanical ventilation, shorter length of stay, and lowered probability of hospital readmissions.

Pressure Threshold-Based Example: EMST 150

  • Challenges expiratory muscles more than the 75 model.
  • Operates using a spring inside a valve.
  • Turning the cap compresses the spring, making it harder to push open.
  • Device is calibrated to produce a specific pressure load.
  • Subject must participate to achieve the pressure stimulus needed for strength.
  • Initial stages of using this, pressure threshold based ones like this one had a lot more research. Now the breeder's kinda catching up: because it does both, I'm kinda leaning towards that one more.

Muscles Targeted by RMST

  • Abdominal and internal intercostal muscles in the chest cavity
  • Submental muscles under the chin (crucial for laryngeal elevation and excursion)
  • Muscles that move the vocal folds
  • Muscles of the pharynx, larynx, and soft palate

Respiratory Pressures

  • Measured in centimeters of water
  • Speech: 5-10 cm of water
  • Cough: 100-200 cm of water
  • Bowel movement: 200-300 cm of water
  • Devices vary: 0-150 (EMST 150), 0-75 (EMST 75)

Inspiratory vs. Expiratory

  • Inspiratory:

    • Targets inhalation
    • Aids vent weaning
    • Good for tracheostomy patients
    • Helps shortness of breath due to COPD, emphysema, asthma.
    • Increases lung volumes and improves vocal fold opening.

  • Expiratory:

    • Targets exhalation
    • Focuses on swallowing and cough force increase
    • Improves vocal fold closure
    • Improves phlegm and mucus management
    • Improves diaphragmatic weakness

Using the EMST 150

  • Adjust the spring to the proper tension.

    • Turning the valve clockwise makes it more difficult to exhale.
    • Turning the valve counterclockwise makes it easier.

  • Insert the mouthpiece into the EMST; interchangeable mouthpieces are available.

  • Determine maximum expiratory strength:

    • Place nose clip on nose or hold nose closed.
    • Turn the blue knob until the screw lines up with 30.
    • Take a deep breath, insert the mouthpiece, and make a tight lip seal.
    • Blow hard and fast through the device until air rushes through, then stops.
    • Increase the resistance by turning the knob clockwise one-quarter turn and repeat.
    • Continue until you cannot move any air through.

Training Protocol

  • Think "five": five sets of exercises, five days a week, for five weeks.
  • Start with the least amount of resistance and increase by small increments.
  • Rest for about five minutes between trials to allow expiratory muscles to recover.
  • Initial stages of using this, pressure threshold based ones like this one had a lot more research. Now the breeder's kinda catching up: because it does both, I'm kinda leaning towards that one more.

Considerations and Contraindications

  • High blood pressure, recent head and neck surgery.
  • People use the line rather than the number: if the screw is kind of at the level of the line, that's how I measure it. When it's flush on it, that's like I'm on 90 now. Does that make sense?

Adjusting Protocols

  • Remember to consider these thoughts when personalizing the equipment for the patient.

Contraindications for RMST

  • Pregnancy
  • Uncontrolled hypertension (always get doctor clearance)
  • Recent head and neck surgery
  • GERD (reflux disease)
  • Hiatal hernias
  • Severe secretions
  • Recent cardiac/thoracic surgery
  • Arrhythmias

IMST with Vent and Trach Patients

  • Has superior outcomes.

Inclusion Criteria Summary:

  • Patient must be:

    • medically stable
    • have a decent cognitive status
    • and have tolerated the PMV well.

  • Ventilator settings should be:

    • FiO2 of 50% or less
    • PEEP of 10 or less

  • Working with respiratory therapy is important.

Neuroplasticity with RMST

  • Retrains neural pathways to perform better; targets voice, swallow, and cough triad.

Research Highlights

  • Parkinson's disease: Increases expiratory pressures related to muscle strength; helps voluntary cough.
  • Subacute stroke patients: Reduces pulmonary complications and need for PEGs.
  • Voice users: Improves patient's self-perception of voice.
  • Helps people that have penetration and aspiration.

Emerging ALS Research Considerations:

  • Whole-body exercise and RMT are safe and well-tolerated, but research is still emerging.
  • FEAST sensory testing in ALS patients: tests if they can sense to aspirate because ALS causes deterioration of the ability to cough immediately.