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.