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Despite the high estimated prevalence of dysphagia in OSA, there is a paucity of evidence supporting behavioral interventions for treatment. The purpose of this study was to assess the impact of expiratory muscle strength training (EMST) on validated, standardized metrics of swallow and airway clearance capacity functions in moderate-to-severe OSA. 10 participants with OSA (mean age = 65.2 years) completed four weeks of EMST training employing a prospective single-arm, double-baseline interventional design. The Modified Barium Swallow Impairment Profile (MBSImP) Component and Composite (Oral Total [OT] and Pharyngeal Total [PT]) scores measured swallow physiology. Airway clearance capacity measures included maximum expiratory pressure (MEP) and peak cough flow (PCF). A historical normative database was used for OSA patient comparison of swallowing metrics. A total of 234 swallows were analyzed. At baseline, impairments in lingual control, oral residue and esophageal clearance were observed. However, no significant differences in the MBSImP Composite (OT/PT) scores were observed between the OSA and healthy referent group. After EMST intervention, there were no significant differences in pre- to post-intervention Composite (OT/PT) scores. However, large effect size was observed for MEP (p < 0.001, d = 3.0), and non-significant, but moderate effect size was observed in PCF (p = 0.19, d = 0.44). Study findings further quantify swallowing in moderate-to-severe OSA and provide preliminary evidence supporting the impact of EMST on airway clearance capacity.

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Dyspnea secondary to lung impairment can persist following the acute phase of COVID-19. Thoracic expansion measurements have been used as a diagnostic tool to evaluate chest wall mobility, respiratory function, and the effects of respiratory muscle strength training. Changes in chest wall mobility may occur because of altered chest biomechanics in individuals with respiratory diseases and an elevated body mass index (BMI). The purpose of this secondary analysis was to evaluate whether BMI influences thoracic expansion or forced expiratory volume over 1 second (FEV1) in individuals with persistent dyspnea following COVID-19. This study assessed the relationship between BMI and thoracic expansion, pulmonary symptoms, and exercise capacity following a home-based pulmonary rehabilitation intervention. A secondary data analysis was conducted with a sample of 19 adults with persistent dyspnea following COVID-19 infection who participated in a 12-week, home-based pulmonary rehabilitation study. Participants received expiratory muscle strength training devices and were instructed to perform pulmonary rehabilitation exercises three times per week over the study period. Pulmonary function, pulmonary symptoms, exercise capacity, and BMI measurements were collected. For analysis, study participants were divided into obese (BMI > 30 kg/m2) or nonobese (BMI < 30 kg/m2) categories. Correlations using the change scores from baseline to 12 weeks between thoracic expansion, FEV1, pulmonary symptoms, and exercise capacity were assessed. In addition, the minimal detectable change (MDC) in thoracic expansion was explored. Thoracic expansion was significantly improved after 12 weeks of training (p = .012) in the nonobese group. There was a significant correlation between the change in walking distance and pulmonary symptoms (r = -.738, p < .001) and in thoracic expansion (r = .544, p = .020), and walking distance, when controlling for BMI, but no change in FEV1. Average MDC was 1.28 for inspiration and 0.91 for expiration. Measurements of thoracic expansion were significantly lower in post-COVID individuals with an increased BMI. Individuals with persistent dyspnea and a higher BMI may require additional measures to increase chest mobility or to detect pulmonary changes following COVID-19.

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OBJECTIVE: Expiratory muscle strength training (EMST) and sensorimotor training of airway protection (smTAP) are two exercises intended to improve cough and swallowing in people with Parkinson's Disease (PwPD). The aims of this study were to (1) examine whether EMST or smTAP elicit changes to vocal fold bowing; and (2) describe the safety of EMST and smTAP as it relates to the development of vocal fold lesions. METHOD(S): This was a secondary analysis of data from PwPD who completed EMST or smTAP as part of a prospective randomized controlled trial. Vocal fold bowing (BI) and the presence of laryngeal lesions were blindly analyzed from flexible endoscopic evaluation of swallowing (FEES) using ImageJ software and operational definitions. Linear regression was used to examine the influence time (pre- vs. post-therapy) and therapy (EMST vs. smTAP) on vocal fold bowing. Descriptive statistics were used to describe the presence of laryngeal lesions. RESULT(S): Overall, 56 participants were included, 28 per group. The median BI scores pre- and post-therapy were 8.2% and 8.3% for the EMST group and 11.3% and 8.4% for the smTAP group, respectively. Statistical analyses revealed insufficient evidence to suggest an effect of time and treatment type on BI (p > 0.05) or on the presence of vocal fold lesions (p > 0.05). CONCLUSION: Based on these and previous findings, it appears that changes in vocal fold bowing do not drive treatment effects following EMST and smTAP. Also, this study further supports the safety of smTAP and EMST despite the required forceful exhalation and repetitive coughing. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1127-1132, 2024.

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Dysphagia and chronic aspiration are common post-irradiation complications in nasopharyngeal carcinoma (NPC) survivors. Expiratory Muscle Strength Training (EMST) is a simple device-driven exercise therapy for swallowing training. This study investigates the effectiveness of EMST in a group of post-irradiated NPC patients. This prospective cohort, including twelve patients with previous irradiation for NPC and with swallowing disturbance, was performed between 2019 and 2021 in a single institution. Patients were trained with EMST for 8 weeks. Non-parametric analyses examined effects of EMST on primary outcome, maximum expiratory pressure. Secondary outcomes were measured with Penetration-aspiration scale, Yale pharyngeal residue severity rating scale (YPRSRS) by flexible endoscopic evaluation of swallowing, and Eating Assessment Tool (EAT-10) and M.D. Anderson Dysphagia Inventory questionnaire. Twelve patients, with a mean (SD) age of 64.3 (8.2) were recruited. There was no patient dropout with 88.9% overall compliance of training. Maximum expiratory pressure improved by 41% (median 94.5 to 133.5 cmH2O, p = 0.003). There was reduction in Penetration-aspiration scale with thin liquid (median 4 to 3, p = 0.026), and in YPRSRS at pyriform fossa with mildly thick liquid (p = 0.021) and at vallecula with thin liquid (p = 0.034), mildly thick liquid (p = 0.014) and pureed meat congee (p = 0.016). Questionnaire scores did not significantly change statistically. EMST is an easy-to-use and effective exercise therapy to improve airway safety and swallowing function in post-irradiated NPC survivors.

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PURPOSE: This study explored how respiration, voice, and speech were affected following expiratory muscle strength training (EMST) and maintenance training in persons with Parkinson's disease (PD) or multiple sclerosis (MS). METHOD: Nine participants with PD and six with MS participated in a randomised study, where the effects of EMST, sham, and maintenance treatment were investigated. Outcome measures included maximum expiratory pressure (MEP); maximum phonation time (MPT); intelligibility; verbal diadochokinesis (DDK); speech rate; a self-report form on voice, speech, and communication; and open questions about how the participants experienced the intervention. Group comparisons were performed within and between groups. RESULT: The PD and the MS groups both improved significantly in MEP, and this improvement remained after 3 months of maintenance EMST. An improvement was also seen in DDK. Post-EMST, 33% of the PD group and 80% of the MS group reported a positive effect on communication. CONCLUSION: The results of this study support previous evidence that EMST has positive effects on expiratory pressure in persons with PD or MS, but its effect on voice and speech remains unclear. Since subjective reports of the intervention and effects on communication were predominantly positive, further research is needed on larger groups to explore appropriate outcome measures.

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Background: The effects of expiratory muscle strength training (EMST) has not yet been investigated in MSA patients. Objective: The primary objective was to test the effects of EMST on expiratory muscle strength and voluntary peak cough flow (vPCF) in patients with multiple system atrophy (MSA). The secondary objective was to assess the suitability of the pulmonary dysfunction index as a tool for identifying MSA patients with expiratory muscle weakness and reduced voluntary peak cough flow. Methods: This was an open label, non-controlled study, with an 8-week intensive home-based EMST protocol. The outcome measures included: maximal expiratory pressure (MEP) and vPCF. The sensitivity and specificity of the index of pulmonary dysfunction in the respiratory diagnostic process were assessed using receiver operating characteristic (ROC) analysis. Results: Fifteen MSA patients were enrolled in the study. Twelve MSA patients completed the training period. After the training period, MEP significantly increased (P = 0.006). Differences in vPCF were not significant (P = 0.845). ROC analysis indicated that the overall respiratory diagnostic accuracy of the index of pulmonary dysfunction had an outstanding capability to detect patients at risk of less effective coughing and an acceptable capability of detecting patients with decreased expiratory muscle strength. Conclusions: These findings indicate non-significant differences in vPCF after 8 weeks of EMST. The index of pulmonary dysfunction appears to be a promising prognostic screening tool for identifying altered cough efficacy in MSA patients. Test cut-offs may be used to select an appropriate respiratory physiotherapy technique.

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It is estimated that at least 10% of people who have had COVID-19 will experience ongoing symptoms such as shortness of breath, fatigue, and cognitive disturbances. Pulmonary exercise has demonstrated improved dyspnea outcomes in other respiratory conditions. Thus, the purpose of this study was to assess the efficacy of a home-based pulmonary rehabilitation program in post-COVID-19 survivors who continue to experience dyspnea. This was a longitudinal, single group pilot study in which 19 patients received a home-based expiratory muscle strength training program over 12 weeks. Outcomes measured at baseline, 6 weeks, and 12 weeks included pulmonary symptoms, functional performance, thoracic expansion, forced expiratory volume, and expiratory resistance measures. Significant improvements were found in pulmonary symptoms (p < .001), functional performance (p = .014), and progressive expiratory resistance capabilities (p < .001). A home-based pulmonary program may be an inexpensive strategy for post-COVID-19 survivors who continue to experience dyspnea.

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BACKGROUND: The effects of expiratory muscle strength training (EMST) with different intensity on stages of sleep were not examined in patients with obstructive sleep apnea syndrome (OSAS). OBJECTIVES: The aim of this study was to compare the effects of high- and low-intensity EMST (H-EMST and L-EMST) on disease severity, sleep stages, disease-related symptoms, daytime sleepiness, fatigue severity, and sleep quality in adult patients with severe OSAS using non-invasive mechanical ventilation (NIMV). METHODS: Thirty-one clinically stable patients with severe OSAS were included in this prospective, randomized controlled, double-blinded study. These were randomly divided into two groups. The H-EMST group underwent training at 60% of maximum expiratory pressure (MEP) and the L-EMST group at 30% of MEP, seven days a week for eight weeks. Apnea hypopnea index (AHI), sleep stages, and respiratory sleep parameters were recorded using polysomnographic sleep analysis. RESULTS: AHI decreased by 34.57% and 20.20% in the H-EMST and L-EMST groups, respectively. A statistically significant improvement in disease severity classifications distributions was observed in the H-EMST group after training (p = 0.016). A greater number of symptoms improved in the H-EMST. The effects of training on respiratory muscle strength, daytime sleepiness, fatigue perception, and sleep quality levels were comparable between the two groups (p>0.05). CONCLUSIONS: H-EMST training is more effective in reducing disease severity and disease-related symptoms than L-EMST. Further studies are warranted for evaluating the long-term effects of EMST with larger sample sizes in OSAS.

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Objective: To systematically evaluate post-exercise outcomes related to function and quality of life in people with ALS. Methods: PRISMA guidelines were used for identifying and extracting articles. Levels of evidence and quality of articles were judged based on The Oxford Centre for Evidence-based Medicine Levels of Evidence and the QualSyst. Outcomes were analyzed with Comprehensive Meta-Analysis V2 software, random effects models, and Hedge's G. Effects were examined at 0-4 months, up to 6 months, and > 6 months. Pre-specified sensitivity analyses were performed for 1) controlled trials vs. all studies and 2) ALSFRS-R bulbar, respiratory, and motor subscales. Heterogeneity of pooled outcomes was computed with the I2 statistic. Results: 16 studies and seven functional outcomes met inclusion for the meta-analysis. Of the outcomes explored, the ALSFRS-R demonstrated a favorable summary effect size and had acceptable heterogeneity and dispersion. While FIM scores demonstrated a favorable summary effect size, heterogeneity limited interpretations. Other outcomes did not demonstrate a favorable summary effect size and/or could not be reported due to few studies reporting outcomes. Conclusions: This study provides inconclusive guidance regarding exercise regimens to maintain function and quality of life in people with ALS due to study limitations (e.g., small sample size, high attrition rate, heterogeneity in methods and participants, etc.). Future research is warranted to determine optimal treatment regimens and dosage parameters in this patient population.

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BACKGROUND: Chronic radiation-associated dysphagia (C-RAD) is considered to be one of the most severe functional impairments in head and neck cancer survivors treated with radiation (RT) or chemoradiation (CRT). Given the major impact of these late toxicities on patients' health and quality of life, there is a strong need for evidence-based dysphagia management. Although studies report the benefit of strengthening exercises, transference of changes in muscle strength to changes in swallowing function often remains limited. Therefore, combining isolated strengthening exercises with functional training in patients with C-RAD may lead to greater functional gains. METHODS: This 3-arm multicenter randomized trial aims to compare the efficacy and possible detraining effects of mere strengthening exercises (group 1) with a combination of strengthening exercises and functional swallowing therapy (group 2) and non-invasive brain stimulation added to that combination (group 3) in 105 patients with C-RAD. Patients will be evaluated before and during therapy and 4 weeks after the last therapy session by means of swallowing-related and strength measures and quality of life questionnaires. DISCUSSION: Overall, this innovative RCT is expected to provide new insights into the rehabilitation of C-RAD to optimize post-treatment swallowing function. TRIAL REGISTRATION: International Standard Randomized Controlled Trials Number (ISRCTN) registry ID ISRCTN57028065. Registration was accepted on 15 July 2021.

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In addition to typical motor dysfunction, Parkinson's disease is also characterized by respiratory-related dysfunction. As a means of rehabilitation, respiratory muscle strength training (RMST) has been applied to restore Parkinson's disease (PD) functions. However, the current clinical value of RMST in the application for PD has not been widely established. This article aims to review the research progress of the application of RMST in PD rehabilitation to provide new sight into respiratory-related impairments management in people with PD.

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Expiratory muscle strength training (EMST) is an exercise program designed to strengthen the muscles of expiration by increasing expiratory load during breathing exercises using either resistive or pressure threshold devices. Previous research has shown that EMST may increase submental suprahyoid muscle activity as measured with surface electromyography. The impact of EMST on submental muscles is of interest to those who treat dysphagia. The purpose of this study was to determine whether the cross-sectional area of the geniohyoid muscle changes as observed with ultrasound during a 5-week EMST program performed at 75% of maximum expiratory strength using the EMST150 device in healthy adults. Ten healthy adults participated in the 5-week program. Maximum expiratory pressure (MEP) and cross-sectional area of the geniohyoid muscle were measured weekly. Geniohyoid cross-sectional area was measured from ultrasound images recorded in the coronal plane. Repeated Measures ANOVA was used to determine whether there were significant changes among the dependent variables over the study period. Both MEP and geniohyoid area increased significantly in response to a 5-week program of EMST. EMST in healthy adults is effective at strengthening the geniohyoid muscle as reflected by significantly increased cross-sectional area measured with B-mode ultrasound. This is the first study to document weekly change in muscle morphology as a result of EMST. Increasing geniohyoid muscle mass and consequent strength through a program of EMST may be beneficial for persons with pharyngeal stage dysphagia resulting from reduced hyolaryngeal elevation, reduced laryngeal closure, or reduced UES opening.

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BACKGROUND: The efficacy of expiratory muscle strength training (EMST) in patients with multiple sclerosis (MS) is controversial. The current study's primary objective was to test the effects of a progressive and intensive 12 week home based EMST program on expiratory muscle strength and voluntary cough strength. The secondary objective was to determine the retention of EMST benefits. METHODS: Thirty-five severely disabled MS patients (relapsing-remitting MS, n = 15; primary progressive MS, n = 5; secondary progressive MS, n = 15) with Expanded Disability Status Scale (EDSS) 5.0 - 7.0 were included in the study. Within 36 weeks, patients completed 12 weeks of a non-training period, 12 weeks of EMST and 12 weeks of a detraining period. Maximal expiratory pressure (PEmax) and voluntary peak cough flow (vPCF) were assessed 4 times: at week 0 (baseline), week 12 (pre-training), week 24 (post-training), and week 36 (post-detraining). MS patients included in the study were compared to age- and sex-matched healthy subjects. In the healthy controls, the PEmax and vPCF were assessed once to obtain normative data. RESULTS: Twenty-six patients completed the training period (mean age 52.7 ± 10.2, EDSS 5.9 ± 0.6) and were compared to 26 sex- and age-matched healthy subjects (mean age 53.5 ± 5.8). Patients with MS had a lower PEmax (p = 0.002) and vPCF (p = 0.022) at baseline than the healthy control group. In training period, the PEmax and vPCF increased (p = 0.0000; effect size: d = 0.94 and p = 0.0036; d = 0.57 respectively) in comparison with the non-training period (p = 0.0692; d = -0.36 and p = 0.5810; d = 0.11 respectively). Following the 12 weeks detraining period, the PEmax and vPCF declined but remained 16.7% and 5.5% respectively above the pre-training values. No differences were observed in the PEmax and vPCF between the MS group at the post-training and post-detraining timepoint and the healthy control group normative values. CONCLUSIONS: EMST improves expiratory muscle strength and voluntary cough strength in severely disabled MS patients.

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INTRODUCTION: Bulbar impairment represents a hallmark feature of amyotrophic lateral sclerosis (ALS) that significantly impacts survival and quality of life. Respiratory complications arise because of the weakness of the upper airway and respiratory muscles leading to respiratory failure, impaired swallowing, and reduced airway safety. Breath stacking and respiratory muscle endurance training are techniques that have been described to improve respiratory and bulbar function in patients with ALS. Considering the above, a respiratory technique named TR3 was developed. This study aimed to measure the acute effects of this technique on the upper airway through videofluoroscopy and to assess its clinical trial feasibility in patients with ALS. MATERIAL AND METHODS: In this cross-sectional study, we enrolled participants diagnosed with ALS to perform a single session of TR3. Epidemiological data and baseline assessments were collected. The assessments included kinematics from videofluoroscopy measuring the retropalatal airspace size, the size of the narrowest airway, and the pharyngeal area during rest and TR3. RESULTS: Eight participants were included. During TR3, an acute increase of 15% was observed in the retropalatal airspace size (t = 5.14, p < 0.01), a 123% increase was observed in the size of the narrowest airway (t = -4.18, p < 0.001), and a 277% increase was observed in the pharyngeal area (t = -5.34, p < 0.001). CONCLUSIONS: During the intervention, TR3 showed acute effects in increasing pharyngeal constriction, pharyngeal expansion, retropalatal airspace size, and post-lingual narrowest airway size and is feasible for a larger research program. A clinical trial (NCT04226144) is already being conducted to assess the chronic therapeutic effects of this technique and its impact on the clinical evolution of ALS.

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Expiratory muscle strength training (EMST) exercise programmes aim to improve respiratory function by increasing the force generating capability of expiratory muscles by resistance training. In neuromuscular conditions, in which cough flow generation is often decreased, there is increasing interest in EMST as a therapeutic intervention. We present data showing efficacy of EMST in a patient with adult onset Myotonic Dystrophy Type 1 (DM1). A domiciliary training programme (5 days per week over 32 weeks) resulted in increases in maximum expiratory mouth pressure (from 15 cmH2O to 38 cmH2O) and peak cough flow (300 L/min to 390 L/min). Improvements were also seen in maximum inspiratory mouth pressure (26 cmH2O to 52 cmH2O) and sniff nasal inspiratory pressure (40 cmH2O to 69 cmH2O). No changes were detected in speech or swallowing. This novel study demonstrates that cough flow generation in DM1 may be increased by a programme of expiratory muscle training. A clinical trial of EMST in DM1 is warranted.

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BACKGROUND: Respiratory muscle strength declines in certain disease states, leading to impaired cough, reduced airway clearance and an increased risk of aspiration pneumonia. Respiratory muscle training may therefore reduce this risk. OBJECTIVES: To assess current evidence of expiratory muscle strength training (EMST) on maximum expiratory pressure, cough flow and spirometry. DATA SOURCES: Databases including CINAHL, Medline, Science Direct and PEDRo were searched. ELIGIBILITY CRITERIA: Randomised controlled trials investigating expiratory muscle strength training on maximum expiratory pressure, pulmonary function or cough in any adult population, published before December 2017. STUDY APPRAISAL: Data were extracted to a trial description form and study quality evaluated by two reviewers. Meta-analysis was performed with calculation of mean differences and 95% confidence intervals. RESULTS: Nine studies met inclusion criteria and ranged in size from 12 to 42 participants. Trials investigated EMST in healthy adults (2), multiple sclerosis (3), COPD (2), acute stroke (1) and spinal cord injury (1). Overall, EMST improved maximum expiratory pressure (15.95cmH2O; 95% CI: 7.77 to 24.12; P<0.01) with no significant impact on cough flow (4.63L/minute; 95%CI -27.48 to 36.74; P=0.78), forced vital capacity (-0.16L; 95%CI -0.35 to 0.02; P=0.09) or forced expiratory volume in 1second (-0.09L; 95%CI -0.10 to -0.08; P<0.001) vs control or sham training. CONCLUSIONS: Meta-analysis indicated a small significant increase in maximum expiratory pressure following EMST. Improvements in maximum expiratory pressure did not lead to improvements in cough or pulmonary function. LIMITATIONS: Variations in protocol design and population limited the overall effect size. Systematic Review Registration PROSPERO CRD42018104190.

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BACKGROUND: Expiratory muscle strength training (EMST) is a treatment for swallowing dysfunction due to its activation of the suprahyoid muscles. Current EMST devices have numerous limitations. OBJECTIVE: The purpose was to evaluate the utility of elevation training mask as an alternative respiratory muscle strength training (RMST) device. METHODS: A closed system, simulating expiration was designed. Air was delivered through a pressure gauge with a measurement range of 0-15 psi. The EMST150TM and the Elevation Training Mask 2.0® (ETM) maximal resistance levels were measured and compared. RESULTS: EMST150 produced increasing expiratory resistance pressures of 0.3, 0.6, 1.2, 1.9 and 2.1 psi, which correspond to its indicator of 30, 60, 90, 120 and 150 cmH2O. The ETM resistance pressure produced expiratory resistance pressures of 0.1 and 0.2 psi at simulated altitudes of 3000 and 6000 feet, respectively. A stable expiratory resistance pressure of 0.25 psi was measured at simulated altitudes of 9000, 12,000, 15,000 and 18,000 feet. CONCLUSION: ETM provides adjustable expiratory muscle strength resistance pressures. Further investigation is necessary to evaluate safety, compliance and clinical efficacy in patients with swallowing dysfunction. SIGNIFICANCE: ETM can serve as an effective treatment modality for pulmonary dysfunction and swallowing disorders through RMST.

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PURPOSE: To investigate the effects of expiratory muscle strength training on communication and swallowing outcomes in adults with acquired motor based communication and/or swallowing difficulties of any aetiology. METHOD: A systematic review was conducted. Six databases (CINAHL, MEDLINE, EMBASE, SPEECHBYTE, AMED and PUBMED) were searched from inception until end of May 2016. Randomised and non-randomised controlled studies and pre-test/post-test studies published in English that investigated the effects of expiratory muscle strength training were included. Study quality was assessed using the PEDro scale. Data were analysed descriptively and effect sizes and associated 95% confidence intervals were calculated. RESULT: Seven articles reporting data from five studies were included. Preliminary data suggests expiratory muscle strength training improved airway safety during swallowing in people with dysphagia and increased the strength of the expiratory muscles in all patient groups. There was little evidence to suggest changes in communication outcomes after expiratory muscle strength training. CONCLUSION: Speech-language pathologists might consider using expiratory muscle strength training to improve airway safety in adults with swallowing disorders.

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INTRODUCTION: The purpose of this study was to determine the impact of an in-home expiratory muscle strength training (EMST) program on pulmonary, swallow, and cough function in individuals with amyotrophic lateral sclerosis (ALS). METHODS: EMST was tested in a prospective, single-center, double-blind, randomized, controlled trial of 48 ALS individuals who completed 8 weeks of either active EMST (n = 24) or sham EMST (n = 24). The primary outcome to assess treatment efficacy was change in maximum expiratory pressure (MEP). Secondary outcomes included: cough spirometry; swallowing; forced vital capacity; and scoring on the ALS Functional Rating Scale-Revised. RESULTS: Treatment was well tolerated with 96% of patients completing the protocol. Significant differences in group change scores were noted for MEP and Dynamic Imaging Grade of Swallowing Toxicity scores (P < 0.02). No differences were noted for other secondary measures. DISCUSSION: This respiratory training program was well-tolerated and led to improvements in respiratory and bulbar function in ALS. Muscle Nerve 59:40-46, 2019.

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