Respiratory muscle strength training devices, whether threshold or resistance devices, are simple training aids that can be used to build strength in the muscles we use to inhale and exhale over a relatively short period of time. There is no machine at the gym or health club that can accomplish this kind of strength training for you or your patient. If you are looking for means to improve breathing force and/or endurance, a respiratory device can help you to achieve this easily and efficiently.

Yes, respiratory muscle strength training has been studied since the late 1970s. Leith and Bradley conducted initial research, and others followed with research into the use of respiratory muscle strength training programs for athletes, as well as patients with spinal cord injuries, chronic obstructive pulmonary disease, and neurodegenerative disorders. The EMST150 research team started investigating how patients with limited glottal airway spaces could benefit from the use of respiratory devices. From there we shifted our focus to other patients with muscle weakness, including those with multiple sclerosis, spinal cord injuries and other conditions. Our latest research has focused on patients with Parkinson’s disease. The EMST150 was used in one of the largest randomised clinical trials of behavioral swallowing treatment in Parkinson’s patients. Researchers found that a third of the volunteers who participated improved their ability to swallow and the findings were published in the 2010 issue of the Neurology Journal (Troche et al., 2010).

Strength training programs vary in frequency, intensity and volume (Vaughn & Micheli, 2008). There has been extensive debate over the optimal number of repetitions, or sets, required in order to improve muscular strength. Some believe that multiple sets are necessary to realise optimal results (Kramer et al., 1997; & Rhea at el., 2002; Schlumberger et al., 2001). Others contend that a single set per training session is all that is required, and that it is no more beneficial to complete successive sets (Carpinelli & Otto, 1998; Carpinelli et al., 2002; Otto & Carpinelli, 2006).

Incentive spirometry uses a medical device to help open the airways and improve the functioning of the lungs following surgery. The devices do not build respiratory muscle strength. In fact, they have been found to offer inadequate training resistance (Dekhuijzen et al., 1990; 1991; Larson et al., 1988). Incentive spirometers are also strongly affected by how much air moves through the device and how quickly the air moves. Resistive training can involve breathing through a device with small openings that become progressively smaller (Jederlinic, 1984), or breathing through a device with many small holes. As the device dial is turned, the number of open holes decreases. This type of resistive training is impacted by the user’s breathing pattern, or rate of airflow, while respiratory strength training is not affected by flow rate (Larson et al., 1988). Respiratory strength training devices load the respiratory muscles at measurable intervals and help to build muscle strength. Each of these device types is useful in the right context and depending on the desired outcome, Ie. incentive spirometry should be used to open the airways after surgery, and pressure threshold trainers should be used to build muscle strength.

As with any form of training, patients should consult a medical professional to determine wither the selected training is suitable. In our opinion, respiratory training devices should not be used in individuals who have suffered or suffer from an acute stroke, untreated hypertension, untreated gastroesophageal reflux, reactive airway disease (like asthma) and women who are pregnant, or who suspect they may be pregnant.

Three important variables guide strength training: intensity, volume, and frequency. In an attempt to develop training guidelines based on existing studies, researchers in the area of respiratory training, modeled their guidelines off existing limb training research. Most respiratory training paradigms, for example, follow the limb strength training principle – that training be completed at 75-80% of the limb’s maximum strength. Some patients, however, may not be able to achieve 75-80% maximum expiratory pressure (MEP). In these instances, the medical professional guiding training should start the patient off at a level that is comfortable enough to allow the patient to successfully complete 25 repetitions. Progress should be monitored weekly and the training intensity level should be modified based on changes in strength. When it comes to frequency of training, we recommended five sets of five repetitions be completed for 4-5 weeks. This guideline is also based on limb exercise research. When deciding on a patient’s respiratory training plan, the clinician should take stock of the individual’s needs and the therapeutic goal. If the goal is to increase endurance, then completing more repetitions at a lower intensity might be best. Alternatively, if the goal is to become stronger, then the intensity should be set at 75-80% of maximum expiratory strength and the frequency should be at least five sets of five repetitions.

As with intensity and frequency of training, there are no exact guidelines determining when training should be stopped. We recommend the “power of 5” principle described above – completing at least five sets of five repetitions for five weeks. It is, however, interesting to note that we have witnessed patients become increasingly stronger where training is continued beyond five weeks. Saleem et al., (2005) described a woman with moderate Parkinson’s disease who indicated she wished to train beyond the four-week mark. She trained for a total of 20 weeks. At four weeks, she demonstrated a 50% improvement in maximum expiratory pressure. By week 20, her MEP had improved by 158%. This in spite of suffering from an underlying neurodegenerative disease. At one point, training was suspended for four weeks and the woman’s MEP decreased by 16% decrease. The results of this study leads into the following question.

When training ceases or the body undergoes a long period of inertia (or detraining) following a period of physical training, it loses some or all of the positive gains achieved during training (Mujika & Padilla 2001; Tokmakidis et al., 2009). This suggests that training should take place continually in order to maintain the benefits of an exercise program, particularly in individuals with neurodegenerative disease, like Parkinson’s, which results in accelerated deterioration of muscle function over time. It is impractical, however, to expect people to participate in training indefinitely. Studies into the effects of inactivity, after a period of training with the EMST150 device, have shown a decrease in MEP after four weeks and after eight weeks of detraining. MEPs did, however, tend to remain above baseline values (Baker et al., 2005; Chiara et al., 2006). A similar study of healthy people participating in inspiratory muscle strength training proved the benefits of training were maintained above baseline after six months of detraining, or with minimal maintenance (two exercise days per week), (Romer & McConnell 2003). These studies suggest continued training through a maintenance program is essential if the benefits are to be continued.

Not in all cases. If air is leaking out of the nose during the training, wear the nose clips to prevent air escape as the training will not be effective with air leaking out of the nose during training.

Yes. We suggest a one to two-minute rest in between sets.

No, the EMST150 should be considered a personal device. Sharing is not recommended, as germs may be transferred. Think of it as you would your toothbrush.

Use dishwashing soap and warm water to wash and thoroughly rinse the EMST150.

We believe testing the effectiveness of a RMST device through a multisite, randomized clinical trial is essential. That is, can medical professionals achieve the same or even better results than those previously achieved in a single group. This would offer valuable insight into whether the beneficial outcomes of RMST training can be duplicated in large groups of people, thereby offering a superior alternative to standard treatment.

Caregivers within families, whether they are a spouse, a partner, a relative or a close friend, make an important contribution to patient care. To help make the patient feel as comfortable as possible, and to help set routines in place, it’s best for one caregiver to assist the patient as often as possible. This makes it easier for the caregiver to pick up on abnormalities or changes with the patient. When it comes to respiratory muscle strength training, the caregiver can offer valuable help by reminding the patient about his/her training schedule, recording training progress, and helping the patient to hold the device during training if necessary. If illness or any other challenge prevent a patient from training during a training week, an additional week can be added to the program. If however the challenges persist over two or more weeks, or if medication dosages need to be changed during the program, training should be stopped.