Breathe! A Review of RMST for the Med SLP: Applications, Evidence, and Starting a Program
Author: Ainsley Martin, MS, CCC-SLP
Edited by: Heather Bolan, MA, CCC-SLP
Name of Course: Respiratory Muscle Training for the Med SLP: Applications, Evidence, and Starting a Program
Instructors: Brooke Richardson, MS, CCC-SLP
Cost: $295
Number of CEUs Earned: 0.75 CEUs
Format: Live lecture with a hands-on breakout session.
Duration: 1 Day
Subject: Respiratory Muscle Strength Training/Dysphagia/Dysarthria/Vent Weaning/Dystussia/Voice
Level of Difficulty: Intermediate
Applicable Patients/Disorders: Dystussia (cough dysfunction)- weak or ineffective cough, dysphagia with airway invasion, velopharyngeal insufficiency, dysphonia, dysarthria, Multiple Sclerosis (MS), Amyotrophic Lateral Sclerosis (ALS), Parkinson’s Disease, Myasthenia Gravis, Guillain-Barre, Acute Inflammatory Demyelinating Polyneuropathy (AIDP), spinal cord injury (SCI), failure to wean from mechanical ventilation, professional voice users, vocal cord dysfunction (VCD)/paradoxical vocal fold motion (PVFM), head and neck cancer (HNC), cardiopulmonary diseases, Chronic Obstructove Pulmonary Disease (COPD), cerebrovascular accidents (CVA), sedentary elderly, others with reduced maximum inspiratory pressure (MIP) or maximum expiratory pressure (MEP).
This training is applicable to SLPs in any clinical setting!
Content: Respiratory muscle strength training (RMST) is an evidenced-based exercise program which is applicable for patients with respiratory issues secondary to a range of disease processes. While RMST is becoming widely used in the field of speech-language pathology to treat dysphagia, voice disorders, dysarthria, and cough function, many clinicians still have questions about where to start, what devices to use, appropriate patients and contraindications to treatment. In Respiratory Muscle Training for the Med SLP, Brooke Richardson skillfully lays a foundation of respiratory anatomy and physiology, details the way in which RMST fits in accordance with the principles of exercise physiology, provides extensive evidence based information of various patients, disorders, and disease processes which could benefit from RMST, a comparison of the different devices available, and resources to start your own RMST program at your place of employment.
Usefulness of Resources: Resources provided in this course include PowerPoint slides of all information covered and a handout to assist in developing a RMST inservice consisting of; sample documentation for completing an RMST assessment, short and long term goals for RMST, images of equipment including care and cleaning instructions, set up and maintenance for treatment devices, troubleshooting for patient factors or barriers in completing RMST training, normative values for MIP and MEP, a detailed plan for creating and rolling out an RMST program in a hospital or SNF, a quiz following inservicing, RMT competency forms, a home exercise program for patients completing RMST, and instructions for initiating training with patients who are trach or vent dependent. As if that was not enough, Brooke also graciously provides course attendees with an excel spreadsheet she developed which will calculate the maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) for a patient based on their age and gender for you- so you won’t have to do the math! Lastly, information is provided re: vendors for the various devices used in the program including the Micro RPM digital manometer (for assessing a patient’s MIP and MEP), the EMST 150, and the Philips Respironics Positive Expiratory Pressure (PEP) and Inspiratory Muscle Trainer (IMT). While course attendees are no longer provided with the RMST devices as they were when I took the course, the hands-on manipulation of the devices is invaluable if you want to start training with your patients. This course was truly developed by a clinician who desires to set up other clinicians to be successful in implementing RMST with their patients and in their facilities.
As you may recall from the review of Respiratory Muscle Strength Training Theory and Practice by Christine Sapienza and Michelle Troche, the primary structures required for the life sustaining function of ventilation (air movement into and out of the lungs) and respiration (gas exchange) include the nose/mouth, larynx, trachea, lungs, diaphragm, and respiratory muscles forming the upper aerodigestive tract as these structures are also involved in swallowing and phonation (Coyle, 2010). Disruptions in the coordination of respiration and deglutition, respiratory muscle weakness, or damage to one of these structures can result in a myriad of issues including; dysphagia with airway invasion, ineffective cough for airway clearance, inability to fill the lungs with air, and other issues. If you think about this, this fits the profile of many patients we work with every day. RMST has been shown to be an effective evidence-based intervention for these patients by strengthening the muscles of respiration.
In the first section of this course, Brooke details the anatomy and physiology of the respiratory system and connects RMST to the three principles of strength training- intensity, specificity, and transference. She then further separated RMST into three categories: inspiratory muscle strength training (IMST), expiratory muscle strength training (EMST), and respiratory muscle strength training (RMT) which is a combination of IMST and EMST.
She also provided examples for when to pursue the different categories of RMST based on disorders, disease categories, and patient characteristics.
Following this section, course attendees were lead through a deep dive into the various disorders, disease processes, and diagnoses that may benefit from RMST. For example, in neuromuscular diseases such as MS or ALS, mortality is often the result of respiratory failure or pneumonia. In neuromuscular diseases, areas which can be affected include ventilatory function (decreased ability to move air through the lungs), cough function for clearance of penetrant or aspirant material, and decline in swallowing function.
In fact, a reduction in maximum inspiratory pressure may be a sign that respiratory failure is imminent. Research was then provided to support the use of IMST, EMST, or RMT for the disease processes described.
The devotion to evidence based practice and provision of a multitude of references were certainly appreciated!
As mentioned above, RMST is appropriate for a wide range of patients with an even wider range of goals, impairments, and disorders. RMST has been shown to be effective in;
dystussia (cough dysfunction)- weak or ineffective cough
dysphagia with airway invasion
velopharyngeal insufficiency
dysphonia
dysarthria
Multiple Sclerosis (MS)
Amyotrophic Lateral Sclerosis (ALS)
Parkinson’s Disease (PD)
Myasthenia Gravis (MG)
Guillain-Barre
Acute Inflammatory Demyelinating Polyneuropathy (AIDP)
spinal cord injury (SCI)
failure to wean from mechanical ventilation
professional voice users
vocal cord dysfunction (VCD)/paradoxical vocal fold motion (PVFM)
head and neck cancer (HNC)
cardiopulmonary diseases
Chronic Obstructive Pulmonary Disease (COPD)
cerebrovascular accidents (CVA)
sedentary elderly
others with reduced MIP/MEP.
The second half of the course focused on assessment and treatment with hands on learning opportunities, documentation, case studies, and finally starting your own RMST program.
Prior to starting a patient with RMST, an assessment of their current maximum inspiratory pressure (MIP) and/or maximum expiratory pressure (MEP) will assist you in determining a starting point for therapy. The resistance or goal level for treatment is usually measured as a percentage of the MIP or MEP. During the assessment section, attendees were introduced to the MicroRPM, a digital manometer used to calculate maximum inspiratory and maximum expiratory pressure.
Retrieved from: https://mdspiro.com/microrpm
Brooke also patiently walked us through the formula for calculating a person’s predicted MIP or MEP based on age and gender. (add pic of MicroRPM)
MEP: Males: 174 – (0.83 X age) = ___cmH2O
Females: 131 – (0.86 X age) = ___cmH2O
MEP Lower Level of Normal (LLN):
Males: 117 – (0.83 X age) = ___cmH2O
Females: 95 – (0.57 X age) = ___cmH2O
MIP: Males: 120 – (0.41 X age) = -___cmH2O
Females: 108 – (0.61 X age) = -___cmH2O
MIP Lower Level of Normal:
Males: 62 – (0.15 X age) = -___cmH2O
Females: 62 – (0.50 X age)[HC1] = -___cmH2O
(Evans and Whitelaw, 2009)
For example, as a then 27 y/o female, my MEP should range from 79.04-106.92cmH20 and my MIP should range from -48--90.92cmH20. All in attendance, including myself, were quite surprised to discover that my MEP was 169cmH20 and my MIP was -162 cmH20! I’m an overachiever, really. As mentioned, Brooke also provides an excel spreadsheet which can calculate the MIP and MEP for you, so you won’t have to worry about memorizing the formula!
If a clinician does not have access to devices such as the MicroRPM, the treatment devices can also be used to assess MEP and MIP by incrementally increasing the resistance until the patient reaches their one repetition maximum.
Now to move on to treatment! There are two types of RMST devices: resistive devices and pressure threshold devices. As explained in the Respiratory Muscle Strength Training Theory and Practice review, resistive devices provide resistance through either smaller orifices or a decreased number of orifices where air can flow through while pressure threshold devices have a spring loaded valve which is not impacted by the effect of airflow. Most of the research involving RMST have used pressure threshold devices; however, research has also shown that resistance devices such as the Breather or the Power Lung can also have positive therapeutic effects.
EMST 150
The devices used during the training included the EMST 150, Threshold PEP, and Threshold IMT- all pressure threshold devices. Determining the starting level for treatment is dependent on the patient’s medical diagnosis and health status. For example, a patient with a neuromuscular disease such as ALS may start at a lower percentage of their MEP or MIP than a person who has had a CVA.
Threshold PEP and Threshold IMT
During the hands on treatment portion, course attendees were allowed to manipulate the devices, change the mouthpieces, increase and decrease the resistance. I found this portion of the training invaluable as I was able to better describe to my patients what using the devices should feel and sound like.
This easily feels like it could have been a two day course as the day was packed with so much information!
Fortunately, at the end, we were able to bring everything together by reviewing case studies. Before taking this course, I had a definite interest in pursuing RMST with my patients, but became overwhelmed with all the information. I asked many questions similar to the ones I see regularly on the facebook forums. Like you may be feeling, I wasn’t sure which devices I should use and didn’t know the difference between resistive devices vs pressure threshold. I actually didn’t even know that the Threshold PEP and IMT devices existed. I now use them regularly with patients at my SNF. Between the expert instruction, detailed course slides, reference lists, and the RMST inservice packet, I felt like I was prepared to start my own RMST program at my facility. And that is exactly what I did! Be sure to stay tuned for an upcoming post about starting an RMST program. I have also contributed three resources to the Med SLP Collective on RMST and I have this course to thank for providing me with a solid foundation.
If you are interested in learning more about RMST and taking this course, please visit Brooke Richardson’s website for more information. https://sites.google.com/view/rmtmedslp/home?authuser=0
You can also check our her facebook group: Respiratory Muscle Training for the Med SLP. https://www.facebook.com/groups/RMT.MedSLP/
References:
· Coyle, J. (2010). Ventilation, Respiration, Pulmonary Diseases, and Swallowing . Perspectives on Swallowing and Swallowing Disorders (Dysphagia) 19(4), p 91-97.
· Evans, J. A., & Whitelaw, W. A. (2009). The Assessment of Maximal Respiratory Mouth Pressures In Adults. Respiratory Care, 54(10), 1348-1359.
