Expiratory Muscle Strength Training for Adult Speech Therapy

Expiratory Muscle Strength Training (EMST) is one of many great tools in your SLP toolbox.

EMST is an evidence-based way to improve respiratory muscle strength and treat the symptoms of dysphagia, dysarthria, and dysphonia.

In this article you’ll learn:

  • Who to use EMST with
  • Contraindications
  • An EMST speech therapy protocol
  • Recommended EMST training courses

What is Expiratory Muscle Strength Training?

expiratory muscle strength training

Expiratory muscle strength training (EMST) is a strength training program for people with respiratory muscle weakness.

This weakness is often caused by neuromuscular disease, COPD, heart failure, prolonged mechanical ventilation, or surgery (Richardson, n.d.)

EMST is similar to weight training—but for breathing! It uses strength training principles to increase strength over time, with the help of a protocol and a device.

By increasing strength, EMST has been shown to improve symptoms of dysphagia, dysphonia, and dysarthria.

What Muscles Does EMST Target?

EMST targets the expiratory muscles, abdominal muscles, and some upper airway muscles. 

EMST Device

Image from emst150.com

EMST uses a handheld device that a patient exhales forcefully into. The device gives resistance, which strengthens both the breathing and swallowing muscles.

EMST devices often have a springloaded pressure threshold and an adjustable value.

When starting an EMST device, you’ll make an individualized program for each patient.

Based on their specific needs, you’ll choose an initial resistance and then progressively adjust the value to increase resistance and strength.

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EMST Protocol

EMST protocol

Again, individualize your EMST protocol for each person.

We recommend taking an EMST course before trying it with patients—more on courses below.

Here is a sample EMST session:

  • Measure the patient’s maximum expiratory pressure (MEP) using a respiratory pressure meter.
  • Set the EMST-appropriate device (e.g. EMST 150) to the recommended MEP percentage (e.g. 70-75% of MEP).
  • Instruct the patient to use the EMST device:
    • Plug your nose/use a nose plug (if needed to prevent air loss through the nose).
    • Take a deep breath and hold briefly.
    • Place the device behind your teeth with lips tight around the mouthpiece.
    • Blow forcefully through the device. If needed, hold your cheeks with your free hand to maintain a tight seal.
    • Rest 15-30 seconds before repeating.
    • Repeat 5 repetitions, 5 times per day (25 reps total), 5 days per week, for around 4 weeks (depending on the patient).
  • Maintenance. When the program is completed, you may recommend a maintenance program to carry over results.

Patients Who May Benefit From EMST

who would benefit emst

Many adult speech therapy patients benefit from EMST.

The following is a list of the conditions that EMST may help. We’ll go over some of them in detail below.

Conditions that may benefit from EMST:

  • Dysphagia due to weak cough 
  • Reduced airway protection
  • Dysarthria/dysphonia with respiratory-phonatory impairments 
  • Chronic obstructive pulmonary disorder (COPD)
  • Stroke
  • Traumatic brain injury (TBI)
  • Neurogenic and neuromuscular disorders affecting voice, swallowing, or speech, including:
    • ALS (only to treat dysphagia and only early in the disease process)
    • Parkinson’s disease
    • * Multiple sclerosis
    • * Myasthenia gravis
    • Guillain-Barre syndrome
    • Cerebral palsy
    • Post-polio

* See contraindications

EMST Contraindications

emst contraindications

Proceed With Caution

If a patient has any of the following conditions, get physician approval first and proceed with caution:

  • VP shunt
  • Recent neurosurgery
  • Hemorrhagic stroke
  • Current myasthenia gravis (MG) crisis
  • Present multiple sclerosis (MS) flare-up
  • Pregnant women
  • Uncontrolled hypertension
  • Subdural hematoma (acute or chronic)
  • Coronary artery disease (CAD)
  • COPD with bullae or blebs

Don’t Use EMST

Don’t use EMST if a patient is/has:

  • Not safe to do the Valsalva maneuver (e.g. “bearing down”)
    • These patients may have heart rhythm issues, patent foramen ovale (PFO), heart failure, heart or heart valve disease, increased risk of stroke, retinopathy, intraocular lens implants, etc.
    • When in doubt, check with their physician first
  • Unhealed traumatic pneumothorax
  • Unhealed rib fractures
  • History of spontaneous pneumothorax
  • Tympanic membrane perforation or myringotomy within 30 days

There are other scenarios and conditions where EMST is contraindicated. Check with the patient’s primary care physician—and get trained!

How To Get EMST Training?

emst speech therapy exercises

The following are two top-notch EMST course providers:

  1. Aspire Respiratory Products (EMST 150)
  • In-person (U.S.) or online (UK & Europe)
  • $199.00 USD
  • 4-6 hours
  • ASHA CEUs included

  1. The Modern MedSLP (Brooke Richardson)
  • Online or in-person
  • $95- $495 USD
  • 1 hour to 10.5 hours
  • ASHA CEUs included

EMST For Dysphagia

emst for dysphagia

EMST is an evidence-based treatment for patients with oropharyngeal dysphagia due to stroke, Parkinson’s disease, head and neck cancer, ALS (early stages only), and COPD, amongst others (Winiker and Kertscher, 2023; Brooks, 2019, Plowman, 2019; Richardson, n.d.)

It’s been shown to improve swallowing safety, swallowing function, expiratory pressure, cough, and hyolaryngeal function (Troche, 2010; Winiker and Kertscher, 2023). 

EMST likely increases the activity of the segmental and suprahyoid muscles, which can improve hyoid displacement and upper esophageal sphincter (UES) opening.

Strengthening expiratory muscles can also improve cough strength. When a patient contracts their expiratory muscles, it creates a force to clear the airway. EMST may increase this force.

EMST Speech Therapy For Voice & Dysarthria

EMST for voice

A recent systematic review found that EMST can improve respiratory and voice outcomes in people with voice disorders (Desjardins, 2020).

Since EMST strengthens expiratory muscles, it can increase respiratory strength during phonation.

When there is more strength behind the vocal cords, the quality, duration, and intensity of the voice improves. This in turn makes speech more clear and intelligible. 

It can also improve the coordination of respiration, phonation, and resonance (Pitts et al 2009) which contribute to a healthy, clear, and intelligible voice.

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References

  • Airway Protection Program: Expiratory Muscle Strength Training for Dysphagia Treatment. (2021). National Foundation of Swallowing Disorders. Retrieved January 11, 2024, from https://swallowingdisorderfoundation.com/expiratory-muscle-strength-training
  • Brooks, M., McLaughlin, E., & Shields, N. (2019). Expiratory muscle strength training improves swallowing and respiratory outcomes in people with dysphagia: A systematic review. International journal of speech-language pathology21(1), 89–100. https://doi.org/10.1080/17549507.2017.1387285
  • Desjardins, M., & Bonilha, H. S. (2020). The Impact of Respiratory Exercises on Voice Outcomes: A Systematic Review of the Literature. Journal of voice : official journal of the Voice Foundation34(4), 648.e1–648.e39. https://doi.org/10.1016/j.jvoice.2019.01.011
  • Park, J. S., Oh, D. H., Chang, M. Y., & Kim, K. M. (2016). Effects of expiratory muscle strength training on oropharyngeal dysphagia in subacute stroke patients: a randomised controlled trial. Journal of oral rehabilitation43(5), 364–372. https://doi.org/10.1111/joor.12382
  • Plowman, E. K., Tabor-Gray, L., et al. (2019). Impact of expiratory strength training in amyotrophic lateral sclerosis: Results of a randomized, sham-controlled trial. Muscle & nerve59(1), 40–46. https://doi.org/10.1002/mus.26292
  • Richardson, B. (n.d.) Foundations of Respiratory Muscle Training: Dysphagia Therapy. Medbridge. Retrieved January 18, 2023 from https://www.medbridge.com/courses/details/foundations-of-respiratory-muscle-training-dysphagia-therapy-brooke-richardson
  • Troche, M. S., Okun, M. S., Rosenbek, J. C., Musson, N., Fernandez, H. H., Rodriguez, R., Romrell, J., Pitts, T., Wheeler-Hegland, K. M., & Sapienza, C. M. (2010). Aspiration and swallowing in Parkinson disease and rehabilitation with EMST: a randomized trial. Neurology75(21), 1912–1919. https://doi.org/10.1212/WNL.0b013e3181fef115
  • Winiker, K., & Kertscher, B. (2023). Behavioural interventions for swallowing in subjects with Parkinson’s disease: A mixed methods systematic review. International Journal of Language & Communication Disorders, 58(4), 1375-1404. https://doi.org/10.1111/1460-6984.12865
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