Medical Speech Pathology

Curiosity, Dialogue, and Knowledge

Dysphagia Instruments


EXPIRATORY MUSCLE STRENGTH TRAINER (EMST)

A picture of someone using the Expiratory Muscle Strength Trainer by Aspire

PURPOSE

To improve the strength of exhalatory muscles for breathing, improve voluntary cough, and movement of the hyolaryngeal complex.  

APPLICABILITY

Patients with decreased exhalatory muscle strength, poor cough, or decreased movement of the hyolaryngeal complex.

SUPPLIES

EMST and you

INSTRUCTIONS

1.  Find your Maximum Expiratory Pressure-MEP (see instructions with device).

2. Set the device at 75% of your MEP and complete 5 breaths (frequent rests needed for some patients between each exhalatory push).  Rest is recommended for all users between sets.  The rest should last at least 1-2 minutes.

3. Complete 5 sets of 5 repetitions per day, 5 days a week for at least 4-6 weeks.

TRAINING

No specific training is required besides what is listed in the manual.

PRICE

As of 6-10-12 the website lists the product at $39.95.

References

Baker S, Davenport P, Sapienza C. Examination of strength training and detraining effects in expiratory muscles. J Speech Lang Hear Res 2005;48:1325–1333.  

Chiara T, Martin D, Davenport P, Bolser D. Expiratory muscle strength training in persons with multiple sclerosis having mild to moderate disability: effect on maximal expiratory pressure, pulmonary function, and maximal voluntary cough. Arch Phys Med Rehabil 2006;87:468–473.  

Chiara T, Martin D, Sapienza C. Expiratory muscle strength training: speech production outcomes in patients with multiple sclerosis. Neurorehabil Neural Repair 2007;21:239–249.  

Kim J, Davenport P, Sapienza CM. Effect of expiratory muscle strength training on elderly cough function. Arch Gerontol Geriatr 2008;48:361–366.  

Pitts T, Bolser D, Rosenbek JC, Troche M, Okun MS, Sapienza C. Impact of expiratory muscle strength training on voluntary cough and swallow function in Parkinson disease. Chest 2009;135:1301–1308.  

Saleem AF, Sapienza CM, Okun MS. Respiratory muscle strength training: treatment and response duration in a patient with early idiopathic Parkinson’s disease. Neurorehabilitation 2005;20:323–333. 

Sapienza CM, Davenport PW, Martin D. Expiratory muscle training increases pressure support in high school band students. J Voice 2002;16:495–501.  

Schultz JL, Perlman AL, VanDaele DJ. Laryngeal movement, oropharyngeal pressure, and submental muscle contraction during swallowing. Arch Phys Med Rehabil 1994;75:183–188.

Troche MS, Okun MS, Rosenbek JC, Musson N, Fernandez HH, Rodriguez R, Romrell J, Pitts T, Wheeler-Hegland KM, Sapienza CM. Aspiration and swallowing in Parkinson disease and rehabilitation with EMST: a randomized trial. Neurology 2010; 75(21): 1912-9.

Wheeler KM, Chiara T, Sapienza CM. Surface electromyographic activity of the submental muscles during swallow and expiratory pressure threshold training tasks. Dysphagia 2007;22:108–116.  

Wingate JM, Brown W, Shrivastav R, Davenport P, Sapienza C. Treatment outcomes for professional voice users. J Voice 2007;21:433–449.  

IOWA ORAL PRESSURE INSTRUMENT (IOPI)

A picture of the Iowa Oral Pressure Instrument

photo retrieved from IOPI northwest at flickr.com

PURPOSE

To improve lip strength, tongue strength, and assist with controlled tongue movements. To quantitatively measure strength of these articulators.

APPLICABILITY

Patients who have weakness of the lips and tongue, and those that need assistance with controlled tongue movements.

SUPPLIES

IOPI and accouterments

INSTRUCTIONS

Specific Instructions for use are included with purchase of the device.

TRAINING

No specific training is required besides what is listed in the manual.

PRICE

As of 6-10-12 the website lists the product at $1,125 (10 tongue bulbs, 1 connecting tube, carrying case, owners manual, and 2 year warranty). Additional supplies listed at these prices: box of 10 bulbs = $50, connecting tube = $20.

References

While I counted at least 43 references on the IOPI website, none of them were available to actually read from the site. I’m unsure at this point, how many of these are to show established norms for comparison, how many used the device in a particular study, and how many are just generally pointing towards the efficacy of tongue strengthening in general. If someone with more experience using this device can help whittle this list down, I’ll place the pertinent list here. At this time, I’ll just make a link here, to allow people to peruse the list themselves.

REVIEW

None available at this time.

MADISON ORAL STRENGTHENING THERAPEUTIC (MOST) DEVICE

A picture of the MOST device for improving tongue strength and precision

PURPOSE

The MOST device performs a dual role of identifying risk for dysphagia/screening by quantitatively assessing tongue muscle strength and therapy by serving as an exercise device for strengthening tongue muscles.

APPLICABILITY

Patients who have weakness of the tongue, and those that need assistance with controlled tongue movements.

SUPPLIES

___ MOST Device and accouterments

INSTRUCTIONS

Specific Instructions for use are included with purchase of the device.

TRAINING

No specific training is required besides what is listed in the manual.

PRICE

As of 6-10-12 the website lists the product at $1,800 with a possible discount for pre-order coming in at $1,440 this includes: MOST system, pressure transducer, 2 mouthpieces, and notebook. Additional supplies listed at these prices: single mouthpiece = $130 / $104 (pre-order), 5 pack of mouthpieces= $600 / $480 (pre- order).

References

6 references are listed on the site. However full citation wasn’t available on the reference page. In comparison to the IOPI, however, these articles all look to be much more specific to this device. The picture below will give you the information I have at this point:

graphic display of reference list on the MOST site

REVIEW

None available at this time.

SURFACE ELECTROMYOGRAPHY (sEMG)

A picture of a patient with surface electrodes placed on the neck and face muscles of swallowing

retrieved from science direct’s site as a teaser for the article by Michael Vaiman, MD, PhD, Ephraim Eviatar, MD, & Samuel Segal, MD click her to learn more

PURPOSE

To provide visual and or auditory biofeedback to patients while they complete swallowing exercises.

APPLICABILITY

This can aid with teaching specific swallow techniques (e.g.- the Mendelsohn Maneuver) or it can give precise feedback on the amount of energy being exerted by the laryngeal musculature during a given swallow.

SUPPLIES

___ Electrodes

___ sEMG device

INSTRUCTIONS

1. Apply the electrodes to the appropriate muscles on the anterior neck and or submental muscles.

2. Each model will differ in regard to specific settings.

3. View the graph depicting activation of the muscles during the swallow and at rest.

4. Target specific training area (strength, duration of contraction, or swallow onset)

PRICE

Devices range in price: The Pathway MR-20 is listed at roughly $1,100 dollars for a portable sEMG system, the combination of sEMG and Vital Stim with Experia costs $13,880 (there are many units in between none of which I am familiar with).

TRAINING

Recommended

References

Bryant, M.H., & Bryant, M.L. (1991). Biofeedback in the treatment of a selected dysphagia client.Dysphagia, 6, 140–144.

Crary, M.A. (1995). A direct intervention program for chronic neurogenic dysphagia secondary to brainstem stroke. Dysphagia, 10, 6–18.

Crary, M.A. (1997). Surface electromyographic characteristics of swallowing in dysphagia secondary to brainstem stroke. Dysphagia, 12, 180–187.

Crary, M.A., & Groher, M.E. (2000). Basic concepts of surface electromyographic biofeedback in the treatment of dysphagia: a tutorial. American Journal of Speech-Language Pathology, 9(2), 116–125.

Huckabee, M.L., & Cannito, M. (1999). Outcomes of swallowing rehabilitation in chronic brainstem dysphagia: A retrospective evaluation. Dysphagia, 14, 93–109.

REVIEW

I’ll be brief. I have experience with Vital Stim’s version, the Experia, but not with the other machines. I love it when it works. I’ve been given training by a Vital Stim instructor on how to use the sEMG part of the Experia, but I still run into a lot of problems with how consistently I get the machine to do what it is supposed to. Other clinicians may have had more success than myself with this. I’ve used all of the tricks, but fail to get consistent results with my patients. This is frustrating. Also frustrating is the fact that while the research seems to be robust for this particular device (much more than I actually listed above), there is not a well-known company marketing portable versions of these to SLPs (that I am aware of). It’s a shame since this is a non-controversial, well researched, instrument for swallow therapy.

NEURO-MUSCULAR ELECTRICAL STIM (VITAL STIM)

A picture of the portable vital stim unit and the larger experia machine

PURPOSE

“The VitalStim® Therapy System … increases muscle strength, accelerates cortical reorganization, and increases the effectiveness of the exercise therapy,” per their site.

APPLICABILITY

Most all patients with dysphagia (per their site).

SUPPLIES

___ Electrodes

___ Vital Stim device

INSTRUCTIONS

Training is required to use this device.  No instructions are listed due to the nature of electrical stim, and the dangers of it being applied improperly to the anterior neck.

PRICE

Devices range in price: the portable unit costs $1,595;  the combination of sEMG and Vital Stim with Experia costs $13,880.  Electrodes run anywhere from $209 for 12 to $1300 for 100.  Training costs through Ciao Seminars is $775.

References

I will link to both the recent ASHA article that discusses this topic from two different points of view, and the file of data that Vital Stim has generated where they list and rate the research (not surprisingly, unfavorable research got a lower grade).

Here is the ASHA article.

Here is the Vital Stim Reference List.

REVIEW

I will leave a review at a later date.  It’s more than I want to delve into at this point.

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9 comments on “Dysphagia Instruments

  1. Émie
    November 6, 2013

    Where can we buy a expiratory pressure threshold trainer ?

      • Admin
        November 10, 2013

        This is the only place that I’ve gotten the EMST devices from, and I’ve had no real issues with the product. There may be other places that also have good equipment, but I’m not familiar enough with them to recommend them. I hope you like them. I found them easy to use and of great benefit to many of my patients. I did find, however, that several patients wanted a real demonstration of the product because they felt it was “broken”. This wasn’t the case. They simply had a dramatically reduced respiratory capacity and/or poor labial seal. For some of my patients with facial paralysis, we had to have them place it far to the left or right side of the mouth (whichever was the strong side) and manually pinch the more flaccid side to achieve a good seal. Let me know what you think of the device if you purchase one.

        Best Regards,

        Walt Greenslade, M.S., CCC-SLP

  2. Rebecca B. Hill
    November 30, 2013

    Hello,
    I am in the process of learning about Respiratory Muscle Strength Training, and I have a couple of questions that I am hoping you may be willing to answer. Does the patient purchase the product (such as the Aspire) or does your facility purchase the product and then charge the patient? Also, do you market yourself to pulmonologists and allergy/asthma specialists?

    Thank you for your time,

    Rebecca B. Hill, M.S., CCC-SLP

    • Admin
      December 1, 2013

      Hello Rebecca,

      Some of the patients that I’ve worked with have bought their own, but we have also purchased some ourselves as a hospital. While I really like the product, I don’t use them with all my dysphagia patients, so the cost is not that great; especially compared to NMES electrodes and other such items.

      We probably ought to market this to pulmonologists and to the Parkinson’s specialist (see Dr. Rosenbek’s research on EMST and Parkinson’s), but as of yet we have not. We do, as an aside, always get a doctor’s order for the use of the device due to the high amounts of pressure it creates in the body. While the risks, in my opinion, are low. MD approval is always important with modality use.

  3. Rebecca B. Hill
    January 4, 2014

    Hi- thank you for your response! Would you mind sharing how the physician should word the order, as I am collaborating with a local ENT. Thank you for your assistance!

    • Admin
      January 4, 2014

      I would leave the wording up to them, but I would just make sure that they were aware of the increase in intracranial pressure involved and potential effects on a patient with poorly controlled hypertension. They would then likely write the order just like they would for any other modality (e.g. – Pt. to have X modality for dysphagia).

  4. Rebecca B. Hill
    January 6, 2014

    Thank you again!

  5. Pingback: Effect of expiratory muscle strength training on swallowing-related muscle strength in community-dwelling elderly individuals: a randomized controlled trial | Disfagia Brasil

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