“The human voice is the most beautiful instrument of all, but the most difficult to play.” Richard Strauss
“The human voice is the organ of the soul.” Henry Wadsworth Longfellow
Précis: Have you ever had a pill get stuck in your throat while swallowing? Have you ever gagged and choked, trying to swallow a piece of steak? Have you ever coughed several times while trying to swallow some food? Do you snore or have Obstructive Sleep Apnea? Some of these are signs of a swallowing defect (dysphagia) and may be related to Parkinson’s. This blog post describes how to improve expiratory muscular function to deal with some of these issues.
“Words mean more than what is set down on paper. It takes the human voice to infuse them with deeper meaning.” Maya Angelou
Introduction: My first issue with Parkinson’s was a swallowing defect (dysphagia). Additionally, my voice lost some resilience and got softer. Furthermore, my diaphragm did not fully function before my diagnosis. Besides replacing missing dopamine, I needed strengthening of the expiratory muscles for breathing, coughing, and voice. The answer is the EMST 150, an exercise device. Breathing, coughing, and swallowing are vital physiological functions. *If any of these actions are modified by your Parkinson’s, I recommend using this little device to strengthen your expiratory muscles. Gain back some control over these critical bodily functions of coughing and swallowing.
*This blog post contains advice and information related to health care. It is not intended to replace medical advice. It should be used to supplement rather than replace regular care from your neurologist. You should seek your physician’s advice/approval before embarking on any new health plan or changes to your existing plan/routine.
“I think the greatest sound in the world is the human voice.” Miles Davis
Aspiration Pneumonia and Coughing: Aspiration pneumonia develops when too much food or liquid enters your airway. This type of material lodged in the lungs can lead to a life-threatening infection. A swallowing defect alters how the muscles in the throat safely allow food and liquid to clear the back of the mouth and enter the esophagus instead of entering the airway. Many People-with-Parkinson’s (PwP) have such a swallowing defect (dysphagia) that leads to choking or coughing, as the PwP tries to prevent food/liquid from entering one’s airway. As one might expect, PwP, compared to aged match controls without Parkinson’s, are more likely to get aspiration pneumonia, and the outcome is also more severe than the controls.
Controlling the cough is a mechanism of airway clearance that normal lung ciliary action cannot remove. As Pitts et al. (2009) described, coughing is a three-event phenomenon: first, an inspiratory effort, followed by a rapid vocal fold adduction and a contraction of the expiratory muscles. The cough uses all the abdominal and, internal, and external oblique muscles.
“It is said that love and a cough cannot be hid.” Dorothy L. Sayers
The Pattern of Breathing: It has been estimated that we breathe in and out about 20,000 times daily. The vast majority of these breaths are done automatically without thinking. These respiratory muscles pump air in containing oxygen, and they pump out wastes like carbon dioxide. The rib cage muscles, abdominal wall muscles, and the diaphragm are essential.
When one exhales, it involves several accessory muscles to assist, including the abdominal wall (transversus abdominis muscle, internal oblique muscle, external oblique muscle, and rectus abdominis muscle) and some of the rib cage muscles (e.g., the internal intercostal muscles and the triangularis sterni muscle). Breathing in, breathing out, or exhalation is both voluntary and involuntary. If you need an extra breath exhaled out, one has control over the process. The figure below highlights anatomically the location of some of these expiratory respiratory muscles.
“We swallow greedily any lie that flatters us, but we sip only little by little at a truth we find bitter.” Denis Diderot
A Problem With Parkinson’s: PwP may have decreased in cough function. Thus, aspiration may occur during swallowing, potentially leading to pneumonia. Therefore, the goal is to strengthen the muscles involved in coughing; the cough would be more substantial when needed. Furthermore, strengthening these muscles would bolster breathing, swallowing, and voice and help contribute to the PwP’s overall quality of life.
“When I study philosophical works I feel I am swallowing something which I don’t have in my mouth.” Albert Einstein
EMST 150 Device: The EMST 150 was developed by Dr. Christine Sapienza, Dr. Paul Davenport, and Dr. Daniel Martin, at the University of Florida. Expiratory muscle strength training (EMST) is a treatment for increasing maximal expiratory pressure. The EMST 150 device uses a calibrated, one-way, spring-loaded valve. The idea behind the EMST 150 is to overload the expiratory muscles mechanically. As one produces sufficient power to unblock the device, the device creates a condition that results in the conditioning of these muscles. Ultimately, the result is increased strength in the cough and expiration muscles. The EMST 150 is pictured and highlighted below.
Using the EMST 150: The use of the device is relatively straightforward, and it is outlined in the following few slides. These have been extracted from the EMST 150 User’s Manual.
“Laughter makes the bitter swallowing of truth, for some, a little easier.” Bill Hicks
Using the EMST 150: I purchased the EMST 150 device from Amazon.com (https://rb.gy/4dg46) for $69.99 (USD). You can also buy it directly from the manufacturer.
Setting up the EMST 150 is easy, and the exercises are not complicated. Keep track of the “THINK 5” activity description; all should be well. Does it work? There have been previous studies documenting that PwP gain strength with this device. Does this mean using it will prevent aspiration pneumonia? No, but it gives you the satisfaction that the respiratory exhalation muscles have been reinforced. This means your ability to cough vigorously should be available when swallowing incorrectly, and one needs to cough out the food or substance. And yes, I am a firm believer in being proactive.
Suppose you are exercising daily in an attempt to slow the disorder’s progression. Why not assist another set of muscles dedicated to helping one prevent aspiration leading to aspiration pneumonia, a life-or-death situation?
A final thought. Depending on the treatment strategy I am currently following, I will take >30 pills, capsules, and caplets each day. Over a year, that is almost 11,000 swallowing events. Already knowing that I have dysphagia, using the EMST 150 should be a priority.
References Used to Prepare this Blog Post:
Docu Axelerad, Any, Alina Zorina Stroe, Oana Cristina Arghir, Daniel Docu Axelerad, and Anca Elena Gogu. “Respiratory dysfunctions in Parkinson’s disease patients.” Brain Sciences 11, no. 5 (2021): 595.
D’Arrigo, Andrea, Stefano Floro, Francesca Bartesaghi, Chiara Casellato, Giuseppe Francesco Sferrazza Papa, Stefano Centanni, Alberto Priori, and Tommaso Bocci. “Respiratory dysfunction in Parkinson’s disease: a narrative review.” ERJ Open Research 6, no. 4 (2020).
Pitts, Teresa, Donald Bolser, John Rosenbek, Michelle Troche, Michael S. Okun, and Christine Sapienza. “Impact of expiratory muscle strength training on voluntary cough and swallow function in Parkinson disease.” Chest 135, no. 5 (2009): 1301-1308.
Troche, M. S., M. S. Okun, J. C. Rosenbek, N. Musson, H. H. Fernandez, R. Rodriguez, J. Romrell, T. Pitts, K. M. Wheeler-Hegland, and C. M. Sapienza. “Aspiration and swallowing in Parkinson disease and rehabilitation with EMST: a randomized trial.” Neurology 75, no. 21 (2010): 1912-1919.
van de Wetering-van Dongen, Veerle, Johanna G. Kalf, Philip J. van der Wees, Bastiaan R. Bloem, and Maarten J. Nijkrake. “The effects of respiratory training in Parkinson’s disease: a systematic review.” Journal of Parkinson’s Disease 10, no. 4 (2020): 1315-1333.
Won, Jun Hee, Seong Jun Byun, Byung-Mo Oh, Sang Jun Park, and Han Gil Seo. “Risk and mortality of aspiration pneumonia in Parkinson’s disease: a nationwide database study.” Scientific reports 11, no. 1 (2021): 6597.
Shi, Zhong-Hua, Annemijn Jonkman, Heder de Vries, Diana Jansen, Coen Ottenheijm, Armand Girbes, Angelique Spoelstra-de Man, Jian-Xin Zhou, Laurent Brochard, and Leo Heunks. “Expiratory muscle dysfunction in critically ill patients: towards improved understanding.” Intensive care medicine 45 (2019): 1061-1071.
Pleil, Joachim D., M. Ariel Geer Wallace, Michael D. Davis, and Christopher M. Matty. “The physics of human breathing: Flow, timing, volume, and pressure parameters for normal, on-demand, and ventilator respiration.” Journal of breath research 15, no. 4 (2021): 042002.
Aliverti, Andrea. “The respiratory muscles during exercise.” Breathe 12, no. 2 (2016): 165-168.
Gautier, H., J. E. Remmers, and D. Bartlett Jr. “Control of the duration of expiration.” Respiration physiology 18, no. 2 (1973): 205-221.
“Our voice resonates with life. Because this is so, it can touch the lives of others. The caring and compassion imbued in your voice finds passage to the listener’s soul, striking his or her heart and causing it to sing out; the human voice summons something profound from deep within, and can even compel a person into action.” Daisaku Ikeda
Journey with Parkinson's 