International Journal of Speech-Language Pathology

ISSN: 1754-9507 (Print) 1754-9515 (Online) Journal homepage: http://www.tandfonline.com/loi/iasl20

Expiratory muscle strength training improves

swallowing and respiratory outcomes in people
with dysphagia: a systematic review

Marinda Brooks, Emma McLaughlin & Nora Shields

To cite this article: Marinda Brooks, Emma McLaughlin & Nora Shields (2017): Expiratory
muscle strength training improves swallowing and respiratory outcomes in people with
dysphagia: a systematic review, International Journal of Speech-Language Pathology, DOI:
10.1080/17549507.2017.1387285

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International Journal of Speech-Language Pathology, 2017; Early Online: 1–12

Expiratory muscle strength training improves swallowing and

respiratory outcomes in people with dysphagia: a systematic review

MARINDA BROOKS1, EMMA MCLAUGHLIN2,3 & NORA SHIELDS1,2

1
Department of Allied Health, Northern Health, Epping, Australia, 2School of Allied Health, La Trobe University,
Melbourne, Australia, and 3Department of Allied Health, Castlemaine Health, Castlemaine, Australia

Abstract
Purpose: To investigate the effects of expiratory muscle strength training on communication and swallowing outcomes in
adults with acquired motor based communication and/or swallowing difficulties of any aetiology.
Method: A systematic review was conducted. Six databases (CINAHL, MEDLINE, EMBASE, SPEECHBYTE, AMED
and PUBMED) were searched from inception until end of May 2016. Randomised and non-randomised controlled studies
and pre-test/post-test studies published in English that investigated the effects of expiratory muscle strength training were
included. Study quality was assessed using the PEDro scale. Data were analysed descriptively and effect sizes and associated
95% confidence intervals were calculated.
Result: Seven articles reporting data from five studies were included. Preliminary data suggests expiratory muscle strength
training improved airway safety during swallowing in people with dysphagia and increased the strength of the expiratory
muscles in all patient groups. There was little evidence to suggest changes in communication outcomes after expiratory
muscle strength training.
Conclusion: Speech–language pathologists might consider using expiratory muscle strength training to improve airway safety
in adults with swallowing disorders.

Keywords: Expiratory muscle strength training; maximum expiratory pressure; dysphagia; voice impairment; speech–
language pathologist; intervention

Introduction Expiratory muscle weakness can be caused by

The expiratory muscles expel air from the lungs and
play a vital role in communication and swallowing.
Active expiration is coordinated by the internal
intercostal muscles, which lower the rib cage and
decrease thoracic volume; and the abdominal wall
muscles (internal and external obliques, rectus
abdominis and transverse abdominis), which press
the abdominal organs upwards into the diaphragm,
reducing the thoracic cavity (Sapienza & Troche,
2012). Coughing is a coordinated activity involving
expiratory muscle contraction to build up high
positive intra-pleural and intra-airways pressures
and develop peak expiratory flow rates that helps
people clear mucous and aspirated material from the
lungs. Expiratory muscle contraction also assists
communication by moving air through the airways,
and the glottis, which vibrates the vocal folds
resulting in phonation and in the case of forced
exhalation, such as in singing or yelling, by generat-
ing abdominal and thoracic pressure to push air out
of the lungs (Sapienza & Troche, 2012).
peripheral and central nervous system conditions
including stroke, multiple sclerosis and Parkinson’s
disease. Reduced expiratory muscle strength may
negatively affect a person’s ability to generate
adequate expiratory pressure for voice production,
and also result in an ineffective cough, placing
individuals at risk of not being able to clear the
airway if aspiration occurs (Sapienza & Troche,
2012). Strengthening the expiratory muscles may
improve communication by requiring less force to
produce higher sound volumes. This might be
particularly important for people with neuromuscu-
lar health conditions associated with insufficient
vocal loudness. There are fewer research studies
investigating the impact of expiratory muscle
strength training on speech function in populations
with other health conditions (Chiara et al., 2006).
However, available studies such as Wingate et al.
(2007) suggest expiratory muscle strength training in
addition to voice therapy may have beneficial effects
for people with dysphonia or benign vocal lesions.

Correspondence: Marinda Brooks, Northern Health, 185 Cooper Street, Epping, Victoria 3076, Australia. Email: Marinda.brooks@nh.org.au
ISSN 1754-9507 print/ISSN 1754-9515 online ß 2017 The Speech Pathology Association of Australia Limited
Published by Informa UK Limited, trading as Taylor & Francis Group
DOI: 10.1080/17549507.2017.1387285
2 M. Brooks et al.
Respiratory muscle strength training is a motor
exercise technique where resistive load is increased
during inspiration and/or expiration using a pressure
threshold device (Sapienza, Troche, Pitts, &
Davenport, 2011). The key principle in strength
training is progressive overload. Extensive clinical
research has been completed in this field, and
expiratory muscle strength training is an emerging
intervention option for speech–language patholo-
gists working with individuals presenting with
acquired motor based communication and/or swal-
lowing impairments that may be related to expira-
tory muscle weakness. The training aims to increase
active expiratory pressure by increasing the ability of
the expiratory muscles to generate enough force for
adequate ventilation and cough. Research has also
demonstrated that during expiratory muscle strength
training there is increased and prolonged activation
of the suprahyoid muscle group (Wheeler, Chiara, &
Sapienza, 2007; Wheeler-Hegland, Rosenbek, &
Sapienza, 2008). The suprahyoid muscle group
(digastric, stylohyoid, geniohyoid and mylohyoid) is
located above the hyoid bone in the neck. These
muscles assist in elevating the hyolaryngeal complex
and opening the upper oesophageal sphincter during
swallowing. These movements are important for
airway defence during swallowing and breathing
(Wheeler et al., 2007). Expiratory muscle strength
training has been shown to increase movement of the
hyolaryngeal complex during swallowing and
increased opening of the upper oesophageal sphinc-
ter (Troche et al., 2010; Wheeler-Hegland et al.,
2008).
Expiratory muscle strength training uses short
duration, isometric contractions of the expiratory
muscles to generate the maximum pressure to open
the pressure release valve in a handheld respiratory
pressure threshold device (Sapienza et al., 2011).
During the training the pressure threshold device is
adjusted incrementally, to progressively increase the
resistance (progressive overload). The resistance is
determined initially by measuring an individuals’
maximum expiratory pressure (MEP) using a man-
ometer, and setting the device to a percentage of
MEP for training (e.g. 75% of MEP). The ‘‘dose’’ of
expiratory muscle strength training is typically
defined in terms of the number of repetitions, sets
and training days per week. A typical example of a
training regime is five repetitions per set, with five
sets completed per day, 5 days per week, with the
device resistance set at 75% of the participant’s
MEP and progressed each week (Troche et al.,
2010).
Expiratory muscle strength training has been
shown to improve MEP in patients with neurological
and respiratory conditions (Chiara, Martin,
Davenport, & Bolser, 2006; Kim, Davenport, &
Sapienza, 2009; Pitts et al., 2009). A narrative
review exploring the benefits of expiratory muscle
strength training suggested that this intervention
may improve dysphagia secondary to neuromuscular
impairments (Laciuga, Rosenbek, Davenport, &
Sapienza, 2014). Research has also investigated the
impact of expiratory muscle strength training on
professional voice users. Wingate et al. (2007)
employed a repeated measures design, and investi-
gated treatment outcomes of a combined interven-
tion of expiratory muscle strength training and voice
therapy compared to both voice therapy alone and
expiratory muscle strength training alone in two
groups of participants presenting with dysphonia or
benign vocal lesions. Results from this study sug-
gested the combined treatment approach of expira-
tory muscle strength training and voice therapy was
more effective than either treatment alone (Wingate
et al., 2007). Research investigating the impact of
expiratory muscle strength training on speech func-
tion in neurological populations is less robust likely
due to the nature of the speech disorders not solely
being due to reduced expiratory muscle strength but
also involving motor and other impairments (Chiara
et al., 2006).
To date, there has been no systematic evaluation
of the evidence regarding the effectiveness of expira-
tory muscle strength training for individuals pre-
senting with acquired motor based communication
and/or swallowing impairments of any aetiology.
Such synthesised information would help inform
clinical practice among speech–language patholo-
gists working with these populations.
Therefore, the primary aim of this systematic
review was to investigate the effects of expiratory
muscle strength training on acquired motor based
communication and swallowing outcomes in adults
with communication and/or swallowing difficulties
of any aetiology. The secondary aims were to
investigate the effects on respiratory and quality of
life outcomes, and to describe how expiratory
muscle strength training has been applied in previ-
ous studies. Communication and swallowing dis-
orders can have a profound impact on an
individual’s quality of life, therefore understanding
how any treatment affects their daily life, is import-
ant to improving quality of care.
Method
This review was prepared and reported with refer-
ence to the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) guidelines
(Moher, Liberati, Tetzlaff, & Altman, 2009). This
systematic review was registered on the PROSPERO
database (CRD42015026722).
Search strategy
The following databases were searched from the
earliest date available through to June 2016:
CINAHL, MEDLINE, EMBASE, SPEECHBYTE
and AMED databases. PUBMED was also searched

from 2010 for more recent publications. Two con-
cepts related to the research questions were used to
construct the search strategy: (1) terms related to
communication and swallowing disorders treated by
speech–language pathologists and (2) expiratory
muscle strength training (Supplementary
Appendix 1). Synonyms for these concepts were
used in developing the search strategy. In addition to
database searches, citation tracking of the included
articles was performed using Google Scholar and
manual searches of the reference lists of these
articles were also completed.
The yields from the database searches were
imported into bibliographic software (EndNote,
version X7, Thompson Reuters, Philadelphia, PA).
Duplicate articles were removed. Using predeter-
mined inclusion and exclusion criteria, two
reviewers independently screened each item for
relevance by title and abstract. In cases where a
decision could not be made as to whether the
eligibility criteria were met based on the title and
abstract, the full text of the article was obtained and
the criteria re-applied by the two reviewers inde-
pendently. Only the items which met the eligibility
criteria at this stage were included in the review.
Disagreements were resolved by consensus.
Eligibility criteria
Studies were eligible for inclusion if they met the
following criteria: (1) participants were aged 18
years or older and had a diagnosed or self-reported
communication disorder (voice and/or motor
speech) and/or swallowing dysfunction; (2) the
intervention was expiratory muscle strength train-
ing of at least 4-weeks duration with no concurrent
interventions; (3) at least one outcome measure
was related to swallowing, communication, respira-
tory function or quality of life; (4) the article was
published in English; and (5) the study design was
a randomised controlled study, non-randomised
controlled study, pre-test/post-test study or cohort
study. Studies were excluded if they included only
healthy participants, or if only a single session of
expiratory muscle strength training was completed.
Narrative reviews, single case studies, case series
designs, abstracts, posters and opinion pieces were
excluded. The authors defined randomised con-
trolled study as outlined with the CONSORT
statement (Moher et al., 2010) as an experiment
in which two or more interventions, possibly
including a control intervention or no intervention,
are compared by being randomly allocated to
participants.
Data extraction
A customised form was developed for data extrac-
tion. The following data were extracted: character-
istics of the study participants (e.g. age, gender and
diagnoses), details about the intervention (e.g. type,
Expiratory muscle strength training for dysphagia 3
duration, frequency of intervention, resistance and
programme delivery), details about any control
group (e.g. type, duration, frequency of intervention
and who delivered the programme), intervention
setting (e.g. in-patient, out-patient and home pro-
gramme), outcome measures (quantitative and
qualitative) relating to communication and swallow-
ing dysfunction and results. Data extraction was
completed by one reviewer and reviewed for accur-
acy by a second reviewer. These are the minimum
requirements recommended by the Cochrane
Handbook for Systematic Reviews (Higgins &
Green, 2011) for the data extraction process.
Disagreements were resolved by consensus.
Assessment of risk of bias
Two researchers independently applied the PEDro
scale to rate the methodological quality of the
included studies (Maher, Sherrington, Herbert,
Moseley, & Elkins, 2003). The PEDro scale is a
validated quality assessment tool for randomised
controlled trials. Eleven items are rated as either
meeting or not meeting the criteria; a maximum
score of 10 is possible as the first item (eligibility
criteria) is not scored. The 11 items are: eligibility
criteria, random allocation, concealed allocation,
baseline comparability, blinding of assessors, ade-
quate follow-up, intention-to-treat analysis,
between group comparisons and point estimates
and variability. A study with a PEDro score of 6
is considered to be high quality (Moseley,
Herbert, Sherrington, & Maher, 2002).
Disagreement between the reviewers was resolved
through discussion until a consensus was reached
(Supplementary Appendix 2).
Data syntheses
Descriptive analysis was completed to identify and
describe the major characteristics of the included
studies. Effect sizes and 95% confidence intervals
were calculated for data from randomised controlled
studies which provided means and standard devi-
ations using web-based software (Curriculum
Evaluation and Management Centre, 2016). For
pre-test/post-test study designs, effect sizes were
calculated by measuring the difference between pre-
and post-test within group scores divided by the
standard deviation of the difference score. Where
raw data were not available, approximations were
made through comparison of the standard deviation
to the re-test estimates of reliability for relevant
outcomes or by d ¼ ptN, (where d ¼ effect size,
t ¼ reported t-test value, N ¼ number of participants)
with associated 95% confidence intervals
(Rosenthal, 1991). Effect size values were inter-
preted as follows: a small effect if 0.2, a moderate
effect if 0.5, and a large effect if 0.8 (Cohen, 1988).
Meta-analysis was not performed due to the hetero-
geneity of outcomes measures used.
4 M. Brooks et al.
Results
Study selection
The search strategy yielded 2898 potentially relevant
articles (Figure 1). After removal of duplicates, the
inclusion and exclusion criteria were applied to the
titles and abstracts of 1153 articles. There was good
agreement between reviewers when applying eligi-
bility criteria to titles and abstracts (k ¼ 0.969 95%
CI 0.926–1.000). Full-text copies for 37 articles
were retrieved. Thirty articles were excluded after
review of the full text (Figure 1). For example,
Wingate et al. (2007) was excluded because the
intervention combined voice therapy with expiratory
muscle strength training; Reyes et al. (2015) was
excluded as it used a combined intervention of
inspiratory and expiratory muscle strength training;
Figure 1. Study selection process to identify eligible articles for inclusion in the review.
Chiara et al. (2006) was excluded because the
participants with multiple sclerosis ‘‘had never
received speech therapy for any speech or voice
problem’’ and it was unclear if all participants had
dysarthria pre-treatment; Plowman et al. (2015) was
excluded as only five of the 15 participants with
Amyotrophic Lateral Sclerosis (ALS) had dysphagia;
and Hegland et al. (2016) was excluded as it was
unclear whether all participants had dysphagia.
Seven articles reporting data from five studies were
retained for inclusion in the review (Park, Oh,
Chang, & Kim, 2016; Pitts et al., 2009; Roy et al.,
2003; Sapienza et al., 2011; Troche et al., 2010;
Troche, Rosenbek, Okun, & Sapienza, 2014; Tsai,
Huang, Liou, & Kuo, 2016).
Four of the included studies were randomised
control trials (Park et al., 2016; Roy et al., 2003;
 Expiratory muscle strength training for dysphagia 5

Idiopathic Parkinson’s disease

Idiopathic Parkinson’s disease

Idiopathic Parkinson’s disease
Idiopathic Parkinson’s disease
Troche et al., 2010; Tsai et al., 2016) and the fifth
had a single group pre-test/post-test study design

Dysphagia post stroke

(Pitts et al., 2009) (Table I). The five studies

Diagnoses
included 190 participants: 70 participants with

Voice impairment

Voice impairment
idiopathic Parkinson’s disease (mean age 69 years;
18% female), 93 participants with voice impairment
and 27 with dysphagia secondary to a recent stroke
(mean age 65 years, 55% female).

Risk of bias assessment

22M 8F
22M 8F

2M 12F
Control

6M 7F
The overall average quality of the five studies was

NR
moderate (mean PEDro score was 5, range 1–9;

Gender
Table I). Two of the five studies employed blinded
assessment (Park et al., 2016; Troche et al., 2010)

25M 5F
25M 5F

1M 14F
EMST

8M 2F

6M 8F
and two studies used intention to treat analysis

10M

NR
(Troche et al., 2010; Tsai et al., 2016). There was
one high quality study that was a randomised,
blinded, sham-controlled trial where the participants

65.8 (11.3) (47–82)

and therapists were blinded to the intervention

Control
(Troche et al., 2010). The quality of the two single

Age (years) Mean (SD)

68.5 (10.3)
68.5 (10.3)
group pre-test/post-test studies was lower (Table I).

Note: EMST ¼ Expiratory Muscle Strength Training; NR ¼ not reported; RCT ¼ Randomised Control Trial; M ¼ male; F ¼ female.
There was moderate agreement between reviewers

NR

NR
when rating the quality of the included studies
(k ¼ 0.571 95% CI 0.378–0.763).

42.0 (10.6)

64.3 (10.7)
66.7 (8.9)
66.7 (8.9)
70.0 (6.4)
Description of the expiratory muscle
EMST

(50–80)
strength training
72.9

NR
Table II summarises the key features of the expira-
tory muscle strength training intervention delivered
10

60
60
10

64

29
27
in the included studies and highlight their simila-
n

rities in terms of the content of the programmes

implemented. Two studies (Park et al., 2016; Troche
Control – no intervention
Voice amplification OR
Comparison/Control

et al., 2010) included a sham control group, one

study (Roy et al., 2003) compared expiratory muscle
resonance therapy
Sham controlled
Sham controlled

Sham controlled
strength training to voice amplification and reson-
ance therapy and one study (Tsai et al., 2016) had a
no intervention control group. The programmes
ranged from 4 to 6 weeks in duration, using an
intensity of between 70 and 80% MEP. The resist-
–

ance was adjusted weekly in three studies (Pitts

et al., 2009; Troche et al., 2010; Tsai et al., 2016),
Pre-post single

Pre-post single
group study

group study
Study Design

twice in 6 weeks in one study (Roy et al., 2003) and

was not adjusted at all in one study (Park et al.,
RCT
RCT

RCT

RCT
RCT

2016). Participants in all studies were instructed

how to complete the training in a health clinic or
hospital and the intervention was completed at home
Table I. Characteristics of included studies.

PEDro Score

except for one study that was completed in the

(max 10)

inpatient hospital setting (Park et al., 2016). In two

2

8
8
1

6
7

studies (Troche et al., 2010; Tsai et al., 2016),

participants were reviewed weekly by a health
professional either in the clinic or at home. Written
instructions were provided to participants in three of
Sapienza et al. (2011)
Troche et al. (2010)

Troche et al. (2014)

the studies (Pitts et al., 2009; Roy et al., 2003;

Park et al. (2016)
Pitts et al. (2009)

Tsai et al. (2016)

Roy et al. (2003)

Troche et al., 2010). Two studies (Roy et al., 2003;

Troche et al, 2010) requested participants complete
a training logbook but data on programme adher-
Study

ence was only reported in one study (Roy et al.,

2003) that rated adherence as 4.3 out of 5.
 6
M. Brooks et al.

Table II. Characteristics of the intervention and control programmes.

Intervention Control

Frequency Description Resistance/load Description

Study Description Duration (days/week) (reps) (%MEP) Delivery Description Duration Frequency (reps) Resistance Delivery
Pitts et al. EMST 4 weeks 5 days 5 sets  5 75% MEP, Handheld device, – – – – – –
(2009) breaths ¼ 25 adjusted weekly home practice
Troche et al. EMST 4 weeks 5 days 5 sets  5 75% MEP, Handheld device, Sham EMST 4 weeks 5 days per 5 sets  5 Adjusted Hand held
(2010), breaths ¼ 25 adjusted weekly home practice device week breaths ¼ 25 weekly EMST
Sapienza et al. breaths however device,
(2011) no actual home
Troche et al. resistance practice
(2014) load
Roy et al. Respiratory 6 weeks 5 days 5 sets  5 80% MEP, Hand held treat- No control, 2 VA and RT using Daily – – –
(2003) Muscle breaths ¼ adjusted twice ment device, other therapy
Training 25 breaths in week 2 and Trained by clin- intervention programme.
using a pressure week 4 ician and groups, 1.
threshold then home VA, 2 RT.
device practice
Tsai et al. EMST 5 weeks 3 days 5 sets  75% MEP, Handheld device, No intervention – – – – –
(2016) 5 breaths ¼ adjusted weekly location not
25 breaths specified
Park et al. EMST 4 weeks 5 days 5 sets  70% MEP, not Expiratory muscle Sham EMST 4 weeks 5 days 5 sets  5 Adjusted Hand held
(2016) 5 breaths ¼ specified strength trainer device breaths ¼ 25 weekly EMST
25 breaths device, in breaths however device, in
hospital no actual hospital
resistance
load

Note: Pemax ¼ measurement of expiratory respiratory strength; MEP ¼ Maximal Expiratory Pressure; EMST ¼ Expiratory Muscle Strength Training; VA ¼Voice amplification; RT ¼ Resonance therapy.

Effectiveness of expiratory muscle strength
training
The five studies measured quantitative outcomes
related to swallowing (Park et al., 2016; Pitts et al.,
2009; Troche et al., 2010); communication (Roy
et al., 2003; Tsai et al., 2016) and respiration (Roy
et al., 2003; Sapienza et al., 2011; Troche et al.,
2010; Tsai et al., 2016). Figure 2 displays the effect
sizes for these outcomes at completion of expiratory
muscle strength training. No studies explicitly
reported on adverse events as a result of expiratory
muscle strength training.
Effect on swallowing
The effect of expiratory muscle strength training
on swallow function was evaluated in three studies
(Park et al., 2016; Pitts et al., 2009; Troche et al.,
2010), using four different outcome measures; the
Penetration–Aspiration Scale (Rosenbek, Robbins,
Roecker, Coyle, & Woods, 1996) (a validated
ordinal measure used to rate the degree of laryn-
geal penetration and/or aspiration observed during
swallowing), the Functional Oral Intake Scale
(Crary, Mann, & Groher, 2005) (a 7-point scale
used to evaluate oral intake of foods and liquids),
activity of the suprahyoid muscles as measured by
surface electromyography (sEMG) and hyolaryn-
geal movement analysed via digital recordings
post-Videofluorscopy Swallowing Studies (VFSS).
All three studies (Park et al., 2016; Pitts et al.,
2009; Troche et al., 2010) reported a reduction in
scores on the Penetration–Aspiration Scale after
expiratory muscle training intervention. These
results suggest that an intervention targeting
expiratory muscle strength and activation of the
suprahyoid muscle group resulted in decreased
aspiration, with a large effect for fluids and a
moderate effect size for solids (Figure 2). It is
important to highlight that Troche et al. (2010)
reported 11 participants had improved
Penetration–Aspiration Scale scores following the
training programme as compared to five in the
sham group. Furthermore, the Penetration-
Aspiration scores of three participants had deterio-
rated following the intervention compared to 16 in
the sham group. This study also reported that the
number needed to treat to gain one additional
benefit was 1.8 (95% CI 1.2–3.4). Despite the
small participant numbers reported, mean
Penetration–Aspiration Scale scores improved for
the expiratory muscle strength training group only
(0.61  1.43; 95% CI 0.10–1.11) and age and
disease severity had no significant influence on
treatment effects (Troche et al., 2010). Raw scores
for penetration and aspiration numbers were not
reported by Park et al. (2016).
Detraining effects on swallow function were
investigated in a small convenience sample of 10
participants with Parkinson’s disease three months
Expiratory muscle strength training for dysphagia 7
after expiratory muscle strength training programme
was discontinued and found mean scores remained
17% above baseline values (Troche et al., 2010).
Seven participants had no change in their
Penetration–Aspiration Scale scores, one partici-
pant’s scores had deteriorated, and two participants
had improved scores (Troche et al., 2010). This is a
small participant sample and so these data (includ-
ing their generalisability to the broader population)
should be interpreted with caution.
Park et al. (2016) demonstrated a significant
improvement in activity of the suprahyoid muscles in
favour of the expiratory muscle strength training
group. Troche et al. (2010) study revealed that there
was no statistically significant change in the duration
of hyoid movement over time in the expiratory
muscle strength training group, but there was a
significant decrease over time for this outcome in the
sham group.
Effect on communication
Two studies (Roy et al., 2003; Tsai et al., 2016)
investigated the effect of expiratory muscle strength
training on communication outcomes. Both studies
used voice related quality outcome measures as their
primary outcome measure. Roy et al. (2003) found
no reduction in perceived voice handicap as mea-
sured by the Voice Handicap Index (Jacobsen et al.,
1997), which assesses self-perceived psychosocial
consequences of voice disorders, nor demonstrated a
reduction in self-perceived voice severity, in the
group allocated the expiratory muscle strength
training intervention. Tsai et al. (2016) found
significant improvement in self-awareness of vocal
symptoms in the domains of ‘‘effects on work’’ and
‘‘effects on mood’’ in favour of the expiratory muscle
strength training group using a questionnaire
designed specifically for their study (Figure 2).
Tsai et al. (2016) also reported no change in
maximum phonation time (maximum time in sec-
onds for which a person can sustain a vowel sound
when produced on one deep breath) and s/z ratio (a
measure of vocal adduction efficiency and laryngeal
control) after expiratory muscle strength training.
Maximal phonation time and s/z ratio measures have
been suggested for diagnostic use in voice evalu-
ations. Limited normative data are available for
maximum phonation time in healthy older individ-
uals, and research reporting normative data for s/z
ratios has been inconsistent with differing proced-
ures and practice effects impacting the reliability and
validity of this measure (Gelfer & Pazera, 2006).
Tsai et al. (2016) did not report clear procedures or
the inter-rater reliability scores for either of these
outcomes. Standardised procedures for maximum
phonation time and s/z ratio would improve meas-
urement of these outcomes within studies, diminish
the impact of errors and improve the ability to
reliably measure treatment effects (Maslan et al.,
2011).
8 M. Brooks et al.

Figure 2. Standardised mean differences and 95% confidence intervals for swallowing outcome measures respiratory outcomes measures
and communication outcomes measures for expiratory muscles strength training. *RCT, }pre/post, ^pre-/post-data from single group
within a RCT.

Effect on respiration muscle strength training intervention (Figure 2).

Four studies (Pitts et al., 2009; Roy et al., 2003;
Troche et al., 2010; Tsai et al., 2016) investigated
the effect of expiratory muscle strength training on
respiratory outcome measures and found improve-
ments in MEP across all studies post-expiratory
Additional MEP data of only half of the participants
allocated into the expiratory muscle strength group
(n ¼ 12) was provided by Roy et al. (2003) for
participants randomly allocated into their expiratory
muscle strength training group. Results from these

four studies suggest the intervention was effective in
improving MEP scores using an expiratory muscle
strength training intervention. Pitts et al. (2009) also
reported improvements in some parameters of the
cough wave form (e.g. cough acceleration volume)
related to increased effort in the expiratory phase of
respiration. Parameters of the cough wave form
dependent on pulmonary function did not change
significantly due to 80% of the participants with
Parkinson’s disease in this study having restrictive
lung disease. No improvement in pulmonary func-
tion parameters was demonstrated in two studies
that investigated this outcome (Troche et al., 2010;
Tsai et al., 2016).
Effect on quality of life
Only one study (Troche et al., 2010) evaluated the
effect of expiratory muscle strength training inter-
vention on quality of life. This study reported an
improvement in swallowing-related quality of life
overall (F ¼ 3.007, p ¼ 0.007) but found no differ-
ence between the groups that received active and
sham expiratory muscle strength training
intervention.
Discussion
Data from this review found that expiratory muscle
strength training improved maximal expiratory pres-
sure scores across four studies including participants
with different conditions: people with Parkinson’s
disease, stroke survivors and people with self-
reported voice problems (Pitts et al., 2009; Roy
et al., 2003; Troche et al., 2010; Tsai et al., 2016).
This review also provides preliminary evidence that
expiratory muscle strength training may be effective
in improving airway protection in adults with
dysphagia secondary to Parkinson’s disease or
stroke (Park et al., 2016; Pitts et al., 2009; Troche
et al., 2010). This could have significant implica-
tions for the management of dysphagia by speech–
language pathologists in the health setting as effect-
iveness of airway protection and the presence/
absence of penetration and/or aspiration are often
key factors underpinning a variety of safe swallowing
recommendations (Troche et al., 2010).
Preliminary evidence from three studies suggests
expiratory muscle strength training may improve
airway protection in adults with dysphagia (Park
et al., 2016; Pitts et al., 2009; Troche et al., 2010).
These studies found a reduction in participant
scores on the Penetration–Aspiration Scale after
expiratory muscle training, that is, less laryngeal
penetration and/or aspiration was observed during
swallowing. This indicates a functional improvement
in airway protection. Superior and anterior hyolar-
yngeal excursion is the pattern of movement directly
involved in airway protection and clearance of
material through the pharynx. Improved airway
protection as a result of expiratory muscle strength
Expiratory muscle strength training for dysphagia 9
training is probably related to a change in supra-
hyoid muscle function. The suprahyoid muscles are
responsible for elevation of the hyolaryngeal com-
plex and opening the upper oesophageal sphincter
during swallowing (Wheeler et al., 2007). Research
shows targeted exercise can activate the suprahyoid
muscles in stroke survivors with dysphagia (Shaker
et al., 2002), producing improved swallow outcomes
by increasing anterior hyolaryngeal excursion and
opening the upper oesophageal sphincter (Shaker
et al., 2002). There is also preliminary evidence
from sEMG studies in healthy participants showing
that expiratory muscle strength training increases
the timing and amplitude of suprahyoid muscle
activity (Wheeler et al., 2007). This suggests that
expiratory muscle strength training increases motor
unit recruitment of the suprahyoid muscle complex
(Wheeler et al., 2007). Together this literature
suggests that speech–language pathologists may
implement expiratory muscle strength training as
one way to achieve improved airway protection in
patients with dysphagia. Studies are needed to
compare expiratory muscle strength training and
other more traditional ways of improving swallowing
safety.
The effect of expiratory muscle strength training
on voice function remains unclear and there is no
conclusive evidence supporting this intervention in
isolation for voice therapy. Roy et al. (2003)
acknowledge that within their participant group
they did not define/diagnose the precise nature of
voice disturbance or identify severity of vocal fold
pathology. Nonetheless, despite significant changes
in MEP following treatment, this did not translate
into functionally perceived voice improvements by
participants (Roy et al., 2003; Tsai et al., 2016). It is
clear that further research is needed, utilising func-
tional communication outcome measures, to identify
which populations benefit from expiratory muscle
strength training as a clinical utility in relation to
motor based communication impairments.
Overall, there is a paucity of research investigating
the effects of expiratory muscle strength training,
among people with swallowing and/or acquired
motor-based communication impairments, on out-
comes relevant to speech–language pathologists.
Only three studies (Park et al., 2016; Pitts et al.,
2009; Troche et al., 2010) assessed swallow related
outcomes and two studies (Roy et al., 2003; Tsai
et al., 2016) assessed communication. Therefore, it
is unclear if individuals with dysphagia caused by
neuromuscular or neurodegenerative conditions
other than Parkinson’s disease or stroke would also
benefit from expiratory muscle strength training.
Further research is required to understand the range
of individuals with acquired motor based communi-
cation and swallowing impairments who might
benefit most from this intervention and the optimal
time to intervene.
10 M. Brooks et al.
The strength training literature recommends
programmes of at least 6 weeks’ duration to observe
changes in muscle strength and implementing the
principle of progressive overload (i.e. need to con-
tinually increase the exercise demands on the
muscle) (Burkhead, Sapienza, & Rosenbek, 2007).
An expiratory muscle strength training hand-held
device as utilised in the reviewed studies can be
adjusted to increase the load or resistance of the
training. None of the included studies implemented
both of these recommendations. The three studies
that included progressive overload were of less than
6 weeks duration (Pitts et al., 2009; Troche et al.,
2010; Tsai et al., 2016) and the one study that
implemented a 6-week programme did not apply
progressive overload (Roy et al., 2003). It is unclear
if a 6-week programme combined with progressive
overload would have resulted in greater change in
the swallow and communication outcomes mea-
sured. Further research is also needed on the
adherence of participants to the training programme
as this was not documented adequately in any study.
Adverse outcomes were not reported by any
study. Completion of the intervention each day
does require a small time commitment; however, no
reports of hardship or burden were reported.
Anecdotally, improved swallow function for individ-
uals with dysphagia is a strong motivator.
Swallowing rehabilitation techniques aimed at res-
toration of function provide an opportunity for the
individual to actively participate in their rehabilita-
tion and recovery. Troche et al. (2010) concluded
from their study that in addition to expiratory
muscle strength training being beneficial it was also
not considered burdensome for patients and can
result in improved quality of life.
Expiratory muscle strength training has been
investigated in other populations including seden-
tary older adults, and people with multiple sclerosis,
chronic obstructive pulmonary disease, spinal cord
injury, myasthenia gravis, ALS and Huntington’s
Disease, among others. We acknowledge that there
are other studies that are potentially relevant to this
area that were not included in this review as it was
unclear if the participants in these studies had an
existing communication and/or swallowing impair-
ment (Chiara et al., 2006; Hegland et al., 2016;
Plowman et al., 2015) or because a combined
intervention was employed (Reyes et al., 2015;
Wingate et al., 2007). This highlights the need for
speech–language pathologists to advocate for
improved reporting of participant characteristics in
publications and the inclusion of participants with
communication and swallowing difficulties in clin-
ical trials. It is important that studies in these
population groups more comprehensively describe
the characteristics of their participants in relation to
communication and/or swallowing to enable clin-
icians to ascertain the clinical utility of expiratory
muscle strength training and other interventions for
their clients.
Several of these excluded studies do have results,
relevant to speech–language pathologists, in clinical
populations that often present with acquired com-
munication or swallowing difficulties during the
trajectory of their disease (Chiara et al., 2006;
Hegland et al., 2016; Plowman et al., 2015; Reyes
et al., 2015). Many of these excluded studies report
significant improvements in MEP post-expiratory
muscle strength training intervention (Chiara et al.,
2006; Hegland et al., 2016; Plowman et al., 2015) as
found in this review. However, these excluded
studies report mixed results on the effect of expira-
tory muscle strength training on dysphagia. For
example, there was no significant reduction in
Penetration–Aspiration Scale scores after expiratory
muscle strength training in a group of stroke patients
(Hegland et al., 2016) or in five people with ALS
(Plowman et al., 2015). One excluded study also
reported no change in voice production outcome
measures or voice related quality of life in people
with multiple sclerosis (Chiara et al., 2006). Further
research is important to investigate the benefit of
expiratory muscle strength training in conjunction
with a swallow specific or communication specific
rehabilitation programme in patient groups with
conditions of neurological aetiology.
This review was registered with PROSPERO and
used a broad search strategy to identify the evidence
base. However, the final yield was small, comprising
seven articles that reported outcomes for five
studies. Five of the seven articles included were
generated by the same research group (Pitts et al.,
2009; Troche et al., 2010, 2014) and it is unclear the
extent to which the participants recruited to these
studies overlap. Therefore, participant duplication
cannot be ruled out as a source of bias. The available
data from the five included studies were also
heterogeneous representing different diagnostic
groups (dysphagia and voice impairment), and in
one case (Roy et al., 2003) additional data on MEP
was provided for 12 participants who had been
randomly allocated to the expiratory muscle strength
training group.
Other limitations of this review include that only
English language articles were considered. However,
the titles and abstracts of articles written in other
languages were reviewed, and none appeared to
meet the inclusion criteria. Research using more
than one or combining multiple interventions, such
as expiratory and inspiratory muscle training were
also excluded. This was to ensure that any change in
outcome measures could be attributed solely to the
expiratory muscle strength training programme. We
also excluded data that had not been published in a
peer-reviewed journal and therefore grey literature
that may include other relevant data were not
included in the review. Finally, it is also acknowl-
edged that a further limitation of this review is the

use of the PEDro scale to assess the methodological
quality for non-RCT trials as this scale is designed
for randomised controlled trials. However, non-
randomised controlled trials and pre-test/post-test
studies are less robust than randomised controlled
trials and their lower scores on the PEDro scale
reflect this. An alternate approach would have been
to use two quality assessment scales to assess
randomised controlled trials and non-randomised
controlled trials separately but this was not per-
formed as a direct comparison of methodological
quality across included studies would not be
possible.
Conclusion
There is preliminary evidence that expiratory muscle
strength training may improve respiratory and swal-
lowing outcomes in individuals with dysphagia due
to Parkinson’s disease or stroke. Expiratory muscle
strength training may have application for individ-
uals presenting with acquired motor based commu-
nication impairments. However, further research
needs to be conducted using specific, reliable and
valid communication outcome measures in specific
populations with clear participant descriptions high-
lighting pre-morbid/pre-existing communication
and/or swallowing impairments. At this stage, the
optimal programme design is unclear; however, it is
recommended that training programmes be at least 6
weeks long and employ progressive overload.
Further research is required to help determine how
best speech–language pathologists can incorporate
expiratory muscle strength training into their clinical
practice.
Declaration of interest
The authors report no declarations of interest.
ORCID
Nora Shields http://orcid.org/0000-0002-6840-2378
Supplementary material
Supplemental data for this article can be accessed at
https://doi.org/10.1080/17549507.2017.1387285.
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