Recently I watched the movie Soul Surfer, about a young surfer who lost her arm in a shark attack. Surfers, snowboarders, and professional skateboarders are examples of athletes with incredible core strength. Core muscles improve your balance and stability, and in fact you need to build a stable core before you can build strength anywhere in your body, and a weak core results in bad posture and injuries.

Core exercise is a component of almost any exercise program whether you are an elite athlete or an average person trying to stave off the effects of aging. Performing core exercises for older adults can help prevent falls, decrease back pain, and help to maintain independence for longer.

Your core encompasses 29 different muscles, including muscles involved in breathing as well as those connected to your pelvis or spine. These muscles, including your oblique muscles, upper and lower back muscles, and glutes, are necessary to do virtually any physical activity from picking up a tissue off the floor to swinging a golf club to twisting around to look behind you. Your core acts as a stabilizer for the rest of your body, and a weak core increases your fall risk. 

If you are someone with Parkinson’s or a related disease diagnosis, you won’t be surprised to hear that the number one concern patients often report to me on their initial visit has to do with balance and fear of falling. In Parkinson’s, decreased physical activity and subsequent weakness often occurs with disease progression. Decreased muscle force production and general muscle weakness is associated with a deficit in the central activation of muscles leading to a generalized loss of skeletal muscle mass and strength with resulting sarcopenia. (age related loss of muscle mass). A higher prevalence of frailty in persons with PD has been documented and factors such as lifestyle alteration caused by decreasing motor function, malnutrition caused by movement and swallowing problems, and neuroinflammation are thought to be involved.[i]

Respiratory muscle fatigue can contribute to swallowing problems, in particular, altering the respiratory-breathing pattern that is required for airway protection. Weak and stiff muscles also may make it difficult for the person with PD to sustain sufficient airflow and air pressure for speech.

[1] Wu YN, Chen MH, Chiang PL, Lu CH, Chen HL, Yu CC, Chen YS, Chang YY, Lin WC. Associations between Brain Structural Damage and Core Muscle Loss in Patients with Parkinson’s Disease. J Clin Med. 2020 Jan 16;9(1):239. doi: 10.3390/jcm9010239. PMID: 31963202; PMCID: PMC7019762.                                          Photo surfer

How Can Respiratory Muscle Training Help?

Currently, there are no disease-modifying therapies to prevent or slow down or reverse the neurodegenerative process associated with Parkinson’s and related diseases. Available therapies are symptomatic and act to improve the symptoms related to the dopamine deficit in the brain.

Exercise and physical activity have been proposed as interventions that could both decrease the risk of developing PD and modify the course of the disease.

Exercise programs typically comprise four core elements: aerobic and endurance training, strength training, flexibility training, and balance. There are many published reports of exercise benefit for persons with PD when following a particular protocol, but comparison of studies, like in much of research, is difficult due to study design, participant variables and methods used to evaluate results. Consequently, an exercise prescription that would suit all persons with PD has not been identified. But then, that should not be a surprise since we all are drawn to different forms of exercise, and in any given week may dance for endurance and aerobic training, lift weights for strength and use resistance bands for strength and endurance training that more closely mimics everyday movements.

What is RMT? 

Respiratory muscle trainers (RMT) are hand-held devices that are designed to improve the strength and use of the respiratory muscles, and thereby facilitate cough strength and mucus clearance, and provide increased strength and stability to the core. Respiratory abnormalities may become more pronounced with advanced PD due to autonomic failure, dyskinesia and other motor fluctuations, and weakness of upper airway muscles. When the muscles of breathing are weak due to an underlying illness or disease individuals may be at higher risk for development of pneumonia or other respiratory problems.

Improving and maintaining strength of the respiratory muscles should be a consideration for individuals with Parkinson’s or related disease diagnosis. Respiratory muscle strength training (RMST) can be conducted using various devices with the primary design distinction being a pressure threshold or flow resistance device. RMT devices can also focus on expiratory muscles only, inspiratory muscles only, or a combination of both. Just as we have a variety of options for strength training of skeletal muscles, e.g., free weights, cybex machine or resistance bands, the type of RMT device selected may depend on a persons baseline level of functioning, including pulmonary status, personal preference, and the outcome they hope to achieve (e.g., strength? endurance? co-ordination of breathing-swallowing?)

Which Device is Best for You or Your Patients to Use?

While there are a few published studies documenting benefit from expiratory muscle strength training for persons with PD using a threshold device, there are no published studies comparing threshold and flow resistance devices using the same methods and outcome measures, and so, the device recommended to you by your therapist may be based on personal preference and experience. In addition, device manufacturers spend thousands of dollars to bring a device to market, and so their own marketing efforts will naturally be biased towards the use of their own device. 

Don’t be afraid to try more than one type of device. In fact, many of my patients have several RMT devices. They may add a device as they gain strength or change devices if they desire more integrative strength training by targeting inspiratory AND expiratory muscles. Strengthening the respiratory muscles using an RMT device can follow some of the same principles applied in whole body workouts which often use a variety of techniques to improve flexibility,strength, power, endurance and agility, and coordination. Using your RMT device while seated on a stability ball or standing on a balance trainer in physical therapy may further engage the core and strengthen muscles. 

Disclaimer: The Breather is a combined inspiratory-expiratory respiratory muscle trainer (cRMT) that was introduced to my practice in the mid 1990’s by a pulmonary rehabilitation therapist. I reached out at that time to its inventor, Peggy Nicholson, a respiratory therapist, inquiring about its use with patients who had a tracheostomy and were on a ventilator, as that was the population I was working with at the time. We forged an interest in continuing to investigate the benefits of cRMT use for patients receiving speech therapy for voice and swallowing problems. In 2016, I approached the manufacturer, PN Medical about distributing their product through my website. I also reached out to the manufacturer of a pressure threshold device, EMST-150, but at that time, the company had a different distribution model. I frequently recommend either device as well as several other PEP (positive expiratory pressure) devices to patients depending on their symptoms, therapy goals, and baseline level of functioning.

Just as no two people are alike, exercise aproaches or therapy goals cannot be the same for every person, and it is important for you and your therapists to identify what symptoms you hope to ameliorate or function you hope to improve and identfiy the approach that you are WILLING and ABLE to do!

The Breather is available from Voice Aerobics and also on Amazon along with the EMST-150 and various other RMT devices.

                                                      RMT kit with manometer provides targeted feedback

When using the Breather, I combine it with a medical manometer, which provides feedback regarding pressure generated with each expiratory breath and is helpful during training and setting resistance.

Visit the Voice Aerobics website to learn more:

My MissionTo enlist individuals in their treatment, and help them express their personality & spirit through voice. To educate  and empower. Mary Spremulli, MA, CCC-SLP * FiTOUR® Group Exercise Instructor * Voice Aerobics® A Whole Body Approach to Voice Practice

             Voice Aerobics the heART and Science of Voice Practice