<%BANNER%>

Physiological Effects of Expiratory Muscle Strength Training with the Sedentary Healthy Elderly: Pulmonary, Cough, Swall...

xml version 1.0 encoding UTF-8
REPORT xmlns http:www.fcla.edudlsmddaitss xmlns:xsi http:www.w3.org2001XMLSchema-instance xsi:schemaLocation http:www.fcla.edudlsmddaitssdaitssReport.xsd
INGEST IEID E20110218_AAAADK INGEST_TIME 2011-02-18T20:36:30Z PACKAGE UFE0013643_00001
AGREEMENT_INFO ACCOUNT UF PROJECT UFDC
FILES
FILE SIZE 8550 DFID F20110218_AACGRF ORIGIN DEPOSITOR PATH kim_j_Page_147thm.jpg GLOBAL false PRESERVATION BIT MESSAGE_DIGEST ALGORITHM MD5
435bc8d1eefdc62af9abec3ed8170a37
SHA-1
1b22a624bb3e2ce475456d26a2b10016f4a57c39
8587 F20110218_AACGQR kim_j_Page_133thm.jpg
360ec19b5ebe3a42a9ddceb360b8bfed
f952a05f6c52dc53cb3ebaf18ec2b9171e4b1751
2761 F20110218_AACFOD kim_j_Page_149.txt
313ae5271934a57130e38f6b9e03b07a
1b9fa96b3048205b57e11a6e23f37557d9217009
2314 F20110218_AACFNP kim_j_Page_135.txt
0fc8f0ca5794a3888d0719b33173bd29
118b1d0377c8cea61b146e4a8ab915b4443ad373
8851 F20110218_AACGRG kim_j_Page_148thm.jpg
db00dcef72a14540e73cfc1fed2b20d4
8d4f68ef814750d9f62d1d2a86a497bbe01dd27c
8514 F20110218_AACGQS kim_j_Page_134thm.jpg
e0c95a131678e671d5675453ccca3836
4e33b8243d74aa33d10722197b01a42eec32e0c1
2654 F20110218_AACFOE kim_j_Page_150.txt
54464092167f6055082e1ea7a0c00829
c81f787daed77fff575791646ef621ae8ac0684a
2591 F20110218_AACFNQ kim_j_Page_136.txt
f149e542db485afab2314c66ad21f0ca
a507f9dc5a119a517738ee96c2f0c88770b0a7c0
8733 F20110218_AACGRH kim_j_Page_149thm.jpg
55dc0c0fdf633ae8061bf796e92ed3dc
ca2d785410cda6fd09c2a23df884245968109c4d
8027 F20110218_AACGQT kim_j_Page_135thm.jpg
a7eacc4181c3c9390b0c45d3509a21c2
b1254c369783c6a9317b6ae04f15f24138d27f46
1546 F20110218_AACFOF kim_j_Page_151.txt
67caabb2fedea3710f062dda3c5ceeef
56da6c73d67da8e83ad8b24c539c0ca1e04ca5fa
2549 F20110218_AACFNR kim_j_Page_137.txt
b327f8473ecaae91ab260e53b115d46d
e879791e85dda65487d6e779f3471eaa9abc3b1a
8674 F20110218_AACGRI kim_j_Page_150thm.jpg
6370be3102c697681d854101f10202b3
55d0f360243520684b3d73e45b8579dab933cec8
8496 F20110218_AACGQU kim_j_Page_136thm.jpg
51dc9ae2252041cb2c74e41c83a38f8c
690fa32d5347f3c67380f824e45680dcfa0d38f6
1217 F20110218_AACFOG kim_j_Page_152.txt
69d8b92d91588bb239e819c0b6938657
175db924a0afed86b95927c6c33f1b0b3d09dca9
2859 F20110218_AACFNS kim_j_Page_138.txt
2180c9dfaf85784667850521e83765b6
27ae2af74345ec8e8cb32d2e8c723d3ea50cbe7a
5503 F20110218_AACGRJ kim_j_Page_151thm.jpg
34758e9aa04c20fe56899817ae578b27
1f16a82bd049324baba03a85a69bc03adfc72caa
8438 F20110218_AACGQV kim_j_Page_137thm.jpg
1d8c7b9313278d29aa7aecdb0ea66ee8
d01bb5b61b3c20f9b6b8cd386e6e93f5244654bb
9732 F20110218_AACFOH kim_j_Page_001.pro
78b12958fa17743dfd55453bc930322a
f3a794724041c13ad7b4e7b040140bb94db5082b
2533 F20110218_AACFNT kim_j_Page_139.txt
64d382f9df7422a2d529640d4265c7b8
fd0538af4280d6d74a19d318be9e58d2ca173622
5198 F20110218_AACGRK kim_j_Page_152thm.jpg
182cfaf4cb625484c025b51a7ae0ff6f
41a76664a247beb97da43cfcaafb09591bcecd52
9054 F20110218_AACGQW kim_j_Page_138thm.jpg
7aaec0f39573a64bcc2a135e2de42690
f5afbceb534ffaf4504e245a44557123209b21a1
1042 F20110218_AACFOI kim_j_Page_002.pro
31688648514cccba1bd2822908a2fc8a
128eeca48a2dd33f055461f4977c0c5c2ba2f750
2569 F20110218_AACFNU kim_j_Page_140.txt
bef7b2c4a2e5d3ff5a762679c471df65
0e6106cebca5e44241d18436f85f9c05e9798532
774965 F20110218_AACGRL kim_j.pdf
cacd8b7a6874848cd48cdaa3741ebb35
97c74ef88b6cab4ce159738f8532f8b28a57f397
8563 F20110218_AACGQX kim_j_Page_139thm.jpg
789fdac16b9d3d520d7580415e0315a9
d4ef6117d784fc3c9c286ef9509fe7c48c753f0f
2665 F20110218_AACFOJ kim_j_Page_003.pro
b7057b1b7ad03d297220480c633c0fc6
58c3d4ddf56e6cb096d5feca57cc58635166b815
2361 F20110218_AACFNV kim_j_Page_141.txt
72f87be1563aff356a4e148f364d9e54
c7206f2ff3e2024b33934db0e4e05852ea215a7e
176859 F20110218_AACGRM UFE0013643_00001.mets FULL
2efe48837d1aed27139b618b40cbb3d6
570aaf4ff0c293c1c477677c16644ec969db4976
8483 F20110218_AACGQY kim_j_Page_140thm.jpg
c2c6eecec553c1b90d822af198088203
76dd70d29306a7d6253634be28b6c82c30f5e818
41043 F20110218_AACFOK kim_j_Page_004.pro
c3340e5eae6682a967f5ab54d9530579
1dac3c55cad9a1b80f59545a24c07e4cd413729c
2305 F20110218_AACFNW kim_j_Page_142.txt
a6bd48a4346722e6a6ea54a8a541ff6b
21069be2ae129a74223ac3f3f00dfb69855b1d57
8045 F20110218_AACGQZ kim_j_Page_141thm.jpg
190b35cb3e25fb6b36b49037e04349ef
1c02831e70b482d91f7d4dcacaf035dfbcc7e517
18568 F20110218_AACFOL kim_j_Page_005.pro
59d9074d96f8e0f9891b292f255af085
a5eb239bc4ac752ed2aa00dcb7e69406134289f6
2523 F20110218_AACFNX kim_j_Page_143.txt
b49c748a0ed572d99b53526305372c88
d6626f74345032a421e2ad53dd685d566f38a344
80482 F20110218_AACFOM kim_j_Page_006.pro
cca93a7222c6522ea2b2fa8a5913de83
1a6f80992381d73271c587a2907b0e0685624991
49452 F20110218_AACFPA kim_j_Page_020.pro
3da9e6540b5bfaa633eef4690fafdfba
c88373d865b25351d73127622af1bf78d684de73
55153 F20110218_AACFON kim_j_Page_007.pro
663027ff1b3ff89c09757bc8932d69c5
7c8854154da5b0ced35865b25eb164b266280a06
2537 F20110218_AACFNY kim_j_Page_144.txt
6b969711d6484194292d0f4341fabf8c
f6c621e729d60b0d26bcdeb96bfada9dbbcb7330
51506 F20110218_AACFPB kim_j_Page_021.pro
d16d47e44a2d6c2b8551bfaa6d0eaaab
a1e513156473982b954a6c4b0b215e5412dc4885
57930 F20110218_AACFOO kim_j_Page_008.pro
58d0c448bd6e2bd74a55433ba6f82ac2
1a47833fe9015b91c1ba9987f2cfe3bb91ba3899
2631 F20110218_AACFNZ kim_j_Page_145.txt
4fff20a3747e4c1ae30a9cb4475c20e4
845ad1c69fb580d1c11e53714680260a26afda6d
50636 F20110218_AACFPC kim_j_Page_022.pro
7905532040016828cf8f03d91c1c8734
0390cb05a67b91ff42fc47a4e898c7873efd2694
46107 F20110218_AACFOP kim_j_Page_009.pro
e9e6c19778dbac6030ed22afa676899b
5cdfc7a5dabad68a55f272f5888debcf51c2cd80
48510 F20110218_AACFPD kim_j_Page_023.pro
31d1b3a07a9af2f895b162919839f93f
ae1b14fe6588649c7cc57509114188d15ae76c3c
50804 F20110218_AACFOQ kim_j_Page_010.pro
d72953eefedce6f92e1315b8ecba9520
1ef47f4f10852cdfc4d1e0c3118eae005077c733
62450 F20110218_AACFPE kim_j_Page_024.pro
98528502f4dcf56c152f833852627c2e
c635f84e95b08898d0af59a51bd29eb908591bb9
39757 F20110218_AACFOR kim_j_Page_011.pro
21e2e84d78cfaba5e71ef0066ccd3fe6
8472dd37e6f282ade540c293fead6a201e1b9079
50766 F20110218_AACFPF kim_j_Page_025.pro
ababf89f8ad26a16017b0f0b281c2934
94374858e3d674885090652284f9ac924cf0f9c6
37839 F20110218_AACFOS kim_j_Page_012.pro
97ffb36e5aeefddc79c7f1519a2d0ae0
23507d1f4ee90b76763707f7e243ca229dba1f7c
50498 F20110218_AACFPG kim_j_Page_026.pro
c5eb99e154ce83fe08265280028af2ad
6d93e01aa6add4c46c5c750a5f0d1113a8e710d2
44765 F20110218_AACFOT kim_j_Page_013.pro
5d174b41c5aa493aead948f39ccea338
b60f61c94cae69e5535694f54fc7942a63439e89
50903 F20110218_AACFPH kim_j_Page_027.pro
7cea43642f0150d6f609c6bfca91690d
742e60ac1ed7aceb3b883c048676de578da6fccb
53252 F20110218_AACFOU kim_j_Page_014.pro
627dcc2c3b8b57189009fe656221e61d
5b21fed56c102749a1cf69ee0f3dde10c6d9c67d
50217 F20110218_AACFPI kim_j_Page_028.pro
4f4773423d1856cfd1c79f978b0c87b6
80a774a20725c315c06705c0ecf81c6cff2211ad
51165 F20110218_AACFOV kim_j_Page_015.pro
76b3824ff64e34d0260c618ac463ef1b
018e1e6c55fc97c29ab0972750d930744e7d87f6
48159 F20110218_AACFPJ kim_j_Page_029.pro
df83e48901be6bbb1216e890166dadcd
db245b1767676fffd6c3a16bfd0d700ca2601cd9
52379 F20110218_AACFOW kim_j_Page_016.pro
369447e1fd225ca7364416af8fd025a8
add514b729aa2ca73d93678018df0f0fbcceef81
86414 F20110218_AACFPK kim_j_Page_030.pro
0ea9ca69b81e5c947092cdf121028cec
573935e2e96e0df6cc502765e2e0ce3540cce928
52210 F20110218_AACFOX kim_j_Page_017.pro
11e1060c0a8aea89a6f89aa35e508489
263ec8ab325c4fc93c9a10944809bc3079278942
50646 F20110218_AACFPL kim_j_Page_031.pro
c45b86d16d6df2f9432ca235c24e5352
1097ed0221b5a94c55a1396635946e13ad4c170b
51747 F20110218_AACFOY kim_j_Page_018.pro
86bd42188f165326f4a58438054a56dd
2baabb26940be5ca1fe07ce80e7e42d97ab08140
47066 F20110218_AACFQA kim_j_Page_046.pro
3b254b2a83f5bf9fdcd2a8ec6a8b681b
e63bfca3111997fcd505168f595b1add6272cdba
48644 F20110218_AACFPM kim_j_Page_032.pro
3987d76ffc0be69ad477d6c2caddd888
b24465be8b8b662e9211d4e2b4b242006aeb0935
55603 F20110218_AACFQB kim_j_Page_047.pro
9d4fe8620fda4d4f9862605bb417c228
35c8c127727c5c5edc6d49660270b2e30bec02eb
49775 F20110218_AACFPN kim_j_Page_033.pro
5b3861c67da2645352838b08efb11c74
4a98a4dcd83ca192ecac1303916c8aed4c1bc045
49752 F20110218_AACFOZ kim_j_Page_019.pro
bb9906c7daf7f472adc38a93022767dc
167230fd8f35b0a8d3456889af32d9f6767d556d
46015 F20110218_AACFQC kim_j_Page_048.pro
c24782382948304fc35119a096b645a2
45003e5865bc15ff7875e9d19bdd09fcd301f5aa
51988 F20110218_AACFPO kim_j_Page_034.pro
bc7ebec65f97ac48b63d361864df8f11
815c2856e0e479130d2338d200561ef2baa2e718
45764 F20110218_AACFQD kim_j_Page_049.pro
0f930191b9c8f9db87f21e5cfc1a49d7
442778928b5f61c83158ace31151104bdb358511
50808 F20110218_AACFPP kim_j_Page_035.pro
84d3b4b57d9654f6de198dc350625e85
91453c1ff5edf650f8dae33c79770cc59f7da6ff
46443 F20110218_AACFQE kim_j_Page_050.pro
af37a1e38534d9545ba53ed687fef68f
2dbea7e71a79508ed98cf3fc11607c22b1e0ffec
48849 F20110218_AACFPQ kim_j_Page_036.pro
13785fbeab52b678eb3a3673c52250e6
d00652f33759a9f4a3b8f4e1e610edb35f2ec86b
51853 F20110218_AACFQF kim_j_Page_051.pro
54fea18accd7ede524e6ddae93b79084
e2546a7a5c79036e63cb68fafdc5d0eb93e4a653
51123 F20110218_AACFPR kim_j_Page_037.pro
c7e8342a160ac11712eaa6dd58cf021d
f3e1e4792c94f94101bd993e55dd1c899dbd485f
14524 F20110218_AACFQG kim_j_Page_052.pro
bd4f2c73d90410e83f2b7edc6dafb0ee
cb479aa7a3df5ce66b4a35d330d113ee8c641ab6
50366 F20110218_AACFPS kim_j_Page_038.pro
f5453a60685803067b49439bbd8e1818
df4b4bab767bb503a1f88ecf69c05e7438aaf4fd
48534 F20110218_AACFQH kim_j_Page_053.pro
2e830347aa8fecb26a73578370f2b35b
3f0994b085ca1144a507446306f3b0563de1a4e3
52154 F20110218_AACFPT kim_j_Page_039.pro
b7a61fa932f86bffbfaee7a3b8f61c3d
a5372e20e012ae807366ca22b29b9bbc297badaa
38280 F20110218_AACFQI kim_j_Page_054.pro
16076f223f325d3ad64e7dce0d32578b
3d24013e63deec139051f949e4fa714a10dbe004
52306 F20110218_AACFPU kim_j_Page_040.pro
3b65a319802b27c4a1415309af0a63ca
4bc4e4ea7e3626170c6988445a9cb8c8834eec93
34902 F20110218_AACFQJ kim_j_Page_055.pro
dc6cbeb19af11ce6fae1af392688ae18
4faf03891ff61dbd19f646146cc7130198d77468
52061 F20110218_AACFPV kim_j_Page_041.pro
7eec0afb7032a83304d8b8ec50923c25
a137d63b857678441202596bb3d108d19235c1a8
49993 F20110218_AACFQK kim_j_Page_056.pro
19e82d4fcd83469d474802538c910711
15b1bc2a6fce7b10fb923065cccc69a8e00fac44
48609 F20110218_AACFPW kim_j_Page_042.pro
f29fc5538c6ea9a3a6770b6b346ea634
7b07b1d297f095512ef33d1b32f9bfb18beed0b6
47051 F20110218_AACFQL kim_j_Page_057.pro
331d74b62950bc1dcdf94ec949c4fa4b
0aa174a88af2e1a0c60f1cbb73c9b9edb43c89a8
43930 F20110218_AACFPX kim_j_Page_043.pro
9b440c7f6fc12b2cafec089063314827
703597759f02e972f4ffaea24a8aa59952fdf9ed
5359 F20110218_AACFRA kim_j_Page_072.pro
a83c5ff266a1813eee794c41199f20a7
756c79e087c2af0fc5e55dee7bd99e29791c4fef
29669 F20110218_AACFQM kim_j_Page_058.pro
41054f4224697747d9a29ef8b36ae846
b794d6126aa82c3e642a9291503bb403b6971165
34208 F20110218_AACFPY kim_j_Page_044.pro
0cd168f18e8cfb15194acc348e459cc0
4ebaf1651dfa21fa87ab454018f0780468600ca0
29983 F20110218_AACFRB kim_j_Page_073.pro
186d05a1fef51a26a42164283457f59c
f03ddfea97cfce3206afa513ddbeaa1fd2f49b64
30395 F20110218_AACFQN kim_j_Page_059.pro
3b023d3697400d01cc1ce6c3259b9d4c
b28f3d002f0de1a6c39a82189858896225435ae1
40563 F20110218_AACFPZ kim_j_Page_045.pro
7271605ec514c0484b6bb11fb55240e0
3bdf6544946bef567431e16f9ce653aae81c81f6
49988 F20110218_AACFRC kim_j_Page_074.pro
0293cd9646b98a072f7a44583fa75578
44d21793889b31b52545b97e011f665c7d458eb4
52031 F20110218_AACFQO kim_j_Page_060.pro
c1ea9dd0888e062094b7b85acdd383dc
25a55ac9fd986b33b8482d33bfff9dcdc59f73e7
52407 F20110218_AACFRD kim_j_Page_075.pro
280e075d01a5726c44e3de5c785e6e50
0968df2e3449e841ac6ad436ff1c40aa36c2e41e
49780 F20110218_AACFQP kim_j_Page_061.pro
a8064343856306c119d5c9c740328b92
29988414b9b5edd83e05fb57092edc747792d4c3
30057 F20110218_AACFRE kim_j_Page_076.pro
5df93b5516b63d8efd3573ef6d7bb4e1
c5001618971ae1d71bae9112617d0e5e7375bb1a
32526 F20110218_AACFQQ kim_j_Page_062.pro
b332abe64cd9495580b4af4442143054
0868c0d3d62f8f065ecbb479c813a685f5920341
10485 F20110218_AACFRF kim_j_Page_077.pro
0b6b0ae10bf32fdbcf27976e1bc6b810
b266f12b1b7de2dddd40a82815d823cc0a0afb27
52104 F20110218_AACFQR kim_j_Page_063.pro
0e7ee23acfef06914a53cb78ee03ed38
81390c893d4659cf8fe899c8d6ac847c96051d16
48561 F20110218_AACFRG kim_j_Page_078.pro
0d460c0fc7fe9e3ae487112c5bfc86f7
2abca3d38f9255f27ec421c3de8fb128e3c25c39
52606 F20110218_AACFQS kim_j_Page_064.pro
f4a329207a403ce86000582f41cc0c5a
9e37daa390dfa841fa11c4505e68fc8c57715827
24933 F20110218_AACFRH kim_j_Page_079.pro
048d566c369eef336acfbd3e7cd300a8
a43cd13a6419283334adedac053794755e624809
52226 F20110218_AACFQT kim_j_Page_065.pro
48e458d5e4497fada5815ee93af75c42
28ea41c5410a6ec8bb55cd08258464ffc9ce4889
28989 F20110218_AACFRI kim_j_Page_080.pro
ed15f5e86626433f2f74aea76575b679
f7d36300fe8d4382e8dfdbd0d91fb8ecf89b9fa6
55017 F20110218_AACFQU kim_j_Page_066.pro
d5c85555ba90077adfa12d84d9b0a45f
cbf661acf820b60c6268b6dcc847b9adac768d30
18055 F20110218_AACFRJ kim_j_Page_081.pro
b50ef1ea8c10a71daf74f507e7309cb3
80d5069d5a80ea0a7c36e4c63b5d47a52bd9f097
34986 F20110218_AACFQV kim_j_Page_067.pro
a77df7a6645bd10998d325f2c12e2e1f
c211a6841d06cfd4db640d8c3f0b9e4d42715c28
17883 F20110218_AACFRK kim_j_Page_082.pro
a95f153cf110bef6c53d7a8ac24ef7b7
4f1cba56f3b71bc54b22fe15c9d58a11f92a2005
40704 F20110218_AACFQW kim_j_Page_068.pro
cd8ee76b6bf3aaf3c9089f33e34b547f
3646b0e4792de3e1154e41a48d3a2413922cb34c
35862 F20110218_AACFRL kim_j_Page_083.pro
5e0006af6ccf36959515546e6727489b
146140675f5b5e5e1b3028d0c86744cbca5f3fe6
43691 F20110218_AACFQX kim_j_Page_069.pro
4d973660e9b8f9b61f3929fe49606c9b
dce685a9bcd391c866c5a9ff515fd50b0f536eaf
60477 F20110218_AACFRM kim_j_Page_084.pro
9538f30780ee73ffcc7c606b70fe0cbf
a9df6053ae6a977502d995ac4d5feee737d2e184
31161 F20110218_AACFQY kim_j_Page_070.pro
bad12b3847d633dd25482e717b7b368e
bee36699ee03d6f6fd0fed4186e0910ab8f4d80e
15773 F20110218_AACFSA kim_j_Page_098.pro
470278d52c8253fac2a33d64429c5659
9f34beb4b58df7df528d0b4e4d871b5282e78d8e
46105 F20110218_AACFRN kim_j_Page_085.pro
f0fd33d636d1fac1273744e61a5238de
67b4ad6bc18e383c0b52df18a5016c6c5ff07cb9
44714 F20110218_AACFQZ kim_j_Page_071.pro
d88ba94ca9ada1d98f45bc933be2485d
3e8bd810264cd602f93190237f3ddbf846848184
42296 F20110218_AACFSB kim_j_Page_099.pro
0fcd37b0c90a868f94542f5c559f9fe9
9d5e8c2b83b7acc463c1f83818753ee853bdbe94
18314 F20110218_AACFRO kim_j_Page_086.pro
98a498a5f779fa6f09644c7066bca72c
1468091f04dd268e5cef3eaac9bc5d2c59376567
52712 F20110218_AACFSC kim_j_Page_100.pro
eff7e6907ab7f08dfdd4c5bb65abd10c
ead15ea52514f4779f0d665dff7a9d242eb25d30
44479 F20110218_AACFRP kim_j_Page_087.pro
1e0f671adcd2beef311de534af0c2c76
7cf792cfa1a1916a10dedbca0b476e3317462866
50631 F20110218_AACFSD kim_j_Page_101.pro
a4df21d63cf6602e316bf5a623bb1e92
ad0888ea4159e653214079bb546992b6d551d37d
33230 F20110218_AACFRQ kim_j_Page_088.pro
a9272e18863811d205ac774ec249eca1
16915f58a4e0cb117c24d94958fc72d1c0bca53f
51578 F20110218_AACFSE kim_j_Page_102.pro
b3fc5cb523dd7f3d3e15083c8adb2d8c
39103d5388e1fb6d5e41be57918c88d5803091dc
59365 F20110218_AACFRR kim_j_Page_089.pro
0199a033443243a267c17529f0debbdc
4d31f7ae234baa3ab8db5726d32318a6dbfdc929
50810 F20110218_AACFSF kim_j_Page_103.pro
05b9713a445faa28c494afbe3f316034
ac96cdaf4cac77428ef774b47e07f00e4628f426
17383 F20110218_AACFRS kim_j_Page_090.pro
2758fdf2e4dec369ad180444876c8c67
b60b13128c569f506cad323deb5f4c53a7e8a8f0
45333 F20110218_AACFSG kim_j_Page_104.pro
d9677717b4a5e92a8124d9d2cc4e2366
01310beb864bdc8e631f4cdd6f861db62b27f6dc
51834 F20110218_AACFRT kim_j_Page_091.pro
9ed1533220c0c01665ad1aee6a4b72f2
ef5724b3f69c9aee33f2c0fb1f227a6883011f98
50386 F20110218_AACFSH kim_j_Page_105.pro
fbc9366a152fef03a1a829b0fd99f492
b4bae0e9990cea4d30b704c2d45bdc41dff3f1aa
48723 F20110218_AACFRU kim_j_Page_092.pro
2e8457fc04d606f4c150ca37a9b4ae5d
7a2b93a37df44be89a434e88c6eea1d137b16b0b
48028 F20110218_AACFSI kim_j_Page_106.pro
0cbddbda64c05e82f8f75c9cd900ac1a
c17f98ad6cb35128ad0b834a3faa3038b31f9b81
44622 F20110218_AACFSJ kim_j_Page_107.pro
b5adc6f6cea918ece9e3464fcd21e8bf
8af5269f6b959cab31436ebca661240aaf718088
66924 F20110218_AACFRV kim_j_Page_093.pro
9d9f641917c76ebc7a1a7cc82de1f7b4
d20ef8e05eadc692541d3b6a2e4899a002ec39fd
49823 F20110218_AACFSK kim_j_Page_108.pro
5556324044d9e4672b59b662c5810efc
22160b57c09749e3e46d7ebea8cea52dc5ee28ab
24910 F20110218_AACFRW kim_j_Page_094.pro
62bf04f3dd30ccc1e73003b0bf13438a
754a81e6fa0453e8720c1f20d8ccdf51b65d9800
47172 F20110218_AACFSL kim_j_Page_109.pro
fedbfe45530e0109de12b4fa3de0202d
86f72f2c88392e53e8c4be5a9f8a81da0c047d5e
66030 F20110218_AACFRX kim_j_Page_095.pro
b6f356ab443b291f05a6ccc0ac332479
a336f2dfed00038d49c992c5c2c644975c8439af
38502 F20110218_AACFTA kim_j_Page_124.pro
bfe3b5b517fb24dd70dac525982cf33b
a11d01b1a570a692d510b990e4fc8c03e7f139d2
50744 F20110218_AACFSM kim_j_Page_110.pro
0ab58438157d5adddf64db37d64df0c0
59842bfc2e1aec643bcee18b139b269e0ad0a8c2
33199 F20110218_AACFRY kim_j_Page_096.pro
0bc5ff77ef7e39ee75fc80ed3a8e4b64
c509db00a23d48c1560bf876aa54f541e19ecf9d
17059 F20110218_AACFTB kim_j_Page_125.pro
adb0de62fce13e008913a6b1cd4dc46b
fa78443ea92d28d527e92a5a0dca5f933ddef633
48311 F20110218_AACFSN kim_j_Page_111.pro
0058143757a068a04a8d06384b4acf0d
6e19f0a93a8df86a00eef1796b5af4e57e7642f3
40679 F20110218_AACFRZ kim_j_Page_097.pro
58612ea26cf62d9055e734f0b9d1c6b1
7996118b22be90ab0077913dd2d4ba56626d76bd
31181 F20110218_AACFTC kim_j_Page_126.pro
4c39a2e9bd87a93c1f0855fc76a8bb5f
00a82fe91c5667a381fbb98edea206ef9bd1619b
48575 F20110218_AACFSO kim_j_Page_112.pro
fac455c942862ddc565ec5cceb72b225
c02dbdc233ec34dbd3202d4d3905b7c13499da7b
24917 F20110218_AACFTD kim_j_Page_127.pro
a1954fd5694fa2e72863230aff55dab8
59cf2b7feef334eaad8d296b93801e5a57809c60
50216 F20110218_AACFSP kim_j_Page_113.pro
9d933bb1d6ecfe5036de26aa889eb082
df4e1c56b57a4e41695f7bc345e1e68638c61de2
45133 F20110218_AACFTE kim_j_Page_128.pro
dab167ad40c695b2e26f99aedc785243
8ee90a40497d4b0ada22b93090acba381648f642
51198 F20110218_AACFSQ kim_j_Page_114.pro
47319f66f09a64039c0775662cea90a7
b0a7eaf74b4c0287c52a0c5afe77e732113eb427
14332 F20110218_AACFTF kim_j_Page_129.pro
0f78b66aeedeb9a490db329e9b3e66ef
d7158ac2a06ef0e1eca7b034a15b562702be6048
51720 F20110218_AACFSR kim_j_Page_115.pro
6035b03c0135422ed5853727328c7ede
9454a7217a35de666af22f7251f331d662d6cff0
14675 F20110218_AACFTG kim_j_Page_130.pro
683abb1083d93a4cca011cf36f825e48
b27c6d3ded9fd807fa7b5fa8df7295f3a315abed
51081 F20110218_AACFSS kim_j_Page_116.pro
fcae1896c9808931a78c52a0ebcf31bb
6c117bb48140a0ad3845c657d886171cca7f6a81
29222 F20110218_AACFTH kim_j_Page_131.pro
fbbdd1ae74b08974cb7995408df75fa9
e024a0fa95131b28bd39d3fe0cf4f6ba724104e1
48187 F20110218_AACFST kim_j_Page_117.pro
08413e6214c085cbc6034716c27a3f58
ea07875356a246fa0277745a01bde33c1c6a8d89
50620 F20110218_AACFTI kim_j_Page_132.pro
a434fdb95ddb41e472f33bc28e863cd5
033f65dfe2ed86047bb518fc8d32997d1cb50c7e
50939 F20110218_AACFSU kim_j_Page_118.pro
6c45c0a8e110fc8242c8cceb29f3aa55
2d834e0b254c1efcb3a6d17050a258c1849879bd
60879 F20110218_AACFTJ kim_j_Page_133.pro
3d09cb70259789952a73954262766ed5
b963e34e3c615b6f246e9aecfa1add195f75492c
48050 F20110218_AACFSV kim_j_Page_119.pro
750a2e08050da7a255be7b5ef1327044
92eeca64840b0c2efe5d33540a11b3e60eab3f8d
61845 F20110218_AACFTK kim_j_Page_134.pro
6e2e05abac12742f6520b210393d45c9
b5049e30937dcb6ee380b365bf95eeabe26c791e
49972 F20110218_AACFSW kim_j_Page_120.pro
92cebef5c77cffe7f100e3355f5f3fd9
d99a542873018d13db1396cb96c7f10b6e55b7c4
56616 F20110218_AACFTL kim_j_Page_135.pro
27b862f72f9e24477be7e670c550de14
efea56fd055d5a5757be9264e6ad74bce0e0974d
49876 F20110218_AACFSX kim_j_Page_121.pro
23bca102e3da4a7640d624b8564a4d90
0237a88093e982a01edecb0708c8dce7bd2a05e7
63551 F20110218_AACFTM kim_j_Page_136.pro
378cfd3c5e8bbe4216c14315ab7854ea
597bdc81658b0a1f6678d731b0ae77973c079846
7433 F20110218_AACFSY kim_j_Page_122.pro
a50bbba2dd4f9353cc3e5b8f230aa986
3091854e2d39a159eca46793c5d0416c29ecf499
65219 F20110218_AACFUA kim_j_Page_150.pro
ff381dcda8533687c492e7f835d814a4
10f55a1e9f82cbe8d033cfb2f9fe921e575e47da
62639 F20110218_AACFTN kim_j_Page_137.pro
4318713313ee2231fe94c28975604760
18debd6a5677c374c97e01b9440d02cfb7e2f4ec
20891 F20110218_AACFSZ kim_j_Page_123.pro
707813fba486abd2fad0bcb5784f2809
b19b281c4d0015c260cd1a9f7fcff2e817538549
37765 F20110218_AACFUB kim_j_Page_151.pro
3e142d700f3d73ab75d9266bdf50eccd
ac4c1febb0d981903808ba56b6cf271413ca4bc3
70285 F20110218_AACFTO kim_j_Page_138.pro
b2e52acdd7573039043b53c5ad89e03a
d05d2f107afbaf4fdfcfbb78789d9fd193c5199a
29470 F20110218_AACFUC kim_j_Page_152.pro
23892946283f7a0cec71b8717c8651c2
97b86fdcc500bf954ee295849de9791f3d85d106
62335 F20110218_AACFTP kim_j_Page_139.pro
a94411892cab542d92f51e221d19ac57
a3246c8756cb8b6c33821d92b9de8fd755d13d98
32154 F20110218_AACFUD kim_j_Page_001.jpg
0277479f31dbdbd107b065bdc26c1540
2be98ebc4936c2d2b1d93c8716e6a50cde690da5
62990 F20110218_AACFTQ kim_j_Page_140.pro
8999b5e5c159ffb945d311e663b9de20
eb05a23bd0d586ca472e6a54215d0ec43b736eff
9593 F20110218_AACFUE kim_j_Page_001.QC.jpg
6ca4b87b6cfa53a7e3dcda218e728bb4
86bf9cd6aa78a92a9e89a7ad1d5af0f886f5725c
57927 F20110218_AACFTR kim_j_Page_141.pro
49f810d219928487d1ae071667b7e070
5a071edbded4cb0c467766100dc18347f5f486f3
98680 F20110218_AACGAA kim_j_Page_078.jpg
89a4ec2b260f7b3852098ca46cd9b313
d5a69414e1d3e6e70a55c8a9a2a5fa9ab5342565
4374 F20110218_AACFUF kim_j_Page_002.jpg
c8d977d762bf7e53a806df23b62fda07
2c32d2ece1e54af2b381221c9e28bc83b2dbd125
56552 F20110218_AACFTS kim_j_Page_142.pro
5e008376b9d4efc9f38befd4e3d7a7fb
2b3a526a80a4b2299b0f213c70837a558e86c108
32432 F20110218_AACGAB kim_j_Page_078.QC.jpg
d76d0c750aa92486a0caadbc0f328fde
e0e42b318ca3b5ac31773530afce84e8542b8945
1436 F20110218_AACFUG kim_j_Page_002.QC.jpg
b8b8ede4f362bd93e02cae78f01518e7
bb44574593d9ec86e96915cb4cdc038d24ba9fe3
62276 F20110218_AACFTT kim_j_Page_143.pro
4988be852107149a58d2c4445b711c50
d85dc32c60736ec71073642b9f90399f07c1052a
59888 F20110218_AACGAC kim_j_Page_079.jpg
eb1c82f215ed7e9b92dc666790042240
79310b74866de24d77f2e0925e35bdfe3b11acb4
8375 F20110218_AACFUH kim_j_Page_003.jpg
f075a16d1da97db65295abf56e24e413
3db65632d8f9b6f4e63bac87e12f6e27cd02366f
62963 F20110218_AACFTU kim_j_Page_144.pro
c6fe3298f002a5e6c84c2da58dab6173
99035d0d39a16a39ae11688f267a4272a9913d85
19772 F20110218_AACGAD kim_j_Page_079.QC.jpg
1d9c801880f0bff69b20cea3303d172e
d964069e07d2b0d9c663781cc6a3cf1eb1649c35
2104 F20110218_AACFUI kim_j_Page_003.QC.jpg
4f37a38f84ef84e5478593314af5c921
91d43e7eb45eea1779079c13850419b242f53f0e
64652 F20110218_AACFTV kim_j_Page_145.pro
d02f875ad61842bd3eb8872670b9bfe2
ece3b952a2e004d5bd7021b27bf08cc8d2f4fa1b
66183 F20110218_AACGAE kim_j_Page_080.jpg
3ce13838f83989be8caaa5d79369e605
b021eb7a9517b1f955b6f626b8c34bc9f8566435
85276 F20110218_AACFUJ kim_j_Page_004.jpg
aea5567f00d6d6174bde2843b21783f1
61c726dd63f8175b2d474efb0618afea1b9bd8f5
66826 F20110218_AACFTW kim_j_Page_146.pro
6611742631b5d19b3485f072e6d36526
0a6fceebdf363893dfc01c8192495ce7571ac4cf
21651 F20110218_AACGAF kim_j_Page_080.QC.jpg
89975369109f66d71dd8d0ad4993658d
3e04bbcec48d594a4252e1b4d94fccbf4c956493
27605 F20110218_AACFUK kim_j_Page_004.QC.jpg
ef99ae94863dea46e55154dee7889145
7958bb51f95dabb3c0385d5d9e575a1c5ffb324d
66157 F20110218_AACFTX kim_j_Page_147.pro
ce9afaf2821e5bd42057036dbe750255
3102cb79dfea92c5d741e490599c7ecaeb5e8461
16796 F20110218_AACGAG kim_j_Page_081.QC.jpg
a4d0b2f6226d82597d2ae89bda8603b1
3636206f5a8ff679586fd060fcc5b3352f672348
41608 F20110218_AACFUL kim_j_Page_005.jpg
e7e547d12a11473330f615c2265233b6
9f6d8ce640958d149112d39c6cbb0bc4ffd6294f
66999 F20110218_AACFTY kim_j_Page_148.pro
d1d4b5940bc71e3efba9c15bd3610691
192dd676e98e012b596bead89b5b8c83ed77eaf9
34870 F20110218_AACGAH kim_j_Page_082.jpg
961cad6e9a149d8e196935c7224886db
08e5f536769b18c86bd522edbfca4ec30be0fbf6
26878 F20110218_AACFVA kim_j_Page_012.QC.jpg
04981e9266987ccef03b2a35d57df5d7
3667bf06733465abf5a7e1d3404bab7cda5e7286
13531 F20110218_AACFUM kim_j_Page_005.QC.jpg
36949649d9c4a118c325b0d39d72372a
539610eb06b2967f6404a0ebbefec43722b1409f
68217 F20110218_AACFTZ kim_j_Page_149.pro
a5dada10f4e86a78b6b228cdb8a6f1e4
2d795c98f06578110089f48cd335e5d11e7c5103
11711 F20110218_AACGAI kim_j_Page_082.QC.jpg
c3cf23997104959bbc469bf8d1339382
dfee8a9189a64e9151ae4d13bdc2f29fc18615a8
93445 F20110218_AACFVB kim_j_Page_013.jpg
49650e47547c54594bd866bdbbadfc9f
2999e3bbe0ac6e89690068636d5d4ef0763c5844
77762 F20110218_AACFUN kim_j_Page_006.jpg
683e74c5807b0b80e2ff687ddfcf8e3c
e55536cbad7d2c4c325615ff94bf3f74a9fc16b7
38273 F20110218_AACGAJ kim_j_Page_083.jpg
4fc19f076bab1f9f925128e7db9091b6
f9e860e536084cf07907ea388e0fbca93bfdb640
30124 F20110218_AACFVC kim_j_Page_013.QC.jpg
e0e687d549e6e9d36c4a1e99c80e1743
2fb86d7fde66504179d7457459f651aafe184a80
17273 F20110218_AACFUO kim_j_Page_006.QC.jpg
73f0740965681482717ad57781f518f3
02dd1cd2982c4c562e256af23cd69792847336b2
107144 F20110218_AACFVD kim_j_Page_014.jpg
45667baf574abdea530013a714573de2
1379bb0743315fc56270b429e3b81f59e438cb7d
65168 F20110218_AACFUP kim_j_Page_007.jpg
3fdac33f5dd234fa24e8da190d2a9a54
27e8e924689b4690d6add378a537276b13a30dad
11850 F20110218_AACGAK kim_j_Page_083.QC.jpg
4d2a170bb918276bf6d8a86aedb9a842
248180477b38e791d889801ace7f750e4c879d74
35669 F20110218_AACFVE kim_j_Page_014.QC.jpg
a819277efab497656c018a9693a7bdee
ed8b4ab5f10d8606d1f2fe607d5c0f153d4f074a
16774 F20110218_AACFUQ kim_j_Page_007.QC.jpg
228fcee18605028e3d7ad2e3002f7022
f58a7c2b8341919cfe574b436a86ec32b5dcf0a6
60998 F20110218_AACGAL kim_j_Page_084.jpg
d8b025dd02512ee0f517214d69af544c
c4c2d1e6cf5f9da88d36fd134accca190ef8a790
106213 F20110218_AACFVF kim_j_Page_015.jpg
71b6549d65b03ffc81a7348a7d4ffe11
3e1e980f3de0262f3579572d8e3ae84eb66f044e
83166 F20110218_AACFUR kim_j_Page_008.jpg
17f42d37846192ac835d1f3e0f950fc6
095b5914c774103391f64c7a12302885525a3657
28494 F20110218_AACGBA kim_j_Page_091.QC.jpg
cacdd92b32f9acf24b9866f7b35748a5
40be7ddd2cae6e19413efce4e18e32f7ac671dff
16913 F20110218_AACGAM kim_j_Page_084.QC.jpg
0930816ba9a879588ea2b4032cdaf3e4
60ebef93314349d4d354524f21ead7f12a373818
34277 F20110218_AACFVG kim_j_Page_015.QC.jpg
63a969927939b1187b3d4c19a02b80b1
882b591a5777e354dff7be52e1b268cb43395fa2
24235 F20110218_AACFUS kim_j_Page_008.QC.jpg
d6a5a51d4cf88c82f1f41c46b8f5de67
b4ea9e18c5c37c1df6de3142233207796381dd88
81561 F20110218_AACGBB kim_j_Page_092.jpg
90f8735cb7a9e95106f066e7026dda87
b398bbd1ef757c515fef59ccd39db6e7826cb26c
80729 F20110218_AACGAN kim_j_Page_085.jpg
10757b776d6e43e8687eba9b9843603d
18028d42af623e08af0602a26da673813801c936
106511 F20110218_AACFVH kim_j_Page_016.jpg
bf4db369c374cfb9c165a6983c0b45b8
c39cc2baa81a53a5451b0cd723643246ce89dac8
68661 F20110218_AACFUT kim_j_Page_009.jpg
2cd5dbfff7b80571f3ac049bfcbde4c6
c1c8a65ebc9fdfb46e230a94049b624df064e79b
26337 F20110218_AACGBC kim_j_Page_092.QC.jpg
0839f90ae11477ac9d8a223ba97bb510
14c596cac53fa2b4d5ed6e698991fc3065940041
26957 F20110218_AACGAO kim_j_Page_085.QC.jpg
0594563221f432b3c68d09793e745529
00bc2866fef1f0a4476501acdf91ec9f05db7e33
35431 F20110218_AACFVI kim_j_Page_016.QC.jpg
7aa6bee0bed16ef105b1178bd3bc11f1
6fa07e5bdc7991195e30a0253871f23fec879829
19356 F20110218_AACFUU kim_j_Page_009.QC.jpg
d01debfc2f9bcd560dd61d37fe35760d
734ded0e2c834e93d4a2c1e05b1cab2da916ce21
111993 F20110218_AACGBD kim_j_Page_093.jpg
9fea39e9d957801d6b5fc680893807e8
ccbef99cead59d3f4774a87fc89222d93cbb70f2
38813 F20110218_AACGAP kim_j_Page_086.jpg
c83de3f0d9bd2181de64c696c854c3e2
1afa62eb97295efe22e9033ec8ce84de4952fe4d
105616 F20110218_AACFVJ kim_j_Page_017.jpg
ae6a2340af198f606a4646186cef9b1f
0b745005d7c8061340662bffd44c8b1eeff99691
55066 F20110218_AACFUV kim_j_Page_010.jpg
6f6e57a4f44f65853932bdee8ff02bc2
e481545d5627551d0ae159dcd3fdc6f3c4ca9c8c
34609 F20110218_AACGBE kim_j_Page_093.QC.jpg
1c32376a11c7ddf9b5b480eca74951d4
8b1ad2345369289c25ad79c73c10d304f0b65093
13181 F20110218_AACGAQ kim_j_Page_086.QC.jpg
fb7a0d1bbd39feae1e20e6e9b3240766
bbddf8f70754fc0bfb768b40f5103b72000d5a28
34565 F20110218_AACFVK kim_j_Page_017.QC.jpg
7c99efb89f1eb7f04c5ffd665c1e3c47
b8039406899539fff15b2e39bb43c78320c0c794
15840 F20110218_AACFUW kim_j_Page_010.QC.jpg
1021052ac546b53442a6ab6ce2e7b337
cea56c05d341bbc355091fab43843fd8bae62dc0
47558 F20110218_AACGBF kim_j_Page_094.jpg
218f2c27897b49d2b6555dc141ec29e9
09fc2dfeddd71d0d744a22c3a5b5ff84b314dab3
33699 F20110218_AACFWA kim_j_Page_025.QC.jpg
1d01642ff6c70d3c6b4e529afa2220d2
43cb9987bb159ef16674221776b1d4164333d8f2
83223 F20110218_AACGAR kim_j_Page_087.jpg
42a750f7483f4b30414496aea8cf2722
3675c75e7cf8a452faec46f33560c7d8931bd152
106718 F20110218_AACFVL kim_j_Page_018.jpg
b39e1368bc57b8e7160e43ac3df6279f
092d849a6969995123b8c784e20a61a77a73c122
86889 F20110218_AACFUX kim_j_Page_011.jpg
6f3f549e88f0845d7cec0f695d78c2ff
be16116535a0ad68f3d8f60ffa87d5ef2b6b7919
14828 F20110218_AACGBG kim_j_Page_094.QC.jpg
0e0beaef00705976abd38b74787f4c18
6b0a873805e656a3b51bbed7462018f7b206720e
27959 F20110218_AACGAS kim_j_Page_087.QC.jpg
4503f015e90b5d5c38bc820d3b861040
c8cd344474dad970dabb15892aa04b94e2401ba4
34806 F20110218_AACFVM kim_j_Page_018.QC.jpg
a2e7f5ca8f10900aa69955a323a46e5a
03d0ee15fc4a139e25c6abc06b4982413a4e037d
26785 F20110218_AACFUY kim_j_Page_011.QC.jpg
721ed6f6c8b2b48bc959d3391cdb1558
74ab53870544b9b9f93169cb727d02db17afa658
112971 F20110218_AACGBH kim_j_Page_095.jpg
61fc847bda556818d598edb5ec5052e0
98dcf05deda6a82d60e2b29b87d4b8e2be50472b
102211 F20110218_AACFWB kim_j_Page_026.jpg
d06388bc9b5fe463b5914dcfaa526db7
eda740d76108652264c18c614d8f7bfe7480c2b1
61979 F20110218_AACGAT kim_j_Page_088.jpg
faa62595b7c1b94948e2ede2bd9338c6
2fec25f9c3ab1c79148fd33e4d7c6b3ddd95f6f7
99712 F20110218_AACFVN kim_j_Page_019.jpg
ed50e3881483ae0df40743b634850556
51be4fbd5fe0c2ece8a491950ad24d1171bcc435
83709 F20110218_AACFUZ kim_j_Page_012.jpg
1deae023d5e1ea361fd207dde4a83740
84f3821381ca001b65acfdb64b0b117f014dd556
32590 F20110218_AACGBI kim_j_Page_095.QC.jpg
040d8d1a9a152143113d8108fd0b5503
57919aec1a6abb92bcbf5b909675499c3e7f5211
33082 F20110218_AACFWC kim_j_Page_026.QC.jpg
6924c03a0825139d4da36a8d233b852a
9aaf713db72d4e776deb687ad06cff23c0737b42
19135 F20110218_AACGAU kim_j_Page_088.QC.jpg
ca7fa9aa5a23bf4450fe0f9179c70382
8d12d5d462017c2110b616c40f05b5bfcac3e207
32990 F20110218_AACFVO kim_j_Page_019.QC.jpg
65ca44384c7002ab24bd5f16e88af3ea
27d119ec13dfca13d3451d840dbbde84bfbb341f
62572 F20110218_AACGBJ kim_j_Page_096.jpg
6bd0780b7bab413727e513ded2cb0539
973e028d9c4ff08b28c2fc4c4cced178c98d5814
103825 F20110218_AACFWD kim_j_Page_027.jpg
dd6d28096da7b4d3bd0135a1cc52c125
dd5209f23d12097e87f8b2bdbfdfde712f56442b
105977 F20110218_AACGAV kim_j_Page_089.jpg
3fac0b40341734ba45d3f4cd4bc20366
178788aa27d769348d68331728deb5460fb5e5fd
101444 F20110218_AACFVP kim_j_Page_020.jpg
a44f898352a402923b4905daea72d544
f0e7035296eec7d9a9a1b76cd79d72d7eafa2f54
21095 F20110218_AACGBK kim_j_Page_096.QC.jpg
b1954f061b792ee371160f84014dc3af
d236768ea4ca06c4b57b2e9eb738d807d74820cd
33988 F20110218_AACFWE kim_j_Page_027.QC.jpg
29faba7c1fa80e7ee5f3bcb0d3e59d47
68535b2dfce7578b0c8fb9cb0917bb90b3e97398
30156 F20110218_AACGAW kim_j_Page_089.QC.jpg
153e689e0d3b4689b9c65598b767ea62
5981016bbed446bb98bddca4c9224b586c8cf6f5
32926 F20110218_AACFVQ kim_j_Page_020.QC.jpg
3385931ba2cd7cd1a46f00c79bb8f781
b44b94f441a1053b99ddcb7d58418e09c008364e
103195 F20110218_AACFWF kim_j_Page_028.jpg
23a8b78687644b3af8785a3ad81e52ac
c7605a05e978212b83fe89e9001b4a71dbc9690c
31598 F20110218_AACGAX kim_j_Page_090.jpg
2ab6c51031f278ab39db50fbf0d05d70
3421543482a24a70e773a27acde8b3214880ad09
104009 F20110218_AACFVR kim_j_Page_021.jpg
30a89d37f481477e3582edf03d5b14a7
deedd0604b4966c9a79dc685a8c0a1ff98e5985d
31561 F20110218_AACGCA kim_j_Page_104.QC.jpg
93fc89d96ee3a45c6d92e3fc589688d9
175c5cf9a6fcf7625d350edc50d33d2b5ce81ccb
73904 F20110218_AACGBL kim_j_Page_097.jpg
65fe6393c20dcbee449e660c84bfaea2
24240d528fcfeaeae676a5533da0e39fe7c1f824
33780 F20110218_AACFWG kim_j_Page_028.QC.jpg
6f8323c1805112747e3a0a436eff1de8
bd29737d4c476bde23e467846c71435f75f18a48
10309 F20110218_AACGAY kim_j_Page_090.QC.jpg
5c0ce9e989a775efe5f687a743707a8f
764ebb39223f88cb2a3aca30330bc43aeffdd962
34114 F20110218_AACFVS kim_j_Page_021.QC.jpg
ca3ce63b50d6d30dc12cec6579481a3c
a75c2924c620171f3ff05751dd03bfc67988c6a9
104265 F20110218_AACGCB kim_j_Page_105.jpg
b47eaac4fda81d881d247d648c34460c
45c3e2928f67818137654220353abc0ee1aa8067
24570 F20110218_AACGBM kim_j_Page_097.QC.jpg
39d05056bb35f66dd50dfb1bd940145d
f330b0f76bcb59df20ae8010efa7f878280b8f6e
101119 F20110218_AACFWH kim_j_Page_029.jpg
3b8e13468fee2812e6a44e01d8817c08
b3d63ac8b42d56cafa3bc5abd409e2e8df41f472
94035 F20110218_AACGAZ kim_j_Page_091.jpg
1e6e4b04edc60e7685caebe16b7fca57
c2d1477b0234c970a13094a29b533acc577844c0
104813 F20110218_AACFVT kim_j_Page_022.jpg
e1bcf7404dbc932f0472315910195061
3081b7f789fccb9ef07296a35d0344e39d3823f9
33369 F20110218_AACGCC kim_j_Page_105.QC.jpg
b20df156cb1148fd608b11496e94daf3
00f5f2a2ea75d307a990ad7b05257cc2d9d1c58c
32051 F20110218_AACGBN kim_j_Page_098.jpg
46d09a0ab46795ea77b90b02de6b7cfc
cbb3f4e3518fcc998556c8071257c49fb9f1c73a
32671 F20110218_AACFWI kim_j_Page_029.QC.jpg
d83194776022d07ec7619d005556dc62
bbd06f4459ffc3f133b3c34136ce43e9db6e33d7
34070 F20110218_AACFVU kim_j_Page_022.QC.jpg
1c160faf4feba8f5aa94abf7245d4396
5108bdcead229b3f85ca59962c9e49d5dc27850a
100298 F20110218_AACGCD kim_j_Page_106.jpg
d1532553f573f5cf0fb94da2949a5cbf
92caf87b09308ea6910c80a1df9fd6f0501c11af
10438 F20110218_AACGBO kim_j_Page_098.QC.jpg
9ec9faaed9525551aa2ff649f819983e
271b353a3774e8f880f0d9013e515afe112f2ebe
111132 F20110218_AACFWJ kim_j_Page_030.jpg
ef1b5cd861e3bf9640976aa97951a998
1628d79c12e20dffdb47907cc5704a41b2007108
99628 F20110218_AACFVV kim_j_Page_023.jpg
c6332a7aa9d27cf31cc4d34dc76ffbe2
cc4cca3e24e8fe3978594f113830620fb1bc48f1
32271 F20110218_AACGCE kim_j_Page_106.QC.jpg
0926e1412e9d7a61d66d7e84faab1218
0ab061313f5a9e3057e5d6b4b00f50269832ee78
90849 F20110218_AACGBP kim_j_Page_099.jpg
e79f380a2df23c9a7b677a9b94dbfcc2
6267908a7bc41cfa90817090402ba4d43a059fd7
32077 F20110218_AACFWK kim_j_Page_030.QC.jpg
2230c6fe3efba975db3e1055488a67f9
4dbcd4dfac9ee1913e7c5e78943f0a602fc98641
31907 F20110218_AACFVW kim_j_Page_023.QC.jpg
cacd88ddb38489b26ff4cdbd5912f865
0fe3a6e57512f611ca6110c23259198ffae8b7fc
91928 F20110218_AACGCF kim_j_Page_107.jpg
b57685cdb3fc48cfd0f48679ecf887fa
0bbb381598877e3165e1baf7c59c629347f1bf6e
28491 F20110218_AACGBQ kim_j_Page_099.QC.jpg
0ce376fe1b04baa4dd28950b2e33e32b
e0c5f296aeb109957a3913eb0fdfa99dd1c81797
105662 F20110218_AACFWL kim_j_Page_031.jpg
6318cac60ea32bfc3ad95ae89a974828
8c2ca375e2c3024949b5f36252aaef6c6a5281de
86867 F20110218_AACFVX kim_j_Page_024.jpg
e945fbbf74262d274d545ecd1f0a9aad
48e5e752481347d7499d9c721804340a3a2274dc
29898 F20110218_AACGCG kim_j_Page_107.QC.jpg
23f076730d2c6009102770ac9f1efe94
7c290b2e73ed58db43208fedd433d287ab73e242
33597 F20110218_AACFXA kim_j_Page_038.QC.jpg
c1f3463412fb7160d78fb2fd35a736a2
461372e783bb13632e960bab7dac6c97b24f3c4c
106626 F20110218_AACGBR kim_j_Page_100.jpg
0bb95c8d5551d3b4778d629eada89988
71e1550b54b917634e58b08eaa996e8df023069e
34266 F20110218_AACFWM kim_j_Page_031.QC.jpg
f4fd8821ac8419b72be45a283d555b22
dcf774f1c2a99c47958d47bca16c70d8de0a99df
25826 F20110218_AACFVY kim_j_Page_024.QC.jpg
e23091dd16f3444ad9c3724a1a792387
8fadbe56ccaa8c085dcdb1d7e40cc1a94487eeb0
102729 F20110218_AACGCH kim_j_Page_108.jpg
69149ca7bdf46d3fe96e0e3789380f68
e21f8957d8ecb2868f4da182e77e6ed8521c0938
105379 F20110218_AACFXB kim_j_Page_039.jpg
cbb07f84bb81abd9302d6e801a49206c
5953cf6a3f1c43f32254bccb49dfffd08710570c
34409 F20110218_AACGBS kim_j_Page_100.QC.jpg
8a86679124cf4b21a42694af849ba874
5d1733e3dae1bef10d638744e18d4916205c3a3f
99230 F20110218_AACFWN kim_j_Page_032.jpg
3c5a0669adc3097408e40338fa930db1
027ef5ad4c0632a2cf3b7c6d4adbc0e2cc47cf70
101613 F20110218_AACFVZ kim_j_Page_025.jpg
7d859303639085e2b0e779a9156dc3bc
3cb07a54788543423e060bec024d8f09d4108862
33752 F20110218_AACGCI kim_j_Page_108.QC.jpg
29ce29239356aeddd85b2955ac3c6543
c9742dd0b27e9326745a007e3a6b802ac49f06f4
104345 F20110218_AACGBT kim_j_Page_101.jpg
98fdf64b7bbc694233a8ad07d093c5f2
9aafc7c307169cf393ae61d513b690b7102a10de
32429 F20110218_AACFWO kim_j_Page_032.QC.jpg
e9a4dba1d05aed5897f4518d907ba63d
bd239ba2fa6fe3dbb7529c5ef8088ba629020f4d
97334 F20110218_AACGCJ kim_j_Page_109.jpg
18fea5acfa5761158076adae471a6c6d
da42f328c9cc1102e34700e7734aaf8551bcfbf2
34140 F20110218_AACFXC kim_j_Page_039.QC.jpg
f8195bd6dff9c049e941119952daabcc
ac4aef7b0ea261d59ff2532272a80efed1319bcc
33857 F20110218_AACGBU kim_j_Page_101.QC.jpg
9f7b592f57277b06c67a48e6a72c6e7f
5be86074432c3ec6dfc3c7d5f2c897e97b741bc3
103019 F20110218_AACFWP kim_j_Page_033.jpg
89febdec838407a400331d7dd7dd0130
3e4a4ed1bda41559964f25cf3ad2c37899479ddf
30873 F20110218_AACGCK kim_j_Page_109.QC.jpg
c5e03ae83cc16559c6d04b14daa84fc7
32cfc599b63d51e90aae373ed507e189d54bb11b
106982 F20110218_AACFXD kim_j_Page_040.jpg
d2744a64d97226dc8818663d4300ac71
61894ffdf837d795ac8b947f6098827697666d25
107091 F20110218_AACGBV kim_j_Page_102.jpg
009e3ec68397b4e4277a1949389da760
d827fd87e8a7782724e3df5beb6a44568c5583d3
32906 F20110218_AACFWQ kim_j_Page_033.QC.jpg
b89368ae1d682512baaed2d98fb4c6f3
d93ddbf6db133c1004509f09ee1b1d6a1eea1811
105116 F20110218_AACGCL kim_j_Page_110.jpg
f6a0889059cbc4a4efddf1855910b647
86cd3ea3798b8d16102c4b25dac92153afbdba2f
34619 F20110218_AACFXE kim_j_Page_040.QC.jpg
de5ac8dd5fda11b36fd77a64e04e69c9
d3e67b77f8d578e37f7d0d271e0c65b6290f6495
34569 F20110218_AACGBW kim_j_Page_102.QC.jpg
26ef0cfeef03af268554f3aac4b651a1
bfcfa10738045bbd415eabc28ed2dce340eefd52
105523 F20110218_AACFWR kim_j_Page_034.jpg
5e646cabcd5c10ba895221cd7800e7ae
191365fd575b54d65258b60efd518ef6b98bed20
32334 F20110218_AACGDA kim_j_Page_117.QC.jpg
8d04fe99e368b74c730ca3c167e4b7ce
1d3cac8727df8ae6cb8d13b1221d63e964bfdfba
107765 F20110218_AACFXF kim_j_Page_041.jpg
aa10b7df1944a7e173e2c2d91b0e293f
06f51cdcbb065daeff23e8213d8eb62000adf0c5
102521 F20110218_AACGBX kim_j_Page_103.jpg
3ecef33fd98f5427083a4944eaf1606f
68b36a23703985e471c8bd72e0061bfe3fda7b35
104105 F20110218_AACGDB kim_j_Page_118.jpg
b4e570ad90252af9c1d6263fbafce77c
e52d5404e91b8dbee7f4d61fd583dee5a1927a76
35199 F20110218_AACGCM kim_j_Page_110.QC.jpg
dd3f8baa6163bd5958c6c1b8ef828ada
988214cfd1d6c19dff3071dff025197023a99ebd
35264 F20110218_AACFXG kim_j_Page_041.QC.jpg
a6938c8c5ca811a7d36a076ffbdb056f
ffdc2e43816b69d5e173479558c8ecd2fee354e6
32999 F20110218_AACGBY kim_j_Page_103.QC.jpg
a1bd7aabcc6dd96e417ed36e89de2cec
1f20edf1a6d20220672dbb9aec7ed78e9a9d8687
34046 F20110218_AACFWS kim_j_Page_034.QC.jpg
9ce03ef83beb258eb8bda29dd27eca70
f3ab4756dcafe1d4f553e0872642ab5fb24f363e
35211 F20110218_AACGDC kim_j_Page_118.QC.jpg
9b322cb551ccc5feb9136f1189b1bdd6
17c1c7f1334090e872d40e383234f3a349c75dec
100594 F20110218_AACGCN kim_j_Page_111.jpg
ca00be8057d6b9d2a83432d68dddd687
d03e6aad964ed4997fb1e198f39de92bbe02591d
98729 F20110218_AACFXH kim_j_Page_042.jpg
e2232aa69411ba063bd5195b435caba1
ab2ac2ef4bf74dced651e2cf6280454a7f2cd10b
94845 F20110218_AACGBZ kim_j_Page_104.jpg
d3c33f21bd22010aeeebef98acd84602
a0bef6624daa05164e7a2fccd243903a470ea436
105188 F20110218_AACFWT kim_j_Page_035.jpg
c6428eb78fbcb6cf7916b2efb6ad481f
58a642a73fe88fa01bef2c2b052fab6424924b7e
98433 F20110218_AACGDD kim_j_Page_119.jpg
b9c163d03e6ce8a5509943c07d4cf91b
cf121fbf9c9529f4d67163ff0cf9046909d88745
32364 F20110218_AACGCO kim_j_Page_111.QC.jpg
7292128c64d431463d92eaccff2a3ec6
3750d1c3cd8b9203c58a0d090cb845f29b31bd30
31493 F20110218_AACFXI kim_j_Page_042.QC.jpg
1c28a303267f8ab8efe17624e63c5074
71e7bd1bd24fc36d10f028a4e04d9b7899abd819
34357 F20110218_AACFWU kim_j_Page_035.QC.jpg
f0a0169bb33dae63f8e1620ed7a9e662
d36ee127b7329f1e629890b9adc31732ed4606b1
32824 F20110218_AACGDE kim_j_Page_119.QC.jpg
f27660743c685111ceca8ad897ca2258
f88474fa00382bd5d0cea5b1aea3f8494e0f6854
98325 F20110218_AACGCP kim_j_Page_112.jpg
1594712ec540de1d594a593ed4c1be34
da21e9804e0475378bcda533b15892aaaa4c28de
92289 F20110218_AACFXJ kim_j_Page_043.jpg
54d8a8d23b7f93ad2f781967553757b3
13b4b3a33ab9d3da385c112d8f349529a3882141
101286 F20110218_AACFWV kim_j_Page_036.jpg
cb636de9a788db814a379e8442a0f31d
37f44f1dd5f7a644ebe7fab60487a55ed4370906
102848 F20110218_AACGDF kim_j_Page_120.jpg
95f51befcb6e53f339345ad63378c95e
d9d1b4d42d3c1fef5b819e1719500f24dc3a71d4
31405 F20110218_AACGCQ kim_j_Page_112.QC.jpg
6def8153aaae41247f756f85321ab33c
5e9f6dd87c6a5e023c017a374fc580cd332ce269
29967 F20110218_AACFXK kim_j_Page_043.QC.jpg
f36a0133b48b8767e2a1b8a054598844
6c2932ec41bbc0ed434d0b023490edb67f9a91af
32322 F20110218_AACFWW kim_j_Page_036.QC.jpg
45b7d4b34d53a7972f4649c98d6ece34
aaccfa604af89a2c8041a033775c005d4cccbac6
33601 F20110218_AACGDG kim_j_Page_120.QC.jpg
d642bd6062bad064a35433faa60e138c
b64fccd5c59ab58dacf279e1aa0be52f84349db3
44274 F20110218_AACFYA kim_j_Page_052.jpg
a545238aeffa59d5a891e7e91d7403d1
d5958ba6f5503b2a6a6637c0ac040ce7ea1324c9
104706 F20110218_AACGCR kim_j_Page_113.jpg
d17e7bbd55f1f484667634f601a3f22c
e7917d13ef427b3399cf9e7cbae9f8843f72e41f
72923 F20110218_AACFXL kim_j_Page_044.jpg
7c7291260c162cfb220fa83e7490ccc7
cbe9b88d1747363a88e4d8021af7b6176357d91c
106083 F20110218_AACFWX kim_j_Page_037.jpg
eac698b744ff4e6d978103e395c65101
34f001cf259031d541d986f2c32fdee02f348489
101868 F20110218_AACGDH kim_j_Page_121.jpg
a5644e9bfed35eeb787b2c74b435aa28
d8b86b03a90d1b198945daeca09debe1bc1078cc
15496 F20110218_AACFYB kim_j_Page_052.QC.jpg
902e9decbb7144a93c7ccded355fcc6a
380fc7fe83df9833358ee4be39648c5fe527aee0
34804 F20110218_AACGCS kim_j_Page_113.QC.jpg
d05dad2bd28170f8d89605bba9573c1a
b242c6ed8bd9378a5dc347540485212becafc064
24194 F20110218_AACFXM kim_j_Page_044.QC.jpg
b67378de116f4c43204f3fdcf025b187
9a9333212094f789c17e27466cfe3f6a1ff27a63
34457 F20110218_AACFWY kim_j_Page_037.QC.jpg
af77b433df007dde67e8d5605b9238b5
b64f1939a116ee3044fa846b99603a86f4906a9a
33258 F20110218_AACGDI kim_j_Page_121.QC.jpg
0392e50c47110a3e7aa18508b6a76657
159eefd389a9d5e45fd282c32487ba60a213aada
102100 F20110218_AACFYC kim_j_Page_053.jpg
9ab5facdd626adee43414da6f92af741
46d790b42cc05a8ca823c380b00c0398e1203480
105201 F20110218_AACGCT kim_j_Page_114.jpg
ba10128d3764c2c8b3966dbcac3e9e01
0c0217118bd79f1c70c61c2d45c330c5eedc985e
85690 F20110218_AACFXN kim_j_Page_045.jpg
ab16c6822cc4fd9a884c9b4abeeaa77b
d255ccbe271db2177f0e84715c74001a1ae881ed
103212 F20110218_AACFWZ kim_j_Page_038.jpg
7a383e399ce851fce446b5c12fb6d6dc
fe34b1e36d0fdca8f2749a21ae359a32164177d2
17737 F20110218_AACGDJ kim_j_Page_122.jpg
150104e5a287da3a5952837495a228bb
e546fd7ab9915a2e5ddec85a7847773a1d0fd39b
34144 F20110218_AACGCU kim_j_Page_114.QC.jpg
dd050589a6810e3442f6d58568eec110
1d0526a61e7b850a386fc826f6ccf92c61827d57
27608 F20110218_AACFXO kim_j_Page_045.QC.jpg
e0776349237ee3e54ea65f213974137f
6f2ad76f3bc7f19064312a775feef80ee3514aae
6209 F20110218_AACGDK kim_j_Page_122.QC.jpg
30f09edc5a30adfba7bdbf5744939162
24779d0fbab7402ed69ff30829e14224c16cc7e9
32483 F20110218_AACFYD kim_j_Page_053.QC.jpg
433f5fa9ca4751a00da2edeb6021a5fd
55be6b5545f1ae8d9988b6a1f0549cfda830d675
107244 F20110218_AACGCV kim_j_Page_115.jpg
ccbb11c9658584b0e191b2e6310fd3c7
95a18baf550c480d84d4c0416633b356bc4d62bd
98128 F20110218_AACFXP kim_j_Page_046.jpg
2bf8935363033b3fcbbd043bbc3bf168
ba73c2309c8624ad261d1bb2ff8b15df6a832a44
71121 F20110218_AACGDL kim_j_Page_123.jpg
373fe46b970b4d2ae5e97168e2c1535f
4ccbebbbf81648dcba11735c6b88f0dca497957a
82673 F20110218_AACFYE kim_j_Page_054.jpg
4e0b64f9b0a61f76086ee249856f953c
6f53893e98778dae896a1fa15a90dc8be95b5e94
34801 F20110218_AACGCW kim_j_Page_115.QC.jpg
27198b6a6a1a71000f5a7033b116dbde
235372b80cef36ed5e180f86974f4d4e85b83813
32551 F20110218_AACFXQ kim_j_Page_046.QC.jpg
b3fd168803753cef25418e03a75d22d2
a901ed48b5f7874b482dc99170bbd5c0ca588ed3
24080 F20110218_AACGDM kim_j_Page_123.QC.jpg
4cc74c56c909541cd153a49b3da6634e
8cf5e843cb9bb91a6e89aafd4aacf5329b8186cc
27268 F20110218_AACFYF kim_j_Page_054.QC.jpg
d0b97bd489cc1ad3281e3764ba2b9de1
a05df28f17a4061064634114dbb2bfb52773d339
104663 F20110218_AACGCX kim_j_Page_116.jpg
ced36efa8cc1440a3ee6443d64a69bfb
82d87b64b3f815cf71cb9a2f9d07de6f18faa980
110015 F20110218_AACFXR kim_j_Page_047.jpg
eefab8f0eb096dcfa0882b639524180e
f532e672be8b06e636949c906ce867dc8e37ead3
18452 F20110218_AACGEA kim_j_Page_130.QC.jpg
f402c7ecfb543a0b89268022a8be6cdd
f4f48aee560114cf4018c514c61cf110791e4a1a
78524 F20110218_AACFYG kim_j_Page_055.jpg
e7281a38c64c2713833419b4ae04d16e
c6f48fb1c10cd578cdf7587bc829baab6289888d
33965 F20110218_AACGCY kim_j_Page_116.QC.jpg
06318fbbe2bcc0654fe1575844ce219f
7dec7f215d9ccc7d26e6ce0fc1d8365958477084
31829 F20110218_AACFXS kim_j_Page_047.QC.jpg
ff389f246947b8219417fc64bf5ca089
7cf4750fbc7b8aad5448216c7e25a06c28220dda
67329 F20110218_AACGEB kim_j_Page_131.jpg
0c1d6896bc71a778fadb7b4f7604c53b
e9dc0f4d17906bb9e4e417630e97d12a0391c6ee
94443 F20110218_AACGDN kim_j_Page_124.jpg
34c7a9db584cf998df8c0ff7e4515280
08ccef0dc166f3b68b4b9d56c4a076985d7a6d8a
25331 F20110218_AACFYH kim_j_Page_055.QC.jpg
5050ffffdc63ec63737fcd2778bc2026
10a90e819db90f27d3c0ce146a6433a6390f3836
100400 F20110218_AACGCZ kim_j_Page_117.jpg
14ef49db3c6a64897fd0665704fee8f5
7ecaddc0ed006becd7d25405682dc4fbda8068a7
94485 F20110218_AACFXT kim_j_Page_048.jpg
6d67c29493c8a01a71e70f416ad9d3bc
170e38205881bd9b22786ad68ad0ba89de904364
18176 F20110218_AACGEC kim_j_Page_131.QC.jpg
2a9306fc8731d75fdd5e120feea4afa7
576c6adc53ed0b15481f931e4a314b786866f42a
29225 F20110218_AACGDO kim_j_Page_124.QC.jpg
e40532c3322115c365ad71e520680e81
b716b770ca98295a0152dc8209a85aa1663e5d29
103740 F20110218_AACFYI kim_j_Page_056.jpg
9577ae29436b25c867395153747db763
b00ee9bf714375d1608b2234fabbc0c73c8aaaaf
30507 F20110218_AACFXU kim_j_Page_048.QC.jpg
3ecf0a01a3b1b71068fa59795754d8fb
5947d8b223140af566967882de5e918481003702
102079 F20110218_AACGED kim_j_Page_132.jpg
b5625b7a7d305c29527bbf6105d8d03a
6838c083cf05eb70edd5a8fec395f3498a8ba0be
33078 F20110218_AACFYJ kim_j_Page_056.QC.jpg
21e58ebd940fc6a59eb638f3df3b69ab
0347b308ddb61185ecc8603b8a128640b8690f63
76346 F20110218_AACFXV kim_j_Page_049.jpg
c31c7238a51b60356a2572f07881fa8b
e6caea272c07a4b43677835a9414ac2ef2e7826d
28937 F20110218_AACGEE kim_j_Page_132.QC.jpg
63e3d799e4825282c472f9c3ef0ce562
0215c0b213060f2fdb96da22b314bd18056909ec
40474 F20110218_AACGDP kim_j_Page_125.jpg
844fdc57bcb7ca617f333f694d6dec72
b7ce4726fdf146798b28651146992bc39e603a20
98903 F20110218_AACFYK kim_j_Page_057.jpg
7e3a79456c5f850ebb78e67445979ba9
1438185316eede67acfe5929b1cbdc5e07cbfdd2
25075 F20110218_AACFXW kim_j_Page_049.QC.jpg
ccc4a3b2fce9e2cc01be1fa5d4dfeeed
56acf651e910432f7e6b57232c11398b60230529
123040 F20110218_AACGEF kim_j_Page_133.jpg
e137b024b3ffc30b28678c0d6795a402
e1bb82ba342d8d2351d33104af4e1cf7c50a1735
13319 F20110218_AACGDQ kim_j_Page_125.QC.jpg
9fe2a3cf6436afdb7b7a376aa4ad5f4d
283ff52e2f3c18f016acdeb96bddf60c304329d9
32389 F20110218_AACFYL kim_j_Page_057.QC.jpg
a186e11c264720f8afa3191353ab1df0
272b7dbe05e15f0d230f367a64b839d3585aedfb
31648 F20110218_AACFXX kim_j_Page_050.QC.jpg
96928e25981d1ae5bfae434082f551af
b19e4351ea3e4d56b665d603c2bf6a43439aac4c
34486 F20110218_AACGEG kim_j_Page_133.QC.jpg
343b65f9fc64696be2c0beaab2824e37
06692450e4462395e58409455f204b71da17fa7e
95580 F20110218_AACFZA kim_j_Page_065.jpg
65831c5823492ca1d2cf81b08ff03102
e80846c5583e522ddf27817364d9f54b7ba118fa
66696 F20110218_AACGDR kim_j_Page_126.jpg
246cec41fb950d027166fd6e9399a92e
73e4297eac69efb2d9d86be3a9cab64ca88bc1bf
71854 F20110218_AACFYM kim_j_Page_058.jpg
4f0c00f3a09a4c892f2ffe839a4aa027
999d28eb0f80c92103107f0493bc7ff619988625
106844 F20110218_AACFXY kim_j_Page_051.jpg
08af97f401e1f04ae1039e98683b8e81
abe593573c1a61be08571cda4bc195599138208c
123693 F20110218_AACGEH kim_j_Page_134.jpg
d8cc752ce7e85c91dff0ac42bf1b37f7
840cf65bbac27a0b21e3bb6a8ca1802fa2b45935
31314 F20110218_AACFZB kim_j_Page_065.QC.jpg
5c0f015caf8a2b9ff7f8c63330b540a1
a3cb23c076b7d4d10e2cc9d1a4a82db2a65cb2fa
20942 F20110218_AACGDS kim_j_Page_126.QC.jpg
58304b73b30f08013c2150cd957bb60a
308c34d886699e6b1ac7ece9e88b3341769838fd
23298 F20110218_AACFYN kim_j_Page_058.QC.jpg
e44098927c7fadff4217d70cf1008606
499e0a24842f081dbd6e5a8df518e6a86774e0ac
34536 F20110218_AACFXZ kim_j_Page_051.QC.jpg
3feaf10263a311b8c6bd7498ac7c30eb
b442304d5908fb0a203415808414d8813bc6f531
35087 F20110218_AACGEI kim_j_Page_134.QC.jpg
1ea655f386e36a01faf6afe050fd90f7
34b217149cdd47f44d54197c4b65f2ea8bf01f09
101317 F20110218_AACFZC kim_j_Page_066.jpg
f8db6939fe75994409c5d1ccdf2876c9
fe8073e00251c453a7879eab2f819e4a850864f5
59475 F20110218_AACGDT kim_j_Page_127.jpg
f1b8a57c38fbadedadbb88fa16ecddd8
e05ee5b8f6fcede9e6c2540786bd29924bb4aa5d
78357 F20110218_AACFYO kim_j_Page_059.jpg
bdc104a85714216a93a016b6e7f6bf38
36e6d08888be6b70bf306bacbca9380befba2ad6
112444 F20110218_AACGEJ kim_j_Page_135.jpg
c91c0f970710edd60056353f4375e32f
0b7eafd703457be36598c5952c4914cbdfc86cc6
32354 F20110218_AACFZD kim_j_Page_066.QC.jpg
49924053c6f8ceea8ebfbcb000c4eca6
7d99956be9abae663399df849ba31914fd9c0041
18793 F20110218_AACGDU kim_j_Page_127.QC.jpg
e7e96b25b7aed0e203432c6ef6baa9bd
756327c5d977de0ee94f1b2eaeb63c06e29f546d
26300 F20110218_AACFYP kim_j_Page_059.QC.jpg
9bdb32c4df56b76ba5c409b18392b5e5
e6a3024587926ca272483a630c3a7381bb9281d3
31935 F20110218_AACGEK kim_j_Page_135.QC.jpg
87b2d440a26d9c44cf87b8e38bc50f54
504d423ed0acca4e032fe9b8d13c3cbbd61b908e
92455 F20110218_AACGDV kim_j_Page_128.jpg
5602f435d75fc2af959140c496d9875b
11ea2bf1d4c522171bc6da130f0cc2fe26015207
103809 F20110218_AACFYQ kim_j_Page_060.jpg
e3b3a2ae3dee32167d4df28eef5be4a0
8ac4eda1130afeedb11886300a3ae006a0faa87f
124471 F20110218_AACGEL kim_j_Page_136.jpg
d3b6a60e6f147dcb05894c7433c9afa9
150bc47319b6d86e62236682dadeebee3f19d01a
71819 F20110218_AACFZE kim_j_Page_067.jpg
ff598136587f583d34b3267cfcf46e48
cadd708cba5d87b7f414df814046f8c17c26f24a
27267 F20110218_AACGDW kim_j_Page_128.QC.jpg
9a929ebbc768cfee6aabd97c9842d24b
18ddd615bf66336147732c3edf878fe534e2d09c
33573 F20110218_AACFYR kim_j_Page_060.QC.jpg
4a206746195eb1a91cd4a3c1adf786c7
b466e7e9542df41314be29ca4d795ea146a5729e
35785 F20110218_AACGFA kim_j_Page_143.QC.jpg
18cd10f33e9ac02847ccb2f6bd091c25
b234fb315009d92ddf8b14e396d6a63a64873594
34997 F20110218_AACGEM kim_j_Page_136.QC.jpg
24f98ccb093a97d966eba4043cc92be2
b8d3809ed211afeb0f3cf3fcf72b5a41518ce407
23929 F20110218_AACFZF kim_j_Page_067.QC.jpg
7bc8d4f8c5496cb1fa1dc1257e76be0c
517a424238d2720b7edd1d74307678ccc74d6426
47498 F20110218_AACGDX kim_j_Page_129.jpg
e73347c2e6f8b0cd277b3a458f928600
a8e7d4c4e25165807113e50ab9ec2a3b593c5397
103478 F20110218_AACFYS kim_j_Page_061.jpg
afdfc837ad00e3ebfbbaf39d8c782043
ee07ceb18957918d0f26c89c5864f73ac18a6ed2
123401 F20110218_AACGFB kim_j_Page_144.jpg
8463eef76612e62003e3a948e4a552e1
1f90807b1120745b6bdef34f62028db6e0be2c8d
124159 F20110218_AACGEN kim_j_Page_137.jpg
01d4a9fedf3240b5f317a21e7c77f4e5
9175937f63973de7aa662cf87e4b08e0c2faabdd
85010 F20110218_AACFZG kim_j_Page_068.jpg
829a95fcec99ee613d08ee101a3a2fbc
968c91e1a3f1d82c3134c034682c0d970b30c22e
17244 F20110218_AACGDY kim_j_Page_129.QC.jpg
f93e43f547d59d703a3f1a72405c4c4f
a5f601480a30be410780f82f933728bf63a157d9
34782 F20110218_AACFYT kim_j_Page_061.QC.jpg
dab6153daf6425bfbce8c0f53911310e
d93372451e56488fe89801c173e96a402cc51bc3
35574 F20110218_AACGFC kim_j_Page_144.QC.jpg
b559efb92175c8a590c85bd063f574e8
8b100e662c05b3f18d76401669ab2e8688d21ecb
27213 F20110218_AACFZH kim_j_Page_068.QC.jpg
8a6bc3b4f02716d7ba099b15f52b522e
88aacad8255320a4897522c29a3a327eae1954a9
49007 F20110218_AACGDZ kim_j_Page_130.jpg
1eb7c709569b68e9ccbfd04333dd4f77
2af48b6819b7283f27b4ce7eef646c487d674c60
75748 F20110218_AACFYU kim_j_Page_062.jpg
881af4d463fe42563d38df853ba834a9
faf5a20d1b29fdcae7ebe9048c59fb0cf213ad99
130682 F20110218_AACGFD kim_j_Page_145.jpg
6326bf972e2312bce21d90d7b69622f3
f7b8c563bbf052dba2cd8704ee566cbbbe744480
34469 F20110218_AACGEO kim_j_Page_137.QC.jpg
87cd7edf1233d672742a0972ad33fcd9
e3ff2ae27928d2facdd9a84a2ac3b7787812f060
93041 F20110218_AACFZI kim_j_Page_069.jpg
eca1e6a899b5d1d21b09d78121614d35
2e24d3004e3de572ee1940f4e46e69b5321ac89f
25924 F20110218_AACFYV kim_j_Page_062.QC.jpg
9b8c92fe339ef3f88c77f64c9de3bb29
c403782e57e49c6920cb93dc7cb44972a95530db
36440 F20110218_AACGFE kim_j_Page_145.QC.jpg
e2ea7b2eb6ef7aa4040267fb8fac72d7
76aa0d1b80135f1cc4cf80446a5abb07e6b85912
134045 F20110218_AACGEP kim_j_Page_138.jpg
1e2fdf1dcdca1011f931879e6f08353f
aaba9c1948bb6afcce5093bbce05d9c599d4728f
30955 F20110218_AACFZJ kim_j_Page_069.QC.jpg
f54aa6f62f98ea016b37bbb4b238d1d8
e7239a165b1a8983b0f463b1c61d2ea71723ac69
106078 F20110218_AACFYW kim_j_Page_063.jpg
c05e2df84c5a3856d4b69cac53addd69
58413efc2b415632994de717502ea60c466c8d17
132110 F20110218_AACGFF kim_j_Page_146.jpg
ef3f06d1dd1bf63a729280f637afe4ee
30d61b8f22cd426e897d044210bc033afafaff8c
37448 F20110218_AACGEQ kim_j_Page_138.QC.jpg
124c4ba747523458036f04dfe1473e33
b4143f7b9c33393440b20f10f71a86700dd55409
70397 F20110218_AACFZK kim_j_Page_070.jpg
2d026417dc37afb914a89a9bb88742c5
ca0847fe3b982c60dea752d69ab9cdd065dad717
34667 F20110218_AACFYX kim_j_Page_063.QC.jpg
0cd626c13d269288bbefb5bda35a1e8a
32e365af49f69bb45e67fe47e78c585d77c3478b
35953 F20110218_AACGFG kim_j_Page_146.QC.jpg
ef51e101fefc7eed097b0d9b26e7c5b2
876305f5398dc081c943e5e0a5affbbf77704a92
128559 F20110218_AACGER kim_j_Page_139.jpg
19a645e319d10c80efa84026c7cdab69
8cf58e7fcc4e78c76043cd1154f4760a1c36f40f
23856 F20110218_AACFZL kim_j_Page_070.QC.jpg
d1b84e7d8fd7029195635265f21c1ab4
81059e44e590d722a774435391d458d9327c15c4
107535 F20110218_AACFYY kim_j_Page_064.jpg
e189b1ba23b24c0f7c1cfdff3f7216bf
e3a915a28979635877d44557f91e11cbe8314a07
132156 F20110218_AACGFH kim_j_Page_147.jpg
a7b1534033c7c55df49bd9123a7c0839
7fe304cedb73ae6919a0572519cf70dd2b259450
35251 F20110218_AACGES kim_j_Page_139.QC.jpg
8569a586279f30d2d7f3700c043d4c27
b43a50037b4f5fc5f1d3535768158455609839a8
94605 F20110218_AACFZM kim_j_Page_071.jpg
397e4694d9434b3d507cc6a5230863dc
d92c0e8aec00659db99223e554b8d8c56d0f509f
35367 F20110218_AACFYZ kim_j_Page_064.QC.jpg
f10d4e0d9580aa44c1de8d366784a18d
f743df27d0bcb13935dcfe1c5ee109cbb61f4d65
36645 F20110218_AACGFI kim_j_Page_147.QC.jpg
e8a52123bb835eea603ac1be7c9a3197
84c466d19c08d40e13700d2be1061826f7ef3ef0
125111 F20110218_AACGET kim_j_Page_140.jpg
bd509086464eb5bb4533cfd358222684
5bafece864d1fd2abf4c2d847361b9f255a51644
31056 F20110218_AACFZN kim_j_Page_071.QC.jpg
65f2649080f8b6764b6ebb455339da75
a3378dfaee41927347df808c77ead8c34be9fcad
131655 F20110218_AACGFJ kim_j_Page_148.jpg
49f8ca24cebfe79578ccc47fcd30753b
585bc207890eb09079017fbcf638ec1dc74e73ea
34537 F20110218_AACGEU kim_j_Page_140.QC.jpg
1b0f26595c387feed2188a2838addf65
511df33e2dc978540b61a27cfed9eeaf7650fb8a
20721 F20110218_AACFZO kim_j_Page_072.jpg
fb3394987743236c0446918464bfd8a3
00713587381649715750c4a8c15e20935c1037e6
36672 F20110218_AACGFK kim_j_Page_148.QC.jpg
1ab2f9e28e31e5183391933b74a12025
eec7613ab2a46799bc5f485bacfd772ce72f3c65
114273 F20110218_AACGEV kim_j_Page_141.jpg
7953698b7e52e19b32fd347fe6048e4f
da23c63595b27013a44c687fda5b9d7df6d51a2f
7598 F20110218_AACFZP kim_j_Page_072.QC.jpg
808cac3bdb4e4787caec2e28b9100209
87f4f48390fed8a40cdc64f2ed1863abf472f08e
137238 F20110218_AACGFL kim_j_Page_149.jpg
7f27d9700e8af7db2016f0519f040a3f
1382d1ba94fcc164c89f97e5e624580a0a2fac45
32684 F20110218_AACGEW kim_j_Page_141.QC.jpg
e899a41804083d700489abb5f159f15d
8186f4adf8819a72fe33a302de3a75b29d53939b
68036 F20110218_AACFZQ kim_j_Page_073.jpg
c6d9da33e770b2a01f185aff5f64fe14
8d3fa64b5cf7cffc5acca58b807ef97d7198387e
48171 F20110218_AACFCK kim_j_Page_081.jpg
8faa434a319c49862c7159d8febc0958
dc8f19d2ea04f92dd331ef48470018dcffa16723
36921 F20110218_AACGFM kim_j_Page_149.QC.jpg
9f6e7cb84876aa142737e3c14c89d641
8591fc10d4d79f66cf382f08bc998653b39a1993
115603 F20110218_AACGEX kim_j_Page_142.jpg
65c466c1370955470457a5a677dbe935
9b3c67e33dbf66c2f1f5a8ba6fc1b2b277edc6ae
22442 F20110218_AACFZR kim_j_Page_073.QC.jpg
cf74ee5c8e3226d2870b6a87dfe59c50
15b6fc13f0b04455f7223ec0f185819a560d13c4
910904 F20110218_AACGGA kim_j_Page_008.jp2
4a2689752e8f08efa49f606b2947e347
0ef2160309ecaaea9996a190adae07afa227c649
97071 F20110218_AACFCL kim_j_Page_050.jpg
0be47cb9fa4fc9296c6a28111b9224dd
12b34b90aafa7a613baec22ec4e90255f5008c85
132990 F20110218_AACGFN kim_j_Page_150.jpg
c894de0d01587127154b14b25d4e4f67
f5594061fa9d063718559ea0ecaf9c6a0d98ff6c
32603 F20110218_AACGEY kim_j_Page_142.QC.jpg
05dad13ee91620d8f200851a6f31ae62
b692edfb1a1edeb145ca2239c768d1ff5c3f9fdd
103468 F20110218_AACFZS kim_j_Page_074.jpg
95dee06690fed964e3a4ef51f6efe1a0
f89b1876ce0723cc898f4a4e02e6ff6c6c9f56fc
729468 F20110218_AACGGB kim_j_Page_009.jp2
708723af50905885b3bf0afb61ecc5b3
51a475d1f343d4e89fee484a29744fab14467d9f
1970 F20110218_AACFCM kim_j_Page_121.txt
ff578826b60dd06b2ea16c5601c8ff8f
6dbcaf476a493f3f61704788f86b5acfb1c9a250
36778 F20110218_AACGFO kim_j_Page_150.QC.jpg
df3a3d18a9f5bd04c3bad73fe22dd794
09b257c1eba3edbd16da929de4f083f54212ec69
129083 F20110218_AACGEZ kim_j_Page_143.jpg
567239b0a1f1c298ee36ca4dd8fbc7e0
33b8f2ef52c7cb5575b377b375411ead1e4e71ed
34083 F20110218_AACFZT kim_j_Page_074.QC.jpg
31b9e70c420bbf1d690cf6de4db379a7
f2e4bba43ef7c460a5dd5ea4fe89fba8c4f97fc8
8423998 F20110218_AACFDA kim_j_Page_011.tif
0728ee2e913d0b061b99c5cc2fb87f0f
d55adf0f6e11c1734c6d6046c82346f284f0a51f
569457 F20110218_AACGGC kim_j_Page_010.jp2
b6dc5c85a57900646fa11b7134fafc52
a1f48fe0fddc22f5d9d4782d577c93c3090f4b17
105968 F20110218_AACFZU kim_j_Page_075.jpg
20cb4231b986c2c1ead0b9ba3fbd6d94
baa204d164c509aca10b2255f55c7d3f7bed4931
F20110218_AACFDB kim_j_Page_012.tif
d8953d1b19a1749c4a524e218c1063c9
383b77941a6216fb54aa21bc9560de8314e15ef7
936700 F20110218_AACGGD kim_j_Page_011.jp2
36184d5b6755cc61bf5172151fd76bae
10c2a02b9f71de79e2526ee8164fc6796558f840
242322 F20110218_AACFCN UFE0013643_00001.xml
b727034681a7c759b9f6070ad26b7265
bb065ba1b65368896c431221e23e4d03cde296dd
82444 F20110218_AACGFP kim_j_Page_151.jpg
1395244dc97ab5b6be908942de182998
b2522827faa659a79846092779dc4d20e3d32bdd
35277 F20110218_AACFZV kim_j_Page_075.QC.jpg
3224cf735314cea3e4763a6b3bbf4568
dc878340fc5c7feb9f79a1a8ea82a29c9e3e4e99
F20110218_AACFDC kim_j_Page_013.tif
46e4d03564aa7cdaa38d203207e9a7e1
1792835266db6e4ac7ad7a4c6d8bd153da37493f
886670 F20110218_AACGGE kim_j_Page_012.jp2
c6532e96eeeecb027776d5f0937a3ba9
155faa3ca6f2f01121543eab125d4f822b357e88
22474 F20110218_AACGFQ kim_j_Page_151.QC.jpg
1ae98911e70cbe795a186c48dda1507d
58625c100df31236df70bab36b27025f71db0570
69582 F20110218_AACFZW kim_j_Page_076.jpg
367d4287c923cb4e2c425b257bfcfd8a
3a5cd4df08fc5bda6af0484e3ab5e6a2a6e5a235
F20110218_AACFDD kim_j_Page_014.tif
ada7cc269ea1f40f8b8c439f08a62545
6cb0d0a5b55c082d8c0b1d84ec2eb6d08f173dfe
1014546 F20110218_AACGGF kim_j_Page_013.jp2
93e9e2ef0db56cab6237b7bb5f4ed5a3
0d797c2a4544529e30b1ca182c7373789d65b079
64215 F20110218_AACGFR kim_j_Page_152.jpg
93633793494883f27de7d8f88eaa69a3
900f1bfe7decdb56e7b7dfd44c8207198e296a15
22725 F20110218_AACFZX kim_j_Page_076.QC.jpg
79ecc678a6d7e7be20e94e4e580d60a1
b13f4058ee9d767a7ded6a7373b23389757ac735
F20110218_AACFDE kim_j_Page_015.tif
2928db5106d746e7388dec22a9f020ea
17db88925cb6d66f7e470ea332dacda3b1d24f8c
1051901 F20110218_AACGGG kim_j_Page_014.jp2
df94a46bdf11fcf29d4a3083d32b4487
be7661981ee13d76b7b5a0c25c98dce436c83ef7
F20110218_AACFCQ kim_j_Page_001.tif
17616a8d30c27e5d54542a6c72cd2f7a
23402cb902fae3959c70cfcce561741c1c70b270
20637 F20110218_AACGFS kim_j_Page_152.QC.jpg
a4b7d08bfb3ea211aca063d362479299
60b5c76a2053e5d04d498f606d2b0c791a9e774b
33652 F20110218_AACFZY kim_j_Page_077.jpg
2551f8d2ae40c79d68d3fc3efc1177e8
3ba2b4ff74e08e41a80ca334b7e0f5d9a1dd17e3
F20110218_AACFDF kim_j_Page_016.tif
d7ab350a74c49a374387abeb96000731
677674186a0035bf20a60cec8b9bbc247c9e8982
1051970 F20110218_AACGGH kim_j_Page_015.jp2
743aa8d69d4d130ca80ecb683a2e2a4f
249f1c085d4293f835b0211cfb186f13affe16c9
F20110218_AACFCR kim_j_Page_002.tif
92a25358daa224ce9a128e766e10a75c
7873701bd400a2c9a6cc7408f1bcedc3643bd245
293112 F20110218_AACGFT kim_j_Page_001.jp2
5c2b338b067f54cfd6e13ccf15a76566
346aa25220eec2a971036d9f7be1aee890848416
11985 F20110218_AACFZZ kim_j_Page_077.QC.jpg
9d0259ff59f459461f2ace887e782e34
a0a52098c5c0e2fe252be60a706fe0070958fe10
F20110218_AACFDG kim_j_Page_017.tif
37bd622e8c7125d7969773971bceec24
3fd9bc213137e0be581e5a9fc98b0cf788f162dc
1051959 F20110218_AACGGI kim_j_Page_016.jp2
7f8bc412b0962937fb2e0b3499abaa86
3af090ccd12652da35e7205640f0a8ff426dbf06
F20110218_AACFCS kim_j_Page_003.tif
df6156b4b4e9c6943c8ac98a5d985022
434cab18ad5129a12406f65f154757c0c8f22cd6
24327 F20110218_AACGFU kim_j_Page_002.jp2
3049b89a889b4530d0cd89a39d4f8316
ba47b72232cbf3c33445e3281da21ea8575d6c4f
F20110218_AACFDH kim_j_Page_018.tif
7e228f72aab476e8b24606dc2cf70092
d53c50342ccf22068ecaeff01faffb23ae894127
1051881 F20110218_AACGGJ kim_j_Page_017.jp2
bf198f7d7025f272304d2b0e648ef512
bd9e040304c0265ae2513f5f1012e67aeed5f3c9
F20110218_AACFCT kim_j_Page_004.tif
c8978deea3b2b2e4448a93de73954dfa
0e0f91f15dfc76852bc599f2859940da4db0d631
62194 F20110218_AACGFV kim_j_Page_003.jp2
208f37a33945e8680a103c77bf4d02b1
a2b8df6f56d95e1915e4b237972f74eaeef3f8a6
F20110218_AACFDI kim_j_Page_019.tif
e384ef42ab3f10765f51bbf8d8bc17ad
8538e38fa0e6e98467288f99cb04bed2989b08b5
1051981 F20110218_AACGGK kim_j_Page_018.jp2
dc616072fa8afb1675bb6f2617395e1e
7d2951faaf2ec9e84aa0834e8427bc647bcb31cf
F20110218_AACFCU kim_j_Page_005.tif
a75d20c3773d8021a36b8a5d18598d0a
8a2378ad74355936d625684be2e5ca64b1379e5c
923545 F20110218_AACGFW kim_j_Page_004.jp2
b4e313cc0e868044c5af2265984e462e
9ffaed09299afca17083398b95cfc69a836c2045
F20110218_AACFDJ kim_j_Page_020.tif
74f4b950dda4287e295fef26700a2215
c781902a9233b668a695970181f33efb628187ca
1051950 F20110218_AACGGL kim_j_Page_019.jp2
5e4c7acd9f90939102bf5a9366485402
4d1e5cdb434d99a656f4ef29ee10339c6464edc8
1051939 F20110218_AACGHA kim_j_Page_034.jp2
b1ddfca172b4ae03d91edd0a7a99dce8
b006effc6a882636296b92c6b6fcaee7f25589b3
F20110218_AACFCV kim_j_Page_006.tif
13408d76857dd50a38d4820fdb5c233d
4120a296624d1985537f17550c9f79d7e23f10f3
434184 F20110218_AACGFX kim_j_Page_005.jp2
a408ae2274c9a95a1982e08088ed5330
eb8b6189d9409261ca00c2ff9d1efd5508816dd4
F20110218_AACFDK kim_j_Page_021.tif
708157529355faf58dbb922fc7b1e0aa
fd3f0b739fe05401d7c8ad24a000770882c6db9d
1051965 F20110218_AACGGM kim_j_Page_020.jp2
a508f2441f7282787d437ab587252039
a5ae2b99eea262a45f78d78fe91bba54ae90da04
F20110218_AACGHB kim_j_Page_035.jp2
c28a40bde09b2ddebc067b244f8b68bb
a5845b60cca03525be1b03f941bad3b9f18c25f3
F20110218_AACFCW kim_j_Page_007.tif
277599570658d556e1589b2438cb8349
13500fef25ce7d776eb1998e2918c04f128b92ee
788262 F20110218_AACGFY kim_j_Page_006.jp2
10127556780081d667aaed66c65ce6d9
87cd052294b920b82a528ff50377ad18eabc750c
F20110218_AACFDL kim_j_Page_022.tif
da59afe34e079a34bc51522edcd6f7c9
2619cf6deaf6434f7b3c5349f1b83c167e4ce3c2
1051951 F20110218_AACGGN kim_j_Page_021.jp2
1f725a0bdd54ad4b90fbdad4a6217db1
c7047347b508ccfef7918f288c717a3133c8ba85
1051985 F20110218_AACGHC kim_j_Page_036.jp2
723ead88997af64d20d12acdb041cea2
f35c1646dcb3115f1742082247defdcd301e3d25
F20110218_AACFCX kim_j_Page_008.tif
5b9aec831943eefe95f2369f79d5533b
f6add0b80a6889aab5b3b9248c573806bbf0ac39
633624 F20110218_AACGFZ kim_j_Page_007.jp2
651df6b15b1f5ac67926e1e57301a6fe
fc551a1e4b151a93c483707867e0288241706ebe
F20110218_AACFEA kim_j_Page_037.tif
81c77469b5d384ea2f85a855d637941a
206422570bc1d72063ad836edbc52aa1b0aaf5fd
F20110218_AACFDM kim_j_Page_023.tif
94ae57395dac8e8f2d2e2c45d03f3407
6ae01a7785c67d7407f5568a5ba220c5af8dac26
1051978 F20110218_AACGGO kim_j_Page_022.jp2
4508d8434e5d4aa2d02693b71bcd6129
f004024a04f4955544f83482c83fc3ca85964160
1051963 F20110218_AACGHD kim_j_Page_037.jp2
90aa72f3f4c3fadf9575762a924dd556
df4645a640dd01219112a6c2a9eddd18ab21c42c
F20110218_AACFCY kim_j_Page_009.tif
de2b8e1d8f3d38765da5fa6367cbe76d
800f9c328c02d36e18ec41760b34e262e13db19f
F20110218_AACFEB kim_j_Page_038.tif
ae8b81addcca0240371dc517c2914d6c
cf2b5518da826947cf024667f1f3a629a11c7420
F20110218_AACFDN kim_j_Page_024.tif
c7b3a3f716df6f5ea1b54da93db01534
794407ee2405e91bdfbc54909c6c487021d1e3c2
1051924 F20110218_AACGGP kim_j_Page_023.jp2
6926c83e9cfec880d4f38a27b1cdae03
2c4de7d4fd672a94b58b7d1a9fb5433b50edcafa
1051947 F20110218_AACGHE kim_j_Page_038.jp2
0e34bc9c9fed5b0eb8644428cb530d0f
213a0994a8e0751fb4c178b9337ed043d0633127
F20110218_AACFCZ kim_j_Page_010.tif
613c255f168417172c792ae5f44e480a
baea51b8d6b12fb3e09faa115bd519fb3afef56a
F20110218_AACFEC kim_j_Page_039.tif
f617ecb3ab515cff099d36318e2f047f
7f0f1b028ca9fe296e12df6e0ff7c15f66145f36
1051933 F20110218_AACGHF kim_j_Page_039.jp2
35953e53b3e05f7940564d6f403ab095
18959537be79446206a0ee616649c7d7156f5d82
1001111 F20110218_AACGGQ kim_j_Page_024.jp2
6ad150a0acdb74b68dddb6527f8109d7
7e48b33ad60654d47260bf75103a9dc959037391
F20110218_AACFED kim_j_Page_040.tif
36952a823cfc2d070f36f1a7476e0c1e
022e95e59ca4cdd5defa32fd8716ca0fe2a7c415
F20110218_AACFDO kim_j_Page_025.tif
32d4441c8f31ab7f8ad99a851f47f69f
23b772683c124ece6e068c9437054877ea0159d8
1051905 F20110218_AACGHG kim_j_Page_040.jp2
940841f3f22b0c4a1a4b075c5aa46302
0ebaad667dead0a297b68e24da3c74324c401e38
1051960 F20110218_AACGGR kim_j_Page_025.jp2
72f26ebe42b585b8eeae8d35f33cf34b
872f986b291c8f6398f1994e0169fb952210683b
F20110218_AACFEE kim_j_Page_041.tif
f0e3362bb9fc97cb6021b9e65399a280
fda8cda6d24e2f3a5c523df427c99d02027f697b
F20110218_AACFDP kim_j_Page_026.tif
74a5214daaf97c23b65322263dbfb3d7
060fb81fa73c743d34ded285ca56b2715873e1d4
1051971 F20110218_AACGHH kim_j_Page_041.jp2
cd03af7ddfa83d3188b4e4e472c7e228
41ce3ca81b13937ab39705a0b6347d70b9064863
1051974 F20110218_AACGGS kim_j_Page_026.jp2
289d880dee1f5231309554022148e63c
682e97c05e5a918325a6b3c1143542d3b3aa79b3
F20110218_AACFEF kim_j_Page_042.tif
8651ab5b4e0a8356ac414ca84738c053
cf8b71dea77322419a0b5192db18319874b1f824
F20110218_AACFDQ kim_j_Page_027.tif
5144db924c077625d8a06206ba0ab662
5ed1fb5ffaa40bde68c4c02d1581c13a6b4a0bf4
1051954 F20110218_AACGHI kim_j_Page_042.jp2
be143d70dcbca4ff300baf6c1a9e5b2e
f7c7abb52d0e9dbf5195e33dd64ad193339acf15
F20110218_AACGGT kim_j_Page_027.jp2
73422c4c53cd15e57960ac78148fdfbf
22bb3c464ff58cd2ef3dbd2279b106ad1a7c7ec4
F20110218_AACFEG kim_j_Page_043.tif
77d69435afcfaabb4129e50b0103f80c
82d077de0a96c2d85a088e551169b8cd034f1b32
F20110218_AACFDR kim_j_Page_028.tif
959c5ec3ba6925c68f952950caa934de
851a91f41329b933cd082473ef6ee0c459745068
1007720 F20110218_AACGHJ kim_j_Page_043.jp2
180b0c5753e00d4ddce715ecc685585f
2221a3d26c4d7ce008d91caabfb19ba472fb38d0
1051958 F20110218_AACGGU kim_j_Page_028.jp2
2f014ca6fa080242174764597dd850a7
a3b8ab3ff5ade30032d3c785f445463ef6b618f3
F20110218_AACFEH kim_j_Page_044.tif
98442f40640df31eac599e3a1548cd5d
20cd1180655f25e8674087f8f597bb5ffb6b0888
F20110218_AACFDS kim_j_Page_029.tif
94e2c5fcbd03275a9667df8214ea4b87
50f2aaed6087bbad573a5dcd42de6752cfae1b5d
789911 F20110218_AACGHK kim_j_Page_044.jp2
a553285265bd32c15f26048fdba959ca
15603d422af797bcf8a3fbb929acfd2dfd72877d
1051986 F20110218_AACGGV kim_j_Page_029.jp2
a6f45ed55f865c6a0af73a92679b97bd
8843eb8fb5a03468529fb63e62e2537bd02c7817
F20110218_AACFEI kim_j_Page_045.tif
9f5f86960ce960e64c71a4f1f2430d85
bc3868efcfbb7318115371f8db48354b78a66aa3
F20110218_AACFDT kim_j_Page_030.tif
d8534dcb88864388107d7090c324bcbc
187090228966bcb912e93035e5564aa42d9aba96
937692 F20110218_AACGHL kim_j_Page_045.jp2
0e722377e1feda7b08a181c196a9c181
de9e1f26d9b8b2eb92415232d1656327494fd350
1051982 F20110218_AACGGW kim_j_Page_030.jp2
aac58a3e61265d3f071c412b29cf526e
46e152201ea44675fc9e28f8e8847c5bf2e37581
F20110218_AACFEJ kim_j_Page_046.tif
5bcef2db6f08a2c53d5c73a6c1f470a7
e782a223cb4a12d9f31b226d5a305cb5bae6736c
F20110218_AACFDU kim_j_Page_031.tif
3e8241dd022f9b3ef9e5e0a4cac697a5
527386ae9a9898589e9a58d01e2878ff8826d682
1051957 F20110218_AACGIA kim_j_Page_060.jp2
a0e313f4528e83bdaf42271ba193ff81
322e30e211a9c0a6d673b9aa00d31cb062b85b6c
F20110218_AACGHM kim_j_Page_046.jp2
14c79eaecbd5312af4533f5a1798837f
6d7be31695b950ac5e9e928fdf3958b417f43f4b
1051919 F20110218_AACGGX kim_j_Page_031.jp2
90efa0f540cbb8d9130903bf6e654234
da66603e2236e9fff7a84d57276dc9ff93b097bb
F20110218_AACFEK kim_j_Page_047.tif
5c9fc43582417100bb7bc924895e4b34
9e12ae1382b6500794fbbfd07e75ab82a03a1589
F20110218_AACFDV kim_j_Page_032.tif
49ddc740785ef312d99ad5e6f6024759
adbe82818820f11ab006d72fbd45689b2fb330a9
1051909 F20110218_AACGIB kim_j_Page_061.jp2
f981084f6cbc2efe0e3731e3708ff08d
546633a9a2c6f337da2fcecca4a282b065301f35
1051944 F20110218_AACGHN kim_j_Page_047.jp2
928e2e16b9df5c7d4eb238b9b722683c
35a8f4dd411ffefef1201bd4aa2782b15b1aa005
F20110218_AACGGY kim_j_Page_032.jp2
3411e5397df465f6baa3f2bda8b15c92
305338d0810bda3be58d6452acc2ef3cc36d5113
F20110218_AACFEL kim_j_Page_048.tif
e55ec1d392588b2e4cace09fa8fc517f
ca6e45cbd34574c74e658effc26ca90c849ad472
F20110218_AACFDW kim_j_Page_033.tif
5fe92c3ab6dcedd1f6029da849dad4de
5dfb21f11fccd0024bb3388de0b4e45af3f93b0e
847674 F20110218_AACGIC kim_j_Page_062.jp2
d9211a638120a7b6b64ab732810183fe
9afbd2f16a4d9f64b92a2d6982b9858bbe9d820e
1020458 F20110218_AACGHO kim_j_Page_048.jp2
e77972c8b20c1d441ff7adbbc61e4239
6e75b6bcb812f9ecd035d34c6e204f6c14449418
F20110218_AACGGZ kim_j_Page_033.jp2
2498ceefce99db47655ac7070cc33572
ee6d3057ffd4585265a79e4e40e63263ce6a7ad8
F20110218_AACFFA kim_j_Page_063.tif
912fc0f6874917b9cc9d95e760c8eff5
f6e3714977203c3ef4ff4e16a8214b752b5d2f91
F20110218_AACFEM kim_j_Page_049.tif
3464135f08c743794a93f672a9bb5186
6cd98e7a749f2dfa195a28e9d5f56c594d51d638
F20110218_AACFDX kim_j_Page_034.tif
9ae6a17898fc38e4801966efa4e74d05
3554baa6590e5bdbbcdd3b65f94e68dc68991d57
F20110218_AACGID kim_j_Page_063.jp2
b1469b984edf1f97f33c4b7cc1d7a9e5
557d77ffe996c7ccd80c16a379946a811506760f
782523 F20110218_AACGHP kim_j_Page_049.jp2
5962c086ceaf07cebad14643bade5c71
2b13a9e063b27a8ce0e2151141745fe23dd07f74
F20110218_AACFFB kim_j_Page_064.tif
fd6cb1d400f204fb420b22eb03249271
2b3be724dcb471b2503b1fd7fbdc2067f21af1ee
F20110218_AACFEN kim_j_Page_050.tif
03015cb208cf130d380c9eb9867ef229
180ae04ed6909c77430d41c03e13d722c09bab76
F20110218_AACFDY kim_j_Page_035.tif
6d53b260ebbcb7eba40eb7b201be6f2d
efa836875e1fc2763c46224ee61dcecb8fe93a29
1051946 F20110218_AACGIE kim_j_Page_064.jp2
089bdbb9078779d600b6d3c29c8e5894
e53b9c75dc5f2dcda4488192d7cf10b4d6400dfc
1050278 F20110218_AACGHQ kim_j_Page_050.jp2
ef010ba5d948b23bc68998d6fb834c54
a845a3590573332a6a8ada3509af2b3c7b9cbae0
F20110218_AACFEO kim_j_Page_051.tif
0b2caf700357b32cd02e359ced27a366
5fd1369b7471b6b0c1c3436a12037c64e93922be
F20110218_AACFDZ kim_j_Page_036.tif
205e6873e5df665756357e1619a68353
85bb752e5c88e5351f2506690839ee9c4cf62bb6
F20110218_AACFFC kim_j_Page_065.tif
febec641df20b9111d089d8ce579d6e6
5e6d132404368736dc234a1b21f54551f0fe9987
997812 F20110218_AACGIF kim_j_Page_065.jp2
3d70b080098694d8aa943276d67d9484
66e100f7b70d821031aee6e6e1d9c938ee5778bf
F20110218_AACFFD kim_j_Page_066.tif
edb5d12bf51d3463d74e8bbada053d6d
f1126890ff6feeec47eec37c46054d2e90af85a0
1042484 F20110218_AACGIG kim_j_Page_066.jp2
213d77cf191187e6d7bd375930f0b0c9
0f1c780eae3c1487e59d1b4fde0d3ef103a2a6b1
1051975 F20110218_AACGHR kim_j_Page_051.jp2
9f3da77d383bdaf16242b03cf1fc6be2
bf9b93988255fb058bd044d46baa3e069b9a275e
F20110218_AACFEP kim_j_Page_052.tif
c3c23b920d18502ce352e1e8f924f3a6
8645313fe986ea671031d725bbc9ac2ad56a2abb
F20110218_AACFFE kim_j_Page_067.tif
f670beec4bb08de9abd0063b2bb9b7ee
93464d7a993175d24b15efb08a2ef94c99442d6c
777218 F20110218_AACGIH kim_j_Page_067.jp2
971641ac8866776ace4b176d4b5ea29f
2675698e3df5acf2e3a29b19913ad3e5da44ab78
396390 F20110218_AACGHS kim_j_Page_052.jp2
3d2163bf68be31e08171422e6ea27b3c
05379c77628da1262df06db79eb3bbaf05adbb4e
F20110218_AACFEQ kim_j_Page_053.tif
5cc9eb9c71ed43c25d8cbd9bcd2049eb
ad87068997d4b2bf13ccff13a44e79dd8762b8f0
F20110218_AACFFF kim_j_Page_068.tif
12d905426f117c781ff9125940e21884
015f5d5560bf3033bcda345b6b592dc411b8cfbb
909516 F20110218_AACGII kim_j_Page_068.jp2
6774a0d2ab4f7ada6af26c57db440634
b0085a56dafe5b5c8687ea34edaff1926deb6d74
F20110218_AACGHT kim_j_Page_053.jp2
48df38dd2df25720fac11da9c71a21ac
8d861ef59894ffdbe9e598cc5ce84380458efaee
F20110218_AACFER kim_j_Page_054.tif
236d74965d962b0919a3449681a61af1
39e9e7cb46493d5d470ee7c19043354141c61e42
F20110218_AACFFG kim_j_Page_069.tif
d88328a5795a04c715965ac48548da52
611beb69e6fbdcae7cf6e424db249d74485bda2f
987199 F20110218_AACGIJ kim_j_Page_069.jp2
7dbb82e433b695c0b22acbd80ca9d116
142f62aca2017b3e8d4ffb637d5faabe1de73ff4
870107 F20110218_AACGHU kim_j_Page_054.jp2
af8f7cfba1e8ccced8afb1a495050356
5f0acb1a6dbf3a49f9d3cf795bb2a932aff4cb67
F20110218_AACFES kim_j_Page_055.tif
15971a9d324f7948dd837b592aa1396b
9ecd5bdcb4742281f8ccfb9f578c5094e7c96383
F20110218_AACFFH kim_j_Page_070.tif
0c159049ce7f338408af59e9fa21a1cf
0f281c029a303fc5d5109d7469da5ba60ade3b7d
710249 F20110218_AACGIK kim_j_Page_070.jp2
1cefb9bbdba4e9af20c2383cd11238a1
d28c887e44a5d45d717105c6f083e42f3029e5b6
818836 F20110218_AACGHV kim_j_Page_055.jp2
0e452a8d3d7d95a7ba70e04f57998af5
e0e31ce8a27eec098cfb537ff7ea1cb8b36d7c7a
F20110218_AACFET kim_j_Page_056.tif
c33507dd83bfa7749aef03dd1cad8f61
170f67d9487fbc03efcd8f62f2b147316b76db10
F20110218_AACFFI kim_j_Page_071.tif
3beaed970b14e1e65cfacd85e1bc9948
be7e8e3ffc659432543a3ab9176ad98958c45d8a
1008270 F20110218_AACGIL kim_j_Page_071.jp2
a2ce53c3ec3050d5ee176ef1983b5e05
71e4044ebf6fc4185c80112a21a901acc584810d
1051956 F20110218_AACGHW kim_j_Page_056.jp2
e81af39556e9c8093295027ac7c8ecc2
d781777afe8014c1a32a4b3e5f5989f92a74cc5a
F20110218_AACFEU kim_j_Page_057.tif
0470ea6910030c3c9758b52e17c51950
bb2ce5b4a223b08b0cd6fe47b9d7fcd0392c8e1c
F20110218_AACFFJ kim_j_Page_072.tif
5e1cda9e1cc0d7bc42596b948e132a76
45b31b3a3d2e65af15dccdaeb18c463eddd7d74a
359857 F20110218_AACGJA kim_j_Page_086.jp2
d3eb728786f2e3760469953675274ed6
7b6e740b9eb2dade5269377dbac4d702bbf963fa
157518 F20110218_AACGIM kim_j_Page_072.jp2
67ab369b635eff375537d5028be1bd81
f5e1098862e3fc7aaf060a8ed186afac98c215a1
F20110218_AACGHX kim_j_Page_057.jp2
30a228736c7f2e49b31e32d2a11937cf
dd9ff13b80bacb153678bf4881bf6361cc9d248c
F20110218_AACFEV kim_j_Page_058.tif
5d48decd139a082c30031fdd3b14ba1d
f744c9ae5d59c982d1fbd773a062eea49262badc
F20110218_AACFFK kim_j_Page_073.tif
1fc18f04ed7e08e3e59d31118bf2d5ff
29689da939891f5e364d8a4fc66adc4ba7f30adf
856153 F20110218_AACGJB kim_j_Page_087.jp2
5431d97d30849a249e8b6e1aaffdbeee
6849aeb91acc5aff93698a2b868a14d88893a99d
688098 F20110218_AACGIN kim_j_Page_073.jp2
1f81b921adab0a25be7b1bc5a1704cf4
5ad5537f90e2330133ca19528ebb5285a3563ec7
774916 F20110218_AACGHY kim_j_Page_058.jp2
6c6ab8a64d32c47c490122696f9d2525
06a0628993de05761fee3e70934b35c95bfcd9c2
F20110218_AACFEW kim_j_Page_059.tif
a07f22e72b7c2b854dea1c5393b60d0a
ac74baadd3f17e06f5227fd3ca79d2cb710607e7
F20110218_AACFFL kim_j_Page_074.tif
0f5e567b5ae94d48ce202acb1bb974b2
ef560eca95fab7b7ef7514f4ed21cf08c30edaa9
609533 F20110218_AACGJC kim_j_Page_088.jp2
8efae267aa98dfd15f6c3757b7f92d3f
07c83774690eef2aa5c0245ead53a6512eeca118
1051972 F20110218_AACGIO kim_j_Page_074.jp2
6cc088c9122c99a657a237629bbd1653
ac95f4fc69624fa3fd31fb47c0590b1a73013a2c
815072 F20110218_AACGHZ kim_j_Page_059.jp2
e53f3a4c953600533664d2ae841d55b7
41a078c37d61b611d350d7788943e72a8d378e22
F20110218_AACFEX kim_j_Page_060.tif
8affd268189d31101ace1f257700b958
b2f50aba3a62757bd5b913f916bc49d9abb192d0
F20110218_AACFGA kim_j_Page_089.tif
81b7cd168fd3b872de444370d948a260
1480c49d6275462f2d3f41ff13f276ee23a80b63
F20110218_AACFFM kim_j_Page_075.tif
0cae28aa602d11c999006b080b638ba0
70f19260862ccdd825fb9b3e3cb58fcbbc013e80
F20110218_AACGJD kim_j_Page_089.jp2
bad7379d0d50f8d645ef13b9d20a4036
d8397ebfedb4aa18bb419967891913e6ba95fed2
F20110218_AACGIP kim_j_Page_075.jp2
b0367bf4221ab75a978c0a5c6e91af69
bbfc00fbabb81b63008938b39adf1250137c3ca3
F20110218_AACFEY kim_j_Page_061.tif
257b38f8844bbb8f225d498bc111c200
7588a2ea4abae280d527bf4a1a9767a1f05c25e9
F20110218_AACFGB kim_j_Page_090.tif
be9ca2dfe740623e885ec3804ed945bc
b24b7173473818b8ce07ba229787b383570f8cea
F20110218_AACFFN kim_j_Page_076.tif
9d20b28495a8be1bd90af3e34b77ac07
50f381ac11ce1219b727c6033b55cee2e02fe9bf
289857 F20110218_AACGJE kim_j_Page_090.jp2
01e2642369d51c7e0195ad2af00a1223
f6d3a96cc17456256e5695e801a41db2d6c3b665
682261 F20110218_AACGIQ kim_j_Page_076.jp2
4bd9f87adf4d507ac065badb009b85e3
d7a146a66117ff5305a7293998bb572c322a1711
F20110218_AACFEZ kim_j_Page_062.tif
f74ce9d7dc4cb79ffa5ba7870329fdc7
a93cac92992228fdcbba2de29eed06c6975e67f9
F20110218_AACFGC kim_j_Page_091.tif
f5a70d19310844670e39f383a6d1e5d5
d19bbf0db0e6584cbf16e495201b70af5c5b82ab
F20110218_AACFFO kim_j_Page_077.tif
10a54077a3abd6cda3f8d659b66eb36d
ad7cf7a05add3cfc6ff84c1c21f60fbe435ec869
967367 F20110218_AACGJF kim_j_Page_091.jp2
914843fa06e4da1316e52701acdf8520
6f208bb35a10642203d11e2d8a7b3d8f6eb648eb
281998 F20110218_AACGIR kim_j_Page_077.jp2
a1a0e8c1b7413bb426eae7c2b98b7ebf
dc7cf07d8473c8a0e7993f1f039e01ab32afad69
F20110218_AACFGD kim_j_Page_092.tif
7748aa6a3e1067092669ad7367daacae
31ad36e39a64d37657c859ebe2f3c1695a2d7de9
F20110218_AACFFP kim_j_Page_078.tif
809255e914d469c15579be9a5cda834b
b71e1a1431a6231ab6cf07231a932417a402746f
832827 F20110218_AACGJG kim_j_Page_092.jp2
43c74516c1ba12d13c26a2f3899aeb90
0d6159c7fff74444728f4cf521f6cf6c65eeb58c
F20110218_AACFGE kim_j_Page_093.tif
6e131c940cfacbd6819060f6ac33927e
2836715837e04665d5f45b4c54c5891a6fe0c22c
1051983 F20110218_AACGJH kim_j_Page_093.jp2
a38f79b87a67f90df3abc8fd70be4869
3b323f011c5088a9d25dbf1faedf2c337411529f
1051935 F20110218_AACGIS kim_j_Page_078.jp2
72b781b293294a85c9cd6c79b128d232
bc7b7663348d6a2588c84dc83302c0db813e4392
F20110218_AACFGF kim_j_Page_094.tif
8840a24e990de01bbe646344157fd93a
c7bbbfa6e12e4c6792bb66dcc6a5fe72cb483f51
F20110218_AACFFQ kim_j_Page_079.tif
057d009298cc23a41d03a399294bab9b
50592adfc025741c9bcfe4d0da61e92789610075
467885 F20110218_AACGJI kim_j_Page_094.jp2
542da4c91f51a268473891444f1546b2
01382f543dbd0eb7276aa37b0e2205c7e1b34680
576418 F20110218_AACGIT kim_j_Page_079.jp2
62f5de514fea05f116fd309e408fee64
408daf813e4e0482da61676372a419e71700e8f0
F20110218_AACFGG kim_j_Page_095.tif
81f42e828a07450814a9c2eced7351e7
6e13ec68282da074061051624615c53eae29820e
F20110218_AACFFR kim_j_Page_080.tif
54947068438890d714b51f3747a3ac15
8e500d062cacd67b7a260145d690d6fa8f6e2a6e
F20110218_AACGJJ kim_j_Page_095.jp2
8ad39a8c6ff5a0429e03c6880dc3730f
4942425429e3a00cd615ce63aacaf21e06d227d5
684318 F20110218_AACGIU kim_j_Page_080.jp2
ae2e49bfe3c2477a33beb2d994daa7be
7140cd369f88aafe0045fd1de7e8be4a21a6c9f2
F20110218_AACFGH kim_j_Page_096.tif
8b4383ebf5e75730d1d8310c17e45524
a6ef752f97ac12aaf5009a82e39a5bb5fee82d3a
F20110218_AACFFS kim_j_Page_081.tif
ccd52bcc1d7f1bfe47f3974205cc2747
01d5ce3ca67e2b88865f6da97abf854650810334
613980 F20110218_AACGJK kim_j_Page_096.jp2
9eb12e11b04c3e52e064f5e9b5b55561
abf94dd2c47f556426e47ae000415b85a4fe6b2d
451508 F20110218_AACGIV kim_j_Page_081.jp2
c95c22b94b574beae48d37ab3ec8446b
5bf2be7c7f30b25199318faa2e62f0f12d30e914
F20110218_AACFGI kim_j_Page_097.tif
34aa2870cffcc70693a92bb1df7eb98e
f48d5ccc640dbab0165f2ab7ff727ab788756338
F20110218_AACFFT kim_j_Page_082.tif
52391dc5e342828a6eb89b36ae788773
af3c60e219559d15b5918b9d3a42928c8227a22e
749857 F20110218_AACGJL kim_j_Page_097.jp2
55e8699ae511822268a83d2308a33a89
3cb22acd2ff65ebdbcf2c9c5282080c5e8d164d3
329861 F20110218_AACGIW kim_j_Page_082.jp2
3d0b42f40af4bc9ab669432025414e80
8709d1dd75754963e28e76268b22ef52ace37094
F20110218_AACFGJ kim_j_Page_098.tif
46fe03972ba7c6f1fbae4d0d833d43e0
6e722e71dff11eb102ac3fd696e392d89bd06a62
8425398 F20110218_AACFFU kim_j_Page_083.tif
f58e0df126ff76f33f2349fbe14d631c
a17785a887d7c77d3b592363d4caf7d83e436cf8
F20110218_AACGKA kim_j_Page_112.jp2
2400c1c5e042468c89007b7eaa33b8f1
7567a90753504c33f09dd652797208c21a7bb57a
283231 F20110218_AACGJM kim_j_Page_098.jp2
f32b7dfb59f8b691f740a0bfd3309379
8c40d952be8428ca433a0d3162d6706f5caab5ab
629134 F20110218_AACGIX kim_j_Page_083.jp2
69dbbbecaad39c40b6aa145457fd7241
62b41184354c4bcd5bd7bff90590897c450e5767
F20110218_AACFGK kim_j_Page_099.tif
2fc881903331c63518e9a4757522a06c
2a286081b78ffe6f8d8982b44ef8dd646b9a4bc8
F20110218_AACFFV kim_j_Page_084.tif
3d6fbdf61c09821e9f754e1ae87a8cdf
19755bf6eef7a77a1cd3bf76fc459736b52ae765
1051979 F20110218_AACGKB kim_j_Page_113.jp2
4641c80b63eced8e76024f21fd577ed2
e0f9aae6c0633ea2ffc6e8db01f27c948fe832de
976031 F20110218_AACGJN kim_j_Page_099.jp2
44aeafae0467b3d0d92506a7a3975e30
9b31f3660584abb9d632b5878a6978252173e7a8
1031349 F20110218_AACGIY kim_j_Page_084.jp2
532e55b97b9573f7609e9143de64d268
f78d921b050bd64a1ca08baf0ba3d1ed18f5044b
F20110218_AACFGL kim_j_Page_100.tif
0f10c812b911721502cf996acb3e1cdf
3b1cd809725f90fb817542cdbaff23d67da0bb4b
F20110218_AACFFW kim_j_Page_085.tif
d094575190f97de3f5d29050d23426ff
b0818f141399bb6dc635ff4563af6380f69fc86d
1051926 F20110218_AACGKC kim_j_Page_114.jp2
2ab3747411e2f66f719d884f0d7b7205
f10bad5738723a23ec44c8c8f55605ce2fbe9c0e
1051962 F20110218_AACGJO kim_j_Page_100.jp2
11c03e44af65bf217f568a6e36b72175
b3b32b2cc48fb35164df690154a69f140d030fed
802279 F20110218_AACGIZ kim_j_Page_085.jp2
42373da0441207c323c354376143f065
c8defa818012bed28733c95b7724e249f62c8360
F20110218_AACFHA kim_j_Page_115.tif
9a9c25c7b331611cad47c31459cdb858
84cf5f68dab7e0f488e0a1fd98dd3236486eb406
F20110218_AACFGM kim_j_Page_101.tif
a204d18c22c6a363648e97f651b5a99f
74dcd02c752f01869a038502ee18177094f20d81
F20110218_AACFFX kim_j_Page_086.tif
4719d30dd80100f89c477165466c7e7a
941ad80f34b3a79713f1b517db3ffffd637fab13
F20110218_AACGKD kim_j_Page_115.jp2
c67590b4cc3157870c7fab784c4b1537
15749416bf0e42ba9451cd74ded719f731fa1016
F20110218_AACGJP kim_j_Page_101.jp2
5d8ed7dd8fabd5126248e4ebb961eb09
692b9dc9dbd87768ae8283b2b3f05845109df989
F20110218_AACFHB kim_j_Page_116.tif
d6a430c05b32ec214ed87f0524bcdf09
a55cb2280c8d1559d2f69b2e70e8c9eaba11d6d2
F20110218_AACFGN kim_j_Page_102.tif
96ed562f4c93d12b393e4fe76a6cf84d
53568d13008db082d2acb8c242f5e3cdbcbc3dbd
F20110218_AACFFY kim_j_Page_087.tif
430bdc6cde8f58a61999f9c89ff63df6
11bd1187765c7ea0f76d036c45380bf854afb10c
F20110218_AACGKE kim_j_Page_116.jp2
1b2cc22e9aac605a78b0c8c0612b7403
7b0d15f674e2cbabd61cb4f11e6f6dad00fb82d0
F20110218_AACGJQ kim_j_Page_102.jp2
767128ce5e1dda02f869931b6b39f8ad
4f5041a2a622327f1d09b56cf4b7e24fcace167c
F20110218_AACFHC kim_j_Page_117.tif
721fb7e30fe5209fa1ae580098b288d9
a7d52bce91a5910312e92296e074d0f05f6a7724
F20110218_AACFGO kim_j_Page_103.tif
811f1d3a9c6c01444dbdbd015e32a6b4
1ca2036ec0fb0dd3cebecae6bb927013ed18fc4f
F20110218_AACFFZ kim_j_Page_088.tif
331684cf3cfa66bad1aa472a9d63e3d1
67bd0477caf5b76213e9dc13bb2c2a3e16a18503
F20110218_AACGKF kim_j_Page_117.jp2
cfc238cbe971ef26cf33db0672931bf2
eb5ecf290be76f6a7ebc31470fd2635c74752bd8
1051969 F20110218_AACGJR kim_j_Page_103.jp2
96453c54756130324292d3bd23044660
605dead9b9a91b3bda42183b8742729d2e2e8816
F20110218_AACFHD kim_j_Page_118.tif
9803f720c9f1cb9539910af019644c05
27da525c360bfbc120e8804185f1122b9b96d4f4
F20110218_AACFGP kim_j_Page_104.tif
d85d5bb2875838f13e002d32ee11ad32
3fe2c830375374db82af47f437289973194e48a1
F20110218_AACGKG kim_j_Page_118.jp2
8445239ae964a08c082a8ee4b56ffd02
9fc7f5bc34725279bcd54a03c7f91854bb58d297
1031074 F20110218_AACGJS kim_j_Page_104.jp2
c03084214402fa785cc93bac4ff72314
62bc3f1a93d7271bcbe8b14dd5be22c6fc37863d
F20110218_AACFHE kim_j_Page_119.tif
908a4c85592084ec1f6a8396f117d60a
b93ee7a7ec43791b87ef304d3f53e79e00453c4f
F20110218_AACFGQ kim_j_Page_105.tif
23a350b9cb2d29f59048d07c1a5bf3fb
1930f2982b45fdf9783f9ac33f1f15c0c581357e
1051964 F20110218_AACGKH kim_j_Page_119.jp2
bac4e3479f249f31a8a6707d3d3772bd
eed977716a6e13222f1a603d7e1560bb7b3e39d5
F20110218_AACFHF kim_j_Page_120.tif
db409d1650646497d1dc24edb517c01d
34fe94e883fdf1e5509520c460c756b20e4fcb64
1051961 F20110218_AACGKI kim_j_Page_120.jp2
e2e236b292c6945384bbdb7ac7068316
08a8d8bc9d2cc07bcec55a8c995f2e7bfe3efa0e
1051976 F20110218_AACGJT kim_j_Page_105.jp2
6a7eeb20b8a5c0990208ed00726b9b7d
e4dab97fc80d48b69d7f4d58ad5bf257f0dd3ba7
F20110218_AACFHG kim_j_Page_121.tif
4ca85fc7e626ecac8f5c2e41eecc821a
aaa7ade8a87233c4b36ec49822b04fd10ae5028f
F20110218_AACFGR kim_j_Page_106.tif
2193309b2e1333577f4ec353104ff619
953d080d6427f3c8e1496899ac8e3921bd99d9ba
F20110218_AACGKJ kim_j_Page_121.jp2
3e2782b7d51bb5fcb584275488b5f02c
04895c10a418afc7edff129f7e1b50297baf0974
F20110218_AACGJU kim_j_Page_106.jp2
075b50ebbcd49a071afafa6237b26d02
bae8107af23c3bc723de5e3a7717cf47c8abdd85
F20110218_AACFHH kim_j_Page_122.tif
6518dbd7294b92ad977f6748f6d56212
1826824841accb62980597d85b09362462b59cf2
F20110218_AACFGS kim_j_Page_107.tif
b9bde6a6b372c8f74c03c95e3c847aaf
0d5c577e3f95a6a9b885fe39c01442022aecc277
167325 F20110218_AACGKK kim_j_Page_122.jp2
c0954b8446778aab78455fd1bf4c9b54
ed0d0aa6985d9248d4ccf74737b70c6f89bf96dd
1010571 F20110218_AACGJV kim_j_Page_107.jp2
3ba86b6309ee4369cfb8a0538d2fea79
9cb98c9ebf0592b1316041a44d16fea42dd48e15
F20110218_AACFHI kim_j_Page_123.tif
ab85664f1093fa868988cb5cd0823964
d723ffcc09a2529f22e2eda3e2c6a4eaecba1e5e
F20110218_AACFGT kim_j_Page_108.tif
1633d5f4b9bd94f0d9188abcc9cb654e
45ef3cf1df00c14011985e04be1fe7674d0a7e31
703304 F20110218_AACGKL kim_j_Page_123.jp2
bc271c08f3e9ac3e8bb2d5acefc68999
0478b0ca5c55a31056d5c31f530ec88237a667c2
1051934 F20110218_AACGJW kim_j_Page_108.jp2
c9be8336c8ef0f4d83daf0334a5700b7
b8a93525711d3cb4e0278504c0072e14f93c344a
F20110218_AACFHJ kim_j_Page_124.tif
a25f5c5dc8b5d2a2a3c3272d2fc72cdb
cdc107e376662a9f1f3132eefaef1a9a2a5a348b
F20110218_AACFGU kim_j_Page_109.tif
b7fbd4e36adbe30d74059dc08a88e0b0
ccfecbd1d74c091c1db2b04aeb413d51c76f2455
F20110218_AACGLA kim_j_Page_138.jp2
b669962348edd83f528785b69a77f02e
fbb2bfa778ab7f445e4c94a07ef7fd0877deb69c
897629 F20110218_AACGKM kim_j_Page_124.jp2
b719d9dc1e57803d3a8c9b4d20aea0b5
d149140d8ff20a5a0adf796148465cad12f21a7b
F20110218_AACGJX kim_j_Page_109.jp2
26dc279df874dcd1fc232c95b8afa952
0909cc62e76185163a60bf5b050ae8fa4de8c2e9
F20110218_AACFHK kim_j_Page_125.tif
e843135ef305472d03b220d0940b43b4
b3183fd6842eedf1584edca6ba9e6172ca5981f3
F20110218_AACFGV kim_j_Page_110.tif
3a4ea5b06b790140691d149722edea3f
1f6764ab84d0da2c63b6539d47e36209fbe1b777
1051941 F20110218_AACGLB kim_j_Page_139.jp2
a94c534e135661371b1ee937b9dcf590
482a68c1cc59604ea8f63cffdb10c4f370b736c6
387853 F20110218_AACGKN kim_j_Page_125.jp2
d0b74d6ad8c97df9a1997aaecca2e0bd
6de955ca2c60a72690fce381c1ffff63242d801b
F20110218_AACGJY kim_j_Page_110.jp2
1f8910e46838241304ba99d1f8d806e2
8415727c367f35f269780a49bc6ecb67d651f7ae
F20110218_AACFHL kim_j_Page_126.tif
a3d67ffa9f5f8464358bd82647804b45
78483f4c8cb243cb1bbcb4ce8346c8cfaa29a521
F20110218_AACFGW kim_j_Page_111.tif
56b73b5e05085a663dfdf1d27b9b0846
f544eb04c231b7109685f92f8ca228a631a71733
F20110218_AACGLC kim_j_Page_140.jp2
b6a7549e9eb116256baf48c19d9da765
45b2b2d667f33258ca3db28e68fd9331d3600729
678154 F20110218_AACGKO kim_j_Page_126.jp2
7ae6562507a49d53ebd1f5b6de4beddc
715686d02b4d128c7cb0f172fadc10960f87ce5a
1051973 F20110218_AACGJZ kim_j_Page_111.jp2
a78d4c9b0689294b7f1e9f683b67477a
d338c46b343e0d92ced37b79e93a12eaefddf2af
F20110218_AACFHM kim_j_Page_127.tif
02ba3929d87b4fbdfc25bfcaff51c8fd
1ecd98ffe97a3eab9a3a12493dafd9f6e77f705f
F20110218_AACFGX kim_j_Page_112.tif
dd360a00058f3f66db58479d6fb40742
5cbdaa0ac4dd8cceb439188a0b94836fc311317f
F20110218_AACFIA kim_j_Page_141.tif
248069258b1148fc65a4269aa5977172
cc432fc4ca5618a9b4a149f8bc6cbf3fac1fa075
1051980 F20110218_AACGLD kim_j_Page_141.jp2
ee162815859065c31c7f83348104314d
1b14a5c8b2a27ae0aee785c76662c8e88def86cf
607255 F20110218_AACGKP kim_j_Page_127.jp2
9e8882f6c4db62924a626e22c7798e1f
989947a1c6d314e0f79809501d3fdccd00c769d1
F20110218_AACFHN kim_j_Page_128.tif
db33e48cb06784c80f4aaaaf7d776f18
4a633cdcb6120c41b2245142cfb87cd7705acee9
F20110218_AACFGY kim_j_Page_113.tif
e6cb90481619941ccac45771ff5e584f
a44141b7d0baa40e432d3152d07b205c4594ec32
F20110218_AACFIB kim_j_Page_142.tif
b389c25660b137bb7269ab0568857b59
9cdaebef21e88c2d29f6ad26bfcc86be684bb0a0
1051984 F20110218_AACGLE kim_j_Page_142.jp2
be420b30014ebce0d6bbb8703fd765d8
1df4562e6d4153bed865eeba041de1b1be0a36af
990630 F20110218_AACGKQ kim_j_Page_128.jp2
a54d70ea5b47df212792d7b9ddd37e6e
a1115d347a09db0169ec3de8d81c8a259d97cb20
F20110218_AACFHO kim_j_Page_129.tif
6b395f2fc01b068176a9b26cf3358cb8
7e2f5ac502506c28bd4bfce161de4dc01f8ea89b
F20110218_AACFGZ kim_j_Page_114.tif
00379b8816e1ec8ba1cfa0b39acdd98b
fc474be53275fbf40120a9e94c2518d6389157f2
F20110218_AACFIC kim_j_Page_143.tif
148e54b39bd02d6878d394453b00dbb3
982a9ff1418b0a869abc235d9b4075689f30072b
1051952 F20110218_AACGLF kim_j_Page_143.jp2
c96a8ff78742f1551b3ca81df9acce14
c8cc756c4b8393343fdf1867b5ce89a33f8a30c4
382783 F20110218_AACGKR kim_j_Page_129.jp2
1c94ffb2d7c907ae83849c3ab032c411
b71b2e7cb0821a26cf609c60fd314ea09a245296
F20110218_AACFHP kim_j_Page_130.tif
f991e08535309f7f5b68cc34d135aaf5
6669504d23da6c9d67c1f94430a8ea3d42911610
F20110218_AACFID kim_j_Page_144.tif
1369c1a43133201ebe86d8081aa7f118
966ddc60fc0968597b6dca55b06c3c239a113e32
F20110218_AACGLG kim_j_Page_144.jp2
297bf4c60e1fddecd47dc6fa12ae27c3
8861bd1d549b959d5b540f9625643f65fcdf77d2
419010 F20110218_AACGKS kim_j_Page_130.jp2
2d7385c1eabbfc7e7ef845e1e746f782
2e510494932085df1c52fec152e2add16db4a1c3
F20110218_AACFHQ kim_j_Page_131.tif
43ee9e315f1c7246935c9109b523eed6
faccec985993e5f6e38dc544934bf9655350a3c8
F20110218_AACFIE kim_j_Page_145.tif
e0c4ba3aa77432d0143e8071085a5f9a
e53ef8bfe55c8afa5c01d74b2cfdde64f1c5e7d9
F20110218_AACGLH kim_j_Page_145.jp2
ee473d3a2309a750c0cbabc2ce0a96ad
bde6c601facaa869fdffefc04fa5bc1d2e7164ca
682125 F20110218_AACGKT kim_j_Page_131.jp2
bd07f49765e87a736c0df9224a5bb54a
79001d4da1a331cdeec4c44b836b0c367a65f9a1
F20110218_AACFHR kim_j_Page_132.tif
74620f1247dc22b25711b525ee928bb9
4c246a0660136b5eed4efc828c3617ccb8bd12dd
F20110218_AACFIF kim_j_Page_146.tif
57cf9fc503cf28a2e93e81fd0d9ad683
1f13695d18e54cb01605b3f8bb67dba85b82502e
1051949 F20110218_AACGLI kim_j_Page_146.jp2
e3c0fdc3096a3c5639d9653c2575d1ff
e3191b50e7a6a61595deaeb2fa360d6bff15630a
F20110218_AACFIG kim_j_Page_147.tif
809274a6ce46ce2746b9923d5ec8af7b
ee52cd6a03d747b20f77ae7e855fcbb6f6c9f456
F20110218_AACGLJ kim_j_Page_147.jp2
e76059f559c1806c7ec7076b50d18694
f30dffe2c4b2f72346cc339c99e04a3b00acabe3
1051967 F20110218_AACGKU kim_j_Page_132.jp2
fa35b48ef9aba7d7948bad88578ab09e
b045959d21793813860de7024876211e1427088d
F20110218_AACFHS kim_j_Page_133.tif
636f0caa341d392a79bae9107f6339c8
72e7b52ffaa2fc628ec8c95329ce172ad0a91556
F20110218_AACFIH kim_j_Page_148.tif
5e8f407bd2293378becc9f7e074b2341
0cda41fb2a9e4ca0ae6785f49cae8e2a222b90b7
F20110218_AACGLK kim_j_Page_148.jp2
0a02696dee22f1bd8fb6fd5f292d3a36
574cc77c88924f90b47631a7c50220dbfe7185d0
F20110218_AACGKV kim_j_Page_133.jp2
01b566053c7d1c3fdd530d419fe632d2
91756605bd0a5e1004a83cd87e61101e2b30252b
F20110218_AACFHT kim_j_Page_134.tif
1d71d41470dd02c7d22d1fe073f0c643
ed856afd8f66ef7778c24340d2ddc4dec2c64c73
F20110218_AACFII kim_j_Page_149.tif
ae948a5142e14f5a8433560affe6a798
1e4ce6fb6d550dc2c358955928b3747c15181624
F20110218_AACGLL kim_j_Page_149.jp2
167684ec2d92b7fe572850d5d45e98d3
e87651ae7d9f83cb1a0a1a0a258f8fd568456ed1
F20110218_AACGKW kim_j_Page_134.jp2
61d0de325a9c70c82fc6026080b99afb
d9005fcdbb7357400aba39451a9b1af0338a97b0
F20110218_AACFHU kim_j_Page_135.tif
09dacaa40876bf987f428624fbefae80
7416011293441241235eb1ab42a203356cb53f9e
F20110218_AACFIJ kim_j_Page_150.tif
1f11f329bbe16833c06154d68202e920
2364b50559ef516f06239f32a499e7967acfa4f7
6922 F20110218_AACGMA kim_j_Page_012thm.jpg
6c143b6ed74ab081f46aae14594103f8
509a611f21c6afb2d2c194465d21a3f540ac701f
F20110218_AACGLM kim_j_Page_150.jp2
c729f96d355598030cbbaa90fbbe8cee
12cc28c0abf0453a6f674b7c3b9c200b8e059e81
F20110218_AACGKX kim_j_Page_135.jp2
9e81ff66db815b1ee18dcf4927aedde8
e5827a3beaf7d3b05f63ace216f492d13721377c
F20110218_AACFHV kim_j_Page_136.tif
242854b27f51700df6bb176dd73e458b
bb4a728de0f2017f4183b835171b4cdbab657555
F20110218_AACFIK kim_j_Page_151.tif
3e858dc65a3344d2b81f04a96ff71d32
5271ebb19a0266f5f54eac4500c3cc1d1d22ccfe
7541 F20110218_AACGMB kim_j_Page_013thm.jpg
26089cf688691dfcaac3f77d250d03ce
fd7724424f514daeb44e959fda9254b0b99391c4
851187 F20110218_AACGLN kim_j_Page_151.jp2
6169521e2a7607938caa706356ba086f
44bdab5e9cb1c4ec07f9a65ce3ae31a30a0bfed9
1051849 F20110218_AACGKY kim_j_Page_136.jp2
c85af2111d7e3b11830c7caaccb40a70
235ceb1be6f1a27b4da527a4a1b714872fd24363
F20110218_AACFHW kim_j_Page_137.tif
c4c2ba8d3c5ff3d69dfbf5fa7c7fb027
e6792f12861b0ad79ab7f5f48e54893ea94dfc9c
F20110218_AACFIL kim_j_Page_152.tif
eb1e3e760872a81b03aff9c900129194
dd2fa61190e92c963e07d5be2d1e37a8cdfafa52
F20110218_AACGMC kim_j_Page_014thm.jpg
4b173a9915c397f892ff38b5628e34df
1e2c9f18b029be96bcae0079a018761948af0183
674772 F20110218_AACGLO kim_j_Page_152.jp2
2b3e7ff0018e7a10499b47800b6b74b2
b376b5ced848ba1eeeee697a271988274d5b36a5
1051977 F20110218_AACGKZ kim_j_Page_137.jp2
a7fea933a02846d70bd9f0beab6383fe
6dee88f0922b8b21a4830f3c21ca95ce3ac82843
F20110218_AACFHX kim_j_Page_138.tif
a3902140a69c9d1c3884f58b4d0506b2
866813201cd49230d9666b67802f1ecab106f646
2008 F20110218_AACFJA kim_j_Page_015.txt
97e7fca40dedbba2947d9e4069275ab4
6fecb38e2b2cba4b37d5bf3b399ee5d28a171123
525 F20110218_AACFIM kim_j_Page_001.txt
3b6920f6e8f60663741a802ece0c09ee
2fc29db7811ef6c634e3c0aed89c389bdeaa7105
8569 F20110218_AACGMD kim_j_Page_015thm.jpg
8076a75db73ab049489c0753cc5dec6f
c96f036bf3992ccb938562e3aaf42b24b55de1e2
2547 F20110218_AACGLP kim_j_Page_001thm.jpg
e645ad7723df0c891e1ff4acda490410
1b01438109d880d3a6862c1b26f97aec8e59af41
F20110218_AACFHY kim_j_Page_139.tif
42f40f88f3711ef32084c4d4259141ff
ace4cca74f2b0485b4dd606c86539db1a36b7a78
2066 F20110218_AACFJB kim_j_Page_016.txt
b4fdc957dad8709e76171b46957fa1c5
72523f54c0c21c549d73246787eb2b6c0b5c689a
107 F20110218_AACFIN kim_j_Page_002.txt
3f11236bea2766ee5be4ee81f0bd354d
f44c282c05596bf65c260a76b07c95ba601ca115
8578 F20110218_AACGME kim_j_Page_016thm.jpg
bf39bcb91d48fa2195ba659cc5bbefd1
f3a0bddec28aa675a022ef041c820f6822c70453
557 F20110218_AACGLQ kim_j_Page_002thm.jpg
62f0654cdaf77beccc2e4428a85da82a
052a317e5205fd4d0dfced34cdcf777d403c61be
F20110218_AACFHZ kim_j_Page_140.tif
b25de67f252d5da1c9ea43beb2acf3f2
b10fd790e6637e3896104a93596257cd6bebd488
2060 F20110218_AACFJC kim_j_Page_017.txt
f214647d43f0aabf2186b406fc293ae6
4bd6337a44bfd9685f4b74eedc9eb8316cc544f1
187 F20110218_AACFIO kim_j_Page_003.txt
5a3e870659114e240c2910889e825bca
681968ecf78668f497ef6a1582163574fb53234e
8579 F20110218_AACGMF kim_j_Page_017thm.jpg
e4079484ba74f904379435d0fe5cbf75
b280bfdd8b5c4f0701c86d44f680933f236ea18c
853 F20110218_AACGLR kim_j_Page_003thm.jpg
55845e2e44e9077643c22511a20c9ee0
846f031dc21b1f98ea9306de16f0ba939fafd750
2030 F20110218_AACFJD kim_j_Page_018.txt
d18270c70ad1826f08a2a1e80a4be0e3
32b52fce446c7f42e198256cadbc6f6562a71c88
1666 F20110218_AACFIP kim_j_Page_004.txt
4720dd80d9aca8f25b79726cdeb20a64
b97bdcc4d879410e6b0c716387bc010c908175ab
8703 F20110218_AACGMG kim_j_Page_018thm.jpg
a2f551033222bd9e8674d7f9d3f57edb
147099b197c01bddc3de50f62a597af1208ed050
7074 F20110218_AACGLS kim_j_Page_004thm.jpg
4819a2f60e8881e7bba5d3576017d8c3
c68d273d6c4dc42e45237bdc82b458881589e8f5
1959 F20110218_AACFJE kim_j_Page_019.txt
c5f744133782ff527437c8c9dfef2f30
eb9439dd3d2f03f6e217842225cc70b83717f1ec
757 F20110218_AACFIQ kim_j_Page_005.txt
84a90c4a3c130ad23675dd010afd6cad
c3ebe1890b7b96d587cef70a176de9a8b4fd60ae
8281 F20110218_AACGMH kim_j_Page_019thm.jpg
41531a92f76da59e2ad8ade9e5aee831
ad147ed32c4b3f89826470ef130ed9ecfdad8602
3607 F20110218_AACGLT kim_j_Page_005thm.jpg
4140c0f2ccfa73dac3a22b8c9f2421cc
0e29b552851fea8869bb1373af880bf6bf6697d8
1946 F20110218_AACFJF kim_j_Page_020.txt
6e4f763efbd0a43aa7dd3e5f4172a08a
266fbdc2bb9533e278c8bc2305ecc68c13d29ddf
3295 F20110218_AACFIR kim_j_Page_006.txt
d7e32f9ac73dbf399bf6cd1e20fa54e0
79c78fde4f2c2a953e82110d67f6acb5bfa79a82
8224 F20110218_AACGMI kim_j_Page_020thm.jpg
af4dec602f4bac05847ee1188feb2b97
d5048684d09df8e655f4c0220519a33b737433af
4036 F20110218_AACGLU kim_j_Page_006thm.jpg
8270ad77efa795c071d2b0eb19df82f4
fdd86e5cf2869336ae8fd050a9e182ded192403a
2059 F20110218_AACFJG kim_j_Page_021.txt
41bbc4515aa71d637f0423603d2e40f0
6eb21889cacd51242adee092630bd56d8a74ddf1
2158 F20110218_AACFIS kim_j_Page_007.txt
61e1d7b28703f7ac491c34a37c96d0eb
58090b3e6f196cba4143109fcbf5c863906d72ee
8266 F20110218_AACGMJ kim_j_Page_021thm.jpg
b63ff30b335c42b1fbbb81cdf6daef26
de2e2a64f43b86d1e1ae6329c15d6211e6ec2dde
1991 F20110218_AACFJH kim_j_Page_022.txt
a197671e8f504e631693f0bc1a64d22a
0efd30f3206f5f94f655efe82802973aab5f5d58
8586 F20110218_AACGMK kim_j_Page_022thm.jpg
3153b5d7d4b5b526502aa4dd7b78891d
7ac96854121e9a34962965cab3d484839ed8a8b4
3859 F20110218_AACGLV kim_j_Page_007thm.jpg
bd611688d79c55a1f3039b1e3e343982
c4951da6f770c6c243f2fe6cb03e4299bf569261
1916 F20110218_AACFJI kim_j_Page_023.txt
102565b759135fa57933978cb31e2800
9f37acebd9a018c920397d2d738443776a098d55
2327 F20110218_AACFIT kim_j_Page_008.txt
d682570eb46d9157e29a642504e4daee
ffdacf756bc5312b1a25662ae3244f46b2b0f929
8017 F20110218_AACGML kim_j_Page_023thm.jpg
6a43d569d34ab3a53bc9d9a95a2e5a26
8b48cdcb31441b162d35f659a82201894d0c8c1d
6141 F20110218_AACGLW kim_j_Page_008thm.jpg
9209f04496934ba9bd68751e14c34047
ca65550068dfff2ee0a98a801912addcab701c43
2788 F20110218_AACFJJ kim_j_Page_024.txt
73385eedbcaaeb9ec3668feac921a3c3
a3fdb369aad1cbd52f13d35fb322838b4558fc94
1842 F20110218_AACFIU kim_j_Page_009.txt
f5c2acc2b0e0bd05f7a29f03bf4a0b92
3fac1a77df7d691eff37a85dce0779c82ba4287e
8352 F20110218_AACGNA kim_j_Page_038thm.jpg
173ca95bb16ed6bb71beb938adcd7c93
cbf1ce95b21f59eee5788d93fe4088502bcb82ad
6405 F20110218_AACGMM kim_j_Page_024thm.jpg
3ec65eaf1d7cfbf0c060afea15137d3f
f11b3b8cdcf8890c993dcfb97b891131dc60233f
4902 F20110218_AACGLX kim_j_Page_009thm.jpg
d453c2c22fb3fff82e0e2dd4c85db228
cc80e70939feccd78e089d4f0ba75e5730a5839b
2010 F20110218_AACFJK kim_j_Page_025.txt
c60cfa59c4917ad1eacdaccb860ac495
419196eddaafb0b35f4335d3ca3bf9ba1901bb8d
2070 F20110218_AACFIV kim_j_Page_010.txt
75c543d035e716eeeb599073af825242
a81aa6a70d034f8c1c00e4c2e6698c3b9506537f
8519 F20110218_AACGNB kim_j_Page_039thm.jpg
a76370cdb184ce5527bb5bde8171f489
5a09f7b22800bc8cda58746c59e6a5cefc91bec9
8417 F20110218_AACGMN kim_j_Page_025thm.jpg
519b2e6521959226b0f14451558d8e26
8f8d602bce86fe2dc21f5e9acd74a593ca60aa4e
4176 F20110218_AACGLY kim_j_Page_010thm.jpg
4f2598c8cdd0200b2f7a80e3ddb067b6
0144b0b48922e0ebb39010b8050102ad3de9590a
1989 F20110218_AACFJL kim_j_Page_026.txt
f8409cbc985ce99a0fd43c1d91aaf12f
b74630ae2f8152d61553076c6c144c0c1f9ffd97
1750 F20110218_AACFIW kim_j_Page_011.txt
8870351bb17f8c212f9c7f5c7f312e0b
3cea6648647013ba9f482e6c758901dc3110724d
8620 F20110218_AACGNC kim_j_Page_040thm.jpg
ba9e751d0c4484cc9814da67238a125e
44db693b4e0e2c952659c462de701266bcb35d9b
8440 F20110218_AACGMO kim_j_Page_026thm.jpg
35484ad9779b0e9d5e6a372d8f83f69b
55abf1c31eda3d0b05b7bcf858dad96147336f38
6783 F20110218_AACGLZ kim_j_Page_011thm.jpg
cd71183b7297818de5e09d9853a4920f
b776c1025ffae814282b26c3d20ac4c38f9be1c9
1997 F20110218_AACFJM kim_j_Page_027.txt
88518f1dded2e1e82e073c561bf432c3
122b027a5cd3c348445ce8c01dd9730d3bf5d556
1516 F20110218_AACFIX kim_j_Page_012.txt
240fb18eeff7cb9c0b4d71ec83665936
7c39d10424ee01ef5e20f308c6c28471a4be6e46
2073 F20110218_AACFKA kim_j_Page_041.txt
28fb43d7c77d47ddfd22ea9f31b3fe5e
771741a53786dc5a92928cda6a20b6dfef7067d5
8414 F20110218_AACGND kim_j_Page_041thm.jpg
6a0d48c574d59a500b549c48ff1764fe
67df0624d01094ccd5ac14f3283c534515c0c506
F20110218_AACGMP kim_j_Page_027thm.jpg
81e9f11a2c508c22c69506db5a0dc341
fa58c2ca774383e26f4faeb9960c4557e95cb9ff
1979 F20110218_AACFJN kim_j_Page_028.txt
00dbc147fccbc2bbbdf60a0398262ef2
827a05ba4e4b6ab71d63a924ec31561f19d18f99
1828 F20110218_AACFIY kim_j_Page_013.txt
bec897342e963582795ee91aecffae74
a31fb0c6ab1fa399f0efc7c10415c2b4b877901f
1915 F20110218_AACFKB kim_j_Page_042.txt
6faf08b908bc455dbe8593ac7249fcc5
11e7ef599d460dcb728213d8b358e8300e4599b2
8300 F20110218_AACGNE kim_j_Page_042thm.jpg
e4d56f150d16ea2b24b62d7091f32334
f5f8a6937f1b977b984a4efff9114aae066d8bb1
8506 F20110218_AACGMQ kim_j_Page_028thm.jpg
e0aba4374553cc185216613af55f5dba
abc737c60bb8671e6597955d4201a4a835e8d8a8
1894 F20110218_AACFJO kim_j_Page_029.txt
4fc368ae1fe36213495a5e8a12bd49e3
9de30be01d1a64df8145a3d4e63eaf46d885fd37
2106 F20110218_AACFIZ kim_j_Page_014.txt
3fccdf8b7cad928d5dd24e06c222ef0b
20df608291fb600316ebf427a002f7530122a387
1816 F20110218_AACFKC kim_j_Page_043.txt
4f93d3a4c6d2943a5b966aaa3bfcdd71
a5a40f73c0f599f90f28fa25149eff8c596d8846
7706 F20110218_AACGNF kim_j_Page_043thm.jpg
830b51ec5dba623295dabebc34815964
65a8c7e6572491f5b5ac3f1f8ddbad8ce1ff31f8
7967 F20110218_AACGMR kim_j_Page_029thm.jpg
20d7fd810c2bd6430b4d9cc10115a656
252d328422d2cb698ac8e6ca0477a61991f1d7c4
4021 F20110218_AACFJP kim_j_Page_030.txt
75d78a30d4278328f2c86e0dbbd154d0
4299ba72abf785cbc1dbcc3df90f728e74adf013
1393 F20110218_AACFKD kim_j_Page_044.txt
103a0af17d48ff6ce1d15de1f61bb5ab
360b37ceaa027dbfc58369a33c374fca00017c95
6261 F20110218_AACGNG kim_j_Page_044thm.jpg
3c4b42f391970fcf22e3d7050527cfc1
54f77652176779d0a72670f31c7911c210f92be9
8097 F20110218_AACGMS kim_j_Page_030thm.jpg
1c6341e56980bc92965048fbdb241cdb
ac20006d02462f30f3859857bfbb479ee2fac3a5
2019 F20110218_AACFJQ kim_j_Page_031.txt
23b385a61f7b489ce1501975e7ccd0b3
e4f4fa90a19584fe09df5728a0ccd9a7397f4dad
1677 F20110218_AACFKE kim_j_Page_045.txt
4c367e2092e82cd90083687bfaa60284
79ddb18120243807a82e5b93e1891b8dd919fb31
6944 F20110218_AACGNH kim_j_Page_045thm.jpg
2e184a27fd32dfa7c483cef6466b8da9
c2416165fc93bb871e89e09d639a42c7f93a00e4
8546 F20110218_AACGMT kim_j_Page_031thm.jpg
13eec39793dda7a1e00a51202670c52e
1bd76e064f1e6cdeb7b11ce998e2dbaa8260d5df
F20110218_AACFJR kim_j_Page_032.txt
c3808796ea41a12def7a735f2dcfbc59
9f01380d9465bed43882676718607f4ba77104c1
1911 F20110218_AACFKF kim_j_Page_046.txt
2f156600a39c69e604924f84f2151094
9256034854a46391961df8fbb369acc5abcef9b2
8160 F20110218_AACGNI kim_j_Page_046thm.jpg
33718471d85742d6842225e41937cd5c
413e09c6ccd26bfe95d09b670ce829f9ee1db459
8127 F20110218_AACGMU kim_j_Page_032thm.jpg
f39499300ed5b09dbc5d59a21dfbbef0
21ab88ad3e8d40d9798aafd83d82e151fdcf11ea
1964 F20110218_AACFJS kim_j_Page_033.txt
3113e87c7181fc34936e2dddf35a77f6
fab1a34ccadd068b3d2ef1c9561b90cdeb9d70f3
2370 F20110218_AACFKG kim_j_Page_047.txt
1ea0d4b07f995ae05775a4e76eb817e0
8647e42ec0e0daf67f1da1ee954bbe86910d5df0
7593 F20110218_AACGNJ kim_j_Page_047thm.jpg
6f03952ec36ba79eee2aa9dcf3477151
36ca452fef81d9f9805d397b3cb7792376158505
8178 F20110218_AACGMV kim_j_Page_033thm.jpg
c237f7e453e31e6485fb801cdf21fb05
f48447213935bc20ae6ba2e5c8c5c76e98288a43
2045 F20110218_AACFJT kim_j_Page_034.txt
6f3c5e29cc077bc2f5e29cc4049d1396
68a6ac0c72c3579bcb638caedd4d42c44852e1ea
1892 F20110218_AACFKH kim_j_Page_048.txt
a25afeadf9cd9b98c9046d17915a0a47
f4430ab3ad5ec74d0f508cfff37ba7a462a852f3
7353 F20110218_AACGNK kim_j_Page_048thm.jpg
a2ff4ceea75e094da77f304fc51e6f3e
7a4f7d83e8167c80467249feede0e34e75398d20
2436 F20110218_AACFKI kim_j_Page_049.txt
a5b6e2819c03cabc82957372f9965858
a381a4081390e89dc855e35ae00c8c01706f5dad
6236 F20110218_AACGNL kim_j_Page_049thm.jpg
c15b6400b1261d977f7f181def971f92
5bf6f71668f50221667150b8927712dfcba1099a
8491 F20110218_AACGMW kim_j_Page_034thm.jpg
1cf503e7c2f123651cd6c10b40c062eb
5e98600ea78b5c5a526314028258b2f691b1be0a
1995 F20110218_AACFJU kim_j_Page_035.txt
a1bf42474e488591d5d6b16081d67ee2
8b979862e1e21f9ac990661e89998ffc04f16ba1
1833 F20110218_AACFKJ kim_j_Page_050.txt
e2cfedbbf158041423ac254c60309a52
2444a4fd2ade62aae2799e8f518651c8a255f23a
8441 F20110218_AACGOA kim_j_Page_064thm.jpg
273f84d6b6ffd631873752dcebdb68a3
fc6fc9e94151a6d343b4faa4d5c8713343d9baba
7904 F20110218_AACGNM kim_j_Page_050thm.jpg
942cfeb5f4d82ace11d3126171513119
e696edef9b9872f5b24ef49dc7c93bd59aaf36a2
F20110218_AACGMX kim_j_Page_035thm.jpg
4db99c1dcd5f93191644d111baf17a3d
cf3c584a94d754673b743a53e2e548d7912e35b8
1929 F20110218_AACFJV kim_j_Page_036.txt
bee50c4f72e8c923487ec000acf127f2
ba53d6a7134e37dd612e20b2a37267af15ed4f76
2034 F20110218_AACFKK kim_j_Page_051.txt
7ca38ee661724360ba7dd3ea28aa686a
0a407325c77d937f591f6528e6d76c22204f13c5
7685 F20110218_AACGOB kim_j_Page_065thm.jpg
ee78cf525247f85cd14b8ce6770cbe0b
29d1064e92add66f19f10c73afc23227163d8c60
8536 F20110218_AACGNN kim_j_Page_051thm.jpg
66a4885fbd158e055f76bc558d7b0a03
96475120d33a225ec84771ea5ae967b9c132e4e5
8261 F20110218_AACGMY kim_j_Page_036thm.jpg
5da3263f03aebbce316b9efe92200e96
aa44aba26877431ba8c1e9b079d20e52add751e8
2001 F20110218_AACFJW kim_j_Page_037.txt
f57a15c496a8861660e809958cd67ec8
7cf36a09d95db75f206001c012fbf5da40bdfe9f
730 F20110218_AACFKL kim_j_Page_052.txt
ba1b8ceb312a452ee97fe6b981fc2ccd
95b5358950a9cdcda61a4c81f0f5ad28e0d956f7
8360 F20110218_AACGOC kim_j_Page_066thm.jpg
2b77fa5e075c74115c7e1f94e333ac6b
e6764603e5ef6315653ead9d1af920f281ca1fba
4610 F20110218_AACGNO kim_j_Page_052thm.jpg
f7738577bc7e3f57c7deebb4b58fef40
ab476773a6042b3c2658608dbd094c5448aefe84
8466 F20110218_AACGMZ kim_j_Page_037thm.jpg
422cdfc83687ee43365220d9df156ca8
11253cd96501ae4e2d89792e20e9fedccd1c2158
1977 F20110218_AACFJX kim_j_Page_038.txt
3657a6e45c48c25d98c76dbc867a1581
d31d3123f1ed88ff068f8def3f9ff48fbeba439e
1400 F20110218_AACFLA kim_j_Page_067.txt
54a0af049e4e47e5bcc50032512c39d0
85ee7ba809f64cea49833cb018cfbe4ba27db898
F20110218_AACFKM kim_j_Page_053.txt
2b0c44ee24d9c51fd4a5aca72985dc2e
7970d72b2829772b9bc4534435d4e92055d79854
5860 F20110218_AACGOD kim_j_Page_067thm.jpg
1d686438f3344d51981f1d0fdd2aaf53
1e128a98010b7cb5e8d8c4f65049f918d7a30bc1
8001 F20110218_AACGNP kim_j_Page_053thm.jpg
d41fa03fd8e3531abcd7c7ae9b38d4d6
d4539b6b676af0ada7d2735f8ed7d52f6ca7a192
F20110218_AACFJY kim_j_Page_039.txt
d9db40890a8363364d743a6527ded6b6
6167afeeab43794a931151b0dd1dc938552f16c3
1785 F20110218_AACFLB kim_j_Page_068.txt
45d0e34f3cbf7454510b65edeae56509
a9068dc56c2dc309f79b43a1b113b2e6e29d8c0a
1832 F20110218_AACFKN kim_j_Page_054.txt
89624beaaef601b663996775abd7a7a0
aa98a614171d4757379d871bbb36b1d1e191cbcf
6946 F20110218_AACGOE kim_j_Page_068thm.jpg
49683b811a8b07717de08d3d0a8db0c9
40b69dd8ed8e02937c9a4d580e64d91e2918b348
7158 F20110218_AACGNQ kim_j_Page_054thm.jpg
d187b1450921ea2705bc70367b0a0a4c
67f23c3c427a4641d59099b9694c5ec783588293
2046 F20110218_AACFJZ kim_j_Page_040.txt
b1fc5eaf1e0f75f20b4180cc9dcba52f
4baebcd6f079ad3f7b090ef69c6b28efd6d0e102
1758 F20110218_AACFLC kim_j_Page_069.txt
3fa99457ff41616af52a144a2f58a697
ed6ab12a9a598be2259bc6b916190c138dfa179c
1840 F20110218_AACFKO kim_j_Page_055.txt
01d466936e964e6d6ad0e19bf3de320e
f2c0d024b6710429e6a5feb5d726f44dd287e4ba
7696 F20110218_AACGOF kim_j_Page_069thm.jpg
38dcfe722d0d18a68769e287ef7096f1
89a90ca50298959ae08a65fc08d9e3ef05a15aca
6847 F20110218_AACGNR kim_j_Page_055thm.jpg
5a4100e7d8bae61476aba08ea902a55b
ad280df4e0ba54d7a4fb7234ab091c59b07c2b61
1367 F20110218_AACFLD kim_j_Page_070.txt
f5387572f23856b459c187f8d65fc9ca
e30a9521e0bff455debfb32f2cd2495d3865d4c8
1963 F20110218_AACFKP kim_j_Page_056.txt
28e8dd1dd2cf81d6f4689e19fd2e5f2e
26d3fa2b916f16e1f5d164b1ded3a1fd0a988609
6402 F20110218_AACGOG kim_j_Page_070thm.jpg
4435e38bcc1d275874673a23fa94ef83
685fe8f4e42e9175bab961829fb580ffb83c8db0
8474 F20110218_AACGNS kim_j_Page_056thm.jpg
593f8de20d0cf8f4476f4b57ebbf1f6a
dc69bbd48d8ed033498257b973a92b40530a6516
1770 F20110218_AACFLE kim_j_Page_071.txt
23b1aa3ad718f46243bf808b0f5c2cc6
48c0a18b8c6790d9da45cb6ca6d29054c19cb60c
1859 F20110218_AACFKQ kim_j_Page_057.txt
d0f1e5c41c3e8901e48d457d787988c9
3e723e2f073b50cd4ed0e0b2ddd23e730b8cb0a0
7745 F20110218_AACGOH kim_j_Page_071thm.jpg
2f1a48fe7c0b6d601bf4213a81294271
5d0e4f0d0d1f7d2b0623005581d7ed3a3ad22649
8104 F20110218_AACGNT kim_j_Page_057thm.jpg
c0b2819def8565a0aea9b4b5bd054930
a71c64c96ac424befb983752cbaa3715e1cbb2a6
558 F20110218_AACFLF kim_j_Page_072.txt
6a82a0ab6b75d287d855f1669843f263
cea2b5516e9a77eb96b540642d44632fc54da304
1408 F20110218_AACFKR kim_j_Page_058.txt
68c33aa56b05140c73a7bb451fb76a4f
91c26e820a77c6e791e6197976a5eae6dde4b684
2904 F20110218_AACGOI kim_j_Page_072thm.jpg
582c53976201f9f265c4fa25f273e489
f2eabe991ad40be5dd9012b5c15b041f82c4947f
6502 F20110218_AACGNU kim_j_Page_058thm.jpg
e31eb2b3b68bac93cec31ef1bbf6ad98
07d57eae21c79e36776313a41be2a730bce1317d
1350 F20110218_AACFLG kim_j_Page_073.txt
79d7b805a1800fa86fb03b2bba5f9c72
d7a50860b704cb21a86d42cde3e2d406160de637
1323 F20110218_AACFKS kim_j_Page_059.txt
6eb51e3576e97e403e82c007d0d7deeb
0b4a71802aa7cf400acb6100a5237c8bf39ed526
5943 F20110218_AACGOJ kim_j_Page_073thm.jpg
6e2c58550a7363626858c087d9d9a6e7
eed60d38b32e822393de3f6dd0de8e1bbe53c44f
6856 F20110218_AACGNV kim_j_Page_059thm.jpg
e63e33b39c13b3432cadc44a7caa3d14
87fa8f65ac8b2e7806c2633b387d8ed9905cb1c8
1965 F20110218_AACFLH kim_j_Page_074.txt
cf284b3ada73f96f3acac1ac33c5c03f
7ce1415de7b3fff7d1f1fe1010991197b18bc600
2042 F20110218_AACFKT kim_j_Page_060.txt
5e3489c8ec8f3dc1180968b9397f1ee6
51e023372a07848dbcc145efd01573805ef121dd
F20110218_AACGOK kim_j_Page_074thm.jpg
4712ba5a46e041c41dda1603f48924e5
1ddf5b1296faf19e472f50e6a497397738c7906d
8343 F20110218_AACGNW kim_j_Page_060thm.jpg
36879dd05198757984fcf44af25fc48e
fea3fbe7597fdf4cfa9a60ecf0f920e1b9527bb8
2056 F20110218_AACFLI kim_j_Page_075.txt
aaa6417edd11fdc6e29a42333d59728a
861e6978e8766f273e41b8cc75ca78a10c2aa68b
F20110218_AACFKU kim_j_Page_061.txt
bc6dea8ffd9409b0e85fd6559a26fae2
326db8a67e8a6dd120435c66369687681bf35f4f
F20110218_AACGOL kim_j_Page_075thm.jpg
ceb360f52f245459864ea0b932d219f6
68668d968fbf201d46ecaddfa856744050c5ea4a
1389 F20110218_AACFLJ kim_j_Page_076.txt
e873470f95845ee2bd416bc2971bbcd8
00ccc5f6d14a1d0ef935ed0743f353b381829d40
3085 F20110218_AACGPA kim_j_Page_090thm.jpg
b21ca8d31d15164394f59c2273494bd3
8f311d28712db7aea3a5f20601440e14c20b6315
6361 F20110218_AACGOM kim_j_Page_076thm.jpg
4746f4aeaccf7caaafc864b182137619
d591da46845ba2b8a85136fb23c1db0b5ca50274
8369 F20110218_AACGNX kim_j_Page_061thm.jpg
0e3c714cd4cce3237950ce1957467d91
730ad9e5b8e0be75a3f56c20f3626d7b58809662
505 F20110218_AACFLK kim_j_Page_077.txt
d71f46972f2c9d7a84e646b5ad5895d8
dfb7e37dfcab1eff9c1a86047e4bb5bef236fa42
1306 F20110218_AACFKV kim_j_Page_062.txt
f232809d1e509288f5a50b5e00f94ef9
b630c6f089212eb05667cd69843c0e812f486345
7985 F20110218_AACGPB kim_j_Page_091thm.jpg
c1762c5868cae6d982005a5756e7510f
70358fa0e5b71351febd60137e43a8c91d9d3614
3947 F20110218_AACGON kim_j_Page_077thm.jpg
f09ad9e5499a9384323c48700a6b5be4
e5a34203ab6ddf6b131bd64fb987992c1ebec3e6
6667 F20110218_AACGNY kim_j_Page_062thm.jpg
b30493f3eb4c3f5ba52cc2f2f8d4ad1a
88e4e625421831eb76790011f1e550c07611fff0
1917 F20110218_AACFLL kim_j_Page_078.txt
5060f055263dbcf2855c175ff1d8b6f0
f155626837bc7ecad62309cf10fabcbb18bd37f0
2087 F20110218_AACFKW kim_j_Page_063.txt
b6cf723536375a9f0701e22f0a5ca9b9
4c0816223bf15c176c9767fcb82f903f8620a30e
7308 F20110218_AACGPC kim_j_Page_092thm.jpg
558a094707214c16af1a34d2d2a3c02f
953cad07cf1986ef57e1648aea5ec44ec8e2437e
7896 F20110218_AACGOO kim_j_Page_078thm.jpg
9c0893bd6162d77f3aaaab0be0c6a821
753a8cc49a034f53c0a7e92dd2ec468f37c66758
8297 F20110218_AACGNZ kim_j_Page_063thm.jpg
90c8ff51b0bdf924ae85905837dce162
1a39f9ac94a1ba46e419fbaa36082d47e284cc77
3422 F20110218_AACFMA kim_j_Page_093.txt
e44c2c1b474b702aff93f2bcf151210f
fbc4a0f20eff9c562845c17e6558305bc0b01636
1222 F20110218_AACFLM kim_j_Page_079.txt
44d8bb0349f396d951925836e7155f5c
633f1694c13b3cf2284da5f6eb5ad1db3f75432b
2092 F20110218_AACFKX kim_j_Page_064.txt
60023d389b0bb8c0b81d246ef7c7672a
64c886a26170ddebe645a03fcfcd6d289d44b4f7
8029 F20110218_AACGPD kim_j_Page_093thm.jpg
ea4c2bc7c90a1f0d219677fca72383e6
2915d2c050ffc644b394887560e2cf6df26efb59
5816 F20110218_AACGOP kim_j_Page_079thm.jpg
9ad2d52bc18a8d4189c19bdbbe74fd31
ca02786f7e8ea82f9a7ad35967a780241580c8e8
1121 F20110218_AACFMB kim_j_Page_094.txt
40e80c85dced12fb96fa464c60124dc8
28b347fcf59036b88fa8c0560ba438722c23a946
1277 F20110218_AACFLN kim_j_Page_080.txt
f1ca9309f04a818c17b4810d165e6bfa
68f114a5fd7d8577dbce035d009b639db8c6fdff
2377 F20110218_AACFKY kim_j_Page_065.txt
e015cb30b2419cab3022ac2d89faff5f
016f45535975d2d229ff45e5903e0d9a1f63fdb9
4028 F20110218_AACGPE kim_j_Page_094thm.jpg
41e6642cbba7d21f1f3af2aeaaf56cd8
ea533635c23f4ff1a153d6b0a4fd82f8167bf5ba
6061 F20110218_AACGOQ kim_j_Page_080thm.jpg
add6131973e3bc0faaf58da5779a99d2
a3559f3a4718a3e3b6490c3a4f530cf9a086dff8
3445 F20110218_AACFMC kim_j_Page_095.txt
7d0ba90a0c24b59ccb2b7ac4a1178028
5a4862fa33deb06464db23489630dc15a0fe65c2
767 F20110218_AACFLO kim_j_Page_081.txt
a52cb318cbc08bfa3386e1fb3081ce5f
567a92a14fcba17b065ed6502936e2f8d66d5e68
2750 F20110218_AACFKZ kim_j_Page_066.txt
93c9c412ff3d0c299b52e2c7a6923229
4e92cf1ac8ae2d9905ce4d65730187c29ea43542
8196 F20110218_AACGPF kim_j_Page_095thm.jpg
e208b60fbdbe8501a1cfbf8c4408f231
f76176fcc5b21d8639b4db7780f35024acc7daef
4641 F20110218_AACGOR kim_j_Page_081thm.jpg
9ae1d645b2dca9d70630ddcba909dba3
8a3b5a9c10338cd637d9da69af4ecfecf9d93475
1807 F20110218_AACFMD kim_j_Page_096.txt
9268bb46b58be6f5f8ff86fd8b2afb2b
e9dee1a6e674f6e020b7b427ee7885543d9a06ce
871 F20110218_AACFLP kim_j_Page_082.txt
ea2f8bed42ce86d08780b0b731431ca6
eb591f63c95573a796d57b230dc8678103738e72
5830 F20110218_AACGPG kim_j_Page_096thm.jpg
77250df502fdeb611421401a739b0a02
9f2c2a60df4c0b3b44cd10639560a55082a15c8f
3662 F20110218_AACGOS kim_j_Page_082thm.jpg
316b4cda3a527023bd6706cccd68acb2
d3ec134ddfe1d54a2a8315aef6d5857ae52e9429
1972 F20110218_AACFME kim_j_Page_097.txt
ce33c39da397f8038b10482b50903560
c79a8746d6677c73c3649b2c3406376d0dc15d50
1803 F20110218_AACFLQ kim_j_Page_083.txt
99d9d0015bdbc7dfbf8d23cb37d92b34
4bdf258f15674b064a9920650f019c2c9f62da37
7006 F20110218_AACGPH kim_j_Page_097thm.jpg
9178f6dee7310a4fd90b750b3d0f1586
dee22edc692277dc756f7eaf79faa4b225fd4474
3170 F20110218_AACGOT kim_j_Page_083thm.jpg
5958082654c3304d2f31dc9fd9afbaea
84a0b2aa2da68802a2cba9fc921c5df4b737fc29
798 F20110218_AACFMF kim_j_Page_098.txt
7c6ce4b9a4b8f266bc1a6172e75f6418
0856d00026b659cdca14259b0d748217b9baff4b
2938 F20110218_AACFLR kim_j_Page_084.txt
cd1441c7947043604ba8fb78993c6891
3eb3f6cc6c88fd649e3ea8ef6679b2a88df832d1
2879 F20110218_AACGPI kim_j_Page_098thm.jpg
05fc7b44cb53a43d8ac8cbf87a49c451
0d7f5f3cf762efaa27892bd075c3369fd246d347
4114 F20110218_AACGOU kim_j_Page_084thm.jpg
57813548e68a28aae6345be094dcfa1a
63b71875e6a866f035d04ce08372cd1e0786fcc5
1782 F20110218_AACFMG kim_j_Page_099.txt
e837525e873fa38e20db803e3d2cb33c
4095dc210c160dc052f89837edde29673a8f0e48
2622 F20110218_AACFLS kim_j_Page_085.txt
b35cf66640147ffff09d6c4fad7cab50
42b57295808cd10647c7e12292b7ab1af31438a1
7445 F20110218_AACGPJ kim_j_Page_099thm.jpg
78af25df88295adb9164268f1e417ba8
0e4b106a904309a19bd6a7cdcbe5048b15d75284
6991 F20110218_AACGOV kim_j_Page_085thm.jpg
9db79503e6a3063fc33c7eb30d4c468c
292fee8aa9c6a843ccb1f227e2ac697631977d8f
2071 F20110218_AACFMH kim_j_Page_100.txt
70eaf1d26aba1ba7a377dbcdcbd47a79
4b865cfac83f59e78d9f5b785b75c0bd47818214
972 F20110218_AACFLT kim_j_Page_086.txt
7bf4f284ec2d8254bfd18d9d6e7b6d7a
81de0ad0a893bb453aa15040297154fad937f0a2
8555 F20110218_AACGPK kim_j_Page_100thm.jpg
6a60be5063faef6b7799011d0bdbb9b0
f7397f9b98462fc0b869cdc0b9a10d6f9d13ed31
3237 F20110218_AACGOW kim_j_Page_086thm.jpg
4c8f5fe3fa1945e444114b542bacb6f4
6c01f36e5d541793040dfa24d1250f55bf1c52ac
1993 F20110218_AACFMI kim_j_Page_101.txt
84c7642928bcd8785856b57a90f85717
7436159b931a95ad9650aa68eb7334568dbb7172
2121 F20110218_AACFLU kim_j_Page_087.txt
b745764bb2b173eb514ac39b3bb643ef
7275b04b491d1c3300ec6ed84678244bd0c128d3
8552 F20110218_AACGPL kim_j_Page_101thm.jpg
2afc372ed51279b9487ad680bc26a322
89ff4c2fad4a719aabf36a60b4cf3aa183e3f43f
7663 F20110218_AACGOX kim_j_Page_087thm.jpg
fdb3eef600ca987e2acce63ea97e4deb
05b5e7237e06db3b4083c9e7148092bd8a606b01
2032 F20110218_AACFMJ kim_j_Page_102.txt
632b5a1b8321466626f75edad64d20a4
549025523c29c7f0d319e2474457a3cd1a9251d1
1713 F20110218_AACFLV kim_j_Page_088.txt
5eeff27fff57ed70529c8b6415522905
b3909c746ef875d27f4a66cfa8e56063adad1db6
8497 F20110218_AACGQA kim_j_Page_116thm.jpg
65cd105bc37c000cfd21b74b1db331b1
bc3ebf0bf1d82e0e32fba95f39a41af51b43c0a6
8640 F20110218_AACGPM kim_j_Page_102thm.jpg
b6a5bd9787a8eee24578be97b7c3f6ba
2218117b9b224c3e3106594b81c2012ec7744766
1994 F20110218_AACFMK kim_j_Page_103.txt
3f161d6a41330e8f624b7afa4e143274
5df55126f8c0743e9ea60517a0f682275dc59641
F20110218_AACGQB kim_j_Page_117thm.jpg
0769d5a98df6a05cc2d9a841bfd46dc7
3a56595b8c5d0892e2c03dd88d25d3e9093cc338
F20110218_AACGPN kim_j_Page_103thm.jpg
d2afa639cb48a7fabf4bf5128f390339
66bd9378204bdc7bdaaa92789b662c83faa5708f
5028 F20110218_AACGOY kim_j_Page_088thm.jpg
0c5826ccb03ecc7653dc44f78201b998
5ea5f98b0f95f2d3059a68464c47ca5fe9a74587
1798 F20110218_AACFML kim_j_Page_104.txt
46714fc9c29328b3a109cd9856322a22
c65b7cd12e5a059c51d451a43ebef970f2ad9217
3254 F20110218_AACFLW kim_j_Page_089.txt
cf9f5d2e973b1e25ee5f1c722721f3e8
3e60eaa8a88d9425f4bf7ced392d2213ddbee5b7
8368 F20110218_AACGQC kim_j_Page_118thm.jpg
aaf8fe39c103a483ec37b685e1388084
1be59b05f0558ea8b62d3cee15ed629e6f39ea38
8084 F20110218_AACGPO kim_j_Page_104thm.jpg
3418b4914aec5198d280ce457d79feb9
a1be36b9515b95015b9915ad428172c0d46d289a
8019 F20110218_AACGOZ kim_j_Page_089thm.jpg
24985784f9462b147f723a2edb6195e1
668e45da22abe0d3f27739e203bbd70bd15654f3
1982 F20110218_AACFMM kim_j_Page_105.txt
3ee7813dedefdf097faa63f20a9e3c26
477492458bcdf240299f6a72e42d792884423c08
1057 F20110218_AACFLX kim_j_Page_090.txt
22375f4cd665e9580745eb153ab6fd30
94945b64cfb38431f77e3db7534d23f8f2d13c97
1902 F20110218_AACFNA kim_j_Page_119.txt
7bf8a89077f9862f0bec9b1bf45f8e61
27062203ff663e5005efd0ff1011020b953b369c
7865 F20110218_AACGQD kim_j_Page_119thm.jpg
a55a8ccd40583be93e2b404db523866a
6cfb08128ea094d768dfe5dbda0ee30559d05c1e
8655 F20110218_AACGPP kim_j_Page_105thm.jpg
db743e31d025aa8a4c8d8a99130bd270
b3dbd836fa6416c505f1b1d6aa0ad9852a622bf2
F20110218_AACFMN kim_j_Page_106.txt
d456820d0d5b8d9f21d18b418c317e0c
da7f49738c146515de72ad380c9fd61f19f6a6af
2802 F20110218_AACFLY kim_j_Page_091.txt
e2caee01b7f0df0b9cabac88da342740
41cc6de1c465b8b6c2550f61e4e56eef740811cf
2005 F20110218_AACFNB kim_j_Page_120.txt
e1d1be2990f44e92951de172c29fb389
4ccc5582d9a73eef96f493cf5c29be1ac568b650
8144 F20110218_AACGQE kim_j_Page_120thm.jpg
6feadaacc299e3b3f000bddd857e5be6
cab2740e4332145138cb62136baad2dc1734564d
8163 F20110218_AACGPQ kim_j_Page_106thm.jpg
081dcba8396790cf2c9c8d875812d3d4
ddb63bdd33f6acdd0729a2018b709eaec879c7cf
1823 F20110218_AACFMO kim_j_Page_107.txt
b317595a62b15f32a55d21121a34423f
3da50bfe80763307ceae62eb5fd8da86b6779534
2744 F20110218_AACFLZ kim_j_Page_092.txt
c424072f4b6285fe1c755399f8d34a23
581950a382fd8c8e579c9c6bbffa78ba1de7a152
338 F20110218_AACFNC kim_j_Page_122.txt
82afd0538d2038d681356cd981de3ece
ac7b3ffda94a91b8d6a00c6ebfdb7f7a81b86547
8333 F20110218_AACGQF kim_j_Page_121thm.jpg
7e9769e9b897e4fa5f44335a2b84e735
7fbdd50d57c4cef97c39c1bc582c107bdd6152f9
7842 F20110218_AACGPR kim_j_Page_107thm.jpg
3c01c0f49223a8c273fdd73f898ae935
1f2a32ade381828e53484a661f193014d8d11f27
1966 F20110218_AACFMP kim_j_Page_108.txt
479740debcfbccedf736627798b99e2a
c039214d41d648ac88ba0fd3ccbe47dac7951e32
1079 F20110218_AACFND kim_j_Page_123.txt
a3a4949740d95d0dfe329bd5f04aad23
06401989628aa710627b13263f8fd8d274240cc9
1732 F20110218_AACGQG kim_j_Page_122thm.jpg
20da836bab19222c67d655a859839793
52c048623a559b454462f0192db638e44c4a4a64
8170 F20110218_AACGPS kim_j_Page_108thm.jpg
db405bdf9df60a3b1698c5fa60d825da
097578b2be6360e47363f2099921e5327a4aa57d
1863 F20110218_AACFMQ kim_j_Page_109.txt
89a90748ba4b62b881b27ec38760d2e2
264477fd85646c670832fc3eb9bbc6fee5bb2c9b
2057 F20110218_AACFNE kim_j_Page_124.txt
e5a84baf43c241d3df9984b053990d7c
c58523a8aa47984d2a0c34344d404447ac243f21
7007 F20110218_AACGQH kim_j_Page_123thm.jpg
3e915808c641818b0fbd868e8679f062
2952a9539e08588d727fd388738f5144b87eb131
7791 F20110218_AACGPT kim_j_Page_109thm.jpg
993efdda042446dffdeb44e0663a0e5f
65cde598bacb5735c432634e8f54bf3db78c2d6b
F20110218_AACFMR kim_j_Page_110.txt
b6c80670ab9455943df5642e95a230f6
53c351006f6c0b12f8d2aeec5c0e0e85f377e4c2
751 F20110218_AACFNF kim_j_Page_125.txt
1597f7ca565b3043c4907cf6774e2809
a9a846b41aedb9677d75108dd97f45e8cb6f82f1
7381 F20110218_AACGQI kim_j_Page_124thm.jpg
147dc0656f18eed8edac9285ad7e05de
feff9d40768c35a3c0445676c5d77d8fae32188f
8639 F20110218_AACGPU kim_j_Page_110thm.jpg
167dd36c7bfc118641d6a87a0bbfb825
f4c4a1802e42805bb14554e2d653f3b0a380791a
1908 F20110218_AACFMS kim_j_Page_111.txt
60e8d66b463a1a5a62b62ccf38a960f9
368d0b2323b0e9068f66a34f6021a3148c2f6f4c
1464 F20110218_AACFNG kim_j_Page_126.txt
667f5457f0791abb65050029fd7b08a5
d34ebb5b124bd13e1475d8bdbdd16f36c0a99d96
3964 F20110218_AACGQJ kim_j_Page_125thm.jpg
ed8f2b7e70657d5b2aae1fadebd42c01
10f303a6d511d9e92d959f1cdefe3594ed325a7d
8141 F20110218_AACGPV kim_j_Page_111thm.jpg
03039c33c7a0d6210b00dd341ee60fda
0bd3cf854b3e3b3c87c95644c7800313646b00bf
1914 F20110218_AACFMT kim_j_Page_112.txt
1b77afa2315b22e38bd17dfc194f3aed
8f82cb2c00b744ca026bb28c152f1743c6a0a7a9
1098 F20110218_AACFNH kim_j_Page_127.txt
5c16041e0fdd52f8489325bd42b04744
9efd8e0929a8caf7e13be9b60530841e15bc91b4
5781 F20110218_AACGQK kim_j_Page_126thm.jpg
6d52b8ece686ca3dfe7c63fc297850b4
ce3d85ae3ac532505c59bd6e32150ebabcb9ae01
8089 F20110218_AACGPW kim_j_Page_112thm.jpg
5039fceb2265d71bf8da6759bfccfb5c
b7e740b3e9545337739fd1b8eb72a0e4e7f9e7d8
F20110218_AACFMU kim_j_Page_113.txt
c21190c55c1abee5c2cc3df5133553f2
5d9e2ad4b417c0dfad44e61577819d135fc23be6
1867 F20110218_AACFNI kim_j_Page_128.txt
377a404b23e5adca40d62099894b4fdc
1f62e9e759a4772c40e3afb253f7e46a34e73c83
5092 F20110218_AACGQL kim_j_Page_127thm.jpg
0351acfa29dabaade85765923d305a75
9fcf1ec6c23883f9818b0d808a968aa305a934c2
F20110218_AACGPX kim_j_Page_113thm.jpg
404bd3e5ab3a30c2dc438c51139ef9fe
4cd55b6eb774f501a168b2e648dcb6f6a14258f9
2013 F20110218_AACFMV kim_j_Page_114.txt
271212595493b739a08bae03f57ceed9
4785e656572089d06884dbccab755022c30e0e0b
851 F20110218_AACFNJ kim_j_Page_129.txt
11cc3675cbad5e0f91c2260dda10c5aa
f904da415f18edf7cdeae35073eabf326f936505
8267 F20110218_AACGRA kim_j_Page_142thm.jpg
68dede5c1f00c75fd5260fbf461da0b3
9309929343687b90263d9a4d96802958d0da727c
6819 F20110218_AACGQM kim_j_Page_128thm.jpg
9eac175fdbafafb41eef9bc0a9a78a6b
e223b4fa33c14e9deec8e38ff61e65c995659767
8632 F20110218_AACGPY kim_j_Page_114thm.jpg
2aab81f360808dd03541bbfda6d3327a
fa5bb62cb0f5e5d05ba7a5338ff018ee09f74cd6
2029 F20110218_AACFMW kim_j_Page_115.txt
44431ae3db228f40f05e7089f2b20002
e682ffbee082a3e4805cafe762e0285e8efaed7d
861 F20110218_AACFNK kim_j_Page_130.txt
2b41665548e25a7a364c08e9279ec7c1
f81699b860f437dcfe5bb4c7185e0c3056c0204c
8541 F20110218_AACGRB kim_j_Page_143thm.jpg
63db6722fc852ed0b3d0fcef675ec652
58ebb9d388a5e499780aa22cf2bbf9b54e9c2290
5308 F20110218_AACGQN kim_j_Page_129thm.jpg
1e91e98541330a9678da0da1967b4112
d91eb4ab83db2b5c0d4e689536ab2a9014f960ad
1171 F20110218_AACFNL kim_j_Page_131.txt
f224d17b0fb7038dfd0c401f6bf7f3cf
b940f44a73cde70cf098125a6c341c0ec13fe49a
8502 F20110218_AACGRC kim_j_Page_144thm.jpg
a92d008a310e6dbde0b6c51e6e72ff72
30c35db7cbaa30c8c673221a433a46beda89f22b
5496 F20110218_AACGQO kim_j_Page_130thm.jpg
0495a85de4048edcf9ed0aa593f0f5a1
4a49246c2df0af5d59433e8e56035641863cf66f
8628 F20110218_AACGPZ kim_j_Page_115thm.jpg
4d6259d1cc327b634be6351598e1bb2c
bb5f86f4cd7d483ff32a343c5ee12dd173f1bf9f
2709 F20110218_AACFOA kim_j_Page_146.txt
7b2268a77108d4c2503931e381ad60db
e73b82dfd93a98ba4aff01ff9cf11e19b875a6f7
2062 F20110218_AACFNM kim_j_Page_132.txt
593a58e93f9386d1271b3d94f6220ec9
c3dc46b1d1e2af1628bc2773b0c4d94b6aa19945
F20110218_AACFMX kim_j_Page_116.txt
197928e392b8c1c814706f55f24b6d30
c93bd646d9d030a99605b1bddca325c229dc17d4
8819 F20110218_AACGRD kim_j_Page_145thm.jpg
75a49bc16425eba9cda8415e7debe587
6c68a4b5d7ac2f7f101981e0d415e43edeb4d8a6
4543 F20110218_AACGQP kim_j_Page_131thm.jpg
936ed37ce6a3f585230fc685da78cbad
655ef32405e28515c3ce2f94d5b612b17a7d35dc
2674 F20110218_AACFOB kim_j_Page_147.txt
2c59aa55560b62f4adfdad35e04d10b6
f33b321fc078480f87e63240bc0eb56b2507268e
2473 F20110218_AACFNN kim_j_Page_133.txt
e97fe43590762312225c5e70f8b1fda2
b123c16d7ca73f8e2c2ce9ae5dc24e8f07fb3191
1938 F20110218_AACFMY kim_j_Page_117.txt
6329556a3674c1a8154802838efce705
e190f011c481d1a3d3f1fc8cd4b1b4b72f1a46fe
8854 F20110218_AACGRE kim_j_Page_146thm.jpg
0eaffa72503251ff775d700d7b96f849
ed8ac6f38986dca611d07e9cbafd18c6c7112625
7370 F20110218_AACGQQ kim_j_Page_132thm.jpg
2c56b9f4f147f507a9f271d7ae2b034c
5e679d9c4b6c2389546d5acad9edb71b6a20790c
2702 F20110218_AACFOC kim_j_Page_148.txt
6a23b633b5c5fa9660677a884274547f
c17c7c82f3fffd464a344f6761b8fc6b5772c2fb
2512 F20110218_AACFNO kim_j_Page_134.txt
9e08527955e8b2f5df59fc18588df0fe
81a9bcd31fb5408ee363712a2ee3e7de7245ce6d
F20110218_AACFMZ kim_j_Page_118.txt
027391e771c68befa503d299d7a21240
5f114d5cbe8340fb5b32ef72931c986d8017bc20



PAGE 1

PHYSIOLOGICAL EFFECTS OF EXPIRATORY MUSCLE STRENGTH TRAINING WITH THE SEDENTARY HEALTHY ELDERLY: PULMONARY, COUGH, SWALLOW, AND SPEECH FUNCTIONS By JAEOCK KIM A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2006

PAGE 2

Copyright 2006 by Jaeock Kim

PAGE 3

This document is dedicated to my daughters, Yoonji and Yoonha, and my husband, Heesun Yang.

PAGE 4

iv ACKNOWLEDGMENTS There were many who deserve my gratitude for their contributions in the successful completion of this dissertation. First of all, I am greatly thankful to my advisor, Dr. Christine Sapienza. She has been instrume ntal in ensuring my academic, professional, and personal development. None of my ach ievements during the graduate school years would have been possible without her mentoring. I would like to extend my acknowledgment to Dr. Paul Davenport. His invaluable support and instruction were essential in condu cting the experiment for this dissertation project. Generously, he has provided his lab to collect the data and instructed whatever and whenever I needed. It is also my great honor to have two other professors, Dr. W.S. Brown and Dr. Rahul Shrivastav, as my committee members. They have provided precious advice and instruction. I also owe a huge debt of gratitude to Dr. Alice Dyson. She was the person who encouraged me to st ep into the area of communication sciences and disorders and inspired me to discover what I wanted for my future academic goal. I am especially grateful to two undergraduate students, Megan Herndon and Katherine Monahan. Their time and effort to help analyze the data were very important to ensure the completion of this project. Additionally, I woul d like to express my appreciation to my colleagues, who provide d their sincere support and encouragement, especially Dr. Judy Wingate, Maisa Haj Tas, Karen Wheeler, Michelle Troche, Chris Carmichael, Erin Pearson, and Teresa Pitts.

PAGE 5

v I also appreciate the Madelyn M. Lockha rt Graduate Fellowship and the Florida Association of Speech-Language Pathologists and Audiologists Research Grant for their financial support which enabled me to complete the study successfully. A penultimate thankfulness goes to my parents and parents-in-law. Their unconditional love and dedica tions have encouraged me in achieving my academic goal during the past years. Finally, I wish to acknowledge my husba nd, Heesun Yang, with the most heartfelt gratitude. Without his endless support a nd companionship, my completion of this dissertation would not have been possible. His love and encouragement were the most valuable support to accomplish my dream.

PAGE 6

vi TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iv LIST OF TABLES...........................................................................................................viii LIST OF FIGURES.............................................................................................................x ABSTRACT....................................................................................................................... xi CHAPTER 1 INTRODUCTION AND REVIEW OF THE LITERATURE.....................................1 Respiratory System Changes with Age........................................................................2 Respiratory Muscle Atrophy a nd Strength in the Elderly............................................4 Muscle Strength and Sedentary Lifestyle in the Elderly..............................................9 Measurement of Respiratory Muscle Strength.............................................................9 Respiratory Muscle Strength Training in the Elderly.................................................13 Expected Outcomes with EMST in the Elderly..........................................................19 Statement of the Problem............................................................................................29 Purpose of the Study...................................................................................................31 Hypotheses..................................................................................................................31 2 METHODOLOGY.....................................................................................................33 Sample Size Determination........................................................................................34 Recruitment and Selection..........................................................................................34 Inclusion Criteria.................................................................................................35 Exclusion Criteria................................................................................................35 Participant Demographics...........................................................................................36 Measures.....................................................................................................................37 Pulmonary Measures...........................................................................................38 Cough Measures..................................................................................................41 Swallow Measures...............................................................................................44 Speech Measures.................................................................................................47 Training Protocol........................................................................................................49 Compliance.................................................................................................................51 Statistical Analysis......................................................................................................52

PAGE 7

vii 3 RESULTS...................................................................................................................56 Reliability...................................................................................................................5 6 Correlation Between MEP and Ot her Dependent Variables......................................56 Pulmonary Function....................................................................................................57 Cough Function..........................................................................................................58 Swallow Function.......................................................................................................61 Speech Function..........................................................................................................67 4 DISCUSSION.............................................................................................................87 Pulmonary Function....................................................................................................87 Cough Function..........................................................................................................95 Swallow Function.....................................................................................................101 Speech Function........................................................................................................105 Summary...................................................................................................................108 APPENDIX A INFORMATION FLYER.........................................................................................111 B SCREENING PHYSICAL ACTIVITY QUESTIONNAIRE..................................112 C SCREENING HEALTH QUESTIONNAIRE..........................................................113 D CAPSAICIN SOLUTION PREPARATION............................................................115 E RESPIRATORY MUSCLE TRAINING PROGRAM.............................................116 F PRESSURE THRESHOLD TRAINING LOG........................................................117 G ABBREVIATION TABLE......................................................................................119 LIST OF REFERENCES.................................................................................................120 BIOGRAPHICAL SKETCH...........................................................................................140

PAGE 8

viii LIST OF TABLES Table page 1-1 Normal maximum expiratory pressure (MEP) values with age...............................12 1-2 Summary of expiratory muscle strength training (EMST) studies..........................18 2-1 Demographic information fo r participants in the study...........................................37 2-2 Paired-samples t -test between the two pre-training conditions for the pulmonary and cough function dependent variables..................................................................53 2-3 Paired-samples t -test between the two pre-training conditions for the swallow function dependent variables....................................................................................54 2-4 Paired-samples t -test between the two pre-training conditions for the speech function dependent variables....................................................................................54 3-1 Results of intraand inter-judge reliabili ty of cough, swallow, and speech function variables.....................................................................................................70 3-2 Correlation matrix of dependent variables...............................................................71 3-3 Descriptive statistics for preand pos t-training on pulmonary function variables..73 3-4 MANOVA result for the effects of tr aining and gender on pulmonary function variables...................................................................................................................73 3-5 Univariate ANOVA results for training effect on pulmonary function variables....74 3-6 Descriptive statistics for preand post-training on cough function variables..........75 3-7 MANOVA result for the effects of training and gender on cough function variables...................................................................................................................75 3-8 Univariate ANOVA results for traini ng effects on cough function variables..........76 3-9 MANOVA result for the effects of tr aining and gender on total number of coughs and total number of expulsive events...........................................................76 3-10 Descriptive statistics for preand pos t-training on swallow function variables......77

PAGE 9

ix 3-11 Mauchly’s test of sphericity for tr aining, consistency, and gender effects on swallow function variables.......................................................................................78 3-12 Univariate ANOVA (mixed design) result s for the combined effects of training, consistency, and gender on swallow function variables..........................................79 3-13 Mauchly’s test of sphericity for tr aining and consistency on swallow function variables...................................................................................................................80 3-14 Univariate ANOVA results without gender effect for the combined effects of training and consistency on sw allow function variables..........................................80 3-15 Simple main effect tests of training and consistency on PA....................................81 3-16 Multiple pairwise comparisons for DUR by training and by consistency...............82 3-17 Simple main effect tests for the eff ects of training and consistency on IA..............83 3-18 Descriptive statistics for preand post-training on speech function variables.........84 3-19 Univariate ANOVA result for the comb ined effects of training and gender on PEL............................................................................................................................84 3-20 Univariate ANOVA result for the comb ined effects of training, loudness, and gender on MPD........................................................................................................85 3-21 Univariate ANOVA result for the combin ed effects of training and loudness on MPD.........................................................................................................................85 3-22 Simple main effect tests of training and loudness on MPD.....................................86

PAGE 10

x LIST OF FIGURES Figure page 2-1 Graphical depiction of FVC and FEV1....................................................................40 2-2 Graphical depiction of ERV.....................................................................................40 2-3 Airflow during reflexive cough production.............................................................42 2-4 Cough magnitudes in one cough..............................................................................43 2-5 SM-sEMG Activity..................................................................................................46 2-6 Cycle variables function...........................................................................................47 2-7 Expiratory pressure threshold training device..........................................................50 3-1 Effects of training on MEP and MIP........................................................................58 3-2 Effects of training on CPD.......................................................................................60 3-3 Effects of training on PEFR.....................................................................................60 3-4 Effects of training on PPPIA....................................................................................61 3-5 Effects of training and consistency on PA...............................................................64 3-6 Effects of training on DUR......................................................................................65 3-7 Effects of consistency on DUR................................................................................65 3-8 Effects of training and consistency on IA................................................................67 3-9 Effect of training on PEL...........................................................................................68 3-10 Effects of training and loudness on MPD................................................................69

PAGE 11

xi Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy PHYSIOLOGICAL EFFECTS OF EXPIRATORY MUSCLE STRENGTH TRAINING WITH THE SEDENTARY HEALTHY ELDERLY: PULMONARY, COUGH, SWALLOW, AND SPEECH FUNCTIONS By Jaeock Kim May 2006 Chair: Christine M. Sapienza Major Department: Communica tion Sciences and Disorders With age, physical functions decline whic h can influence respiratory performance. One of the physical changes is sarcopenia With sarcopenia, elderly individuals experience reduced muscle mass and strength in the respiratory muscul ature. Age-related loss of muscle strength in expiratory muscles with reductions in elas tic recoil of the lungs and chest wall compliance may compromise the necessary lung pressure for both ventilatory and non-ventilatory activities. This study examined the effects of a 4-week expiratory muscle strength training (EMST) program in healthy but sedentary elderly adults as measured by maximum expiratory pressure (MEP) as well as magnitudes of pulmonary, cough, swallow, and speech functions. Eighteen healthy sedentary elderly people pa rticipated in this study. Sedentary was defined as a person with 24-hours maximum ex ertion time below 50 in a physical activity scale described within a physical activity ques tionnaire. Pulmonary measures included maximum expiratory pressure (MEP), maxi mum inspiratory pressure (MIP), forced

PAGE 12

xii expiratory volume in 1 second (FEV1), forced vital capacity (FVC), the ratio of FEV1 to FVC (FEV1/FVC), and expiratory reserve vol ume (ERV). Cough measures during capsaicin induced cough included inspirator y phase duration, compression phase duration (CPD), peak expiratory flow rate (PEFR), and post-peak plateau duration, and post-peak plateau integral amplitude (PPPIA). Swallo w measures included peak amplitude (PA), duration, and integral amplitude (IA) of submental muscle group activity in surface electromyography (SM-sEMG) dur ing maximal voluntary dry (saliva) swallow, wet swallow (5 cc and 10 cc water), and thin past e swallow (5 cc and 10 cc pudding). Speech measures included aerodynamic measures a nd acoustic measures including excess lung pressure (PEL) as well as maximum phonation durati ons (MPDs) at comfortable and loud intensity levels. Results indicated significant improvements in MEP and MIP, decrease in CPD, increases in PEFR and PPPI A during reflexive coughs produc ed by capsaicin challenge, PA and IA of SM-sEMG during maximal vol untary dry and 10 cc pudding swallows as well as increase in PEL and MPD at comfortable intensity level. The utility of EMST as a method of st rength training for rehabilitation of respiratory muscle weakness/sarcopenia in sedentary elderly seems to be a viable consideration as a treatment tool, given the positive outcomes of this treatment on multiple physiological functions.

PAGE 13

1 CHAPTER 1 INTRODUCTION AND REVIEW OF THE LITERATURE With aging, physiological capacities can become greatly limited resulting in increased incidence of disease and disabil ity (Oskvig, 1999). The United States has a population of 280 million, and among them, a pproximately 12% (33.6 millions) are 65 years and older (U.S. Census Bureau, 2002, 2003). Additionally, our population is growing fast, with the fastest growing group being those over 85 years of age (Oskvig, 1999). Within the next 10 years, the number of people aged 85 and older is estimated to increase by more than 6 million (U.S. Census Bureau, 2003). “Aging is the irreversible normal changes in a living organism that occur as time passes” (DiGiovanna, 1994, p. 2). Several theori es have been postulated to explain the causes and mechanisms of aging from biological, psychological, and cultural perspectives. But no one particular theory can explain the aging process perfectly. While aging is not a disease proce ss but a normal developmental change, almost all age changes reduce a person’s ability to maintain healthy survival and a high qua lity of life (Bowling & Dieppe, 2005; DiGiovanna, 1994; Sarkisian, Hays, & Mangione, 2002; Seeman et al., 1994). Additionally, the aging process is co rrelated with a very high incidence of diseases. Increased detrimental changes of the body and exposure to harmful factors with aging cause a decline in physical, psychological, and social functions which can increase the susceptibility of diseases. Particularly, the respiratory system dem onstrates significant changes in anatomy and physiology as a function of age. Respir ation is a function th at is critical for

PAGE 14

2 sustaining life but also signifi cantly important for generating the pressure needed to cough, swallow, and speak (Brooks & Faul kner, 1995; Campbell, 2001; Mizuno, 1991). For the clinician, knowledge of age-related chan ges in the respiratory system is important information since these changes can increas e the chance of respiratory disease and aggravate acute or chronic respiratory failure and may influence di agnostic criteria and therapeutic choices (Enright, Kronmal, Higgins, Schenker, & Haponik, 1993; Krumpe, Knudson, Parsons, & Reiser, 1985; Pack & Millman, 1988). Respiratory System Changes with Age The main functional changes in the respir atory system with aging are associated with an increase in the lung compliance (i .e., a decrease of the lung elastic recoil: Campbell, 2001; Chan & Welsh, 1998; K nudson, 1991; Mahler, 1983; Niewoehner, Kleinerman, & Liotta, 1975; Pride, 1974; Turn er, Mead, & Wohl, 1968) and a decrease in chest wall compliance (i.e., an increase of the chest wall stiffness: Janssens, Pache, & Nicod, 1999; Kahane, 1981; Mahler, 1983; Tu rner et al., 1968). Decreased lung elasticity is related to the loss of elastic fibers attached with in the lungs, dilatation of the alveolar ducts, the fusion of adjacent alveoli, and other changes (Campbell, 2001; Knudson, 1991; Oskvig, 1999). This reduced elas tic recoil of the lungs results in increasing residual volume (RV) and decreasing vital capacity (VC). In other words, as the lungs are more distensible with age, more air is trapped into the lungs causing more stale air to remain and less fresh air brought into the lungs with each breath. Increased chest wall stiffness is due to the calcification of intercostal cartilages and other structures within the rib cage and its articulation as well as gradual atrophy and weakened intercostal muscles (Janssens et al., 1999; Turn er et al., 1968). If an elderly person has kyphosis (curvature of the spine) or osteoporosis (loss of bony tissue), he/she will have

PAGE 15

3 even more significant reduction in chest wa ll compliance (Turner et al., 1968). This decreased chest wall compliance modifies th e curvature of the diaphragm implicating negatively on its mechanical force capabil ities; thus the functional residual capacity (FRC) and RV are increased (Janssens et al., 1999). It is known th at RV increases by approximately 50% and VC decreases to about 75% between 20 and 70 years of age (Janssens et al., 1999). It is also reported that forced expiratory volume in 1 second (FEV1) decreases by 14 to 30 mL a year and by 15 to 24 mL a year in nonsmoking men and women after the age of 20, respectively, a nd after age 65 the rate of declination is even greater (Knudson, Lebowitz, Holberg, & Burrows, 1983; Tockman, 1994). In summary, these changes contribut e significantly to an age-rela ted progressive decline of forced vital capacity (FVC), FEV1, forced expiratory flow (FEF), and expiratory reserve volume (ERV) and an increase in FRC due to ri se in RV (Burr, Phillips, & Hurst, 1985; Gibson, Pride, O'Cain, & Quagliato, 1976; Knudson et al., 1983; Schmidt, Dickman, Gardner, & Brough, 1973; Wate rer et al., 2001). Respiratory muscle function also signifi cantly decreases with age (Berry, Vitalo, Larson, Patel, & Kim, 1996; Brooks & Fa ulkner, 1995; Chan & Welsh, 1998; Chen & Kuo, 1989; Enright, Kronmal, Manolio, Schenker, & Hyatt, 1994; Janssens et al., 1999). Because of the difficulty in accurately quantif ying the age-related changes to respiratory muscles, specific changes in either morphol ogical or functional prope rties of respiratory muscles with aging have not been reported extensively (Brooks & Faulkner, 1995). Most of the deficits of the respiratory muscle, co mposed mainly of skeletal muscle much like the upper and lower limbs, are estimated by meas ures of the deficits that occur in the limbs (Powers & Howley, 2001; Tolep & Kelsen, 1993). The most common change in

PAGE 16

4 skeletal muscles with aging is muscle fibe r atrophy, especially w ith a disproportionate atrophy of the fast-twitch fibers (i.e., type II fibers). Type II fibers are responsible for fast and powerful movements. Respiratory Muscle Atrophy and Strength in the Elderly Skeletal muscle atrophy (i.e., a reducti on in skeletal muscle mass) causes a reduction in muscle strength and power, wh ich is referred to as sarcopenia (Doherty, Vandervoort, & Brown, 1993; Greenlund & Na ir, 2003; Roubenoff, 2000). Sarcopenia, first coined by Rosenberg (1989), is highl y prevalent in the elderly population. Generally, the prevalence of sarcopenia in ge neral skeletal muscles ranges from 6 to 30% in persons over the age of 60 years (Baumg artner et al., 1998; Me lton et al., 2000; Tanko, Movsesyan, Mouritzen, Christiansen, & Svendsen, 2002), and varies depending on measurement, definition, and participant select ion as well as the gender of the individual. Furthermore, some studies have postulated th at sarcopenia increases more than 50% after 80 years of age (Baumgartner et al., 1998; Iannuzzi-Sucich, Pr estwood, & Kenny, 2002). Generally, prevalence rates are much higher in men than in women since testosterone produced by the testes and ad renal glands are greatly redu ced in elderly men (IannuzziSucich et al., 2002; Melton et al., 2000). Testosterone co ntributes to the build up of skeletal muscle mass influencing strength and function of skeletal muscles. Even though the possible causes of sarcopenia are not cl early known, major contributing factors are evident, including decreased physical activit y, altered neuromuscular function (e.g., less motor units innervating muscle), and inad equate nutrition, as well as changes in molecular status (e.g., mitochondrial volume and activity) and anabolic hormonal status (e.g., testosterone, dehydroepi androsterone, growth hormone, insulin growth factor-I) with age (Morley, Baumgartner, Roubenoff, Mayer, & Nair, 2001).

PAGE 17

5 Characterized by decreases in muscle mass (cross-sectional area) and a decrease in the number and size of muscle fibers (Melton et al., 2000), sarcopenia re sults in a skeletal muscle cross-sectional area decrease by 20% to 40% between the ages of 20 and 60 years (Doherty, Vandervoort, Taylor, & Brown, 1993; Lexell, Taylor, & Sjostrom, 1988; Overend, Cunningham, Paterson, & Lefcoe, 1992; Young, Stokes, & Crowe, 1985). By age 80, muscle mass is dramatically reduced by up to one-half of the total muscle mass (Lexell et al., 1988). Most muscle atrophy and reductions in the number and size of muscle fibers with age are explained by e ither age-related physical inability or neuromuscular changes that include a decr eased number of motor units, changes in neuromuscular junctions, and loss of peri pheral motor neurons (Booth & Weeden, 1993). Skeletal muscles, in general, consist of several different muscle fiber types of which the characteristics are determined by th e properties of the mo tor units innervating them. The type of fibers in skeletal muscles is mostly composed of type I and type II. Type I, slow oxidative (slow-twitch) fibers are innervated by slow fatigue resistant motor units, and type II (fasttwitch) fibers are subcategorized into type IIa (fast oxidativeglycolytic) fibers innervated by fast fatigue resistant mo tor units and type IIb (fast glycolytic) fibers innerv ated by fast fatigable motor units (Doherty, 2003). Age-related atrophy is predominantly show n in type II fibers (Booth & Weeden, 1993; Brown & Hasser, 1996; Lexe ll et al., 1988; Morley et al ., 2001; Proctor, Balagopal, & Nair, 1998; Tolep & Kelsen, 1993). Type I fibers are also decreased in number and size; however, the extent of th eir reduction is much less th an that of type II fibers, particularly type IIa (Proctor et al., 1998). Previous studi es demonstrate that the mean area of type II fibers in individuals age 70 years decreases from 20 to 50% (Doherty,

PAGE 18

6 Vandervoort, Taylor et al., 1993; Lexell et al., 1988) and the pe rcentage of type II fibers relative to total muscle fibers also decreas es by 40% in the elderly aged 60 years and above (Larsson, 1983; Lexell, Downham, Larsson, Bruhn, & Morsing, 1995). The decrease in the proportion of t ype II fibers can be explained by either a direct loss in the total number of type II fibers due to decr eases in muscle protein synthesis or the conversion from type II to type I fibers due to selective denervation (Booth & Weeden, 1993; Doherty, Vandervoort, Ta ylor et al., 1993; Tolep & Kelsen, 1993). With aging, progressive loss of motor neurons in the spinal cord results in denervation of fast-twitch fibers along with reinnervation of these fi bers by axonal sprouting from adjacent slowtwitch motor neurons (Brooks & Faulkner, 1995) Age-related skeletal muscle atrophy results in the loss of muscle size and strength (Powers & Howley, 2001). Muscle strength is defined as the maximum force generation capacity and is divided into isometric (sta tic) and dynamic (including is okinetic) muscle strength (Macaluso & De Vito, 2004). Is ometric strength is the maximum force when there is no change in muscle length, while dynamic stre ngth is the maximum fo rce generated from actions and accounts for the maximum power wh ich is the product of force and speed of muscle contraction when movement exists (Macaluso & De Vito, 2004). Several studies have shown that muscle strength of both th e isometric and dynamic types declines with aging. Isometric muscle strength decreases by 20% to 40% in elde rly individuals after age 60 (Larsson, Grimby, & Karlsson, 1979; Murr ay, Gardner, Mollinger, & Sepic, 1980; Young, Stokes, & Crowe, 1984; Young et al., 1985) and maximally up to 76% (Hakkinen & Hakkinen, 1991; Overend, Cunningham, Kr amer, Lefcoe, & Paterson, 1992). In addition, losses in dynamic muscle strength have been reported with an almost 50 to 60%

PAGE 19

7 loss of isokinetic strength in limb muscles between the ages of 30 and 80 (Frontera, Hughes, Lutz, & Evans, 1991; Murray et al., 1980). Changes in proportion of fiber types may also explain a reduction of tension a nd velocity of contr action and relaxation compared with those of young mu scles (Narici, Bordini, & Ce rretelli, 1991; Roos, Rice, Connelly, & Vandervoort, 1999) which can redu ce power of the skeletal muscles. Sarcopenia of the respiratory muscles also oc curs decreasing their potential strength. Chen and Kuo (1989) indicated that respiratory muscle stre ngth and endurance decreases by approximately 20% by the age of 70. The respiratory muscles include the inspir atory and expiratory muscle groups. The diaphragm, internal intercostals of the para sternal region, external intercostals, and other accessory muscles mainly constitute the insp iratory muscles. The lateral internal intercostals, external obliques, internal obliq ues, transverse abdomi nis, rectus abdominis, serratus posterior inferior, and quadratus lumborum constitute the expiratory muscles (Mizuno, 1991). These muscles not only act as the major pump for ventilation, but also play a role in non-ventilatory activities su ch as coughing, sneezing, valsalva maneuver, talking, singing, vomiting, swallowing, and other functions that are accompanied by expiratory effort. A decrease in respiratory muscle strength w ith aging can deteriorate ventilatory as well as non-ventilatory functions (Burzynski, 1987; Mizuno, 1991). During expiration at rest, the passive elastic recoil of the lungs is typically used to generate expiratory force/pressure. However, the expiratory mu scles must contract to produce the necessary lung pressure during non-vent ilatory activities (Burzynski 1987) and contract below FRC (Zeleznik, 2003). Mizuno (1991) reported th at the mean fiber cross-sectional area

PAGE 20

8 of expiratory internal intercostal muscles de creases by approximately 7% to 20% at about 50 years of age because of a reduction of bot h type I and type II fibers, predominantly type II fibers. However, these changes are not observed in the diaphragm (Mizuno, 1991). Other studies observing changes in the respiratory muscles demonstrated no or less change in muscle mass and no change in muscle fiber types in diaphragmatic muscle and inspiratory external intercostal muscle s with aging (Caskey, Zerhouni, Fishman, & Rahmouni, 1989; Krumpe et al., 1985; Polkey et al., 1997; Tolep, Higgins, Muza, Criner, & Kelsen, 1995), suggesting the expiratory muscles are more affected by the aging process than the inspiratory muscles. Declining lung and chest wall functions, wh ether due to aging or disease, would require more muscular effort in both expiratory and inspiratory phases. In an early study of lung and chest wall compliance, Turner et al. (1968) examined changes in lung elasticity as a function of age. Their findings concur with more recent reviews of lung elastic recoil and chest wall compliance by Janssens, Pache, and Nicod (1999) that showed decreased chest wall compliance and de creased static elastic recoil of the lungs with aging. With decreases in chest wall compliance and lung elasticity, respiratory muscles will be required to work more to move the chest wall during breathing and doing other non-ventilatory tasks. Chen and Kuo (1989) also reported th at 70% of the total elastic work of breathing is required at age 70 years compared with 40% of the requirement for a 20-year-old. Thus, stre ngthening respiratory muscles should help minimize the physical changes associated with the loss of lungs and chest wall compliance as a function of age, since respir atory muscle contraction is necessary for moving the chest wall and the lungs.

PAGE 21

9 Muscle Strength and Sedentar y Lifestyle in the Elderly It is well known that muscle atrophy resu lts from muscle disuse, which can be caused by immobilization or by the reduced loading of a muscle that are closely related to a sedentary lifestyle (Powers & Howley, 2001; Rolland et al., 2004). Particularly, a reduction in the strength and pow er of skeletal muscles as a function of age is closely related with a decreasing physical activity with sedent ary lifestyle (Mizuno, 1991; Rolland et al., 2004; Taylor et al., 2004). Considerably, the prevalence of elderly individuals with a sedentary lif estyle is increasing (DiPietro, 2001). It is estimated that around 10% of elderly individuals participate in regular exerci se, but that more than 50% of the population over 65 years of age has a sedentary lifestyle (Pollock, Lowenthal, Graves, & Carroll, 1992; Taylor et al., 2004). Inactivity, due to the lack of physical exercise, accelerates the changes in muscul oskeletal structures and, thus, speeds-up the aging process (Campbell, Sheets, & Str ong, 1999). Many of the changes in the musculoskeletal system result more from disuse than from simple aging. Further, decreases in muscular strength and power in the respiratory musculature accompanied with sedentary lifestyle in the elderly ma y accelerate reductions in the ventilatory and non-ventilatory functional capacities. Measurement of Respiratory Muscle Strength While directly measuring the number and size of muscle fibers might be useful to assess respiratory muscle strength relate d to muscle mass, doing so would require invasive procedures to directly measure the morphology of the respiratory muscles in vivo. Direct measurement of the force output of the human respiratory muscles is also impractical (Tolep & Kelsen, 1993). Therefor e, the morphological changes that occur in respiratory skeletal muscles with aging have been studied in rodents or other animals

PAGE 22

10 (Kelly et al., 1991; Maltin, Duncan, & Wilson, 1985; Powers et al., 1994; Powers, Lawler, Criswell, Lieu, & Dodd, 1992; Tolep & Kelsen, 1993; Zhang & Kelsen, 1990). Available data on the morphological aspects of human respiratory muscles with aging come largely from the results of Mizuno’s postmortem study (Mizuno, 1991). Another, less invasive way to measure the strength of the overall respiratory muscles is by testing the function of respirat ory muscles using indexes, such as maximum inspiratory pressures (MIPs) and maximum e xpiratory pressures (MEPs) (Berry et al., 1996; Black & Hyatt, 1969; Bruschi et al., 1992; Chen & Kuo, 1989; En right et al., 1994; Karvonen, Saarelainen, & Nieminen, 1994; Mc Connell & Copestake, 1999; McElvaney et al., 1989; Ringqvist, 1966). These measures provide an indirect way of examining maximum strength of the respiratory muscle s. Researchers use MIPs to measure inspiratory muscle strength at the level of either FRC or RV and MEPs to measure expiratory muscle strength at the level of tota l lung capacity. Ringqvist’s study (1966) which investigates th e ventilatory capac ity and respiratory forces in healthy individuals aged 18 to 83 years, many others have investigated the relationship between age and MIPs or ME Ps. Black and Hyatt (1969) measured respiratory muscle strength in participants from 20 to 86 years of age. They observed that respiratory muscle strength declin es at a rate between 0.25 to 0.79 cm H2O a year for MIP and between 1.14 to 2.33 cm H2O a year for MEP in both men and women, respectively. Enright et al. (1994) also found similar age-re lated decrements in both MIP and MEP with a rate of dec line in MIP at about 1 cm H2O a year and that for MEP about 2 to 3 cm H2O a year for those between 65 to 85 years of age. Results from other studies indicate no statistically significant negativ e relationship between age and MIP and MEP

PAGE 23

11 due to other variances, such as the number of participants or body surface area; however, some degree of decreased MEPs were found, es pecially in men over the age of 55 years (Bruschi et al., 1992; McElvane y et al., 1989). Based on thes e findings it appears that respiratory muscle strength reduces with ag ing. Furthermore, these data suggest that strength of the expiratory mu scles is more reduced than the strength of the inspiratory muscles with aging. Table 1-1 summarizes studies supporting th e decline of MEP levels in both men and women as a function of age. All studies demonstrated higher MEPs in men than in women since MEPs are related to height (Ringqvist, 1966) and me n are typically of greater height than women. Obvious diffe rences were found in the MEPs across the studies in Table 1-1. Some factors that ma y be related to the di fferences obtained in MEPs across the studies follow. First, the pa rticipants in the Chen and Kuo study (1989) were Asian and physically of smaller statur e than those in the Ringqvist (1966) and the Black and Hyatt (1969) studies, which incl uded Caucasian participants. Second, the study of Chen and Kuo was done 20 years after the Ringqvist and the Black and Hyatt studies. Differences in the types of pressu re transducers, their sensitivity, and other measurement protocol issues could certainl y contribute to the database variations. Since MIPs and MEPs are used to refl ect an individual’s respiratory muscle strength, these indices can be used to study the relationship between strength and ventilatory and non-ventilatory functions. Recen t studies support that MEPs are the most appropriate indices for quantifyi ng respiratory muscle strength in the elderly (Berry et al., 1996; Chen & Kuo, 1989; Enright et al., 1994; Karvonen et al., 1994; McConnell & Copestake, 1999).

PAGE 24

12 Table 1-1. Normal maximum expiratory pressure (MEP) values with age. Ringqvist1 Black & Hyatt2 Chen & Kuo3 Enright et al.4 Berry et al. 5 Age range Men ( n ) Women ( n ) Men ( n ) Women ( n ) Men ( n ) Women ( n ) Men ( n ) Women ( n ) Men ( n ) Women ( n ) 18-29 247 41 (37) 170 29 (33) 141.2 8.8 (20) 97.9 5.4 (20) 30-39 248 38 (12) 163 29 (8) 136.6 8.9 (20) † 92.8 4.2 (20) † 40-49 253 52 (15) 178 33 (12) 50-59 252 32 (13) 157 28 (12) 218 74 (5) 145 40 (8) 133.6 8.9 (20) ‡ 88.4 6.2 (20) ‡ 60-64 209 49 (16) § 157 27 (17) § 209 74 (3) 140 40 (4) 117.4 7.4 (20) 75.1 5.1 (20) 65-69 197 74 (7) 135 40 (6) 188 (113) 125 (176) 190 55 (44) ** 125 36 (57) ** 70-74 200 42 (13) 165 29 (10) 185 74 (10) 128 40 (10) 179 (105) 121 (119) 75-79 161 (59) 102 (85) 80-84 142 (43) 84 (34) 85+ 131 (9) 94 (13) Note : MEP value or mean MEP st andard deviation (in cm H2O) included. 1Ringqvist, T. (1966). The ventilatory capacity in healthy subjec ts. An analysis of causal fa ctors with special reference to the respiratory forces. Scand J Clin Lab Invest Suppl, 88, 67. 2Black, L.F. & Hyatt, R.E. (1969). Maxima l respiratory pressures: Normal values and relationship to age and sex. Am Rev Respir Dis. 99(5), 698–99. 3Chen, H.I. & Kuo, C.S. (1989). Relationship between respirat ory muscle function and age, sex, and other factors. J Appl Physiol, 66(2), 945. 4Enright, P.L., Kronmal, R.A., Manolio, T. A., Schenker, M.B., & Hyat t, R.E. (1994). Respiratory muscle strength in the elderly. Correlates and reference va lues. Cardiovascular Health Study Resear ch Group. Am J Respir Crit Care Med, 149(2 Pt 1), 432. 5Berry, J.K., Vitalo, C.A., Larson, J.L. Patel, M., & Kim, M.J. (1996). Respir atory muscle strength in older adults. Nurs Res., 45(3), 155. Linear regression for men, MEPs = 360 2.47 age; for women MEPs = 242 1.75 age. *Number of participants in each group in this column was not defined in the original paper, so it was estimated number of participants from the figure shown in published manuscript. †Range of age = 31–45. ‡Range of age = 46–60. §Range of age = 60–69. Range of age = 61–75. **Range of age = 65 and older. Ability to generate maximal expiratory force plays a critical role for nonventilatory tasks, such as cough, swallow, a nd speech (Enright et al., 1994; Karvonen et

PAGE 25

13 al., 1994), which are important functions with which elderly patients demonstrate problems, particularly those post-stroke or with other neuromuscular diseases such as Parkinson’s disease, spinal cord injury, or multiple sclerosis (Chiara, 2003; Kang et al., 2005; Saleem, 2005). Respiratory Muscle Strength Training in the Elderly Given the age-related declines in respir atory muscle strength, a mechanism for training the muscles might be be neficial and actually aid and/ or prevent a certain degree of muscle wasting (Powers, Coombes, & De mirel, 1997). Progressive resistance training of skeletal muscles has result ed in significant improvements in limb muscle strength in the young, elderly, and even in the frail elde rly (Bemben & Murphy, 2001; Charette et al., 1991; Hakkinen, Kallinen et al., 1998; Lexe ll, Robertsson, & Stenstrom, 1992; Pyka, Lindenberger, Charette, & Marcus, 1994). El derly individuals enro lled in strength training programs demonstrate increased muscle strength and endurance of lower extremity muscles, similar to what is obser ved for young people (Fiatarone et al., 1990; Fiatarone et al., 1994). Strength training is associated with a co mbination of both central (neural) and peripheral (muscle mass) adaptations. Afte r a person completes a few days to a few weeks of strength training, a rapid improvement of muscle strength is noticed without hypertrophy. This rapid improvement relates to neural adaptations, including increases in the number of motor neurons and recruitment of motor units to agonist muscles, an increased discharge rate of motor units to agonist muscles, decreases in antagonist coactivation, or fiber type transitions from type IIb to type IIa fibers which are associated with the acquisitions in muscle strength obser ved in the early stage of training (Carolan & Cafarelli, 1992; Hakkinen, Newton et al., 1998; Patten, Kamen, & Rowland, 2001;

PAGE 26

14 Powers & Howley, 2001; Staron et al., 1990). The result of neural adaptations has been consistently demonstrated across studies in elderly and young participants. However, the exact mechanisms of central adaptations ar e not clearly understood. Preliminary studies provide indirect evidence of neural adaptations from meas uring maximal voluntary neural activation recorded on surface electromyogr aphy (Hakkinen, Alen, Kallinen, Newton, & Kraemer, 2000; Hakkinen, Kraemer, Newton, & Alen, 2001) as well as motor unit discharge rate using an indwelling electrode (Leong, Kamen, Patten, & Burke, 1999; Patten et al., 2001) in both shortand long-te rm muscle strength training programs. In these studies, neural activities and maximal mo tor unit discharge rates of trained muscles were significantly increased with maximal vol untary contraction after muscle strength training. The peripheral adaptations are related to muscle hypertrophy and increased contractile capacity and occur in later stages (generally, after 6 weeks) of muscle strength training programs (Baker, 2003; Fleck & Kr aemer, 1997; Goto et al., 2004; Hakkinen, 1989). Researchers have shown that strength training promotes an increase in muscle protein synthesis, resulting in muscle hypertr ophy, an increase in muscle strength with an overload stimulus (Frontera et al., 2003; Yarasheski, Zachwieja, Campbell, & Bier, 1995), and a cross-sectional area increase in both type I and II single muscle fibers of skeletal muscles of the elderly (Trappe et al ., 2000). In addition, sa tellite cells, which are important for muscle fiber regeneration a nd hypertrophy, are also increased in their proportion and activities following stre ngth trainings (Roth et al., 2001). Interest in the potential of a training program to increase the strength and/or endurance of respiratory muscles in an elderl y population has increa sed in the last few

PAGE 27

15 years (Tolep & Kelsen, 1993). Leith and Brad ley (1976) were one of the first to attempt to train respiratory muscles by performing strength and endurance training to target specific ventilatory muscle groups. Four part icipants with mean age of 27 years were trained 5 days a week for 5 weeks maintaining CO2 levels at a specific level, which is called as voluntary isocapnic hyperpnea (McC onnell & Romer, 2004a). The training required extensive equipment to monitor the CO2 levels and this training consumed a relatively large amount of time and highly depended on a subject motivation (McConnell & Romer, 2004a). Consequently, other respiratory muscle strength training programs were developed to overstep the limitation of Leith and Br adley’s complex equipment requirement. Commonly executed respiratory mu scle strength training prog rams were flow-dependent resistance training and flow-independent pres sure-threshold training. Resistance training does not depend on the lung pressure generate d by respiratory muscles but depends on the airflow, which travels th rough a variable diameter orif ice of the training device (McConnell & Romer, 2004a). The limitation of this training is that respiratory pressure developed during the training vari es with flow and the orifice size. Therefore, during this training, breathing pattern should be monito red carefully. McConell and Romer (2004a) also mentioned that this training is a relatively time consuming and physically demanding. In contrast, pressure-threshol d training of respiratory muscles has good reliability and is relatively easy to use (B aker, 2003; McConnell & Romer, 2004a). This involves a participant performi ng a certain number of repetiti ons a week with a specific number of exercise sets of tr aining in each day. This training requires that an individual produce a certain amount of lung pressure to open a one-way valve on the training device

PAGE 28

16 so that air from the lungs flows through the devi ce. It was also postu lated that pressurethreshold training would result in greater training effect than resistance training because it requires a higher level of force to meet the lo ad presented at a specific level compared to resistance training and allows the clinicia ns to set the training pressure-threshold depending on participants maximal pressure regardless of their br eathing pattern or respiratory flow (Baker, 2003; Martin, Davenport, Franceschi, & Harman, 2002). Most training paradigms with the elderl y have used inspiratory resistive or inspiratory threshold loading (de Bruin, de Bruin, Lees, & Pride, 1993; Harver, Mahler, & Daubenspeck, 1989; Hsiao, Wu, Wu, & Wa ng, 2003; Larson, Kim, Sharp, & Larson, 1988; McConnell & Romer, 2004b; Olgiati, Girr Hugi, & Haegi, 1989; Sturdy et al., 2003; Tolep & Kelsen, 1993; Weiner, Maga dle, Beckerman, Weiner, & Berar-Yanay, 2004; Wiens, Reimer, & Guyn, 1999). Many of th ese studies have focused especially on inspiratory muscle strength training (IMST) in elderly patients w ith pulmonary disease (e.g., asthma, chronic obstructive pulmonary di sease) or those with respiratory muscle weakness (e.g., multiple sclerosis, Parkinson’ s disease) with expectations to improve ventilatory capacity. However, interest in expiratory musc le strength training (EMST) has developed more recently, particularly for improving non-ventilatory functions such as cough, swallow, and speech. Evidence that EMST increases expiratory muscle strength is evident from other studies of healthy adults (Baker, 2003; O'Kroy & Coast, 1993; Suzuki, Sato, & Okubo, 1995), high school band students (Sapien za, Davenport, & Martin, 2002), hypotonic children (Cerny, Panzarella, & Stathopoulus, 1997), high-ri sk performers (HoffmanRuddy, 2001), patients with chronic obstr uctive pulmonary (Weiner, Magadle,

PAGE 29

17 Beckerman, Weiner, & Berar-Yanay, 2003a), multiple sclerosis (Chiara, 2003; Gosselink, Kovacs, Ketelaer, Carton, & D ecramer, 2000; Smeltzer, Lavietes, & Cook, 1996), Parkinson’s disease (Saleem, 2005; Saleem, Sapienza, & Okun, 2005), and myasthenia gravis (Weiner et al., 1998). These studies demonstrated that EMST is effective in increasing the strength of expiratory muscles resulting in augmenting expiratory driving pressure which is utilized for cough, swallow, or speech (Table 1-2). Little outcome data are available on respirat ory muscle strength tr aining in the healthy elderly in either an inspiratory or expirato ry direction, and use of respiratory muscle strength training may be beneficial for pr evention or treatment of normal age-related respiratory muscular weakness (Tolep & Kelsen, 1993). Watsford, Murphy, Pine, and Coutts (2004) trained 26 older female partic ipants (mean age of 64.4 years) with 8 weeks of 12 respiratory muscle training sessi ons with both IMST and EMST using a commercially available training device (PowerlungTM PowerLung Inc., Houston, Texas, USA). They obtained significant increases in maximum voluntar y ventilation, MIPs, MEPs, and other performance assessments such as time-to-rate of perceived exertion 15 walking test. However, this study only doc umented healthy elderly female performance and there was no detailed explanation regardi ng whether respiratory muscle training was aimed to improve expiratory muscle strength or inspiratory muscle strength. In addition, the outcome measures were associated only w ith ventilatory capacities. To date, no study has examined the effect of EMST on expirato ry muscle strength in healthy elderly males and females and other studies of EMST on expi ratory muscle strength have attempted to train elderly persons with diseases.

PAGE 30

18 Table 1-2. Summary of expi ratory muscle strength training (EMST) studies. Study Participants N Training program Training (wks) Training Load MEP gain (%) Significance Level Functional Improvement O’Kroy & Coast1 Healthy adults 6 RT 4 32% of MEP NS NS Not applicable Suzuki et al.2 Healthy adults 6 PT 4 30% of MEP 25 p < 0.01 Not applicable Cerny et al.3 Hypotonic children 9 RT 6 2.5-7.5 cm H2O 69 p < 0.001 Speech Smeltzer et al.4 Multiple Sclerosis 10 PT 12 Not reported 37 No testing completed Cough (subjective report) Gosselink et al.5 Multiple Sclerosis 9 PT 12 60% of MEP 35 NS Cough (subjective report) HoffmanRuddy6 High risk performers 8 PT 4 75% of MEP 84 No testing completed Speech Sapienza et al.7 High school band students 26 PT 2 75% of MEP 47 p < 0.001 Not applicable Baker8 Healthy young adults 32 PT 4-8 75% of MEP 29-50 p < 0.05 Speech & cough Chiara9 Multiple Sclerosis 17 PT 8 40-80% of MEP 40 p < 0.05 Speech Wingate et al.10 Professional voice users 18 PT 5 75% of MEP 77 p < 0.001 Speech Saleem11 Parkinson Disease 10 PT 4 75% of MEP 22-37 p < 0.001 Cough & swallow 1O’Kroy, J.A. & Coast, J.R. (1993). Effects of flow and resi stive training on respiratory muscle endurance and strength. Respiration, 60(5), 279–283. 2Suzuki, K.S., Sato, M, & Okubo, T. ( 1995). Expiratory muscle training and se nsation of respiratory effort during exercise in normal subjects. Thorax, 50(4), 366–370. 3Cerny, F.J., Panzarella, K., & Stathopoulos, E.T. (1997). Expi ratory muscles conditioning in hypotonic children with low vocal intensity levels. J Med Speech Lang Pathol, 5, 141–152. 4Smeltzer, S.C., Lavietes, M.H., & Cook, S.D. (1996). Expiratory training in multiple sclerosis. Arch Phys Med Rehabil, 77(9), 909–912. 5Gosselink, R., Kovacs, L., Ke telaer, P., Carton, H., & Decramer, M. (2000). Respiratory muscle weakness and respiratory muscle training in severely disabled multiple sclerosis patients. Arch Phys Med Rehabil, 81(6), 747–751. 6Hoffman-Ruddy, B. (2003). Expiratory pressure threshold tr aining in high-risk performers, Unpublished doctoral dissertation, University of Florida, Florida. 7Sapienza, C.M., Dave nport, P.W., & Martin, A.D. (2002). Expiratory muscle training increases pressure support in high school band students. J Voice, 16(4), 495–501. 8Baker, S.E., Davenport, P., & Sapienza, C. (2005). Examination of tr aining and detraining effects in expiratory muscles. J Speech Lang Hear Res, 48(6), 1325-1333. 9Chiara, T. (2003). Expiratory muscle strength training in individuals with multiple sclerosis and health controls. Unpublished doctoral dissertation, Univ ersity of Florida, Florida. 10Wingate, J., Sapienza, C.M., Shrivastav, R., & Brown, W.S. (in press) Treatment outcomes for professional voice users. J Voice. 11Saleem, A.F. (2005). Expiratory muscle strength training in patients with idio pathic parkinson’s disease: Effects on pulmonary, cough, and swallow function. Unpublished doctora l dissertation, University of Florida, Florida. MEP = maximum expiratory pressure, N = number of subjects w ho were trained with EMST program PT = pressure-threshold training, RT = re sistance training, NS = not significant

PAGE 31

19 Expected Outcomes with EMST in the Elderly Promising results from preliminary studies investigating the eff ects of expiratory muscle strength in different groups of particip ants suggest that EMST is able to increase expiratory muscle strength, improve cough function, promote swallow performance, and positively affect speech characteristics, in healthy young and clinical populations (Cerny et al., 1997; de Bruin et al ., 1993; Gosselink et al., 2000; Hoffman-Ruddy, 2001; Saleem, 2005; Smeltzer et al., 1996). Hence, one would expect that EMST would improve respiratory function as well as the ability to clear the airway, swallow, and speak in the healthy elderly. To expect that EMST would improve resp iratory function by enhancing expiratory muscle strength in the healthy elderly population is reasonable. Specifically, FEV1, FVC, and ERV would likely be affected. With age, expiratory force is diminished because of reduced elastic recoil of the lungs, compliance of the chest wall, and expiratory muscle strength. Therefore, FEV1, FVC, and ERV are decreased in elderly individuals relative to younger counterparts (Waterer et al., 2001). Consequently, RV increases up to 50% and vital capacity decrease s by about 75% maximally as adults reach age 70 (Gibson et al., 1976). Strengthening expiratory muscles by EMST would enhance the ability of the elderly to generate more expiratory for ce and compress the chest wall to a smaller volume as a compensatory mechanism, resulting in an increase in FEV1, FVC, and ERV. As shown in Table 1-2, MEP levels were in creased by a significant amount in healthy young adult participants and c linical populations regardless of the training program, duration of training, a nd training load. EMST would also increase MIPs. Previous studies have showed that MIP levels increase following EMST in patients with multiple sclerosis (Chiara, 2003; Gosselink et

PAGE 32

20 al., 2000). Gosselink et al. ( 2000) speculated that the im proved inspiratory muscle strength is related to reduced RV caused by a reduction of expira tory lung volume to allow the inspiratory muscles to operate easily with a more advantageous part of their length-tension relationship. It is anticipated that EMST would increa se peak expiratory flow rate during cough production. Cough is a reflexive protective m echanism to clear foreign substances or excessive mucous in the airways to reduce resp iratory infection using higher velocities of forced expiratory airflow (Shannon, Bosler, & Lindsey, 1997). Coughing is composed of three consecutive phases: an inspiratory phase, a laryngeal compressive phase, and an expiratory phase (Leith & Bradley, 1976). In the inspiratory phase, once foreign substances or mucous stimulate the periphera l receptors and the stimulus is conducted to the central cough cente r located in the medulla (Bour os, Siafakas, & Green, 1995), the vocal folds abduct to open the glottis and allow air to fill the lungs. Then, during the laryngeal compression phase, the vocal folds addu ct to close the glottis and the expiratory muscles contract to build up high positive intrap leural and intrathoracic pressures as high as 300 mmHg in a very short period of tim e (less than 200 ms) (Chung, Widdicombe, & Boushey, 2003; McCool, 2006; Irwin et al., 1998). Finally, the air from the intrathoracic airways is expired through a slightly opened glottis by the contraction of expiratory muscles with a velocity as great as 28,000 cm per second (Chung et al., 2003). During the expiratory phase, foreign substances are removed by the generation of the high velocity of expiratory airflow. During thes e three phases, the interactive activity of various respiratory muscles contro ls the cough mechanism intricately.

PAGE 33

21 Reduced mucociliary clearance function (Bouros et al., 1995; Puchelle, Zahm, & Bertrand, 1979), decreased sens itivity of pharyngoglottal clos ure reflex (Shaker et al., 2003), and a diminished laryngeal valvi ng mechanism (Hoit & Hixon, 1987) are the major causes of accumulation of mucous or aspiration in intrathor acic airways in the elderly. This eventually increases the mort ality or morbidity of the elderly population from respiratory diseases (Kikawada, Iw amoto, & Takasaki, 2005; Logemann, 1998). To replace these regressed mechanisms, cough play s an important role in expelling foreign materials or secretions (McCool & Leith, 1987). Ineffective cough is also possibly related to reduced expiratory flow rates as well as lengthened la ryngeal compression time (McCool & Leith, 1987). McCool and Leith (19 87) noted that decrea sed expiratory peak flow is closely related to decreases in insp iratory or expiratory muscle strength. Specific methods for increasing cough stre ngth and timing have not been greatly studied to date. Of the limited treatment studies done on cough in patients with respiratory muscle weakness, the approach es rely on physical procedures, such as percussion and shaking, and manually assisted cough or mechanical insufflation and/or exsufflation (Bott & Agent, 2001; Chatwin et al., 2003; Mustfa et al., 2003). The implications are non-trivial fo r the elderly population. Alt hough not a testable hypothesis in this research it is hoped EM ST with the elderly has the po tential to decrease or delay the development of respiratory complications by increasing expiratory muscle strength and increasing the ability to voluntarily cl ear the airway with a strong cough. An improvement in cough function should significan tly reduce the occurrence of respiratory infections, thus enhancing the overall health of the elderly. Cough magnitude is directly

PAGE 34

22 related to the amount of expiratory driving pressure and ex piratory pressure is the direct target of the expiratory traini ng technique (Irwin et al., 1998). Specifically, it is expected that EMST would increase the ex piratory strength including peak expiratory flow rate and pos t-peak plateau during c oughing as a result of overcoming high peripheral airway resistance. Peak expiratory flow rate during cough reflects the changes in muscular strength. Po st-peak plateau is defined as the sustained expiratory airflow after the peak expirato ry flow during a cough and it increase with increasing expiratory driving pressures as expiratory muscular strength is enhanced (Saleem, 2005). In fact, expiratory flow ra te during cough is less in the elderly when compared to younger counterparts, which is related to decreased respiratory muscle strength (Babb & Rodarte, 2000) and decrease in lung elasti city (Babb & Rodarte, 2000) as well as an increase in the collapsibility of peripheral airways (Janssens et al., 1999). In addition, EMST should decrease the laryngeal compression time. Changed afferent inputs in pressure are transferred to the central cough centers (Bouros et al., 1995) and this process should alter efferent out puts to the adductory laryngeal muscles. As a result, laryngeal compression time shoul d decrease (de Bruin et al., 1993). These potential effects would decrease the chan ce of aspiration and d ecrease potential of respiratory infection. Baker (2003) and Saleem (2005) found that a 4-week EMST program improved peak expiratory flow a nd reduced laryngeal compression time during maximum voluntary cough in healthy young adults and patien ts with Parkinson’s disease, respectively. In a study of pa tients with multiple sclerosis, increased expiratory pressure achieved with a 3-month pressure threshold EMST program was effective in increasing cough function, although the repo rts were subjective (Gosse link et al., 2000). This

PAGE 35

23 qualitative effect was also demonstrated in another study of an EMST program with patients with multiple sclerosis (Smeltzer et al., 1996). Ten participants in this study reported diminished choking events post-EMST. Those studies measured the cough characteristics during maximu m voluntary cough production. It is also expected that EMST w ill improve swallow function. Swallow dysfunction can be a major lif e-threatening problem in th e elderly (Logemann, 1998). Explicit evidence exists rega rding age-related changes in structure and physiology of swallowing, resulting in a high risk of swallowing problems in individuals ove r the age of 60 years. Significantly deteriorated effi ciency of all phases of swallowing (oral preparatory, oral transit, phar yngeal, and esophageal phases) ha s been reported in several studies. These changes include increased duration of the oral stage of swallowing (Jaradeh, 1994; Logemann, 1998), reduced refl exes to trigger la ryngeal closure (e.g., pharyngeal reflex, pharyngo-upper esophageal sphincter contractile reflex; McKee, Johnston, McBride, & Primrose, 1998; Ren et al., 2000; Robbins, Hamilton, Lof, & Kempster, 1992; Shaker et al., 2003), reduced laryngeal and hyoid anterior and vertical (superior) movement (i.e., reduced neuromus cular reserve; Logemann et al., 2000; Tracy et al., 1989; Yokoyama, Mitomi, Tetsuka, Taya ma, & Niimi, 2000), diminished laryngeal valving capacity (Hoit & Hixon, 1987; Honjo & Isshiki, 1980; Ptacek & Sander, 1966; Titze, 1994), decreased pharyngeal flexibili ty (i.e., reduced pharyngeal contraction; Logemann et al., 2000), increased duration of the pharyngeal swallow (Jaradeh, 1994; Logemann, 1990; McKee et al., 1998; Tracy et al., 1989), impaired opening of the upper esophageal sphincter (Tracy et al., 19 89), increased duration and width of cricopharyngeal opening (Kahrilas & Logema nn, 1993; Tracy et al., 1989), and delayed

PAGE 36

24 and less efficient esophageal tr ansit and clearance (Mandels tam & Lieber, 1970). Elderly individuals are more likely to aspirate if they have any circumstances of medical conditions, such as neurologic or neuromus cular diseases (Kikawada et al., 2005; Kobayashi, Hoshino, Okayama, Sekizawa, & Sasaki, 1994; Mandelstam & Lieber, 1970; Teramoto, Matsuse, & Ouchi, 1999). An EMST program should contribute to th e reduction of the m echanisms of agerelated neuromuscular deterioration in th e swallowing structures. Several possible mechanisms are expected to improve the swallow function with an EMST program. As predicted previously, EMST will increase expira tory lung volume and force, resulting in high expiratory airflow. In tu rn, this would increase the a fferent stimulus on the sensory receptors of the tongue and oropharynx, leading to an increase in the activation of the swallow sensory recognition center located in the medulla or lower brainstem (Doty, Richmond, & Storey, 1967; Gross, Atwood, Grayhack, & Shaiman, 2003; Logemann, 1998). After this incoming information is dec oded in the nucleus tractus solitarius, the efferent information from the nucleus ambiguous is delivered to motor units participating in oropharyngeal swallow moto r pattern (Doty et al., 1967). The increased activity of motor units would improve the efferent mo tor activities of oropharyngeal, velar, and laryngeal musculatures as well as the speed of oropharyngeal swallow. Consequently, the improved activities and sp eed of swallowing structures would reduce the general duration of swallowing. Another possible mechanism for improvement in swallow function could be related to an increase in the hyolaryngeal displacement with increased expiratory force as a result of the EMST program. During the orophar yngeal swallowing phase, the hyoid bone is

PAGE 37

25 pulled up which elevates the larynx anterior ly and vertically by the contraction of submental muscle group including the supra hyoid muscles, in other words, laryngeal elevator muscles (Logemann, 1998; Perlman, Palmer, McCulloch, & Vandaele, 1999). This muscle group is composed of the ante rior belly of the digastric, mylohyoid, and geniohyoid muscles. Yokoyama et al. (2000) suggested that ve rtical hyolaryngeal movement causes laryngeal closure so as to protect the lower airway and that anterior hyolaryngeal movement contri butes to decreasing the upper-esophageal sphincter pressure to enable a bolus into the uppe r-esophageal sphincter readily. In turn, anterovertical hyolaryngeal movement associ ated primarily with the contraction of submental muscles is important for effec tive and safe passage of a bolus to the esophagus. Hyoid and laryngeal elevations during oropharyng eal swallowing have been commonly observed using submental muscle group activity in surface electromyography (Ding, Larson, Logemann, & Rademaker, 2002; Ertekin et al., 1995; Perlman et al., 1999; Vaiman, Eviatar, & Segal, 2004a, 2004b; Wh eeler & Sapienza, 2005). As mentioned previously, elderly individuals have a decrease in hyolaryngeal displacement, which can reduce the laryngeal closure and cause a bolus to escape into other cavities, resulting in high risk of aspiration (Logemann et al., 2000; Yokoyama et al., 2000). However, hyolaryngeal displacement may be increased by forced expiration with EMST. Fink and Demarest (1978) noted that laryngeal displ acement is induced by the respiratory cycle, with inspiration associated with downw ard movement and expiration with upward movement. Particularly, upward laryngeal movement is related to the mechanical contribution of laryngeal elevator muscles. If expiratory force increases, it would enhance the activities an d strength of laryngeal elevator muscles, resulting in enhancing

PAGE 38

26 hyolaryngeal displacement. With increased hyolaryngeal displacement during swallowing, the glottal closure should be e nhanced, thus moving the bolus into the esophagus more easily. This assumption was supported by the study of Wheeler and Sapienza (2005) which compared the submenta l muscle group activities using surface electromyography during swallow task and resp iratory task using EMST device set at 25% and 75% of MEP in 20 young healthy adults Their study showed that the EMST task produced significantly higher peak amp litude and greater average amplitude of submental muscle group activity compared to either dry swallow or wet swallow tasks. They also observed increased hyoid elev ation, while using the EMST device, on videofluoroscopy from one participant. They suggested that EMST enhances the activation of the submental muscle group for swallowing and may impose central and peripheral adaptations during the EMST program. Finally, it is predicted that the EMST progr am will improve speech characteristics. It is well known that the cont raction of expiratory muscles is necessary for certain types of speech tasks since it controls the outflow of air in or der to speak as well as provides the necessary pressure when elastic recoil fo rces are not great enough to vibrate the vocal folds (Hixon, 1973). Isshiki (1964) noted th at improvements in sound quality, speech intelligibility, duration, and intensity are a f unction, to some extent, of the degree of expiratory pressure that can be deve loped. Even though reduced lung volume and pressure, resulting from decreased respiratory muscle strength, thor acic compliance, and elastic lung recoil pressure do not seem to cause major problems associated with breathing at rest or comforta ble effort, the necessary volume and pressure to sustain speech for a long period of time and to pe rform loud speech or singing cannot be

PAGE 39

27 achieved. These tasks require greater lung pre ssure associated with expiratory muscle force (Hoit & Hixon, 1987). In fact, inadequa te lung pressure for speech or singing results in severely decreased vocal intensit y and shortened utteran ce length per breath (Titze, 1994). Particularl y, chest wall rigidity and respiratory muscle weakness associated with aging results in compromise d lung volumes available for speech (Titze, 1994). Specifically, normal inspiratory volum es cannot be produced by the elderly, thus limiting the available passive recoil pressure for speech and high-effort tasks. When inspiratory volumes are limited and the subglot tal pressure demand fo r particular speech tasks cannot be met (e.g., long durations of speech or loud speech), active expiratory muscles must be recruited to generate th e positive airway pressure for these tasks (Burzynski, 1987). When an individual increas es expiratory muscle strength, chest wall rigidity may reduce because the individual is able to move the chest wall with greater force (Hoit & Hixon, 1987). This should resu lt in increased speech durations, greater sound pressure level, and improved voice quality, and speech intelligibility. Previous studies demonstrated that both elderly males and females produce more than 6 dB lower sound pressure level ( SPL) in maximum vowel intensities (sound pressure drops by half) than younger count erparts (Morris & Brown, 1994; Ptacek & Sander, 1966; Teles-Magalhaes, Pegoraro -Krook, & Pegoraro, 2000). In addition, a comparative study of young versus elderly male voices indicated a significantly lower vocal intensity in elderly male voices with reduced lung pressure, peak airflow, and open quotient during syllable train production (H odge, Colton, & Kelley, 2001). Hodge et al. (2001) noted that SPL was gr eater for young men than for el derly men at all different intensity conditions. In the study, mean l ung pressures in the loud condition were 10.82

PAGE 40

28 cm H2O and 7.96 cm H2O in the control young group and in the elderly group, respectively. The difference of the lung pre ssure between the contro l and elderly groups was statistically significant in this condition. These results suggest that lung pressure is significantly decreased in the elderly group as compared with the young group. Changes in lung pressure are closely associated with changes in SPL. The SPL increases at a rate of 8 to 9 dB when lung pressure is doubl ed (Hodge et al., 2001). Thus, reduced lung pressure for loud phonation in the elderly comp ared to the young represents a reduction in lung pressure which may be accompanied w ith weakness of the expiratory muscles. Additionally, several re searchers report reduced vocal fold closure (Honjo & Isshiki, 1980; Linville, 1992; Tanaka, Hirano, & Ch ijiwa, 1994), histologic and neuromuscular changes in laryngeal muscles (Rodeno, Sanc hez-Fernandez, & Ri vera-Pomar, 1993), and decreased laryngeal muscle activity with ag e (Baker, Ramig, Sapir, Luschei, & Smith, 2001; Luschei, Ramig, Baker, & Smith, 1999). Therefore, it was suggested that the changes in lung pressure may be necessary to overcome an age-related changes in laryngeal structure and mechanism to control airflow and air pressure for speech in the elderly (Baker et al., 2001). Furthermore, it has been shown that the number of syllables produced per breath group are reduced with age (Hoit & Hix on, 1987), which is related to the reduced duration of phonation in the elderly. However, th ese age-related changes in speech might be compensated for by EMST in that it may assist the active expiratory force to positively affect speech characteristics such as increasing expiratory pressure to produce loud phonation or sustain phonation for a long period of time as well as overcoming high laryngeal resistance. In a study of a 4-week EMST program with patients with Parkinson’s disease, signifi cant improvements in the range of vocal

PAGE 41

29 loudness during sustained vowel phonation tasks was found (Saleem et al., 2004). It is also known that EMST program for individua ls with neurologic impairments improves their speech parameters like vocal intensit y. Following a 6-week EMST program, nine children with hypotonia demonstrated signifi cant increases in vo cal intensity among participants (Cerny et al., 1997). Furthermore, an 8-week of EMST improved acoustic components of speech including vowel prolongation as well as subjectively reported voice-related quality of life in 17 patients with multiple sclerosis (Chiara, 2003). The participants with multiple sclerosis described an ability to breathe easier and talk louder after EMST program. In a study with high risk performers working in a theme park who were singing along with choreography, expi ratory muscle strength and utterances duration per breath significantly increased after a 4-week EMST program (HoffmanRuddy, 2001). Additionally, professional voice users with voice problems after the combined treatment of 5 weeks EMST and 6 se ssions of traditional voice therapy showed significant improvements in voice handicap sc ores, voice rating scale scores, subglottal pressure for loud intensity, phonetogram ar ea in both frequency and amplitude, and dynamic range (Wingate, Sapienza, Shrivasta v, & Brown, in press). These previous works with the EMST program in the hea lthy and the clinical populations indicate improvements in pressure support for voice and speech quality post-EMST including increases in vowel and phrase durations, incr eased SPL, as well as decreased frequency variability, and reductions in brea thlessness, and in vocal fatigue. Statement of the Problem It is known that EMST has a great impact on increasing expiratory muscle strength in healthy and clinical populat ions. However, very few have investigated the effect of EMST on healthy elderly populat ion. As described earlier, after the age of 60, people

PAGE 42

30 have reduced mass and changed fiber types of expiratory muscles resulting in reduction of muscle strength. This latt er age-related changes in skel etal muscles, referred to as sarcopenia, often combined with the sedent ary lifestyle in the elderly, leading to a significant reduction in reserve capacity of muscular strengt h. Reduced physical activity accelerates the changes in respiratory muscle structures with muscle atrophy, which can affect the reduction of particular functions of breathing, cough, swallow, and speech in the elderly. Therefore, this study will reveal how EM ST impact on expiratory muscles which play a major role in breathing, cough, swa llow, and speech in the sedentary healthy elderly. Previous studies have shown that EMST is an effective training paradigm to increase expiratory muscle strength result ing in improvements in certain physiological functions in healthy adults a nd certain clinical populations. However, very few studies have sought to quantify real th erapeutic gains direc tly attributable to the interventions that have employed EMST with regard to breathing, cough, swallow, and speech. Previously, the effects of EMST on cough have quantified in maximum voluntary coughs. Cough is a reflexive event. To exam ine the effects of EMST on coughs should be measured in reflexive coughs. Most re cently, the inhaled irritant of choice for investigation of cough in human has been capsaic in. This irritant is safe and reproducibly elicits cough in virtually all participants (Dicpinigaitis, 2003; Dicpinigaitis & Alva, 2005; Ertekin et al., 1995; Nieto et al., 2003; Prudon et al., 2005). Thus, cough measures in this study were completed using capsaicin-indu ced cough productions. Additionally, the effects of EMST on swallow have quantified w ith videofluoroscope or subjective reports

PAGE 43

31 from the participants in the previous st udies. However, no study has measured the strength changes in the muscles used fo r swallowing. Surface electromyography (sEMG) has been commonly used to evaluate the st rength changes in the swallow muscle group activity. sEMG is a simple, reliable, and noninvasive method to assess temporal and neural activities of complex muscle group. Particularly, the ac tivity of submental muscles which are the primary muscle group of hyolaryngeal eleva tion during the early stage of swallowing could be repetitively measured using sEMG without invasive procedure in preand post-EMST. Purpose of the Study The purpose of this study is to investig ate the physiological effects of EMST on expiratory muscle strength in otherwise h ealthy, but sedentary, elderly as measured by the primary dependent variable of maximum expiratory pressure (MEP). Additionally, this study will examine the potential effects of EMST on maximum inspiratory pressure (MIP), breathing, cough, swallow, and speech functions affected by the aging process. Hypotheses Central Hypothesis: It is hypothesized th at a 4-week EMST program will improve maximum respiratory pressure, breathing, cough, swallow, and speech functions in otherwise healthy, but sedentary, elderly adults due to expect ed increases in expiratory muscle strength. The specifi c hypotheses are the following: Hypothesis 1: Expiratory muscle stre ngth, as indicated by increased MEP, and inspiratory muscle strength, as indicated by increased MIP due to changes in pulmonary mechanics, will improve after 4 weeks of strength training with an expiratory pressure threshold device.

PAGE 44

32 Hypothesis 2: Increased expiratory mu scle strength will be translated to improvements in breathing functions. Specifi cally, improvements in forced expiratory volume in 1 second (FEV1), forced vital capac ity (FVC), and expiratory reserve volume (ERV) will be affected. But the ratio of FEV1 to FVC will not be changed. Hypothesis 3: Improved expiratory mu scle strength will increase the peak expiratory flow rate (PEFR) and the post-p eak plateau duration (PPPD) and the post-peak plateau integral amplitude (PPPIA) as well as decrease inspiratory phase duration (IPD) and compression phase duration (CPD) duri ng the capsaicin-induced reflexive cough production. Hypothesis 4: Increased cough magnitude s are not the influence of increased sensitivity to capsaicin challenge. Hypothesis 5: Increased expiratory force and hyolaryngeal displacement will increase the peak amplitude (PA) and integr al amplitude (IA) of submental muscle group activity and decrease the duration (DUR) of submental muscle group activity during maximal voluntary dry (saliva) and thin pa ste bolus (5 cc and 10 cc pudding) swallows. Hypothesis 6: Increased expiratory mu scle strength will increase excess lung pressure (PEL) as well as the maximum phonation durations (MPDs) at comfortable intensity and at loud intensity.

PAGE 45

33 CHAPTER 2 METHODOLOGY The project design was a prospective, complete repeated measures design. Participants were assigned to use a specific experimental training de vice for expiratory muscle strength training. The independe nt variables were tr aining status (Pretraining/Post-training) and gender for all f unctions, consistency (maximal voluntary dry, 5 cc water, 10 cc water, 5 cc pudding, a nd 10 cc pudding) for swallow function, and loudness (comfortable/loudest) for the speech function. The dependent variables for pulmonary function were maximum expiratory pressure (MEP) and maximum inspiratory pressure (MIP), force vital capacity (FVC), forced expiratory volume in 1 second (FEV1), the ratio of FEV1 to FVC (FEV1/FVC), and expiratory rese rve volume (ERV). Cough dependent variables were in spiratory phase duration (IPD) compression phase duration (CPD), peak expiratory flow rate (PEFR) post-peak plateau duration (PPPD), and postpeak plateau integral amplitude (PPPIA) as well as total number of coughs and total number of expulsive events. Swallow depe ndent variables were peak amplitude (PA), duration (DUR), and integral amplitude (IA) of submental (S M) rectified surface electromyography (sEMG) during maximal volunt ary dry and 5 cc and 10 cc boluses of wet (water) and thin paste (pudding) swallows. Speech dependent variables included excess lung pressure (PEL) as well as maximum phonation durations of sustained vowel production (MPDs) at two levels of intens ities, comfortable and maximum loudness.

PAGE 46

34 Sample Size Determination Sample size calculation was performed usi ng one dependent variable as suggested by Marks (Marks, 2002). The maximum expira tory pressure (MEP) was used as the variable to determine sample size since this measure was considered the primary outcome measure for determining the effect of EMST. The standard deviation of MEP, denoted as was determined from the range of MEP values obtai ned in a pilot study (Kim, Sapienza, & Davenport, 2005). The range was 75.86 cm H2O, which yielded a of 18.97 cm H2O. The minimum clinical significan t difference, or bound on error (B), between the average MEP values before EM ST and average MEP value after EMST was determined to be 20% of the average ba seline MEP. Since the average MEP was measured at 73.57 cm H2O, B value was calculated and yielded a value of 14.71 cm H2O. Using the obtained values of and B, DELTA ( ) was calculated using the formula: = B/ and determined to be as 0.775. The significance level ( ), or probability of executing a Type I error, was predetermi ned at 0.05. The power of the test (1), or the ability to reject the null hypothesis if the null is false, was set at 90%. Using the sample size table provided in Marks (2002), the num ber of participants needed was 18. Therefore, 18 participants were recruited for this study. Recruitment and Selection An approval for the study was obtained from the University of Florida Health Science Center Institutional Review Board (IRB# 402-2004) prior to recruiting participants. All particip ants in this study signed an informed consent document authorized by the IRB. Participants were recruited from local community members (via residential facilities, social and professi onal organizations, churches, and retirement

PAGE 47

35 communities) in the Gainesville area. Prin ted flyers containing information about the study and contact information were posted at various locations across local communities (Appendix A). Inclusion Criteria Participants were included based on the following criteria: 1. Over 65 years. 2. Sedentary: Sedentary was defined as a person with 24-hours (24-h) of maximum exertion time (MET-Time) < 50 in physical activity as described in the physical activity questionnaire (Aadahl & Jorgensen, 2003) (Appendix B). The chosen activities were listed in th e physical activity scale in nine levels of physical exertion, ranging from sleep or inactivity to strenuous activities. The physical activity scale was composed of the number of minutes (15, 30, or 45 min) and hours (1 to10-h) spent on each MET activity level on an average 24-h weekday. This allowed fo r a calculation of the total MET-time, representing 24-h of sleep, work, and leisure time on an average weekday. MET activity level: A = 0.9 MET, B = 1.0 MET, C = 1.5 METs, D = 2.0 METs, E = 3.0 METs, F = 4.0 METs, G = 5.0 METs, H = 6.0 METs, and I 6 METs). For each activity level (A to I) the MET-Value was multiplied by the time spent on that particular level and MET from each level was added to total 24h MET-time, representing physical ac tivity level on an average weekday. 3. Able to maintain his/her current level of physical activity duri ng participation in this study. Participants were asked to report to the investigator any significant changes in their level of physical activity duri ng their participation in the study with regards to intensity and frequency of ex ercise during the en tire training (e.g., a sedentary person begins exercising 2 to 4 days per week). 4. Able to complete the informed consent to participate in the study Exclusion Criteria Participants were excluded from the st udy if they reported any of the following: 1. History of the following medical conditi ons: chronic and acute cardiac disease including untreated hyperten sion (systolic blood pressure > 140 mmHg, diastolic

PAGE 48

36 blood pressure > 90 mmHg), pulmonary dise ase, neuromuscular disease, and/or immune system disease, or others as reported on a health questionnaire (Appendix C). 2. Upper respiratory infection at the time of the baseline measurements as reported on the health questionnaire or during the training period. If symptoms persisted for more than 1 week of training, the pa rticipant was excluded from the study. 3. Pulmonary function test values below 70% of the predicted normative value (e.g., FEV1 < 70% or FVC < 70%). 4. History of smoking or tobacco us e within the last 5 years. 5. Extreme athletes (e.g., marathon r unner, professional weightlifter). 6. Other illness that would prevent pa tient from completing the protocol. 7. Significant change in activity level. Participant Demographics Twenty one participants, 16 women and five men, were recruited in the study. Two women completed only the first pre-training baseline measures and withdrew from the study due to uncomfortable feeling of the cap saicin challenge. One man completed the first and the second pre-training baseline meas ures and withdrew from the study due to the concern about a low, but potential health risk invol ved, particularly, with high intensity pressure threshold tr ainer during the development of high expiratory pressure. Thus, a total of 18 sedentary healthy elderly individuals completed the study. Four of these participants were men and 14 were wo men. The average age of the participants was 77 years with a range of 68 to 89 years. The age of men ranged from 72 to 89 years (mean age of 78.25 7.80) and the age of women ranged from 68 to 84 years (mean age of 76.64 5.27). Demographic information of part icipants is summarized in Table 2-1.

PAGE 49

37 Measures Participants were asked to fill out a p hysical activity questionnaire (Appendix B) and health questionnaire (Appendix C). Blood pressure was measured by the investigator to determine if the participan ts qualified to be in the study. This study included a 7-week experimental protocol for each participant. Week 1 and week 2 were two pre-training baseline measurement conditions. Participan ts were exposed to the training program during weeks 3 to 6. Week 7 was the post-tr aining measurement c ondition. Measures of pulmonary function (i.e., maximum respir atory pressures and breathing measures), cough, swallow, and speech were obtained for each participant. Table 2-1. Demographic informati on for participants in the study. Participant Gender Age (yrs) Height (cm) Weight (kg) Physical Activity (METs) 1 F 77 154.94 63.05 31.70 2 F 73 154.90 49.50 23.45 3 F 68 157.00 93.60 48.30 4 F 83 165.00 58.95 40.80 5 M 73 177.80 112.50 17.55 6 M 72 177.80 77.40 38.90 7 F 74 160.02 74.25 28.82 8 F 81 152.40 70.00 46.90 9 F 81 152.40 53.10 30.45 10 F 75 167.64 70.65 31.92 11 F 84 165.10 61.20 23.45 12 F 77 152.40 65.90 25.45 13 F 69 167.64 74.25 26.10 14 M 79 175.26 N/A 41.70 15 M 89 172.72 74.25 15.70 16 F 83 160.02 74.25 25.70 17 F 71 165.10 72.00 30.45 18 F 77 167.64 72.00 20.95 Note : N/A = Not applicable

PAGE 50

38 Maximum respiratory pressures, MEPs and MIPs were recorded from all participants in two pre-training conditions and following each week of training for 4 weeks as well as post-EMST. All other measures were recorded from all participants in two pre-training conditions and post-EMST. Pulmonary Measures Maximum Respiratory Pressures Maximum expiratory pressures (MEP) and maximum inspiratory pressure (MIP) were measured using a disposable mouthpiece connected to a Smart 350 series pressure manometer (Meriam Process Technologies, Cleveland, Ohio, USA) by 50 cm of 6 mm inner diameter tubi ng with a 20-gauge (2 mm) needle air-leak at the mouth to prevent the participant from sustaining pressure with a glottal closure (Berry et al ., 1996; Enright et al., 1994; Ka rvonen et al., 1994; O'Kroy & Coast, 1993). During the completion of the MEP and MIP tasks, each participant stood with his/her nose occluded w ith a nose clip while he/she used the Smart 350 series pressure manometer. For MEP, after inha ling to total lung cap acity, the participant placed his/her lips around a mouthpiece and blew out as forcefully as possible. For MIP, after exhaling to residual volume, the indi vidual placed his/her lips around a mouthpiece and inspired as forcefully and fast as possible through the mouthpiece connected to a pressure gauge with the nose occluded by a nose clip. Repeated measures were taken with a 1 to 2 minute rest between trials for both the MEP and MIP measures, until three measurements were obtained within 5% of each other and no further improvement was obtained. The average of these three values was used for analysis. Approximately 5 to 10 trials were necessary per particip ant to obtain the 3 trials within 5% of each other.

PAGE 51

39 Breathing Measures Pulmonary function tests ( PFTs) were completed using a computerized MasterScreen PFT system (Jaeger Toennies, Erich Jaeger Gmbh, Leibnizstrasse 7, D-97204 Hoechberg). Du ring the completion of the PFTs, the participant sat in front of the MasterScreen PFT. To obtain PFTs, the guidelines of the American Thoracic Society were followed. Breathing function parameters measured in this study were forced vital capacity (FVC ), forced expiratory volume in 1 second (FEV1), the ratio of FEV1 to FVC (FEV1/FVC), and expiratory reserve volume (ERV). For FVC and FEV1, each individual placed their mouth around a disposable mouthpiece. The nose was occluded by a nose clip to preven t air leak. Next, the participant was asked to take a deep breath and inspired to tota l lung capacity, followed by taking three tidal volume breath cycles. The individual then bl ew out as forcefully as possible into a mouthpiece, being verbally encouraged to “bla st out” all the air in the lungs. FVC was defined as the total volume of air expired during a maximally forced expiration after a full inspiration (Figure 2-1). FEV1 was defined as a measure of expiratory volume during the first second of expiration during the fo rced vital capacity maneuver with maximal expiratory effort (Figure 2-1). FEV1/FVC ratio was calculated by dividing the FVC value by the FEV1 value taken from the PFTs. This pa rameter provides a clinically useful index of airflow limitation. All PFT measures were completed a minimum of three times with a 1 to 2 minute rest between trials to ensure similar values were obtained at each attempt. The best three measurements were averaged and recorded for analysis. For ERV, each participant was asked to place th eir mouth around a disposable mouthpiece. The nose was occluded by a nose clip to preven t air leak and they were asked to rest breathe for three cycles. Next, the partic ipant was asked to carry out, consecutively, a

PAGE 52

40 maximal slow inspiration, a maximal slow e xpiration, and then one more maximal slow inspiration into a mouthpiece connected to th e MasterScreen PFT. ERV was defined as the maximum volume of air that can be e xpired after normal expiration (i.e., tidal volume; Figure 2-2). Figure 2-1. Graphical de piction of FVC and FEV1. Figure 2-2. Graphical depiction of ERV. 4 3 2 1 4 0 1 2 34Time (s) 5Volume ( L ) FEV FVC -2 -1.5 -1 -0.5 0 0.5 1 1.5 2 10 20 30 40 50Time (s)Volume (L) Expiratory Reserve Volume

PAGE 53

41 Cough Measures Cough magnitude was measured from an expiratory flow waveform produced during a capsaicin-induced cough. To obtain an acceptable cough signal, the participants were seated comfortably in a chair. The mask, connected to a pneumotachometer (Hans Rudolph Inc., Kansas City, MO, USA) was plac ed on the participants face and they were given a verbal cue to take a single vital capacity breath of 100 microMolar ( M) capsaicin in 80% physiological saline, 10% Tween 20, and 10% Ethanol capsaicin solution (Appendix D) via an air-powered ne bulizer (KoKo Digidoser; Pulmonary Data Services Instrumentation Inc., Louisville, CO). The nebulizer output was set at 10 L. A differential pressure transducer (Validyne MP 45-2-871, Validyne Engineering Corp. Northridge, CA, USA) in ranges as low as 2 cm H2O was attached to the facemask pneumotachometer. Next, the participants were asked to take a single deep inspiration of a 10 L of 0.9% saline solution followed by capsaicin solution to eliminate capsaicin residue from the facemask. Capsaicin a nd saline was administered five times alternatively in pre-training and post-training conditions. Each test of inspiration was separated by an interval of 1 to 2 minutes. This attachment was fitted directly into the Power Lab/8SP data acquisition system ( ADInstruments, ML750, Colorado Springs, CO, USA). Prior to collection of cough measures from each participant in the baseline sessions, the pneumotachometer was calibrated with 1 L/s flow source. A calibration routine within Chart 4.2.3 fo r Windows software (ADInstr uments, Colorado Springs, CO, USA) was used to calculate volume and flow. All cough signals were reco rded using the Chart 4.2.3 so ftware. The signal was low-pass filtered at 300 Hz through the filter in the Powerlab unit, as the filter in the

PAGE 54

42 spirometer capable of filtering to 100 Hz, was inadequate to filter the high frequency components of the waveform during cough. Me asurements of cough flow were analyzed using Chart 5 for Windows so ftware (ADInstruments, Colo rado Springs, CO, USA). The sampling rage was set at 2,000 samples per second for all cough measures. A cough was defined as having an inspirat ory phase, a compression phase, and one or more expulsive events (i.e., cough refract ory; CR) on a single inspiration. Expulsive events are composed of one strong expulsive event (SE) followed by reflexive expulsive events (RE; Figure 2-3). The total number of coughs (N of coughs) was counted from the airflow signal taken from each of the five tria ls of capsaicin inhalati on and then averaged. In addition, the total number of expulsive events (N of CR), sum of all SEs and REs, was counted independent of the inspiration from the cough airflow taken from each of the five trials of capsaicin inhalation and then averaged. Figure 2-3. Airflow during re flexive cough production. CR5 represents five expulsive events. The total number of coughs is three and the total number of expulsive events is nine in this Figure. -2 0 2 4 6 8 10 4.28 4.30 4.32 4.34 4.36 4.38 Time ( s ) Strongest Expulsive Event ( SE ) Reflexive Expulsive Events ( RE ) Expulsive Events CR5 CR2 CR2 Airflow (L/s)

PAGE 55

43 Cough magnitudes measured in this study were inspiratory phase duration (IPD), compression phase time (CPD), peak expirato ry flow rate (PEFR), post-peak plateau duration (PPPD), and post-peak plateau inte gral amplitude (PPPIA; Figure 2-4). The magnitudes of the coughs having the highest PE FR, were taken from each of the five trials of capsaicin inhalation, we re collected and then averaged. Figure 2-4. Cough magnitudes in one cough. IPD (in seconds) was defined as the time from the beginning to the end of the inspiratory phase marked by departing and return ing of the airflow to 0 L/s. PEFR (L/s) was defined as the highest peak of expirato ry flow rate following the inspiratory phase during the capsaicin-induced cough. CPD (i n seconds) was defined as the duration between the end of the inspir atory phase and the beginning of the expiratory phase. PPPD (in seconds) was defined as the time of sustained airflow that occurred after the peak expiratory flow. This was visually determined by observing the expiratory flow Time (s) -2 0 2 4 6 Peak Expiratory Flow Rate Inspiratory Phase Duration Compression Phase Duration Post-Peak Plateau Duration Airflow (L/s) 3.24 3.26 3.28 3.30 3.32 Post-peak plateau integral amplitude

PAGE 56

44 waveform. The initiation point for PPPD was marked as the time immediately after the transient overshoot of the peak airflow signal when the flow became stable. PPPD termination was marked as the final time-poi nt where the stable flow ended prior to another rapid descent in the expi ratory flow rate. PPPIA (L/s s) was defined as the area under cough airflow curve between PPPD initiation and PPPD termination. Swallow Measures Submental surface electromyographic signals (SM-sEMG) were obtained using an 8-channel Bagnoli EMG System (Delsys Inc., Boston, MA, USA) to record submental muscle group activity. Two surface electr odes (DE-2.1 single differential electrodes, Delsys Inc., Boston, MA, USA) were attached and taped to the skin beneath the chin, bilaterally, to record the strength of su bmental (SM: suprahyoid) muscles over the mylohyoid, geniohyoid, and anterior digastric muscle complex during three trials of each consistency. A paper ruler, width of 1 cm, measured the length from the tip of the nose to the point where two electrodes were attach ed on the chin in the first pre-training baseline measurement session and recorded to help keep consistent place for electrodes attachment in baseline measurements and pos t-training measurement. The output of the Bagnoli systems was connected directly to th e Power Lab/8SP data acquisition system. The software program, Chart 4.2.3 for Windows from ADInstruments, was used to record the swallow measures online and Chart 5 for Windows was used to analyze the data offline. The signal from two sEMG electrodes was amplified with a gain of 1000 V/V, lowpass filtered at 1,000 Hz, and hi gh pass-filtered at 100 Hz in order to remove any DC offset and high-frequency noise. The original EMG signal was rectified by the root mean square (RMS) method. This method used the sq uare root of the average of the squared

PAGE 57

45 values of the preceding data points over the time set (20 ms). Chart 4.2.3 was set up to display 4 different channels. Channel 1, ch annel 2, channel 3, and channel 4 displayed the right SM-sEMG raw data, the left SM -sEMG raw data, the right SM-sEMG RMS data, and the left SM-sEMG RMS data, respec tively. SM-sEMGs were collected during five different consistencies which included dr y voluntary maximal effortful swallow, wet (5 cc and 10 cc water) swallow, and thin pa ste (5 cc and 10 cc pudding) swallow. A total of 15 trials were randomly assi gned to the participants. Swallow dependent variables were peak amplitude (PA), duration (DUR), and integral amplitude (IA) of SM-sEMG activity during swallowing (Figure 2-5). The maximum strength of SM muscles was defined as the PA (mV) of the RMS of SM-sEMG signal activity during swallowing. The DUR (s) of SM-sEMG during swallowing was determined by measuring the interval between the onset and the offset (offset time minus onset time) of SM-sEMG activity (Ding et al ., 2002; Ertekin et al., 1995). The IA (mV/s s) of SM muscles was also calculated as the area of RMS under the SM-sEMG activity curve between the onset and offset of the swallo w. This measured the output of total SM muscles activity during swallowing. The onset and offset in SM-sEMG activity were determined by Cycle Variables function in Chart 5 (Figure 2-6). Cycle Variables function is defined as channel calculation that identifies cycles in the SM-s EMG waveform. It calculates and displays cycles extracted from the waveform and e xplicitly takes into account the waveform’s cyclic aspects. Chart 5 software provides two different types of cyclic variables including temporal quantities, such as pe riod, frequency, or rate and amplitude-related

PAGE 58

46 characteristics, such as cyclic maximum, cyc lic minimum, cyclic mean, or cyclic height. In this analysis, cyclic mean was used as cyclic variables in channel 1. Figure 2-5. SM-sEMG Activity. R SM, L SM, and RMS denote right, submental muscle, left submental muscle, a nd root mean square, respectively. Cyclic mean is the mean value of the data points contained in one cycle of a waveform to display the cycle-by-cycle m ean value of SM-sEMG recording. SM-sEMG baseline before each swallow task was measured in an individual and was used for setting up the sensitivity of cycle detection algor ithm by adjusting 2% noise threshold of baseline, a percentage of the selected data ra nge. Cycle Variables i gnore fluctuations in the waveform less than the set-up noise thresh old value. The onset and offset of SM activity during swallowing were determined th e zero points which were the closest time Time (s) 4 4.2 4.4 4.64.855.25.4 5.6 Duration Peak Amplitude Integral Amplitude 0 20 40 60 100 0 100 60 40 20 0 200 -100 0 100 200 R SM-sEMG (mV) L SM-sEMG (mV) R RMS (mV) L RMS (mV)

PAGE 59

47 before the peak of SM-sEMG and the closest time after the peak of SMsEMG, respectively. Before measuring swallow function, as a standardized test of SM-sEMG activity, participants were asked to blow into the e xpiratory pressure thre shold trainer which was set up at 50 cm H2O. These were taken during two pre-training baseline measurements and compared in PA, DUR, and IA of SM-sEMG activity. Figure 2-6. Cycle variables function. From Chart 5 for Windows software (ADInstruments, Colorado Springs, CO, USA). Speech Measures Dependent variables related to speec h production were examined using aerodynamic and acoustic analysis. Aerodyna mic measures included air pressure measures (explained below). Participants we re asked to repeat syllables while a small disposable plastic pitot tube (2 mm diamete r) was placed into the or al cavity between the lips and behind the front teeth. The tube was connected to a pressure transducer (PTL-1, Glottal Enterprises, Syracuse, NY, USA) low pass-filtered at 30 Hz which recorded the 4.6 4.8 5.0 5.2 Time (s) 0 40 20 Amplitude (mV) Cyclic Mean

PAGE 60

48 air pressure signal. The pressure tr ansducer was calibrated with 5 cm H2O prior to data collection (MCU-4, Glottal Enterprises, Syr acuse, NY, USA). All pressure measures were recorded using Power Lab/8SP data acquisition system with Chart 4.2.3 for Windows software. The sampling rate wa s set at 10,000 samples per second for all pressure measures. Air pressure measures we re obtained by three task s. The first task was the repetition of a syllable train /p a / seven times in one breath at the softest vocal intensity level. The second task was the gr adual increase in the vocal intensity to the maximum effort level. The third task was the repetition of a syllable train /p a / seven times in one breath at the maximum effort level. The participants were instructed to take a breath just before starting the next task. The first and third were completed randomly. If individuals initiated from the third task, they were asked to decrease the vocal intensity gradually to the softest possibl e intensity level. During these tasks, participants were instructed to produce each consonant in the syllable with approximately equal stress and to maintain a syllable rate of about 1.5 syllabl es per second. In repe ating a syllable train at the softest possible intensity level, particip ants were instructed to initiate voice at the lowest possible intensity level without whispering. The initiating effort level of syllable repetition was randomly assigned. Five trials of this task in each individual were recorded on Chart 4.2.3 for Windows and were an alyzed on Chart 5. The recordings for air pressure were completed in a quiet room. Air pressure measures incl uded excess lung pressure (PEL) calculated from phonation threshold pressure (Pth) and lung pressure (PL). Pth and PL values were estimated from intraoral pressure (Po) measurements (Hodge et al., 2001; Rothenberg, 1982; Smitheran & Hixon, 1981). Po was defined as the pressure within the oral cavity

PAGE 61

49 during the production of the voiceless stop segm ent /p/ produced in the syllable train /p a / at both the softest and the loudest possible intensity levels. Pth was defined as the minimum pressure required for initiating vocal fold vibration (Titze, 1994). Measurement of Po at the softest possible level was utilized for estimating Pth. PL used in this study was defined as the Po at the loudest po ssible level. PEL was defined as the difference between the PL and Pth (Hodge et al., 2001). The pressure peaks of Po values from the middle five of seven repeated /p a / at both the softes t and loudest possible intensity levels were measured and averaged to estimate PL and Pth values from Po. The relative change in pressure was calculated in cm H2O. Acoustic measures included maximum phona tion durations (MPDs) of sustained vowel phonation at two levels of intensities, comfortable and loud. MPD was defined as the greatest length of time over which sust ained vowel could be prolonged (Baken & Orlikoff, 1998). Participants sat on a chai r comfortably and wore a cardioid headset microphone (ATM73a, Audio-Technica, Japan) placed 2 cm from the right corner of the mouth. Participants’ phonations were recorded on a portabl e digital audio tape (DAT) recorder (TAS CAM DA-P1, TEAC Corporation, Ja pan). Participants were instructed to take a deep breath and sustain the vowel / a / as long as they could at the comfortable and the loudest effort levels. Each task was pe rformed three times and the order of the tasks was randomly assigned. Three trials of MP D in each intensity level was analyzed and averaged using the software program, TF 32 for 32-bit Windows (Milenkovic, Wisconsin, USA). Training Protocol After completion of the two pre-training baseline sessions discussed above, each participant was provided with th e expiratory pressure threshol d trainer. The expiratory

PAGE 62

50 pressure threshold trainer used to comp lete the EMST program was a cylindrical plexiglass tube that consiste d of a mouthpiece and an adjustable one-way spring-loaded valve (Figure 2-7). This device allowed the pressure threshold to be set up to 150 cm H2O. The spring contained in this device was adjustable to allow for the required pressure threshold to be increased. The valv e blocked expiratory airflow until a sufficient threshold pressure was reached to overcome the spring force. Participants had to overcome a threshold load by generating an ex piratory pressure sufficient to open the expiratory spring-loaded valve. Figure 2-7. Expiratory pressure threshold training device. As stated previously, the participants’ ME P was measured at the initiation of the study and following each week of training as well as post-training. The training protocol for each participant lasted 4 weeks and consisted of five sets of five breaths, 5 days per week with the pressure threshold set at 75% of the participant’ MEP at the time of measurement (Baker, 2003; Chiara, 2003; Saleem 2005; Wingate et al., in press). This percentage was based on skeletal muscle training research that demonstrates that the most

PAGE 63

51 effective muscle strengthening occurs when a near maximal load is placed on the muscle (Powers & Howley, 2001). Each training breath lasted 3 to 4 seconds. In the initial training session, an individual was informed of the time frame of training, proper device handling procedures, appropriate mouth cl osure around the device’s mouthpiece, and air leak prevention techniques. To prevent possibl e air leak, the individu al was instructed to place his/her lips tightly around the device’s mouthpiece and one of his/her hands held his/her cheeks around the lips firmly. The i ndividual was then instructed to blow as forcefully as possible into the device’s mouthpiece from total lung capacity (TLC) to open the valve. The individual was also traine d how to correctly discriminate the sounds between success and failure of opening valve by successive opening valve trials. As air passes through the device following the opening th e valve, the individu al could listen to a distinct audible sound such as whistle sound or air popping sound. A weekly readjustment meeting was ma intained with each participant and the investigator. At that meeting, the particip ant’s MEP and MIP was measured in the same manner stated earlier, and the average value of each was used in the dataset. The device was readjusted by the investigator according to the newly measured average MEP value. To ensure that the new training load was appropriate, the participant was needed to complete the one set of five breaths in th e clinician’s attendan ce. Any participant concern regarding the training progr am was addressed at that time. Compliance To insure participant’s compliance with the training protocol, participants were provided with written (Appendix E) and verbal instructions for the use of their devices and the EMST protocol. During home trai ning period, participants recorded their completion of training sets daily at home on a log sheet (Appendix F) during the 4 weeks

PAGE 64

52 of EMST. Participants were also instructed to call the investigator at any time if they had questions or if problems arose in their practice procedure. Statistical Analysis The mean, standard deviation, and percen t change were calculated from the database to describe the trends in the dependent variable from preto post-training. If the first pre-training measures were not statistically di fferent from the second pre-training measures, the two datasets were averaged and used as the average pre-training measures to be compared with the post-training meas ures. Differences be tween the pre-training condition 1 and the pre-training condition 2 were examined by paired-samples t -test for all dependent variables. Th ere were no significant differe nce between the pre-training condition 1 and pre-training condition 2 for any of the dependent variables of pulmonary, cough, swallow, and speech functions, therefore t hose were averaged and then used as the average pre-training measures that were compar ed with the post-training measures (Table 2-2, 2-3, 2-4). Three doubly multivariate repeated measures analyses of variance (MANOVA) were used to examine the effects of EMST on pulmonary and cough functions. Repeated measur es univariate analysis of variances (ANOVAs) were conducted to evaluate the effects of EMST on swallow and speech functions. Doubly multivariate repeated measures design has multiple dependent variables measured in different levels of one or more within-subjects factors or in different levels of betweenwithin (mixed) design with multiple repeated dependent variables (Tabachnick & Fidell, 1996). In these repeated measures designs, sphericity as sumptions (i.e., homogeneity of variance assumption) were checked using Mauc hly’s test of sphericity. Sphericity assumption is a mathematical assumption that assumes all variances of the differences for each pair of categories of the within-subjects factor are equal in the populations sampled.

PAGE 65

53 In advance, it is expected that the observ ed samples variances of the differences are similar if the sphericity assumption is met. In this study, if this assumption was violated, Greenhouse-Geisser adjustment test for the wi thin-subjects effect was conducted. This test adjusts the degrees of freedom (df) downward for the usual F test statistic to overcome the reduced p-value for the within-s ubjects effect (Agres ti & Finlay, 1999). However, Pillai’s Trace was used in this study since unequal sample sizes occurred for the men and women involved in this st udy. Usually, Pillai’s Trace provides good power and is most unlikely to violate stat istical assumptions as well as it is more appropriate when sample sizes are sma ll or cell sizes are unequal (Olsen, 1976; Tabachnick & Fidell, 1996; Walker, 1998). Table 2-2. Paired-samples t -test between the two pre-training conditions for the pulmonary and cough function dependent variables. 1st Pre-training 2nd Pre-training DV M SD M SD t df p MEP (cm H2O) 75.956 20.513 78.317 20.558 -1.351 170.194 MIP (cm H2O) 38.497 13.304 39.661 15.081 -0.462 170.650 FEV1 (L) 1.907 0.527 1.981 0.464 -1.810 170.088 FVC (L) 2.525 0.707 2.568 0.574 -0.947 170.357 FEV1/FVC 76.232 8.546 77.109 6.253 -0.611 170.549 ERV (L) 0.995 0.656 0.947 0.592 0.823 170.422 IPD (s) 1.094 0.277 1.196 0.401 -0.956 170.352 CPD (s) 0.384 0.215 0.311 0.205 1.815 170.087 PEFR (L/s) 4.885 3.252 5. 076 2.091 -0.246 170.809 PPPD (s) 0.232 0.087 0.24 0 0.086 -0.357 170.725 PPPIA (L/s s) 3.369 2.750 3.607 2.940 -0.350 170.730 N of Coughs 40.778 15.125 37.611 12.391 1.826 170.085 N of CR 13.944 4.734 14.444 3.974 -0.486 170.633 indicates that the mean difference is significant at = 0.05.

PAGE 66

54 Table 2-3. Paired-samples t -test between the two pre-training conditions for the swallow function dependent variables. 1st Pre-training 2nd Pre-training DV Consistency M SD M SD t df p PA (mV) DRY 56.04220.56965.25129.250 -1.600 17 0.128 5W 53.50331.79051.81239.797 0.352 17 0.729 10W 53.83030.73651.00937.893 0.502 17 0.622 5P 52.86623.59454.75237.564 -0.282 17 0.781 10P 52.12025.59258.30141.531 -0.987 17 0.338 DUR (s) DRY 0.9950.1710.9260.149 1.905 17 0.074 5W 0.9120.1540.9390.147 -0.915 17 0.373 10W 0.9580.1470.9280.170 1.018 17 0.323 5P 1.0120.1320.9740.134 1.465 17 0.161 10P 1.0140.1421.0120.160 0.071 17 0.944 IA (mV) DRY 25.1688.62628.12311.441 -1.100 17 0.286 5W 22.34712.91221.52413.622 0.385 17 0.705 10W 23.19712.36921.33313.113 0.741 17 0.469 5P 25.12410.58325.17114.679 -0.017 17 0.987 10P 22.6778.50226.07115.607 -1.106 17 0.284 indicates that the mean difference is significant at = 0.05. Table 2-4. Paired-samples t -test between the two pre-training conditions for the speech function dependent variables. 1st Pre-training 2nd Pre-training DV M SD M SD t df p PEL (cm H2O) 12.879 5.12214.3925.480-1.819 170.087 MPD – COMF (s) 17.529 8.76618.0257.312-0.626 170.540 MPD – LOUD (s) 19.449 11.14919.39411.2290.052 170.959 indicates that the mean difference is significant at = 0.05. If the effect of gender was not significant at = 0.05, it was eliminated from the MANOVA or ANOVA, then another MANOVA or ANOVA was carried out only using the within-subjects factors. If any MANOVA or ANOVA indicated a significant interaction among factors at = 0.05, simple main effects tests using paired-samples t tests were conducted with the level set at 0.01. If any MANOVA or ANOVA indicated

PAGE 67

55 a significant main effect at = 0.05, univariate comparisons of the specific outcome variables were explored. In univariate compar isons (i.e., multiple pairwise comparisons), the inflated level was adjusted by using the Bonf erroni adjustment to reduce Type I error rate when multiple tests are performed on the same data (Tabachnick & Fidell, 1996). Type I error occurs when one reject s the null hypothesis when it is true. All analyses were carried out us ing SPSS software version 11.5. In addition, the relationshi p between the change in MEP and other pulmonary, cough, swallow, and speech functions were investigated using Pearson r correlation. Interand intra-judge reliab ility were also completed on 10% of the data that were measured by hand. To test th e inter-judge reliability of the dependent variables, a different examiner, a student trained by the investigator in anal yzing and scoring the various measures, re-analyzed the data. The student was blinded to the purpose of the study. Pearson r correlations were used to determ ine if there was any significant difference between the values obtained by di fferent examiners. To test intra-judge reliability, the investigator repeated the anal yses of 10% of the data sets and compared the first set of measures to the second set using Pearson r correlations again.

PAGE 68

56 CHAPTER 3 RESULTS This study determined the effects of a 4-w eek expiratory muscle strength training (EMST) program on pulmonary, cough, swallo w, and speech functions in otherwise healthy, but sedentary, elderly adults. Reliability Pearson r correlations were calculated to evaluate the intra-judge measurement reliability for cough, swallow, and speech functions (Table 3-1). Strong correlations were found, indicating high intra-judge reliabilit y. For intra-judge re liability, the Pearson r correlation between the first and second sets of measurement ranged from 0.905 to 1.000. Likewise, Pearson r correlations were calculated to test the inter-judge measurement reliability for cough, swallow, a nd speech functions. Results also showed moderate to strong correlations between rati ngs made by the two different judges. For inter-judge reliability, the Pearson r correlation between two measurers for cough, swallow, and speech functions ranged fr om 0.743 to 1.000. Given these data, the reliability of the all measures in cough, swallow, and speech functions was considered adequate for the purpose of the present experiment. Correlation Between MEP and Other Dependent Variables A Pearson r correlation was performed between MEP and the other dependent variables included in the study. The results of the correlation are pr esented in Table 3-2 and show that MEP was both moderately pos itively and negative ly correlated with variables such as MIP ( r = 0.532, p = 0.001), CPD ( r = -0.367, p = 0.028), PEFR ( r =

PAGE 69

57 0.526, p = 0.001), PPPIA ( r = 0.472, p = 0.004), and PEL ( r = 0.363, p = 0.029). However, MEP was not significantly correlate d with other pulmonary and any swallow dependent variables. Pulmonary Function Table 3-3 depicts the descriptive statis tics for all of the pulmonary function measures preand post-training as a function of gender. A 2 2 doubly multivariate repeated measures analysis of variance (MANOVA) was conducted to analyze the results of MEP, MIP, FEV1, FVC, FEV1/FVC, and ERV as affected by training and gender. Sphericity assumptions were met. The results of the MANOVA indicated a non-significant two-way interaction between training and gender at = 0.05 (Table 3-4). The main effect of training significantly affected the combination of MEP, MIP, FEV1, FVC, FEV1/FVC, and ERV (Pill ai’s Trace = 0.827, F (6, 11) = 8.766, p = 0.001, 2 = 0.827). Gender did not significantly affect the combination of pulmonary function dependent variables. Hence, a one-way repeated measures MANOVA without the gender eff ect was conducted. Again, sphericity assumptions were met. The results of MA NOVA indicated that the main effect of training was significant on the combination of pulmonary dependent variables (Wilks’ = 0.189, F (6, 12) = 8.576, p < 0.001, 2 = 0.811). Therefore, one-way repeated measures univariate ANOVAs to determine th e specifics of the training effect were conducted (Table 3-5). The ANOVA results in dicated that MEP was significantly greater in post-training ( F (1, 17) = 40.978, p < 0.001, 2 = 0.707). MIP also significantly increased with training ( F (1, 17) = 18.513, p < 0.001, 2 = 0.521). However, no

PAGE 70

58 significant effects of tr aining were found on FEV1, FVC, FEV1/FVC, and ERV. MEP and MIP increased from preto post-train ing by 44% and 49%, respectively (Figure 3-1). MIP post MIP pre MEP post MEP preMean +2 SE (cmH2O)140 120 100 80 60 40 20 Figure 3-1. Effects of training on MEP and MIP. Cough Function Table 3-6 shows the descript ive statistics for the dependent variables associated with cough function preand post-trai ning as a function of gender. A 2 2 doubly multivariate repeated measures analysis of variance (MANOVA) was used to analyze the results of IPD, CPD, PEFR, PPPD, and PPPIA as affected by training and gender. Sphericity assumpti ons were met. Table 3-7 shows the MANOVA results and indicates that th e two-way interaction between training and gender was not significant. The main effects of training a nd gender were then examined and indicated that training was not significan t on the combination of dependent variables of IPD, CPD, PEFR, PPPD, and PPPIA, but close to significance of = 0.05 (Pillai’s Trace = 0.520, F (5, 12) = 2.598, p = 0.081, 2 = 0.520). Gender was not sign ificant. Hence, a one-way

PAGE 71

59 repeated measures MANOVA without the gend er effect was conducted. The result of MANOVA without the gender eff ect indicated a significant effect of training on the combination of cough dependent variables (Wilks’ = 0.351, F (5, 13) = 4.803, p = 0.010, 2 = 0.649). One-way repeated measures univariate ANOVAs of the training effect were then completed (Table 3-8) The ANOVA results revealed that CPD was significantly decrease d with training ( F (1, 17) = 13.590, p = 0.002, 2 = 0.444). PEFR was also significantly increased with training ( F (1, 17) = 29.620, p < 0.001, 2 = 0.635) and was PPPIA ( F (1, 17) = 16.826, p = 0.001, 2 = 0.497). However, no significant effect of training was found for IPD as well as PPPD. The results for CPD, PEFR, and PPPIA are illustrated in Fi gure 3-2, Figure 3-3, and Figur e 3-4, respectively. CPD decreased from preto post-t raining by 53% and PEFR and P PPIP increased from preto post-training by 61% and 96%, respectively. To evaluate the effects of training and gender on the tota l number of coughs (N of coughs) and the total number of expulsive events (i.e., N of cough refractories; N of CR), a 2 2 doubly multivariate repeated measur es analysis of variance (MANOVA) was conducted. Sphericity assumptions were me t. There was no significant interaction between training and gender (Table 3-9). Th e main effects of training and gender were not significant. Therefore, a univariate M ANOVA was completed to test for the training effect after excluding the gender effect. The results of the MANOVA indicated no significant effect of training on the N of coughs and the N of CR (Pillai’s Trace = 0.210, F (2, 16) = 2.130, p = 0.151, 2 = 0.210).

PAGE 72

60 TrainingPost PreMean +2 SE (s).5 .4 .3 .2 .1 0.0 Figure 3-2. Effects of training on CPD. TrainingPost PreMean +2 SE (L/s)10 9 8 7 6 5 4 3 Figure 3-3. Effects of training on PEFR.

PAGE 73

61 TrainingPost PreMean +2 SE (L/s*s)10 8 6 4 2 0 Figure 3-4. Effects of training on PPPIA. Swallow Function Table 3-10 shows the descriptiv e statistics for preand pos t-training values of all of the swallow function measures as a function of gender. A 5 2 2 MANOVA could not be conducted since the small sample size ( N = 18) and unequal sample sizes in gender were used, resulting in a reduction of power. Instead, 5 2 2 repeated measures univariate ANOVAs we re examined to determine the effects of training, consistency, and gender on PA, DUR, and IA of submental muscle group activity. Sphericity a ssumptions, presented in Table 3-11, were significan tly violated by the interaction between training a nd consistency on IA (Mauchly’s W (9) = 0.066, p < 0.001), by consistency on PA (Mauchly’s W (9) = 0.025, p < 0.001), and by consistency on IA (Mauchly’s W (9) = 0.121, p < 0.001). Therefore, Greenhouse-Geisser correction for the violation of sphericity assumption wa s applied. Sphericity assumptions, however, were met by training on all dependent vari ables, consistency on DUR, interaction

PAGE 74

62 between training and consistency on PA and DUR. The results of the ANOVA indicated no significant three-way interaction among the three factors on PA, DUR, and IA (Table 3-15). No significant two-way interactions between training and gender on PA, DUR, and IA, between consistency and gende r on PA, on DUR, and on IA, and between training and consistency on any of swa llow dependent variables were found. Accordingly, the main effects of training, consistency, and gender on PA, DUR, and IA were assessed for further evaluation (Table 3-12). Training signifi cantly increased IA ( F (1, 16) = 6.744, p = 0.019, 2 = 0.297), but did not change PA and DUR. Consistency also significantly increased IA ( F (2.368, 37.884) = 4.143, p = 0.018, 2 = 0.206), but did not change both PA and DUR. No significant effects of gender were found on any of the swallow dependent variables. Therefore, 2 5 repeated measures univariate ANOVAs were conducted after excluding the gender effect to verify the effects of training and consistency on PA, DUR, and IA. Again, sphe ricity assumptions, presented in Table 313, were checked and were also violated by the interaction between training and consistency on IA (Mauchly’s W (9) = 0.069, p < 0.001), by consistency on PA (Mauchly’s W (9) = 0.029, p < 0.001), and by consistency on IA (Mauchly’s W (9) = 0.121, p < 0.001). Greenhouse-Geisser corrections we re applied for violations of these ANOVA assumptions of sphericity. Spheri city assumptions, however, were met by training on all swallow dependent variable s, consistency on DUR, the interaction between training and consistency on PA and DUR. Table 3-14 shows the univariate ANOVA resu lts without the ge nder effect. For PA, a significant two-way interaction between training and consistency was observed ( F (4, 68) = 3.122, p = 0.020, 2 = 0.155). Thus, simple main effect tests using paired-

PAGE 75

63 samples t -tests were submitted to further explore the effects of training and consistency on PA at = 0.01 (Table 3-15). The results of thes e tests indicated that the PAs between any of two different consistency pairs in pretraining were not signifi cantly different from each other. However, two different consis tency pairs in post-tr aining had significantly different PAs. Specifically, the PA measur ed for 10 cc pudding swallow in post-training was significantly higher than the 5 cc water swallow in post-training ( t = -3.388, p = 0.003) and also significantly higher than the 10 cc water swallow in post-training ( t = 3.319, p = 0.004). Additionally, one pair having different cons istencies in different training levels had significan tly different PAs. The PA for 10 cc pudding swallow in post-training was significantly greater than the 10 cc water swallow in pre-training ( t = 3.041, p = 0.007). Furthermore, the profile plot s were created by consistency as the horizontal axis, each preand post-training as the separate bar in PA (Figure 3-5). The plots illustrated the significantly different am ount for the increases in PA from preto post-training in five different consistencies. Specificall y, the PAs for maximal voluntary dry swallow (17% change), the 5 cc puddi ng swallow (16% change), and the 10 cc pudding swallow (18% change) had larger in creases than the 5 cc water swallow (5% change) and the 10 cc water swallow (3% ch ange) from preto post-training. The results of univariat e ANOVA for DUR indicated no significant two-way interaction between training and consistency (T able 3-14). The main effect of training on DUR was significant ( F (1, 17) = 4.966, p = 0.040, 2 = 0.226) and the main effect of consistency on DUR was also significant ( F (4, 68) = 3.869, p = 0.007, 2 = 0.185). Thus, multiple pairwise comparisons using the Bonferroni adjustment were completed to examine the effects of training and co nsistency on DUR (Table 3-16).

PAGE 76

64 Consistency10P 5P 10W 5W DRYPA (mV)140 120 100 80 60 40 20 0 Training Pre Post Figure 3-5. Effects of trai ning and consistency on PA. The training effect on DUR is illustrated in Figure 3-6 and the consistency effect on DUR is in Figure 3-7. Those indicated that post-training ( M = 1.016, SE = 0.032) had significantly longer DUR than pre-training ( M = 0.967, SE = 0.026; p = 0.040). However, there was no significant training e ffect on DUR in each consistency. Ten cc pudding swallow ( M = 1.039, SE = 0.036) had significantly longer DUR than 5 cc water swallow ( M = 0.948, SE = 0.029; p = 0.016) and 10 cc water swallow ( M = 0.958, SE = 0.030; p = 0.012). Examining the univariate ANOVA results without the gender effect on IA, also presented in Table 3-14, indica ted a significant two-way inte raction between training and consistency ( F (1.987, 33.778) = 3.396, p = 0.046, 2 = 0.167). Thus, simple main effect tests using paired-samples t -tests were evaluated to exam ine the effects of training and consistency on IA at = 0.01.

PAGE 77

65 TrainingPost PreMean +2 SE (s)1.06 1.04 1.02 1.00 .98 .96 .94 .92 Figure 3-6. Effects of training on DUR. Consistency10P 5P 10W 5W DryMean +2 SE (s)1.2 1.1 1.0 .9 .8 Figure 3-7. Effects of consistency on DUR. Table 3-17 demonstrates the results of th ese tests and indicates that only one different consistency pair in pre-training had si gnificantly different IAs. The IA for the 5

PAGE 78

66 cc pudding was significantly highe r than the 5 cc water ( t = -2.811, p = 0.012). Five different consistency pairs in di fferent training levels had sign ificantly different IAs. The IA for 10 cc pudding swallow in post-traini ng was significantly higher than the 5 cc water swallow in pre-training ( t = -3.570, p = 0.002), than the 10 cc water swallow in pretraining ( t = -3.610, p = 0.002), and than the 10 cc pudding swallow in pre-training ( t = 2.867, p = 0.011). The IA for maximum voluntary dry swallow in post-training was also significantly higher than the 5 cc wa ter swallow in pre-training ( t = -2.800, p = 0.012) and the 10 cc water swallow in pre-training ( t = -2.725, p = 0.014). Additionally, four different consistency pairs in post-training had significantly different IAs. Specifically, the IA for 5 cc water swallow in post-training was significantly lower than the dry swallow in post-training ( t = 3.291, p = 0.004), than the 5 cc pudding swallow in posttraining ( t = -2.974, p = 0.009), and than the 10 cc pudding swallow in post-training ( t = 3.485, p = 0.003). The IAs for 10 cc water swallow in post-training was also significantly lower than the 10 cc pudding swallow ( t = -3.041, p = 0.007). The profile plots were created with consistency as the hor izontal axis, each preand post-training as the separate bars in IA (Fi gure 3-8). The plots depicted the significantly different amounts of IA increases from pr e-training to post-training in different consistencies. The IAs for maximal volunt ary dry swallow (16% change) and the 10 cc pudding swallow (33% change) dramatically in creased from preto post-training. However, the IAs for 5 cc water swallow (6 % change), the 10 cc water swallow (12% change), and the 5 cc pudding swallow (9% ch ange) increased with small amounts from preto post-training.

PAGE 79

67 Consistency10P 5P 10W 5W DRYIA (mV/s s)60 50 40 30 20 10 0 Training Pre Post Figure 3-8. Effects of trai ning and consistency on IA. Speech Function Table 3-18 shows the descriptive statistics for the speech function measures preand post-training as a function of gender. The ANOVA result on PEL, presented Table 3-19, indi cated a significant two-way interaction between training and gender ( F (1, 16) = 5.866, p = 0.028, 2 = 0.268). However, no main effect of gender was found. Therefore, a one-way repeated measures ANOVA without gender effect on PEL was further examined. Again, sphericity assumptions were met on PEL. The ANOVA result indicated PEL was significantly increased by training ( F (1, 17) = 24.031, p < 0.001, 2 = 0.586). The result for PEL is illustrated in Figure 3-9. PEL increased from preto post-training by 45%.

PAGE 80

68 TrainingPost PreMean +2 SE (cm H2O)24 22 20 18 16 14 12 10 Figure 3-9. Effect of training on PEL. For MPD, a 2 2 2 repeated measures univariate ANOVA was examined to analyze the effects of training, loudness, and gender. For PEL, a 2 2 repeated measures univariate ANOVA was conducted to determin e the effects of training and gender. Sphericity assumptions were met by all factors in those ANOVAs. The ANOVA results on MPD indicated no significant three-wa y interaction among training, loudness, and gender (Table 3-20). Non-si gnificance of two-way interac tions between training and gender, between loudness and gender, or between training and loudness were found. Further, all main effects of training, loudness, and gender were not significant. Thus, a 2 2 repeated measures univariate ANOVA without the gender effect on MPD were evaluated. Sphericity assump tions of MPD were not violated. Table 3-21 shows the ANOVA results on MPD without gender wh ich indicates a significant two-way interaction between training and loudness ( F (1, 17) = 10.431, p = 0.005, 2 = 0.380).

PAGE 81

69 Simple main effect tests using paired-samples t -tests were then followed (Table 3-22). The MPDs at the comfortable intensity le vel between preand post-trainings were significantly different at the = 0.01 ( t = -3.070, p = 0.007). The profile plots created by preand post-training as the horizontal axis, tw o intensity levels as the separate bars in MPD show a large increase of MPD for the comf ortable intensity level from preto posttraining by 26% compared to the small change fo r the loudest intensity level from preto post-training by 3% (Figure 3-10). LoudnessLOUD COMFMPD (s)50 40 30 20 10 0 Training Pre Post Figure 3-10. Effects of training and loudness on MPD.

PAGE 82

70 Table 3-1. Results of intraand inter-judge reliability of cough, swallow, and speech function variables. Intra-Judge Inter-Judge Measures r p r p Cough IPD 0.962 < 0.001* 0.939 0.005* CPD 0.992 < 0.001* 0.957 0.003* PEFR 1.000 < 0.001* 0.999 < 0.001* PPPD 0.939 < 0.001* 0.882 0.020 PPPIA 0.974 < 0.001* 0.996 < 0.001* Swallow PA 0.992 < 0.001* 0.983 < 0.001* DUR 0.905 < 0.001* 0.743 < 0.001* IA 0.910 < 0.001* 0.987 < 0.001* Speech MPD 0.998 < 0.001* 0.974 < 0.001* PEL 1.000 < 0.001* 1.000 < 0.001* Correlation is significant at the 0.05 level.

PAGE 83

71Table 3-2. Correlation matrix of dependent variables. Pulmonary Cough Speech MIP FEV1 FVC FEV1/FVC ERV IPD CPD PEFR PPPD PPPIA COMF LOUD PEL Pulmonar y MEP 0.532* 0.232 0.215 0.082 0.194 -0.115 -0.367* 0.526* -0.305 0.472* 0.312 0.139 0.363* MIP 0.257 0.161 0.275 0.087 0.090 -0.194 0.350* -0.229 0.105 0.233 0.043 0.183 FEV1 0.952 0.151 0.554* -0.088 -0.245 0.465* 0.065 0.391* 0.577* 0.543* 0.018 FVC -0.140 0.635* -0.225 -0.303 0.420* 0.097 0.409* 0.464* 0.443* 0.054 FEV1/FVC -0.198 0.456* 0.179 0.194 -0.123 0.056 0.384 0.326 0.056 ERV 0.045 -0.117 0.245 0.067 0.378* 0.403* 0.294 0.004 Cou g h IPD 0.125 0.034 0.059 -0.011 0.361* 0.159 -0.195 CPD -0.625* 0.023 -0.498* -0.005 0.023 -0.301 PEFR -0.319 0.847* 0.492* 0.384* 0.402* PPPD -0.136 -0.128 -0.250 0.038 PPPIA 0.462* 0.264 0.464* Swallow PA DRY -0.089 0.198 -0.119 5W 0.256 0.651* -0.314 10W 0.200 0.587* -0.280 5P 0.028 0.346* -0.282 10P 0.142 0.489* -0.301 Swallow DUR DRY 0.169 -0.024 0.554* 5W -0.039 -0.071 0.254 10W 0.125 0.056 0.259 5P 0.177 0.112 0.154 10P 0.262 0.128 0.307 Swallow IA DRY 0.120 0.110 0.256 5W 0.010 0.073 0.177 10W 0.026 0.039 0.154 5P 0.032 -0.014 0.107 10P -0.061 -0.059 0.339* S p eech COMF 0.703* -0.006 LOUD -0.194

PAGE 84

72Table 3-2. Continued. Swallow PA Swallow DUR Swallow IA DRY 5W 10W 5P 10P DRY 5W 10W 5P 10P DRY 5W 10W 5P 10P Pulmonar y MEP -0.034 0.075 0.096 -0.018 -0.024 0.139 0.072 0.053 0.016 0.084 0.257 0.026 0.082 0.020 0.084 MIP -0.136 0.022 0.006 -0.089 -0.024 -0.015 0.103 0.185 0.196 0.093 0.268 0.012 0.153 0.097 0.219 FEV1 -0.179 0.244 0.192 -0.036 0.121 0.306 0.036 0.269 0.154 0.188 -0.158 -0.393* -0.402* -0.407* -0.310 FVC -0.235 0.197 0.172 -0.056 0.082 0.342* 0.082 0.248 0.110 0.213 -0.271 -0.465* -0.493* -0.496* -0.413* FEV1/FVC 0.139 0.108 0.028 0.019 0.080 0.053 -0.007 0.200 0.236 0.078 0.401 0.315 0.360 0.361 0.379 ERV -0.272 0.010 0.022 -0.143 -0.022 0.274 0.116 0.184 0.032 0.235 -0.345* -0.285 -0.279 -0.335* -0.247 Cou g h IPD 0.123 0.107 0.073 0.096 0.153 -0.065 -0.054 0.048 0.048 0.009 0.265* 0.375* 0.435* 0.390* 0.386* CPD -0.216 -0.085 -0.082 -0.129 -0.090 -0.196 0.062 0.125 0.066 0.246 0.085 0.256 0.261 0.403* 0.129 PEFR 0.132 0.216 0.198 0.074 0.150 0.420* -0.001 0.023 0.069 0.039 0.286 -0.084 -0.077 -0.167 0.069 PPPD -0.089 -0.351* -0.353* -0.288 -0.218 -0.022 0.173 0.191 0.154 0.233 -0.310 -0.320 -0.288 -0.279 -0.248 PPPIA 0.171 0.159 0.153 0.091 0.128 0.541* 0.148 0.117 0.124 0.223 0.167 -0.043 -0.067 -0.116 0.039 Swallow PA DRY 0.643* 0.620* 0.844* 0.803* -0.172 -0.010 -0.089 -0.133 -0.196 0.360* 0.386* 0.346* 0.300 0.314 5W 0.970* 0.862* 0.915* -0.213 -0.030 -0.036 -0.077 -0.095 0.197 0.178 0.125 0.104 0.032 10W 0.850* 0.909* -0.263 0.017 -0.026 -0.163 -0.106 0.150 0.161 0.122 0.055 0.034 5P 0.940* -0.249 -0.018 -0.169 -0.192 -0.199 0.150 0.241 0.184 0.177 0.107 10P -0.242 0.048 -0.005 -0.122 -0.102 0.206 0.225 0.188 0.163 0.126 Swallow DUR DRY 0.428* 0.441* 0.531* 0.530* 0.180 0.058 -0.037 0.052 0.027 5W 0.749* 0.594* 0.692* -0.041 0.111 0.104 0.127 0.024 10W 0.632* 0.754* 0.200 0.149 0.152 0.245 0.177 5P 0.744* 0.163 0.031 -0.002 0.226 -0.061 10P 0.170 0.049 0.024 0.243 0.022 Swallow IA DRY 0.609* 0.625* 0.733* 0.656* 5W 0.971* 0.884* 0.765* 10W 0.871* 0.808* 5P 0.766* Note : All abbreviations are listed in Appendix G. Correlation is significant at the 0.05 level.

PAGE 85

73 Table 3-3. Descriptive statistics for pr eand post-training on pulmonary function variables. Pre Post DV Gender M SD M SD Change (%) MEP (cm H2O) Men 76.503 23.623132.285 21.491 72.915 Women 77.316 20.115104.695 24.548 35.412 Average 77.136 20.199110.826 26.108 43.676 MIP (cm H2O) Men 42.130 10.91562.790 17.361 49.039 Women 38.206 13.99857.176 19.515 49.652 Average 39.078 13.17958.423 18.713 49.504 FEV1 (L) Men 2.079 0.6112.213 0.687 6.445 Women 1.906 0.4681.974 0.477 3.568 Average 1.945 0.4882.027 0.517 4.216 FVC (L) Men 2.863 0.6722.928 0.858 2.270 Women 2.467 0.6242.557 0.644 3.648 Average 2.555 0.6382.639 0.687 3.288 FEV1/FVC Men 71.742 6.57876.947 6.312 7.255 Women 78.078 6.44978.076 5.721 -0.002 Average 76.670 6.84077.826 5.683 1.508 ERV (L) Men 1.089 0.2491.190 0.424 9.275 Women 0.938 0.6871.171 0.670 24.840 Average 0.972 0.6131.176 0.613 20.988 Table 3-4. MANOVA result for the effects of training and gender on pulmonary function variables. Factor Statistic Value F Hypothesis df Error df p 2 Intercept Pillai's Trace 1.000 4726.314 6 11 0.000 1.000 Gender Pillai's Trace 0.259 0.640 6 11 0.698 0.259 Training Pillai's Trace 0.827 8.766 6 11 0.001* 0.827 Training Gender Pillai's Trace 0.372 1.086 6 11 0.427 0.372 Note : 2 = effect size. indicates that the mean difference is significant at = 0.05.

PAGE 86

74 Table 3-5. Univariate ANOVA results fo r training effect on pulmonary function variables. Factor DV SS df MS F p 2 Training MEP 10215.482110215.48240.978 0.000* 0.707 MIP 3368.06113368.06118.513 0.000* 0.521 FEV1 0.06210.0623.556 0.077 0.173 FVC 0.06410.0643.806 0.068 0.183 FEV1/FVC 12.020112.0200.873 0.363 0.049 ERV 0.37410.3741.853 0.191 0.098 Error MEP 4238.00217249.294 MIP 3092.88217181.934 FEV1 0.294170.017 FVC 0.285170.017 FEV1/FVC 234.1451713.773 ERV 3.430170.202 Note : 2 = effect size. indicates that the mean difference is significant at = 0.05.

PAGE 87

75 Table 3-6. Descriptive statis tics for preand post-traini ng on cough function variables. Pre Post DV Gender M SD M SD Change (%) IPD (s) Men 0.932 0.224 0.758 0.350 -18.669 Women 1.206 0.243 1.357 0.495 12.521 Average 1.145 0.262 1.224 0.524 6.899 CPD (s) Men 0.229 0.097 0.122 0.068 -46.689 Women 0.382 0.201 0.173 0.185 -54.563 Average 0.348 0.192 0.162 0.166 -53.412 PEFR (L/s) Men 4.985 2.810 6.483 2.969 30.155 Women 4.979 2.097 8.431 3.056 69.127 Average 4.981 2.181 7.998 3.064 60.635 PPPD (s) Men 0.206 0.02 8 0.213 0.041 3.538 Women 0.244 0.078 0.227 0.084 -7.066 Average 0.236 0.071 0.224 0.075 -5.008 PPPIA (L/s s) Men 3.308 4.210 4.043 3.746 22.210 Women 3.539 1.948 7.624 4.033 115.411 Average 3.488 2.457 6.829 4.155 95.767 N of coughs Men 2.700 0.983 2.650 1.025 -1.852 Women 2.879 0.720 3.400 1.109 18.114 Average 2.839 0.757 3.233 1.109 13.894 N of CR Men 6.850 2.965 6.700 3.118 -2.190 Women 8.121 2.622 9.729 4.229 19.789 Average 7.839 2.665 9.056 4.132 15.521 Table 3-7. MANOVA result for the effects of training and gender on cough function variables. Factor Statistic Value F Hypothesis df Error df p 2 Intercept Pillai's Trace 0.982 129.655 5 12 0.000 0.982 Gender Pillai's Trace 0.451 1.968 5 12 0.156 0.451 Training Pillai's Trace 0.520 2.598 5 12 0.081 0.520 Training Gender Pillai's Trace 0.373 1.427 5 12 0.283 0.373 Note : 2 = effect size. indicates that the mean difference is significant at = 0.05.

PAGE 88

76 Table 3-8. Univariate ANOVA results for training effects on cough function variables. Factor DV SS df MS F p 2 Training IPD 0.056 10.0560.664 0.426 0.038 CPD 0.310 10.31013.590 0.002* 0.444 PEFR 4609.588 14609.5 8829.620 0.000* 0.635 PPPD 0.001 10.0011.259 0.277 0.069 PPPIA 100.427 1100.42716.826 0.001* 0.497 Error IPD 1.429 170.084 CPD 0.388 170.023 PEFR 2645.640 17155.626 PPPD 0.017 170.001 PPPIA 101.465 175.969 Note : 2 = effect size. indicates that the mean difference is significant at = 0.05. Table 3-9. MANOVA result for the effects of training and gender on total number of coughs and total number of expulsive events. Factor Statistic Value F Hypothesis df Error df p 2 Intercept Pillai's Trace 0.915 80.710 2.000 15.000 0.000 0.915 Gender Pillai's Trace 0.081 0.661 2.000 15.000 0.531 0.081 Training Pillai's Trace 0.068 0.548 2.000 15.000 0.589 0.068 Training Gender Pillai's Trace 0.096 0.794 2.000 15.000 0.470 0.096 Note : 2 = effect size. indicates that the mean difference is significant at = 0.05.

PAGE 89

77 Table 3-10. Descriptive statistics for pr eand post-training on swallow function variables. PrePos t DV Gender M SD M SD Change ( % ) PA ( mV ) DRY Men 43.5662.60352.510 10.196 20.528 Women 65.52722.89776.102 25.812 16.139 Average 60.64722.14470.860 25.094 16.840 5W Men 34.9935.71533.841 5.293 -3.293 Women 57.70437.81461.352 31.135 6.322 Average 52.65834.54855.239 29.745 4.902 10W Men 36.0306.26632.799 4.509 -8.967 Women 57.10335.43060.256 30.509 5.522 Average 52.42032.37454.154 29.212 3.309 5P Men 39.7366.73141.968 10.016 5.616 Women 57.82930.58668.533 29.898 18.509 Average 53.80927.98762.630 28.817 16.393 10P Men 36.3393.97637.767 7.109 3.930 Women 60.88834.13873.304 30.197 20.392 Average 55.43231.69165.407 30.616 17.994 DUR (s) DRY Men 0.9460.1161.080 0.122 14.127 Women 0.9640.1511.016 0.217 5.310 Average 0.9600.1411.030 0.199 7.240 5W Men 0.8920.2080.947 0.209 6.192 Women 0.9350.1200.977 0.125 4.494 Average 0.9260.1380.971 0.141 4.858 10W Men 0.9350.1460.988 0.178 5.627 Women 0.9450.1510.968 0.129 2.424 Average 0.9430.1450.972 0.136 3.130 5P Men 0.9550.1611.019 0.146 6.707 Women 1.0040.1121.047 0.164 4.284 Average 0.9930.1211.041 0.156 4.802 10P Men 0.9760.0931.010 0.135 3.522 Women 1.0240.1491.081 0.196 5.590 Average 1.0130.1371.065 0.183 5.147 IA DRY Men 18.7241.78730.241 11.982 61.509 Women 28.9058.14531.125 10.223 7.680 Average 26.6438.38230.929 10.267 16.086 5W Men 16.3880.64119.299 3.925 17.765 Women 23.52113.82424.345 11.962 3.503 Average 21.93612.47123.223 10.807 5.871 10W Men 16.6980.77220.457 4.925 22.513 Women 23.85512.75826.143 11.850 9.592 Average 22.26511.57424.880 10.844 11.746 5P Men 19.8252.87223.975 2.748 20.930 Women 26.66812.49028.555 12.808 7.075 Average 25.14711.37227.537 11.428 9.502 10P Men 19.2941.81626.837 6.874 39.093 Women 25.82611.84034.008 17.802 31.682 Average 24.37410.75132.415 16.127 32.986

PAGE 90

78 Table 3-11. Mauchly’s test of sphericity fo r training, consistency, and gender effects on swallow function variables. Factor DV Mauchly’s W 2 df p Training PA 1.000 0.000 0 1.000 DUR 1.000 0.000 0 1.000 IA 1.000 0.000 0 1.000 Consistency PA 0.025 53.437 9 0.000* DUR 0.389 13.602 9 0.140 IA 0.121 30.486 9 0.000* Training Consistency PA 0.616 6.990 9 0.640 DUR 0.721 4.724 9 0.859 IA 0.066 39.234 9 0.000* indicates that the mean difference is significant at = 0.05.

PAGE 91

79 Table 3-12. Univariate ANOVA (mixed design) results for the combined effects of training, consistency, and gender on swallow function variables. Factor DV SS df MS F p 2 Within-Subjects PA 738.360 1738.3601.265 0.277 0.073 DUR 0.096 10.0964.260 0.056 0.210 Training IA 637.877 1637.8776.744 0.019*0.297 PA 324.115 1324.1150.555 0.467 0.034 DUR 0.005 10.0050.210 0.653 0.013 Training Gender IA 65.220 165.2200.690 0.419 0.041 PA 9336.621 16583.53 DUR 0.362 160.023 Error (Training) IA 1513.351 1694.584 PA 2698.133 1.4081915.6492.792 0.097 0.149 DUR 0.126 40.0312.205 0.078 0.121 Consistency IA 787.3032.368332.5154.143 0.018*0.206 PA 236.542 459.1360.245 0.912 0.015 DUR 0.028 40.0070.499 0.737 0.030 Consistency Gender IA 7.088 41.7720.037 0.997 0.002 PA 15460.024 22.536686.030 DUR 0.912 640.014 Error (Consistency) IA 3040.167 37.88480.250 PA 422.414 4105.6032.041 0.099 0.113 DUR 0.011 40.0030.536 0.710 0.032 Training Consistency IA 175.570 1.87193.8532.404 0.111 0.131 PA 78.743 419.6860.380 0.822 0.023 DUR 0.009 40.0020.424 0.791 0.026 Training Consistency Gender IA 87.985 421.9961.205 0.317 0.070 PA 3311.880 6451.748 DUR 0.339 640.005 Error (Training Consistency) IA 1168.390 29.93139.036 Between-Subject PA 328872.375 1328872.37553.101 0.000 DUR 120.846 1120.846869.716 0.000 Intercept IA 73087.519 173087.51974.724 0.000 PA 19296.632 119296.6323.116 0.097 DUR 0.014 10.0140.102 0.754 Gender IA 1165.650 11165.6501.192 0.291 PA 99094.255 166193.391 DUR 2.223 160.139 Error IA 15649.637 16978.102 Note : 2 = effect size. indicates that the mean difference is significant at = 0.05.

PAGE 92

80 Table 3-13. Mauchly’s test of sphericity for training and consistency on swallow function variables. Factor DV Mauchly’s W 2 df p Training PA 1.000 0.000 0 1.000 DUR 1.000 0.000 0 1.000 IA 1.000 0.000 0 1.000 Consistency PA 0.029 54.371 9 0.000* DUR 0.402 14.055 9 0.122 IA 0.121 32.622 9 0.000* Training Consistency PA 0.628 7.183 9 0.620 DUR 0.744 4.552 9 0.872 IA 0.069 41.306 9 0.000* indicates that the mean difference is significant at = 0.05. Table 3-14. Univariate ANOVA results without gender effect for the combined effects of training and consistency on sw allow function variables. Factor DV SS df MS F p 2 PA 1998.88811998.8883.517 0.078 0.171 DUR 0.10710.1074.966 0.040*0.226 Training IA 623.9561623.9566.720 0.019*0.283 PA 9660.73517568.279 DUR 0.366170.022 Error (Training) IA 1578.5711792.857 PA 3748.0241.4412600.1754.059 0.042*0.193 DUR 0.21440.0533.869 0.007*0.185 Consistency IA 1122.6032.367474.1876.263 0.003*0.269 PA 15696.56624.505640.554 DUR 0.940680.014 Error (Consistency) IA 3047.25640.24675.715 PA 622.5834155.6463.122 0.020*0.155 DUR 0.00740.0020.365 0.833 0.021 Training Consistency IA 251.0111.987126.3293.396 0.046*0.167 PA 3390.6236849.862 DUR 0.348680.005 Error (Training Consistency) IA 1256.37433.77837.195 Note : 2 = effect size. indicates that the mean difference is significant at = 0.05.

PAGE 93

81 Table 3-15. Simple main effect test s of training and consistency on PA. Facto r M ( I ) ( J ) ( I ) ( J ) (I-J) SE t p Pre, DRY Pre, 5W 60.647 52.658 7.989 5.829 1.371 0.188 Pre, 10W 52.420 8.227 5.203 1.581 0.132 Pre, 5P 53.809 6.838 3.544 1.929 0.071 Pre, 10P 55.432 5.215 4.181 1.247 0.229 Post, DRY 60.647 70.860 -10.213 4.537 -2.251 0.038 Post, 5W 55.239 5.410 5.246 1.031 0.317 Post, 10W 54.154 6.492 5.002 1.298 0.212 Post, 5P 62.630 -1.983 4.608 -0.430 0.672 Post, 10P 65.407 -4.760 4.775 -0.997 0.333 Pre, 5W Pre, 10W 52.658 52.420 0.238 1.350 0.176 0.862 Pre, 5P 53.809 -1.151 3.271 -0.352 0.729 Pre, 10P 55.432 -2.776 2.959 -0.938 0.362 Post, DRY 52.658 70.860 -18.202 8.012 -2.272 0.036 Post, 5W 55.239 -2.581 3.400 -0.759 0.458 Post, 10W 54.154 -1.497 2.707 -0.553 0.587 Post, 5P 62.630 -9.972 6.365 -1.567 0.136 Post, 10P 65.407 -12.749 4.934 -2.584 0.019 Pre, 10W Pre, 5P 52.420 53.809 -1.389 2.842 -0.489 0.631 Pre, 10P 55.432 -3.012 2.487 -1.211 0.242 Post, DRY 52.420 70.860 -18.440 7.410 -2.488 0.023 Post, 5W 55.239 -2.819 3.055 -0.923 0.369 Post, 10W 54.154 -1.735 2.487 -0.697 0.495 Post, 5P 62.630 -10.210 5.594 -1.825 0.086 Post, 10P 65.407 -12.987 4.271 -3.041 0.007* Pre, 5P Pre, 10P 53.809 55.432 -1.623 1.691 -0.960 0.350 Post, DRY 53.809 70.860 -17.051 6.306 -2.704 0.015 Post, 5W 55.239 -1.430 3.830 -0.373 0.714 Post, 10W 54.154 -0.345 3.491 -0.099 0.922 Post, 5P 62.630 -8.821 5.079 -1.737 0.100 Post, 10P 65.407 -11.598 4.469 -2.595 0.019 Pre, 10P Post, DRY 55.432 70.860 -15.427 7.075 -2.181 0.044 Post, 5W 55.239 0.193 3.900 0.050 0.961 Post, 10W 54.154 1.278 3.458 0.370 0.716 Post, 5P 62.630 -7.198 5.635 -1.277 0.219 Post, 10P 65.407 -9.974 4.602 -2.167 0.045 Post, DRY Post, 5W 70.860 55.239 15.621 5.792 2.697 0.015 Post, 10W 54.154 16.705 6.233 2.680 0.016 Post, 5P 62.630 8.230 3.727 2.208 0.041 Post, 10P 65.407 5.453 4.699 1.161 0.262 Post, 5W Post, 10W 55.239 54.154 1.084 2.251 0.482 0.636 Post, 5P 62.630 -7.391 4.236 -1.745 0.099 Post, 10P 65.407 -10.168 3.001 -3.388 0.003* Post, 10W Post, 5P 54.154 62.630 -8.475 4.523 -1.874 0.078 Post, 10P 65.407 -11.252 3.390 -3.319 0.004* Post, 5P Post, 10P 62.630 65.407 -2.777 3.171 -0.876 0.393 indicates that the mean difference is significant at = 0.01.

PAGE 94

82 Table 3-16. Multiple pairwise comparisons for DUR by training and by consistency. Factor M (I) (J) (I) (J) (I-J) SE p Pre, DRY Post, DRY 0.960 1.030 -0.070 -1.870 0.079 Pre, 5W Post, 5W 0.926 0.971 -0.045 -1.422 0.173 Pre, 10W Post, 10W 0.943 0.972 -0.030 -1.118 0.279 Pre, 5P Post, 5P 0.993 1.041 -0.048 -1.634 0.121 Pre, 10P Post, 10P 1.013 1.065 -0.052 -1.923 0.071 DRY 5W 0.995 0.948 0.047 0.037 1.000 10W 0.958 0.037 0.035 1.000 5P 1.017 -0.022 0.031 1.000 10P 1.039 -0.044 0.035 1.000 5W 10W 0.948 0.958 -0.010 0.020 1.000 5P 1.017 -0.069 0.025 0.135 10P 1.039 -0.091 0.024 0.016* 10W 5P 0.958 1.017 -0.059 0.022 0.139 10P 1.039 -0.081 0.021 0.012* 5P 10P 1.017 1.039 -0.022 0.019 1.000 indicates that the mean difference is significant at = 0.05 using Bonferroni adjustment for multiple comparisons.

PAGE 95

83 Table 3-17. Simple main effect tests for the effects of tr aining and consistency on IA. Facto r M ( I ) ( J ) ( I ) ( J ) (I-J) SE t p Pre, Dry Pre, 5W 26.643 21.936 4.707 2.121 2.219 0.040 Pre, 10W 22.265 4.378 2.043 2.143 0.047 Pre, 5P 25.147 1.496 1.618 0.924 0.368 Pre, 10P 24.374 2.268 1.679 1.351 0.194 Post, Dry 26.643 30.929 -4.286 2.111 -2.030 0.058 Post, 5W 23.223 3.419 1.799 1.901 0.074 Post, 10W 24.880 1.763 1.550 1.138 0.271 Post, 5P 27.537 -0.894 2.000 -0.447 0.661 Post, 10P 32.415 -5.772 3.005 -1.921 0.072 Pre, 5W Pre, 10W 21.936 22.265 -0.329 0.651 -0.506 0.620 Pre, 5P 25.147 -3.212 1.143 -2.811 0.012* Pre, 10P 24.374 -2.439 1.099 -2.220 0.040 Post, Dry 21.936 30.929 -8.993 3.212 -2.800 0.012* Post, 5W 23.223 -1.288 1.169 -1.102 0.286 Post, 10W 24.880 -2.944 1.302 -2.262 0.037 Post, 5P 27.537 -5.601 2.382 -2.352 0.031 Post, 10P 32.415 -10.479 2.935 -3.570 0.002* Pre, 10W Pre, 5P 22.265 25.147 -2.883 1.210 -2.381 0.029 Pre, 10P 24.374 -2.110 0.943 -2.236 0.039 Post, Dry 22.265 30.929 -8.664 3.180 -2.725 0.014* Post, 5W 23.223 -0.959 1.344 -0.713 0.486 Post, 10W 24.880 -2.615 1.316 -1.987 0.063 Post, 5P 27.537 -5.272 2.405 -2.193 0.043 Post, 10P 32.415 -10.150 2.811 -3.610 0.002* Pre, 5P Pre, 10P 25.147 24.374 0.773 0.695 1.111 0.282 Post, Dry 25.147 30.929 -5.781 2.780 -2.080 0.053 Post, 5W 23.223 1.924 1.019 1.889 0.076 Post, 10W 24.880 0.267 1.006 0.266 0.793 Post, 5P 27.537 -2.390 1.763 -1.356 0.193 Post, 10P 32.415 -7.267 3.063 -2.373 0.030 Pre, 10P Post, Dry 24.374 30.929 -6.554 2.805 -2.337 0.032 Post, 5W 23.223 1.151 1.043 1.103 0.285 Post, 10W 24.880 -0.505 0.909 -0.556 0.586 Post, 5P 27.537 -3.162 1.966 -1.609 0.126 Post, 10P 32.415 -8.040 2.805 -2.867 0.011* Post, Dry Post, 5W 30.929 23.223 7.705 2.341 3.291 0.004* Post, 10W 24.880 6.049 2.263 2.673 0.016 Post, 5P 27.537 3.392 2.053 1.652 0.117 Post, 10P 32.415 -1.486 3.122 -0.476 0.640 Post, 5W Post, 10W 23.223 24.880 -1.656 0.637 -2.601 0.019 Post, 5P 27.537 -4.313 1.451 -2.974 0.009* Post, 10P 32.415 -9.191 2.638 -3.485 0.003* Post, 10W Post, 5P 24.880 27.537 -2.657 1.499 -1.772 0.094 Post, 10P 32.415 -7.535 2.478 -3.041 0.007* Post, 5P Post, 10P 27.537 32.415 -4.878 2.831 -1.723 0.103 indicates that the mean difference is significant at = 0.01.

PAGE 96

84 Table 3-18. Descriptive statisti cs for preand post-training on speech functi on variables. Pre Post DV Loudness Gender M SD M SD Change (%) PEL Men 11.9023.30322.9835.774 93.102 Women 14.1315.42318.8146.730 33.140 Average 13.6365.00219.7416.610 44.771 MPD COMF Men 16.81612.14116.4769.744 -2.023 Women 18.0526.86624.0489.813 33.216 Average 17.7777.89522.36610.044 25.809 LOUD Men 13.2485.57213.2516.303 0.022 Women 21.18611.61621.87013.099 3.232 Average 19.42210.96419.95512.321 2.745 Table 3-19. Univariate ANOVA result for the combined effects of training and gender on PEL. Factor SS df MS F p 2 Within-Subjects Training 386.5411386.54135.619 0.000*0.690 Training Gender 63.654163.6545.866 0.028*0.268 Error (Training) 173.6341610.852 Between-Subject Intercept 7157.02417157.024123.795 0.000 0.886 Gender 5.85115.8510.101 0.755 0.006 Error (Gender) 925.0131657.813 Note : 2 = effect size. indicates that the mean difference is significant at = 0.05.

PAGE 97

85 Table 3-20. Univariate ANOVA result for th e combined effects of training, loudness, and gender on MPD. Factor SS df MS F p 2 Within-Subjects Training 31.299 131.299 1.487 0.240 0.005 Training Gender 38.308 138.308 1.820 0.196 0.102 Error (Training) 336.794 1621.050 Loudness 26.506 126.506 0.446 0.514 0.027 Loudness Gender 46.711 146.711 0.785 0.389 0.047 Error (Loudness) 951.781 1659.486 Training Loudness 19.200 119.200 3.209 0.092 0.167 Training Loudness 24.870 124.870 4.157 0.058 0.206 Gender Error (Training 95.724 165.983 Loudness) Between-Subject Intercept 16340.793 116340.793 48.378 0.000 0.751 Gender 500.476 1500.476 1.482 0.241 0.085 Error (Gender) 5404.406 16337.775 Note : 2 = effect size. indicates that the mean difference is significant at = 0.05. Table 3-21. Univariate ANOVA result for the combined effects of training and loudness on MPD. Factor SS df MS F p 2 Within-Subjects Training 118.024 1 118.024 5.349 0.034* 0.239 Error (Training) 375.102 17 22.065 Loudness 2.642 1 2.642 0.045 0.835 0.003 Error (Loudness) 998.492 17 58.735 Training Loudness 73.994 1 73.994 10.431 0.005* 0.380 Error (Loudness) 120.593 17 7.094 Note : 2 = effect size. indicates that the mean difference is significant at = 0.05.

PAGE 98

86 Table 3-22. Simple main effect te sts of training and loudness on MPD. Factor M (I) (J) (I) (J) (I-J) SE t p COMF, Pre COMF, Post 17.777 22.366 -4.588 1.495 -3.070 0.007* LOUD, Pre 19.422 -1.644 1.991 -0.826 0.420 LOUD, Post 19.955 -2.178 2.532 -0.860 0.402 COMF, Post LOUD, Pre 22.366 19.422 2.944 1.601 1.838 0.084 LOUD, Post 19.955 2.411 1.830 1.317 0.205 LOUD, Pre LOUD, Post 19.422 19.955 -0.533 1.003 -0.532 0.602 indicates that the mean difference is significant at = 0.01.

PAGE 99

87 CHAPTER 4 DISCUSSION This study investigated the physiological effects of expiratory muscle strength training (EMST) with the sedentary healthy elderly using a pressu re-threshold training device over a 4-week time frame in order to assess the effects on pulmonary, cough, swallow, and speech functions. Pulmonary Function Maximum Respiratory Pressure. It was hypothesized that EMST would increase both maximum expiratory pressure (MEP) a nd maximum inspiratory pressure (MIP). The results indicated significant improveme nts in both MEP and MIP following the 4week EMST program. MEPs significantly incr eased by an average of 44% (range of 8% to 158%) from preto post-training. Incr eases in MEP represent improved expiratory muscle strength. The MEP gains in the current study are comparable to previous studies completed in healthy young adults as well as clinical populations that used the same pressure-threshold training de vice (Baker, Davenport, & Sa pienza, 2005; Chiara, 2003; Hoffman-Ruddy, 2001; Saleem, 2005; Sapienza et al., 2002; Wingate et al., in press). Table 1-2 shows that the change in MEP fo llowing a 4-week EMST program in healthy young adults ranged from 25% to 47%. Suzuki et al. (1995) reported an increase in MEP from 165 71 cm H2O pre-training to 202 77 cm H2O post-training, a 25% increase for six healthy men. Suzuki’s group used a thre shold pressure breathing device (Threshold Inspiratory Muscel Trainer, Healthscan Products, Cedar Grove, New Jersey, USA). Sapienza et al. (2002) re ported that MEP increase d from 99.7 25.2 cm H2O pre-training

PAGE 100

88 to 147.0 31.9 cm H2O post-training, which is a 47% increase, in 22 healthy men and women. Baker et al. (2005) reported MEPs preto post-training from 99.1 34.7 cm H2O to 127.5 41.1 cm H2O, respectively, with an increase by 29% in 32 healthy participants. Together, these re sults suggest that an EMST pr ogram is applicable to both young and old healthy individuals to enhance the strength of the expiratory muscles. Age-related muscle atrophy in the respirat ory musculature is observed primarily in the expiratory intercostal muscles, however not in the inspiratory intercostal muscles (Mizuno, 1991). The atrophy of these muscles dur ing the normal aging process is similar to what can be expected for those living a sedentary lifestyle. However, combining a sedentary lifestyle with normal aging can a ggravate sarcopenia, or loss of muscle mass with age, in the respiratory musculature. The current study demonstrates that expiratory muscles in the sedentary elderl y can be strengthened. The strength may translate to gains in muscle mass/hypertrophy, in response to increased load delivered via EMST over a long enough time frame. The respiratory musc le strength increases achieved with the sedentary elderly are likely rela ted to rapid increases in the ne ural adaptations at the level of the motor unit. As descri bed earlier, strength gains in sk eletal muscles result from a combination of both neural adaptation and mu scle mass adaptation. Neural adaptations commonly occur in the early stage (4 to 6 weeks) of training in both young and elderly individuals. After 4 to 6 weeks of training, strength gains in young people are predominately related to muscle hypertrophy, wh ile in elderly people strength gains are mainly due to neural adaptation, even afte r 6 weeks of training (Moritani & deVries, 1980). These findings suggest that a continua l EMST program in the healthy sedentary elderly could be helpful in preventing the alterations in muscle architecture in the

PAGE 101

89 expiratory muscles. The time frame in whic h muscle structure changes is not known but would be a reasonable study to design particular ly in an animal model where exercise in a sedentary animal could be compared to a control group preand post-exercise. In a human model, some limitations exist for documenting changes in muscle architecture particularly since the respiratory muscles are less accessible, less amenable to biopsy, particularly if recruiting a large sample, and more difficult to image. However, if the animal model proved a positive outcome w ith respiratory strength training then translation of theory could occur to human application. Maximum inspiratory pressure (MIP) also increased by an average of 49%, with a range of 10% to 287%, following 4 weeks of tr aining. Several studies have demonstrated increases in MIPs using inspiratory muscle strength training (IMST: Gozal & Thiriet, 1999; Hsiao et al., 2003; Larson et al., 1988; Lotters, van Tol, Kwakkel, & Gosselink, 2002; Martin et al., 2002; McCool & Tzel epis, 1995; Olgiati et al., 1989; RamirezSarmiento et al., 2002; Sturdy et al., 2003; Tr ueblood et al., 2004; Weiner et al., 2004), a combined program of IMST and EMST (Watsf ord et al., 2004; Weiner et al., 2003a), or EMST alone (Chiara, 2003; Gosselink et al., 2000). Since no previous study has used an EMST program independently with a healthy elderly population, the investigat or sought to determine the effects of EMST on MIP in the sedentary elderly population. As reported previously, with age gradual reduction in inspiratory muscle strength is accompanied by a decrease in the elastic recoil properties of the lungs. The results of the present study indicated that inspirat ory muscle strength increased following the EMST program. Enha ncing expiratory muscle strength with EMST increases expiratory reserve volume (ERV) and decreases residual volume (RV),

PAGE 102

90 which can increase elastic recoil pressure, thus increasing MIP. Fu rthermore, during the EMST program, participants are told to inhale to total lung capacity before exhaling to overcome the threshold load set on the training device. This repeated maneuver increases the use of the inspiratory muscles, thus s timulating a potential training effect. These assumptions have been put forth by other i nvestigators (Chiara, 2003; Gosselink et al., 2000). Gosselink et al. (2000) demonstrated EM ST effects on MIP in nine patients with multiple sclerosis (MS), with a mean change by 39 41% of initial after 3 months of training. They suggested two possibilities for the significant cha nge in inspiratory muscle strength with EMST. First, EMST w ould decrease RV, resul ting in an increased inspiratory lung volume. This mechanism would allow inspiratory muscles to move easily with increased elastic recoil pressure. The other assumption was that EMST would reduce expiratory lung volume indirectly, thus improving the length-tension of the inspiratory muscle mobility. Likewise, Wa tson and Hixon (2001) support that abdominal wall trussing places the diaphragm length in an optimum length-tension position thereby resulting in an increase of the potential transdiaphragma tic pressure. EMST may be platforming the diaphragm similarly, thus resu lting in greater activity of the diaphragm during the production of MIPs. EMST move s the diaphragm in a headward position, which lengthens the muscle fibers of the dia phragm. Repeated practice of the EMST task may lead to modulation of the sarcomere of the diaphragm, which increase the neural drive to the diaphragm toward in spiration (Watson & Hixon, 2001). Chiara (2003) also reported MIP gains for both MS and healthy controls ranging from 72.3 4.6 cm H2O to 79.0 4.8 cm H2O following 8 weeks of EMST. In that study, the MS group had an 8% MIP gain preto post-training. Ch iara (2003) proposed

PAGE 103

91 that EMST requires the inspiratory muscles to be activated repeatedly in order to reach a near-total lung capacity necessary to achieve the pressure requirements imposed by the pressure-threshold device. However, it is doubtf ul that a substantial training effect on the inspiratory muscles would occur in the absen ce of any moderate to maximum load on the inspiratory muscles. If that were the case th en tasks such as incentive spirometry would result in a strength gain in crease and the concep t of imposing a physiological load on muscles to increase strength would not be as strongly advocated as they are (Powers & Howley, 2001). Therefore, the presumption of Chiara may not be supported. Another study examining abdominal muscle recruitment in patients with chronic obstructive pulmonary disease (COPD) suggested that increasing the strength of the expiratory muscles in patients with severe COPD allows increases in the diaphragm muscle length and force generating capabilities at the ons et of inspiratory muscle contraction by increasing the load on the inspiratory muscles (Gorini et al., 1997). This in turn would result in a greater MIP. Whether this translat es to the biomechanics of healthy subjects is unknown. Hence, it is reasonable to conclude th at EMST is an effective program for increasing overall respiratory muscle strength in the sedentary healthy elderly. Older respiratory muscles preserve a high degree of adaptability in response to strength training similar to other limb muscles (Fiatarone et al., 1994; Gauchar d, Tessier, Jeandel, & Perrin, 2003; Narici, Reeves, Morse, & Maga naris, 2004). Thus, strength training specifically targeting respiratory muscles may compensate for the age-related changes in function and morphology of the aging human resp iratory muscle. This implies that if elderly individuals are involved in a formal exercise program targeting respiratory muscle

PAGE 104

92 strength training, the deleterious repercussions of sarcopenia may be reduced. If so, this may result in improvement of breathing, cough, swallow, and speech functions, and further the quality of life in the elderly. The effects of EMST on these functions are discussed next. Breathing It was hypothesized that breat hing function would be enhanced following EMST. However, the results of the training program did not support this hypothesis. There was no si gnificant improvement in FEV1, FVC, and ERV preto posttraining. Exploration of th e relationship between MEP and these pulmonary values indicated no significant correlation as well. The current results are congruent with the results of Simpson (1983). There has been one previous study using EMST with healthy elderly women to observe the effects on breathi ng function. This respirator y muscle strength training program, using both inspiratory and expirato ry muscle strength training, revealed no changes in breathing function (W atsford et al., 2004). Thirte en elderly women (mean age of 64.4 2.7 years) were trained with a pr essure-threshold device (PowerlungTM PowerLung Inc., Houston, Texas, USA) focusing on three modalities (hypertrophy, endurance, and strength based) of tr aining. No significant changes in FEV1 or FVC preto post-training occurred. The study with healthy young people examining the effect of EMST on breathing function with eigh t healthy adults (mean age of 36.8 8.8 years) using a combination of IMST and EMST with a commercially available resistive device (PowerlungTM, PowerLung Inc., Houston, Texas, US A) indicated non-si gnificant changes in FEV1 and FVC during 4 weeks of traini ng (Amonette & Dupler, 2001).

PAGE 105

93 Strength training with a method other than resistive loading has also been designed to increase abdominal muscle strength. Fo llowing 12 sessions of isokinetic trunk curlsup, breathing function in 16 healthy adults (10 women, 6 men; mean age of 22 years) showed no significant gains from preto post-training in FEV1 and FVC (Simpson, 1983). MEP was not measured in this study. One study examined the breathing-control training in singers and wind-instrument play ers to determine the effect on breathing function. No significant diffe rences were found in FEV1 and FVC compared to a control group (Schorr-Lesnick, Teirstein, Brown, & Mille r, 1985). It would seem that breathing function in healthy young or el derly individuals is not aff ected by training to increase expiratory muscle strength. Like healthy populations, clin ical populations have also exhibited no improvements in breathing function following EMST. In a study including patients with MS, Chiara (2003) used EMST with the same device used in the current study. No changes in FEV1 nor FVC with any of the 17 MS patients (14 women, 3 men; mean age of 48.7 years) or 14 healthy controls (12 women, 2 men; mean age of 43.4 year s) occurred. The changes of slow vital capacity in patients with MS were also not significant following 3 months and 6 months of EMST (Gosselink et al., 2000). Furthermore, FEV1 and FVC in 8 patients (1 women, 7 men; mean age of 63.1 3.1 years) with COPD trained with EMST and in 8 patients (2 women, 6 men; mean age of 62.7 3.0 years) with COPD trained with the combination of EMST and IMST al so were unchanged (Weiner et al., 2003a). Patients with COPD and sedentary healthy el derly adults have compromised expiratory flow including a low FEV1 and FVC due to changes in th e lung tissue with low elastic recoil of the lungs. Expiratory flow may de pend on the status of th e lung tissue (Chiara,

PAGE 106

94 2003; Turato et al., 2003), thus increasing resp iratory muscle strength might not alter the lung tissue in patients with COPD and se dentary healthy elde rly adults, having no significant changes in breathing function. There was one study which reports improvements in breathing function following EMST in a clinical population. Saleem ( 2005) reported significant improvement in FEV1 by 9% and in FVC by 8% from initial pre-training baseline in patients with PD following 4 weeks of EMST using the same device as us ed in the current st udy. Saleem’s positive results in comparison to the other st udies that showed no change in FEV1 and FVC might be explained by the differences in the part icipant population being given the training. FEV1 and FVC in healthy young and elderly adul ts are already with in normal limits before the training. No further benefit fr om EMST in healthy populations would be expected. In addition, the study of Saleem (2005) used multiple observations in each training condition, which might systematically increase the overall variance associated with the training effect. This could cause th e variance portion related to the training main effect to be misinterpreted as the variance a ssociated with the between-subject difference, resulting in an increase in the significance level. In the current study, there was no signifi cant effect found for EMST on ERV, but descriptive analysis demonstrated that ERV increased by 21% from preto post-training from 0.97 0.61 L and 1.18 0.61 L, respectively. Gosselink (2000) speculated that an increase in MIP followed by improved expiat ory muscle strength might be related to reduced RV. Decrease in RV would increase ERV, which allows the lungs to expand more easily during breathing. However, th is was not well documented by the current

PAGE 107

95 study. Since available outcomes examining the effects of EMST on ERV or RV are limited, further studies are needed to explai n the effect of EMST on ERV and RV. In general, expiratory muscle streng thening with an EMST program does not appear to improve FEV1 or FVC in sedentary healthy el derly. However, the effect of increasing the strength of expira tory muscles on ERV or RV in either healthy or clinical populations may be promising. Cough Function It was hypothesized that EMST would be effective in enhancing cough production as a result of increased expiratory pressure. The results in the current study substantiated this hypothesis in some cough parameters. It is known that declines in expiratory muscle strength lead to decreases in peak expiratory flow rate (PEFR) and peak-pos t plateau integral amplitude (PPPIA) during coughing in the elderly (Beardsmo re et al., 1987; Irwin et al., 1998). In the current study, the average value of PEFR obt ained before training was 4.98 2.18 L/s. This value is comparable to previous reported values (Ebihara et al., 2003; Smith Hammond et al., 2001). A study comparing aspiration risk in 18 healthy men controls (mean age of 65 3 years) and men with stroke demonstrated the PEFR values produced by the healthy elderly adults was 3.62 0.34 L/s (Smith Hammond et al., 2001). Sixteen healthy elderly women controls (mean age of 69.8 10.3 years) in a study examining cough efficacy in the patients with PD had a PEFR value of 5.27 1.17 L/s (Ebihara et al., 2003). As predicted, significant improvements in PEFR and PPPIA during the capsaicininduced cough were found in the curren t study following EMST. After the EMST

PAGE 108

96 program the average PEFR values increased by 61%, from 4.98 2.18 L/s to 8.00 3.06 L/s; the PPPIA values increased by 96%, from 3.49 2.46 L to 6.83 4.16 L. Once the glottis opens following the laryngeal compression phase, the high intrathoracic pressure which has built up promotes a burst of expiratory flow, with a rate as high as 12 L/s and extends through the e xpiratory phase with a gradual decrease to lower flow rates between 3 and 4 L/s (Irwin et al., 1998; McCool & Leith, 1987). During the sustained expiratory flow (i.e., post-peak plateau in the curre nt study), lung volume declines and intrathoracic pressure decreases. This is because intrathoracic pressure decreases leading to decreased cough expirato ry flow. It is therefore expected that increasing intrathoracic pressu re by providing an efficient fo rce-length relationship in the expiratory muscles may enhance cough expirato ry flow. However, enhancing expiratory muscle force with increasing intrathoracic pressure does not affect the PEFR values during coughs by healthy individuals because fl ow is independent of expiratory effort. As expiratory force is increased, increased resi stance within the airway to expiratory flow compresses the airways dynamically. This was observed in the EMST study with young healthy adults which did not show changes in the PEFR from pr eto post-training, regardless of MEP changes (Baker, 2003). Howe ver, individuals with expiratory muscle weakness, who begin with low intrathoraci c pressures during cough might increase cough expiratory flow because they are able to develop greater in trathoracic pressures (Baker, 2003; Irwin et al., 1998). This has been demonstrated in previous studies with other groups. The PEFR in individuals with PD increased following 4-weeks of EMST (Saleem, 2005). Additionally, PEFR increased in individuals with amyotrophic lateral

PAGE 109

97 sclerosis following insufflation and/or exsuffl ation or manual assistance (Mustfa et al., 2003). There is a close relationship between PEFR and lung volume and between PPPIA and lung volume. Both PEFR and PPPIA increa se with increases in expiratory force at high lung volumes. However, at mid or low volumes they do not increase with additional intrathoracic pressure associated with increasi ng expiratory force sinc e elastic recoil is reduced at those lung volumes (West, 1995). In individuals with respiratory muscle weakness, breathing up to higher lung volumes prior to the expira tory phase of cough may increase and sustain the intrathoracic pre ssures, which would subsequently result in increased PEFR and PPPIA. In fact, increa sed inspiratory muscle strength, and possibly reduced RV, resulting from EMST would l ead to increased lung volumes in the inspiratory phase, which would then result in greater intrathoracic pressures, thereby improving PEFR and PPPIA. Unfortunately, in spiratory volumes were not measured as part of this study. Further, increasing expiratory force with EMST would enhance the dynamic compression of the airways during the expi ratory phase of cough due to the higher intrathoracic pressures, which increases expirato ry flow velocities (Irwin et al., 1998). Higher velocities of expirato ry airflow may promote airway clearance that reduces the aspiration rate in individuals with respiratory muscle weakne ss such as sedentary elderly adults. In summary, increased expiratory force resulting from EMST may increase cough efficiency by increasing intr athoracic pressure and by increasing lung volume. This leads to increased expiratory flow rate and dyna mic airway narrowing, ultimately resulting in higher velocity of expiratory airflow.

PAGE 110

98 The compression phase duration (CPD) was significantly reduced from 0.35 0.19 seconds to 0.16 0.17 seconds, a 53% decrease followi ng 4 weeks of EMST. The CPD of young healthy people commonly lasts an average of 0.2 seconds (Chung et al., 2003; Irwin et al., 1998; McCool, 2006; Smith Hamm ond et al., 2001). The duration of the compression phase measured post-training was si milar to the average CPD value reported previously. The effect of EMST on CPD in the current study agrees with others who have examined effects of EMST. CPD significantly decreased from 0.62 0.51 seconds to 0.54 0.52 seconds by a 13% change afte r 4 weeks of EMST in young healthy individuals (Baker, 2003). The CPD in pati ents with PD, particularly the female participants, also significan tly decreased from a mean of 0.35 seconds pre-training to 0.22 seconds post-training by a change of 37% (Saleem, 2005). Shortening duration of vocal fold closure before the expiratory phase starts during cough production may be explained by changes in the speed of th e neural mechanism of cough. The airway receptors in the subglottal area detect increas es in intrathoracic pressure following EMST. Increased intrathoracic pressure builds up the sp eed of airflow, result ing in high velocity of airflow. Increased velocity of airflow at the vocal folds decreases the pressure rapidly, thus closing the vocal folds qui ckly (Bernoulli effect), lead ing to decreases in CPD. Reduced vocal fold closure time also aids in reducing expiratory muscle shortening velocity (Irwin et al., 1998; McCool, 2006). In addition, it is expected that the ac tivities of muscles involving laryngeal adduction during coughing may be affected by EMST It has been reported that laryngeal valving capacity is reduced in the elderl y (Hoit & Hixon, 1987; Honj o & Isshiki, 1980; Ptacek & Sander, 1966; Titze, 1994). This may increase the risk of aspiration. A

PAGE 111

99 previous study reported that increases in l ung volume and expiratory force influence the activation of the lateral cric oarytenoid muscle (Koizumi, Kogo, & Matsuya, 1996). The lateral cricoarytenoid muscle is a laryngeal a dductor muscle that causes the vocal folds to close tightly (Kogo, Kurimoto, Koizumi, Ni shio, & Matsuya, 1992). Kuna and Vanoye (1994) observed that the activ ity of the laryngeal adducto r muscles are increased by elevated expiratory force. Therefore, increasing lung volume and force during EMST should improve laryngeal adduction during c oughing, leading to a reduced risk of aspiration. These hypotheses were not tested in the current study, and there are no known studies which have investigated the e ffect of EMST on laryngeal closure. Also, given the significant increase in PE FR, cough effectiveness is enhanced. CPD can be minimized with increasing PEFR Shortening of CPD with co-occurring increases in PEFR makes sense since th e primary cough clearance mechanism is increased expiratory flow. As PEFR incr eased post-training, the need to increase laryngeal closure to generate intr athoracic pressures was minimized. The inspiratory phase duration (IPD) and post-peak plateau duration (PPPD) following EMST were not changed in the current study. A longer duration of the inspiratory phase may be needed to increase FVC to acquire a sufficient inspiratory lung volume before initiating expulsi ve events of cough (Saleem, 2005). The lack of findings with regard to PD accompanied by increased MIP with EMST may indicate that higher lung volumes can be achieved without increasin g the duration of inhalation. An absence of significant effects of EMST on the measure of PPPD in the face of a significant effect on PPPIA indicates that EMST likely increases the strength of expiratory muscles

PAGE 112

100 without changing the capability of expiratory muscles to sust ain their expira tory driving force. On the other hand, the total number of c oughs and the total number of expulsive events were counted and compared to invest igate whether changes in cough parameters are solely attributed to EMST, or possibly be tter explained by other factors such as the sensitivity of cough receptors. Since the cu rrent study utilized ca psaicin challenge to induce reflexive coughing from the particip ants, it is possible that increased cough sensitivity may be attributable to repeated capsaicin challenges. Counting the number of coughs has been commonly employed to exam ine cough sensitivity (Hara et al., 2005; Nieto et al., 2003; Plevkova, Brozmanova, Pecova, & Tatar, 2006). Theoretically, as cough sensitivity to capsaicin increases, the number of coughs should increase. However, neither the number of coughs nor ex pulsive events significantly changed from preto post-training. This finding indicates that enhanced cough efficiency in sedentary healthy elderly individuals was affected mainly by EMST not by changes in cough sensitivity to capsaicin challenge. This study was the first attempt to examine the effects of EMST on reflexive coughs induced by capsaicin challenge. Previous studies have examined maximal voluntary coughs to determine effects of an EMST program (Baker, 2003; Chiara, 2003; Saleem, 2005). The results demonstrated in t hose studies were inconsistent. This may be due to differences in the instructions given to elicit volunta ry coughs from the participants, differences in the maximal effort level of individual pa rticipants, or in the overall populations recruited in each study. Ho wever, cough is a reflexive event and as such the coughs should be reflexive in nature in order to clearly measure cough

PAGE 113

101 parameters and accurately determine the eff ects of EMST on cough function. Therefore, the results found for the capsaicin induced c ough, in the investigat or’s opinion, clearly reflect the potential EMST ha s an enhancing cough function. In conclusion, EMST is an effective pr ogram to increase the expiratory muscle strength and enhance the laryngeal valvi ng mechanism in sedentary healthy elderly individuals. These change s contribute to an enhan ced cough production mechanism, which may provide protection from aspirati on and effectively remove substances and pathogens trapped in the airway s of the elderly population. Swallow Function The effects of EMST on peak amplitude (PA), duration (DUR), and integral amplitude (IA) of submental (SM) muscle activity obtained from surface electromyography (sEMG) with various bolus consistencies were al so examined. The bolus consistencies were divided into three categories: maximal voluntary dry (saliva), wet (water), and thin paste (pudding), with tw o different volumes (5 cc and 10 cc). It was hypothesized that swallow func tion, especially with maximal voluntary dry and 10 cc pudding swallows, would improve as a result of the EMST program. This hypothesis was supported by noted increases in the peak am plitude (PA) and integral amplitude (IA) of SM muscle group activity from preto post-training. There were noticeable increases on the PAs in maximal voluntary dry and thin paste (i.e., 5cc pudding and 10cc pudding) swallows even though those increases were not statistically si gnificant. The PAs increased by 17% in maximal voluntary dry swallow, by 16% in 5 cc pudding swallow, and by 18% in 10 cc pudding swallows follo wing EMST. However, the PAs did not significantly change in wet swallows for bot h 5 cc and 10 cc volumes. The IA of SM muscle group activity significantly incr eased in 10 cc pudding swallow and was not

PAGE 114

102 significant but evident increase in maximal voluntary dry swallow. The percent change from preto post-training was 33% in 10 cc pudding and 16% in maximal voluntary dry swallows. The IAs of the other consistenc ies and volumes also increased, but those increases were not significant. Small amount of volumes and wet swallows are submaximal tasks which likely did not need to recruit maximal motor units, so these tasks may not have responded to EMST or a more sensitive test, such as needle EMG for examining the motor unit changes in submenta l muscle group may be necessary. Since no previous study examined the effects of EM ST on SM muscle activ ity utilizing sEMG, the changes of SM muscle activ ity in the current study was not compared with others. The PAs and IAs of SM muscle group activ ity were also signi ficantly different among each consistency. Examining overall PAs and IAs of the SM muscle group revealed that the maximum and integral ac tivity were significantly higher in maximal voluntary dry swallow than the two other consis tencies. Further, the PA and IA of SMsEMG activity was significantly higher in thin paste swallow than in wet swallow, which was consistent with the previous find ings (Ding, Logemann, Larson, & Rademaker, 2003; Reimers-Neils, Logemann, & Larson, 1994). However, there were no volume dependent differences in the PAs and IAs of SM-sEMG activity, which is also concurrent with the findings from the previous studies (Dantas & Dodds, 1990; Ding et al., 2003). As described earlier, elde rly individuals experience a reduction in swallow function. Vaiman, Eviatar, and Segal (2004b) tested voluntary dry swallows as well as water swallows in groups aged 18 to 30, a nd over 70 years and found that the elderly group presented with significantly lower activity of SM-sEMG than the younger group. In addition, an age group between those two groups demonstrat ed a significan t decline in

PAGE 115

103 the range of SM muscle group activity. Decreased SM muscle group activity with aging is generally accompanied by lower motor unit discharge rates, which can impact the swallow mechanism (Kamen, 2005). However, the EMST program may alter this agerelated swallow dysfunction. The EMST device augmented employment of the SM muscle group, thus increasing the PAs and IAs of SM-sEMG activity recorded during swallowing. Increased amplitude of sEMG activ ity can be interpreted as increased neural drive from the central nervous system to peripheral muscle fibers, resulting in enhancement of muscle streng th (Gabriel, Kamen, & Fros t, 2006; Kamen, 2005; Powers & Howley, 2001). The neural drive is relate d to motor unit discha rge rate, motor unit recruitment, rate coding, double firing (doubl et; 2 closely spaced neural firing), and motor unit synchronization (Gabriel et al., 2006 ; Kamen, 2005). This mechanism is quite resilient to strength training in the elderly. With only a br ief period of retraining, elderly people regain muscle strength and with shor t-term detraining, they lose the muscle strength (Sforzo, McManis, Black, Luniewski, & Scriber, 1995; Taaffe, 1997). In fact, the results from the current study indicate that an EMST pr ogram could increase neural drive to SM muscle group, resulting in incr eased strength of the SM muscle group during swallowing in healthy elderly adults. Further, long term application of this program may facilitate sustained strength of musc les associated with swallow function. Enhanced SM muscle group activity may also be achieved via increased expiratory lung volume and expiratory force resulting from EMST. Subsequently, resulting increases in expiratory airflow may facilitate the swallow sensory de tection mechanism. Conceivably, increased afferent feedback to the brainstem could s timulate efferents to deliver information to motor units of the SM muscle group and other muscles involved in

PAGE 116

104 the swallow process. The increased activ ity and recruitment of motor units would theoretically increase the activity of swallow musculature, including the SM muscle group. However, this assumption regarding tim ing parameters, specifically the duration of SM muscle group activity, was not suppor ted by the findings. The duration of SM activity during swallowing was not significantly differe nt from preto post-training for any consistency tested, thus not supporting the hypothesis. It is possible that an increase in SM musc le group activity as a result of the EMST program would increase hyolar yngeal displacement. During oropharyngeal swallowing, the hyoid bone moves superiorly, thereby elev ating the larynx, via contraction of SM muscles (Iwarsson & Sundberg, 1998). As hyolaryngeal displacement increases during swallowing, laryngeal glottal closure should be enhanced, thus allowing movement of the bolus into the esophagus more easily (Loge mann et al., 2000; Yokoyama et al., 2000). Increased hyoid elevation during 5 cc and 10 cc thin paste (barium) swallows as a result of EMST has been observed using videofl uoroscopy in 10 patients with PD and one healthy young adult (Saleem, 2005; Wheeler & Sapienza, 2005). There were significant effects of consis tency on the duration of SM muscle group activity. SM-sEMGs for maximal voluntary dry and thin paste swallows were longer in duration than for wet swallow. In other words, with increasing bolus viscosity the duration of SM muscle group activity significan tly increased. Ding et al. (2003) revealed that differing bolus viscosities altered the dur ation of SM activity and infrahyoid muscle activity in both young and old pa rticipant groups. Reimers-Ne ils et al. (1994) also found a significant effect of bolu s viscosity on total swallow duration and on average sEMG activity of the SM muscle group. However, the current study did not find a significant

PAGE 117

105 effect of bolus volume on the duration of SM muscle group activity, which was in agreement with in a study by Dantas and D odds (1990). These investigators concluded that bolus volume did not affect the durati on of the oropharyngeal phase. The duration of SM muscle group activity is affected only by bolus viscosity but not by bolus volume during swallowing. Based on the results of this study, it is concluded that EMST may have positive effects on the swallow function of sedentary healthy elderly individuals. The long-term continuation of an EMST program may prev ent the sedentary healthy elderly from experiencing a decline in normal swallow f unction. This may be important for reducing the risk of aspiration. Additionally, the curr ent study found little variat ion in the range of electrical activity from the sEMG measures within each consistency or training task, further supporting the use of sE MG as a reliable technique to measure the muscle activity during swallowing. This method is a simple noninvasive, reproducible way to measure the changes of muscle activity (Ding et al., 2002; Vaiman et al., 2004a, 2004b). Speech Function Aerodynamic and acoustic measures were employed to assess speech function. Excess lung pressure (PEL) was used to measure the aerodynamic component, and the acoustic component was measured based on maximum phonation durations (MPDs) of sustained vowel phonation at two levels of intensities, comfortable and maximum loudness. For the aerodynamic measure, it was hypothesized that PEL would increase significantly after a 4-week EMST program. PEL was defined as the difference between phonation threshold pressure (Pth) and lung pressure at the loudest possible intensity (PL). As was predicted, PEL was significantly affected by the EMST program. The mean PEL

PAGE 118

106 was 13.63 5.00 cm H2O in pre-training and 19.74 6.61 cm H2O post-training. Pth was not changed by EMST. The Pth was 3.11 1.17 cm H2O in pre-training and 2.94 0.77 cm H2O in post-training. These values are c ongruent with previous findings which reported average Pth values ranging from 3 to 4 cm H2O (Baken & Orlikoff, 1998; GriniGrandval, Bingenheimer, Maunsell, Ouakni ne, & Giovanni, 2002; Hodge et al., 2001; Titze, 1994). In contrast to Pth, PL significantly increased from pre-training with a mean of 16.36 6.05 cm H2O to post-training with a mean of 22.85 6.77 cm H2O. Therefore, it is concluded that the increased PEL resulted from an increase in PL and not by a change in Pth. This indicates that by increasing e xpiratory muscle strength following EMST, chest wall rigidity in the sedentary he althy elderly may be compensated for by development of the more adequate positive pressures, leading to increases in sound pressure level (Hixon, 1973; Isshiki, 1964). As explained earlier, EMST also increased inspiratory muscle strength and possibly re duced RV, resulting in increasing inspiratory lung volume. Increased inspiratory lung volume can add more positive subglottal pressure necessary to produce loud speech. Furthermore, an increase in lung pressu re following EMST may play a role in compensating for age-related decreases in the ability of the laryngeal system to control vocal loudness (Baker et al., 2001). It is known that both the respiratory system and laryngeal mechanisms play an important ro le in controlling vo cal loudness (Baker, Ramig, Luschei, & Smith, 1998; Hodge et al., 2001; Holmberg, Hillman, & Perkell, 1988; Stathopoulos & Sapienza, 1993a, 1993b)}. Th e laryngeal system in the elderly is not an efficient mechanism to increase vocal loudness secondary to insufficient vocal fold closure resulting from senes cent changes in the laryngeal musculature, joints, and

PAGE 119

107 nervous innervation (Honjo & Isshiki, 1980; Linville, 1992; Paulsen & Tillmann, 1998; Tanaka et al., 1994). Baker et al. (2001) sugge sted that higher expiratory efforts may be needed to compensate for the age-related stiffness of the vocal folds that cause a reduction in laryngeal adductory mechanism. Accordingly, EMST would theoretically be conducive in overcoming the inefficient la ryngeal adductory mechanism in elderly individuals, thereby impr oving the control of vocal loudness by augmenting the expiratory driving force. The MPD of a sustained vowel at the comfor table effort intensity level significantly increased after EMST as predicted in the hypothesis. However, MPD at the loudest possible intensity did not change. MPD at the comfortable intens ity level ranged from 5.51 to 33.91 seconds (mean of 17.78 7.90) pre-training and from 7.05 to 42.73 seconds (mean of 22.37 10.04) post-training. This increa se in MPD during the comfortable loudness level may be explained by increased expiratory driving fo rce as supported by increased MEP or increased inspiratory lung volume. It is important to note that these elderly participants were hesitant to produce loud phonation and that may have influenced the ou tcome of MPD during the loud task. Most participants reported that phonating loudly wa s not commonly used in their day to day routine and that they felt uncomfortable phonati ng at their loudest pos sible level. This may not have resulted in the best elicita tion of loud phonation, even with prompting from the investigator. To minimize this limitation in maximum phonation task, the use of white noise would be recommended to increase the in tensity level of speaker’s voice. Speakers increase their vocal loudness in the presence of increasing white noise increased (Howell, 1990).

PAGE 120

108 Summary With age, physical functions decline that can influence respiratory performance. Reductions in respiratory musc le strength, elastic recoil of the lungs, and chest wall compliance change the lung pressures nece ssary for ventilatory and non-ventilatory functions in the elderly. Th is study was designed to inves tigate the physiological effects of a 4-week EMST program on pulmonary, cough, swallow, and speech functions in the sedentary healthy elderly. The program was easy for the se dentary healthy elderly to learn and to utilize. The EMST program em ployed a user-friendly small device that was adjustable to each individual’ s capabilities and which provided significant improvements in various aspects of physiological function ove r a short period of time. Furthermore, most participants in the present study reporte d the changes in their attention to breathing and reduced number of choking events. Admittedly, there were some limitations to this study. First, eighteen elderly people participated, four men and 14 women. On e of the aims of th e current study was to document the gender differences in the eff ect of EMST. However, the unbalanced sample size for gender did not allow for co mparison of differential effects of EMST based on gender. There are more elderly women than men in the general population. According to a recent report, 60% of people 65 years or older and 72% of those 85 years or older are women (U.S. Ce nsus Bureau, 2003). Additiona lly, elderly women tend to have higher social engagement than elde rly men (Smith & Baltes, 1998; Strawbridge, Cohen, & Shema, 2000). Many elderly men were reluctant to particip ate in this study when the investigator was recruiting particip ants from retirement communities. For these reasons, the number of healt hy elderly men participating in the study was much smaller number than healthy elderly women.

PAGE 121

109 Second, EMST involves production of high expi ratory efforts which are associated with health risks, particularly for individua ls with high blood pressu re or hernia. One study participant withdrew because he was c oncerned about increases in blood pressure, even though he had no history of it. EMST is not applicable for the elderly who have heart or vascular problems or those with untreated hypertension since EMST needs high pressure to overcome the pressure threshold se t in the training device. Thus clinicians or researchers should use caution when examining the health status of the elderly before implementing the EMST program. Third, the present study explored the effect of only 4 weeks of EMST. A recent study in a patient with early id iopathic Parkinson's disease re ported that a longer duration of the EMST program leads to more improveme nt in expiratory muscle strength (Saleem et al., 2005). This re sult is a very important finding, esp ecially for the elderly population. Since aging is a continuous process, continuing the EMST program in the elderly may help to prevent or compensate for age -related deteriorations in pulmonary, cough, swallow, and speech mechanisms. However, the present study does not have direct evidence to support this explanation. In conclusion, the results from this study supported that EMST may be an effective way to change or compensate for age-relate d neuromuscular deterioration in pulmonary, cough, swallow, and speech functions. These e ffects have the potential to decrease the risk of aspiration in the sedentary elderly by increasing expiratory flow rate during cough, by augmenting submental muscle activation during swallowing, and by enhancing the laryngeal adductory mechanism. Results of this study also suggest that sarcopenia might be reversible, and that continued EMST ma y prevent sarcopenia and the subsequent

PAGE 122

110 impact on pulmonary, cough, swallow, and speech functions. This may lead to improvement in the quality of life of elderly individuals. EMST seems to be a viable treatment tool for overcoming functional dec line resulting from sarcopenia in the healthy sedentary elderly.

PAGE 123

111 APPENDIX A INFORMATION FLYER Are You Interested in Exercising Your Breathing Muscles? To be eligible you must: be over 65 years of age and sedentary have no history of cardiac, lung, neuromuscular, immune system disease, or untr eated hypertension have no history of smoking or toba cco use in the last five years For more information, pleas e contact Jaeock Kim at jokim@csd.ufl.edu Phone: (352) 392-2046, ext. 221. To gain mo re information about her dissertation project supervised by Dr. C. Sapienza at sapienza@csd.ufl.edu The Communication Sciences and Disorders Department is looking for subjects to participate in a research study to measure the effect of breathing exercise training in healthy elderly.

PAGE 124

112 APPENDIX B SCREENING PHYSICAL ACTIVITY QUESTIONNAIRE Describes total amount of physical activity on an average weekday. Examples Minutes Hours Time: Sleep, rest 15 30 45 1 2 3 4 5 6 7 8 9 10 Sitting quietly, watching television, listening to music or reading 15 30 45 1 2 3 4 5 6 7 8 9 10 Working at a computer or desk, sitting in a meeting, eating 15 30 45 1 2 3 4 5 6 7 8 9 10 Standing, washing dishes or cooking, driving a car or truck 15 30 45 1 2 3 4 5 6 7 8 9 10 Light cleaning, sweeping floors, food shopping with grocery cart, slow dancing or walking downstairs 15 30 45 1 2 3 4 5 6 7 8 9 10 Bicycling to work or for pleasure, brisk walking, painting or plastering 15 30 45 1 2 3 4 5 6 7 8 9 10 Gardening, carrying, loading or stacking wood, carrying light object upstairs 15 30 45 1 2 3 4 5 6 7 8 9 10 Aerobics, health club exercise, chopping wood or shoveling snow 15 30 45 1 2 3 4 5 6 7 8 9 10 More effort than level H: Running, racing on bicycle, playing soccer, handball or tennis 15 30 45 1 2 3 4 5 6 7 8 9 10 Source: Aadahl, M. & Jorgnense n, T. (2003). Validation of a new self-report instrument for measuring physical activity. Medicine and Science in Sports and Exercise, 35 (7), 1196-1202.

PAGE 125

113 APPENDIX C SCREENING HEALTH QUESTIONNAIRE I. Demographics Name__________________________________________ Sex___________ Address_______________________________________________ City____________________ State________ Zip Code_________ Birth of date________________ Tel: (H) ________________ (W)________________ II. Physical Characteristics 1. Height______________ Weight____________ 2. Rate your health on this scal e compared to others your age 1 2 3 4 5 1= very good 2= good 3= fair 4= poor 5= very poor 3. List the major surgeries you have had within the last 5 years. 4. Are you being treated at the present time for any medical conditions? If yes, please specify. 5. Please list your medications. 6. Blood pressure (It will be m easured by the investigators.) Systolic / Diastolic (mmHg) ______________ / ______________

PAGE 126

114 III. Physical Activity Rate your daily physical ac tivity on this scale. 1 2 3 4 5 1= not active 5= extremely active 2. Do you plan to increase or decrease your physical activity over the next several months? Yes/No If yes, how do you plan to change? IV. Medical History 1. Do you currently have or have a history of the following: Check as many as apply. _____ Smoking in the last 5 years _____ Respiratory/breathing problems/asthma _____ Diagnosis of lung cancer in the last 1 year _____ Upper of lower respiratory trac t infection in the last 2 weeks _____ Musculoskeletal disorders _____ Hypertension (treated or untreated) _____ Immune system diseases _____ Aneurysm _____ Stroke _____ Hernias _____ Gastroesophageal reflux disease _____ Cardiovascular problems _____ Neuromuscular problems 2. __Y __N Do you have asthma or other conditions that affect your breathing? 3. __Y __N Have you had a recent cold or flu? 4. __Y __N Do you have allergies? 8. __Y __N Have you ever smoked tobacco products? If you used to smoke, for how ma ny years and when did you stop? Developed by Laryngeal Func tion Laboratory, Department of Communication Sciences and Disorders, University of Florida. July, 2004.

PAGE 127

115 APPENDIX D CAPSAICIN SOLUTION PREPARATION 0.06108g of Capsaicin dissolved in 0.40ml of EtOH (500mM) Add 0.200ml of Tween 80 and 1.400ml of Saline Final = 100mM Capsaicin in 70% Saline, 20% EtOH, 10% Tween 80 0.300ml of 100mM Capsaicin Stock + 149.700ml of Saline Final Concentration = 200M Capsaici n in Saline (0.02% Tween, 0.04% EtOH) Make 500mls of Saline with final concentration 0.02% Tween, 0.04% EtOH to be used in all remaining dilutions 150M Capsaicin in Vehicle = 52.5 ml of 200M + 17.5ml of Vehicle 100M Capsaicin in Vehicle = 35 ml of 200M + 35ml of Vehicle 50M Capsaicin in Vehicle = 20ml of 150M + 40ml of Vehicle 25M Capsaicin in Vehicle = 15ml of 100M + 45ml of Vehicle 10M Capsaicin in Vehicle = 10 ml of 50M + 40ml of Vehicle 5M Capsaicin in Vehicle = 10ml of 25M + 40ml of Vehicle Provided by Department of Physiological Sc iences, College of Veterinary Medicine, University of Florida. July, 2004.

PAGE 128

116 APPENDIX E RESPIRATORY MUSCLE TRAINING PROGRAM INSTRUCTIONS This training is to increase the strength of your respiratory muscles just like a general body exercise program. You will complete this training program 5 da ys per week. You will complete 5 sets of the exercises with 5 repetitions each time you complete your training. You have been given a respiratory trainer to complete your trai ning at home. You will use this same trainer for the next 4 w eeks that you are particip ating in this study. EACH WEEK OF TRAINING 1. Place the nose clip on your nose. 2. Breathe in as much air as you can, a nd place the mouth piece in your mouth. 3. As soon as the mouth piece is your mouth, breathe out as much air as you can. o Keep a tight seal with your mouth around the mouth piece. o When the expiratory pressure is strong enough to open the valve, you will hear a rush of air move through the device. 4. Repeat this expiratory exercise 5 times (steps 1-4), resting for 30 seconds to 1 minute in between each inspiration. 5. When you have finished all 5 expirations, rest for 2 minutes (you have completed 1 set) 6. After you have rested for 2 minut es, repeat steps 1-5 (for the 5 repetitions) 7. You will continue with this pattern of 5 expirations and 2 minute breaks until you have completed the 5 expirations procedure 5 times (now you have completed 5 sets) 8. On your training log, record the date a nd the time you completed these exercises 9. You will need to complete steps 1-8, 5 times during the week. 10. At the end of this training week, you w ill have an appointment during which your maximum expiratory pressure will be taken and your respiratory tr ainer will be reset.

PAGE 129

117 APPENDIX F PRESSURE THRESHOLD TRAINING LOG TRAINING LOG Week 1 Start Date MEP 1 MEP2 MEP3 Avg. MEP Trainer Setting Date Time SET 1 (5 breaths) SET 2 (5 breaths) SET 3 (5 breaths) SET 4 (5 breaths) SET 5 (5 breaths) Week 2 Start Date MEP 1 MEP2 MEP3 Avg. MEP Trainer Setting Date Time SET 1 (5 breaths) SET 2 (5 breaths) SET 3 (5 breaths) SET 4 (5 breaths) SET 5 (5 breaths)

PAGE 130

118 Week 3 Start Date MEP1 MEP2 MEP3 Avg. MEP Trainer Setting Date Time SET 1 (5 breaths) SET 2 (5 breaths) SET 3 (5 breaths) SET 4 (5 breaths) SET 5 (5 breaths) Week 4 Start Date MEP1 MEP2 MEP3 Avg. MEP Trainer Setting Date Time SET 1 (5 breaths) SET 2 (5 breaths) SET 3 (5 breaths) SET 4 (5 breaths) SET 5 (5 breaths) If you have any question or comment, cont act Jaeock Kim at (352) 392-2046 x 221 or after hours at (352) 871-3361; E-mail at jokim@csd.ufl.edu

PAGE 131

119 APPENDIX G ABBREVIATION TABLE Abbreviation Titles 5W 5 cc water swallow 5P 5 cc pudding swallow 10W 10 cc water swallow 10P 10 cc pudding swallow COMF Comfortable intensity level CPD Compression phase duration DRY Maximal voluntary dry swallow DUR Duration of submental muscle group activity DV Dependent variable EMST Expiratory muscle strength training ERV Expiratory reserve volume FEV1 Forced expiratory volume in 1 second FEV1/FVC The ratio of FEV1 to FVC FVC Forced vital capacity IA Integral amplitude of s ubmental muscle group activity IMST Inspiratory muscle strength training IPD Inspiratory phase duration LOUD Loudest possible intensity level MEP Maximum expiratory pressure MIP Maximum inspiratory pressure MPD Maximum phonation duration PA Peak amplitude of subm ental muscle group activity PEFR Peak expiratory flow rate PEL Excess lung pressure PL Lung pressure Pth Phonation threshold pressure PO Intra-oral pressure PPPD Post-peak plateau duration PPPIA Post-peak plateau integral amplitude SM Submental muscle group sEMG Surface electromyography

PAGE 132

120 LIST OF REFERENCES Aadahl, M., & Jorgensen, T. (2003). Validat ion of a new self-report instrument for measuring physical activity. Medicine and Science in Sports and Exercise, 35 (7), 1196-1202. Agresti, A., & Finlay, B. (1999). Compari ng groups: analysis of variance methods (Chapter 12). In Statistical methods for the social sciences. (2nd ed., pp. 472). New York, NY.: Macmillan Coll Div. Amonette, W. E., & Dupler, T. L. (2001). The effects of respiratory muscle training on maximal and submaximal cardiovascular and pulmonary measurements. University of Houston-Clear Lake: Fi tness & Human Performance Laboratory. Babb, T. G., & Rodarte, J. R. (2000). Mechan ism of reduced maximal expiratory flow with aging. Journal of Applied Physiology, 89 (2), 505-511. Baken, R. J., & Orlikoff, R. F. (1998). Clinical measurement of speech and voice. (2nd ed.). San Diego, CA: Singular. Baker, K. K., Ramig, L. O., Luschei, E. S., & Smith, M. E. (1998). Thyroarytenoid muscle activity associated with hypophoni a in Parkinson disease and aging. Neurology, 51 (6), 1592-1598. Baker, K. K., Ramig, L. O., Sapir, S., Lusche i, E. S., & Smith, M. E. (2001). Control of vocal loudness in young and old adults. Journal of Speech, Language, and Hearing Research, 44 (2), 297-305. Baker, S., Davenport, P., & Sapienza, C. (2005). Examination of strength training and detraining effects in expiratory muscles. Journal of Speech, Language, and Hearing Research, 48 (6), 1325-1333. Baker, S. E. (2003). Expiratory muscle strength tr aining and detraining: effects on speech and cough production. Unpublished doctoral di ssertation, University of Florida, Gainesville, Florida. Baumgartner, R. N., Koehler, K. M., Gallaghe r, D., Romero, L., Heymsfield, S. B., Ross, R. R., Garry, P. J., & Lindeman, R. D. (1998). Epidemiology of sarcopenia among the elderly in New Mexico. American Journal of Epidemiology, 147 (8), 755-763.

PAGE 133

121 Beardsmore, C. S., Wimpress, S. P., Thom son, A. H., Patel, H. R., Goodenough, P., & Simpson, H. (1987). Maximum voluntary cough: an indication of airway function. Bulletin Europeen de Physi opathologie Respiratoire, 23 (5), 465-472. Bemben, M. G., & Murphy, R. E. (2001). Age related neural adaptation following short term resistance training in women. The Journal of Sports Medicine and Physical Fitness, 41 (3), 291-299. Berry, J. K., Vitalo, C. A., Larson, J. L., Pa tel, M., & Kim, M. J. (1996). Respiratory muscle strength in older adults. Nursing Research, 45 (3), 154-159. Black, L. F., & Hyatt, R. E. (1969). Maximal respiratory pressures: normal values and relationship to age and sex. The American Review of Respiratory Disease, 99 (5), 696-702. Booth, F., & Weeden, S. (1993). Structural aspe cts of aging human skeletal muscle. In J. A. Buckwalter, V. M. Goldberg & S. L. Y. Woo (Eds.), Musculoskeletal soft-tissue aging: Impact on Mobility. Rosemont, IL: American Academy of Orthopaedic Surgeons. Bott, J., & Agent, P. (2001). Physiother apy and nursing during non-invasive positive pressure ventilation. In A. K. Simonds (Ed.), Non-invasive respiratory support: a practical handbook (pp. 230-247). London: Arnold. Bouros, D., Siafakas, N., & Green, M. (1995). Cough: Physiological and pathophysiological considerati ons. In C. Roussos (Ed.), The thorax (pp. 13351354). New York, NY: Marcel Dekker. Bowling, A., & Dieppe, P. (2005). What is su ccessful ageing and who should define it? Bmj, 331 (7531), 1548-1551. Brooks, S. V., & Faulkner, J. A. (1995). Effect s of aging on the structure and function of skeletal muscle. In C. Roussos (Ed.), The thorax: part A: physiology. (Vol. 85, pp. 295-312). New York, NY: Marcel. Dekker. Brown, M., & Hasser, E. M. (1996). Complex ity of age-related change in skeletal muscle. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 51 (2), B117-123. Bruschi, C., Cerveri, I., Zoia, M. C., Fanfulla F., Fiorentini, M., Ca sali, L., Grassi, M., & Grassi, C. (1992). Reference values of maximal respiratory mouth pressures: a population-based study. The American Review of Respiratory Disease, 146 (3), 790793. Burr, M. L., Phillips, K. M., & Hurst, D. N. (1985). Lung function in the elderly. Thorax, 40 (1), 54-59.

PAGE 134

122 Burzynski, C. M. (1987). The voice. In H. G. Mueller & V. C. Geoffrey (Eds.), Communication disorders in agi ng: assessment and management. Washington, DC: Gallaudet University. Campbell, E. (2001). Physiologic changes in respiratory function. In M. Katli (Ed.), Principles and practice of geriatric surgery (pp. 396-405). New York, NY: Springer-Verlag. Campbell, M. L., Sheets, D., & Strong, P. S. (1999). Secondary health conditions among middle-aged individuals with chronic physic al disabilities: imp lications for unmet needs for services. Assistive Technology, 11 (2), 105-122. Carolan, B., & Cafarelli, E. (1992). Adaptations in coactivation after isometric resistance training. Journal of Applied Physiology, 73 (3), 911-917. Caskey, C. I., Zerhouni, E. A ., Fishman, E. K., & Rahmouni, A. D. (1989). Aging of the diaphragm: a CT study. Radiology, 171 (2), 385-389. Cerny, F., Panzarella, K., & Stathopoulus, E. (1997). Expiratory muscles conditioning in hypotonic children with low vocal intensity levels. Journal of Medical SpeechLanguage Pathology (5), 141-152. Chan, E. D., & Welsh, C. H. (1998) Geriatric respiratory medicine. Chest, 114 (6), 17041733. Charette, S. L., McEvoy, L., Pyka, G., Snow-H arter, C., Guido, D., Wiswell, R. A., & Marcus, R. (1991). Muscle hypertrophy res ponse to resistance training in older women. Journal of Applied Physiology, 70 (5), 1912-1916. Chatwin, M., Ross, E., Hart, N., Nickol, A. H., Polkey, M. I., & Simonds, A. K. (2003). Cough augmentation with mechanical insuffl ation/exsufflation in patients with neuromuscular weakness. The European Respiratory Journal, 21 (3), 502-508. Chen, H. I., & Kuo, C. S. (1989). Relationshi p between respiratory muscle function and age, sex, and other factors. Journal of Applied Physiology, 66 (2), 943-948. Chiara, T. (2003). Expiratory muscle strength trai ning in individuals with multiple sclerosis and health controls. Unpublished doctoral disse rtation, University of Florida, Gainesville, Florida. Chung, F., Widdicombe, J., & Boushey, H. (2003). Cough: causes, mechanisms and therapy. Massachusetts, MA: Blackwell Publishing. Dantas, R. O., & Dodds, W. J. (1990). E ffect of bolus volume and consistency on swallow-induced submental and in frahyoid electromyographic activity. Brazilian Journal of Medical and Biological Research, 23 (1), 37-44.

PAGE 135

123 de Bruin, P. F., de Bruin, V. M., Lees, A. J ., & Pride, N. B. (1993). Effects of treatment on airway dynamics and respiratory musc le strength in Parkinson's disease. The American Review of Respiratory Disease, 148 (6 Pt 1), 1576-1580. Dicpinigaitis, P. V. (2003). Shortand l ong-term reproducibility of capsaicin cough challenge testing. Pulmonary Pharmacology & Therapeutics, 16 (1), 61-65. Dicpinigaitis, P. V., & Alva, R. V. (2005). Safety of capsaicin cough challenge testing. Chest, 128 (1), 196-202. DiGiovanna, A. G. (1994). Human aging: biological perspective s. New York, NY: McGraw-Hill Inc. Ding, R., Larson, C. R., Logemann, J. A ., & Rademaker, A. W. (2002). Surface electromyographic and electr oglottographic studies in normal subjects under two swallow conditions: normal and during the Mendelsohn manuever. Dysphagia, 17 (1), 1-12. Ding, R., Logemann, J. A., Larson, C. R., & Ra demaker, A. W. (2003). The effects of taste and consistency on swallow physiology in younger and older healthy individuals: a surface electromyographic study. Journal of Speech, Language, and Hearing Research, 46 (4), 977-989. DiPietro, L. (2001). Phys ical activity in aging: changes in patterns and their relationship to health and function. The Journals of Gerontology. Se ries A, Biological Sciences and Medical Sciences, 56 Spec No 2 13-22. Doherty, T. J. (2003). Invited review: Aging and sarcopenia. Journal of Applied Physiology, 95 (4), 1717-1727. Doherty, T. J., Vandervoort, A. A., & Brow n, W. F. (1993). Effects of ageing on the motor unit: a brief review. Canadian Journal of Applied Physiology, 18 (4), 331358. Doherty, T. J., Vandervoort, A. A., Taylor, A. W., & Brown, W. F. (1993). Effects of motor unit losses on strength in older men and women. Journal of Applied Physiology, 74 (2), 868-874. Doty, R. W., Richmond, W. H., & Storey, A. T. (1967). Effect of medullary lesions on coordination of deglutition. Experimental Neurology, 17 (1), 91-106. Ebihara, S., Saito, H., Kanda, A., Nakajoh, M ., Takahashi, H., Arai, H., & Sasaki, H. (2003). Impaired efficacy of cough in patients with Parkinson disease. Chest, 124 (3), 1009-1015.

PAGE 136

124 Enright, P. L., Kronmal, R. A., Higgins, M., Schenker, M., & Haponik, E. F. (1993). Spirometry reference values for wo men and men 65 to 85 years of age. Cardiovascular health study. The American Review of Respiratory Disease, 147 (1), 125-133. Enright, P. L., Kronmal, R. A., Manolio, T. A., Schenker, M. B., & Hyatt, R. E. (1994). Respiratory muscle strength in the el derly. Correlates a nd reference values. Cardiovascular Health Study Research Group. American Journal of Respiratory and Critical Care Medicine, 149 (2 Pt 1), 430-438. Ertekin, C., Pehlivan, M., Aydogdu, I., Ertas, M., Uludag, B., Cele bi, G., Colakoglu, Z., Sagduyu, A., & Yuceyar, N. (1995). An elect rophysiological i nvestigation of deglutition in man. Muscle & Nerve, 18 (10), 1177-1186. Fiatarone, M. A., Marks, E. C., Ryan, N. D., Me redith, C. N., Lipsitz, L. A., & Evans, W. J. (1990). High-intensity strength traini ng in nonagenarians. Effects on skeletal muscle. The Journal of the American Medical Association, 263 (22), 3029-3034. Fiatarone, M. A., O'Neill, E. F., Ryan, N. D., Clements, K. M., Solares, G. R., Nelson, M. E., Roberts, S. B., Kehayias, J. J., Lipsitz L. A., & Evans, W. J. (1994). Exercise training and nutritional supplementation for phys ical frailty in very elderly people. The New England Journal of Medicine, 330 (25), 1769-1775. Fink, B. R., & Demarest, R. J. (1978). Laryngeal biomechanics Cambridge, MA: Harvard University. Fleck, S. J., & Kraemer, W. J. (1997). Resist ance training and exerci se prescription. In Designing Resistance Training Programs (2nd ed., pp. 81179). Champaign, IL: Human Kinetics. Frontera, W. R., Hughes, V. A., Krivickas, L. S., Kim, S. K., Foldvari, M., & Roubenoff, R. (2003). Strength training in older wo men: early and late changes in whole muscle and single cells. Muscle & Nerve, 28 (5), 601-608. Frontera, W. R., Hughes, V. A., Lutz, K. J ., & Evans, W. J. (1991). A cross-sectional study of muscle strength and mass in 45to 78-yr-old men and women. Journal of Applied Physiology, 71 (2), 644-650. Gabriel, D. A., Kamen, G., & Frost, G. (2006) Neural adaptations to resistive exercise: mechanisms and recommendations for training practices. Sports Medicine, 36 (2), 133-149. Gauchard, G. C., Tessier, A., Jeandel, C ., & Perrin, P. P. (2003). Improved muscle strength and power in el derly exercising regularly. International Journal of Sports Medicine, 24 (1), 71-74.

PAGE 137

125 Gibson, G. J., Pride, N. B., O'Cain, C., & Qu agliato, R. (1976). Sex and age differences in pulmonary mechanics in normal nonsmoking subjects. Journal of Applied Physiology, 41 (1), 20-25. Gorini, M., Misuri, G., Duranti, R., Iande lli, I., Mancini, M. & Scano, G. (1997). Abdominal muscle recruitment and PEEP i during bronchoconstriction in chronic obstructive pulmonary disease. Thorax, 52 (4), 355-361. Gosselink, R., Kovacs, L., Ketelaer, P., Cart on, H., & Decramer, M. (2000). Respiratory muscle weakness and respiratory muscle training in severely disabled multiple sclerosis patients. Archives of Physical Me dicine and Rehabilitation, 81 (6), 747751. Goto, K., Nagasawa, M., Yanagisawa, O., Kiz uka, T., Ishii, N., & Takamatsu, K. (2004). Muscular adaptations to combinations of highand low-intensity resistance exercises. Journal of Strength and Conditioning Research, 18 (4), 730-737. Gozal, D., & Thiriet, P. (1999). Respiratory muscle training in neuromuscular disease: long-term effects on strength and load perception. Medicine and Science in Sports and Exercise, 31 (11), 1522-1527. Greenlund, L. J., & Nair, K. S. (2003). Sa rcopenia--consequences, mechanisms, and potential therapies. Mechanisms of Ageing and Development, 124 (3), 287-299. Grini-Grandval, M. N., Bingenheimer, S., Ma unsell, R., Ouaknine, M., & Giovanni, A. (2002). Phonatory threshold pressure in a healthy population before and after aerosol treatment, a preliminary study. Revue de Laryngologie, Otologie, & Rhinologie, 123 (5), 311-314. Gross, R. D., Atwood, C. W., Jr., Grayhac k, J. P., & Shaiman, S. (2003). Lung volume effects on pharyngeal swallowing physiology. Journal of Applied Physiology, 95 (6), 2211-2217. Hakkinen, K. (1989). Neuromuscular and hor monal adaptations during strength and power training. A review. The Journal of Sports Medici ne and Physical Fitness, 29 (1), 9-26. Hakkinen, K., Alen, M., Kallinen, M., Ne wton, R. U., & Kraemer, W. J. (2000). Neuromuscular adaptation during prolonged strength training, detraining and restrength-training in middleaged and elderly people. European Journal of Applied Physiology, 83 (1), 51-62. Hakkinen, K., & Hakkinen, A. (1991). Muscle cross-sectional area, force production and relaxation characteristics in women at different ages. European Journal of Applied Physiology and Occupational Physiology, 62 (6), 410-414.

PAGE 138

126 Hakkinen, K., Kallinen, M., Izquierdo, M., J okelainen, K., Lassila, H., Malkia, E., Kraemer, W. J., Newton, R. U., & Alen, M. (1998). Changes in agonist-antagonist EMG, muscle CSA, and force during stre ngth training in middle-aged and older people. Journal of Applied Physiology, 84 (4), 1341-1349. Hakkinen, K., Kraemer, W. J., Newton, R. U., & Alen, M. (2001). Changes in electromyographic activity, muscle fibre and force production characteristics during heavy resistance/power strength tr aining in middle-aged and older men and women. Acta physiologica Scandinavica, 171 (1), 51-62. Hakkinen, K., Newton, R. U., Gordon, S. E., McCormick, M., Volek, J. S., Nindl, B. C., Gotshalk, L. A., Campbell, W. W., Evans, W. J., Hakkinen, A., Humphries, B. J., & Kraemer, W. J. (1998). Changes in muscle morphology, electromyographic activity, and force production characteristic s during progressive strength training in young and older men. The Journals of Gerontology. Se ries A, Biological Sciences and Medical Sciences, 53 (6), B415-423. Hara, J., Fujimura, M., Myou, S., Oribe, Y ., Furusho, S., Kita, T., Katayama, N., Abo, M., Ohkura, N., Herai, Y., Hori, A., Ishiur a, Y., Nobata, K., Ogawa, H., Yasui, M., Kasahara, K., & Nakao, S. (2005). Comparis on of cough reflex sensitivity after an inhaled antigen challenge between activel y and passively sensitized guinea pigs. Cough, 1 6. Harver, A., Mahler, D. A., & Daubenspeck, J. A. (1989). Targeted inspiratory muscle training improves respiratory muscle functi on and reduces dyspnea in patients with chronic obstructive pulmonary disease. Annals of Internal Medicine, 111 (2), 117124. Hixon, T. J. (1973). Kinematics of the ch est wall during speech production: volume displacements of the rib cage, abdomen, and lung. Journal of Speech and Hearing Research, 16 (1), 78-115. Hodge, F. S., Colton, R. H., & Kelley, R. T. (2001). Vocal intensity characteristics in normal and elderly speakers. Journal of Voice, 15 (4), 503-511. Hoffman-Ruddy, B. (2001). Expiratory pressure thres hold training in high-risk performers. Unpublished doctoral dissertation, Univ ersity of Florida, Gainesville, Florida. Hoit, J. D., & Hixon, T. J. (1987). Age and speech breathing. Journal of Speech and Hearing Research, 30 (3), 351-366. Holmberg, E. B., Hillman, R. E., & Perkell, J. S. (1988). Glottal airflow and transglottal air pressure measurements for male and female speakers in soft, normal, and loud voice. The Journal of the Acoustical Society of America, 84 (2), 511-529. Honjo, I., & Isshiki, N. (1980) Laryngoscopic and voice characteristics of aged persons. Archives of Otolaryngology, 106 (3), 149-150.

PAGE 139

127 Howell, P. (1990). Changes in voice level cause d by several forms of altered feedback in fluent speakers and stutterers. Language and speech, 33 ( Pt 4) 325-338. Hsiao, S. F., Wu, Y. T., Wu, H. D., & Wang, T. G. (2003). Comparison of effectiveness of pressure threshold and targeted resist ance devices for inspiratory muscle training in patients with chronic obstructive pulmonary disease. Journal of the Formosan Medical Association, 102 (4), 240-245. Iannuzzi-Sucich, M., Prestwood, K. M., & Kenny, A. M. (2002). Prevalence of sarcopenia and predictors of skeletal muscle mass in healthy, older men and women. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 57 (12), M772-777. Irwin, R. S., Boulet, L. P., Cloutier, M. M., Fu ller, R., Gold, P. M., Hoffstein, V., Ing, A. J., McCool, F. D., O'Byrne, P., Poe, R. H ., Prakash, U. B., Pratter, M. R., & Rubin, B. K. (1998). Managing cough as a defe nse mechanism and as a symptom. A consensus panel report of the American College of Chest Physicians. Chest, 114 (2 Suppl Managing), 133S-181S. Isshiki, N. (1964). Regulatory Mechan ism of Voice Inte nsity Variation. Journal of Speech and Hearing Research, 128 17-29. Iwarsson, J., & Sundberg, J. (1998). Effects of lung volume on vertical larynx position during phonation. Journal of Voice, 12 (2), 159-165. Janssens, J. P., Pache, J. C., & Nicod, L. P. (1999). Physiological changes in respiratory function associated with ageing. The European Respiratory Journal, 13 (1), 197205. Jaradeh, S. (1994). Neurophysiology of swallowing in the aged. Dysphagia, 9 (4), 218220. Kahane, J. (1981). Anatomic and physiologic changes in the aging peripheral speech mechanism. In D. S. Beasley & G. A. Davis (Eds.), Aging communication processes and disorders (pp. 21-45). New York, NY: Grune & Stratton. Kahrilas, P. J., & Logemann, J. A. (1993) Volume accommodation during swallowing. Dysphagia, 8 (3), 259-265. Kamen, G. (2005). Aging, resistance traini ng, and motor unit discharge behavior. Canadian Journal of Applied Physiology, 30 (3), 341-351. Kang, S. W., Shin, J. C., Park, C. I., Moon, J. H., Rha, D. W., & Cho, D. H. (2005). Relationship between inspiratory muscle strength and cough capacity in cervical spinal cord injured patients Advance online publication. Retrieved March 1, 2006, from the PubMed database.

PAGE 140

128 Karvonen, J., Saarelainen, S., & Nieminen, M. M. (1994). Measurement of respiratory muscle forces based on maximal insp iratory and expiratory pressures. Respiration, 61 (1), 28-31. Kelly, A. M., Rosser, B. W., Hoffman, R., Pane ttieri, R. A., Schiaffino, S., Rubinstein, N. A., & Nemeth, P. M. (1991). Metabolic and contractile prot ein expression in developing rat diaphragm muscle. The Journal of Neuroscience, 11 (5), 1231-1242. Kikawada, M., Iwamoto, T., & Takasaki, M. (2005). Aspiration a nd infection in the elderly : epidemiology, di agnosis and management. Drugs & aging, 22 (2), 115130. Kim, J., Sapienza, C., & Davenport, P. (2005, November). Respiratory muscle strength training for rehabilitating the elderly: A preliminary study Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, San Diego, CA. Knudson, R. J. (1991). Physiology of the agi ng lung. In R. G. Crystal & J. B. West (Eds.), The lung scientific foundations (pp. 1749-1759). New York, NY: Raven. Knudson, R. J., Lebowitz, M. D., Holberg, C. J., & Burrows, B. (1983). Changes in the normal maximal expiratory flow-vol ume curve with growth and aging. The American Review of Respiratory Disease, 127 (6), 725-734. Kobayashi, H., Hoshino, M., Okayama, K., Sekizawa, K., & Sasaki, H. (1994). Swallowing and cough reflexes after onset of stroke. Chest, 105 (5), 1623. Kogo, M., Kurimoto, T., Koizumi, H., Nishi o, J., & Matsuya, T. (1992). Respiratory activities in relation to palatal muscle contraction. The Cleft Palate-Craniofacial Journal, 29 (2), 174-178. Koizumi, H., Kogo, M., & Matsuya, T. (1996). Coordination between palatal and laryngeal muscle activities in response to rebreathing and lung inflation. The Cleft Palate-Craniofacial Journal, 33 (6), 459-462. Krumpe, P. E., Knudson, R. J., Parsons, G., & Reiser, K. (1985). The aging respiratory system. Clinics in Geriatric Medicine, 1 (1), 143-175. Kuna, S. T., & Vanoye, C. R. (1994). Laryng eal response during forced vital capacity maneuvers in normal adult humans. American Journal of Respiratory and Critical Care Medicine, 150 (3), 729-734. Larson, J. L., Kim, M. J., Sharp, J. T., & Larson, D. A. (1988). Inspiratory muscle training with a pressure threshold br eathing device in patients with chronic obstructive pulmonary disease. The American Review of Respiratory Disease, 138 (3), 689-696.

PAGE 141

129 Larsson, L. (1983). Histochemical characterist ics of human skeletal muscle during aging. Acta physiologica Scandinavica, 117 (3), 469-471. Larsson, L., Grimby, G., & Karl sson, J. (1979). Muscle streng th and speed of movement in relation to age and muscle morphology. Journal of Applied Physiology, 46 (3), 451-456. Leith, D. E., & Bradley, M. (1976). Ventilatory muscle strength and endurance training. Journal of Applied Physiology, 41 (4), 508-516. Leong, B., Kamen, G., Patten, C., & Burke, J. R. (1999). Maximal motor unit discharge rates in the quadriceps muscle s of older weight lifters. Medicine and Science in Sports and Exercise, 31 (11), 1638-1644. Lexell, J., Downham, D. Y., Larsson, Y., Bruhn, E., & Morsing, B. (1995). Heavyresistance training in olde r Scandinavian men and wome n: shortand long-term effects on arm and leg muscles. Scandinavian Journal of Medicine & Science in Sports, 5 (6), 329-341. Lexell, J., Robertsson, E., & Stenstrom, E. ( 1992). Effects of strength training in elderly women. Journal of the American Geriatrics Society, 40 (2), 190-191. Lexell, J., Taylor, C. C., & Sjostrom, M. (1988) What is the cause of the ageing atrophy? Total number, size and proportion of different fiber types studied in whole vastus lateralis muscle from 15to 83-year-old men. Journal of the Neurological Sciences, 84 (2-3), 275-294. Linville, S. E. (1992). Glot tal gap configurations in two age groups of women. Journal of Speech and Hearing Research, 35 (6), 1209-1215. Logemann, J. A. (1990). Effects of aging on the swallowing mechanism. Otolaryngologic Clinics of North America, 23 (6), 1045-1056. Logemann, J. A. (1998). Evaluation and treatment of swallowing disorders (2nd ed.). Austin, TX: Pro-ed. Logemann, J. A., Pauloski, B. R., Rademaker, A. W., Colangelo, L. A., Kahrilas, P. J., & Smith, C. H. (2000). Temporal and biomech anical characteristics of oropharyngeal swallow in younger and older men. Journal of Speech and Hearing Research, 43 (5), 1264-1274. Lotters, F., van Tol, B., Kwakkel, G., & Gosselink, R. (2002). Effects of controlled inspiratory muscle training in patients with COPD: a meta-analysis. The European Respiratory Journal, 20 (3), 570-576.

PAGE 142

130 Luschei, E. S., Ramig, L. O., Baker, K. L., & Smith, M. E. (1999). Discharge characteristics of laryngeal single mo tor units during phonation in young and older adults and in persons with parkinson disease. Journal of Neurophysiology, 81 (5), 2131-2139. Macaluso, A., & De Vito, G. (2004). Musc le strength, power and adaptations to resistance training in older people. European Journal of Applied Physiology, 91 (4), 450-472. Mahler, D. A. (1983). Pulmonary aspects of aging. In S. E. Linville (Ed.), Vocal aging (pp. 19-35). CA: Singular. Maltin, C. A., Duncan, L., & Wilson, A. B. (1985). Rat diaphragm: changes in muscle fiber type frequency with age. Muscle & Nerve, 8 (3), 211-216. Mandelstam, P., & Lieber, A. (1970). Cinera diographic evaluation of the esophagus in normal adults. A study of 146 subjects ranging in age from 21 to 90 years. Gastroenterology, 58 (1), 32-39. Marks, R. (2002). Designing a research project. Gainesville, FL: Renaissance Printing. Martin, A. D., Davenport, P. D., Francesch i, A. C., & Harman, E. (2002). Use of inspiratory muscle strength training to faci litate ventilator wean ing: a series of 10 consecutive patients. Chest, 122 (1), 192-196. McConnell, A. K., & Copestake, A. J. (1999) Maximum static resp iratory pressures in healthy elderly men and women: issues of reproducibility and interpretation. Respiration, 66 (3), 251-258. McConnell, A. K., & Romer, L. M. (2004a). Respiratory muscle training in healthy humans: resolving the controversy. International Journal of Sports Medicine, 25 (4), 284-293. McConnell, A. K., & Romer, L. M. ( 2004b). Dyspnoea in health and obstructive pulmonary disease : the role of resp iratory muscle function and training. Sports Medicine, 34 (2), 117-132. McCool, F. D. (2006). Global physiology and pathophysiology of cough: ACCP evidence-based clinical practice guidelines. Chest, 129 (1 Suppl), 48S-53S. McCool, F. D., & Leith, D. E. (1987). Pathophysiology of cough. Clinics in Chest Medicine, 8 (2), 189-195. McCool, F. D., & Tzelepis, G. E. (1995). Insp iratory muscle training in the patient with neuromuscular disease. Physical Therapy, 75 (11), 1006-1014.

PAGE 143

131 McElvaney, G., Blackie, S., Morrison, N. J., Wilcox, P. G., Fairbarn, M. S., & Pardy, R. L. (1989). Maximal static respirator y pressures in the normal elderly. The American Review of Respiratory Disease, 139 (1), 277-281. McKee, G. J., Johnston, B. T., McBride, G. B., & Primrose, W. J. (1998). Does age or sex affect pharyngeal swallowing? Clinical Otolaryngology and Allied Sciences, 23 (2), 100-106. Melton, L. J., 3rd, Khosla, S., Crowson, C. S., O'Connor, M. K., O'Fallon, W. M., & Riggs, B. L. (2000). Epidemiology of sarcopenia. Journal of the American Geriatrics Society, 48 (6), 625-630. Mizuno, M. (1991). Human respiratory muscles: fibre morphology and capillary supply. The European Respiratory Journal, 4 (5), 587-601. Moritani, T., & deVries, H. A. (1980). Pote ntial for gross muscle hypertrophy in older men. Journal of Gerontology, 35 (5), 672-682. Morley, J. E., Baumgartner, R. N., Roubeno ff, R., Mayer, J., & Nair, K. S. (2001). Sarcopenia. The Journal of Laboratory and Clinical Medicine, 137 (4), 231-243. Morris, R. J., & Brown, W. S., Jr. (1994). Age-related differences in speech intensity among adult females. Folia Phoniatrica et Logopaedica, 46 (2), 64-69. Murray, M. P., Gardner, G. M., Mollinger, L. A., & Sepic, S. B. (1980). Strength of isometric and isokinetic contractions : knee muscles of men aged 20 to 86. Physical Therapy, 60 (4), 412-419. Mustfa, N., Aiello, M., Lyall, R. A., Nikol etou, D., Olivieri, D., Leigh, P. N., Davidson, A. C., Polkey, M. I., & Moxham, J. (2003). Cough augmentation in amyotrophic lateral sclerosis. Neurology, 61 (9), 1285-1287. Narici, M. V., Bordini, M., & Cerretelli, P. (1991). Effect of aging on human adductor pollicis muscle function. Journal of Applied Physiology, 71 (4), 1277-1281. Narici, M. V., Reeves, N. D., Morse, C. I., & Maganaris, C. N. (2004). Muscular adaptations to resistance exercise in the elderly. Journal of Musculoskeletal & Neuronal Interactions, 4 (2), 161-164. Nieto, L., de Diego, A., Perpina, M., Compte, L., Garrigues, V., Martinez, E., & Ponce, J. (2003). Cough reflex testing with inhaled capsaicin in the st udy of chronic cough. Respiratory Medicine, 97 (4), 393-400. Niewoehner, D. E., Kleinerman, J., & Liotta L. (1975). Elastic be havior of postmortem human lungs: effects of aging and mild emphysema. Journal of Applied Physiology, 39 (6), 943-949.

PAGE 144

132 O'Kroy, J. A., & Coast, J. R. (1993). Effects of flow and resistive training on respiratory muscle endurance and strength. Respiration, 60 (5), 279-283. Olgiati, R., Girr, A., Hugi, L., & Haegi, V. (1989). Respiratory muscle training in multiple sclerosis: a pilot study. Schweizer Archiv fur Neurologie und Psychiatrie, 140 (1), 46-50. Olsen, C. L. (1976). On choosing a test statis tic in multivariate an alysis of variance. Psychological Bulletin, 83 579?86. Oskvig, R. M. (1999). Special problems in the elderly. C hest, 115( 5 Suppl), 158S-164S. Overend, T. J., Cunningham, D. A., Kramer, J. F., Lefcoe, M. S., & Paterson, D. H. (1992). Knee extensor and knee flexor stre ngth: cross-sectiona l area ratios in young and elderly men. Journal of Gerontology, 47( 6), M204-210. Overend, T. J., Cunningham, D. A., Paterson, D. H., & Lefcoe, M. S. (1992). Thigh composition in young and elderly men determined by computed tomography. Clinical Physiology, 12( 6), 629-640. Pack, A. I., & Millman, R. P. (1988). The lungs in later life. In A. P. Fishman (Ed.), Pulmonary diseases and disorders (pp. 79-90). New York, NY: McGraw-Hill. Patten, C., Kamen, G., & Rowland, D. M. (2001). Adaptations in maximal motor unit discharge rate to strength tr aining in young and older adults. Muscle & Nerve, 24( 4), 542-550. Paulsen, F. P., & Tillmann, B. N. (1998). Degenerative changes in the human cricoarytenoid joint. Archives of Otolaryngology, Head & Neck surgery, 124( 8), 903-906. Perlman, A. L., Palmer, P. M., McCullo ch, T. M., & Vandaele, D. J. (1999). Electromyographic activity from human laryngeal, pharyngeal, and submental muscles during swallowing. Journal of Applied Physiology, 86( 5), 1663-1669. Plevkova, J., Brozmanova, M., Pecova, R., & Tatar, M. (2006). The effects of nasal histamine challenge on cough refl ex in healthy volunteers. Pulmonary Pharmacology & Therapeutics, 19( 2), 120-127. Polkey, M. I., Harris, M. L., Hughes, P. D., Hamnegard, C. H., Lyons, D., Green, M., & Moxham, J. (1997). The contractile propert ies of the elderly human diaphragm. American Journal of Respiratory and Critical Care Medicine, 155( 5), 1560-1564. Pollock, M. L., Lowenthal, D. T., Graves, J. E., & Carroll, J. F. (1992). The elderly and endurance training. In R. J. She phard & P. O. Astrand (Eds.), Endurance in Sports (pp. 390-406). London: Blackwell Scientific Publications.

PAGE 145

133 Powers, S. K., Coombes, J., & Demirel, H. (1997). Exercise training-induced changes in respiratory muscles. Sports Medicine, 24( 2), 120-131. Powers, S. K., Criswell, D., Lawler, J., Marti n, D., Ji, L. L., Herb, R. A., & Dudley, G. (1994). Regional training-indu ced alterations in dia phragmatic oxidative and antioxidant enzymes. Respiration Physiology, 95( 2), 227-237. Powers, S. K., & Howley, E. T. (2001). Exercise Physiology: theory and application to fitness and performance (4th ed.). New York, NY: McGraw-Hill. Powers, S. K., Lawler, J., Criswell, D., Li eu, F. K., & Dodd, S. (1992). Alterations in diaphragmatic oxidative and antioxidant en zymes in the senescent Fischer 344 rat. Journal of Applied Physiology, 72( 6), 2317-2321. Pride, N. B. (1974). Pulmonary distensibility in age and disease. Bulletin de Physiopathologie Respiratoire, 10( 1), 103-108. Proctor, D. N., Balagopal, P., & Nair, K. S. (1998). Age-related sarcopenia in humans is associated with reduced synthetic rates of specific muscle proteins. The Journal of Nutrition, 128( 2 Suppl), 351S-355S. Prudon, B., Birring, S. S., Vara, D. D., Hall, A. P., Thompson, J. P., & Pavord, I. D. (2005). Cough and glottic-stop reflex se nsitivity in health and disease. Chest, 127( 2), 550-557. Ptacek, P. H., & Sander, E. K. (1966). Age recognition from voice. Journal of Speech and Hearing Research, 9( 2), 273-277. Puchelle, E., Zahm, J. M., & Bertrand, A. (1979). Influence of age on bronchial mucociliary transport. Scandinavian Journal of Respiratory Diseases, 60( 6), 307313. Pyka, G., Lindenberger, E., Charette, S., & Ma rcus, R. (1994). Muscle strength and fiber adaptations to a year-long resistance tr aining program in elderly men and women. Journal of Gerontology, 49( 1), M22-27. Ramirez-Sarmiento, A., Orozco-Levi, M., Gue ll, R., Barreiro, E., Hernandez, N., Mota, S., Sangenis, M., Broquetas, J. M., Casan, P ., & Gea, J. (2002). Inspiratory muscle training in patients with chronic obstruc tive pulmonary disease: structural adaptation and physiologic outcomes. American Journal of Respiratory and Critical Care Medicine, 166( 11), 1491-1497. Reimers-Neils, L., Logemann, J., & Larson, C. (1994). Viscosity effects on EMG activity in normal swallow. Dysphagia, 9( 2), 101-106. Ren, J., Xie, P., Lang, I. M., Bardan, E., Sui, Z., & Shaker, R. (2000). Deterioration of the pharyngo-UES contractile re flex in the elderly. The Laryngoscope, 110( 9), 15631566.

PAGE 146

134 Ringqvist, T. (1966). The ventilatory capacity in healthy subjects. An analysis of causal factors with special referen ce to the respiratory forces. Scandinavian Journal of Clinical and Laboratory In vestigation. Supplementum, 88, 5-179. Robbins, J., Hamilton, J. W., Lof, G. L ., & Kempster, G. B. (1992). Oropharyngeal swallowing in normal adults of different ages. Gastroenterology, 103( 3), 823-829. Rodeno, M. T., Sanchez-Fernandez, J. M., & Rivera-Pomar, J. M. (1993). Histochemical and morphometrical ageing changes in human vocal cord muscles. Acta Otolaryngologica, 113( 3), 445-449. Rolland, Y., Lauwers-Cances, V., Pahor, M., Fillaux, J., Grandjean, H., & Vellas, B. (2004). Muscle strength in obese elderly women: effect of recreational physical activity in a cro ss-sectional study. The American Journal of Clinical Nutrition, 79( 4), 552-557. Roos, M. R., Rice, C. L., Connelly, D. M ., & Vandervoort, A. A. (1999). Quadriceps muscle strength, contractile properties, and motor unit firing rates in young and old men. Muscle & Nerve, 22( 8), 1094-1103. Rosenberg, I. H. (1989). Summary comments. American Journal of C linical Nutrition, 50 (1231-1233). Roth, S. M., Martel, G. F., Ivey, F. M., Lemmer, J. T., Tracy, B. L., Metter, E. J., Hurley, B. F., & Rogers, M. A. (2001). Skeletal muscle satellite cell characteristics in young and older men and women after h eavy resistance strength training. The Journals of Gerontology. Series A, Bi ological Sciences and Medical Sciences, 56( 6), B240-247. Rothenberg, M. (1982). Interpolating subgl ottal pressure from oral pressure. The Journal of Speech and Hearing Disorders, 47 (2), 219-223. Roubenoff, R. (2000). Sarcopenia and its implications for the elderly. European Journal of Clinical Nutrition, 54 Suppl 3, S40-47. Saleem, A. F. (2005). Expiratory muscle strength trai ning in patients with Idiopathic Parkinson's disease: Effects on pu lmonary, cough, and swallow functions. Unpublished doctoral dissertation, Gainesville, Florida. Saleem, A. F., Rosenbek, J. C., Davenport, P., Shrivastav, R., Hoffman-Ruddy, B., Okun, M. S., & Sapienza, C. M. (2004, March). Expiratory muscle strength training in patients with idiopathic Parkinson's disease. Poster session presented at the 12th conference on motor speech, Albuquerque, NM. Saleem, A. F., Sapienza, C. M., & Okun, M. S. (2005). Respiratory muscle strength training: treatment and response duration in a patient with early idiopathic Parkinson's disease. NeuroRehabilitation, 20( 4), 323-333.

PAGE 147

135 Sapienza, C. M., Davenport, P. W., & Marti n, A. D. (2002). Expiratory muscle training increases pressure support in high school band students. Journal of Voice, 16( 4), 495-501. Sarkisian, C. A., Hays, R. D., & Mangione, C. M. (2002). Do older adults expect to age successfully? The associati on between expectations re garding aging and beliefs regarding healthcare seeking among older adults. Journal of the American Geriatrics Society, 50( 11), 1837-1843. Schmidt, C. D., Dickman, M. L., Gardner, R. M., & Brough, F. K. (1973). Spirometric standards for healthy elderly men and women. 532 subjects, ages 55 through 94 years. The American Review of Respiratory Disease, 108( 4), 933-939. Schorr-Lesnick, B., Teirstein, A. S., Brow n, L. K., & Miller, A. (1985). Pulmonary function in singers and wind-instrument players. Chest, 88( 2), 201-205. Seeman, T. E., Charpentier, P. A., Berkman, L. F., Tinetti, M. E., Guralnik, J. M., Albert, M., Blazer, D., & Rowe, J. W. (1994). Pr edicting changes in physical performance in a high-functioning elderly cohort: M acArthur studies of successful aging. Journal of Gerontology, 49( 3), M97-108. Sforzo, G. A., McManis, B. G., Black, D., Luniewski, D., & Scriber, K. C. (1995). Resilience to exercise detrai ning in healthy older adults. Journal of the American Geriatrics Society, 43( 3), 209-215. Shaker, R., Ren, J., Bardan, E., Easterling, C., Dua, K., Xie, P., & Kern, M. (2003). Pharyngoglottal closure reflex: characte rization in healthy young, elderly and dysphagic patients with pr edeglutitive aspiration. Gerontology, 49( 1), 12-20. Shannon, R., Bosler, D., & Lindsey, B. (1997) Neural control of coughing and sneezing. In A. D. Miller, A. L. Bianchi & B. P. Bishop (Eds.), Neural Control of the Respiratory Muscles. New York, NY: CRC Press. Simpson, L. S. (1983). Effect of increased a bdominal muscle streng th on forced vital capacity and forced expiratory volume. Physical Therapy, 63( 3), 334-337. Smeltzer, S. C., Lavietes, M. H., & Cook, S. D. (1996). Expiratory training in multiple sclerosis. Archives of Physical Me dicine and Rehabilitation, 77( 9), 909-912. Smith Hammond, C. A., Goldstein, L. B., Zaj ac, D. J., Gray, L., Davenport, P. W., & Bolser, D. C. (2001). Assessment of aspi ration risk in stroke patients with quantification of voluntary cough. Neurology, 56( 4), 502-506. Smith, J., & Baltes, M. M. (1998). The role of gender in very old age: profiles of functioning and everyday life patterns. Psychology and Aging, 13( 4), 676-695.

PAGE 148

136 Smitheran, J. R., & Hixon, T. J. (1981). A clinical method for estimating laryngeal airway resistance during vowel production. The Journal of Speech and Hearing Disorders, 46 (2), 138-146. Staron, R. S., Malicky, E. S., Leonardi, M. J ., Falkel, J. E., Hagerman, F. C., & Dudley, G. A. (1990). Muscle hypertrophy and fa st fiber type conversions in heavy resistance-trained women. European Journal of Applied Physiology and Occupational Physiology, 60( 1), 71-79. Stathopoulos, E. T., & Sapienza, C. (1993a). Respiratory and la ryngeal function of women and men during vocal intensity variation. Journal of Speech and Hearing Research, 36( 1), 64-75. Stathopoulos, E. T., & Sapienza, C. (1993b). Respiratory and laryngeal measures of children during vocal intensity variation. The Journal of the Acoustical Society of America, 94( 5), 2531-2543. Strawbridge, W. J., Cohen, R. D., & Shema, S. J. (2000). Comparative strength of association between religious attendance and survival. International Journal of Psychiatry in Medicine, 30( 4), 299-308. Sturdy, G., Hillman, D., Green, D., Jenkins S., Cecins, N., & Eastwood, P. (2003). Feasibility of high-intensity, interval-bas ed respiratory muscle training in COPD. Chest, 123( 1), 142-150. Suzuki, S., Sato, M., & Okubo, T. (1995). Expi ratory muscle training and sensation of respiratory effort during exer cise in normal subjects. Thorax, 50( 4), 366-370. Taaffe, D. R. (1997). Dynamic muscle strength alterations to detraini ng and retraining in elderly men. Clinical Physiology, 17( 3), 311-324. Tabachnick, B. G., & Fidell, L. S. (1996). Prof ile analysis of repeated measures (Chapter 10). In Using Multivariate Statistics (pp. 476-483). New York, NY: Harper Collins College Publishers. Tanaka, S., Hirano, M., & Chijiwa, K. (1994) Some aspects of vocal fold bowing. The Annals of Otology, Rhinology, and Laryngology, 103( 5 Pt 1), 357-362. Tanko, L. B., Movsesyan, L., Mouritzen, U., Ch ristiansen, C., & Svendsen, O. L. (2002). Appendicular lean tissue mass and the pr evalence of sarcopenia among healthy women. Metabolism: Clinical and Experimental, 51( 1), 69-74. Taylor, A. H., Cable, N. T., Faulkner, G., Hillsdon, M., Narici, M., & Van Der Bij, A. K. (2004). Physical activity and older adults: a review of health benefits and the effectiveness of interventions. Journal of Sports Sciences, 22( 8), 703-725. Teles-Magalhaes, L. C., Pegoraro-Krook, M. I., & Pegoraro, R. (2000). Study of the elderly females' voice by phonetography. Journal of Voice, 14( 3), 310-321.

PAGE 149

137 Teramoto, S., Matsuse, T., & Ouchi, Y. (1999). Clinical significance of cough as a defense mechanism or a symptom in elderl y patients with aspiration and diffuse aspiration bronchiolitis. Chest, 115( 2), 602-603. Titze, J. R. (1994). V ocal fold physiology. San Diego, CA: Singular Publishing. Tockman, M. S. (1994). Aging of the respir atory system. In W. R. Hazzard, E. L. Bierman, J. P. Blass, W. H. J. Ettinger & J. B. Halter (Eds.), Principles of geriatric medicine and gerontology (pp. 555-564). New York, NY: McGraw-Hill. Tolep, K., Higgins, N., Muza, S., Criner, G ., & Kelsen, S. G. (1995). Comparison of diaphragm strength between h ealthy adult elderly and young men. American Journal of Respiratory and Critical Care Medicine, 152( 2), 677-682. Tolep, K., & Kelsen, S. G. (1993). Effect of aging on respiratory skeletal muscles. Clinics in Chest Medicine, 14( 3), 363-378. Tracy, J. F., Logemann, J. A., Kahrilas, P. J., Jacob, P., Kobara, M., & Krugler, C. (1989). Preliminary observations on th e effects of age on oropharyngeal deglutition. Dysphagia, 4( 2), 90-94. Trappe, S., Williamson, D., Godard, M., Port er, D., Rowden, G., & Costill, D. (2000). Effect of resistance training on single mu scle fiber contractile function in older men. Journal of Applied Physiology, 89( 1), 143-152. Trueblood, N., Means, I., Martin, L., Young, J., Wheeler, M., Thomas, E., Rankin, M., Philips, L., Pamla, P., O'Connell, M., Muhrer, S., Merryman, E., Lamb, J., Kraemer, A., Hamilton, C., Elsalameen, F., Crum, J., Choung, S., Biber, S., Bennett, B., & Allabadi, L. (2004). R e spiratory resistance training increases ventilatory capacity in the elderly. Retrieved January 20, 2006, from http://us.powerlung.com/downloads/evidence/trueblood.pdf Turato, G., Zuin, R., Baraldo, S., Badin, C., Be ghe, B., & Saetta, M. (2003). Pathology of chronic obstructive pulmona ry disease [Abstract]. A n nali dell'Istituto superiore di sanit? 39(4) 507-517. Turner, J. M., Mead, J., & Wohl, M. E. (1968) Elasticity of human lungs in relation to age. J ou rnal of Applied Physiology, 25(6) 664-671. U.S. Census Bureau. (2002). Projection of the total reside nt population by 5-year age groups and sex with special age ca tegories: Middle series, 2006-2010. Retrieved March 2, 2004, from http://www.census.gov/population/www/projections/natsumT3.html U.S. Census Bureau. (2003). American community survey profile: Population and housing profile: the United States. Retrieved March 2, 2004, from http://www.census.gov/acs/www/Products/P rofiles/Single/2 002/ACS/Narrative/010 /NP01000US.htm

PAGE 150

138 Vaiman, M., Eviatar, E., & Segal, S. (2004a ). Evaluation of normal deglutition with the help of rectified surface electromyography records. Dysphagia, 19(2) 125-132. Vaiman, M., Eviatar, E., & Segal, S. (2004b). Surface electromyographic studies of swallowing in normal subjects: a review of 440 adults. Report 2. Quantitative data: amplitude measures. Otolaryngology and Head and Neck Surgery, 131(5) 773780. Walker, M. D. (1998). EPO B 5640: Multivariate analysis for ecologists, course lectures: 6. Retrieved January 20, 2006, from http://www.colorado.edu/epob/e pob4640mwalker/lect6.html. Waterer, G. W., Wan, J. Y., Kritchevsky, S. B., Wunderink, R. G., Satterfiedl, S., Bauer, D. C., Newman, A. B., Taaffe, D. R., Jens en, R. L., & Crapo, R. O. (2001). Airflow limitation is underrecognized in well-functioning older people. Journal of American Geriatric Society, 49, 1 032-1038. Watsford, M. L., Murphy, A. J., Pine, M. J., & Coutts, A. J. (2004). The effects of respiratory muscle training on older females. Retrieved January 20, 2006, from http://www.powerlung.com/lan/en/r esearch/powerlung/watsford.pdf Watson, P. J., & Hixon, T. J. (2001). Effect s of abdominal trussing on breathing and speech in men with cervical spinal cord injury. Journal of Speech, Language, and Hearing Research, 44 (4), 751-762. Weiner, P., Gross, D., Meiner, Z., Ganem, R., Weiner, M., Zamir, D., & Rabner, M. (1998). Respiratory muscle trai ning in patients with moderate to severe myasthenia gravis. The Canadian Journal of Neurological Sciences, 25(3) 236-241. Weiner, P., Magadle, R., Beckerman, M ., Weiner, M., & Berar-Yanay, N. (2003a). Comparison of specific expiratory, insp iratory, and combined muscle training programs in COPD. Chest, 124(4) 1357-1364. Weiner, P., Magadle, R., Beckerman, M ., Weiner, M., & Berar-Yanay, N. (2003b). Specific expiratory muscle training in COPD. Chest, 124(2) 468-473. Weiner, P., Magadle, R., Beckerman, M ., Weiner, M., & Berar-Yanay, N. (2004). Maintenance of inspiratory muscle traini ng in COPD patients: one year follow-up. The European Respiratory Journal, 23(1) 61-65. West, J. B. (1995). Respiratory Physiology: the essentials (5 th ed.). Philadelphia, PA.: Williams & Wilkins. Wheeler, K., & Sapienza, C. M. (2005, November). Submental and infrahyoid sEMG during swallow and expiratory threshold task. Poster session presented at the annual meeting of the American Speech -Language-Hearing Association, San Diego, CA.

PAGE 151

139 Wiens, M. E., Reimer, M. A., & Guyn, H. L. (1999). Music therapy as a treatment method for improving respiratory muscle st rength in patients with advanced multiple sclerosis: a pilot study. Rehabilitation Nursing, 24(2) 74-80. Wingate, J. M., Sapienza, C. M., Shrivasta v, R., & Brown, W. S. (in press). Treatment outcomes for professional voice users. Journal of Voice. Y arasheski, K. E., Zachwieja, J. J., Campbe ll, J. A., & Bier, D. M. (1995). Effect of growth hormone and resistance exercise on muscle growth and strength in older men. The American Journal of Physiology, 268(2 Pt 1), E268-276. Yokoyama, M., Mitomi, N., Tetsuka, K., Taya ma, N., & Niimi, S. (2000). Role of laryngeal movement and effect of aging on swallowing pressure in the pharynx and upper esophageal sphincter. The Laryngoscope, 110(3 Pt 1), 434-439. Young, A., Stokes, M., & Crowe, M. (1984). Si ze and strength of the quadriceps muscles of old and young women. European Journal of Clinic al Investigation, 14(4) 282287. Young, A., Stokes, M., & Crowe, M. (1985). The size and strength of the quadriceps muscles of old and young men. Clinical Physiology, 5(2) 145-154. Zeleznik, J. (2003). Normative ag ing of the respiratory system. Clinics in Geriatric Medicine, 19(1) 1-18. Zhang, Y. L., & Kelsen, S. G. (1990). Effect s of aging on diaphragm contractile function in golden hamsters. The American Review of Respiratory Disease, 142(6 Pt 1), 1396-1401.

PAGE 152

140 BIOGRAPHICAL SKETCH Jaeock Kim received a Bachelor of Nu rsing Sciences degree from the Catholic University, Seoul, South Korea, in February of 1995. After graduation, she worked as a registered nurse in the medical intensive care unit of St. Mary’s Hospital, Seoul, South Korea, for 2 years. In 1997, she started he r graduate studies at the school and obtained her master’s degree in Nursing Sciences in February of 1999. After graduation, she worked as a clinical instructor in several university setting hospitals. She enrolled in the doctoral program in the Department of Co mmunication Sciences a nd Disorders at the University of Florida under the directi on of Alice Dyson, Ph.D., in August of 2000. Following Dr. Dyson’s move to another un iversity, Jaeock began working under the mentorship of Christine Sapienza, Ph.D. Jaeock’s subsequent research during her doctoral program has focused on the mechanics of the human respiratory system and its relationship to voice production, cough mech anism, and swallow function. She will graduate from the University of Florida with a Doctor of Philosophy in May of 2006.


Permanent Link: http://ufdc.ufl.edu/UFE0013643/00001

Material Information

Title: Physiological Effects of Expiratory Muscle Strength Training with the Sedentary Healthy Elderly: Pulmonary, Cough, Swallow, and Speech Functions
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0013643:00001

Permanent Link: http://ufdc.ufl.edu/UFE0013643/00001

Material Information

Title: Physiological Effects of Expiratory Muscle Strength Training with the Sedentary Healthy Elderly: Pulmonary, Cough, Swallow, and Speech Functions
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0013643:00001


This item has the following downloads:


Full Text












PHYSIOLOGICAL EFFECTS OF EXPIRATORY MUSCLE STRENGTH TRAINING
WITH THE SEDENTARY HEALTHY ELDERLY:
PULMONARY, COUGH, SWALLOW, AND SPEECH FUNCTIONS















By

JAEOCK KIM


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


2006

































Copyright 2006

by

Jaeock Kim


































This document is dedicated to my daughters, Yoonji and Yoonha, and my husband,
Heesun Yang.















ACKNOWLEDGMENTS

There were many who deserve my gratitude for their contributions in the successful

completion of this dissertation. First of all, I am greatly thankful to my advisor, Dr.

Christine Sapienza. She has been instrumental in ensuring my academic, professional,

and personal development. None of my achievements during the graduate school years

would have been possible without her mentoring.

I would like to extend my acknowledgment to Dr. Paul Davenport. His invaluable

support and instruction were essential in conducting the experiment for this dissertation

project. Generously, he has provided his lab to collect the data and instructed whatever

and whenever I needed. It is also my great honor to have two other professors, Dr. W.S.

Brown and Dr. Rahul Shrivastav, as my committee members. They have provided

precious advice and instruction. I also owe a huge debt of gratitude to Dr. Alice Dyson.

She was the person who encouraged me to step into the area of communication sciences

and disorders and inspired me to discover what I wanted for my future academic goal.

I am especially grateful to two undergraduate students, Megan Herndon and

Katherine Monahan. Their time and effort to help analyze the data were very important

to ensure the completion of this project. Additionally, I would like to express my

appreciation to my colleagues, who provided their sincere support and encouragement,

especially Dr. Judy Wingate, Maisa Haj Tas, Karen Wheeler, Michelle Troche, Chris

Carmichael, Erin Pearson, and Teresa Pitts.









I also appreciate the Madelyn M. Lockhart Graduate Fellowship and the Florida

Association of Speech-Language Pathologists and Audiologists Research Grant for their

financial support which enabled me to complete the study successfully.

A penultimate thankfulness goes to my parents and parents-in-law. Their

unconditional love and dedications have encouraged me in achieving my academic goal

during the past years.

Finally, I wish to acknowledge my husband, Heesun Yang, with the most heartfelt

gratitude. Without his endless support and companionship, my completion of this

dissertation would not have been possible. His love and encouragement were the most

valuable support to accomplish my dream.
















TABLE OF CONTENTS

page

A C K N O W L E D G M E N T S ................................................................................................. iv

LIST OF TABLES ................................................. ................... viii

LIST OF FIGURES ............................... ... ...... ... ................. .x

ABSTRACT ........ .............. ............. ...... ...................... xi

CHAPTER

1 INTRODUCTION AND REVIEW OF THE LITERATURE ...............................1

R respiratory System Changes w ith A ge ............................................. .....................2
Respiratory Muscle Atrophy and Strength in the Elderly .........................................4
Muscle Strength and Sedentary Lifestyle in the Elderly ...........................................9
Measurement of Respiratory Muscle Strength ..........................................................9
Respiratory Muscle Strength Training in the Elderly..............................................13
Expected Outcomes with EMST in the Elderly ................ .................................... 19
State ent of the Problem ............................. ................... ........ ............... .29
Purpose of the Study ......... .. .. .............................. .................... ........ .... 31
H y p o th e se s ............................................................................................................ 3 1

2 M E T H O D O L O G Y ............................................................................ ................... 33

Sam ple Size D eterm nation ............................................... ............................. 34
R ecruitm ent and Selection .......................................................... ............... 34
Inclusion C criteria .......................................... ........... ... .. ............
E x clu sion C riteria .......... .............................................................. ......... . ... 5
Participant D em graphics .............................................. ....... ........................ 36
M e a su re s .......................................................................................................3 7
P u lm on ary M easu res ................................................................ .....................3 8
C ough M measures ........................ ................ ... .... ........ ......... 41
Sw allow M measures .............................................. ...... ................. 44
Speech M measures .................................. .. .. ...... .......... .....47
T raining P protocol .......................................................................49
Com pliance ..................................... ................................. ........... 51
Statistical A n aly sis............................................................................. ............... 52









3 R E SU L T S ....................................................... 56

R liability .................................................. .....................56
Correlation Between MEP and Other Dependent Variables ......................................56
P ulm onary F unction ........... ............................................................ .......... ....... 57
C ou gh F u n action ................................................................58
Sw allow Function ....................................................... ... ... ...............61
Speech Function................................................... 67

4 D ISC U S SIO N ............................................................................... 87

Pulm onary Function................................................... 87
C ou gh F u n action ................................................................9 5
Swallow Function ................................................................... ... ......... 101
Speech Function.............................................. 105
S u m m a ry ........................................................................................1 0 8

APPENDIX

A IN FO R M A TIO N FLY ER ................................................... ....................111

B SCREENING PHYSICAL ACTIVITY QUESTIONNAIRE ...............................112

C SCREENING HEALTH QUESTIONNAIRE ......................................................... 113

D CAPSAICIN SOLUTION PREPARATION ...........................................................115

E RESPIRATORY MUSCLE TRAINING PROGRAM ............................................116

F PRESSURE THRESHOLD TRAINING LOG .................................................. 117

G A BBREV IA TION TA BLE .................................................... .............. 119

LIST OF REFEREN CES............................................................ ................... 120

BIOGRAPHICAL SKETCH ...................................................................140
















LIST OF TABLES


Table pge

1-1 Normal maximum expiratory pressure (MEP) values with age............................12

1-2 Summary of expiratory muscle strength training (EMST) studies ........................ 18

2-1 Demographic information for participants in the study. ........................................37

2-2 Paired-samples t-test between the two pre-training conditions for the pulmonary
and cough function dependent variables. ..................................... ............... 53

2-3 Paired-samples t-test between the two pre-training conditions for the swallow
function dependent variables ........................................................ ............. 54

2-4 Paired-samples t-test between the two pre-training conditions for the speech
function dependent variables ........................................................ ............. 54

3-1 Results of intra- and inter-judge reliability of cough, swallow, and speech
function variables. .................................... ..... ........ .............. .. 70

3-2 Correlation matrix of dependent variables. .................................... ...............71

3-3 Descriptive statistics for pre- and post-training on pulmonary function variables. .73

3-4 MANOVA result for the effects of training and gender on pulmonary function
v ariables. ............................................................................73

3-5 Univariate ANOVA results for training effect on pulmonary function variables....74

3-6 Descriptive statistics for pre- and post-training on cough function variables..........75

3-7 MANOVA result for the effects of training and gender on cough function
variables. ............................................................................75

3-8 Univariate ANOVA results for training effects on cough function variables..........76

3-9 MANOVA result for the effects of training and gender on total number of
coughs and total number of expulsive events ............. ...........................................76

3-10 Descriptive statistics for pre- and post-training on swallow function variables......77









3-11 Mauchly's test of sphericity for training, consistency, and gender effects on
sw allow function variables ........................................................................ ... ...... 78

3-12 Univariate ANOVA (mixed design) results for the combined effects of training,
consistency, and gender on swallow function variables. .......................................79

3-13 Mauchly's test of sphericity for training and consistency on swallow function
variables. ............................................................................80

3-14 Univariate ANOVA results without gender effect for the combined effects of
training and consistency on swallow function variables .......................................80

3-15 Simple main effect tests of training and consistency on PA..................................81

3-16 Multiple pairwise comparisons for DUR by training and by consistency. ..............82

3-17 Simple main effect tests for the effects of training and consistency on IA..............83

3-18 Descriptive statistics for pre- and post-training on speech function variables.........84

3-19 Univariate ANOVA result for the combined effects of training and gender on
P E L ........................ ........................................................................ 8 4

3-20 Univariate ANOVA result for the combined effects of training, loudness, and
gender on M PD .................................................... ................. 85

3-21 Univariate ANOVA result for the combined effects of training and loudness on
M P D ............................................................................... 85

3-22 Simple main effect tests of training and loudness on MPD ................................86
















LIST OF FIGURES

Figure page

2-1 Graphical depiction of FVC and FEV. ...................................... ............... 40

2-2 G raphical depiction of ERV ........................................................................ ....... 40

2-3 Airflow during reflexive cough production .................................. ...............42

2-4 Cough m agnitudes in one cough. ....................................................................... 43

2-5 SM -sE M G A activity ......................................................................... ...................46

2-6 Cycle variables function................................................ ............................... 47

2-7 Expiratory pressure threshold training device............ ............ ..............50

3-1 Effects of training on MEP and MIP............................ ...... ................. 58

3-2 Effects of training on CPD ........................... ............... ............................. 60

3-3 Effects of training on PEFR .......................... ........................................... 60

3-4 Effects of training on PPPIA ........................... ............... 61

3-5 Effects of training and consistency on PA. .... ................. ................64

3-6 E effects of training on D U R ........................................ ........... ............................65

3-7 Effects of consistency on DUR ........................................ ......................... 65

3-8 Effects of training and consistency on IA. ..... ............... ................67

3-9 E effect of training on P EL ................................................................... ..................... 68

3-10 Effects of training and loudness on MPD. .................................... .................69















Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

PHYSIOLOGICAL EFFECTS OF EXPIRATORY MUSCLE STRENGTH TRAINING
WITH THE SEDENTARY HEALTHY ELDERLY:
PULMONARY, COUGH, SWALLOW, AND SPEECH FUNCTIONS
By

Jaeock Kim

May 2006

Chair: Christine M. Sapienza
Major Department: Communication Sciences and Disorders

With age, physical functions decline which can influence respiratory performance.

One of the physical changes is sarcopenia. With sarcopenia, elderly individuals

experience reduced muscle mass and strength in the respiratory musculature. Age-related

loss of muscle strength in expiratory muscles with reductions in elastic recoil of the lungs

and chest wall compliance may compromise the necessary lung pressure for both

ventilatory and non-ventilatory activities. This study examined the effects of a 4-week

expiratory muscle strength training (EMST) program in healthy but sedentary elderly

adults as measured by maximum expiratory pressure (MEP) as well as magnitudes of

pulmonary, cough, swallow, and speech functions.

Eighteen healthy sedentary elderly people participated in this study. Sedentary was

defined as a person with 24-hours maximum exertion time below 50 in a physical activity

scale described within a physical activity questionnaire. Pulmonary measures included

maximum expiratory pressure (MEP), maximum inspiratory pressure (MIP), forced









expiratory volume in 1 second (FEVi), forced vital capacity (FVC), the ratio ofFEV1 to

FVC (FEV1/FVC), and expiratory reserve volume (ERV). Cough measures during

capsaicin induced cough included inspiratory phase duration, compression phase duration

(CPD), peak expiratory flow rate (PEFR), and post-peak plateau duration, and post-peak

plateau integral amplitude (PPPIA). Swallow measures included peak amplitude (PA),

duration, and integral amplitude (IA) of submental muscle group activity in surface

electromyography (SM-sEMG) during maximal voluntary dry (saliva) swallow, wet

swallow (5 cc and 10 cc water), and thin paste swallow (5 cc and 10 cc pudding). Speech

measures included aerodynamic measures and acoustic measures including excess lung

pressure (PEL) as well as maximum phonation durations (MPDs) at comfortable and loud

intensity levels.

Results indicated significant improvements in MEP and MIP, decrease in CPD,

increases in PEFR and PPPIA during reflexive coughs produced by capsaicin challenge,

PA and IA of SM-sEMG during maximal voluntary dry and 10 cc pudding swallows as

well as increase in PEL and MPD at comfortable intensity level.

The utility of EMST as a method of strength training for rehabilitation of

respiratory muscle weakness/sarcopenia in sedentary elderly seems to be a viable

consideration as a treatment tool, given the positive outcomes of this treatment on

multiple physiological functions.














CHAPTER 1
INTRODUCTION AND REVIEW OF THE LITERATURE

With aging, physiological capacities can become greatly limited resulting in

increased incidence of disease and disability (Oskvig, 1999). The United States has a

population of 280 million, and among them, approximately 12% (33.6 millions) are 65

years and older (U.S. Census Bureau, 2002, 2003). Additionally, our population is

growing fast, with the fastest growing group being those over 85 years of age (Oskvig,

1999). Within the next 10 years, the number of people aged 85 and older is estimated to

increase by more than 6 million (U.S. Census Bureau, 2003).

"Aging is the irreversible normal changes in a living organism that occur as time

passes" (DiGiovanna, 1994, p. 2). Several theories have been postulated to explain the

causes and mechanisms of aging from biological, psychological, and cultural

perspectives. But no one particular theory can explain the aging process perfectly. While

aging is not a disease process but a normal developmental change, almost all age changes

reduce a person's ability to maintain healthy survival and a high quality of life (Bowling

& Dieppe, 2005; DiGiovanna, 1994; Sarkisian, Hays, & Mangione, 2002; Seeman et al.,

1994). Additionally, the aging process is correlated with a very high incidence of

diseases. Increased detrimental changes of the body and exposure to harmful factors with

aging cause a decline in physical, psychological, and social functions which can increase

the susceptibility of diseases.

Particularly, the respiratory system demonstrates significant changes in anatomy

and physiology as a function of age. Respiration is a function that is critical for









sustaining life but also significantly important for generating the pressure needed to

cough, swallow, and speak (Brooks & Faulkner, 1995; Campbell, 2001; Mizuno, 1991).

For the clinician, knowledge of age-related changes in the respiratory system is important

information since these changes can increase the chance of respiratory disease and

aggravate acute or chronic respiratory failure and may influence diagnostic criteria and

therapeutic choices (Enright, Kronmal, Higgins, Schenker, & Haponik, 1993; Krumpe,

Knudson, Parsons, & Reiser, 1985; Pack & Millman, 1988).

Respiratory System Changes with Age

The main functional changes in the respiratory system with aging are associated

with an increase in the lung compliance (i.e., a decrease of the lung elastic recoil:

Campbell, 2001; Chan & Welsh, 1998; Knudson, 1991; Mahler, 1983; Niewoehner,

Kleinerman, & Liotta, 1975; Pride, 1974; Turner, Mead, & Wohl, 1968) and a decrease in

chest wall compliance (i.e., an increase of the chest wall stiffness: Janssens, Pache, &

Nicod, 1999; Kahane, 1981; Mahler, 1983; Turner et al., 1968). Decreased lung

elasticity is related to the loss of elastic fibers attached within the lungs, dilatation of the

alveolar ducts, the fusion of adjacent alveoli, and other changes (Campbell, 2001;

Knudson, 1991; Oskvig, 1999). This reduced elastic recoil of the lungs results in

increasing residual volume (RV) and decreasing vital capacity (VC). In other words, as

the lungs are more distensible with age, more air is trapped into the lungs causing more

stale air to remain and less fresh air brought into the lungs with each breath. Increased

chest wall stiffness is due to the calcification of intercostal cartilages and other structures

within the rib cage and its articulation as well as gradual atrophy and weakened

intercostal muscles (Janssens et al., 1999; Turner et al., 1968). If an elderly person has

kyphosis (curvature of the spine) or osteoporosis (loss of bony tissue), he/she will have









even more significant reduction in chest wall compliance (Turner et al., 1968). This

decreased chest wall compliance modifies the curvature of the diaphragm implicating

negatively on its mechanical force capabilities; thus the functional residual capacity

(FRC) and RV are increased (Janssens et al., 1999). It is known that RV increases by

approximately 50% and VC decreases to about 75% between 20 and 70 years of age

(Janssens et al., 1999). It is also reported that forced expiratory volume in 1 second

(FEVi) decreases by 14 to 30 mL a year and by 15 to 24 mL a year in nonsmoking men

and women after the age of 20, respectively, and after age 65 the rate of declination is

even greater (Knudson, Lebowitz, Holberg, & Burrows, 1983; Tockman, 1994). In

summary, these changes contribute significantly to an age-related progressive decline of

forced vital capacity (FVC), FEV1, forced expiratory flow (FEF), and expiratory reserve

volume (ERV) and an increase in FRC due to rise in RV (Burr, Phillips, & Hurst, 1985;

Gibson, Pride, O'Cain, & Quagliato, 1976; Knudson et al., 1983; Schmidt, Dickman,

Gardner, & Brough, 1973; Waterer et al., 2001).

Respiratory muscle function also significantly decreases with age (Berry, Vitalo,

Larson, Patel, & Kim, 1996; Brooks & Faulkner, 1995; Chan & Welsh, 1998; Chen &

Kuo, 1989; Enright, Kronmal, Manolio, Schenker, & Hyatt, 1994; Janssens et al., 1999).

Because of the difficulty in accurately quantifying the age-related changes to respiratory

muscles, specific changes in either morphological or functional properties of respiratory

muscles with aging have not been reported extensively (Brooks & Faulkner, 1995). Most

of the deficits of the respiratory muscle, composed mainly of skeletal muscle much like

the upper and lower limbs, are estimated by measures of the deficits that occur in the

limbs (Powers & Howley, 2001; Tolep & Kelsen, 1993). The most common change in









skeletal muscles with aging is muscle fiber atrophy, especially with a disproportionate

atrophy of the fast-twitch fibers (i.e., type II fibers). Type II fibers are responsible for

fast and powerful movements.

Respiratory Muscle Atrophy and Strength in the Elderly

Skeletal muscle atrophy (i.e., a reduction in skeletal muscle mass) causes a

reduction in muscle strength and power, which is referred to as sarcopenia (Doherty,

Vandervoort, & Brown, 1993; Greenlund & Nair, 2003; Roubenoff, 2000). Sarcopenia,

first coined by Rosenberg (1989), is highly prevalent in the elderly population.

Generally, the prevalence of sarcopenia in general skeletal muscles ranges from 6 to 30%

in persons over the age of 60 years (Baumgartner et al., 1998; Melton et al., 2000; Tanko,

Movsesyan, Mouritzen, Christiansen, & Svendsen, 2002), and varies depending on

measurement, definition, and participant selection as well as the gender of the individual.

Furthermore, some studies have postulated that sarcopenia increases more than 50% after

80 years of age (Baumgartner et al., 1998; lannuzzi-Sucich, Prestwood, & Kenny, 2002).

Generally, prevalence rates are much higher in men than in women since testosterone

produced by the testes and adrenal glands are greatly reduced in elderly men (lannuzzi-

Sucich et al., 2002; Melton et al., 2000). Testosterone contributes to the build up of

skeletal muscle mass influencing strength and function of skeletal muscles. Even though

the possible causes of sarcopenia are not clearly known, major contributing factors are

evident, including decreased physical activity, altered neuromuscular function (e.g., less

motor units innervating muscle), and inadequate nutrition, as well as changes in

molecular status (e.g., mitochondrial volume and activity) and anabolic hormonal status

(e.g., testosterone, dehydroepiandrosterone, growth hormone, insulin growth factor-I)

with age (Morley, Baumgartner, Roubenoff, Mayer, & Nair, 2001).









Characterized by decreases in muscle mass (cross-sectional area) and a decrease in

the number and size of muscle fibers (Melton et al., 2000), sarcopenia results in a skeletal

muscle cross-sectional area decrease by 20% to 40% between the ages of 20 and 60 years

(Doherty, Vandervoort, Taylor, & Brown, 1993; Lexell, Taylor, & Sjostrom, 1988;

Overend, Cunningham, Paterson, & Lefcoe, 1992; Young, Stokes, & Crowe, 1985). By

age 80, muscle mass is dramatically reduced by up to one-half of the total muscle mass

(Lexell et al., 1988). Most muscle atrophy and reductions in the number and size of

muscle fibers with age are explained by either age-related physical inability or

neuromuscular changes that include a decreased number of motor units, changes in

neuromuscular junctions, and loss of peripheral motor neurons (Booth & Weeden, 1993).

Skeletal muscles, in general, consist of several different muscle fiber types of

which the characteristics are determined by the properties of the motor units innervating

them. The type of fibers in skeletal muscles is mostly composed of type I and type II.

Type I, slow oxidative (slow-twitch) fibers are innervated by slow fatigue resistant motor

units, and type II (fast-twitch) fibers are subcategorized into type IIa (fast oxidative-

glycolytic) fibers innervated by fast fatigue resistant motor units and type lib (fast

glycolytic) fibers innervated by fast fatigable motor units (Doherty, 2003).

Age-related atrophy is predominantly shown in type II fibers (Booth & Weeden,

1993; Brown & Hasser, 1996; Lexell et al., 1988; Morley et al., 2001; Proctor, Balagopal,

& Nair, 1998; Tolep & Kelsen, 1993). Type I fibers are also decreased in number and

size; however, the extent of their reduction is much less than that of type II fibers,

particularly type IIa (Proctor et al., 1998). Previous studies demonstrate that the mean

area of type II fibers in individuals age 70 years decreases from 20 to 50% (Doherty,









Vandervoort, Taylor et al., 1993; Lexell et al., 1988) and the percentage of type II fibers

relative to total muscle fibers also decreases by 40% in the elderly aged 60 years and

above (Larsson, 1983; Lexell, Downham, Larsson, Bruhn, & Morsing, 1995). The

decrease in the proportion of type II fibers can be explained by either a direct loss in the

total number of type II fibers due to decreases in muscle protein synthesis or the

conversion from type II to type I fibers due to selective denervation (Booth & Weeden,

1993; Doherty, Vandervoort, Taylor et al., 1993; Tolep & Kelsen, 1993). With aging,

progressive loss of motor neurons in the spinal cord results in denervation of fast-twitch

fibers along with reinnervation of these fibers by axonal sprouting from adjacent slow-

twitch motor neurons (Brooks & Faulkner, 1995). Age-related skeletal muscle atrophy

results in the loss of muscle size and strength (Powers & Howley, 2001).

Muscle strength is defined as the maximum force generation capacity and is

divided into isometric (static) and dynamic (including isokinetic) muscle strength

(Macaluso & De Vito, 2004). Isometric strength is the maximum force when there is no

change in muscle length, while dynamic strength is the maximum force generated from

actions and accounts for the maximum power which is the product of force and speed of

muscle contraction when movement exists (Macaluso & De Vito, 2004). Several studies

have shown that muscle strength of both the isometric and dynamic types declines with

aging. Isometric muscle strength decreases by 20% to 40% in elderly individuals after

age 60 (Larsson, Grimby, & Karlsson, 1979; Murray, Gardner, Mollinger, & Sepic, 1980;

Young, Stokes, & Crowe, 1984; Young et al., 1985) and maximally up to 76% (Hakkinen

& Hakkinen, 1991; Overend, Cunningham, Kramer, Lefcoe, & Paterson, 1992). In

addition, losses in dynamic muscle strength have been reported with an almost 50 to 60%









loss of isokinetic strength in limb muscles between the ages of 30 and 80 (Frontera,

Hughes, Lutz, & Evans, 1991; Murray et al., 1980). Changes in proportion of fiber types

may also explain a reduction of tension and velocity of contraction and relaxation

compared with those of young muscles (Narici, Bordini, & Cerretelli, 1991; Roos, Rice,

Connelly, & Vandervoort, 1999) which can reduce power of the skeletal muscles.

Sarcopenia of the respiratory muscles also occurs decreasing their potential strength.

Chen and Kuo (1989) indicated that respiratory muscle strength and endurance decreases

by approximately 20% by the age of 70.

The respiratory muscles include the inspiratory and expiratory muscle groups. The

diaphragm, internal intercostals of the parastemal region, external intercostals, and other

accessory muscles mainly constitute the inspiratory muscles. The lateral internal

intercostals, external obliques, internal obliques, transverse abdominis, rectus abdominis,

serratus posterior inferior, and quadratus lumborum constitute the expiratory muscles

(Mizuno, 1991). These muscles not only act as the major pump for ventilation, but also

play a role in non-ventilatory activities such as coughing, sneezing, valsalva maneuver,

talking, singing, vomiting, swallowing, and other functions that are accompanied by

expiratory effort.

A decrease in respiratory muscle strength with aging can deteriorate ventilatory as

well as non-ventilatory functions (Burzynski, 1987; Mizuno, 1991). During expiration at

rest, the passive elastic recoil of the lungs is typically used to generate expiratory

force/pressure. However, the expiratory muscles must contract to produce the necessary

lung pressure during non-ventilatory activities (Burzynski, 1987) and contract below

FRC (Zeleznik, 2003). Mizuno (1991) reported that the mean fiber cross-sectional area









of expiratory internal intercostal muscles decreases by approximately 7% to 20% at about

50 years of age because of a reduction of both type I and type II fibers, predominantly

type II fibers. However, these changes are not observed in the diaphragm (Mizuno,

1991). Other studies observing changes in the respiratory muscles demonstrated no or

less change in muscle mass and no change in muscle fiber types in diaphragmatic muscle

and inspiratory external intercostal muscles with aging (Caskey, Zerhouni, Fishman, &

Rahmouni, 1989; Krumpe et al., 1985; Polkey et al., 1997; Tolep, Higgins, Muza, Criner,

& Kelsen, 1995), suggesting the expiratory muscles are more affected by the aging

process than the inspiratory muscles.

Declining lung and chest wall functions, whether due to aging or disease, would

require more muscular effort in both expiratory and inspiratory phases. In an early study

of lung and chest wall compliance, Turner et al. (1968) examined changes in lung

elasticity as a function of age. Their findings concur with more recent reviews of lung

elastic recoil and chest wall compliance by Janssens, Pache, and Nicod (1999) that

showed decreased chest wall compliance and decreased static elastic recoil of the lungs

with aging. With decreases in chest wall compliance and lung elasticity, respiratory

muscles will be required to work more to move the chest wall during breathing and doing

other non-ventilatory tasks. Chen and Kuo (1989) also reported that 70% of the total

elastic work of breathing is required at age 70 years compared with 40% of the

requirement for a 20-year-old. Thus, strengthening respiratory muscles should help

minimize the physical changes associated with the loss of lungs and chest wall

compliance as a function of age, since respiratory muscle contraction is necessary for

moving the chest wall and the lungs.









Muscle Strength and Sedentary Lifestyle in the Elderly

It is well known that muscle atrophy results from muscle disuse, which can be

caused by immobilization or by the reduced loading of a muscle that are closely related to

a sedentary lifestyle (Powers & Howley, 2001; Rolland et al., 2004). Particularly, a

reduction in the strength and power of skeletal muscles as a function of age is closely

related with a decreasing physical activity with sedentary lifestyle (Mizuno, 1991;

Rolland et al., 2004; Taylor et al., 2004). Considerably, the prevalence of elderly

individuals with a sedentary lifestyle is increasing (DiPietro, 2001). It is estimated that

around 10% of elderly individuals participate in regular exercise, but that more than 50%

of the population over 65 years of age has a sedentary lifestyle (Pollock, Lowenthal,

Graves, & Carroll, 1992; Taylor et al., 2004). Inactivity, due to the lack of physical

exercise, accelerates the changes in musculoskeletal structures and, thus, speeds-up the

aging process (Campbell, Sheets, & Strong, 1999). Many of the changes in the

musculoskeletal system result more from disuse than from simple aging. Further,

decreases in muscular strength and power in the respiratory musculature accompanied

with sedentary lifestyle in the elderly may accelerate reductions in the ventilatory and

non-ventilatory functional capacities.

Measurement of Respiratory Muscle Strength

While directly measuring the number and size of muscle fibers might be useful to

assess respiratory muscle strength related to muscle mass, doing so would require

invasive procedures to directly measure the morphology of the respiratory muscles in

vivo. Direct measurement of the force output of the human respiratory muscles is also

impractical (Tolep & Kelsen, 1993). Therefore, the morphological changes that occur in

respiratory skeletal muscles with aging have been studied in rodents or other animals









(Kelly et al., 1991; Maltin, Duncan, & Wilson, 1985; Powers et al., 1994; Powers,

Lawler, Criswell, Lieu, & Dodd, 1992; Tolep & Kelsen, 1993; Zhang & Kelsen, 1990).

Available data on the morphological aspects of human respiratory muscles with aging

come largely from the results of Mizuno's postmortem study (Mizuno, 1991).

Another, less invasive way to measure the strength of the overall respiratory

muscles is by testing the function of respiratory muscles using indexes, such as maximum

inspiratory pressures (MIPs) and maximum expiratory pressures (MEPs) (Berry et al.,

1996; Black & Hyatt, 1969; Bruschi et al., 1992; Chen & Kuo, 1989; Enright et al., 1994;

Karvonen, Saarelainen, & Nieminen, 1994; McConnell & Copestake, 1999; McElvaney

et al., 1989; Ringqvist, 1966). These measures provide an indirect way of examining

maximum strength of the respiratory muscles. Researchers use MIPs to measure

inspiratory muscle strength at the level of either FRC or RV and MEPs to measure

expiratory muscle strength at the level of total lung capacity.

Ringqvist's study (1966) which investigates the ventilatory capacity and respiratory

forces in healthy individuals aged 18 to 83 years, many others have investigated the

relationship between age and MIPs or MEPs. Black and Hyatt (1969) measured

respiratory muscle strength in participants from 20 to 86 years of age. They observed

that respiratory muscle strength declines at a rate between 0.25 to 0.79 cm H20 a year for

MIP and between 1.14 to 2.33 cm H20 a year for MEP in both men and women,

respectively. Enright et al. (1994) also found similar age-related decrements in both MIP

and MEP with a rate of decline in MIP at about 1 cm H20 a year and that for MEP about

2 to 3 cm H20 a year for those between 65 to 85 years of age. Results from other studies

indicate no statistically significant negative relationship between age and MIP and MEP









due to other variances, such as the number of participants or body surface area; however,

some degree of decreased MEPs were found, especially in men over the age of 55 years

(Bruschi et al., 1992; McElvaney et al., 1989). Based on these findings it appears that

respiratory muscle strength reduces with aging. Furthermore, these data suggest that

strength of the expiratory muscles is more reduced than the strength of the inspiratory

muscles with aging.

Table 1-1 summarizes studies supporting the decline of MEP levels in both men

and women as a function of age. All studies demonstrated higher MEPs in men than in

women since MEPs are related to height (Ringqvist, 1966) and men are typically of

greater height than women. Obvious differences were found in the MEPs across the

studies in Table 1-1. Some factors that may be related to the differences obtained in

MEPs across the studies follow. First, the participants in the Chen and Kuo study (1989)

were Asian and physically of smaller stature than those in the Ringqvist (1966) and the

Black and Hyatt (1969) studies, which included Caucasian participants. Second, the

study of Chen and Kuo was done 20 years after the Ringqvist and the Black and Hyatt

studies. Differences in the types of pressure transducers, their sensitivity, and other

measurement protocol issues could certainly contribute to the database variations.

Since MIPs and MEPs are used to reflect an individual's respiratory muscle

strength, these indices can be used to study the relationship between strength and

ventilatory and non-ventilatory functions. Recent studies support that MEPs are the most

appropriate indices for quantifying respiratory muscle strength in the elderly (Berry et al.,

1996; Chen & Kuo, 1989; Enright et al., 1994; Karvonen et al., 1994; McConnell &

Copestake, 1999).











Table 1-1. Normal maximum expiratory pressure (MVEP) values with age.
Ringqvist' Black & Hyatt2 Chen & Kuo3 Enright et al.4 Berry et al. 5
Age
range Men Women Men Women Men Women Men Women Men Women
(n) (n) (n) (n)* (n) (n) (n) (n) (n) (n)


18-29 247 41 170 29
(37) (33)
30-39 248 38 163 29
(12) (8)

40-49 253 52 178 33
(15) (12)

50-59 252 32 157 28
(13) (12)

60-64 209 49 157 27
(16) (17)

65-69


70-74 20042 165 29
(13) (10)

75-79


141.2 8.8 97.9 5.4
(20) (20)
136.6 8.9 92.8 4.2
(20) t (20) t


218 74 145 40
(5) (8)

209 74 140 40
(3) (4)
197 74 135 40
(7) (6)

185 74 128 40
(10) (10)


80-84


133.6 8.9 88.4 6.2
(20) (20)

117.4 7.4 75.1 5.1
(20)T (20))


188 125 190 55 125 36
(113) (176) (44) (57)

179 121
(105) (119)

161 102
(59) (85)

142 84
(43) (34)
131 94
(9) (13)


Note: MEP value or mean MEP standard deviation (in cm H20) included.
'Ringqvist, T. (1966). The ventilatory capacity in healthy subjects. An analysis of causal factors with special reference
to the respiratory forces. Scand J Clin Lab Invest Suppl, 88, 67.
2Black, L.F. & Hyatt, R.E. (1969). Maximal respiratory pressures: Normal values and relationship to age and sex. Am
Rev Respir Dis. 99(5), 698-99.
3Chen, H.I. & Kuo, C.S. (1989). Relationship between respiratory muscle function and age, sex, and other factors. J
Appl Physiol, 66(2), 945.
4Enright, P.L., Kronmal, R.A., Manolio, T.A., Schenker, M.B., & Hyatt, R.E. (1994). Respiratory muscle strength in
the elderly. Correlates and reference values. Cardiovascular Health Study Research Group. Am J Respir Crit Care Med,
149(2 Pt 1), 432.
5Berry, J.K., Vitalo, C.A., Larson, J.L., Patel, M., & Kim, M.J. (1996). Respiratory muscle strength in older adults.
Nurs Res., 45(3), 155. Linear regression for men, MEPs = 360 2.47 x age; for women MEPs = 242 -1.75 x age.
*Number of participants in each group in this column was not defined in the original paper, so it was estimated number
of participants from the figure shown in published manuscript.
tRange of age = 31-45.
RRange of age = 46-60.
Range of age = 60-69.
Range of age = 61-75.
Range of age = 65 and older.



Ability to generate maximal expiratory force plays a critical role for non-

ventilatory tasks, such as cough, swallow, and speech (Enright et al., 1994; Karvonen et









al., 1994), which are important functions with which elderly patients demonstrate

problems, particularly those post-stroke or with other neuromuscular diseases such as

Parkinson's disease, spinal cord injury, or multiple sclerosis (Chiara, 2003; Kang et al.,

2005; Saleem, 2005).

Respiratory Muscle Strength Training in the Elderly

Given the age-related declines in respiratory muscle strength, a mechanism for

training the muscles might be beneficial and actually aid and/or prevent a certain degree

of muscle wasting (Powers, Coombes, & Demirel, 1997). Progressive resistance training

of skeletal muscles has resulted in significant improvements in limb muscle strength in

the young, elderly, and even in the frail elderly (Bemben & Murphy, 2001; Charette et

al., 1991; Hakkinen, Kallinen et al., 1998; Lexell, Robertsson, & Stenstrom, 1992; Pyka,

Lindenberger, Charette, & Marcus, 1994). Elderly individuals enrolled in strength

training programs demonstrate increased muscle strength and endurance of lower

extremity muscles, similar to what is observed for young people (Fiatarone et al., 1990;

Fiatarone et al., 1994).

Strength training is associated with a combination of both central (neural) and

peripheral (muscle mass) adaptations. After a person completes a few days to a few

weeks of strength training, a rapid improvement of muscle strength is noticed without

hypertrophy. This rapid improvement relates to neural adaptations, including increases in

the number of motor neurons and recruitment of motor units to agonist muscles, an

increased discharge rate of motor units to agonist muscles, decreases in antagonist

coactivation, or fiber type transitions from type lib to type IIa fibers, which are associated

with the acquisitions in muscle strength observed in the early stage of training (Carolan &

Cafarelli, 1992; Hakkinen, Newton et al., 1998; Patten, Kamen, & Rowland, 2001;









Powers & Howley, 2001; Staron et al., 1990). The result of neural adaptations has been

consistently demonstrated across studies in elderly and young participants. However, the

exact mechanisms of central adaptations are not clearly understood. Preliminary studies

provide indirect evidence of neural adaptations from measuring maximal voluntary neural

activation recorded on surface electromyography (Hakkinen, Alen, Kallinen, Newton, &

Kraemer, 2000; Hakkinen, Kraemer, Newton, & Alen, 2001) as well as motor unit

discharge rate using an indwelling electrode (Leong, Kamen, Patten, & Burke, 1999;

Patten et al., 2001) in both short- and long-term muscle strength training programs. In

these studies, neural activities and maximal motor unit discharge rates of trained muscles

were significantly increased with maximal voluntary contraction after muscle strength

training.

The peripheral adaptations are related to muscle hypertrophy and increased

contractile capacity and occur in later stages (generally, after 6 weeks) of muscle strength

training programs (Baker, 2003; Fleck & Kraemer, 1997; Goto et al., 2004; Hakkinen,

1989). Researchers have shown that strength training promotes an increase in muscle

protein synthesis, resulting in muscle hypertrophy, an increase in muscle strength with an

overload stimulus (Frontera et al., 2003; Yarasheski, Zachwieja, Campbell, & Bier,

1995), and a cross-sectional area increase in both type I and II single muscle fibers of

skeletal muscles of the elderly (Trappe et al., 2000). In addition, satellite cells, which are

important for muscle fiber regeneration and hypertrophy, are also increased in their

proportion and activities following strength training (Roth et al., 2001).

Interest in the potential of a training program to increase the strength and/or

endurance of respiratory muscles in an elderly population has increased in the last few









years (Tolep & Kelsen, 1993). Leith and Bradley (1976) were one of the first to attempt

to train respiratory muscles by performing strength and endurance training to target

specific ventilatory muscle groups. Four participants with mean age of 27 years were

trained 5 days a week for 5 weeks maintaining CO2 levels at a specific level, which is

called as voluntary isocapnic hyperpnea (McConnell & Romer, 2004a). The training

required extensive equipment to monitor the CO2 levels and this training consumed a

relatively large amount of time and highly depended on a subject motivation (McConnell

& Romer, 2004a).

Consequently, other respiratory muscle strength training programs were developed

to overstep the limitation of Leith and Bradley's complex equipment requirement.

Commonly executed respiratory muscle strength training programs were flow-dependent

resistance training and flow-independent pressure-threshold training. Resistance training

does not depend on the lung pressure generated by respiratory muscles but depends on

the airflow, which travels through a variable diameter orifice of the training device

(McConnell & Romer, 2004a). The limitation of this training is that respiratory pressure

developed during the training varies with flow and the orifice size. Therefore, during this

training, breathing pattern should be monitored carefully. McConell and Romer (2004a)

also mentioned that this training is a relatively time consuming and physically

demanding. In contrast, pressure-threshold training of respiratory muscles has good

reliability and is relatively easy to use (Baker, 2003; McConnell & Romer, 2004a). This

involves a participant performing a certain number of repetitions a week with a specific

number of exercise sets of training in each day. This training requires that an individual

produce a certain amount of lung pressure to open a one-way valve on the training device









so that air from the lungs flows through the device. It was also postulated that pressure-

threshold training would result in greater training effect than resistance training because it

requires a higher level of force to meet the load presented at a specific level compared to

resistance training and allows the clinicians to set the training pressure-threshold

depending on participants maximal pressure regardless of their breathing pattern or

respiratory flow (Baker, 2003; Martin, Davenport, Franceschi, & Harman, 2002).

Most training paradigms with the elderly have used inspiratory resistive or

inspiratory threshold loading (de Bruin, de Bruin, Lees, & Pride, 1993; Harver, Mahler,

& Daubenspeck, 1989; Hsiao, Wu, Wu, & Wang, 2003; Larson, Kim, Sharp, & Larson,

1988; McConnell & Romer, 2004b; Olgiati, Girr, Hugi, & Haegi, 1989; Sturdy et al.,

2003; Tolep & Kelsen, 1993; Weiner, Magadle, Beckerman, Weiner, & Berar-Yanay,

2004; Wiens, Reimer, & Guyn, 1999). Many of these studies have focused especially on

inspiratory muscle strength training (IMST) in elderly patients with pulmonary disease

(e.g., asthma, chronic obstructive pulmonary disease) or those with respiratory muscle

weakness (e.g., multiple sclerosis, Parkinson's disease) with expectations to improve

ventilatory capacity. However, interest in expiratory muscle strength training (EMST)

has developed more recently, particularly for improving non-ventilatory functions such as

cough, swallow, and speech.

Evidence that EMST increases expiratory muscle strength is evident from other

studies of healthy adults (Baker, 2003; O'Kroy & Coast, 1993; Suzuki, Sato, & Okubo,

1995), high school band students (Sapienza, Davenport, & Martin, 2002), hypotonic

children (Cerny, Panzarella, & Stathopoulus, 1997), high-risk performers (Hoffman-

Ruddy, 2001), patients with chronic obstructive pulmonary (Weiner, Magadle,









Beckerman, Weiner, & Berar-Yanay, 2003a), multiple sclerosis (Chiara, 2003;

Gosselink, Kovacs, Ketelaer, Carton, & Decramer, 2000; Smeltzer, Lavietes, & Cook,

1996), Parkinson's disease (Saleem, 2005; Saleem, Sapienza, & Okun, 2005), and

myasthenia gravis (Weiner et al., 1998). These studies demonstrated that EMST is

effective in increasing the strength of expiratory muscles resulting in augmenting

expiratory driving pressure which is utilized for cough, swallow, or speech (Table 1-2).

Little outcome data are available on respiratory muscle strength training in the healthy

elderly in either an inspiratory or expiratory direction, and use of respiratory muscle

strength training may be beneficial for prevention or treatment of normal age-related

respiratory muscular weakness (Tolep & Kelsen, 1993). Watsford, Murphy, Pine, and

Coutts (2004) trained 26 older female participants (mean age of 64.4 years) with 8 weeks

of 12 respiratory muscle training sessions with both IMST and EMST using a

commercially available training device (PowerlungTM PowerLung Inc., Houston, Texas,

USA). They obtained significant increases in maximum voluntary ventilation, MIPs,

MEPs, and other performance assessments such as time-to-rate of perceived exertion 15

walking test. However, this study only documented healthy elderly female performance

and there was no detailed explanation regarding whether respiratory muscle training was

aimed to improve expiratory muscle strength or inspiratory muscle strength. In addition,

the outcome measures were associated only with ventilatory capacities. To date, no study

has examined the effect of EMST on expiratory muscle strength in healthy elderly males

and females and other studies of EMST on expiratory muscle strength have attempted to

train elderly persons with diseases.







18



Table 1-2. Summary of expiratory muscle strength training (EMST) studies.

Stud Participants Training Training Training MEP Significance Functional
program (wks) Load gain (%) Level Improvement


O'Kroy Healthy
& Coast' adults

Suzuki et Healthy
al.2 adults

Cerny et Hypotonic
al.3 children

Smeltzer Multiple
et al.4 Sclerosis

Gosselink Multiple
et al.5 Sclerosis

Hoffman- High risk
Ruddy6 performers

Sapienza High school
et al.7 band students

Baker8 Healthy
young adults

Chiara9 Multiple
Sclerosis

Wingate Professional
et al.10 voice users

Saleem1 Parkinson
Disease


6 RT


6 PT


9 RT


10 PT


9 PT


8 PT


26 PT


32 PT


17 PT


18 PT


10 PT


4 32% of
MEP

4 30% of
MEP

6 2.5-7.5
cm H20

12 Not
reported

12 60% of
MEP

4 75% of
MEP

2 75% of
MEP

4-8 75% of
MEP

8 40-80%
of MEP

5 75% of
MEP

4 75% of
MEP


NS NS


Not applicable


25 p < 0.01 Not applicable


69 p < 0.001 Speech


37 No testing Cough
completed (subjective report)


35 NS


84 No testing
completed


Cough
(subjective report)

Speech


47 p < 0.001 Not applicable


29-50 p < 0.05 Speech & cough


40 p < 0.05 Speech


77 p < 0.001 Speech


22-37 p < 0.001 Cough & swallow


'O'Kroy, J.A. & Coast, J.R. (1993). Effects of flow and resistive training on respiratory muscle endurance and strength.
Respiration, 60(5), 279-283.
.ii ii... K.S., Sato, M, & Okubo, T. (1995). Expiratory muscle training and sensation of respiratory effort during
exercise in normal subjects. Thorax, 50(4), 366-370.
3Cery, F.J., Panzarella, K., & Stathopoulos, E.T. (1997). Expiratory muscles conditioning in hypotonic children with
low vocal intensity levels. J Med Speech Lang Pathol, 5, 141-152.
4Smeltzer, S.C., Lavietes, M.H., & Cook, S.D. (1996). Expiratory training in multiple sclerosis. Arch Phys Med
Rehabil, 77(9), 909-912.
5Gosselink, R., Kovacs, L., Ketelaer, P., Carton, H., & Decramer, M. (2000). Respiratory muscle weakness and
respiratory muscle training in severely disabled multiple sclerosis patients. Arch Phys Med Rehabil, 81(6), 747-751.
6Hoffman-Ruddy, B. (2003). Expiratory pressure threshold training in high-risk performers, Unpublished doctoral
dissertation, University of Florida, Florida.
Sapienza, C.M., Davenport, P.W., & Martin, A.D. (2002). Expiratory muscle training increases pressure support in
high school band students. J Voice, 16(4), 495-501.
8Baker, S.E., Davenport, P., & Sapienza, C. (2005). Examination of training and detraining effects in expiratory
muscles. J Speech Lang Hear Res, 48(6), 1325-1333.
9Chiara, T. (2003). Expiratory muscle strength training in individuals with multiple sclerosis and health controls.
Unpublished doctoral dissertation, University of Florida, Florida.
'lWingate, J., Sapienza, C.M., Shrivastav, R., & Brown, W.S. (in press). Treatment outcomes for professional voice
users. J Voice.
"Saleem, A.F. (2005). Expiratory muscle strength training in patients with idiopathic parkinson's disease: Effects on
pulmonary, cough, and swallow function. Unpublished doctoral dissertation, University of Florida, Florida.
MEP = maximum expiratory pressure, N = number of subjects who were trained with EMST program
PT = pressure-threshold training, RT = resistance training, NS = not significant









Expected Outcomes with EMST in the Elderly

Promising results from preliminary studies investigating the effects of expiratory

muscle strength in different groups of participants suggest that EMST is able to increase

expiratory muscle strength, improve cough function, promote swallow performance, and

positively affect speech characteristics, in healthy young and clinical populations (Cerny

et al., 1997; de Bruin et al., 1993; Gosselink et al., 2000; Hoffman-Ruddy, 2001; Saleem,

2005; Smeltzer et al., 1996). Hence, one would expect that EMST would improve

respiratory function as well as the ability to clear the airway, swallow, and speak in the

healthy elderly.

To expect that EMST would improve respiratory function by enhancing expiratory

muscle strength in the healthy elderly population is reasonable. Specifically, FEV1, FVC,

and ERV would likely be affected. With age, expiratory force is diminished because of

reduced elastic recoil of the lungs, compliance of the chest wall, and expiratory muscle

strength. Therefore, FEV1, FVC, and ERV are decreased in elderly individuals relative to

younger counterparts (Waterer et al., 2001). Consequently, RV increases up to 50% and

vital capacity decreases by about 75% maximally as adults reach age 70 (Gibson et al.,

1976). Strengthening expiratory muscles by EMST would enhance the ability of the

elderly to generate more expiratory force and compress the chest wall to a smaller

volume as a compensatory mechanism, resulting in an increase in FEV1, FVC, and ERV.

As shown in Table 1-2, MEP levels were increased by a significant amount in healthy

young adult participants and clinical populations regardless of the training program,

duration of training, and training load.

EMST would also increase MIPs. Previous studies have showed that MIP levels

increase following EMST in patients with multiple sclerosis (Chiara, 2003; Gosselink et









al., 2000). Gosselink et al. (2000) speculated that the improved inspiratory muscle

strength is related to reduced RV caused by a reduction of expiratory lung volume to

allow the inspiratory muscles to operate easily with a more advantageous part of their

length-tension relationship.

It is anticipated that EMST would increase peak expiratory flow rate during cough

production. Cough is a reflexive protective mechanism to clear foreign substances or

excessive mucous in the airways to reduce respiratory infection using higher velocities of

forced expiratory airflow (Shannon, Bosler, & Lindsey, 1997). Coughing is composed of

three consecutive phases: an inspiratory phase, a laryngeal compressive phase, and an

expiratory phase (Leith & Bradley, 1976). In the inspiratory phase, once foreign

substances or mucous stimulate the peripheral receptors and the stimulus is conducted to

the central cough center located in the medulla (Bouros, Siafakas, & Green, 1995), the

vocal folds abduct to open the glottis and allow air to fill the lungs. Then, during the

laryngeal compression phase, the vocal folds adduct to close the glottis and the expiratory

muscles contract to build up high positive intrapleural and intrathoracic pressures as high

as 300 mmHg in a very short period of time (less than 200 ms) (Chung, Widdicombe, &

Boushey, 2003; McCool, 2006; Irwin et al., 1998). Finally, the air from the intrathoracic

airways is expired through a slightly opened glottis by the contraction of expiratory

muscles with a velocity as great as 28,000 cm per second (Chung et al., 2003). During

the expiratory phase, foreign substances are removed by the generation of the high

velocity of expiratory airflow. During these three phases, the interactive activity of

various respiratory muscles controls the cough mechanism intricately.









Reduced mucociliary clearance function (Bouros et al., 1995; Puchelle, Zahm, &

Bertrand, 1979), decreased sensitivity of pharyngoglottal closure reflex (Shaker et al.,

2003), and a diminished laryngeal valving mechanism (Hoit & Hixon, 1987) are the

major causes of accumulation of mucous or aspiration in intrathoracic airways in the

elderly. This eventually increases the mortality or morbidity of the elderly population

from respiratory diseases (Kikawada, Iwamoto, & Takasaki, 2005; Logemann, 1998). To

replace these regressed mechanisms, cough plays an important role in expelling foreign

materials or secretions (McCool & Leith, 1987). Ineffective cough is also possibly

related to reduced expiratory flow rates as well as lengthened laryngeal compression time

(McCool & Leith, 1987). McCool and Leith (1987) noted that decreased expiratory peak

flow is closely related to decreases in inspiratory or expiratory muscle strength.

Specific methods for increasing cough strength and timing have not been greatly

studied to date. Of the limited treatment studies done on cough in patients with

respiratory muscle weakness, the approaches rely on physical procedures, such as

percussion and shaking, and manually assisted cough or mechanical insufflation and/or

exsufflation (Bott & Agent, 2001; Chatwin et al., 2003; Mustfa et al., 2003). The

implications are non-trivial for the elderly population. Although not a testable hypothesis

in this research it is hoped EMST with the elderly has the potential to decrease or delay

the development of respiratory complications by increasing expiratory muscle strength

and increasing the ability to voluntarily clear the airway with a strong cough. An

improvement in cough function should significantly reduce the occurrence of respiratory

infections, thus enhancing the overall health of the elderly. Cough magnitude is directly









related to the amount of expiratory driving pressure and expiratory pressure is the direct

target of the expiratory training technique (Irwin et al., 1998).

Specifically, it is expected that EMST would increase the expiratory strength

including peak expiratory flow rate and post-peak plateau during coughing as a result of

overcoming high peripheral airway resistance. Peak expiratory flow rate during cough

reflects the changes in muscular strength. Post-peak plateau is defined as the sustained

expiratory airflow after the peak expiratory flow during a cough and it increase with

increasing expiratory driving pressures as expiratory muscular strength is enhanced

(Saleem, 2005). In fact, expiratory flow rate during cough is less in the elderly when

compared to younger counterparts, which is related to decreased respiratory muscle

strength (Babb & Rodarte, 2000), and decrease in lung elasticity (Babb & Rodarte, 2000)

as well as an increase in the collapsibility of peripheral airways (Janssens et al., 1999).

In addition, EMST should decrease the laryngeal compression time. Changed

afferent inputs in pressure are transferred to the central cough centers (Bouros et al.,

1995) and this process should alter efferent outputs to the adductory laryngeal muscles.

As a result, laryngeal compression time should decrease (de Bruin et al., 1993). These

potential effects would decrease the chance of aspiration and decrease potential of

respiratory infection. Baker (2003) and Saleem (2005) found that a 4-week EMST

program improved peak expiratory flow and reduced laryngeal compression time during

maximum voluntary cough in healthy young adults and patients with Parkinson's disease,

respectively. In a study of patients with multiple sclerosis, increased expiratory pressure

achieved with a 3-month pressure threshold EMST program was effective in increasing

cough function, although the reports were subjective (Gosselink et al., 2000). This









qualitative effect was also demonstrated in another study of an EMST program with

patients with multiple sclerosis (Smeltzer et al., 1996). Ten participants in this study

reported diminished choking events post-EMST. Those studies measured the cough

characteristics during maximum voluntary cough production.

It is also expected that EMST will improve swallow function. Swallow

dysfunction can be a major life-threatening problem in the elderly (Logemann, 1998).

Explicit evidence exists regarding age-related changes in structure and physiology of

swallowing, resulting in a high risk of swallowing problems in individuals over the age of

60 years. Significantly deteriorated efficiency of all phases of swallowing (oral

preparatory, oral transit, pharyngeal, and esophageal phases) has been reported in several

studies. These changes include increased duration of the oral stage of swallowing

(Jaradeh, 1994; Logemann, 1998), reduced reflexes to trigger laryngeal closure (e.g.,

pharyngeal reflex, pharyngo-upper esophageal sphincter contractile reflex; McKee,

Johnston, McBride, & Primrose, 1998; Ren et al., 2000; Robbins, Hamilton, Lof, &

Kempster, 1992; Shaker et al., 2003), reduced laryngeal and hyoid anterior and vertical

(superior) movement (i.e., reduced neuromuscular reserve; Logemann et al., 2000; Tracy

et al., 1989; Yokoyama, Mitomi, Tetsuka, Tayama, & Niimi, 2000), diminished laryngeal

valving capacity (Hoit & Hixon, 1987; Honjo & Isshiki, 1980; Ptacek & Sander, 1966;

Titze, 1994), decreased pharyngeal flexibility (i.e., reduced pharyngeal contraction;

Logemann et al., 2000), increased duration of the pharyngeal swallow (Jaradeh, 1994;

Logemann, 1990; McKee et al., 1998; Tracy et al., 1989), impaired opening of the upper

esophageal sphincter (Tracy et al., 1989), increased duration and width of

cricopharyngeal opening (Kahrilas & Logemann, 1993; Tracy et al., 1989), and delayed









and less efficient esophageal transit and clearance (Mandelstam & Lieber, 1970). Elderly

individuals are more likely to aspirate if they have any circumstances of medical

conditions, such as neurologic or neuromuscular diseases (Kikawada et al., 2005;

Kobayashi, Hoshino, Okayama, Sekizawa, & Sasaki, 1994; Mandelstam & Lieber, 1970;

Teramoto, Matsuse, & Ouchi, 1999).

An EMST program should contribute to the reduction of the mechanisms of age-

related neuromuscular deterioration in the swallowing structures. Several possible

mechanisms are expected to improve the swallow function with an EMST program. As

predicted previously, EMST will increase expiratory lung volume and force, resulting in

high expiratory airflow. In turn, this would increase the afferent stimulus on the sensory

receptors of the tongue and oropharynx, leading to an increase in the activation of the

swallow sensory recognition center located in the medulla or lower brainstem (Doty,

Richmond, & Storey, 1967; Gross, Atwood, Grayhack, & Shaiman, 2003; Logemann,

1998). After this incoming information is decoded in the nucleus tractus solitarius, the

efferent information from the nucleus ambiguous is delivered to motor units participating

in oropharyngeal swallow motor pattern (Doty et al., 1967). The increased activity of

motor units would improve the efferent motor activities of oropharyngeal, velar, and

laryngeal musculatures as well as the speed of oropharyngeal swallow. Consequently,

the improved activities and speed of swallowing structures would reduce the general

duration of swallowing.

Another possible mechanism for improvement in swallow function could be related

to an increase in the hyolaryngeal displacement with increased expiratory force as a result

of the EMST program. During the oropharyngeal swallowing phase, the hyoid bone is









pulled up which elevates the larynx anteriorly and vertically by the contraction of

submental muscle group including the suprahyoid muscles, in other words, laryngeal

elevator muscles (Logemann, 1998; Perlman, Palmer, McCulloch, & Vandaele, 1999).

This muscle group is composed of the anterior belly of the digastric, mylohyoid, and

geniohyoid muscles. Yokoyama et al. (2000) suggested that vertical hyolaryngeal

movement causes laryngeal closure so as to protect the lower airway and that anterior

hyolaryngeal movement contributes to decreasing the upper-esophageal sphincter

pressure to enable a bolus into the upper-esophageal sphincter readily. In turn,

anterovertical hyolaryngeal movement associated primarily with the contraction of

submental muscles is important for effective and safe passage of a bolus to the

esophagus. Hyoid and laryngeal elevations during oropharyngeal swallowing have been

commonly observed using submental muscle group activity in surface electromyography

(Ding, Larson, Logemann, & Rademaker, 2002; Ertekin et al., 1995; Perlman et al., 1999;

Vaiman, Eviatar, & Segal, 2004a, 2004b; Wheeler & Sapienza, 2005). As mentioned

previously, elderly individuals have a decrease in hyolaryngeal displacement, which can

reduce the laryngeal closure and cause a bolus to escape into other cavities, resulting in

high risk of aspiration (Logemann et al., 2000; Yokoyama et al., 2000). However,

hyolaryngeal displacement may be increased by forced expiration with EMST. Fink and

Demarest (1978) noted that laryngeal displacement is induced by the respiratory cycle,

with inspiration associated with downward movement and expiration with upward

movement. Particularly, upward laryngeal movement is related to the mechanical

contribution of laryngeal elevator muscles. If expiratory force increases, it would

enhance the activities and strength of laryngeal elevator muscles, resulting in enhancing









hyolaryngeal displacement. With increased hyolaryngeal displacement during

swallowing, the glottal closure should be enhanced, thus moving the bolus into the

esophagus more easily. This assumption was supported by the study of Wheeler and

Sapienza (2005) which compared the submental muscle group activities using surface

electromyography during swallow task and respiratory task using EMST device set at

25% and 75% of MEP in 20 young healthy adults. Their study showed that the EMST

task produced significantly higher peak amplitude and greater average amplitude of

submental muscle group activity compared to either dry swallow or wet swallow tasks.

They also observed increased hyoid elevation, while using the EMST device, on

videofluoroscopy from one participant. They suggested that EMST enhances the

activation of the submental muscle group for swallowing and may impose central and

peripheral adaptations during the EMST program.

Finally, it is predicted that the EMST program will improve speech characteristics.

It is well known that the contraction of expiratory muscles is necessary for certain types

of speech tasks since it controls the outflow of air in order to speak as well as provides

the necessary pressure when elastic recoil forces are not great enough to vibrate the vocal

folds (Hixon, 1973). Isshiki (1964) noted that improvements in sound quality, speech

intelligibility, duration, and intensity are a function, to some extent, of the degree of

expiratory pressure that can be developed. Even though reduced lung volume and

pressure, resulting from decreased respiratory muscle strength, thoracic compliance, and

elastic lung recoil pressure, do not seem to cause major problems associated with

breathing at rest or comfortable effort, the necessary volume and pressure to sustain

speech for a long period of time and to perform loud speech or singing cannot be









achieved. These tasks require greater lung pressure associated with expiratory muscle

force (Hoit & Hixon, 1987). In fact, inadequate lung pressure for speech or singing

results in severely decreased vocal intensity and shortened utterance length per breath

(Titze, 1994). Particularly, chest wall rigidity and respiratory muscle weakness

associated with aging results in compromised lung volumes available for speech (Titze,

1994). Specifically, normal inspiratory volumes cannot be produced by the elderly, thus

limiting the available passive recoil pressure for speech and high-effort tasks. When

inspiratory volumes are limited and the subglottal pressure demand for particular speech

tasks cannot be met (e.g., long durations of speech or loud speech), active expiratory

muscles must be recruited to generate the positive airway pressure for these tasks

(Burzynski, 1987). When an individual increases expiratory muscle strength, chest wall

rigidity may reduce because the individual is able to move the chest wall with greater

force (Hoit & Hixon, 1987). This should result in increased speech durations, greater

sound pressure level, and improved voice quality, and speech intelligibility.

Previous studies demonstrated that both elderly males and females produce more

than 6 dB lower sound pressure level (SPL) in maximum vowel intensities (sound

pressure drops by half) than younger counterparts (Morris & Brown, 1994; Ptacek &

Sander, 1966; Teles-Magalhaes, Pegoraro-Krook, & Pegoraro, 2000). In addition, a

comparative study of young versus elderly male voices indicated a significantly lower

vocal intensity in elderly male voices with reduced lung pressure, peak airflow, and open

quotient during syllable train production (Hodge, Colton, & Kelley, 2001). Hodge et al.

(2001) noted that SPL was greater for young men than for elderly men at all different

intensity conditions. In the study, mean lung pressures in the loud condition were 10.82









cm H20 and 7.96 cm H20 in the control young group and in the elderly group,

respectively. The difference of the lung pressure between the control and elderly groups

was statistically significant in this condition. These results suggest that lung pressure is

significantly decreased in the elderly group as compared with the young group. Changes

in lung pressure are closely associated with changes in SPL. The SPL increases at a rate

of 8 to 9 dB when lung pressure is doubled (Hodge et al., 2001). Thus, reduced lung

pressure for loud phonation in the elderly compared to the young represents a reduction

in lung pressure which may be accompanied with weakness of the expiratory muscles.

Additionally, several researchers report reduced vocal fold closure (Honjo & Isshiki,

1980; Linville, 1992; Tanaka, Hirano, & Chijiwa, 1994), histologic and neuromuscular

changes in laryngeal muscles (Rodeno, Sanchez-Fernandez, & Rivera-Pomar, 1993), and

decreased laryngeal muscle activity with age (Baker, Ramig, Sapir, Luschei, & Smith,

2001; Luschei, Ramig, Baker, & Smith, 1999). Therefore, it was suggested that the

changes in lung pressure may be necessary to overcome an age-related changes in

laryngeal structure and mechanism to control airflow and air pressure for speech in the

elderly (Baker et al., 2001). Furthermore, it has been shown that the number of syllables

produced per breath group are reduced with age (Hoit & Hixon, 1987), which is related to

the reduced duration of phonation in the elderly. However, these age-related changes in

speech might be compensated for by EMST in that it may assist the active expiratory

force to positively affect speech characteristics such as increasing expiratory pressure to

produce loud phonation or sustain phonation for a long period of time as well as

overcoming high laryngeal resistance. In a study of a 4-week EMST program with

patients with Parkinson's disease, significant improvements in the range of vocal









loudness during sustained vowel phonation tasks was found (Saleem et al., 2004). It is

also known that EMST program for individuals with neurologic impairments improves

their speech parameters like vocal intensity. Following a 6-week EMST program, nine

children with hypotonia demonstrated significant increases in vocal intensity among

participants (Cerny et al., 1997). Furthermore, an 8-week of EMST improved acoustic

components of speech including vowel prolongation as well as subjectively reported

voice-related quality of life in 17 patients with multiple sclerosis (Chiara, 2003). The

participants with multiple sclerosis described an ability to breathe easier and talk louder

after EMST program. In a study with high risk performers working in a theme park who

were singing along with choreography, expiratory muscle strength and utterances

duration per breath significantly increased after a 4-week EMST program (Hoffman-

Ruddy, 2001). Additionally, professional voice users with voice problems after the

combined treatment of 5 weeks EMST and 6 sessions of traditional voice therapy showed

significant improvements in voice handicap scores, voice rating scale scores, subglottal

pressure for loud intensity, phonetogram area in both frequency and amplitude, and

dynamic range (Wingate, Sapienza, Shrivastav, & Brown, in press). These previous

works with the EMST program in the healthy and the clinical populations indicate

improvements in pressure support for voice and speech quality post-EMST including

increases in vowel and phrase durations, increased SPL, as well as decreased frequency

variability, and reductions in breathlessness, and in vocal fatigue.

Statement of the Problem

It is known that EMST has a great impact on increasing expiratory muscle strength

in healthy and clinical populations. However, very few have investigated the effect of

EMST on healthy elderly population. As described earlier, after the age of 60, people









have reduced mass and changed fiber types of expiratory muscles resulting in reduction

of muscle strength. This latter age-related changes in skeletal muscles, referred to as

sarcopenia, often combined with the sedentary lifestyle in the elderly, leading to a

significant reduction in reserve capacity of muscular strength. Reduced physical activity

accelerates the changes in respiratory muscle structures with muscle atrophy, which can

affect the reduction of particular functions of breathing, cough, swallow, and speech in

the elderly.

Therefore, this study will reveal how EMST impact on expiratory muscles which

play a major role in breathing, cough, swallow, and speech in the sedentary healthy

elderly.

Previous studies have shown that EMST is an effective training paradigm to

increase expiratory muscle strength resulting in improvements in certain physiological

functions in healthy adults and certain clinical populations. However, very few studies

have sought to quantify real therapeutic gains directly attributable to the interventions

that have employed EMST with regard to breathing, cough, swallow, and speech.

Previously, the effects of EMST on cough have quantified in maximum voluntary

coughs. Cough is a reflexive event. To examine the effects of EMST on coughs should

be measured in reflexive coughs. Most recently, the inhaled irritant of choice for

investigation of cough in human has been capsaicin. This irritant is safe and reproducibly

elicits cough in virtually all participants (Dicpinigaitis, 2003; Dicpinigaitis & Alva, 2005;

Ertekin et al., 1995; Nieto et al., 2003; Prudon et al., 2005). Thus, cough measures in this

study were completed using capsaicin-induced cough productions. Additionally, the

effects of EMST on swallow have quantified with videofluoroscope or subjective reports









from the participants in the previous studies. However, no study has measured the

strength changes in the muscles used for swallowing. Surface electromyography (sEMG)

has been commonly used to evaluate the strength changes in the swallow muscle group

activity. sEMG is a simple, reliable, and noninvasive method to assess temporal and

neural activities of complex muscle group. Particularly, the activity of submental

muscles which are the primary muscle group of hyolaryngeal elevation during the early

stage of swallowing could be repetitively measured using sEMG without invasive

procedure in pre- and post-EMST.

Purpose of the Study

The purpose of this study is to investigate the physiological effects of EMST on

expiratory muscle strength in otherwise healthy, but sedentary, elderly as measured by

the primary dependent variable of maximum expiratory pressure (MEP). Additionally,

this study will examine the potential effects of EMST on maximum inspiratory pressure

(MIP), breathing, cough, swallow, and speech functions affected by the aging process.

Hypotheses

Central Hypothesis: It is hypothesized that a 4-week EMST program will improve

maximum respiratory pressure, breathing, cough, swallow, and speech functions in

otherwise healthy, but sedentary, elderly adults due to expected increases in expiratory

muscle strength. The specific hypotheses are the following:

Hypothesis 1: Expiratory muscle strength, as indicated by increased MEP, and

inspiratory muscle strength, as indicated by increased MIP due to changes in pulmonary

mechanics, will improve after 4 weeks of strength training with an expiratory pressure

threshold device.









Hypothesis 2: Increased expiratory muscle strength will be translated to

improvements in breathing functions. Specifically, improvements in forced expiratory

volume in 1 second (FEV1), forced vital capacity (FVC), and expiratory reserve volume

(ERV) will be affected. But the ratio of FEV1 to FVC will not be changed.

Hypothesis 3: Improved expiratory muscle strength will increase the peak

expiratory flow rate (PEFR) and the post-peak plateau duration (PPPD) and the post-peak

plateau integral amplitude (PPPIA) as well as decrease inspiratory phase duration (IPD)

and compression phase duration (CPD) during the capsaicin-induced reflexive cough

production.

Hypothesis 4: Increased cough magnitudes are not the influence of increased

sensitivity to capsaicin challenge.

Hypothesis 5: Increased expiratory force and hyolaryngeal displacement will

increase the peak amplitude (PA) and integral amplitude (IA) of submental muscle group

activity and decrease the duration (DUR) of submental muscle group activity during

maximal voluntary dry (saliva) and thin paste bolus (5 cc and 10 cc pudding) swallows.

Hypothesis 6: Increased expiratory muscle strength will increase excess lung

pressure (PEL) as well as the maximum phonation durations (MPDs) at comfortable

intensity and at loud intensity.














CHAPTER 2
METHODOLOGY

The project design was a prospective, complete repeated measures design.

Participants were assigned to use a specific experimental training device for expiratory

muscle strength training. The independent variables were training status (Pre-

training/Post-training) and gender for all functions, consistency (maximal voluntary dry,

5 cc water, 10 cc water, 5 cc pudding, and 10 cc pudding) for swallow function, and

loudness (comfortable/loudest) for the speech function. The dependent variables for

pulmonary function were maximum expiratory pressure (MEP) and maximum inspiratory

pressure (MIP), force vital capacity (FVC), forced expiratory volume in 1 second (FEV1),

the ratio of FEV1 to FVC (FEVi/FVC), and expiratory reserve volume (ERV). Cough

dependent variables were inspiratory phase duration (IPD), compression phase duration

(CPD), peak expiratory flow rate (PEFR), post-peak plateau duration (PPPD), and post-

peak plateau integral amplitude (PPPIA) as well as total number of coughs and total

number of expulsive events. Swallow dependent variables were peak amplitude (PA),

duration (DUR), and integral amplitude (IA) of submental (SM) rectified surface

electromyography (sEMG) during maximal voluntary dry and 5 cc and 10 cc boluses of

wet (water) and thin paste (pudding) swallows. Speech dependent variables included

excess lung pressure (PEL) as well as maximum phonation durations of sustained vowel

production (MPDs) at two levels of intensities, comfortable and maximum loudness.









Sample Size Determination

Sample size calculation was performed using one dependent variable as suggested

by Marks (Marks, 2002). The maximum expiratory pressure (MEP) was used as the

variable to determine sample size since this measure was considered the primary outcome

measure for determining the effect of EMST. The standard deviation of MEP, denoted as

o, was determined from the range of MEP values obtained in a pilot study (Kim,

Sapienza, & Davenport, 2005). The range was 75.86 cm H20, which yielded a o of

18.97 cm H20. The minimum clinical significant difference, or bound on error (B),

between the average MEP values before EMST and average MEP value after EMST was

determined to be 20% of the average baseline MEP. Since the average MEP was

measured at 73.57 cm H20, B value was calculated and yielded a value of 14.71 cm H20.

Using the obtained values of c and B, DELTA (6) was calculated using the formula: 6 =

B/o and determined to be as 0.775. The significance level (ca), or probability of

executing a Type I error, was predetermined at 0.05. The power of the test (1-P), or the

ability to reject the null hypothesis if the null is false, was set at 90%. Using the sample

size table provided in Marks (2002), the number of participants needed was 18.

Therefore, 18 participants were recruited for this study.

Recruitment and Selection

An approval for the study was obtained from the University of Florida Health

Science Center Institutional Review Board (IRB# 402-2004) prior to recruiting

participants. All participants in this study signed an informed consent document

authorized by the IRB. Participants were recruited from local community members (via

residential facilities, social and professional organizations, churches, and retirement









communities) in the Gainesville area. Printed flyers containing information about the

study and contact information were posted at various locations across local communities

(Appendix A).

Inclusion Criteria

Participants were included based on the following criteria:

1. Over 65 years.

2. Sedentary: Sedentary was defined as a person with 24-hours (24-h) of maximum
exertion time (MET-Time) < 50 in physical activity as described in the physical
activity questionnaire (Aadahl & Jorgensen, 2003) (Appendix B).

The chosen activities were listed in the physical activity scale in nine levels
of physical exertion, ranging from sleep or inactivity to strenuous activities.
The physical activity scale was composed of the number of minutes (15, 30,
or 45 min) and hours (1 tol0-h) spent on each MET activity level on an
average 24-h weekday. This allowed for a calculation of the total MET-time,
representing 24-h of sleep, work, and leisure time on an average weekday.

MET activity level: A = 0.9 MET, B = 1.0 MET, C = 1.5 METs, D = 2.0
METs, E = 3.0 METs, F = 4.0 METs, G = 5.0 METs, H = 6.0 METs, and I >
6 METs).

For each activity level (A to I) the MET-Value was multiplied by the time
spent on that particular level and MET from each level was added to total 24-
h MET-time, representing physical activity level on an average weekday.

3. Able to maintain his/her current level of physical activity during participation in
this study.

Participants were asked to report to the investigator any significant changes
in their level of physical activity during their participation in the study with
regards to intensity and frequency of exercise during the entire training (e.g.,
a sedentary person begins exercising 2 to 4 days per week).

4. Able to complete the informed consent to participate in the study

Exclusion Criteria

Participants were excluded from the study if they reported any of the following:

1. History of the following medical conditions: chronic and acute cardiac disease
including untreated hypertension (systolic blood pressure > 140 mmHg, diastolic









blood pressure > 90 mmHg), pulmonary disease, neuromuscular disease, and/or
immune system disease, or others as reported on a health questionnaire (Appendix
C).

2. Upper respiratory infection at the time of the baseline measurements as reported on
the health questionnaire or during the training period. If symptoms persisted for
more than 1 week of training, the participant was excluded from the study.

3. Pulmonary function test values below 70% of the predicted normative value (e.g.,
FEV1 < 70% or FVC < 70%).

4. History of smoking or tobacco use within the last 5 years.

5. Extreme athletes (e.g., marathon runner, professional weightlifter).

6. Other illness that would prevent patient from completing the protocol.

7. Significant change in activity level.

Participant Demographics

Twenty one participants, 16 women and five men, were recruited in the study. Two

women completed only the first pre-training baseline measures and withdrew from the

study due to uncomfortable feeling of the capsaicin challenge. One man completed the

first and the second pre-training baseline measures and withdrew from the study due to

the concern about a low, but potential health risk involved, particularly, with high

intensity pressure threshold trainer during the development of high expiratory pressure.

Thus, a total of 18 sedentary healthy elderly individuals completed the study. Four of

these participants were men and 14 were women. The average age of the participants

was 77 years with a range of 68 to 89 years. The age of men ranged from 72 to 89 years

(mean age of 78.25 + 7.80) and the age of women ranged from 68 to 84 years (mean age

of 76.64 + 5.27). Demographic information of participants is summarized in Table 2-1.










Measures

Participants were asked to fill out a physical activity questionnaire (Appendix B)

and health questionnaire (Appendix C). Blood pressure was measured by the investigator

to determine if the participants qualified to be in the study. This study included a 7-week

experimental protocol for each participant. Week 1 and week 2 were two pre-training

baseline measurement conditions. Participants were exposed to the training program

during weeks 3 to 6. Week 7 was the post-training measurement condition. Measures of

pulmonary function (i.e., maximum respiratory pressures and breathing measures),

cough, swallow, and speech were obtained for each participant.

Table 2-1. Demographic information for participants in the study.
Participant Gender Age Height Weight Physical Activity
(yrs) (cm) (kg) (METs)
1 F 77 154.94 63.05 31.70
2 F 73 154.90 49.50 23.45
3 F 68 157.00 93.60 48.30
4 F 83 165.00 58.95 40.80
5 M 73 177.80 112.50 17.55
6 M 72 177.80 77.40 38.90
7 F 74 160.02 74.25 28.82
8 F 81 152.40 70.00 46.90
9 F 81 152.40 53.10 30.45
10 F 75 167.64 70.65 31.92
11 F 84 165.10 61.20 23.45
12 F 77 152.40 65.90 25.45
13 F 69 167.64 74.25 26.10
14 M 79 175.26 N/A 41.70
15 M 89 172.72 74.25 15.70
16 F 83 160.02 74.25 25.70
17 F 71 165.10 72.00 30.45
18 F 77 167.64 72.00 20.95
Note: N/A = Not applicable









Maximum respiratory pressures, MEPs and MIPs, were recorded from all participants in

two pre-training conditions and following each week of training for 4 weeks as well as

post-EMST. All other measures were recorded from all participants in two pre-training

conditions and post-EMST.

Pulmonary Measures

Maximum Respiratory Pressures. Maximum expiratory pressures (MEP) and

maximum inspiratory pressure (MIP) were measured using a disposable mouthpiece

connected to a Smart 350 series pressure manometer (Meriam Process Technologies,

Cleveland, Ohio, USA) by 50 cm of 6 mm inner diameter tubing with a 20-gauge (2 mm)

needle air-leak at the mouth to prevent the participant from sustaining pressure with a

glottal closure (Berry et al., 1996; Enright et al., 1994; Karvonen et al., 1994; O'Kroy &

Coast, 1993). During the completion of the MEP and MIP tasks, each participant stood

with his/her nose occluded with a nose clip while he/she used the Smart 350 series

pressure manometer. For MEP, after inhaling to total lung capacity, the participant

placed his/her lips around a mouthpiece and blew out as forcefully as possible. For MIP,

after exhaling to residual volume, the individual placed his/her lips around a mouthpiece

and inspired as forcefully and fast as possible through the mouthpiece connected to a

pressure gauge with the nose occluded by a nose clip. Repeated measures were taken

with a 1 to 2 minute rest between trials for both the MEP and MIP measures, until three

measurements were obtained within 5% of each other and no further improvement was

obtained. The average of these three values was used for analysis. Approximately 5 to

10 trials were necessary per participant to obtain the 3 trials within 5% of each other.









Breathing Measures. Pulmonary function tests (PFTs) were completed using a

computerized MasterScreen PFT system (Jaeger Toennies, Erich Jaeger Gmbh,

Leibnizstrasse 7, D-97204 Hoechberg). During the completion of the PFTs, the

participant sat in front of the MasterScreen PFT. To obtain PFTs, the guidelines of the

American Thoracic Society were followed. Breathing function parameters measured in

this study were forced vital capacity (FVC), forced expiratory volume in 1 second

(FEVi), the ratio of FEV1 to FVC (FEV1/FVC), and expiratory reserve volume (ERV).

For FVC and FEV1, each individual placed their mouth around a disposable mouthpiece.

The nose was occluded by a nose clip to prevent air leak. Next, the participant was asked

to take a deep breath and inspired to total lung capacity, followed by taking three tidal

volume breath cycles. The individual then blew out as forcefully as possible into a

mouthpiece, being verbally encouraged to "blast out" all the air in the lungs. FVC was

defined as the total volume of air expired during a maximally forced expiration after a

full inspiration (Figure 2-1). FEV1 was defined as a measure of expiratory volume during

the first second of expiration during the forced vital capacity maneuver with maximal

expiratory effort (Figure 2-1). FEV1/FVC ratio was calculated by dividing the FVC value

by the FEVi value taken from the PFTs. This parameter provides a clinically useful

index of airflow limitation. All PFT measures were completed a minimum of three times

with a 1 to 2 minute rest between trials to ensure similar values were obtained at each

attempt. The best three measurements were averaged and recorded for analysis. For

ERV, each participant was asked to place their mouth around a disposable mouthpiece.

The nose was occluded by a nose clip to prevent air leak and they were asked to rest

breathe for three cycles. Next, the participant was asked to carry out, consecutively, a






40

maximal slow inspiration, a maximal slow expiration, and then one more maximal slow

inspiration into a mouthpiece connected to the MasterScreen PFT. ERV was defined as

the maximum volume of air that can be expired after normal expiration (i.e., tidal

volume; Figure 2-2).


t3- 3

S2

1

4
0


FEV


FVC


1 2 3 4 5
Time (s)


Figure 2-1. Graphical depiction of FVC and FEV1.


KA


\ J 10\ 30
0 -0.5
> Expiratory
-1 Reserve
-1.5 Volume
-2
Time (s)

Figure 2-2. Graphical depiction of ERV.


fth









Cough Measures

Cough magnitude was measured from an expiratory flow waveform produced

during a capsaicin-induced cough. To obtain an acceptable cough signal, the participants

were seated comfortably in a chair. The mask, connected to a pneumotachometer (Hans

Rudolph Inc., Kansas City, MO, USA) was placed on the participants face and they were

given a verbal cue to take a single vital capacity breath of 100 microMolar ([tM)

capsaicin in 80% physiological saline, 10% Tween 20, and 10% Ethanol capsaicin

solution (Appendix D) via an air-powered nebulizer (KoKo Digidoser; Pulmonary Data

Services Instrumentation Inc., Louisville, CO). The nebulizer output was set at 10 [iL. A

differential pressure transducer (Validyne MP 45-2-871, Validyne Engineering Corp.

Northridge, CA, USA) in ranges as low as + 2 cm H20 was attached to the facemask

pneumotachometer. Next, the participants were asked to take a single deep inspiration of

a 10 [iL of 0.9% saline solution followed by capsaicin solution to eliminate capsaicin

residue from the facemask. Capsaicin and saline was administered five times

alternatively in pre-training and post-training conditions. Each test of inspiration was

separated by an interval of 1 to 2 minutes. This attachment was fitted directly into the

Power Lab/8SP data acquisition system (ADInstruments, ML750, Colorado Springs, CO,

USA). Prior to collection of cough measures from each participant in the baseline

sessions, the pneumotachometer was calibrated with 1 L/s flow source. A calibration

routine within Chart 4.2.3 for Windows software (ADInstruments, Colorado Springs, CO,

USA) was used to calculate volume and flow.

All cough signals were recorded using the Chart 4.2.3 software. The signal was

low-pass filtered at 300 Hz through the filter in the Powerlab unit, as the filter in the









spirometer capable of filtering to 100 Hz, was inadequate to filter the high frequency

components of the waveform during cough. Measurements of cough flow were analyzed

using Chart 5 for Windows software (ADInstruments, Colorado Springs, CO, USA). The

sampling rage was set at 2,000 samples per second for all cough measures.

A cough was defined as having an inspiratory phase, a compression phase, and one

or more expulsive events (i.e., cough refractory; CR) on a single inspiration. Expulsive

events are composed of one strong expulsive event (SE) followed by reflexive expulsive

events (RE; Figure 2-3). The total number of coughs (N of coughs) was counted from the

airflow signal taken from each of the five trials of capsaicin inhalation and then averaged.

In addition, the total number of expulsive events (N of CR), sum of all SEs and REs, was

counted independent of the inspiration from the cough airflow taken from each of the five

trials of capsaicin inhalation and then averaged.

Strongest Expulsive
/ Event (SE)
10 Event (SE) Expulsive
Events
8 Reflexive Expulsive
Events (RE)
S6

v 4




0
< 2




-2 CR5 CR2 CR2


4.28 4.30 4.32 4.34 4.36 4.38

Time (s)
Figure 2-3. Airflow during reflexive cough production. CR5 represents five expulsive
events. The total number of coughs is three and the total number of expulsive
events is nine in this Figure.









Cough magnitudes measured in this study were inspiratory phase duration (IPD),

compression phase time (CPD), peak expiratory flow rate (PEFR), post-peak plateau

duration (PPPD), and post-peak plateau integral amplitude (PPPIA; Figure 2-4). The

magnitudes of the coughs having the highest PEFR, were taken from each of the five

trials of capsaicin inhalation, were collected and then averaged.


Peak Expiratory
S6 Flow Rate



4 Post-peak
plateau
Inspiratory Compression integral
2 Phase Duration Phase Duration_ amplitude

I 2

Post-Peak
Plateau
-2 Duration

3.24 3.26 3.28 3.30 3.32

Time (s)
Figure 2-4. Cough magnitudes in one cough.

IPD (in seconds) was defined as the time from the beginning to the end of the

inspiratory phase marked by departing and returning of the airflow to 0 L/s. PEFR (L/s)

was defined as the highest peak of expiratory flow rate following the inspiratory phase

during the capsaicin-induced cough. CPD (in seconds) was defined as the duration

between the end of the inspiratory phase and the beginning of the expiratory phase.

PPPD (in seconds) was defined as the time of sustained airflow that occurred after the

peak expiratory flow. This was visually determined by observing the expiratory flow









waveform. The initiation point for PPPD was marked as the time immediately after the

transient overshoot of the peak airflow signal when the flow became stable. PPPD

termination was marked as the final time-point where the stable flow ended prior to

another rapid descent in the expiratory flow rate. PPPIA (L/s x s) was defined as the area

under cough airflow curve between PPPD initiation and PPPD termination.

Swallow Measures

Submental surface electromyographic signals (SM-sEMG) were obtained using an

8-channel Bagnoli EMG System (Delsys Inc., Boston, MA, USA) to record submental

muscle group activity. Two surface electrodes (DE-2.1 single differential electrodes,

Delsys Inc., Boston, MA, USA) were attached and taped to the skin beneath the chin,

bilaterally, to record the strength of submental (SM: suprahyoid) muscles over the

mylohyoid, geniohyoid, and anterior digastric muscle complex during three trials of each

consistency. A paper ruler, width of 1 cm, measured the length from the tip of the nose

to the point where two electrodes were attached on the chin in the first pre-training

baseline measurement session and recorded to help keep consistent place for electrodes

attachment in baseline measurements and post-training measurement. The output of the

Bagnoli systems was connected directly to the Power Lab/8SP data acquisition system.

The software program, Chart 4.2.3 for Windows from ADInstruments, was used to record

the swallow measures online and Chart 5 for Windows was used to analyze the data off-

line. The signal from two sEMG electrodes was amplified with a gain of 1000 V/V, low-

pass filtered at 1,000 Hz, and high pass-filtered at 100 Hz in order to remove any DC

offset and high-frequency noise. The original EMG signal was rectified by the root mean

square (RMS) method. This method used the square root of the average of the squared









values of the preceding data points over the time set (20 ms). Chart 4.2.3 was set up to

display 4 different channels. Channel 1, channel 2, channel 3, and channel 4 displayed

the right SM-sEMG raw data, the left SM-sEMG raw data, the right SM-sEMG RMS

data, and the left SM-sEMG RMS data, respectively. SM-sEMGs were collected during

five different consistencies which included dry voluntary maximal effortful swallow, wet

(5 cc and 10 cc water) swallow, and thin paste (5 cc and 10 cc pudding) swallow. A total

of 15 trials were randomly assigned to the participants.

Swallow dependent variables were peak amplitude (PA), duration (DUR), and

integral amplitude (IA) of SM-sEMG activity during swallowing (Figure 2-5). The

maximum strength of SM muscles was defined as the PA (mV) of the RMS of SM-sEMG

signal activity during swallowing. The DUR (s) of SM-sEMG during swallowing was

determined by measuring the interval between the onset and the offset (offset time minus

onset time) of SM-sEMG activity (Ding et al., 2002; Ertekin et al., 1995). The IA (mV/s

x s) of SM muscles was also calculated as the area of RMS under the SM-sEMG activity

curve between the onset and offset of the swallow. This measured the output of total SM

muscles activity during swallowing.

The onset and offset in SM-sEMG activity were determined by Cycle Variables

function in Chart 5 (Figure 2-6). Cycle Variables function is defined as channel

calculation that identifies cycles in the SM-sEMG waveform. It calculates and displays

cycles extracted from the waveform and explicitly takes into account the waveform's

cyclic aspects. Chart 5 software provides two different types of cyclic variables

including temporal quantities, such as period, frequency, or rate and amplitude-related










characteristics, such as cyclic maximum, cyclic minimum, cyclic mean, or cyclic height.

In this analysis, cyclic mean was used as cyclic variables in channel 1.



200
R SM-sEMG
(mV) 100

-100
200
L SM-sEMG
(mV) 100


S60 Peak Amplitude
RRMS
(mV) 40
20
Duration
60
LRMS 40
(mV) 20-- Integral Amplitude

4 4.2 4.4 4.6 4.8 5 5.2 5.4 5.6
Time (s)


Figure 2-5. SM-sEMG Activity. R SM, L SM, and RMS denote right, submental
muscle, left submental muscle, and root mean square, respectively.

Cyclic mean is the mean value of the data points contained in one cycle of a

waveform to display the cycle-by-cycle mean value of SM-sEMG recording. SM-sEMG

baseline before each swallow task was measured in an individual and was used for setting

up the sensitivity of cycle detection algorithm by adjusting 2% noise threshold of

baseline, a percentage of the selected data range. Cycle Variables ignore fluctuations in

the waveform less than the set-up noise threshold value. The onset and offset of SM

activity during swallowing were determined the zero points which were the closest time









before the peak of SM-sEMG and the closest time after the peak of SM- sEMG,

respectively.

Before measuring swallow function, as a standardized test of SM-sEMG activity,

participants were asked to blow into the expiratory pressure threshold trainer which was

set up at 50 cm H20. These were taken during two pre-training baseline measurements

and compared in PA, DUR, and IA of SM-sEMG activity.



40




E 20
--


0 ( Cyclic Mean



4.6 4.8 5.0 5.2
Time (s)

Figure 2-6. Cycle variables function. From Chart 5 for Windows software
(ADInstruments, Colorado Springs, CO, USA).

Speech Measures

Dependent variables related to speech production were examined using

aerodynamic and acoustic analysis. Aerodynamic measures included air pressure

measures (explained below). Participants were asked to repeat syllables while a small

disposable plastic pitot tube (2 mm diameter) was placed into the oral cavity between the

lips and behind the front teeth. The tube was connected to a pressure transducer (PTL-1,

Glottal Enterprises, Syracuse, NY, USA) low pass-filtered at 30 Hz which recorded the









air pressure signal. The pressure transducer was calibrated with 5 cm H20 prior to data

collection (MCU-4, Glottal Enterprises, Syracuse, NY, USA). All pressure measures

were recorded using Power Lab/8SP data acquisition system with Chart 4.2.3 for

Windows software. The sampling rate was set at 10,000 samples per second for all

pressure measures. Air pressure measures were obtained by three tasks. The first task

was the repetition of a syllable train /pa/ seven times in one breath at the softest vocal

intensity level. The second task was the gradual increase in the vocal intensity to the

maximum effort level. The third task was the repetition of a syllable train /pa/ seven

times in one breath at the maximum effort level. The participants were instructed to take

a breath just before starting the next task. The first and third were completed randomly.

If individuals initiated from the third task, they were asked to decrease the vocal intensity

gradually to the softest possible intensity level. During these tasks, participants were

instructed to produce each consonant in the syllable with approximately equal stress and

to maintain a syllable rate of about 1.5 syllables per second. In repeating a syllable train

at the softest possible intensity level, participants were instructed to initiate voice at the

lowest possible intensity level without whispering. The initiating effort level of syllable

repetition was randomly assigned. Five trials of this task in each individual were

recorded on Chart 4.2.3 for Windows and were analyzed on Chart 5. The recordings for

air pressure were completed in a quiet room.

Air pressure measures included excess lung pressure (PEL) calculated from

phonation threshold pressure (Pth) and lung pressure (PL). Pth and PL values were

estimated from intraoral pressure (Po) measurements (Hodge et al., 2001; Rothenberg,

1982; Smitheran & Hixon, 1981). Po was defined as the pressure within the oral cavity









during the production of the voiceless stop segment /p/ produced in the syllable train /pa/

at both the softest and the loudest possible intensity levels. Pth was defined as the

minimum pressure required for initiating vocal fold vibration (Titze, 1994).

Measurement of Po at the softest possible level was utilized for estimating Pth. PL used in

this study was defined as the Po at the loudest possible level. PEL was defined as the

difference between the PL and Pth (Hodge et al., 2001). The pressure peaks of Po values

from the middle five of seven repeated /pa/ at both the softest and loudest possible

intensity levels were measured and averaged to estimate PL and Pth values from Po. The

relative change in pressure was calculated in cm H20.

Acoustic measures included maximum phonation durations (MPDs) of sustained

vowel phonation at two levels of intensities, comfortable and loud. MPD was defined as

the greatest length of time over which sustained vowel could be prolonged (Baken &

Orlikoff, 1998). Participants sat on a chair comfortably and wore a cardioid headset

microphone (ATM73a, Audio-Technica, Japan) placed 2 cm from the right corer of the

mouth. Participants' phonations were recorded on a portable digital audio tape (DAT)

recorder (TAS CAM DA-P TEAC Corporation, Japan). Participants were instructed to

take a deep breath and sustain the vowel /a/ as long as they could at the comfortable and

the loudest effort levels. Each task was performed three times and the order of the tasks

was randomly assigned. Three trials of MPD in each intensity level was analyzed and

averaged using the software program, TF32 for 32-bit Windows (Milenkovic, Wisconsin,

USA).

Training Protocol

After completion of the two pre-training baseline sessions discussed above, each

participant was provided with the expiratory pressure threshold trainer. The expiratory









pressure threshold trainer used to complete the EMST program was a cylindrical

plexiglass tube that consisted of a mouthpiece and an adjustable one-way spring-loaded

valve (Figure 2-7). This device allowed the pressure threshold to be set up to 150 cm

H20. The spring contained in this device was adjustable to allow for the required

pressure threshold to be increased. The valve blocked expiratory airflow until a sufficient

threshold pressure was reached to overcome the spring force. Participants had to

overcome a threshold load by generating an expiratory pressure sufficient to open the

expiratory spring-loaded valve.



















Figure 2-7. Expiratory pressure threshold training device.

As stated previously, the participants' MEP was measured at the initiation of the

study and following each week of training as well as post-training. The training protocol

for each participant lasted 4 weeks and consisted of five sets of five breaths, 5 days per

week with the pressure threshold set at 75% of the participant' MEP at the time of

measurement (Baker, 2003; Chiara, 2003; Saleem, 2005; Wingate et al., in press). This

percentage was based on skeletal muscle training research that demonstrates that the most









effective muscle strengthening occurs when a near maximal load is placed on the muscle

(Powers & Howley, 2001). Each training breath lasted 3 to 4 seconds. In the initial

training session, an individual was informed of the time frame of training, proper device

handling procedures, appropriate mouth closure around the device's mouthpiece, and air

leak prevention techniques. To prevent possible air leak, the individual was instructed to

place his/her lips tightly around the device's mouthpiece and one of his/her hands held

his/her cheeks around the lips firmly. The individual was then instructed to blow as

forcefully as possible into the device's mouthpiece from total lung capacity (TLC) to

open the valve. The individual was also trained how to correctly discriminate the sounds

between success and failure of opening valve by successive opening valve trials. As air

passes through the device following the opening the valve, the individual could listen to a

distinct audible sound such as whistle sound or air popping sound.

A weekly readjustment meeting was maintained with each participant and the

investigator. At that meeting, the participant's MEP and MIP was measured in the same

manner stated earlier, and the average value of each was used in the dataset. The device

was readjusted by the investigator according to the newly measured average MEP value.

To ensure that the new training load was appropriate, the participant was needed to

complete the one set of five breaths in the clinician's attendance. Any participant

concern regarding the training program was addressed at that time.

Compliance

To insure participant's compliance with the training protocol, participants were

provided with written (Appendix E) and verbal instructions for the use of their devices

and the EMST protocol. During home training period, participants recorded their

completion of training sets daily at home on a log sheet (Appendix F) during the 4 weeks









of EMST. Participants were also instructed to call the investigator at any time if they had

questions or if problems arose in their practice procedure.

Statistical Analysis

The mean, standard deviation, and percent change were calculated from the

database to describe the trends in the dependent variable from pre- to post-training. If the

first pre-training measures were not statistically different from the second pre-training

measures, the two datasets were averaged and used as the average pre-training measures

to be compared with the post-training measures. Differences between the pre-training

condition 1 and the pre-training condition 2 were examined by paired-samples t-test for

all dependent variables. There were no significant difference between the pre-training

condition 1 and pre-training condition 2 for any of the dependent variables of pulmonary,

cough, swallow, and speech functions, therefore those were averaged and then used as the

average pre-training measures that were compared with the post-training measures (Table

2-2, 2-3, 2-4). Three doubly multivariate repeated measures analyses of variance

(MANOVA) were used to examine the effects of EMST on pulmonary and cough

functions. Repeated measures univariate analysis of variances (ANOVAs) were

conducted to evaluate the effects of EMST on swallow and speech functions. Doubly

multivariate repeated measures design has multiple dependent variables measured in

different levels of one or more within-subjects factors or in different levels of between-

within (mixed) design with multiple repeated dependent variables (Tabachnick & Fidell,

1996). In these repeated measures designs, sphericity assumptions (i.e., homogeneity of

variance assumption) were checked using Mauchly's test of sphericity. Sphericity

assumption is a mathematical assumption that assumes all variances of the differences for

each pair of categories of the within-subjects factor are equal in the populations sampled.









In advance, it is expected that the observed samples variances of the differences are

similar if the sphericity assumption is met. In this study, if this assumption was violated,

Greenhouse-Geisser adjustment test for the within-subjects effect was conducted. This

test adjusts the degrees of freedom (df) downward for the usual F test statistic to

overcome the reduced p-value for the within-subjects effect (Agresti & Finlay, 1999).

However, Pillai's Trace was used in this study since unequal sample sizes occurred

for the men and women involved in this study. Usually, Pillai's Trace provides good

power and is most unlikely to violate statistical assumptions as well as it is more

appropriate when sample sizes are small or cell sizes are unequal (Olsen, 1976;

Tabachnick & Fidell, 1996; Walker, 1998).

Table 2-2. Paired-samples t-test between the two pre-training conditions for the
pulmonary and cough function dependent variables.
1st Pre-training 2nd Pre-training
DV t df p
M SD M SD
MEP (cm H20) 75.956 20.513 78.317 20.558 -1.351 17 0.194
MIP (cm H20) 38.497 13.304 39.661 15.081 -0.462 17 0.650
FEV1 (L) 1.907 0.527 1.981 0.464 -1.810 17 0.088
FVC (L) 2.525 0.707 2.568 0.574 -0.947 17 0.357
FEV1/FVC 76.232 8.546 77.109 6.253 -0.611 17 0.549
ERV (L) 0.995 0.656 0.947 0.592 0.823 17 0.422
IPD (s) 1.094 0.277 1.196 0.401 -0.956 17 0.352
CPD (s) 0.384 0.215 0.311 0.205 1.815 17 0.087
PEFR (L/s) 4.885 3.252 5.076 2.091 -0.246 17 0.809
PPPD (s) 0.232 0.087 0.240 0.086 -0.357 17 0.725
PPPIA (L/sxs) 3.369 2.750 3.607 2.940 -0.350 17 0.730
N of Coughs 40.778 15.125 37.611 12.391 1.826 17 0.085
N of CR 13.944 4.734 14.444 3.974 -0.486 17 0.633
* indicates that the mean difference is significant at a = 0.05.










Table 2-3. Paired-samples t-test between the two pre-training conditions for the swallow
function dependent variables.
lst Pre-training 2nd Pre-training
DV Consistency t df p
M SD M SD
PA (mV) DRY 56.042 20.569 65.251 29.250 -1.600 17 0.128
5W 53.503 31.790 51.812 39.797 0.352 17 0.729
10W 53.830 30.736 51.009 37.893 0.502 17 0.622
5P 52.866 23.594 54.752 37.564 -0.282 17 0.781
10P 52.120 25.592 58.301 41.531 -0.987 17 0.338
DUR (s) DRY 0.995 0.171 0.926 0.149 1.905 17 0.074
5W 0.912 0.154 0.939 0.147 -0.915 17 0.373
10W 0.958 0.147 0.928 0.170 1.018 17 0.323
5P 1.012 0.132 0.974 0.134 1.465 17 0.161
10P 1.014 0.142 1.012 0.160 0.071 17 0.944
IA (mV) DRY 25.168 8.626 28.123 11.441 -1.100 17 0.286
5W 22.347 12.912 21.524 13.622 0.385 17 0.705
10W 23.197 12.369 21.333 13.113 0.741 17 0.469
5P 25.124 10.583 25.171 14.679 -0.017 17 0.987
10P 22.677 8.502 26.071 15.607 -1.106 17 0.284
* indicates that the mean difference is significant at a = 0.05.

Table 2-4. Paired-samples t-test between the two pre-training conditions for the speech
function dependent variables.
lst Pre-training 2nd Pre-training
DV t df p
M SD M SD
PEL (cm H20) 12.879 5.122 14.392 5.480 -1.819 17 0.087
MPD COMF (s) 17.529 8.766 18.025 7.312 -0.626 17 0.540
MPD LOUD (s) 19.449 11.149 19.394 11.229 0.052 17 0.959
* indicates that the mean difference is significant at a = 0.05.

If the effect of gender was not significant at a = 0.05, it was eliminated from the

MANOVA or ANOVA, then another MANOVA or ANOVA was carried out only using

the within-subjects factors. If any MANOVA or ANOVA indicated a significant

interaction among factors at a = 0.05, simple main effects tests using paired-samples t-

tests were conducted with the a level set at 0.01. If any MANOVA or ANOVA indicated









a significant main effect at a = 0.05, univariate comparisons of the specific outcome

variables were explored. In univariate comparisons (i.e., multiple pairwise comparisons),

the inflated a level was adjusted by using the Bonferroni adjustment to reduce Type I

error rate when multiple tests are performed on the same data (Tabachnick & Fidell,

1996). Type I error occurs when one rejects the null hypothesis when it is true. All

analyses were carried out using SPSS software version 11.5.

In addition, the relationship between the change in MEP and other pulmonary,

cough, swallow, and speech functions were investigated using Pearson r correlation.

Inter- and intra-judge reliability were also completed on 10% of the data that were

measured by hand. To test the inter-judge reliability of the dependent variables, a

different examiner, a student trained by the investigator in analyzing and scoring the

various measures, re-analyzed the data. The student was blinded to the purpose of the

study. Pearson r correlations were used to determine if there was any significant

difference between the values obtained by different examiners. To test intra-judge

reliability, the investigator repeated the analyses of 10% of the data sets and compared

the first set of measures to the second set using Pearson r correlations again.














CHAPTER 3
RESULTS

This study determined the effects of a 4-week expiratory muscle strength training

(EMST) program on pulmonary, cough, swallow, and speech functions in otherwise

healthy, but sedentary, elderly adults.

Reliability

Pearson r correlations were calculated to evaluate the intra-judge measurement

reliability for cough, swallow, and speech functions (Table 3-1). Strong correlations

were found, indicating high intra-judge reliability. For intra-judge reliability, the Pearson

r correlation between the first and second sets of measurement ranged from 0.905 to

1.000. Likewise, Pearson r correlations were calculated to test the inter-judge

measurement reliability for cough, swallow, and speech functions. Results also showed

moderate to strong correlations between ratings made by the two different judges. For

inter-judge reliability, the Pearson r correlation between two measurers for cough,

swallow, and speech functions ranged from 0.743 to 1.000. Given these data, the

reliability of the all measures in cough, swallow, and speech functions was considered

adequate for the purpose of the present experiment.

Correlation Between MEP and Other Dependent Variables

A Pearson r correlation was performed between MEP and the other dependent

variables included in the study. The results of the correlation are presented in Table 3-2

and show that MEP was both moderately positively and negatively correlated with

variables such as MIP (r = 0.532, p = 0.001), CPD (r = -0.367, p = 0.028), PEFR (r =

56









0.526,p = 0.001), PPPIA (r = 0.472,p = 0.004), and PEL (r = 0.363,p = 0.029).

However, MEP was not significantly correlated with other pulmonary and any swallow

dependent variables.

Pulmonary Function

Table 3-3 depicts the descriptive statistics for all of the pulmonary function

measures pre- and post-training as a function of gender.

A 2 x 2 doubly multivariate repeated measures analysis of variance (MANOVA)

was conducted to analyze the results of MEP, MIP, FEV1, FVC, FEV1/FVC, and ERV as

affected by training and gender. Sphericity assumptions were met. The results of the

MANOVA indicated a non-significant two-way interaction between training and gender

at c = 0.05 (Table 3-4). The main effect of training significantly affected the

combination of MEP, MIP, FEV1, FVC, FEVi/FVC, and ERV (Pillai's Trace = 0.827, F

(6, 11) = 8.766, p = 0.001, r2 = 0.827). Gender did not significantly affect the

combination of pulmonary function dependent variables. Hence, a one-way repeated

measures MANOVA without the gender effect was conducted. Again, sphericity

assumptions were met. The results of MANOVA indicated that the main effect of

training was significant on the combination of pulmonary dependent variables (Wilks' A

= 0.189, F (6, 12) = 8.576, p < 0.001, r2 = 0.811). Therefore, one-way repeated

measures univariate ANOVAs to determine the specifics of the training effect were

conducted (Table 3-5). The ANOVA results indicated that MEP was significantly greater

in post-training (F (1, 17) = 40.978, p < 0.001, r2 = 0.707). MIP also significantly

increased with training (F (1, 17) = 18.513,p < 0.001, r2 = 0.521). However, no









significant effects of training were found on FEV1, FVC, FEV1/FVC, and ERV. MEP

and MIP increased from pre- to post-training by 44% and 49%, respectively (Figure 3-1).


140


120'


S100.


S-80 -


C 60


40 _


20
MEP pre MEP post MIP pre MIP post

Figure 3-1. Effects of training on MEP and MIP.

Cough Function

Table 3-6 shows the descriptive statistics for the dependent variables associated

with cough function pre- and post-training as a function of gender.

A 2 x 2 doubly multivariate repeated measures analysis of variance (MANOVA)

was used to analyze the results of IPD, CPD, PEFR, PPPD, and PPPIA as affected by

training and gender. Sphericity assumptions were met. Table 3-7 shows the MANOVA

results and indicates that the two-way interaction between training and gender was not

significant. The main effects of training and gender were then examined and indicated

that training was not significant on the combination of dependent variables of IPD, CPD,

PEFR, PPPD, and PPPIA, but close to significance of a = 0.05 (Pillai's Trace = 0.520, F

(5, 12) = 2.598, p = 0.081, r2 = 0.520). Gender was not significant. Hence, a one-way









repeated measures MANOVA without the gender effect was conducted. The result of

MANOVA without the gender effect indicated a significant effect of training on the

combination of cough dependent variables (Wilks' A = 0.351, F (5, 13) = 4.803, p =

0.010, r2 = 0.649). One-way repeated measures univariate ANOVAs of the training

effect were then completed (Table 3-8). The ANOVA results revealed that CPD was

significantly decreased with training (F (1, 17) = 13.590, p = 0.002, r2 = 0.444). PEFR

was also significantly increased with training (F (1, 17) = 29.620, p < 0.001, r2 = 0.635)

and was PPPIA (F (1, 17) = 16.826, p = 0.001, r2 = 0.497). However, no significant

effect of training was found for IPD as well as PPPD. The results for CPD, PEFR, and

PPPIA are illustrated in Figure 3-2, Figure 3-3, and Figure 3-4, respectively. CPD

decreased from pre- to post-training by 53% and PEFR and PPPIP increased from pre- to

post-training by 61% and 96%, respectively.

To evaluate the effects of training and gender on the total number of coughs (N of

coughs) and the total number of expulsive events (i.e., N of cough refractories; N of CR),

a 2 x 2 doubly multivariate repeated measures analysis of variance (MANOVA) was

conducted. Sphericity assumptions were met. There was no significant interaction

between training and gender (Table 3-9). The main effects of training and gender were

not significant. Therefore, a univariate MANOVA was completed to test for the training

effect after excluding the gender effect. The results of the MANOVA indicated no

significant effect of training on the N of coughs and the N of CR (Pillai's Trace = 0.210,

F(2, 16) = 2.130, p = 0.151, r2 = 0.210).







60



.5



.4



UA .3


4.2



.1


0.0
Pre Post


Training

Figure 3-2. Effects of training on CPD.


10

9

S8

7

+ 6




4

3
Pre Post


Training


Figure 3-3. Effects of training on PEFR.










10


S 8*
*



cl
4 4


2-


0
Pre Post

Training

Figure 3-4. Effects of training on PPPIA.

Swallow Function

Table 3-10 shows the descriptive statistics for pre- and post-training values of all of

the swallow function measures as a function of gender.

A 5 x 2 x 2 MANOVA could not be conducted since the small sample size (N= 18)

and unequal sample sizes in gender were used, resulting in a reduction of power. Instead,

5 x 2 x 2 repeated measures univariate ANOVAs were examined to determine the effects

of training, consistency, and gender on PA, DUR, and IA of submental muscle group

activity. Sphericity assumptions, presented in Table 3-11, were significantly violated by

the interaction between training and consistency on IA (Mauchly's W (9) = 0.066, p <

0.001), by consistency on PA (Mauchly's W(9) = 0.025, p < 0.001), and by consistency

on IA (Mauchly's W(9) = 0.121, p < 0.001). Therefore, Greenhouse-Geisser correction

for the violation of sphericity assumption was applied. Sphericity assumptions, however,

were met by training on all dependent variables, consistency on DUR, interaction









between training and consistency on PA and DUR. The results of the ANOVA indicated

no significant three-way interaction among the three factors on PA, DUR, and IA (Table

3-15). No significant two-way interactions between training and gender on PA, DUR,

and IA, between consistency and gender on PA, on DUR, and on IA, and between

training and consistency on any of swallow dependent variables were found.

Accordingly, the main effects of training, consistency, and gender on PA, DUR, and IA

were assessed for further evaluation (Table 3-12). Training significantly increased IA (F

(1, 16) = 6.744, p = 0.019, r2 = 0.297), but did not change PA and DUR. Consistency

also significantly increased IA (F (2.368, 37.884) = 4.143, p = 0.018, r2 = 0.206), but did

not change both PA and DUR. No significant effects of gender were found on any of the

swallow dependent variables. Therefore, 2 x 5 repeated measures univariate ANOVAs

were conducted after excluding the gender effect to verify the effects of training and

consistency on PA, DUR, and IA. Again, sphericity assumptions, presented in Table 3-

13, were checked and were also violated by the interaction between training and

consistency on IA (Mauchly's W(9) = 0.069, p < 0.001), by consistency on PA

(Mauchly's W(9) = 0.029, p < 0.001), and by consistency on IA (Mauchly's W(9) =

0.121, p < 0.001). Greenhouse-Geisser corrections were applied for violations of these

ANOVA assumptions of sphericity. Sphericity assumptions, however, were met by

training on all swallow dependent variables, consistency on DUR, the interaction

between training and consistency on PA and DUR.

Table 3-14 shows the univariate ANOVA results without the gender effect. For

PA, a significant two-way interaction between training and consistency was observed (F

(4, 68) = 3.122, p = 0.020, r2 = 0.155). Thus, simple main effect tests using paired-









samples t-tests were submitted to further explore the effects of training and consistency

on PA at c = 0.01 (Table 3-15). The results of these tests indicated that the PAs between

any of two different consistency pairs in pre-training were not significantly different from

each other. However, two different consistency pairs in post-training had significantly

different PAs. Specifically, the PA measured for 10 cc pudding swallow in post-training

was significantly higher than the 5 cc water swallow in post-training (t = -3.388, p =

0.003) and also significantly higher than the 10 cc water swallow in post-training (t = -

3.319, p = 0.004). Additionally, one pair having different consistencies in different

training levels had significantly different PAs. The PA for 10 cc pudding swallow in

post-training was significantly greater than the 10 cc water swallow in pre-training (t = -

3.041,p = 0.007). Furthermore, the profile plots were created by consistency as the

horizontal axis, each pre- and post-training as the separate bar in PA (Figure 3-5). The

plots illustrated the significantly different amount for the increases in PA from pre- to

post-training in five different consistencies. Specifically, the PAs for maximal voluntary

dry swallow (17% change), the 5 cc pudding swallow (16% change), and the 10 cc

pudding swallow (18% change) had larger increases than the 5 cc water swallow (5%

change) and the 10 cc water swallow (3% change) from pre- to post-training.

The results of univariate ANOVA for DUR indicated no significant two-way

interaction between training and consistency (Table 3-14). The main effect of training on

DUR was significant (F (1, 17) = 4.966, p = 0.040, r2 = 0.226) and the main effect of

consistency on DUR was also significant (F (4, 68) = 3.869, p = 0.007, r2 = 0.185).

Thus, multiple pairwise comparisons using the Bonferroni adjustment were completed to

examine the effects of training and consistency on DUR (Table 3-16).










140

120

100

80.

sC 60-
1 1 1 Training

20. ] Pre

0 -I __ Post
DRY 5W 10W 5P 10P

Consistency

Figure 3-5. Effects of training and consistency on PA.

The training effect on DUR is illustrated in Figure 3-6 and the consistency effect on

DUR is in Figure 3-7. Those indicated that post-training (M= 1.016, SE = 0.032) had

significantly longer DUR than pre-training (M= 0.967, SE = 0.026; p = 0.040).

However, there was no significant training effect on DUR in each consistency. Ten cc

pudding swallow (M= 1.039, SE = 0.036) had significantly longer DUR than 5 cc water

swallow (M= 0.948, SE = 0.029; p = 0.016) and 10 cc water swallow (M= 0.958, SE=

0.030; p = 0.012).

Examining the univariate ANOVA results without the gender effect on IA, also

presented in Table 3-14, indicated a significant two-way interaction between training and

consistency (F (1.987, 33.778) = 3.396, p = 0.046, r2 = 0.167). Thus, simple main effect

tests using paired-samples t-tests were evaluated to examine the effects of training and

consistency on IA at a = 0.01.








1.06-
1.04-
1.02-
1.00.
.98.
.96.
.94-
.92


Post


Training
Figure 3-6. Effects of training on DUR.


Dry 5W 10W 5P 10P

Consistency
Figure 3-7. Effects of consistency on DUR.
Table 3-17 demonstrates the results of these tests and indicates that only one
different consistency pair in pre-training had significantly different IAs. The IA for the 5


i i-i









cc pudding was significantly higher than the 5 cc water (t = -2.811, p = 0.012). Five

different consistency pairs in different training levels had significantly different IAs. The

IA for 10 cc pudding swallow in post-training was significantly higher than the 5 cc

water swallow in pre-training (t = -3.570, p = 0.002), than the 10 cc water swallow in pre-

training (t = -3.610, p = 0.002), and than the 10 cc pudding swallow in pre-training (t = -

2.867, p = 0.011). The IA for maximum voluntary dry swallow in post-training was also

significantly higher than the 5 cc water swallow in pre-training (t = -2.800, p = 0.012)

and the 10 cc water swallow in pre-training (t = -2.725,p = 0.014). Additionally, four

different consistency pairs in post-training had significantly different IAs. Specifically,

the IA for 5 cc water swallow in post-training was significantly lower than the dry

swallow in post-training (t = 3.291, p = 0.004), than the 5 cc pudding swallow in post-

training (t = -2.974, p = 0.009), and than the 10 cc pudding swallow in post-training (t = -

3.485,p = 0.003). The IAs for 10 cc water swallow in post-training was also

significantly lower than the 10 cc pudding swallow (t = -3.041,p = 0.007).

The profile plots were created with consistency as the horizontal axis, each pre- and

post-training as the separate bars in IA (Figure 3-8). The plots depicted the significantly

different amounts of IA increases from pre-training to post-training in different

consistencies. The IAs for maximal voluntary dry swallow (16% change) and the 10 cc

pudding swallow (33% change) dramatically increased from pre- to post-training.

However, the IAs for 5 cc water swallow (6% change), the 10 cc water swallow (12%

change), and the 5 cc pudding swallow (9% change) increased with small amounts from

pre- to post-training.










60


50

40 40
*

130 T

20 Training

10 E] Pre

0 ___ Post
DRY 5W 10W 5P 10P

Consistency

Figure 3-8. Effects of training and consistency on IA.

Speech Function

Table 3-18 shows the descriptive statistics for the speech function measures pre-

and post-training as a function of gender.

The ANOVA result on PEL, presented Table 3-19, indicated a significant two-way

interaction between training and gender (F (1, 16) = 5.866, p = 0.028, r2 = 0.268).

However, no main effect of gender was found. Therefore, a one-way repeated measures

ANOVA without gender effect on PEL was further examined. Again, sphericity

assumptions were met on PEL. The ANOVA result indicated PEL was significantly

increased by training (F (1, 17) = 24.031, p < 0.001, r2 = 0.586). The result for PEL is

illustrated in Figure 3-9. PEL increased from pre- to post-training by 45%.










24

22

20



< 16


14
12

10
Pre Post

Training

Figure 3-9. Effect of training on PEL.

For MPD, a 2 x 2 x 2 repeated measures univariate ANOVA was examined to

analyze the effects of training, loudness, and gender. For PEL, a 2 x 2 repeated measures

univariate ANOVA was conducted to determine the effects of training and gender.

Sphericity assumptions were met by all factors in those ANOVAs. The ANOVA results

on MPD indicated no significant three-way interaction among training, loudness, and

gender (Table 3-20). Non-significance of two-way interactions between training and

gender, between loudness and gender, or between training and loudness were found.

Further, all main effects of training, loudness, and gender were not significant. Thus, a 2

x 2 repeated measures univariate ANOVA without the gender effect on MPD were

evaluated. Sphericity assumptions of MPD were not violated. Table 3-21 shows the

ANOVA results on MPD without gender which indicates a significant two-way

interaction between training and loudness (F (1, 17) = 10.431, p = 0.005, r2 = 0.380).









Simple main effect tests using paired-samples t-tests were then followed (Table 3-22).

The MPDs at the comfortable intensity level between pre- and post-trainings were

significantly different at the c = 0.01 (t = -3.070, p = 0.007). The profile plots created by

pre- and post-training as the horizontal axis, two intensity levels as the separate bars in

MPD show a large increase of MPD for the comfortable intensity level from pre- to post-

training by 26% compared to the small change for the loudest intensity level from pre- to

post-training by 3% (Figure 3-10).


Training


- Pre

[ Post


COMF LOUD


Loudness

Figure 3-10. Effects of training and loudness on MPD.










Table 3-1. Results of intra- and inter-judge reliability of cough, swallow, and speech
function variables.

Measures Intra-Judge Inter-Judge
Sr Measures
r p r p


Cough
IPD
CPD
PEFR
PPPD
PPPIA
Swallow
PA
DUR
IA


0.962
0.992
1.000
0.939
0.974


0.992
0.905
0.910


< 0.001*
< 0.001*
< 0.001*
< 0.001*
< 0.001*


< 0.001*
< 0.001*
< 0.001*


Speech
MPD 0.998 < 0.001*
PEL 1.000 < 0.001*
* Correlation is significant at the 0.05 level.


0.939
0.957
0.999
0.882
0.996


0.983
0.743
0.987


0.974
1.000


0.005*
0.003*
< 0.001*
0.020
< 0.001*


< 0.001*
< 0.001*
< 0.001*


< 0.001*
< 0.001*














Table 3-2. Correlation matrix of dependent variables.
Pulmonary Cough Speech

MIP FEVI FVC FEV1/FVC ERV IPD CPD PEFR PPPD PPPIA COMF LOUD PEL


Pulmonary
MEP
MIP
FEV1
FVC
FEV1/FVC
ERV
Cough
IPD
CPD
PEFR
PPPD
PPPIA
Swallow PA
DRY
5W
10W
5P
10P
Swallow DUR
DRY
5W
10W
5P
10P
Swallow IA
DRY
5W
10W
5P
10P
Speech
COMF
LOUD


0.532* 0.232 0.215
0.257 0.161
0.952


0.082 0.194
0.275 0.087
0.151 0.554*
-0.140 0.635*
-0.198


-0.115 -0.367* 0.526* -0.305
0.090 -0.194 0.350* -0.229
-0.088 -0.245 0.465* 0.065
-0.225 -0.303 0.420* 0.097
0.456* 0.179 0.194 -0.123
0.045 -0.117 0.245 0.067


0.125 0.034 0.059
-0.625* 0.023
-0.319


0.472*
0.105
0.391*
0.409*
0.056
0.378*

-0.011
-0.498*
0.847*
-0.136


0.312 0.139 0.363*
0.233 0.043 0.183
0.577* 0.543* 0.018
0.464* 0.443* 0.054
0.384 0.326 0.056
0.403* 0.294 0.004

0.361* 0.159 -0.195
-0.005 0.023 -0.301
0.492* 0.384* 0.402*
-0.128 -0.250 0.038
0.462* 0.264 0.464*


-0.089
0.256
0.200
0.028
0.142

0.169
-0.039
0.125
0.177
0.262

0.120
0.010
0.026
0.032
-0.061


0.198 -0.119
0.651* -0.314
0.587* -0.280
0.346* -0.282
0.489* -0.301

-0.024 0.554*
-0.071 0.254
0.056 0.259
0.112 0.154
0.128 0.307

0.110 0.256
0.073 0.177
0.039 0.154
-0.014 0.107
-0.059 0.339*

0.703* -0.006
-0.194














Table 3-2. Continued.
Swallow PA Swallow DUR Swallow IA

DRY 5W 10W 5P 10P DRY 5W 10W 5P 10P DRY 5W 10W 5P 10P


Pulmonary
MEP
MIP
FEV1
FVC
FEV1/FVC
ERV
Cough
IPD
CPD
PEFR
PPPD
PPPIA
Swallow PA
DRY
5W
10W
5P
10P
Swallow DUR
DRY
5W
10W
5P
10P
Swallow IA
DRY
5W
10W
5P


-0.034
-0.136
-0.179
-0.235
0.139
-0.272

0.123
-0.216
0.132
-0.089
0.171


0.075 0.096 -0.018 -0.024
0.022 0.006 -0.089 -0.024
0.244 0.192 -0.036 0.121
0.197 0.172 -0.056 0.082
0.108 0.028 0.019 0.080
0.010 0.022 -0.143 -0.022

0.107 0.073 0.096 0.153
-0.085 -0.082 -0.129 -0.090
0.216 0.198 0.074 0.150
-0.351* -0.353* -0.288 -0.218
0.159 0.153 0.091 0.128

0.643* 0.620* 0.844* 0.803*
0.970* 0.862* 0.915*
0.850* 0.909*
0.940*


0.139 0.072
-0.015 0.103
0.306 0.036
0.342* 0.082
0.053 -0.007
0.274 0.116


0.053
0.185
0.269
0.248
0.200
0.184


0.016
0.196
0.154
0.110
0.236
0.032


-0.065 -0.054 0.048 0.048
-0.196 0.062 0.125 0.066
0.420* -0.001 0.023 0.069
-0.022 0.173 0.191 0.154
0.541* 0.148 0.117 0.124

-0.172 -0.010 -0.089 -0.133
-0.213 -0.030 -0.036 -0.077
-0.263 0.017 -0.026 -0.163
-0.249 -0.018 -0.169 -0.192
-0.242 0.048 -0.005 -0.122


0.084
0.093
0.188
0.213
0.078
0.235

0.009
0.246
0.039
0.233
0.223

-0.196
-0.095
-0.106
-0.199
-0.102


0.428* 0.441* 0.531* 0.530*
0.749* 0.594* 0.692*
0.632* 0.754*
0.744*


0.257 0.026 0.082 0.020 0.084
0.268 0.012 0.153 0.097 0.219
-0.158 -0.393* -0.402* -0.407* -0.310
-0.271 -0.465* -0.493* -0.496* -0.413*
0.401 0.315 0.360 0.361 0.379
-0.345* -0.285 -0.279 -0.335* -0.247

0.265* 0.375* 0.435* 0.390* 0.386*
0.085 0.256 0.261 0.403* 0.129
0.286 -0.084 -0.077 -0.167 0.069
-0.310 -0.320 -0.288 -0.279 -0.248
0.167 -0.043 -0.067 -0.116 0.039

0.360* 0.386* 0.346* 0.300 0.314
0.197 0.178 0.125 0.104 0.032
0.150 0.161 0.122 0.055 0.034
0.150 0.241 0.184 0.177 0.107
0.206 0.225 0.188 0.163 0.126

0.180 0.058 -0.037 0.052 0.027
-0.041 0.111 0.104 0.127 0.024
0.200 0.149 0.152 0.245 0.177
0.163 0.031 -0.002 0.226 -0.061
0.170 0.049 0.024 0.243 0.022

0.609* 0.625* 0.733* 0.656*
0.971* 0.884* 0.765*
0.871* 0.808*
0766*


Note: All abbreviations are listed in Appendix G.
* Correlation is significant at the 0.05 level.










Table 3-3. Descriptive statistics for pre- and post-training on pulmonary function
variables.
Pre Post Change
DV Gender ng
M SD M SD (0)
MEP (cm H20) Men 76.503 23.623 132.285 21.491 72.915
Women 77.316 20.115 104.695 24.548 35.412
Average 77.136 20.199 110.826 26.108 43.676
MIP (cm H20) Men 42.130 10.915 62.790 17.361 49.039
Women 38.206 13.998 57.176 19.515 49.652
Average 39.078 13.179 58.423 18.713 49.504
FEV1 (L) Men 2.079 0.611 2.213 0.687 6.445
Women 1.906 0.468 1.974 0.477 3.568
Average 1.945 0.488 2.027 0.517 4.216
FVC (L) Men 2.863 0.672 2.928 0.858 2.270
Women 2.467 0.624 2.557 0.644 3.648
Average 2.555 0.638 2.639 0.687 3.288
FEV1/FVC Men 71.742 6.578 76.947 6.312 7.255
Women 78.078 6.449 78.076 5.721 -0.002
Average 76.670 6.840 77.826 5.683 1.508
ERV (L) Men 1.089 0.249 1.190 0.424 9.275
Women 0.938 0.687 1.171 0.670 24.840
Average 0.972 0.613 1.176 0.613 20.988

Table 3-4. MANOVA result for the effects of training and gender on pulmonary function
variables.
Hypothesis Error 2
Factor Statistic Value F Hypf P 1
df df
Intercept Pillai's Trace 1.000 4726.314 6 11 0.000 1.000
Gender Pillai's Trace 0.259 0.640 6 11 0.698 0.259
Training Pillai's Trace 0.827 8.766 6 11 0.001* 0.827
Training x Gender Pillai's Trace 0.372 1.086 6 11 0.427 0.372
Note: r2 = effect size.
* indicates that the mean difference is significant at a = 0.05.










Table 3-5. Univariate ANOVA results for training effect on pulmonary function
variables.


Factor DV
Training MEP
MIP
FEV1
FVC
FEV1/FVC
ERV
Error MEP
MIP
FEV1
FVC
FEV1/FVC
ERV
Note: r2 = effect size.


SS
10215.482
3368.061
0.062
0.064
12.020
0.374
4238.002
3092.882
0.294
0.285
234.145
3.430


df MS
1 10215.482
1 3368.061
1 0.062
1 0.064
1 12.020
1 0.374
17 249.294
17 181.934
17 0.017
17 0.017
17 13.773
17 0.202


F
40.978
18.513
3.556
3.806
0.873
1.853


p
0.000*
0.000*
0.077
0.068
0.363
0.191


12
0.707
0.521
0.173
0.183
0.049
0.098


* indicates that the mean difference is significant at a


0.05.










Table 3-6. Descriptive statistics for pre- and post-training on cough function variables.
Pre Post Change
DV Gender
M SD M SD (%)


IPD (s)




CPD (s)




PEFR (L/s)




PPPD (s)




PPPIA (L/sxs)




N of coughs




N of CR


Men
Women
Average
Men
Women
Average
Men
Women
Average
Men
Women
Average
Men
Women
Average
Men
Women
Average
Men
Women
Average


0.932
1.206
1.145
0.229
0.382
0.348
4.985
4.979
4.981
0.206
0.244
0.236
3.308
3.539
3.488
2.700
2.879
2.839
6.850
8.121
7.839


0.224
0.243
0.262
0.097
0.201
0.192
2.810
2.097
2.181
0.028
0.078
0.071
4.210
1.948
2.457
0.983
0.720
0.757
2.965
2.622
2.665


0.758
1.357
1.224
0.122
0.173
0.162
6.483
8.431
7.998
0.213
0.227
0.224
4.043
7.624
6.829
2.650
3.400
3.233
6.700
9.729
9.056


0.350
0.495
0.524
0.068
0.185
0.166
2.969
3.056
3.064
0.041
0.084
0.075
3.746
4.033
4.155
1.025
1.109
1.109
3.118
4.229
4.132


-18.669
12.521
6.899
-46.689
-54.563
-53.412
30.155
69.127
60.635
3.538
-7.066
-5.008
22.210
115.411
95.767
-1.852
18.114
13.894
-2.190
19.789
15.521


Table 3-7. MANOVA result for the effects of training and gender on cough function
variables.
Hypothesis Error 2
Factor Statistic Value F Hypf P 1
df df
Intercept Pillai's Trace 0.982 129.655 5 12 0.000 0.982
Gender Pillai's Trace 0.451 1.968 5 12 0.156 0.451
Training Pillai's Trace 0.520 2.598 5 12 0.081 0.520
Training x Gender Pillai's Trace 0.373 1.427 5 12 0.283 0.373
Note: r2 = effect size.
* indicates that the mean difference is significant at a = 0.05.










Table 3-8. Univariate ANOVA results for training effects on cough function variables.
Factor DV SS df MS F p r2
Training IPD 0.056 1 0.056 0.664 0.426 0.038
CPD 0.310 1 0.310 13.590 0.002* 0.444
PEFR 4609.588 1 4609.588 29.620 0.000* 0.635
PPPD 0.001 1 0.001 1.259 0.277 0.069
PPPIA 100.427 1 100.427 16.826 0.001* 0.497
Error IPD 1.429 17 0.084
CPD 0.388 17 0.023
PEFR 2645.640 17 155.626
PPPD 0.017 17 0.001
PPPIA 101.465 17 5.969
Note: 2 = effect size.
* indicates that the mean difference is significant at a = 0.05.

Table 3-9. MANOVA result for the effects of training and gender on total number of
coughs and total number of expulsive events.
Factor Statistic Value F Hypothesis Error
df df
Intercept Pillai's Trace 0.915 80.710 2.000 15.000 0.000 0.915
Gender Pillai's Trace 0.081 0.661 2.000 15.000 0.531 0.081
Training Pillai's Trace 0.068 0.548 2.000 15.000 0.589 0.068
Training x Gender Pillai's Trace 0.096 0.794 2.000 15.000 0.470 0.096
Note: r2 = effect size.
* indicates that the mean difference is significant at a = 0.05.










Table 3-10. Descriptive statistics for pre- and post-training on swallow function
variables.
SGender Pre Post
DV (rind ,r


PA (mV) DRY Men
Women
Average
5W Men
Women
Average
10W Men
Women
Average
5P Men
Women
Average
10P Men
Women
Average
DUR (s) DRY Men
Women
Average
5W Men
Women
Average
10W Men
Women
Average
5P Men
Women
Average
10P Men
Women
Average
IA DRY Men
Women
Average
5W Men
Women
Average
10W Men
Women
Average
5P Men
Women
Average
10P Men
Women
Average


I' Y1--l--


M
43.566
65.527
60.647
34.993
57.704
52.658
36.030
57.103
52.420
39.736
57.829
53.809
36.339
60.888
55.432
0.946
0.964
0.960
0.892
0.935
0.926
0.935
0.945
0.943
0.955
1.004
0.993
0.976
1.024
1.013
18.724
28.905
26.643
16.388
23.521
21.936
16.698
23.855
22.265
19.825
26.668
25.147
19.294
25.826
24.374


SD
2.603
22.897
22.144
5.715
37.814
34.548
6.266
35.430
32.374
6.731
30.586
27.987
3.976
34.138
31.691
0.116
0.151
0.141
0.208
0.120
0.138
0.146
0.151
0.145
0.161
0.112
0.121
0.093
0.149
0.137
1.787
8.145
8.382
0.641
13.824
12.471
0.772
12.758
11.574
2.872
12.490
11.372
1.816
11.840
10.751


M
52.510
76.102
70.860
33.841
61.352
55.239
32.799
60.256
54.154
41.968
68.533
62.630
37.767
73.304
65.407
1.080
1.016
1.030
0.947
0.977
0.971
0.988
0.968
0.972
1.019
1.047
1.041
1.010
1.081
1.065
30.241
31.125
30.929
19.299
24.345
23.223
20.457
26.143
24.880
23.975
28.555
27.537
26.837
34.008
32.415


SD
10.196
25.812
25.094
5.293
31.135
29.745
4.509
30.509
29.212
10.016
29.898
28.817
7.109
30.197
30.616
0.122
0.217
0.199
0.209
0.125
0.141
0.178
0.129
0.136
0.146
0.164
0.156
0.135
0.196
0.183
11.982
10.223
10.267
3.925
11.962
10.807
4.925
11.850
10.844
2.748
12.808
11.428
6.874
17.802
16.127


Change
(%)
20.528
16.139
16.840
-3.293
6.322
4.902
-8.967
5.522
3.309
5.616
18.509
16.393
3.930
20.392
17.994
14.127
5.310
7.240
6.192
4.494
4.858
5.627
2.424
3.130
6.707
4.284
4.802
3.522
5.590
5.147
61.509
7.680
16.086
17.765
3.503
5.871
22.513
9.592
11.746
20.930
7.075
9.502
39.093
31.682
32.986










Table 3-11. Mauchly's test of sphericity for training, consistency, and gender effects on
swallow function variables.

Factor DV Mauchly's W y2 df p

Training PA 1.000 0.000 0 1.000
DUR 1.000 0.000 0 1.000
IA 1.000 0.000 0 1.000
Consistency PA 0.025 53.437 9 0.000*
DUR 0.389 13.602 9 0.140
IA 0.121 30.486 9 0.000*
Training x Consistency PA 0.616 6.990 9 0.640
DUR 0.721 4.724 9 0.859
IA 0.066 39.234 9 0.000*
* indicates that the mean difference is significant at a = 0.05.










Table 3-12. Univariate ANOVA (mixed design) results for the combined effects of
training, consistency, and gender on swallow function variables.
Factor DV SS df MS F p Tr2
Within-Subjects


Training PA
DUR
IA
Training x PA
Gender DUR
IA
Error PA
(Training) DUR
IA
Consistency PA
DUR
IA
Consistency x PA
Gender DUR
IA
Error PA
(Consistency) DUR
IA
Training x PA
Consistency DUR
IA
Training x PA
Consistency x DUR
Gender IA
Error (Training PA
x Consistency) DUR
IA


738.360
0.096
637.877
324.115
0.005
65.220
9336.621
0.362
1513.351
2698.133
0.126
787.303
236.542
0.028
7.088
15460.024
0.912
3040.167
422.414
0.011
175.570
78.743
0.009
87.985
3311.880
0.339
1168.390


1
1
1
1
1
1
16
16
16
1.408
4
2.368
4
4
4
22.536
64
37.884
4
4
1.871
4
4
4
64
64
29.931


738.360
0.096
637.877
324.115
0.005
65.220
583.53
0.023
94.584
1915.649
0.031
332.515
59.136
0.007
1.772
686.030
0.014
80.250
105.603
0.003
93.853
19.686
0.002
21.996
51.748
0.005
39.036


1.265
4.260
6.744
0.555
0.210
0.690




2.792
2.205
4.143
0.245
0.499
0.037




2.041
0.536
2.404
0.380
0.424
1.205


0.277
0.056
0.019*
0.467
0.653
0.419




0.097
0.078
0.018*
0.912
0.737
0.997




0.099
0.710
0.111
0.822
0.791
0.317


0.073
0.210
0.297
0.034
0.013
0.041




0.149
0.121
0.206
0.015
0.030
0.002




0.113
0.032
0.131
0.023
0.026
0.070


Between-Subject
Intercept PA 328872.375 1 328872.375 53.101 0.000
DUR 120.846 1 120.846 869.716 0.000
IA 73087.519 1 73087.519 74.724 0.000
Gender PA 19296.632 1 19296.632 3.116 0.097
DUR 0.014 1 0.014 0.102 0.754
IA 1165.650 1 1165.650 1.192 0.291
Error PA 99094.255 16 6193.391
DUR 2.223 16 0.139
IA 15649.637 16 978.102
Note: 2 = effect size.


* indicates that the mean difference is significant at a


0.05.










Table 3-13. Mauchly's test of sphericity for training and consistency on swallow
function variables.
Factor DV Mauchly's W x2 df p
Training PA 1.000 0.000 0 1.000
DUR 1.000 0.000 0 1.000
IA 1.000 0.000 0 1.000
Consistency PA 0.029 54.371 9 0.000*
DUR 0.402 14.055 9 0.122
IA 0.121 32.622 9 0.000*
Training x Consistency PA 0.628 7.183 9 0.620
DUR 0.744 4.552 9 0.872
IA 0.069 41.306 9 0.000*
* indicates that the mean difference is significant at a = 0.05.

Table 3-14. Univariate ANOVA results without gender effect for the combined effects of
training and consistency on swallow function variables.
Factor DV SS df MS F p r12
Training PA 1998.888 1 1998.888 3.517 0.078 0.171
DUR 0.107 1 0.107 4.966 0.040* 0.226
IA 623.956 1 623.956 6.720 0.019* 0.283
Error (Training) PA 9660.735 17 568.279

DUR 0.366 17 0.022
IA 1578.571 17 92.857
Consistency PA 3748.024 1.441 2600.175 4.059 0.042* 0.193

DUR 0.214 4 0.053 3.869 0.007* 0.185
IA 1122.603 2.367 474.187 6.263 0.003* 0.269
Error PA 15696.566 24.505 640.554
(Consistency)
S DUR 0.940 68 0.014

IA 3047.256 40.246 75.715
Training x PA 622.583 4 155.646 3.122 0.020* 0.155
Consistency
Consistency DUR 0.007 4 0.002 0.365 0.833 0.021

IA 251.011 1.987 126.329 3.396 0.046* 0.167
Error (Training x PA 3390.623 68 49.862
Consistency)
Consistency) DUR 0.348 68 0.005

IA 1256.374 33.778 37.195
Note: 12 = effect size.
* indicates that the mean difference is significant at a = 0.05.










Table 3-15. Simple main effect tests of training and consistency on PA.
V7i +r A If


I a~Lvl Ivl


* indicates that the mean difference is significant at a


SE t


SE


0.01.


(I) (J)
Pre, DRY Pre, 5W
Pre, 10W
Pre, 5P
Pre, 10P
Post, DRY
Post, 5W
Post, 10W
Post, 5P
Post, 10P
Pre, 5W Pre, 10W
Pre, 5P
Pre, 10P
Post, DRY
Post, 5W
Post, 10W
Post, 5P
Post, 10P
Pre, 10W Pre, 5P
Pre, 10P
Post, DRY
Post, 5W
Post, 10W
Post, 5P
Post, 10P
Pre, 5P Pre, 10P
Post, DRY
Post, 5W
Post, 10W
Post, 5P
Post, 10P
Pre, 10P Post, DRY
Post, 5W
Post, 10W
Post, 5P
Post, 10P
Post, DRY Post, 5W
Post, 10W
Post, 5P
Post, 10P
Post, 5W Post, 10W
Post, 5P
Post, 10P
Post, 10W Post, 5P
Post, 10P
Post, 5P Post, 10P


(I) (J)
60.647 52.658
52.420
53.809
55.432
60.647 70.860
55.239
54.154
62.630
65.407
52.658 52.420
53.809
55.432
52.658 70.860
55.239
54.154
62.630
65.407
52.420 53.809
55.432
52.420 70.860
55.239
54.154
62.630
65.407
53.809 55.432
53.809 70.860
55.239
54.154
62.630
65.407
55.432 70.860
55.239
54.154
62.630
65.407
70.860 55.239
54.154
62.630
65.407
55.239 54.154
62.630
65.407
54.154 62.630
65.407
62.630 65.407


(I-J)
7.989
8.227
6.838
5.215
-10.213
5.410
6.492
-1.983
-4.760
0.238
-1.151
-2.776
-18.202
-2.581
-1.497
-9.972
-12.749
-1.389
-3.012
-18.440
-2.819
-1.735
-10.210
-12.987
-1.623
-17.051
-1.430
-0.345
-8.821
-11.598
-15.427
0.193
1.278
-7.198
-9.974
15.621
16.705
8.230
5.453
1.084
-7.391
-10.168
-8.475
-11.252
-2.777


5.829
5.203
3.544
4.181
4.537
5.246
5.002
4.608
4.775
1.350
3.271
2.959
8.012
3.400
2.707
6.365
4.934
2.842
2.487
7.410
3.055
2.487
5.594
4.271
1.691
6.306
3.830
3.491
5.079
4.469
7.075
3.900
3.458
5.635
4.602
5.792
6.233
3.727
4.699
2.251
4.236
3.001
4.523
3.390
3.171


1.371
1.581
1.929
1.247
-2.251
1.031
1.298
-0.430
-0.997
0.176
-0.352
-0.938
-2.272
-0.759
-0.553
-1.567
-2.584
-0.489
-1.211
-2.488
-0.923
-0.697
-1.825
-3.041
-0.960
-2.704
-0.373
-0.099
-1.737
-2.595
-2.181
0.050
0.370
-1.277
-2.167
2.697
2.680
2.208
1.161
0.482
-1.745
-3.388
-1.874
-3.319
-0.876


p
0.188
0.132
0.071
0.229
0.038
0.317
0.212
0.672
0.333
0.862
0.729
0.362
0.036
0.458
0.587
0.136
0.019
0.631
0.242
0.023
0.369
0.495
0.086
0.007*
0.350
0.015
0.714
0.922
0.100
0.019
0.044
0.961
0.716
0.219
0.045
0.015
0.016
0.041
0.262
0.636
0.099
0.003*
0.078
0.004*
0.393










Table 3-16. Multiple pairwise comparisons for DUR by training and by consistency.
Factor M
() ) (I-J) SE p
(I) (J) (I) (J)


Pre, DRY
Pre, 5W
Pre, 10W
Pre, 5P
Pre, 10P
DRY


5W



10W


5P


Post, DRY
Post, 5W
Post, 10W
Post, 5P
Post, 10P
5W
10W
5P
10P
10W
5P
10P
5P
10P
10P


0.960
0.926
0.943
0.993
1.013
0.995


0.948




0.958


1.017


1.030
0.971
0.972
1.041
1.065
0.948
0.958
1.017
1.039
0.958
1.017
1.039
1.017
1.039
1.039


* indicates that the mean difference is significant at a
multiple comparisons.


-0.070
-0.045
-0.030
-0.048
-0.052
0.047
0.037
-0.022
-0.044
-0.010
-0.069
-0.091
-0.059
-0.081
-0.022


-1.870
-1.422
-1.118
-1.634
-1.923
0.037
0.035
0.031
0.035
0.020
0.025
0.024
0.022
0.021
0.019


0.079
0.173
0.279
0.121
0.071
1.000
1.000
1.000
1.000
1.000
0.135
0.016*
0.139
0.012*
1.000


0.05 using Bonferroni adjustment for










Table 3-17. Simple main effect tests for the effects of training and consistency on IA.


M


&


(I-J) SE t p


Factor
(I) (J)
Pre, Dry Pre, 5W
Pre, 10W
Pre, 5P
Pre, 10P
Post, Dry
Post, 5W
Post, 10W
Post, 5P
Post, 10P
Pre, 5W Pre, 10W
Pre, 5P
Pre, 10P
Post, Dry
Post, 5W
Post, 10W
Post, 5P
Post, 10P
Pre, 10W Pre, 5P
Pre, 10P
Post, Dry
Post, 5W
Post, 10W
Post, 5P
Post, 10P
Pre, 5P Pre, 10P
Post, Dry
Post, 5W
Post, 10W
Post, 5P
Post, 10P
Pre, 10P Post, Dry
Post, 5W
Post, 10W
Post, 5P
Post, 10P
Post, Dry Post, 5W
Post, 10W
Post, 5P
Post, 10P
Post, 5W Post, 10W
Post, 5P
Post, 10P
Post, 10W Post, 5P
Post, 10P
Post, 5P Post, 10P


(I) (J)
26.643 21.936
22.265
25.147
24.374
26.643 30.929
23.223
24.880
27.537
32.415
21.936 22.265
25.147
24.374
21.936 30.929
23.223
24.880
27.537
32.415
22.265 25.147
24.374
22.265 30.929
23.223
24.880
27.537
32.415
25.147 24.374
25.147 30.929
23.223
24.880
27.537
32.415
24.374 30.929
23.223
24.880
27.537
32.415
30.929 23.223
24.880
27.537
32.415
23.223 24.880
27.537
32.415
24.880 27.537
32.415
27.537 32.415


4.707
4.378
1.496
2.268
-4.286
3.419
1.763
-0.894
-5.772
-0.329
-3.212
-2.439
-8.993
-1.288
-2.944
-5.601
-10.479
-2.883
-2.110
-8.664
-0.959
-2.615
-5.272
-10.150
0.773
-5.781
1.924
0.267
-2.390
-7.267
-6.554
1.151
-0.505
-3.162
-8.040
7.705
6.049
3.392
-1.486
-1.656
-4.313
-9.191
-2.657
-7.535
-4.878


2.121
2.043
1.618
1.679
2.111
1.799
1.550
2.000
3.005
0.651
1.143
1.099
3.212
1.169
1.302
2.382
2.935
1.210
0.943
3.180
1.344
1.316
2.405
2.811
0.695
2.780
1.019
1.006
1.763
3.063
2.805
1.043
0.909
1.966
2.805
2.341
2.263
2.053
3.122
0.637
1.451
2.638
1.499
2.478
2.831


* indicates that the mean difference is significant at a = 0.01


2.219
2.143
0.924
1.351
-2.030
1.901
1.138
-0.447
-1.921
-0.506
-2.811
-2.220
-2.800
-1.102
-2.262
-2.352
-3.570
-2.381
-2.236
-2.725
-0.713
-1.987
-2.193
-3.610
1.111
-2.080
1.889
0.266
-1.356
-2.373
-2.337
1.103
-0.556
-1.609
-2.867
3.291
2.673
1.652
-0.476
-2.601
-2.974
-3.485
-1.772
-3.041
-1.723


0.040
0.047
0.368
0.194
0.058
0.074
0.271
0.661
0.072
0.620
0.012*
0.040
0.012*
0.286
0.037
0.031
0.002*
0.029
0.039
0.014*
0.486
0.063
0.043
0.002*
0.282
0.053
0.076
0.793
0.193
0.030
0.032
0.285
0.586
0.126
0.011*
0.004*
0.016
0.117
0.640
0.019
0.009*
0.003*
0.094
0.007*
0.103










Table 3-18. Descriptive statistics for pre- and post-training on speech function variables.
Pre Post Change
DV Loudness Gender
M SD M SD (%)
PEL Men 11.902 3.303 22.983 5.774 93.102
Women 14.131 5.423 18.814 6.730 33.140
Average 13.636 5.002 19.741 6.610 44.771
MPD COMF Men 16.816 12.141 16.476 9.744 -2.023
Women 18.052 6.866 24.048 9.813 33.216
Average 17.777 7.895 22.366 10.044 25.809
LOUD Men 13.248 5.572 13.251 6.303 0.022
Women 21.186 11.616 21.870 13.099 3.232
Average 19.422 10.964 19.955 12.321 2.745

Table 3-19. Univariate ANOVA result for the combined effects of training and gender
on PEL.
Factor SS df MS F p r2
Within-Subjects
Training 386.541 1 386.541 35.619 0.000* 0.690
Training x Gender 63.654 1 63.654 5.866 0.028* 0.268
Error (Training) 173.634 16 10.852
Between-Subject
Intercept 7157.024 1 7157.024 123.795 0.000 0.886
Gender 5.851 1 5.851 0.101 0.755 0.006
Error (Gender) 925.013 16 57.813
Note: r2 = effect size.
* indicates that the mean difference is significant at a = 0.05.










Table 3-20. Univariate ANOVA result for the combined effects of training, loudness,
and gender on MPD.
Factor SS df MS F p 12
Within-Subjects
Training 31.299 1 31.299 1.487 0.240 0.005
Training x Gender 38.308 1 38.308 1.820 0.196 0.102
Error (Training) 336.794 16 21.050
Loudness 26.506 1 26.506 0.446 0.514 0.027
Loudness x Gender 46.711 1 46.711 0.785 0.389 0.047
Error (Loudness) 951.781 16 59.486
Training x Loudness 19.200 1 19.200 3.209 0.092 0.167
Training x Loudness x 24.870 1 24.870 4.157 0.058 0.206
Gender
Error (Training x 95.724 16 5.983
Loudness)
Between-Subject
Intercept 16340.793 1 16340.793 48.378 0.000 0.751
Gender 500.476 1 500.476 1.482 0.241 0.085
Error (Gender) 5404.406 16 337.775
Note: r2 = effect size.
* indicates that the mean difference is significant at a = 0.05.

Table 3-21. Univariate ANOVA result for the combined effects of training and loudness
on MPD.
Factor SS df MS F p r2
Within-Subjects
Training 118.024 1 118.024 5.349 0.034* 0.239
Error (Training) 375.102 17 22.065
Loudness 2.642 1 2.642 0.045 0.835 0.003
Error (Loudness) 998.492 17 58.735
Training x Loudness 73.994 1 73.994 10.431 0.005* 0.380
Error (Loudness) 120.593 17 7.094
Note: r2 = effect size.
* indicates that the mean difference is significant at a = 0.05.






86


Table 3-22. Simple main effect tests of training and loudness on MPD.
Factor M
(I-J) SE t p
(I) (J) (I) (J)(-JSEt
COMF, Pre COMF, Post 17.777 22.366 -4.588 1.495 -3.070 0.007*
LOUD, Pre 19.422 -1.644 1.991 -0.826 0.420
LOUD, Post 19.955 -2.178 2.532 -0.860 0.402
COMF, Post LOUD, Pre 22.366 19.422 2.944 1.601 1.838 0.084
LOUD, Post 19.955 2.411 1.830 1.317 0.205
LOUD, Pre LOUD, Post 19.422 19.955 -0.533 1.003 -0.532 0.602
* indicates that the mean difference is significant at a = 0.01.














CHAPTER 4
DISCUSSION

This study investigated the physiological effects of expiratory muscle strength

training (EMST) with the sedentary healthy elderly using a pressure-threshold training

device over a 4-week time frame in order to assess the effects on pulmonary, cough,

swallow, and speech functions.

Pulmonary Function

Maximum Respiratory Pressure. It was hypothesized that EMST would increase

both maximum expiratory pressure (MEP) and maximum inspiratory pressure (MIP).

The results indicated significant improvements in both MEP and MIP following the 4-

week EMST program. MEPs significantly increased by an average of 44% (range of 8%

to 158%) from pre- to post-training. Increases in MEP represent improved expiratory

muscle strength. The MEP gains in the current study are comparable to previous studies

completed in healthy young adults as well as clinical populations that used the same

pressure-threshold training device (Baker, Davenport, & Sapienza, 2005; Chiara, 2003;

Hoffman-Ruddy, 2001; Saleem, 2005; Sapienza et al., 2002; Wingate et al., in press).

Table 1-2 shows that the change in MEP following a 4-week EMST program in healthy

young adults ranged from 25% to 47%. Suzuki et al. (1995) reported an increase in MEP

from 165 71 cm H20 pre-training to 202 77 cm H20 post-training, a 25% increase for

six healthy men. Suzuki's group used a threshold pressure breathing device (Threshold

Inspiratory Muscel Trainer, Healthscan Products, Cedar Grove, New Jersey, USA).

Sapienza et al. (2002) reported that MEP increased from 99.7 25.2 cm H20 pre-training









to 147.0 31.9 cm H20 post-training, which is a 47% increase, in 22 healthy men and

women. Baker et al. (2005) reported MEPs pre- to post-training from 99.1 34.7 cm

H20 to 127.5 + 41.1 cm H20, respectively, with an increase by 29% in 32 healthy

participants. Together, these results suggest that an EMST program is applicable to both

young and old healthy individuals to enhance the strength of the expiratory muscles.

Age-related muscle atrophy in the respiratory musculature is observed primarily in

the expiratory intercostal muscles, however not in the inspiratory intercostal muscles

(Mizuno, 1991). The atrophy of these muscles during the normal aging process is similar

to what can be expected for those living a sedentary lifestyle. However, combining a

sedentary lifestyle with normal aging can aggravate sarcopenia, or loss of muscle mass

with age, in the respiratory musculature. The current study demonstrates that expiratory

muscles in the sedentary elderly can be strengthened. The strength may translate to gains

in muscle mass/hypertrophy, in response to increased load delivered via EMST over a

long enough time frame. The respiratory muscle strength increases achieved with the

sedentary elderly are likely related to rapid increases in the neural adaptations at the level

of the motor unit. As described earlier, strength gains in skeletal muscles result from a

combination of both neural adaptation and muscle mass adaptation. Neural adaptations

commonly occur in the early stage (4 to 6 weeks) of training in both young and elderly

individuals. After 4 to 6 weeks of training, strength gains in young people are

predominately related to muscle hypertrophy, while in elderly people strength gains are

mainly due to neural adaptation, even after 6 weeks of training (Moritani & deVries,

1980). These findings suggest that a continual EMST program in the healthy sedentary

elderly could be helpful in preventing the alterations in muscle architecture in the