The Effects of Expiratory Muscle Strength Training on Blood Pressure, Heart Rate, and Oxygen Saturation in Healthy Adults

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Title:
The Effects of Expiratory Muscle Strength Training on Blood Pressure, Heart Rate, and Oxygen Saturation in Healthy Adults
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1 online resource (51 p.)
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english
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Laciuga,Helena
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University of Florida
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Gainesville, Fla.
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Degree:
Master's ( M.A.)
Degree Grantor:
University of Florida
Degree Disciplines:
Communication Sciences and Disorders, Speech, Language and Hearing Sciences
Committee Chair:
Sapienza, Christine M
Committee Members:
Davenport, Paul W

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Subjects / Keywords:
blood -- cardiovascular -- dysphagia -- emst -- exercise -- expiratory -- heart -- mep -- oxygen -- parkinson -- pressure -- rate -- saturation -- stroke -- valsalva
Speech, Language and Hearing Sciences -- Dissertations, Academic -- UF
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Communication Sciences and Disorders thesis, M.A.
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theses   ( marcgt )
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Electronic Thesis or Dissertation

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Abstract:
The effects of expiratory muscle strength training on blood pressure, heart rate, and oxygen saturation in healthy adults Expiratory Muscle Strength Training (EMST) is a rehabilitative program used to improve, cough, swallow, respiratory function, and vocal production. Studies using EMST have demonstrated benefits for healthy young and elderly individuals, and for patients with progressive neuromuscular diseases such as Parkinson?s disease and Multiple Sclerosis. This study analyzed the changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and oxygen saturation (SpO2) during one session of EMST in thirty-one healthy, young adults. No significant fluctuations of SBP, DBP, HR, or SpO2 during and after the EMST trials were detected. The results suggest that EMST has no significant impact on BP, HR, and SpO2 on healthy young adults. Given the lack of significant cardiovascular responses during EMST in the studied group, there may be less concern over a contraindication of EMST for patients with cardiovascular disease. Further studies must be done to confirm or refute this conclusion.
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In the series University of Florida Digital Collections.
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Includes vita.
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Description based on online resource; title from PDF title page.
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This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Helena Laciuga.
Thesis:
Thesis (M.A.)--University of Florida, 2011.
Local:
Adviser: Sapienza, Christine M.

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UFE0043452:00001


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1 THE EFFECTS OF EXPIRATORY MUSCLE STRENGTH TRAINING ON BLOOD PRESSURE, HEART RATE, AND OXYGEN SATURATION IN HEALTHY ADULTS By HELENA LACIUGA A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ART UNIVERSITY OF FLORIDA 2011

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2 2011 Helena Laciuga

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3 To my children: Emilia, Patrick, and Alexandra

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4 ACKNOWLEDGMENTS I am grateful for all of the support, the advice and guidance I have received from my committee throughout the process of completing this project. I would like to express my gratitude especially to Dr. Christine Sapienza, who has been a mentor to me in addition to serving as cha ir of this committee She has inspired me and supported my interest in research. I would like to thank Dr. Paul Daven port for dedicating his time and sharing his experience in the process of developing the study design. I want to thank Dr. Ra hul Shrivastav for serving as this study supervisor. I would like to thank all the people who contributed to the process of completing this project: the study participants, my colleagues, and those who helped me with data analysis. Finally, I want to thank my husband an d my children who deserve the recognition for their emotional support throughout my entire graduate program.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 7 LIST OF FIGURES ................................ ................................ ................................ .......... 8 LIST OF ABBREV IATIONS ................................ ................................ ............................. 9 ABSTRACT ................................ ................................ ................................ ................... 11 CHAPTER 1 IN T RODUCT I ON AND BACKGROUND ................................ ................................ 13 The Applications and Rehabilitative Impact of Expiratory Muscle Strength Training Program ................................ ................................ ................................ 13 The Cardiovascular Changes Related to the Valsalva Maneuver ........................... 14 The Cardiovascular Responses to Skeletal Muscle Exercise ................................ 17 The Present Study ................................ ................................ ................................ .. 19 The Purpos e of the Study ................................ ................................ ................. 19 The Hypothesis ................................ ................................ ................................ 20 2 METHODS ................................ ................................ ................................ .............. 21 Participants ................................ ................................ ................................ ............. 21 Population and C riteria for Inclusion ................................ ................................ ....... 21 Procedure ................................ ................................ ................................ ............... 22 Apparatus ................................ ................................ ................................ ......... 22 Measurements ................................ ................................ ................................ .. 22 3 RESULTS ................................ ................................ ................................ ............... 25 Descriptive Statis tics ................................ ................................ ............................... 25 The Analysis of the Differences in Outcome Measurements Across Tasks ............ 26 Systolic Blood Pressure ................................ ................................ .................... 26 Diastolic Blood Pressure ................................ ................................ .................. 27 Hear t Rate ................................ ................................ ................................ ........ 28 Percent Oxygen Saturation ................................ ................................ .............. 28 Pairwise Comparisons Between Specific Task Points ................................ ............ 29 Valsalva 1 vs. Baseline ................................ ................................ ..................... 29 Valsalva 2 vs. Rest ................................ ................................ ........................... 30 Phase 1 vs. Baseline ................................ ................................ ........................ 30 Phase 2 vs. Baseline ................................ ................................ ........................ 31 Phase 2 vs. Phase 1 ................................ ................................ ........................ 31

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6 Rest vs. Baseline ................................ ................................ .............................. 32 Rest vs. Phase 2 ................................ ................................ .............................. 32 4 DISCUSSION ................................ ................................ ................................ ......... 37 Interpretation of the Principal Findings ................................ ................................ .... 37 Clinical Implications ................................ ................................ ................................ 43 APPENDIX: OUTCOME MEASUREMENTS FOR EACH PARTICIPANT ..................... 44 LIST OF REFERENCES ................................ ................................ ............................... 48 BIOGRAPHICAL SKETCH ................................ ................................ ............................ 51

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7 LIST OF TABLES Table page 3 1 Mean demographic data ................................ ................................ ..................... 32 3 2 The means and standard deviations (SD) of the outcome measurements after performance of each task. ................................ ................................ .......... 33 3 3 The mean values of exertion and rest time for each participant in Phase 1 and Phase 2 of the EMST session. ................................ ................................ .... 34

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8 LIST OF FIGURES Figure page 1 1 Systolic blood pressure and pulse rate during a normal response to the maneuver. ................................ ................................ ......................... 20 3 1 The changes in SBP across the tasks. ................................ ............................... 35 3 2 The changes in DBP across the tasks. ................................ ............................... 35 3 3 The changes in HR across the tasks. ................................ ................................ 36 3 4 The changes in SpO 2 across the tasks. ................................ .............................. 36

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9 LIST OF ABBREVIATION S ATP A denosine trip h osphate energy carrying molecule BMI Body Mass Index BP Blood pressure bpm Beats per minute CAD Coronary artery disease CI Confidence interval CLIMB Trained rock climbers ( Ferguson & Brown, 1997 ) CO Cardiac output COPD C hronic obst ructive pulmona ry disease DBP Diastolic blood pressure df Degree of freedom EMST Expiratory Muscle Strength Training HR Heart rate IRB Institutional Review Board MEP Maximum expiratory pressure MS Multiple sclerosis N The number of participants OSAS Obstructive sleep apnea syndrome p P value PD Ptc, C O 2 Transcutaneous partial pressure of carbon dioxide Ptc, O 2 Transcutaneous partial pressure of oxygen SBP Systolic blood pressure SD Standard deviation

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10 SED Sedentary adults ( Ferguson & Brown, 1997 ) SpO 2 Oxygen saturation SV Stroke volume TMS T ranscortical magnetic s timulation Minute ventilation V 0 2 Oxygen consumption Vt Tidal volume

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11 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Art THE EFFECTS OF EXPIRATORY MUSCLE STRENGTH TRAINING ON BLOOD PRESSURE, HEART RATE, AND OXYGEN SATURATIO N IN HEALTHY ADULTS By Helena Laciuga August 2011 Chair: Christine Sapienza Major: Communication Sciences and Disorders Background and Methods Expiratory Muscle Strength Training (EMST) is a rehabilitative program used to improve respiratory function, cough, swallow function, and vocal production in healthy young and elderly individuals, and in patients with progressive neuromuscular diseases s Sclerosis. In order to assess the cardiovascular responses during EMST, this study analyzed the changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and oxygen saturation (SpO 2 ) during one session of EMST in healthy, young adults. Thirty one participants completed a single session of twenty five trials with the EMST device and a Valsalva maneuver at the beginning and at the end of the EMST session. The values of SBP, DBP, HR, and SpO 2 were obtained and recorded at the baseline, after each completed task, and after five minutes of rest following the EMST respiratory session. Results and Discussion No significant fluctuations of SBP ( p=.17 63), DBP ( p=.84 96), HR ( p=. 4709), or SpO 2 ( p=.16 05) during and after the EMST session or after performing the Valsalva maneuver were detected. Covariates such as sex, maximum

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12 expiratory pressure (MEP), and body mass index (BMI) had significant effects on the outcome measurements across the tasks. T he results suggest that EMST has no significant impact on BP, HR, and SpO 2 in healthy young adults. Because of the major effect of sex, MEP, and BMI on the outcome measurements, these factors should be considered in the further studies assessing the cardio vascular responses during the use of EMST device.

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13 CHAPTER 1 INRODUCTON AND BACKGROUND The Applications and Rehabilitative Impact of Expiratory Muscle Strength Training Program Expiratory Muscle Strength Training (EMST) has been used as a rehabilitation program designed to improve expiratory muscle force generating capacity to increase expiratory driving pressure during cough (Pitts, et al., 2009; Wingate, Brown, Shrivastav, D avenport, & Sapienza, 2007) and to support traditional voice the rapy in the remediation of vocal problems ( Wingate, et al., 2007 ) Studies provide evidence of the benefits of EMST as a treatment for increasing maximal expiratory pressure (MEP ) Multiple Sclerosis (M S ) (Chiara, Martin, Davenport, & Bolser, 2006) as well as both sedentary and healthy elderly ind ividuals (Baker, Davenport, & Sapienza, 2005; Kim, Davenport, & Sapienza, 2009) instrumentalists (Sapienza, Davenport, & Martin, 2002) professional voice users, and healthy young adults ( Kim, et al., 2009 ) EMST has been recently shown as a potential treatment for reducing penetration and aspiration in persons with PD as it provides an i ncrease of submental muscle activity essential in hyolaryngeal complex movement during swallow (Troche, Okun, Rosenbek, Musson, & Sapienza, 2009) The rehabilitative impact of EMST on persons who have suffered stroke has not yet been assessed. However, based on the transcortical magnetic stimulation (TMS) study of expiratory muscle function in ischemic stroke patients, there are implications that EMST could assist in improving respiratory function and reducing pulmonary complications in this population (Harraf, et al., 2008; Kim, Davenport, & Sapienza; Kim, et a l., 2009) The study of Harraf et al. (2008) suggests that cortico respiratory pathways from the affected hemisphere are disrupted in acute ischemic stroke and are

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14 associated with impairments of expiratory muscle function causing a weak cough, which impacts airway clearance and increases the risk of pneumonias with aspir ation. Since a majority of stroke patients are at risk of developing cardiovascular disease and s uffer from hypertension ( Harraf, et al., 2008 ) it is pertinent to assess the cardiovascular responses to EMST prior to the application of the program with this patient group EMST uses a pressure threshold device (EMST 150; Aspire Products; Gainesville, FL) which req uires a sufficient expiratory pressure generation in order to open a calibrated pressure relief valve housed inside the device. This creates an isometric load to the muscles controlling forced expiration. Once sufficient expiratory pressure is generated by the individual using the EMST device, the pressure relief valve opens and air flows through the device ( Pitts, et al., 2009 ) If the expiratory pressure produce d by the user is insufficient to open the valve immediately, the user increases their physical exertion when directing the expiratory flow against the closed valve. During this effort the intra thoracic pressure increases and the effect may be similar to a Valsalva m aneuver. The Cardiovascular Changes Related to the Valsalva Maneuver The Valsalva maneuver involves vocal fold closure at the end of a deep inspiration followed by physical exertion such as required during a bowel movement, or lifting a heavy w eight ( Metzger & Therrien, 1990 ) Studies have shown that prolonged (up to 15 seconds) breath holding and bearing down accompanied by vocal fold closure during activities such as weight lifting ( Narloch & Brandstater, 1995 ) some wind inst rument playing, such as tuba or French horn ( Elghozi, Girard, Fritsch, Laude, & Petitprez, 2008 ) or the supraglottic and super supraglottic swallowing m aneuvers (Chaudhuri, et

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15 al., 2002; Levin, 1966) causes a temporary but significant elevation of blood pressure (BP) as well as changes in heart rate (HR) similar to the Valsalva maneuver. The chan ges in arterial pressure associated with the Valsalva maneuver have been analyzed to test cardiac function, especially in patients with heart failure, mitral stenosis, constrictive pericarditis, and le ft to right shunts ( Levin, 1966 ) The four phases of a normal physiological response to the Valsalva ma neuver are described by Luster et al (1996) and are shown in Figure 1: 1. Intrathoracic pressure rise: As a result of expiratory force application, pressure rises inside the chest forcing blood out of the pulmonary circulation into the left atrium. This causes a mild rise in stroke volume (SV) 2. Reduced venous return and compensation: Return of systemic blood to the heart is obstructed by the pressure inside the chest The cardiac output (CO) is reduced and SV falls. The fall in stroke volume reflexively causes blood vessels to constrict with some rise in pressure. This compensation can be quite marked with pressure returning to near or even above normal, but the CO an d blood flow to the body remains low. During this time the pulse rate increases. 3. Pressure release: The pressure on the chest is released, allowing the pulmonary vessels and the aorta to re expan d causing a further initial slight fall in SV due to decreased left ventricular return and increased aortic volume, respectively. Venous blood can once more enter the chest and the heart, CO begins to increase. 4. Return of CO : Blood return to the heart is enhanced by the effect of entry of blood which had been restricted causing a rapid increase in CO SV transiently rises above normal then returnes to a normal level. With re turn of blood pressure (BP) the pulse rate returns towards normal ( Luster, Baumgartner, Adams, & Convertino, 1996 ; Tiecks, Douville, Byrd, Lam, & Newell, 1996 ) Because performing the Valsalva maneuver may cause the mobilization of venous thrombi, bleeding, ventricular arrhythmias, and asystole, it is contraindicated for the patients with severe coronary artery disease, acute myocardial infarction, or moderate to severe hypovolemia ( Baas, Meissner, & Coughlin, 2002 )

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16 Supraglottic and super supraglottic swallow techniques are commonly used to prevent aspiration by creating a voluntary prolonged a irway closure followed by forc ed expiration similar to a Valsalva maneuver. Because of the risk of cardiac arrhythmia occurring during the supraglottic and super supraglottic swallow maneuvers, these strategies may not be recommended for patients with a hi story of stroke, CAD as well as patients with acute congestive heart failure or uncontrolled hypertension ( Chaudhuri, et al., 2002 ) Playing a wind instrument, such as tuba, involves strenuous expiratory effort, creates high intra thoracic pressure and causes cardiovascular changes similar to those occurring during t he Valsalva maneuver ( Elghozi, et al., 2008 ) The wind instrument players may experience dizzi ness caused by r educed cerebral blood velocity or episodic headaches induced by the increase of intracranial pressure caused by decreased cerebral venous drainage. Another factor contributing to the headache may be BP overshoot which can be quite marked especially during the practice of high resistance wind instruments ( Elghozi, et al., 2008 ) A Valsalva maneuver performed during heavy resistance exercises may contribute to arterial hypertension, which is a risk factor for stroke in healthy young adults There are several reports of intracerebral hemorrhage caus ed by BP elevation during vigorous weight training in healthy adults possibly as sociated with the Valsalva maneuver ( Narloch & Brandstater, 1995 ) The EMST maneuver does not require complete vocal fold closure, but involves the buildup of intraoral and intrathoracic pressure s behind the closed pressure relieve valve comparable to the intrathoracic pressure created during a Valsalva maneuver.

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17 The Cardiovascular Responses to Skeletal Muscle Exercise The EMST program involves a physical exercise of the s keletal muscles involved in active respiration During muscle exercises, the cardiovascular system activates compensatory mechanis ms integrating neural, biomechanical, and physiological factors in the response to the body increased release of energy (O'Rourke, et al., 2001) S ympathetic vasoconstriction acts to redirect blood from areas of non working tissue to the active muscles and contributes to the rise in BP which may help to increase perfusion to the working muscles ( Ferguson & Brown, 1997 ) As a respon se to exercise, CO increases proportionally to metabolic demands of exercised muscles to avoid hypothermia, and to deliver adequate blood flow to essential organs and exercised muscles. CO may fluctuate from the resting value of 3.75 5 L/min up to 20 40 L/min during the exercise ( O'Rourke, et al., 2001 ) The increased HR may vary from 160 to 180 bpm during exercise and may reach a maximum of 240 bpm during short periods of max imal physical activity. At the end of the exercise, due to withdrawal of sympathetic tone and reactivation of vagal activity, HR and CO decrease, while systemic vascular resistance remains lower longer as a result of persistent vasodilatation in the muscle As a consequence, there is a fall of arterial pressure, often below preexercise levels for a period up to 12 hours into recovery to eventually return to the normal levels stabilized by baroreceptor reflexes ( O'Rourke, et al., 2001 ) There are several types of exercises which induce different cardiovascular response patterns. An isotonic (dynamic) exercise involves a larger group of muscle cont raction resulting in movement. During EMST, t he inspiratory muscles (diaphragm and external intercostals) are responsible for the deep inhalations preceding the forced exhalations

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18 which are controlled by the contractions and the movements of the expiratory muscles (internal intercostals and ab dominal muscles). The typical changes occurring during this type of exercise are: increased oxygen consumption (V0 2 ) and vasodilation of vessels in the exercised muscle. As this exercise is prolonged, skeletal muscle metabolism increases the demand for ade nosine triphosphate (ATP), so the oxygen supply is significantly increased, which is possible through the augmentation of the local blood flow a nd increased oxygen extraction ( O'Rourke, et al., 2001 ) Isometric (static) exercise is a type of an exercise that requires a constant contraction of a small muscle group without movement. It increases vascular resistance and provokes a minimal increase in CO and VO 2 The mechanical compression o f blood vessel s during the sustained muscular contraction limits the increase in blood flow. The local blood flow may actually decrease. BP may increase and will be proportional to the exercised muscle tension and the mass of the muscle groups activated. A s a resul t of the elevated BP and the decrease of venous return, SV decreases. HR increases, often out of proportion to the metabolic demand of the exercised muscle, to maintain a higher CO ( O'Rourke, et al., 2001 ) During the use of the EMST device, the contractions of respiratory and abdominal muscles are brief and repetitive which indicates rhythmic isometric and isotonic exerci se components. Ferguson & Brown ( 1997 ) analyzed systolic blood pressure (SBP) diastolic blood pressure (DBP) and HR fluctuations during rhythmic isometric handgrip exercise to fatigue in two groups of young, healthy males: trained rock climbe rs (CLIMB) and sedentary partici pants (SED) CLIMB experienced fatigu e later than SED. Both groups demonstrated changes of all three variables from the beginning up to 75% of the

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19 time of the exercise. SBP decreased in CLIMB after reaching the maximum at 75% of the exercise time, but remained abo ve the resting level DBP and HR continued increasing to the end of the exercise in both groups. They suggest that SBP decrease in CLIMB is associated with the attenuation of pressor response in trained individuals ( Ferguson & Brown, 1997 ) Based on the conclusion of Ferguss on & Brown (1997), the differences in the cardiovascular responses to the exercise between physically active and sedentary individuals may be expected. The participants of the present study have not been selected based on their physical fitness. However, this factor may have an impact on the cardiovascular responses to EMST. EMST involves intense bre athing activity resulting in increased gas exchange in the body system which is a typical mechanism occurring during an aerobic exercise It has been suggested tha t aerobic exercise induces a transient SBP reduction with no significant changes in DBP in normative and hypertensive individuals (Fisher, 2001; Floras, et al., 1989) The Present Study The Purpose of the Study The aim of this project was to test the effects of the EMST on BP HR and SpO 2 levels in young healthy adults to assess potential side effects associated with use of the EMST device. If healthy individuals showed significant (greater than10%) fluctuations of baseline (pre training) measures of BP HR and/or SpO 2 during EMST, it could indicate transient cardiovascular changes similar to the effects observed during the Valsalva maneuver. If observed, these results may suggest that EMST may exert similar eff ects on individuals with cardiovascular disease. As such, the use of EMST may be contraindicated for this population.

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20 The Hypothesis It was hypothesized that the fluctuations of BP, HR and SpO 2 during EMST trials would not exceed a normal range bec ause of the short duration of the isometric phase of the EMST expiratory effort. Since EMST involves a combination of the isotonic, isometric, and aerobic exercises, no particular pattern of cardiovascular responses associated with one type of exercise was antici pated during the study. However, because the addition of an expiratory load increase s intra thoracic pressure potentially similar to a Valsalva maneuver ( Chaudhuri, et al., 2002 ; McConnell & Romer, 2004 ) the cardiovascular responses to EMST must be assessed. Figure 1 1. Systolic blood pressure and pulse rate during a normal response to the Forty millimeter mercury pressure is applied at 5 seconds and relieved at 20 seconds ( Luster, et al., 1996 )

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21 CHAPTER 2 METHODS Participants The study was approved by the University of Florida Institutional Review Board (IRB ) and conducted at the University of Florida, Gainesville, FL, Department of Speech, Language, and Hearing Sciences A group of 31 healthy young, non smoking adults (24 women and 7 men), between the ages of 18 and 30 years participated in the study Each participant was informed about the purpose of the project and a signed informed consent was obtained prior to initiation of the study. Population and Criteria for Inclusion The following exclusionary criteria were established: pregnancy as verified by a pregnancy test prior to enrollment a body mass index (BMI) less than 18 kg/ m 2 and greater than 33 kg/ m 2 ( "Centers for Disease Control and Prevention, About RMI For Adults," ) SBP of at least 140 mm Hg, DBP of at least 90 mm Hg (Black, et al., 1997) SBP of 90 mm Hg or lower and DBP of 65 mm Hg and lower, a fluctuating BP as three consecutive readings different with a variation of 10% or more, and hypoxia with an oxygen saturation of 95% or less at the baseline (Manley, et al., 2001) The volunteers were excluded for diagnos is and/or treat ment for cardiovascular disease, respiratory disease that include d but were not limited to: asthma, chronic obstructive pulmonary disease (COPD), or lung, and head and neck cancer within one year prior to the study. All above mentioned conditions including pregnancy may have an impact on an d pressure, may decrease exercise tolerance, and cause dyspnea a s a result of the physical work out associated with EMST. Participants were asked to avoid

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22 any intense physical activities prior to enrollment and advised not to consume caffeine containing pro ducts at least two hours prior the study. Procedure Apparatus The measurements of BP and HR were taken using a standardized electronic sphygmomanometer (CVS/pharmacy Automatic Blood Pressure Monitor) with an automatically pumped cuff wrapped around the lef t arm of the participant. Pulse oximeter oxygen saturation (SpO 2 ) was measured using a model 8000AA 3 Adult Articulated Finger Clip Sensor (NONIN Medical. Inc) connected to NONIN Pulse Oximeter (NONIN Medical. Inc) and attached to the middle finger of the par right hand. Pulse was obtained using a MP100 Pulse Transducer attached to the index finger of the same hand. Pulse and SpO 2 were measured continuously and recorded by the PowerLab Version 7 hardware and software system (ADInstruments). A digi tal manometer (MP01 mouth pressure meter; Micro Direct Inc.) was use to measure MEP which is an indirect measure of expiratory muscle strength The EMST exercise device was used during the experimental session. Measurements All the measurements were taken while the participant remained in a seated position. The laboratory was maintained at temperatures between 22 and 24C, and the measurements were taken at approximately the same time of a day for each participant. BP HR a nd SpO 2 were measured at baseline to ensure measurement consistency. If the measures varied by more than 10%, a third sample of measurements was taken. If the participant qualified for the study, the average of the two last measurements was considered as b aseline. The participant

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23 performed a Valsalva maneuver for 5 seconds according to the instructions given by the investigator prior to the task. The instructions included the following steps: 1. Take a deep breath, 2. Hold your breath, 3. Bear down as durin g a bowel movement. The duration of the Valsalva maneuver was controlled by the investigator with the use of a stopwatch. BP HR, SpO 2 were measured immediately after completing the Valsalva maneuver The initial tasks and measurements took approximately 1 5 minutes. During the next part of the study MEP was measured. After a deep inhalation, the participant performed a forceful exhalation into a disposable mouthpiece attached to the manometer. This test was repeated at least three times, and each time MEP was recorded. The mean was calculated for the three highest values varying by 5% of one another. Following calculation of average MEP, the threshold pressure of the EMST device was set at 75% of the mean MEP values previously recorded. Obtaining and calcul ating the average MEP values was completed within approximately 7 minutes. After the initial data was collected, as described above, the participant completed tasks using the EMST device. The participant was instructed to perform a deep inhalation followed by a forceful exhalation into the mouthpiece of the EMST device to open the pressure relief valve inside the device. The participant was asked to stop generating the expiratory pressure once the valve opened, which was noticeable by the pressure release and the hissing sound produced by the air coming through the device. The initiation and the termination of the expirato ry effort were controlled by the generating the expiratory pressure. The participant first completed 12 breaths into the device, and BP, HR, and SpO 2 were measured immed iately after the 12 trials were

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24 finished Following the se measurements, 13 remaini ng breaths into the EMST device were completed, and another set of measurements of BP, HR, and SpO 2 was taken immediately after the task HR and SpO 2 were also measured conti nuously as the participant was completing all EMST trials. The tasks and measurements involving the use of EMST device took approximately 7 minutes. The participant was allowed a 5 minute rest following completion of all tasks and after the 5 minute rest, the measures of BP, HR, and SpO 2 were taken. A Valsalva maneuver was performed for 5 sec., and a set of BP, HR, and SpO 2 measurements was again taken. The entire time of a single study session did not exceed 45 minutes. The data collected during the conti nuous SpO 2 and HR were displayed as a waveform and saved using LabChart 7 software for the further analysis. The time of each task was recorded by inserting a marker line on the waveform at the beginning and at the end o f each task. The numeric values of BP, HR, and SpO 2 were stored in Microsoft Office Excel. 2007. SAS version 9.1 was employed for statistical analysis and presentation of results.

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25 CHAPTER 3 RESULTS Descriptive S tatistics SAS version 9.1, a statistical software package was used to generate descriptive statistics of frequencies, means and standard deviations for the variables in the data set. A total of 31 participants (24 women and 7 men) age range 1 8 to 30 years completed the study. The m ean age of the participants in the dataset was 21.7 years (SD=2.56, N=31). The m ean BMI was 22.0 (SD=2.61, N=31) and the mean MEP of all the participants was 87.0 cmH 2 O (SD=25.71, n=31). Mean demographic data is shown in Table 3 1. Mean age for women was 2 1.2 years, SD=2.17, while the mean age for men was 23.1 years, SD=3.53 (p=.0903, t=1.75, df=29). Mean BMI for women was 21.5, SD=2.02, and the mean BMI for men was 23.6, SD=3.92 (p=.0623, t=1.94, df=29). The m edian MEP for women was 73 cmH 2 O, and the medi an MEP for men was 106 (p=.0031, Wilcoxon Z approximation=2.96). The m ean MEP for each sex was not considered for the analysis because the data was not normally distributed The means and standard deviations of the outcome measures after the performan ce of each task are presented in Table 3 2 The following terms to describe the experimental tasks performed by the participants were: Baseline: The mean of two consecutive measurements taken prior to completing the tasks in the study. Valsalva 1: The Valsalva maneuver performed prior to the use of EMST device. Phase 1: The first phase of EMST including 12 trials using the EMST device. Phase 2: The second phase of EMST including 13 trials using the EMST device. Rest: The 5 minute rest period after completing all 25 EMST trials.

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26 Valsalva 2: The Valsalva maneuver performed 5 minutes after completing EMST. Mean duration s of the expiratory effort and rest periods during the EMST trials was calculated for each participant as well as for the entire group. T he mean e xpiratory exertion duration for all participants was 1.25 sec., the mean rest period between the expiratory exertio ns was 7.7 sec., and a mean duration of EMST session was 3 min. 26.2 sec. The Analysis of the Differences in Outcome Measurements Across Task s For each of the four outcome measures, SAS Proc MIXED was used to create a mixed linear model to test for changes across the six time points. In all models, the independent variable was task, and included were the covariates of: sex, BMI and MEP. To dete rmine the statistical power of the study, the standard deviation of the differences between a particular task at baseline and after the Valsalva 1 task were used and the smallest effect size that the study could have detected was determined with at least 90% power using paired samples t tests. There was no significant variation across tasks o n any outcome measurements Some covariates had significant effects on some of the outcomes. Systolic Blood Pressure SBP was approximately normally distributed across all data points with a mean of 107.7 mmHg and a standard deviation of 9.88 mmHg The minimum value of SBP was 89 mmHg and the maximum was 138 mmHg SBP did not change significantly across tasks (F=1.5 5 ; df=5, 1 75; p=.17 63 ). Based on the standard deviation of the differences between SBP at baseline and after Valsalva 1 (SD=4.12), it was estimated that the study had more than 90% power to detect a mean difference in SBP of 2.5 between any two tasks. Sex had a hig hly significant effect on SBP (F= 34.06 ; df= 1, 17 6 ; p<.0001), with women tending to have lower mean SBP across all tasks. Mean SBP for men in the

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27 study was 117.8 mmHg (SD=10.66). Mean SBP for women was 104.7 mmHg (SD=7.40). BMI had a significant effect on SBP (F= 6.37 ; df=1, 17 6 ; p= .0125 ), with SBP increasing with BMI. Mean SBP is estimated to increase by 0. 6 1 points for each additional point of BMI (95% CI=[ .136 1.083 ]). MEP did not have a significant effect on SBP (F= 1.48 ; df=1 17 6 ; p= .2251 ). See Figure 3 1 for the changes in SBP across the tasks. Diastolic Blood Pressure DBP was approximately normally distributed across all data points with mean of 74.8 mmHg and standard deviation of 6.76 mmHg The minimum observation was 61 mmHg and the max imum was 98 mmHg DBP did not change significantly across tasks (F=0.40; df=5, 175; p=.8477). The standard deviation of the differences between DBP at baseline and after Valsalva 1 (SD=5.16 mmHg ) was used to estimate that the study had mor e than 90% power to detect a mean difference in DBP of 3.1 between any two tasks. Sex had a significant effect on DBP (F= 9.42 ; df= 1, 17 6 ; p=.00 25 ), with women tending to have lower mean DBP across all tasks. Mean DBP for men in the study was 79.1 mmHg (SD =6.92). Mean DBP for women was 73.5 mmHg (SD=6.19). BMI had a significant effect on DBP (F= 6.22 ; df=1, 17 6 ; p=.0 135 ), with DBP increasing with BMI. Mean DBP is estimated to increase by 0. 48 mmHg for each additional point of BMI (95% CI=[.1 03 859 ]). MEP did not have a significant effect on DBP (F=0.02; df=1, 17 6 ; p=.8 823 ). See Figure 3 2 for the changes in DBP across the tasks.

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28 Heart Rate HR was approximately normally distributed across all data points T he overall mean was 7 6.4 bpm with a standard devia tion of 10.64 bpm HR did not differ significantly across the six tasks (F=0. 92 ; df=5, 17 6 ; p=. 4709 ). The study had more than 90% power to detect a mean difference in HR of 3.2 between any two tasks using the standard deviation ( SD=5.32 ) of the differenc es between HR at baseline and after Valsalva 1. BMI had a highly significant effect on HR (F= 16.06 ; df=1, 17 6 ; p<.0001), with HR increasing with BMI. On average, mean HR increased by 1.2 bpm for each additional point of BMI (95% CI=[ 0.641 1.867 ]). MEP ha d a significant effect on HR (F= 7.09 ; df=1, 17 6 ; p=. 0085 ) with HR decreasing by 0.098 bpm for each additional cmH 2 O of MEP (95% CI=[ 0.170 0.026 ]). Sex did not have a significant effect on HR (F= 0.05 ; df=1, 17 6 ; p=. 9166 ). See Figure 3 3 for the changes in HR across the tasks. Percent Oxygen S aturation SpO 2 was mildly skewed to the left with mean of 98.5% and standard deviation of 1.29. The minimum observation was 93% (after Rest) and the maximum value was 100%. Tasks performed during the study di d not have a significant effect on SpO 2 (F=1.6 1 ; df=5, 17 6 ; p=.16 05 ). The standard deviation of the differences between SpO 2 at baseline and after Valsalva 1 (SD=0.616) was used to determine the smallest effect size that the study could detect with at leas t 90% power using a paired samples t test. This effect size was 0.37. Consequently, the study had more than 90% power to detect a mean difference in SpO 2 of 0.37 percentage points between any two tasks.

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29 Sex had a significant effect on SpO 2 (F= 4.60 ; df= 1, 17 6 ; p=.0 334 ), with women tending to have higher mean SpO 2 across all tasks. Mean SpO 2 for men in the study was 98.13 % (SD=1.36), for women was 98.62 % (SD=1.25). BMI had a significant effect on SpO 2 (F= 8.75 ; df=1, 17 6 ; p=.00 35 ), with SpO 2 decreasing with increasing BMI. Mean SpO 2 wa s estimated to decrease by .11 % for each additional point of BMI increase (95% CI=[ .185, .0375]). MEP had a significant effect on SpO 2 (F= 4.40 ; df=1, 17 6 ; p=.0 375 ), with SpO 2 increasing with the increa se of M EP. On average, mean Sp O 2 is estimated to increase by 0.009 4 % for each addition cm H 2 O of MEP (95% CI= [.000 6 13, .018 2 ]). See Figure 3 4 for the changes in SpO 2 across the tasks. The current study provided BP, HR, and SpO 2 values obtained during the use of EMST device and five minutes after the completion of the exercise. The last measurements of BP, HR, and SpO 2 were recorded approximately eight minutes after the EMST session. Since the cardiovascular responses to the last task (Valsalva 2) fell within the normal limits, further measurements were not obtained, and the cardiovascular responses did not require any additional monitoring. Pairwise C omparisons B etween S pecific T ask P oints We used t tests to compare BP HR and SpO 2 betwee n specific pairs of task points. Valsalva 1 vs. Baseline The Baseline mean s were slightly higher, but the difference s were not significant for SBP (Baseline mean=110.2 mmHg SD=10.34 mmHg ; Valsalva 1 mean=109.5 mmHg SD=10.71; T=0.28, p=.7778), DBP (Baseline mean=76.1 mmHg SD=6.34 mmHg ; Valsalva 1 mean=74.7 mmHg SD=7.06 mmHg ; T=0.84, p=.4031), and HR (Baseline mean=77.4 bpm SD=10.96 bpm ; Valsalva 1 mean=77.7 bpm SD=11.91

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30 bpm ; T=0.10, p=.9208).The Valsa lva 1 mean was higher than the B aseline mean for SpO 2 but the difference was not significant (Baseline mean=98.38%, SD=1.05%; Valsalva 1 mean=98.64%, SD=1.06%; T=0.97, p=.3367). Valsalva 2 vs. Rest The Rest mean was slightly higher with no significant difference s for SBP (Rest mean=106.8 mmHg SD=8.91 mmHg ; Valsalva 2 mean=106.2 mmHg SD=9.25 mmHg ; T=0.27, p=.7914) and DBP (Rest mean=74.9 mmHg SD=6.62 mmHg ; Valsalva 2 mean=74.3 mmHg SD=6.52 mmHg ; T=0.35, p=.7292) The Valsalva 2 mean was slightly higher than the Rest mean for HR (Rest mean=74.0 bpm SD=9.68 bpm ; Valsalva 2 mean=74.2 bpm SD=9.45 bpm ; T=0.08, p=.9368) and SpO 2 (Rest mean=98.19%, SD=1.43%; Valsalva 2 mean=98.26%, SD=1.17%; T=0.20, p=.8389), but the difference s were not significant. Phase 1 vs. Baseline The differences in changes from Baseline to Valsalva 1 an d from Rest to Valsalva 2 were determined. For each outcome measurement, one sample t tests were performed to determine whether the difference between the two differences was significantly different from 0. These tests showed that the mean difference betwe en Valsalva1 and Baseline was not significantly different from the mean difference between Valsalva 2 and Rest for all measurements: SBP (p=.9127), DBP (p=.6060), HR (p=.9508), SpO 2 (p=.3942). The Baseline mean s were slightly higher with no significant dif ference s for SBP (Baseline mean=110.2 mmHg SD=10.34 mmHg ; Phase 1 mean=102.4 mmHg SD=10.32 mmHg ; T=1.54, p=.1280), DBP (Baseline mean=76.1 mmHg SD=6.34 mmHg ; Phase 1 mean=74.5 mmHg SD=7.94 mmHg ; T=0.91, p=.3664), and HR

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31 (Baseline mean=77.4 bpm SD=10.9 6 bpm ; Phase 1 mean=77.0 bpm SD=10.75 bpm ; T=0.14, p=.8889). The mean SpO 2 in Phase 1 was significantly higher than the mean SpO 2 in Baseline (Baseline mean=98.38%, SD=1.05%; Phase 1 mean=98.94%, SD=1.03%; T=2.11, p=.0390). Phase 2 vs. B aseline The Baseli ne mean s were slightly higher, but the re were no significant difference s in SBP(Baseline mean=110.2 mmHg SD=10.34 mmHg ; Phase 2 mean=107.3 mmHg SD=9.67 mmHg ; T=1.17, p=.2453), DBP (Baseline mean=76.1 mmHg SD=6.34 mmHg ; Phase 2 mean=74.2 mmHg SD=6.29 mm Hg ; T=1.22, p=.2285), and HR (Baseline mean=77.4 bpm SD=10.96 bpm ; Phase 2 mean=77.7 bpm SD=11.00 bpm; T=0.12, p=.9083). The mean SpO 2 in Phase 2 was higher than in the Baseline with no significant difference (Baseline mean=98.38%, SD=1.05%; Phase 2 mean=98.66%, SD=1.79%; T=0.74, p=.4618). Phase 2 vs. Phase 1 The mean values of SBP (Phase 1 mean=106.2 mmHg SD=10.32 mmHg ; Phase 2 mean=107.3 mmHg SD=9.67 mmHg ; T=0.42, p=.6767) an d HR (Phase 1 mean=77.0 bpm SD=10.75 bpm ; Phase 2 mean=77.7 bpm SD=11.00 bpm ; T=0.26, p=.7982) were slightly higher in Phase 2, but the differences were not significant. There was a non significant decrease of DBP (Phase 1 mean=74.5 mmHg SD=7.94 mmHg ; P hase 2 mean=74.2 mmHg SD=6.29 mmHg ; T=0.16, p=.8738) and SpO 2 (Phase 1 mean=98.94%, SD=1.03%; Phase 2 mean=98.66%, SD=1.79%; T=0.76, p=.4523) during Phase 2.

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32 Rest vs. B aseline The mean values of all measurements were slightly lower during Rest with no si gnificant differences between Rest and Baseline: SBP (Baseline mean=110.2 mmHg SD=10.34 mmHg ; Rest mean=106.8 mmHg SD=8.91 mmHg ; T=1.42, p=.1622), DBP (Baseline mean=76.1 mmHg SD=6.34 mmHg ; Rest mean=74.9 mmHg SD=6.62 mmHg ; T=0.75, p=.4536), HR (Baseli ne mean=77.4 bpm SD=10.96 bpm ; Rest mean=74.0 bpm SD=9.68 bpm ; T=1.29, p=.2023), SpO 2 (Baseline mean=98.38%, SD=1.05%; Rest mean=98.19%, SD=1.43%; T=0.58, p=.5625). Rest vs. Phase 2 The values of SBP (Phase 2 mean=107.3 mmHg SD=9.67 mmHg ; Rest mean=106.8 mmHg SD=8.91 mmHg ; T=0.20, p=.8384) HR (Phase 2 mean=77.7 bpm SD=11.00 bpm ; Rest mean=74.0 bpm SD=9.68 bpm ; T=1.41, p=.1639), and SpO 2 (Phase 2 mean=98.66%, SD=1.79%; Rest mean=98.19%, SD=1.43%; T=1.12, p=.2665) were slightly higher during P hase 2, but the difference s were not significant. The Rest mean of DBP was slightly higher (Phase 2 mean=74.2 mmHg SD=6.29 mmHg ; Rest mean=74.9 mmHg SD=6.62 mmHg ; T=0.43, p=.6668) but no significant change was detected Table 3 1. Mean demographic data Demographics Women (N=24) Men (N=7) Mean SD Min Max Mean SD Min Max Age (y) 21.2 2.17 19 .0 30 .0 23.1 3.5 19 .0 28 .0 BMI (kg/m 2 ) 21.5 2.02 18 .0 25.7 23.6 3.9 19.4 28. 9 MEP (cmH 2 O) 79.0 17.59 60 .0 119 .0 114.4 30. 3 79 .0 164 .0 N=number of participants, SD=standard deviation, Min=minimum, Max=maximum, BMI=body mass index, MEP =maximum expiratory pressure, y=year.

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33 Table 3 2. The means and standard deviations (SD) of the outcome measurements after performance of each task. Outcome measure Task (N=31) Baseline mean (SD) Valsalva 1 mean (SD) Phase 1 mean (SD) Phase 2 mean (SD) Rest mean (SD) Valsalva 2 mean (SD) SBP (mmHg) 110.2 (10.34) 109.5 (10.71) 106.2 (10.32) 107.3 (9.67) 106.8 (8.91) 106.2 (9.25) DBP (mmHg) 76.1 (6.34) 74.7 (7.06) 74.5 (7.94) 74.2 (6.29) 74.9 (6.62) 74.3 (6.52) HR (bpm) 77.4 (10.96) 77.7 (11.91) 77.0 (10.75) 77.7 ( 11.0 ) 74.0 ( 9.68 ) 74.2 (9.45) SpO 2 (%) 98.4 (1.05) 98.6 (1.07) 98.9 (1.03) 98.7 (1.79) 98.2 (1.43) 98.3 (1.17)

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34 Table 3 3. The mean values of exertion and rest duration for each participant in Phase 1 and Phase 2 of the EMST session. Phase 1 Phase 2 Participant Number Mean Exertion (mm:ss.0) Mean Rest (mm:ss.0) Mean Exertion (mm:ss.0) Mean Rest (mm:ss.0) 1 00:01.7 00:12.8 00:01.0 00:06.8 2 00:01.3 00:08.7 00:01.6 00:09.7 3 00:01.0 00:07.7 00:01.1 00:07.0 4 00:02.1 00:06.4 00:02.4 00:04.8 5 00:02.3 00:10.6 00:01.9 00:05.9 6 00:02.1 00:06.9 00:01.8 00:06.8 7 00:02.1 00:05.0 00:01.5 00:04.1 8 00:01.4 00:07.2 00:01.0 00:06.0 9 00:01.5 00:07.2 00:01.2 00:05.3 10 00:01.2 00:08.7 00:00.8 00:05.7 11 00:01.3 00:10.5 00:01.3 00:05.0 12 00:01.5 00:10.3 00:01.9 00:07.5 13 00:01.5 00:11.2 00:00.8 00:06.1 14 00:01.8 00:08.1 00:01.0 00:04.7 15 00:01.0 00:10.1 00:01.8 00:04.2 16 00:00.9 00:07.1 00:01.1 00:05.3 17 00:01.2 00:10.5 00:01.2 00:06.2 18 00:01.2 00:12.8 00:02.9 00:04.2 19 00:01.0 00:12.9 00:00.9 00:08.8 20 00:01.1 00:09.0 00:00.8 00:07.3 21 00:00.9 00:07.3 00:03.1 00:03.4 22 00:00.8 00:10.5 00:00.5 00:05.3 23 00:00.9 00:10.8 00:00.5 00:07.4 24 00:00.8 00:07.7 00:00.6 00:05.3 25 00:00.5 00:09.2 00:00.4 00:06.9 26 00:00.6 00:07.3 00:00.8 00:06.0 27 00:00.7 00:08.2 00:00.8 00:05.7 28 00:01.0 00:08.7 00:01.1 00:07.3 29 00:00.7 00:08.7 00:01.4 00:04.0 30 00:01.1 00:18.9 00:00.7 00:05.3 31 00:00.7 00:09.1 00:00.5 00:06.1 Mean For All Participants 00:01.2 00:09.4 00:01.3 00:05.9 mm=minutes, ss=seconds.

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35 Figure 3 1. The changes in SBP across the tasks. Figure 3 2. The changes in DBP across the tasks.

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36 Figure 3 3. The changes in HR across the tasks. Figure 3 4. The changes in SpO 2 across the tasks.

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37 CHAPTER 4 DISCUSSION The main purpose of this study was to examine the cardiovascular response s during expiratory muscle strength training with the use of the EMST device in a cohort of 31 young adult healthy persons. The EMST program has demonstrated positive outcomes for variables related to respiratory function ( Chiara, Martin, & Sapienza, 2007 ) cough production ( Pitts, et al., 2009 ) and swallow function (Troche, et al., 2009; M. Troche, et al., 2010; M. S. Troche, et al., 2010) as well as some minor influences on vocal production ( Wingate, et al., 2007 ) There was an in terest wh ether the EMST device had effects on cardiovascular responses in users given that the task requires the generation of relatively high MEP. This question may have implication, in particular for those suffering from cardiovascular disease. Interpret ation of the Principal Findings The present study showed no significant changes in BP, HR, and SpO 2 during and shortly after a session of 2 5 EMST trials with the training device which suggests little device or expiratory exercise impact on cardiovascular r esponse for the cohort enrolled in this study. This outcome supports the hypothesis that EMST would not induce major fluctuations in cardiovascular response primarily because of the short expiratory effort durations of the task. Even though a high expirato ry pressure is generated to open the valve within the device, the duration of that pressure generation is on the order of 1.25 seconds. This duration is substantially less than a typical Valsalva maneuver which can last anywhere from 15 to 20 seconds or mo re depending on the task ( Luster, et al., 1996 ; Tiecks, et al., 1996 )

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38 Both Chaudhuri et al., (2002) and the present stud y analyzed BP and HR changes during brief, repetitive acts of exertion involving a mechanism similar to the Valsalva maneuver The super supraglottic and supraglottic swallow exercises described in the Chaudhuri et al. (2002) study evoked significant BP ele vation and cardiac arrhythmia. Chaudhuri et al. (2002) reported BP increases (>20 mmHg of SBP or >10 mmHg DBP ) in 8 out of 23 older adults (44 to 90 years of age), including 5 participants with history of coronary artery disease during supraglottic and sup er supraglottic swallow maneuvers. Thirteen out of 15 participants with a history of stroke and dysphagia demonstrated cardiac arrhythmia during swallowing sessions using the same technique. In addition, 7 of the 23 participants experienced lightheadedness during the treatment session ( Chaudhuri, et al., 2002 ) The significant BP changes and cardiac arrhythmia subsided within five minutes after the swallow session and did not recur within a four hour moni toring period. In the Chaudhuri, et al. (2002) study, a Holter monitor was used to record electrical activities of the heart and swallow timing, but the duration of the swallow maneuvers and the baseline measurements of BP and HR were not reported. C ompare d to the results presented by Chaudhuri et al. (2002) the present study participants demonstrated a slight decrease rather than a significant elevation of mean SBP and almost no change in mean DBP across the tasks. Reasons for the study results difference s are likely the following: First, the swallow supraglottic and super against a closed glottis, which was considered a modifi ed Valsalva maneuver ( C haudhuri, et al., 2002 ) While the glottis is narrowing during an EMST trial, it either closes so briefly or never completely closes that a cardiovascular response is

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39 insignificant due to the limited exertion. Second, two thirds of the participants of Chau dhuri et al. (2002) study had a history of stroke and cardiovascular disease which could have elicit ed the abnormal hemodynamic responses to the Valsalva maneuver. The present study results did not show a significant cardiovascular response to any of the Valsalva maneuver s in the studied group. The Valsalva maneuver was shorter (5 sec.) than the 15 20 sec. Valsalva maneuver presented in the literature ( Luster, et al., 1996 ; Tiecks, et al., 1996 ) No considerable BP, HR, or SpO 2 fluctuations were noticed after completing each of the Valsalva maneuvers as compared to the baseline values or the values recorded after EMST phases. Monitoring intrathoracic pressure would have allowed better control over the Valsalva maneuver. Without monitoring individual intrathoracic pressures, the degree of exertion could not be physiologically defined. Measuring the intrathoracic pressure requires an invasive and complicated procedure of inserting an intraesophageal catheter ( Behazin, Jones, Cohen, & Loring, 2010 ) which was beyond the scope of this study. Some covariates had a significant effect on the study measurements. BMI had a significant impact on the participants BP as a function of task. The positive correlation between BMI and BP is consistent with the study results of Johnson et al ., ( 1975 ) showing that the increase in BMI leads to the BP elevation in young adults ( Johnson et al., 1975) BMI had a significant effect on HR in the current stu dy with HR increasing with BMI. Kazumi et al. (2001) found a correlation between BMI, BP, and HR i n young healthy men of age 18 20 years. For example, the mean SBP of 133+ 4 corresponded to a BMI of 23.1+ 4.8, and HR 70+ 10 ( Kazumi, Kawaguchi, Sakai, Hirano, & Yoshino, 2002 ) normal BP and BMI values higher

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40 than the participants with normal and optimal BP showed significantly greater elevation of HR at rest a fter overnight fasting. Kazumi et al.( 2002) suggest that the decreased insulin sensitivity is associated with the resting HR elevation in men ( Kazumi, et al., 2002 ) Along with insulin sensitivity, there are multiple factors that may affect resting HR responses to exercise: stress, anxiety, medications, and stimulant substances such as caffeine, nicotine, o r nutrition supplements. Although the current study participants were screened as healthy and denied use of tobacco products, those who demonstrated elevated HR during EMST trials could have experienced stress, could have used nutritional supplements such as energy drinks, or could have had unknown conditions which altered the cardiovascular responses to EMST. ( Kawachi, Spar row, Vokonas, & Weiss, 1995 ; Licht, de Geus, van Dyck, & Penninx, 2009 ) Mean SpO 2 was significantly affected by BMI for all participants across the tasks. Participants with higher BMI values tended to have lower mean SpO 2 This observation was especially evident for participants12 and 15 who had the highest values of BMI and a SpO 2 low er than most of the participants across the tasks. Considering the fact that a pulse oximeter detects the oxygen present in hemoglobin, it is worth noting that the differences in SpO 2 may be related to the hemoglobin content in blood. Kjellberg et al. (194 9) reported considerable higher amounts of hemoglobin and blood volumes in the physically active participant than in sedentary individuals for both sexes ( Kjel lberg, Rudhe, & SjStrand, 1949 ) This suggests that the participants of the recent study who demonstrated the higher BMI values were less physically active, therefore they had lower levels of hemoglobin and associated with it lower SpO 2 values.

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41 Three p articipants (12, 15, and 26) demonstrated greater SpO 2 fluctuations than the rest of the group across the tasks. The baseline SpO 2 values for all three participants (participant 12: 97.2%, participant 15: 96.2%, and participant 26: 96.1%) were slightly low er than the mean value (98.4%). Interestingly, participant 15 demonstrated the highest mean baseline SBP in the group and 26 demonstrated the mean baseline SBP within the lower margin of the normal range. For both of these participants, the f luctuations of SpO 2 were consistent with SBP changes. They showed the decrease of SpO 2 along with the elevation of SBP and the increase of SpO 2 along with the fall in SBP across the tasks. Knower et al. (2001) studied baseline SpO 2 in patients with COPD as a predictor of potential exercise desaturation. Clinically s ignificant desaturation for their study was considered to be SpO 2 decrease of 4% or more to a lowest point of 88% or less during exercise regardless of the baseline SpO 2 ( Knower, Dunagan, Adair, & Chin, 2001 ) Knower et al. (2001) suggested that a resting SpO 2 of 95% or less could be a reliable predicto r of exercise desaturation. Regardless of transient fluctuations of SpO 2 observed in a few participants, SpO 2 for all participants remained within normal range. The baseline SpO 2 values for all participants in the current study fell above 96% and the great est decrease (by 3%) in SpO 2 was for participant 26. Following the criteria of Knower et al. (2001), no exercise desaturation was not ed for any of the participants. The variable of s ex had a noticeable impact on some of the measures across the tasks. Wome n showed lower mean SBP and DBP values but higher mean SpO 2 than men. Since men demonstrated higher mean BMI than women in this study, the positive correlation between BMI and BP (Johnson, et al., 1975; Kazumi, et al., 2002) may

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42 explain the significant difference in SBP and DBP between these groups. There is no available evidence in the literature which would support the differences in SpO 2 betw een sexes. MEP had a significant impact on SpO 2 where SpO 2 increase was observed as MEP increased. Since the main effect of EMST is an increase of MEP, and the recent study showed the positive correlation between MEP and SpO 2 the likelihood of a subsequ ent impact of EMST on SpO 2 may be considered. This hypothesis could be based on the study results showing a slight mean SpO 2 increase during the EMST session (Figure 3 4). EMST as a respiratory exercise requires an active respiration pattern including a de ep inspiration and a forced expiration. The deep diaphragmatic breathing helps increase Sp O 2 along with a significant increase of transcutaneous partial pressure of oxygen (Ptc, O 2 ), a significant decrease in transcutaneous partial pressure of carbon dioxi de (Ptc, C O 2 ), a significant increase in tidal volume (Vt) and a ( Vitacca, Clini, Bianchi, & Ambrosino, 1998 ) Guimaraes et al. (2009) used balloon inflation with prolo nged nasal inspiration and forced blowing, prolonged vowel production, isotonic and isometric facial, palatal, and lingual muscle exercises to decrease the symptoms of obstructive sleep apnea syndrome (OSAS). The breathing exercise as a component of oropha ryngeal exercises contributed to the significant increase of Sp O 2 in patients with OSAS ( Guimaraes, Dra ger, Genta, Marcondes, & Lorenzi Filho, 2009 ) These findings suggest that respiratory exercises involving a deep inspiration improve the alveolar ventilation and subsequently contribute to the increase in tissue oxygenation. The present study showed a significant increase of mean SpO 2

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43 after Phase 1and a slight SpO 2 increase after Phase 2. These results indicate that EMST intensifies respiratory behaviors and correlated with the cardiovascular activity for ventilation and oxygen transportation. Clinical I mplications Given the lack of significant cardiovascular responses during EMST trials these results suggest less concern over a contraindication of EMST for patient s with cardiovascular disease. One caution is that patients with cardiovascular disease ca n suffer with a multitude of conditions, ranging from hypertension to atherosclerosis which may lead to either cerebral or myocardial infarction. Consultation with a cardiovascular physician is still recommended for these various conditions when considerin g use of EMST with the caveat that no response has been documente d in young healthy individuals. It is crucial for rehabilitation exercises to be tested for their safety particularly for patients in an acute care and those who have a complex medical hist ory where exacerba tion of symptoms could occur during the rehabilitation process. Thorough information regarding the presence or an absence of side effects during the use of an exercise device may guide professional practice. Although the current study did not report any adverse responses during use of the EMST device, f urther clinical study of cardiovascular response during EMST is necessary to generalize the results to clinical populations.

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44 APPENDIX OUTCOME MEASUREMENTS FOR EACH PARTICIPANT N Systolic Blood Pressure ( SBP ) mmHg Mean Baseline Valsalva 1 Phase 1 Phase 2 Rest Valsalva 2 1 118.0 123.0 116.0 114.0 111.0 114.0 2 132.0 136.0 134.0 138.0 135.0 133.0 3 115.0 114.0 114.0 118.0 114.0 117.0 4 114.0 112.0 110.0 119.0 128.0 122.0 5 105.5 104.0 93.0 101.0 106.0 103.0 6 108.5 111.0 104.0 99.0 103.0 104.0 7 108.5 105.0 104.0 108.0 106.0 108.0 8 106.0 99.0 106.0 105.0 104.0 102.0 9 121.0 118.0 114.0 111.0 112.0 107.0 10 94.5 97.0 89.0 100.0 91.0 94.0 11 94.5 97.0 96.0 94.0 94.0 93.0 12 113.5 114.0 112.0 112.0 112.0 108.0 13 106.5 102.0 91.0 98.0 98.0 99.0 14 117.5 112.0 113.0 113.0 118.0 117.0 15 135.0 129.0 123.0 130.0 108.0 118.0 16 102.0 99.0 100.0 100.0 106.0 99.0 17 129.0 131.0 114.0 115.0 111.0 107.0 18 98.0 100.0 103.0 100.0 101.0 94.0 19 105.0 105.0 101.0 103.0 116.0 99.0 20 110.0 100.0 95.0 97.0 100.0 99.0 21 96.5 98.0 100.0 101.0 101.0 101.0 22 110.5 108.0 109.0 107.0 105.0 106.0 23 103.0 104.0 105.0 108.0 99.0 104.0 24 102.5 111.0 101.0 99.0 105.0 105.0 25 117.0 116.0 107.0 107.0 105.0 110.0 26 97.5 100.0 96.0 107.0 106.0 97.0 27 105.5 102.0 104.0 101.0 105.0 116.0 28 122.5 128.0 127.0 112.0 104.0 112.0 29 110.0 110.0 111.0 100.0 103.0 107.0 30 107.5 105.0 96.0 107.0 102.0 93.0 31 111.0 104.0 104.0 101.0 101.0 103.0 N=participant number, SBP=Systolic Blood Pressure

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45 N Diastolic Blood Pressure ( DBP ) mmHg Mean Baseline Valsalva 1 Phase 1 Phase 2 Rest Valsalva 2 1 75.5 76.0 79.0 72.0 76.0 70.0 2 82.0 82.0 85.0 88.0 82.0 81.0 3 86.5 85.0 85.0 85.0 82.0 83.0 4 75.5 73.0 77.0 72.0 81.0 72.0 5 75.0 73.0 71.0 71.0 78.0 71.0 6 81.5 93.0 75.0 75.0 69.0 83.0 7 75.5 75.0 63.0 75.0 75.0 74.0 8 79.5 73.0 70.0 73.0 72.0 78.0 9 80.5 79.0 82.0 77.0 75.0 82.0 10 66.0 67.0 70.0 78.0 66.0 70.0 11 73.0 73.0 67.0 70.0 67.0 70.0 12 79.5 79.0 78.0 79.0 80.0 79.0 13 62.5 62.0 63.0 61.0 73.0 62.0 14 82.0 74.0 72.0 76.0 74.0 78.0 15 86.5 80.0 89.0 84.0 98.0 71.0 16 73.5 72.0 65.0 70.0 68.0 67.0 17 82.0 83.0 96.0 77.0 79.0 92.0 18 67.5 69.0 70.0 65.0 74.0 70.0 19 79.0 71.0 75.0 86.0 70.0 73.0 20 70.5 72.0 74.0 69.0 73.0 72.0 21 68.0 66.0 87.0 71.0 72.0 70.0 22 73.5 74.0 71.0 76.0 68.0 73.0 23 71.5 66.0 66.0 72.0 74.0 72.0 24 80.0 93.0 69.0 72.0 83.0 78.0 25 80.5 75.0 74.0 76.0 71.0 82.0 26 67.5 69.0 73.0 63.0 67.0 68.0 27 72.5 69.0 69.0 71.0 74.0 79.0 28 89.0 75.0 82.0 75.0 76.0 81.0 29 76.5 71.0 73.0 70.0 84.0 70.0 30 75.5 72.0 70.0 81.0 70.0 66.0 31 72.5 75.0 69.0 70.0 71.0 67.0 N=participant number, DBP=Diastolic Blood Pressure

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46 N Heart Rate (HR) bpm Mean Baseline Valsalva 1 Phase 1 Phase 2 Rest Valsalva 2 1 93.0 97.0 94.0 93.0 87.0 88.0 2 75.0 86.0 85.0 74.0 70.0 70.0 3 58.5 60.0 60.0 63.0 56.0 58.0 4 66.0 69.0 69.0 70.0 74.0 75.0 5 97.5 94.0 96.0 92.0 88.0 86.0 6 94.0 95.0 90.0 93.0 85.0 75.0 7 75.0 75.0 78.0 80.0 78.0 76.0 8 81.0 73.0 79.0 81.0 81.0 81.0 9 64.5 59.0 63.0 64.0 59.0 60.0 10 54.0 60.0 62.0 71.0 63.0 72.0 11 63.5 65.0 60.0 63.0 61.0 64.0 12 75.5 75.0 74.0 76 .0 73.0 76.0 13 74.5 70.0 69.0 73.0 87.0 63.0 14 69.0 71.0 70.0 64.0 71.0 69.0 15 86.5 96.0 86.0 84.0 75 .0 71.0 16 67.0 69.0 66.0 67.0 75.0 70.0 17 81.0 85.0 88.0 92.0 86.0 78.0 18 76.5 85.0 78.0 78.0 69.0 70.0 19 87.5 83.0 84.0 86.0 70.0 71.0 20 85.0 85.0 83.0 85.0 84.0 90.0 21 67.5 61.0 68.0 62.0 62.0 59.0 22 73.5 65.0 60.0 62.0 58.0 66.0 23 77.5 86.0 85.0 89.0 84.0 81.0 24 87.0 81.0 84.0 80.0 71.0 85.0 25 83.5 85.0 88.0 97.0 80.0 88.0 26 74.0 67.0 79.0 74.0 78.0 71.0 27 77.5 76.0 84.0 87.0 77.0 82.0 28 92.5 95.0 80.0 85.0 77.0 86.0 29 68.5 72.0 63.0 67.0 62.0 66.0 30 93.0 94.0 88.0 90.0 87.0 89.0 31 81.0 75.0 75.0 68.0 67.0 65.0 N=participant number, HR=Heart Rate

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47 N Oxygen Saturation (Sp O 2 ) % Mean Baseline Valsalva 1 Phase 1 Phase 2 Rest Valsalva 2 1 98.3 98.3 98.0 99.2 98.2 99.3 2 98.3 99.3 98.3 99.3 98.3 98.3 3 98.8 100.2 100.3 100.3 98.3 100.3 4 98.3 98.2 99.3 98.3 99.3 98.3 5 97.3 97.2 97.3 95.2 98.2 98.2 6 98.7 98.2 99.2 99.3 99.2 98.2 7 97.3 96.2 98.3 98.2 98.2 96.2 8 98.2 98.2 98.2 98.2 97.3 97.2 9 99.8 100.3 100.3 100.3 98.2 99.3 10 99.2 99.2 100.3 100.2 99.3 99.2 11 98.3 99.3 98.3 98.2 97.3 97.2 12 97.2 98.3 98.2 98.3 96.2 98.2 13 98.3 99.3 99.2 100.2 99.2 98.2 14 98.3 98.3 100.3 100.2 100.2 99.3 15 96.2 97.2 98.2 93.2 96.2 95.2 16 99.2 99.2 99.3 99.3 98.2 98.2 17 98.3 98.3 97.2 99.2 98.2 96.3 18 98.2 98.2 98.3 99.3 98.2 97.2 19 98.2 99.3 99.2 95.3 98.2 98.3 20 99.8 100.2 100.2 100.3 99.3 99.2 21 98.2 98.2 97.2 98.2 98.2 98.2 22 100.3 99.2 99.2 99.2 98.2 99.3 23 99.8 100.2 100.2 100.3 100.3 100.3 24 98.2 98.3 100.2 99.2 99.3 98.2 25 98.2 99.2 99.2 98.2 98.2 98.2 26 96.1 96.5 97.0 95.2 93.0 97.0 27 99.5 99.2 100.2 100.3 99.2 99.2 28 96.8 97.3 98.2 97.0 96.3 97.2 29 100.3 100.2 99.3 100.3 100.2 99.2 30 98.2 98.3 99.2 99.2 98.2 98.2 31 98.2 98.3 99.2 99.2 97.2 99.3 N=participant number, SpO 2 =Oxygen Saturation

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48 LIST OF REFERENCES Baas, L. S., Meissner, J. E., & Coughlin, A. (2002). Cardiovascular Care. In H. N. Holmes (Ed.), Illustrated Manual of Nursing Practice (3rd ed., pp. 319). Springhouse, PA: Lippincott Williams & Wilkins. Baker, S., Davenport, P., & Sapienza, C. (2005). Examination of Strength Training a nd Detraining Effects in Expiratory Muscles. J Speech Lang Hear Res, 48 (6), 1325 1333. Behazin, N., Jones, S. B., Cohen, R. I., & Loring, S. H. (2010). Respiratory restriction and elevated pleural and esophageal pressures in morbid obesity. Journal of Applied Physiology, 108 (1), 212 218. Black, H. R., Cohen, J. D., Kaplan, N. M., Ferdinand, K. C., Chobanian, A. V., Dustan, H. P., et al. (1997). The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High B lood Pressure. Archives of Internal Medicine, 157 (21), 2413 2446. Centers for Disease Control and Prevention, About RMI For Adults. from www.cdc.gov < http://www.cdc.gov > Chaudhuri, G., H ildner, C. D., Brady, S., Hutchins, B., Aliga, N., & Abadilla, E. (2002). Cardiovascular Effects of the Supraglottic and Super supraglottic Swallowing Maneuvers in Stroke Patients with Dysphagia. Dysphagia, 17 (1), 19 23. Chiara, T., Martin, A. D., Davenpor t, P. W., & Bolser, D. C. (2006). Expiratory muscle strength training in persons with multiple sclerosis having mild to moderate disability: Effect on maximal expiratory pressure, pulmonary function, and maximal voluntary cough. Archives of Physical Medici ne and Rehabilitation, 87 (4), 468 473. Chiara, T., Martin, D., & Sapienza, C. (2007). Expiratory Muscle Strength Training. Neurorehabilitation and Neural Repair, 21 (3), 239 249. Elghozi, J. L., Girard, A., Fritsch, P., Laude, D., & Petitprez, J. L. (2008). Tuba players reproduce a Valsalva maneuver while playing high notes. Clinical Autonomic Research, 18 (2), 96 104. Ferguson, R. A., & Brown, M. D. (1997). Arterial blood pressure and forearm vascular conductance responses to sustain ed and rhythmic isometric exercise and arterial occlusion in trained rock climbers and untrained sedentary subjects. European Journal of Applied Physiology and Occupational Physiology, 76 (2), 174 180. Fisher, M. M. (2001). The Effect of Resistance Exercise on Recovery Blood Pressure in Normotensive and Borderline Hypertensive Women. The Journal of Strength & Conditioning Research, 15 (2), 210 216.

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49 Floras, J. S., Sinkey, C. A., Aylward, P. E., Seals, D. R., Thoren, P. N., & Mark, A. L. (1989). Postexercise hy potension and sympathoinhibition in borderline hypertensive men. Hypertension, 14 (1), 28 35. Guimaraes, K. C., Drager, L. F., Genta, P. R., Marcondes, B. F., & Lorenzi Filho, G. (2009). Effects of Oropharyngeal Exercises on Patients with Moderate Obstructi ve Sleep Apnea Syndrome. Am. J. Respir. Crit. Care Med., 179 (10), 962 966. Harraf, F., Ward, K., Man, W., Rafferty, G., Mills, K., Polkey, M., et al. (2008). Transcranial magnetic stimulation study of expiratory muscle weakness in acute ischemic stroke. Ne urology, 71 (24), 2000 2007. Johnson, A. L., Cornoni, J. C., Cassel, J. C., Tyroler, H. A., Heyden, S., & Hames, C. G. (1975). Influence of race, sex and weight on blood pressure behavior in young adults. The American Journal of Cardiology, 35 (4), 523 530. Kawachi, I., Sparrow, D., Vokonas, P. S., & Weiss, S. T. (1995). Decreased heart rate variability in men with phobic anxiety (data from the normative aging study). The American Journal of Cardiology, 75 (14), 882 885. Kazumi, T., Kawaguchi, A., Sakai, K., H irano, T., & Yoshino, G. (2002). Young Men With High Normal Blood Pressure Have Lower Serum Adiponectin, Smaller LDL Size, and Higher Elevated Heart Rate Than Those With Optimal Blood Pressure. Diabetes Care, 25 (6), 971 976. Kim, J., Davenport, P., & Sapie nza, C. (2009). Effect of expiratory muscle strength training on elderly cough function. Archives of Gerontology and Geriatrics, 48 (3), 361 366. Kjellberg, S. R., Rudhe, U. L. F., & SjStrand, T. (1949). Increase of the Amount of Hemoglobin and Blood Volum e in Connection with Physical Training. Acta Physiologica Scandinavica, 19 (2 3), 146 151. Knower, M. T., Dunagan, D. P., Adair, N. E., & Chin, R., Jr (2001). Baseline Oxygen Saturation Predicts Exercise Desaturation Below Prescription Threshold in Patients With Chronic Obstructive Pulmonary Disease. Arch Intern Med, 161 (5), 732 736. Levin, A. B. (1966). A simple test of cardiac function based upon the heart rate changes induced by the valsalva maneuver. The American Journal of Cardiology, 18 (1), 90 99. Lich t, C. M. M., de Geus, E. J. C., van Dyck, R., & Penninx, B. W. J. H. (2009). Association between Anxiety Disorders and Heart Rate Variability in The Netherlands Study of Depression and Anxiety (NESDA). Psychosomatic Medicine, 71 (5), 508 518.

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50 Luster, E. A., Baumgartner, N., Adams, W. C., & Convertino, V. A. (1996). Effects of hypovolemia and posture on responses to the Valsalva maneuver. Aviation Space and Environmental Medicine, 67 (4), 308 313. Manley, G., Knudson, M. M., Morabito, D., Damron, S., Erickson, V., & Pitts, L. (2001). Hypotension, hypoxia, and head injury: frequency, duration, and consequences. Arch Surg, 136 (10), 1118 1123. McConnell, A. K., & Romer, L. M. (2004). Respiratory muscle training in healthy humans: resolving the controversy. Int J S ports Med, 25 (4), 284 293. Metzger, B. L., & Therrien, B. (1990). Effect of Position On Cardiovascular Response During the Valsalva Maneuver. Nursing Research, 39 (4), 198 202. Narloch, J. A., & Brandstater, M. E. (1995). Influence of breathing technique on arterial blood pressure during heavy weight lifting. Archives of Physical Medicine and Rehabilitation, 76 (5), 457 462. O'Rourke, R. A., Fuster, V., Alexander, R. W., Roberts, R., King, S. B., Nash, I., et al. (2001). Hurst's The Heart Manual of Cardiology (10th ed.). New York: McGraw Hill. Pitts, T., Bolser, D., Rosenbek, J., Troche, M., Okun, M. S., & Sapienza, C. (2009). Impact of expiratory muscle strength training on voluntary cough and swallow function in Parkinson disease. Chest, 135 (5), 1301 1308. S apienza, C. M., Davenport, P. W., & Martin, A. D. (2002). Expiratory Muscle Training Increases Pressure Support in High School Band Students. Journal of Voice, 16 (4), 495 501. Tiecks, F. P., Douville, C., Byrd, S., Lam, A. M., & Newell, D. W. (1996). Evalu ation of impaired cerebral autoregulation by the Valsalva maneuver. Stroke, 27 (7), 1177 1182. Troche, M., Okun, M., Rosenbek, J., Musson, N., & Sapienza, C. (2009). Swallow Outcomes Following Intervention with Expiratory Muscle Strength Training (Emst) in Parkinson's Disease: Results of a Randomized Clinical Trial. Dysphagia, 24 (4), 455 456. Vitacca, M., Clini, E., Bianchi, L., & Ambrosino, N. (1998). Acute effects of deep diaphragmatic breathing in COPD patients with chronic respiratory insufficiency. Euro pean Respiratory Journal, 11 (2), 408 415. Wingate, J. M., Brown, W. S., Shrivastav, R., Davenport, P., & Sapienza, C. M. (2007). Treatment Outcomes for Professional Voice Users. Journal of Voice, 21 (4), 433 449.

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51 BIOGRAPHICAL SKETCH Helena Laciuga was born in Poland. She received a Master of Art degree in vocal performance and acting from Moniuszko Academy of Music, Gdansk in 1994. She graduated from the University of Gdansk and received a diploma of postgraduate study in speech thera py in 1996. Helena began coursework for a degree in communication sciences and disorders at the University of Florida in spring 2008. She continues her education to pursue a PhD degree in the field of speech language pathology.