RMST has strong implications for dysphagia treatment, is surprisingly easy to implement, and (bonus!) is pretty affordable. Whether you’re working in acute care, SNFs, or home health, this is something you’ll want to have in your clinical back pocket.

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What is RMST?

RMST involves strengthening the muscles responsible for inspiration and expiration. There are two main types:

• Inspiratory Muscle Strength Training (IMST) – targets the diaphragm and external intercostals

• Expiratory Muscle Strength Training (EMST) – targets the abdominals and internal intercostals

Inspiration happens when the diaphragm and external intercostals contract, increasing intrathoracic volume and decreasing intrapulmonary pressure—basically pulling air in. Expiration is the natural recoil, but in cases where a forceful breath is needed (hello, cough!), the abdominals and internal intercostals come into play.

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Not All Devices Are Created Equal

A quick heads-up: an incentive spirometer is not the same as an RMST device. Spirometers are typically used post-op to encourage sustained inhalation and help remove anesthesia—not to build strength.

And while resistive trainers like The Breather or Expand-a-Lung might look promising, they often offer only 5 levels of resistance. That’s where pressure threshold devices shine.

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Pressure Threshold Devices: The Gold Standard

Pressure threshold devices require a certain level of force before airflow begins, making them much more consistent and easier to track for therapeutic purposes.

For RMST, there are devices for both IMST and EMST, such as:

• Aspire 150 – recommended in the course and used in many studies; available for ~$39.95

• Threshold IMST

• PowerLung Sport Trainer

These devices allow for more resistance levels and better outcome tracking compared to basic resistive devices like PFlex or BreathBuilder.

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Why It Matters for Dysphagia

So how does this relate to our favorite topic—swallowing?

Well, research has shown that EMST can:

• Improve cough strength, making it easier to clear material from the airway

• Increase hyolaryngeal excursion

• Enhance velopharyngeal closure

In other words, stronger breathing muscles = better swallowing safety.

But a word of caution:
EMST is not recommended for patients with:

• Supplemental oxygen

• COPD

• Untreated GERD

Always check with the physician before implementing EMST in these populations.

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The Protocol: The “Rule of 5”

The Aspire 150 device follows a straightforward protocol known as the Rule of 5:

• 5 breaths

• 5 sets/day

• 5 days/week

• For 5 weeks

That’s 25 targeted breaths a day—and the studies have shown solid outcomes using this exact dosage.

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Who Else Can Benefit?

RMST isn’t just for our dysphagia population. It can also benefit individuals with:

• Voice disorders

• Bilateral vocal fold paralysis

• Professional voice users

• Ventilator dependence

• Parkinson’s Disease (PD)

• Multiple Sclerosis (MS)

• Progressive Supranuclear Palsy (PSP)

• Stroke

• Sedentary elderly

So, pretty much everyone on your caseload. 

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And…..

RMST is research-supported, cost-effective, and clinically impactful—especially for our patients with dysphagia and beyond.

If you haven’t looked into EMST or IMST in a while, now’s a great time to dive back in.

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Want to Learn More?

Here are some great research articles and resources if you’re ready to dive deeper into RMST:

• Burkhead, L. M., Sapienza, C. M., & Rosenbek, J. C. (2007). Strength-training exercise in dysphagia rehabilitation: Principles, procedures and directions for future research. Dysphagia, 22(3), 251–265. https://doi.org/10.1007/s00455-006-9074-z

• 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. https://doi.org/10.1378/chest.08-1389

• Sapienza, C. M. (2008). Respiratory muscle strength training applications. Current Opinion in Otolaryngology & Head and Neck Surgery, 16(3), 216–220. https://doi.org/10.1097/MOO.0b013e3282ffaf0b

• Sapienza, 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. https://doi.org/10.1016/S0892-1997(02)00038-8

• Wheeler-Hegland, K. M., Rosenbek, J. C., & Sapienza, C. M. (2008). Submental sEMG and hyoid movement during Mendelsohn maneuver, effortful swallow, and expiratory muscle strength training. Journal of Speech, Language, and Hearing Research, 51(5), 1072–1087. https://doi.org/10.1044/1092-4388(2008/07-0056)

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Additional Reading

Check out more specific studies and summaries on:

• Large Article Database on RMST

• The EMST150 Device Website

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Got a patient that could benefit from RMST? Make sure to assess for appropriateness, get medical clearance when needed, and train with a device that matches what the research supports

Want a copy of the RMST Quick Clinician Guide. Trust me, you need this if you want to start using RMST in your practice. You can get that here.

Are you ready for a deeper dive with even more resources available? Join the Dysphagia Skills Accelerator today. You will get so many great tools with new tools being added all the time! Click here to join now!

Have you ever wanted a way to create a more standardized protocol for your Clinical Swallow Evaluation?   Do you often forget or leave out parts of the CSE, you know, the parts that are important for your Plan of Care?  You probably need the Clinical Dysphagia Assessment Toolkit if you answered yes.   You can get your copy here.