Combined Respiratory Training in Persons With ALS

The goal of this interventional trial is to learn about lung volume recruitment (LVR) and expiratory muscle strength training (EMST) in a total of up to 39 patients diagnosed with ALS. The following aims will be addressed: Determine the impact of combined LVR and EMST on cough strength and respiratory function in individuals with ALS. Determine the impact of combined LVR and EMST on patient-reported dyspnea and bulbar impairment. Describe the effect of combined LVR and EMST on patient- and caregiver reported burden and quality of life.

In this delayed start, repeated-measures design, pALS will serve as their own control to provide treatment to all participants and control for disease heterogeneity (i.e., interparticipant differences). Participation will include three in-person evaluations and four weekly telehealth therapy sessions (Figure 3). Weekly telehealth therapy sessions will include home peak cough flow assessment, LVR and EMST training sessions to ensure treatment fidelity, maximum phonation time as a surrogate measure of forced vital capacity, and patient-reported outcomes including the ALS Respiratory Symptom Scale. To assess peak cough flow at home, participants will be provided with a commercially available peak cough flow meter (MiniWright, PF100) for guided assessment during telehealth appointments. Study Timeline. Study assessments and procedures at each time point are briefly described below and depicted in Table 1. Screening/Baseline 1 (Week -5). Following consenting and screening procedures, study personnel will complete the initial baseline assessment procedures. Participants will complete the initial baseline assessment in approximately 60-90 minutes. Baseline 2 (Week 0). The Baseline 2 appointment will consist of the identical assessment procedures conducted in the same order as Baseline 1. LVR and EMST training will be introduced and the first training session will be completed during the appointment. Participants will complete the Baseline 2 appointment in ~100-120 minutes. Telehealth Appointments (Active Training Weeks 0-5). Weekly telehealth therapy appointments will be conducted during the active training period using the Zoom platform (Zoom Video Communications, Inc). During these sessions, the research clinician will lead a LVR and EMST training session with the participant, complete peak cough flow and maximum sustained phonation testing, and administered surveys including the ALS Functional Rating Scale- Revised and the ALS Respiratory Symptom Scale. Surveys will be screen shared with the participants and data will be recorded on the source documents by the research clinician. Final Evaluation (Week 5). The Final Evaluation appointment will consist of the identical assessment procedures conducted in the same order as Baseline 2. Follow-up Period (6-months). The follow-up period consists of monthly telehealth visits with the research clinician. Participants who complete the initial 10-week study period will be asked to participate in follow-up. These telehealth visits will include peak cough flow and maximum phonation time assessments, and clinician-administered surveys. During this period, treatment adherence will be tracked using the same daily treatment logs, which will be reviewed during monthly appointments.

All enrolled participants will commence a combined lung volume recruitment and expiratory muscle strength training exercise regimen following a 5-week no-intervention lead-in period.

Airflow parameters will be collected during voluntary cough production. The primary outcome obtained from voluntary cough spirometry will be cough volume acceleration (L/s/s), which is an aggregation of peak expiratory flow rate and peak expiratory rise time.

Vital capacity with and without LVR. Forced vital capacity will be assessed before and after lung volume recruitment and the measurements will be used to determine the difference between FVC and FVC LIC (% predicted age/gender).

Maximum respiratory pressure will be obtained to assess inspiratory and expiratory muscle strength (cmH20).

Maximum phonation time involves the participant sustaining the vowel /ah/ for as long as possible (seconds).

The ALSFRS-R is the validated, gold standard survey assessing ALS symptom and disease progression to determine disease severity ranging from 0 (severe disease symptomology) to 48 (no overt symptoms)

The CNS-BFS is a 21-item validated, patient-reported scale indexing degree of bulbar dysfunction in the domains of speech, salivation and swallowing.

Inclusion Criteria: A diagnosis of probable or definite ALS in accordance with the Revisited El-Escorial Criteria. Disease duration from symptom onset of ≤ 2 years, Lung volume recruitment and expiratory muscle strength training naïve, Reduced peak cough flow (% predicted for age and gender). Exclusion Criteria: History of stroke, head and neck cancer or other concomitant disorder that might contribute to dysphagia or respiratory impairment. Use of prescription cough assist or non-invasive volume ventilation devices. Enrollment in another research investigation that might impact cough or respiratory function. Diagnosis of frontotemporal dementia or advanced cognitive impairment. Tracheostomy placement/Use of invasive mechanical ventilation. Contraindications for respiratory training (i.e., history of pneumothorax, severe chronic obstructive pulmonary disease).