Klaske van Sluis

122 7.4. Discussion Figure 7.4: Individual Peak Expiratory Flow (PEF) scores over time in liter per minute. 31.0) to 31.9dB (95% CI 28.8 – 35.0) after four weeks of training. After period B vocal range in dB returned back to baseline values (mean 27.6dB 95% CI 23.1 to 32.2). 7.4 Discussion To date, this is the first study to investigate feasibility, safety, and compliance of EMST in a group of TL participants. EMST appears to be somewhat chal- lenging, but feasible. MEP improved over time but this did not seem clinically relevant for this group of relatively fit participants. Challenges encountered the need for an adapter, skills of the participants with plugging the voice prosthesis, placing the EMST150 with an adaptor on the tracheostoma, and creating an airtight seal. One safety issue occurred with a participant presenting without a voice prosthesis after a training session. Nevertheless, compliance to the training program was high (>95%). The results show a clear increase in MEP over time in contrast to PEF values in which no change was seen. The increase of MEP as a result of EMST is consistent with both biological rationale and former findings [14, 16, 18, 20, 22, 23, 25]. Baseline MEP scores were higher than predicted for eight out of ten participants when compared with reference values for healthy adults [36]. No normative MEP values for TL patients are found. The higher than expected MEP scores might be the effect of frequent coughing and forced expectoration which is present after TL. The high MEP values are in contrast with the study of Hutcheson et al. [20], in which head and neck cancer patients suffering from chronic aspiration were included. Their group showed reduced average MEPs