Management of Dysphagia in MS

Management of dysphagia in MS

Marta Renom Speech and Language Therapist

CEM-CAT (UNeR) Barcelona

Management of dysphagia in MS INTRODUCTION Epidemiology in MS

33 to 43%

100 90

80 70

60 50 EDSS 40 48 30

20 22 10 11.1 0 <6 6-6,5 >6.5

Adapted from Calcagno P, Ruoppolo G, et al (2002) Dysphagia in multiple sclerosis – prevalence and prognostic factors. Acta Neurol Scand 105:40-43 Management of dysphagia in MS INTRODUCTION Classification According to: Liquids

1. Consistency affected EDSS ≤ 7.5 Solids 2. Severity EDSS ≥ 8

mild safety efficacy moderate

severe penetration nutrition aspiration hydration Management of dysphagia in MS TREATMENT

History taking & Comprehensive screening clinical assessment

Instrumental assessment

Rehabilitation Pharmacological Enteral treatment feeding Management of dysphagia in MS ASSESSMENT

Clinical observations

Voice Cough Laryngeal elevation Posture Secretions Palatal gag

Linden 2005 The probability of correctly predicting subglottig penetration from clilnical observations (n=249) (success to predict 2/3) Management of dysphagia in MS ASSESSMENT Main signs and symptoms

Altered feeding habit

Cough and/or choking while or after eating and drinking Management of dysphagia in MS ASSESSMENT Other signs and symptoms Food sticking in throat Need to repeat the swallowing act Dyspnoea during or after meals Weight loss Recurrent episodes of infections of the upper airways Episodes of either unexplained fever or pneumonia DYMUS Questionnaire Bergamashi et al: The DYMUS questionnaire for the assessment of dysphagia in multiple sclerosis. Journal of the Neurological Sciences 269 (2008) 49-53 Management of dysphagia in MS ASSESSMENT Oral anatomy Sensory-motor assessment

Muscular tone Oropharyngeal reflexes Movement execution V-VST Functional assessment Clavé et al. 2008 Cognitive evaluation MNA ® Nutritional evaluation Guigoz 2006 Impact in daily life SWAL-QOL / SWAL-CARE McHorney CA, et al. 2002 Management of dysphagia in MS ASSESSMENT Instrumental assessment Videofluoroscopy Fiberoptic endoscopic laryngoscopy Electromyography Manofluoroscopy

Dysphagia outcome and severity scale O’Neil KH, Purdy M, Janice F. Dysphagia 1999

Eight-point-penetration-aspiration-scale: Rosenbeck JC, Robins JA, Roecker EB et al. Dysphagia 1996 Management of dysphagia in MS TREATMENT

Goals

↓ Risk of aspiration ↑ Nutrition / hydratation ↑ Quality of life

↑ Independence

↑ Level of participation Therapeutic methods of functional swallowing therapy Disturbance Restitution Compensation Adaptation Reduced lingual control Tongue exercises Head anteflexion Thickening of liquids Impaired tongue base Tongue exercises Head anteflexion Smooth retraction Masako manoeuvre Mendelsohn manoeuvre consistency

Delayed / absent Stimulation of the faucial pilars Supraglottic swallowing Enhancing swallowing reflex Tongue exercises Head anteflexion taste/temperature Reduced laryngeal Positional, compression and Supraglottic swallowing Thickening of closure respiratory support strategies Turning the head to the liquids Pitch / Phonatory exercises stronger side Dysfunction of the Ex: maximizing extent and timig Mendelsohn manoeuvre Thin consistency upper oesophageal of hyoid/laryngeal elevation sphincter Shaker manouvre Reduced pharyngeal Whistling, sucking, snarling Turning head to affected side Smooth contraction Tilting head to stronger side consistency Effortful swallowing

Diminished pharyngeal No evidence-based restitution Supraglottic swallowing Enhancing and/or laryngeal method (if silent aspirations) taste/temperature sensation Repeated swallowing Prosiegel M, Schelling A, Wagner-Sonntag E (2004) Dysphagia and multiple sclerosis. Int MS J 11:22-31 Management of dysphagia in MS TREATMENT Pharmacological treatment

Hypersalivation: anticholinergics, botulinum toxin

Thick secretions: N-acetylcysteine

Hiccup: baclofen + domperidone + proton pump inhibitor

Gastroesophageal reflux disease: proton pump inhib.

UES dysfunction: botulinum toxin

Prosiegel M, Schelling A, Wagner-Sonntag E (2004) Dysphagia and multiple sclerosis. Int MS J 11:22-31 Management of dysphagia in MS TAKE-HOME MESSAGES

Prevalence: relatively high Dysphagia: dangerous consequences Management: early / interdisciplinary Assessment: clinical & instrumental Impact in daily life

Treatment: Different rehabilitative approaches Pharmacotherapy for associated symptoms Enteral feeding in severe cases Management of dysphagia in MS REFERENCES Bernabeu M: Disfagia Neurógena: Evaluación y tratamiento. Fundació Institut Guttmann. Blocs 14. Badalona 2002 De Paw A et al (2002) Dysphagia in multiple sclerosis. Clinical Neurology and Neurosurgery 104:345-351 Prosiegel M et al. (2004) Dysphagia and Multiple Sclerosis. The International MS Journal 2004; 11:22-31 Terré-Boliart R et al (2004): Disfagia orofaríngea en pacientes afectados de esclerosis múltiple. Revista de Neurología 39(8):707-710 Abraham S (1997) Neurologic impairment and disability status in outpatients with multiple sclerosis reportingg dysphagia symptomatology. J Neur Rehab 11:7-13 Giusti A, Giambuzzi M (2008) Management of dysphagia in MS. Neurol Sci 29:364-366 Tassorelli C et al (2008) Dysphagia in multiple sclerosis: from pathogenesis to diagnosis. Neurol Sci 29;360-363 Bergamaschi R et al (2008): The DYMUS questionnaire for the assessment of dysphagia in multiple sclerosis. J Neurol Sci 269:49-53 Calcagno P et al (2002) Dysphagia in multiple sclerosis – prevalence and progrnostic factors. Acta Neurol Scand 105:40-43 Poorjavad M et al (2010) Oropharyngeal dysphagia in multiple sclerosis. Multiple Sclerosis. 16(3) 362–365 Bogaardt H et al (2009) Use of neuromuscular electrostimulation in the treatment of dysphagia in patients with multiple sclerosis. Ann Otol Rhinol Laryngol. Apr;118(4):241-6 Management of dysphagia in MS REFERENCES

DePippo K et al: Validation of the 2 oz. Wather swallow test for aspiration following stroke. Arch Neurol 1992; 49: 1259-61

Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with stroke: rehabilitation, prevention. Edinburg 2002

Clavé P et al. Accuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration. Clin Nur. 2008 Dec; 27(6):806-15