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Donohue C, Vasilopoulos T, Wymer JP, Plowman EK. Relationship between pulmonary, cough, and swallowing functions in individuals with amyotrophic lateral sclerosis. Muscle Nerve 2024; 70:140-147. [PMID: 38742544 DOI: 10.1002/mus.28113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 04/08/2024] [Accepted: 04/28/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION/AIMS Evaluations of pulmonary, cough, and swallow function are frequently performed to assess disease progression in amyotrophic lateral sclerosis (ALS), yet the relationship between these functions remains unknown. We therefore aimed to determine relationships between these measures in individuals with ALS. METHODS One hundred individuals with ALS underwent standardized tests: forced vital capacity (FVC), maximum expiratory/inspiratory pressure (MEP, MIP), voluntary cough peak expiratory flow (PEF), and videofluoroscopic swallow evaluation (VF). Duplicate raters completed independent, blinded ratings using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale. Descriptives, Spearman's Rho correlations, Kruskal-Wallis analyses, and Pearson's chi-squared tests were completed. RESULTS Mean and standard deviation across pulmonary and cough measures were FVC: 74.2% predicted (± 22.6), MEP: 91.6 cmH2O (± 46.4), MIP cmH2O: 61.1 (± 28.9), voluntary PEF: 352.7 L/min (± 141.6). DIGEST grades included: 0 (normal swallowing): 31%, 1 (mild dysphagia): 48%, 2 (moderate dysphagia): 10%, 3 (severe dysphagia): 10%, and 4 (life-threatening dysphagia): 1%. Positive correlations were observed: MEP-MIP: r = .76, MIP-PEF: r = .68, MEP-PEF: r = .61, MIP-FVC: r = .60, PEF-FVC: r = .49, and MEP-FVC: r = .46, p < .0001. MEP (p = .009) and PEF (p = .04) differed across DIGEST safety grades. Post hoc analyses revealed significant between group differences in MEP and PEF across DIGEST safety grades 0 versus 1 and grades 0 versus 3, (p < .05). DISCUSSION In this cohort of individuals with ALS, pulmonary function, and voluntary cough were associated. Expiratory metrics (MEP, PEF) were diminished in individuals with unsafe swallowing, increasing their risk for effectively defending the airway.
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Affiliation(s)
- Cara Donohue
- Aerodigestive Research Core Laboratory, The Ohio State University, Columbus, Ohio, USA
- Department of Hearing and Speech Sciences, Vanderbilt University, Nashville, Tennessee, USA
| | - Terrie Vasilopoulos
- Department of Anesthesiology, University of Florida, Gainesville, Florida, USA
| | - James P Wymer
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Emily K Plowman
- Aerodigestive Research Core Laboratory, The Ohio State University, Columbus, Ohio, USA
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
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A meta-analysis of post-exercise outcomes in people with amyotrophic lateral sclerosis. eNeurologicalSci 2023; 31:100452. [PMID: 36875937 PMCID: PMC9982645 DOI: 10.1016/j.ensci.2023.100452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/06/2023] [Accepted: 02/14/2023] [Indexed: 02/23/2023] Open
Abstract
Objective To systematically evaluate post-exercise outcomes related to function and quality of life in people with ALS. Methods PRISMA guidelines were used for identifying and extracting articles. Levels of evidence and quality of articles were judged based on The Oxford Centre for Evidence-based Medicine Levels of Evidence and the QualSyst. Outcomes were analyzed with Comprehensive Meta-Analysis V2 software, random effects models, and Hedge's G. Effects were examined at 0-4 months, up to 6 months, and > 6 months. Pre-specified sensitivity analyses were performed for 1) controlled trials vs. all studies and 2) ALSFRS-R bulbar, respiratory, and motor subscales. Heterogeneity of pooled outcomes was computed with the I2 statistic. Results 16 studies and seven functional outcomes met inclusion for the meta-analysis. Of the outcomes explored, the ALSFRS-R demonstrated a favorable summary effect size and had acceptable heterogeneity and dispersion. While FIM scores demonstrated a favorable summary effect size, heterogeneity limited interpretations. Other outcomes did not demonstrate a favorable summary effect size and/or could not be reported due to few studies reporting outcomes. Conclusions This study provides inconclusive guidance regarding exercise regimens to maintain function and quality of life in people with ALS due to study limitations (e.g., small sample size, high attrition rate, heterogeneity in methods and participants, etc.). Future research is warranted to determine optimal treatment regimens and dosage parameters in this patient population.
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Key Words
- 25FWT, (25 Feet Walk Test)
- 6MWT, (6 Minute Walk Test)
- ALS, (amyotrophic lateral sclerosis)
- ALSFRS-R, (ALS Functional Rating Scale-Revised)
- Amyotrophic lateral sclerosis
- DIGEST, (Dynamic Imaging Grade of Swallowing Toxicity)
- EAT-10, (Eating Assessment Tool)
- EMST, (Expiratory muscle strength training)
- Exercise
- FAC, (Functional Ambulation Categories)
- FIM, (Functional Independence Measurement)
- FOIS, (Functional Oral Intake Scale)
- FSS, (Fatigue Severity Scale)
- FVC, (forced vital capacity)
- IMST, (Inspiratory muscle strength training)
- ITT, (intention-to-treat)
- KEMS, (knee extension muscle strength)
- MEP, (maximum expiratory pressure)
- MIP, (maximum inspiratory pressure)
- MND, (motor neuron disease)
- MVIC, (maximum voluntary isometric contraction)
- Motor neuron disease
- Outcome measures
- PAS, (Penetration Aspiration Scale)
- PEF, (peak expiratory flow)
- PRISMA-2009, (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)
- RCTs, (randomized controlled trials)
- RPE, (rating of perceived exertion)
- Rehabilitation
- SNIP, (sniff nasal inspiratory pressure)
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Tabor Gray L, McElheny KL, Vasilopoulos T, Wymer J, Smith BK, Plowman EK. Predictors of Peak Expiratory Cough Flow in Individuals with Amyotrophic Lateral Sclerosis. Dysphagia 2023; 38:719-725. [PMID: 35931882 DOI: 10.1007/s00455-022-10503-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022]
Abstract
Dystussia is prevalent in individuals with amyotrophic lateral sclerosis (ALS), leading to a diminished physiologic capacity to effectively defend the airway. We aimed to identify predictors of peak expiratory cough flow rate in individuals with ALS. One hundred and thirty-four individuals with a confirmed diagnosis of ALS (El-Escorial criteria revised) completed the ALS Functional Rating Scale-Revised (ALSFRS-R) and underwent pulmonary function and cough spirometry testing. Pearson's correlation coefficients and hierarchical multiple regression modeling were conducted to determine predictors of voluntary cough peak expiratory flow rate (p < 0.05). The full model including age, bulbar disease, cough spirometry metrics, and respiratory parameters had a marginal R2 = 0.635, F (7, 126) = 30.241, p < 0.0005, adjusted R2 = 0.61. Maximum expiratory pressure, compression phase, and vital capacity did not contribute and were therefore removed (p < 0.05). The most parsimonious predictive model included age, bulbar disease, peak inspiratory flow rate and duration, peak expiratory rise time, and inspiratory pressure generation with a marginal R2 = 0.543. Although expiratory pressure generation has historically served as the therapeutic target to improve dystussia in ALS, the current dataset highlighted that the inability to quickly and forcefully inspire during the inspiratory phase of voluntary cough places patients at a mechanical disadvantage to generate subsequent high-velocity expiratory airflow to clear the airway. Thus, therapeutic training programs that include both inspiratory and expiratory strength targets may optimize airway clearance capacity in this challenging patient population.
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Affiliation(s)
- Lauren Tabor Gray
- Center for Collaborative Research, NOVA Southeastern University, Fort Lauderdale, FL, USA.
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA.
| | - Kasey L McElheny
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA
| | - Terrie Vasilopoulos
- Department of Anesthesiology and Orthopedics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - James Wymer
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Barbara K Smith
- Department of Physical Therapy and Center for Respiratory Research and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Emily K Plowman
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA
- Department of Neurology, University of Florida, Gainesville, FL, USA
- Speech, Language and Hearing Science Department, University of Florida, Gainesville, FL, USA
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Vicente-Campos D, Sanchez-Jorge S, Chicharro JL, Becerro-de Bengoa-Vallejo R, Rodriguez-Sanz D, García AR, Rivoire M, Benet A, Boubekeur S, Calvo-Lobo C. POWERbreathe ® Inspiratory Muscle Training in Amyotrophic Lateral Sclerosis. J Clin Med 2022; 11:jcm11226655. [PMID: 36431132 PMCID: PMC9698064 DOI: 10.3390/jcm11226655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/19/2022] [Accepted: 11/08/2022] [Indexed: 11/11/2022] Open
Abstract
Inspiratory muscle training may benefit respiratory function, cardiocirculatory parameters, quality of life and functionality in neuromuscular diseases. This pilot study aimed to demonstrate the POWERbreathe® inspiratory muscle training effects on maximum inspiratory pressure (PImax), heart rate (HR) and HR variability, as well as the quality of life impairment and functionality in patients with Amyotrophic Lateral Sclerosis (ALS). A pilot single-blinded, non-randomized controlled clinical trial was carried out. A total of 20T ALS patients were enrolled and divided into experimental (n = 10) and control (n = 10) groups. The experimental group received POWERbreathe® inspiratory muscle training in conjunction with usual care, and the control group received only usual care for 8 weeks. PImax (measured by POWERbreathe® KH1), HR and HR variability (evaluated by Polar H7), quality of life impairment [measured by the Amyotrophic Lateral Sclerosis Assessment Questionnaire—40 items (ALSAQ-40)] and functionality [assessed by the ALS Functional Rating Scale Revised (ALSFRS-R)] were collected at baseline and after 8 weeks of intervention. We detected statistically significant differences (p < 0.05) with an effect size ranging from medium to large (Cohen’s d = 0.72−1.37); relative to the control group, the experimental group had an increased PImax (mean difference = 10.80 cm H2O; 95% CI = 3.42−18.17) and ALSFRS-R score (mean difference = 5.30 points; 95% CI = −0.03−10.63) and reduced HR (mean difference = −8.80 beats-per-minute; 95% CI = −20.27−2.67) and R-R interval (mean difference = 78.30 ms; 95% CI = 2.89−153.70). POWERbreathe® inspiratory muscle training, in addition to usual care, may improve inspiratory strength and heart rate in patients with ALS. These results encourage larger and longer trials investigating potential clinically relevant benefits of inspiratory muscle training to these patients over the disease course.
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Affiliation(s)
- Davinia Vicente-Campos
- Faculty of Health Sciences, Universidad Francisco de Vitoria, Pozuelo de Alarcón, 28223 Madrid, Spain
| | - Sandra Sanchez-Jorge
- Faculty of Health Sciences, Universidad Francisco de Vitoria, Pozuelo de Alarcón, 28223 Madrid, Spain
- Correspondence: ; Tel.: +34-913-51-03-03
| | - J. L. Chicharro
- Grupo FEBIO, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | | | - David Rodriguez-Sanz
- Faculty of Nursing, Physical Therapy and Podiatry, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Arianne R. García
- Faculty of Health Sciences, Universidad Francisco de Vitoria, Pozuelo de Alarcón, 28223 Madrid, Spain
| | - Marie Rivoire
- Faculty of Health Sciences, Universidad Francisco de Vitoria, Pozuelo de Alarcón, 28223 Madrid, Spain
| | - Astrid Benet
- Faculty of Health Sciences, Universidad Francisco de Vitoria, Pozuelo de Alarcón, 28223 Madrid, Spain
| | - Sofía Boubekeur
- Faculty of Health Sciences, Universidad Francisco de Vitoria, Pozuelo de Alarcón, 28223 Madrid, Spain
| | - César Calvo-Lobo
- Faculty of Nursing, Physical Therapy and Podiatry, Universidad Complutense de Madrid, 28040 Madrid, Spain
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Therapeutic strategies for C9orf72 amyotrophic lateral sclerosis and frontotemporal dementia. Curr Opin Neurol 2021; 34:748-755. [PMID: 34392299 PMCID: PMC8678157 DOI: 10.1097/wco.0000000000000984] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW An intronic G4C2 expansion mutation in C9orf72 is the most common genetic cause of amyotrophic lateral sclerosis and frontotemporal dementia (C9-ALS/FTD). Although there are currently no treatments for this insidious, fatal disease, intense research has led to promising therapeutic strategies, which will be discussed here. RECENT FINDINGS Therapeutic strategies for C9-ALS/FTD have primarily focused on reducing the toxic effects of mutant expansion RNAs or the dipeptide repeat proteins (DPRs). The pathogenic effects of G4C2 expansion transcripts have been targeted using approaches aimed at promoting their degradation, inhibiting nuclear export or silencing transcription. Other promising strategies include immunotherapy to reduce the DPRs themselves, reducing RAN translation, removing the repeats using DNA or RNA editing and manipulation of downstream disease-altered stress granule pathways. Finally, understanding the molecular triggers that lead to pheno-conversion may lead to opportunities that can delay symptomatic disease onset. SUMMARY A large body of evidence implicates RAN-translated DPRs as a main driver of C9-ALS/FTD. Promising therapeutic strategies for these devastating diseases are being rapidly developed with several approaches already in or approaching clinical trials.
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Donohue C, Khalifa Y, Mao S, Perera S, Sejdić E, Coyle JL. Characterizing Swallows From People With Neurodegenerative Diseases Using High-Resolution Cervical Auscultation Signals and Temporal and Spatial Swallow Kinematic Measurements. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2021; 64:3416-3431. [PMID: 34428093 PMCID: PMC8642099 DOI: 10.1044/2021_jslhr-21-00134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/21/2021] [Accepted: 05/21/2021] [Indexed: 06/13/2023]
Abstract
Purpose The prevalence of dysphagia in patients with neurodegenerative diseases (ND) is alarmingly high and frequently results in morbidity and accelerated mortality due to subsequent adverse events (e.g., aspiration pneumonia). Swallowing in patients with ND should be continuously monitored due to the progressive disease nature. Access to instrumental swallow evaluations can be challenging, and limited studies have quantified changes in temporal/spatial swallow kinematic measures in patients with ND. High-resolution cervical auscultation (HRCA), a dysphagia screening method, has accurately differentiated between safe and unsafe swallows, identified swallow kinematic events (e.g., laryngeal vestibule closure [LVC]), and classified swallows between healthy adults and patients with ND. This study aimed to (a) compare temporal/spatial swallow kinematic measures between patients with ND and healthy adults and (b) investigate HRCA's ability to annotate swallow kinematic events in patients with ND. We hypothesized there would be significant differences in temporal/spatial swallow measurements between groups and that HRCA would accurately annotate swallow kinematic events in patients with ND. Method Participants underwent videofluoroscopic swallowing studies with concurrent HRCA. We used linear mixed models to compare temporal/spatial swallow measurements (n = 170 ND patient swallows, n = 171 healthy adult swallows) and deep learning machine-learning algorithms to annotate specific temporal and spatial kinematic events in swallows from patients with ND. Results Differences (p < .05) were found between groups for several temporal and spatial swallow kinematic measures. HRCA signal features were used as input to machine-learning algorithms and annotated upper esophageal sphincter (UES) opening, UES closure, LVC, laryngeal vestibule reopening, and hyoid bone displacement with 66.25%, 85%, 68.18%, 70.45%, and 44.6% accuracy, respectively, compared to human judges' measurements. Conclusion This study demonstrates HRCA's potential in characterizing swallow function in patients with ND and other patient populations.
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Affiliation(s)
- Cara Donohue
- Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, PA
| | - Yassin Khalifa
- Department of Electrical and Computer Engineering, Swanson School of Engineering, University of Pittsburgh, PA
| | - Shitong Mao
- Department of Electrical and Computer Engineering, Swanson School of Engineering, University of Pittsburgh, PA
| | - Subashan Perera
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, PA
| | - Ervin Sejdić
- Department of Electrical and Computer Engineering, Swanson School of Engineering, University of Pittsburgh, PA
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, PA
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, PA
- Intelligent Systems Program, School of Computing and Information, University of Pittsburgh, PA
| | - James L. Coyle
- Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, PA
- Department of Otolaryngology, School of Medicine, University of Pittsburgh Medical Center, PA
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Sarmet M, Mangilli LD, Costa GP, Paes JPRS, Codeço VM, Million JL, Maldaner V. The relationship between pulmonary and swallowing functions in patients with neuromuscular diseases followed up by a tertiary referral center: a cross-sectional study. LOGOP PHONIATR VOCO 2021; 47:117-124. [PMID: 33586591 DOI: 10.1080/14015439.2021.1879254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Respiratory muscle weakness is common in patients with neuromuscular diseases (NMD). This puts them at risk for dysphagia and other pulmonary complications. OBJECTIVES To investigate the relationship between pulmonary function and swallowing in NMD. MATERIALS AND METHODS In this cross-sectional study, medical records of patients undergoing treatment at the Tertiary Referral Center for Neuromuscular Diseases of Hospital de Apoio de Brasília, Brazil, were reviewed. Respiratory function was assessed through spirometry (FVC and FEV1 measured) and swallowing assessed by the Dysphagia Risk Evaluation Protocol and the Functional Oral Intake Scale. RESULTS Two hundred and twenty-two patients were included. Dysphagia was present in 46.8% of patients and impairment of pulmonary function in 64.0%. The mean FVC observed was 66.9% and FEV1 was 66.0%, indicating restrictive lung disease. A correlation between the decline of pulmonary and swallowing functions was observed in patients with NMDs (FVC vs. DREP, R = 0.46; FVC vs. FOIS, R = 0.42; FEV1 vs. DREP, R = 0.42; FEV1 vs. FOIS, R = 0.40, p<.01). FVC and FEV1 values tend to be lower in patients with dysphagia in the context of NMD. CONCLUSIONS A positive correlation between pulmonary function and swallowing outcomes was observed in patients with NMD. Despite respiratory and swallowing impairment being widely present in the population with NMD, they require different treatments according to the disease's pathophysiology. Future studies should be conducted to explore the disease-specific relationship between pulmonary function and swallowing in patients with NMD.
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Affiliation(s)
- Max Sarmet
- Departments of Speech Therapy and Physical Therapy, Hospital de Apoio de Brasília, Tertiary Referral Center of Neuromuscular Diseases, Brasília, Brazil.,Graduate Department of Health Sciences and Technologies, University of Brasília (UnB), Brasília, Brazil
| | | | - Geovanna Pereira Costa
- Undergraduate Program, College of Medicine, Escola Superior de Ciências da Saúde, Brasília, Brazil
| | | | - Vitor Martins Codeço
- Department of Thoracic Diseases, Hospital Regional da Asa Norte, Brasília, Brazil
| | - Janae Lyon Million
- Department of Human Biology, University of California, Santa Cruz, CA, USA
| | - Vinicius Maldaner
- Departments of Speech Therapy and Physical Therapy, Hospital de Apoio de Brasília, Tertiary Referral Center of Neuromuscular Diseases, Brasília, Brazil.,Undergraduate Program, College of Medicine, Escola Superior de Ciências da Saúde, Brasília, Brazil
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Lind LA, Lever TE, Nichols NL. Tongue and hypoglossal morphology after intralingual cholera toxin B-saporin injection. Muscle Nerve 2020; 63:413-420. [PMID: 33269488 DOI: 10.1002/mus.27131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 11/23/2020] [Accepted: 11/27/2020] [Indexed: 01/23/2023]
Abstract
INTRODUCTION We recently developed an inducible model of dysphagia using intralingual injection of cholera toxin B conjugated to saporin (CTB-SAP) to cause death of hypoglossal neurons. In this study we aimed to evaluate tongue morphology and ultrastructural changes in hypoglossal neurons and nerve fibers in this model. METHODS Tissues were collected from 20 rats (10 control and 10 CTB-SAP animals) on day 9 post-injection. Tongues were weighed, measured, and analyzed for microscopic changes using laminin immunohistochemistry. Hypoglossal neurons and axons were examined using transmission electron microscopy. RESULTS The cross-sectional area of myofibers in the posterior genioglossus was decreased in CTB-SAP-injected rats. Degenerative changes were observed in both the cell bodies and distal axons of hypoglossal neurons. DISCUSSION Preliminary results indicate this model may have translational application to a variety of neurodegenerative diseases resulting in tongue dysfunction and associated dysphagia.
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Affiliation(s)
- Lori A Lind
- Department of Biomedical Sciences, University of Missouri, Columbia, Missouri, USA
| | - Teresa E Lever
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri, Columbia, Missouri, USA
| | - Nicole L Nichols
- Department of Biomedical Sciences, University of Missouri, Columbia, Missouri, USA
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Rogus-Pulia NM, Plowman EK. Shifting Tides Toward a Proactive Patient-Centered Approach in Dysphagia Management of Neurodegenerative Disease. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2020; 29:1094-1109. [PMID: 32650651 PMCID: PMC7844336 DOI: 10.1044/2020_ajslp-19-00136] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Purpose Persons with neurodegenerative disease frequently develop comorbid dysphagia as part of their disease process. Current "reactive" approaches to dysphagia management address dysphagia once it manifests clinically and consist of compensatory approaches. The purpose of this article is to propose a paradigm shift in dysphagia management of patients with neurodegenerative disease from a "reactive to proactive" approach by highlighting amyotrophic lateral sclerosis (ALS) and dementia as case examples. Method The authors present several areas of special consideration for speech-language pathologists (SLPs) treating dysphagia in patients with neurodegenerative disease. The drawbacks of historical "reactive" approaches to dysphagia management are described. Concepts of functional reserve for swallowing and homeostenosis are discussed. A "proactive" patient-centered paradigm of care for these patients is proposed with evidence to support its importance. A rationale for use of this approach in patients with ALS and dementia is provided with strategies for implementation. Results When treating dysphagia in patients with neurodegenerative disease, SLPs must balance a variety of factors in their decision making, including disease severity and expected progression, cultural considerations, goals of care, patient empowerment, and caregiver support. Reactive approaches to dysphagia management in these populations are problematic in that they disempower patients by focusing on use of compensatory techniques (e.g., diet modification, postural changes, feeding tube placement). Proactive approaches that employ rehabilitative interventions to increase functional reserve, such as resistance training, may result in improvement or maintenance of swallowing function longer into disease progression. An interdisciplinary team with early SLP involvement is necessary. Conclusions SLPs play a critical role in the management of dysphagia in patients with neurodegenerative disease and should be integrated early in the care of these patients. By focusing on a proactive patient-centered approach, patients with neurodegenerative conditions, such as ALS and dementia, will experience improved quality of life and health outcomes for a longer time.
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Affiliation(s)
- Nicole M. Rogus-Pulia
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health
- Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI
| | - Emily K. Plowman
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville
- Aerodigestive Research Core, University of Florida, Gainesville
- Department of Neurology, College of Medicine, University of Florida, Gainesville
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