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Swartz JL, Zifan A, Tuttle LJ, Sheean G, Tam RM, Mittal RK. Fecal incontinence patients categorized based on anal pressure and electromyography: Anal sphincter damage and clinical symptoms. Neurogastroenterol Motil 2024; 36:e14810. [PMID: 38689439 DOI: 10.1111/nmo.14810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 03/01/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Disruption of external anal sphincter muscle (EAS) is an important factor in the multifactorial etiology of fecal incontinence (FI). OBJECTIVES We categorize FI patients into four groups based on the location of lesion in neuromuscular circuitry of EAS to determine if there are differences with regards to fecal incontinence symptoms severity (FISI) score, age, BMI, obstetrical history, and anal sphincter muscle damage. METHODS Female patients (151) without any neurological symptoms, who had undergone high-resolution manometry, anal sphincter EMG, and 3D ultrasound imaging of the anal sphincter were assessed. Patients were categorized into four groups: Group 1 (normal)-normal cough EMG (>10 μV), normal squeeze EMG (>10 μV), and normal anal squeeze pressure (>124 mmHg); Group 2 (cortical apraxia, i.e., poor cortical activation)-normal cough EMG, low squeeze EMG, and low anal squeeze pressure; Group 3 (muscle damage)-normal cough EMG, normal squeeze EMG, and low anal squeeze pressure; and Group 4 (pudendal nerve damage)-low cough EMG, low squeeze EMG, and low anal squeeze pressure. RESULTS The four patient groups were not different with regards to the patient's age, BMI, parity, and FISI scores. 3D ultrasound images of the anal sphincter complex revealed significant damage to the internal anal sphincter, external anal sphincter, and puborectalis muscles in all four groups. CONCLUSION The FI patients are a heterogeneous group; majority of these patients have significant damage to the muscles of the anal sphincter complex. Whether biofeedback therapy response is different among different patient groups requires study.
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Affiliation(s)
- Jessica L Swartz
- Doctor of Physical Therapy Program, San Diego State University, San Diego, California, USA
| | - Ali Zifan
- Department of Gastroenterology, UC San Diego, La Jolla, California, USA
| | - Lori J Tuttle
- Doctor of Physical Therapy Program, San Diego State University, San Diego, California, USA
| | | | - Rowena M Tam
- Doctor of Physical Therapy Program, San Diego State University, San Diego, California, USA
| | - Ravinder K Mittal
- Department of Gastroenterology, UC San Diego, La Jolla, California, USA
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Jonkman AH, Warnaar RSP, Baccinelli W, Carbon NM, D'Cruz RF, Doorduin J, van Doorn JLM, Elshof J, Estrada-Petrocelli L, Graßhoff J, Heunks LMA, Koopman AA, Langer D, Moore CM, Nunez Silveira JM, Petersen E, Poddighe D, Ramsay M, Rodrigues A, Roesthuis LH, Rossel A, Torres A, Duiverman ML, Oppersma E. Analysis and applications of respiratory surface EMG: report of a round table meeting. Crit Care 2024; 28:2. [PMID: 38166968 PMCID: PMC10759550 DOI: 10.1186/s13054-023-04779-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/14/2023] [Indexed: 01/05/2024] Open
Abstract
Surface electromyography (sEMG) can be used to measure the electrical activity of the respiratory muscles. The possible applications of sEMG span from patients suffering from acute respiratory failure to patients receiving chronic home mechanical ventilation, to evaluate muscle function, titrate ventilatory support and guide treatment. However, sEMG is mainly used as a monitoring tool for research and its use in clinical practice is still limited-in part due to a lack of standardization and transparent reporting. During this round table meeting, recommendations on data acquisition, processing, interpretation, and potential clinical applications of respiratory sEMG were discussed. This paper informs the clinical researcher interested in respiratory muscle monitoring about the current state of the art on sEMG, knowledge gaps and potential future applications for patients with respiratory failure.
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Affiliation(s)
- A H Jonkman
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - R S P Warnaar
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - W Baccinelli
- Netherlands eScience Center, Amsterdam, The Netherlands
| | - N M Carbon
- Department of Anesthesiology, Friedrich Alexander-Universität Erlangen-Nürnberg, Uniklinikum Erlangen, Erlangen, Germany
| | - R F D'Cruz
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - J Doorduin
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J L M van Doorn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Elshof
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - L Estrada-Petrocelli
- Facultad de Ingeniería and Secretaría Nacional de Ciencia, Tecnología e Innovación (SENACYT) - Sistema Nacional de Investigación (SNI), Universidad Latina de Panamá (ULATINA), Panama, Panama
| | - J Graßhoff
- Fraunhofer Research Institution for Individualized and Cell-Based Medical Engineering, Lübeck, Germany
| | - L M A Heunks
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A A Koopman
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - D Langer
- Research Group for Rehabilitation in Internal Disorders, Department of Rehabilitation Sciences, KU Leuven, 3000, Leuven, Belgium
| | - C M Moore
- Netherlands eScience Center, Amsterdam, The Netherlands
| | - J M Nunez Silveira
- Hospital Italiano de Buenos Aires, Unidad de Terapia Intensiva, Ciudad de Buenos Aires, Argentina
| | - E Petersen
- Technical University of Denmark (DTU), DTU Compute, 2800, Kgs. Lyngby, Denmark
| | - D Poddighe
- Research Group for Rehabilitation in Internal Disorders, Department of Rehabilitation Sciences, KU Leuven, 3000, Leuven, Belgium
| | - M Ramsay
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Rodrigues
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
| | - L H Roesthuis
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A Rossel
- Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - A Torres
- Institut de Bioenginyeria de Catalunya (IBEC), Barcelona Institute of Science and Technology (BIST) and Biomedical Research Networking Centre in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Universitat Politècnica de Catalunya BarcelonaTech (UPC), Barcelona, Spain
| | - M L Duiverman
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - E Oppersma
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands.
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Liberati C, Byrne BJ, Fuller DD, Croft C, Pitts T, Ehrbar J, Leon-Astudillo C, Smith BK. Diaphragm pacing and independent breathing in individuals with severe Pompe disease. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1184031. [PMID: 37583873 PMCID: PMC10423945 DOI: 10.3389/fresc.2023.1184031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/20/2023] [Indexed: 08/17/2023]
Abstract
Introduction Pompe disease is an inherited disease characterized by a deficit in acid-α-glucosidase (GAA), an enzyme which degrades lysosomal glycogen. The phrenic-diaphragm motor system is affected preferentially, and respiratory failure often occurs despite GAA enzyme replacement therapy. We hypothesized that the continued use of diaphragm pacing (DP) might improve ventilator-dependent subjects' respiratory outcomes and increase ventilator-free time tolerance. Methods Six patients (3 pediatric) underwent clinical DP implantation and started diaphragm conditioning, which involved progressively longer periods of daily, low intensity stimulation. Longitudinal respiratory breathing pattern, diaphragm electromyography, and pulmonary function tests were completed when possible, to assess feasibility of use, as well as diaphragm and ventilatory responses to conditioning. Results All subjects were eventually able to undergo full-time conditioning via DP and increase their maximal tolerated time off-ventilator, when compared to pre-implant function. Over time, 3 of 6 subjects also demonstrated increased or stable minute ventilation throughout the day, without positive-pressure ventilation assistance. Discussion Respiratory insufficiency is one of the main causes of death in patients with Pompe disease. Our results indicate that DP in Pompe disease was feasible, led to few adverse events and stabilized breathing for up to 7 years.
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Affiliation(s)
- Cristina Liberati
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA, United States
| | - Barry J. Byrne
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - David D. Fuller
- Department of Physical Therapy, University of Florida, Gainesville, FL, United States
- Breathing Research and Therapeutics (BREATHE) Center, University of Florida, Gainesville, FL, United States
| | - Chasen Croft
- Department of Surgery, University of Florida, Gainesville, FL, United States
| | - Teresa Pitts
- Department of Speech, Language and Hearing Sciences, University of Missouri, Columbia, MO, United States
- Dalton Cardiovascular Center Investigator, University of Missouri, Columbia, MO, United States
| | - Jessica Ehrbar
- Department of Physical Therapy, University of Florida, Gainesville, FL, United States
| | | | - Barbara K. Smith
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
- Department of Physical Therapy, University of Florida, Gainesville, FL, United States
- Breathing Research and Therapeutics (BREATHE) Center, University of Florida, Gainesville, FL, United States
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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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Barnard AM, Lott DJ, Batra A, Triplett WT, Willcocks RJ, Forbes SC, Rooney WD, Daniels MJ, Smith BK, Vandenborne K, Walter GA. Characterizing Expiratory Respiratory Muscle Degeneration in Duchenne Muscular Dystrophy Using MRI. Chest 2022; 161:753-763. [PMID: 34536384 PMCID: PMC9160975 DOI: 10.1016/j.chest.2021.08.078] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/26/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Expiratory muscle weakness and impaired airway clearance are early signs of respiratory dysfunction in Duchenne muscular dystrophy (DMD), a degenerative muscle disorder in which muscle cells are damaged and replaced by fibrofatty tissue. Little is known about expiratory muscle pathology and its relationship to cough and airway clearance capacity; however, the level of muscle replacement by fat can be estimated using MRI and expressed as a fat fraction (FF). RESEARCH QUESTION How does abdominal expiratory muscle fatty infiltration change over time in DMD and relate to clinical expiratory function? STUDY DESIGN AND METHODS Individuals with DMD underwent longitudinal MRI of the abdomen to determine FF in the internal oblique, external oblique, and rectus abdominis expiratory muscles. FF data were used to estimate a model of expiratory muscle degeneration by using nonlinear mixed effects and a cumulative distribution function. FVC, maximal inspiratory and expiratory pressures, and peak cough flow were collected as clinical correlates to MRI. RESULTS Forty individuals with DMD (aged 6-18 years at baseline) participated in up to five visits over 36 months. Modeling estimated the internal oblique progresses most quickly and reached 50% replacement by fat at a mean patient age of 13.0 years (external oblique, 14.0 years; rectus abdominis, 16.2 years). Corticosteroid-untreated individuals (n = 4) reached 50% muscle replacement by fat 3 to 4 years prior to treated individuals. Individuals with mild clinical dystrophic phenotypes (n = 3) reached 50% muscle replacement by fat 4 to 5 years later than corticosteroid-treated individuals. Internal and external oblique FFs near 50% were associated with maximal expiratory pressures < 60 cm H2O and peak cough flows < 270 L/min. INTERPRETATION These data improve understanding of the early phase of respiratory compromise in DMD, which typically presents as airway clearance dysfunction prior to the onset of hypoventilation, and links expiratory muscle fatty infiltration to pulmonary function measures.
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Affiliation(s)
- Alison M Barnard
- Department of Physical Therapy, University of Florida, Gainesville, FL
| | - Donovan J Lott
- Department of Physical Therapy, University of Florida, Gainesville, FL
| | - Abhinandan Batra
- Department of Physical Therapy, University of Florida, Gainesville, FL
| | | | | | - Sean C Forbes
- Department of Physical Therapy, University of Florida, Gainesville, FL
| | - William D Rooney
- Advanced Imaging Research Center, Oregon Health & Science University, Portland, OR
| | | | - Barbara K Smith
- Department of Physical Therapy, University of Florida, Gainesville, FL
| | | | - Glenn A Walter
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, FL.
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Yawata A, Tsujimura T, Takeishi R, Magara J, Yu L, Inoue M. Comparison of physical properties of voluntary coughing, huffing and swallowing in healthy subjects. PLoS One 2020; 15:e0242810. [PMID: 33270679 PMCID: PMC7714348 DOI: 10.1371/journal.pone.0242810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 11/09/2020] [Indexed: 11/18/2022] Open
Abstract
Coughing, huffing and swallowing protect the airway from aspiration. This study was conducted to compare the physical properties of voluntary coughing, huffing and swallowing in healthy subjects. Ten healthy men were asked to huff, cough and swallow repeatedly. Electromyograms (EMGs) were recorded from the left side of the external oblique (EO), sternocleidomastoid, suprahyoid (SH) and thyrohyoid muscles. Airflow was recorded using a face mask with two-way non-rebreathing valves. The expiratory velocity of huffing and coughing and the SH EMG of all actions presented high intraclass correlation coefficients (> 0.8). The inspiratory and expiratory velocities did not differ significantly between coughing and huffing. The expiratory acceleration of coughing was significantly higher than that of huffing, whereas the expiratory volume of coughing was significantly smaller than that of huffing. The EO EMG of coughing and huffing were significantly larger than that of swallowing. The EO EMG activity during the expiratory phase was significantly higher than that of the other phases of both coughing and huffing. The SH EMG of coughing and huffing were significantly smaller than that of swallowing. Correlation analysis revealed that the expiratory velocity of coughing was strongly positively correlated with that of huffing. The expiratory volume of huffing was significantly positively correlated with hand grip strength. These results suggest that EO and SH muscle activities during huffing or coughing differ those during swallowing, and huffing and coughing may work similarly in expiratory function.
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Affiliation(s)
- Akiko Yawata
- Division of Dysphagia Rehabilitation, Niigata University Graduate School of Medical and Dental Sciences, Chuo-ku, Niigata, Japan
| | - Takanori Tsujimura
- Division of Dysphagia Rehabilitation, Niigata University Graduate School of Medical and Dental Sciences, Chuo-ku, Niigata, Japan
| | - Ryosuke Takeishi
- Division of Dysphagia Rehabilitation, Niigata University Graduate School of Medical and Dental Sciences, Chuo-ku, Niigata, Japan
| | - Jin Magara
- Division of Dysphagia Rehabilitation, Niigata University Graduate School of Medical and Dental Sciences, Chuo-ku, Niigata, Japan
| | - Li Yu
- Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Makoto Inoue
- Division of Dysphagia Rehabilitation, Niigata University Graduate School of Medical and Dental Sciences, Chuo-ku, Niigata, Japan
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LoMauro A, Mastella C, Alberti K, Masson R, Aliverti A, Baranello G. Reply to Chacko et al.: Limited Assessment of Respiratory Muscle Response to Nusinersen Treatment in Infants with Spinal Muscular Atrophy. Am J Respir Crit Care Med 2020; 201:624-626. [PMID: 31747301 PMCID: PMC7047463 DOI: 10.1164/rccm.201910-2022le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
| | - Chiara Mastella
- Fondazione IRCCS Cà' Granda Ospedale Maggiore PoliclinicoMilan, Italy
| | - Katia Alberti
- Fondazione IRCCS Cà' Granda Ospedale Maggiore PoliclinicoMilan, Italy
| | - Riccardo Masson
- Fondazione IRCCS Istituto Neurologico Carlo BestaMilan, Italyand
| | | | - Giovanni Baranello
- Fondazione IRCCS Istituto Neurologico Carlo BestaMilan, Italyand.,UCL Great Ormond Street Institute of Child Health LondonLondon, United Kingdom
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