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Woodman MJ, Howard P. Beta-blockers for tenacious saliva: a case report. BMJ Support Palliat Care 2024; 13:e936-e938. [PMID: 35332025 DOI: 10.1136/bmjspcare-2022-003615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/16/2022] [Indexed: 06/14/2023]
Abstract
This case report describes the care of a 75-year-old gentleman with metastatic head and neck cancer who was highly symptomatic with intractable tenacious oropharyngeal secretions. The patient reported subjective benefit from oral atenolol. A literature review was undertaken and identified no previous studies on the use of β-blockers for secretions in malignant disease, although some anecdotal evidence for their use in motor neuron disease. The proposed underlying mechanism is that β1-blockade reduced the protein content of salivary secretions, hence reducing its viscosity. Further studies of both the role of β-adrenoreceptors in the control of secretion viscosity and the potential role of β-blockers in alleviating symptomatic tenacious secretions are warranted.
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Affiliation(s)
- Myles J Woodman
- Department of General Medicine, St Mary's Hospital, Isle of Wight NHS Trust, Newport, Isle of Wight, UK
| | - Paul Howard
- Mountbatten Hospice, Newport, Isle of Wight, UK
- Palliative Care Team, St Mary's Hospital, Isle of Wight NHS Trust, Newport, Isle of Wight, UK
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2
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Berlowitz DJ, Mathers S, Hutchinson K, Hogden A, Carey KA, Graco M, Whelan BM, Charania S, Steyn F, Allcroft P, Crook A, Sheers NL. The complexity of multidisciplinary respiratory care in amyotrophic lateral sclerosis. Breathe (Sheff) 2023; 19:220269. [PMID: 37830099 PMCID: PMC10567075 DOI: 10.1183/20734735.0269-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/20/2023] [Indexed: 10/14/2023] Open
Abstract
Motor neurone disease/amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder with no known cure, where death is usually secondary to progressive respiratory failure. Assisting people with ALS through their disease journey is complex and supported by clinics that provide comprehensive multidisciplinary care (MDC). This review aims to apply both a respiratory and a complexity lens to the key roles and areas of practice within the MDC model in ALS. Models of noninvasive ventilation care, and considerations in the provision of palliative therapy, respiratory support, and speech and language therapy are discussed. The impact on people living with ALS of both inequitable funding models and the complexity of clinical care decisions are illustrated using case vignettes. Considerations of the impact of emerging antisense and gene modifying therapies on MDC challenges are also highlighted. The review seeks to illustrate how MDC members contribute to collective decision-making in ALS, how the sum of the parts is greater than any individual care component or health professional, and that the MDC per se adds value to the person living with ALS. Through this approach we hope to support clinicians to navigate the space between what are minimum, guideline-driven, standards of care and what excellent, person-centred ALS care that fully embraces complexity could be. Educational aims To highlight the complexities surrounding respiratory care in ALS.To alert clinicians to the risk that complexity of ALS care may modify the effectiveness of any specific, evidence-based therapy for ALS.To describe the importance of person-centred care and shared decision-making in optimising care in ALS.
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Affiliation(s)
- David J. Berlowitz
- The University of Melbourne, Parkville, Australia
- Institute for Breathing and Sleep, Heidelberg, Australia
- Department of Physiotherapy, Austin Health, Heidelberg, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Australia
| | - Susan Mathers
- Calvary Health Care Bethlehem, Caulfield South, Australia
- School of Clinical Sciences, Monash University, Clayton, Australia
| | - Karen Hutchinson
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
- Central Coast Local Health District, Gosford, Australia
| | - Anne Hogden
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Kate A. Carey
- The University of Melbourne, Parkville, Australia
- Institute for Breathing and Sleep, Heidelberg, Australia
| | - Marnie Graco
- The University of Melbourne, Parkville, Australia
- Institute for Breathing and Sleep, Heidelberg, Australia
| | - Brooke-Mai Whelan
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Salma Charania
- Motor Neurone Disease Association of Queensland, Oxley, Australia
| | - Frederik Steyn
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Peter Allcroft
- Southern Adelaide Palliative Services, Flinders Medical Centre, Bedford Park, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, Australia
| | - Ashley Crook
- Graduate School of Health, University of Technology Sydney, Chippendale, Australia
- Centre for MND Research and Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Nicole L. Sheers
- The University of Melbourne, Parkville, Australia
- Institute for Breathing and Sleep, Heidelberg, Australia
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Sheers NL, O’Sullivan R, Howard ME, Berlowitz DJ. The role of lung volume recruitment therapy in neuromuscular disease: a narrative review. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1164628. [PMID: 37565183 PMCID: PMC10410160 DOI: 10.3389/fresc.2023.1164628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/16/2023] [Indexed: 08/12/2023]
Abstract
Respiratory muscle weakness results in substantial discomfort, disability, and ultimately death in many neuromuscular diseases. Respiratory system impairment manifests as shallow breathing, poor cough and associated difficulty clearing mucus, respiratory tract infections, hypoventilation, sleep-disordered breathing, and chronic ventilatory failure. Ventilatory support (i.e., non-invasive ventilation) is an established and key treatment for the latter. As survival outcomes improve for people living with many neuromuscular diseases, there is a shift towards more proactive and preventative chronic disease multidisciplinary care models that aim to manage symptoms, improve morbidity, and reduce mortality. Clinical care guidelines typically recommend therapies to improve cough effectiveness and mobilise mucus, with the aim of averting acute respiratory compromise or respiratory tract infections. Moreover, preventing recurrent infective episodes may prevent secondary parenchymal pathology and further lung function decline. Regular use of techniques that augment lung volume has similarly been recommended (volume recruitment). It has been speculated that enhancing lung inflation in people with respiratory muscle weakness when well may improve respiratory system "flexibility", mitigate restrictive chest wall disease, and slow lung volume decline. Unfortunately, clinical care guidelines are based largely on clinical rationale and consensus opinion rather than level A evidence. This narrative review outlines the physiological changes that occur in people with neuromuscular disease and how these changes impact on breathing, cough, and respiratory tract infections. The biological rationale for lung volume recruitment is provided, and the clinical trials that examine the immediate, short-term, and longer-term outcomes of lung volume recruitment in paediatric and adult neuromuscular diseases are presented and the results synthesised.
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Affiliation(s)
- Nicole L. Sheers
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC, Australia
- Institute for Breathing and Sleep, Heidelberg, VIC, Australia
- Department of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Rachel O’Sullivan
- Department of Physiotherapy, Christchurch Hospital, Canterbury, New Zealand
| | - Mark E. Howard
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC, Australia
- Institute for Breathing and Sleep, Heidelberg, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
- Turner Institute of Brain and Mental Health, Monash University, Clayton, VIC, Australia
| | - David J. Berlowitz
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC, Australia
- Institute for Breathing and Sleep, Heidelberg, VIC, Australia
- Department of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
- Department of Physiotherapy, Austin Health, Heidelberg, VIC, Australia
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4
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Wang Y, Yang X, Han Q, Liu M, Zhou C. Prevalence of Sialorrhea Among Amyotrophic Lateral Sclerosis Patients: A Systematic Review and Meta-Analysis. J Pain Symptom Manage 2022; 63:e387-e396. [PMID: 34920148 DOI: 10.1016/j.jpainsymman.2021.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative motor neuron disease (MND), and sialorrhea is a known symptom in patients with ALS, which may cause a social embarrassment and discomfort. However, people do not pay attention to sialorrhea up to now. This study is aimed at conducting a systematic review and meta-analysis of the pooled prevalence of sialorrhea in ALS patients all around the world and raising awareness of salivation. METHODS We searched PubMed and EMBASE databases to obtain the comprehensive literatures which reported the prevalence of sialorrhea. We used AHRQ and NOS to evaluate the literature quality. Subgroup analyses were performed based on screening instruments and severity of sialorrhea. At the meantime, sensitivity analyses was also conducted to identify the source of heterogeneity. RESULTS A total of 17 eligible studies which included 21 groups of data reported prevalence of sialorrhea. The pooled prevalence of sialorrhea among ALS patients was 30.8% (95% CI: 20.0%-44.2%). For studies using ALSFRS-R, direct questioning, postal survey, and ALSSoL average and ALSFRS-R, the pooled prevalence of sialorrhea was 22.7%, 25.8%, 29.8% and 52.0% respectively. According to the severity of sialorrhea, the prevalence of mild, moderate, and severe sialorrhea were 25.1%, 11.2%, and 10.5%, respectively. And none of the studies alone had a significant effect on the overall prevalence of sialorrhea after we eliminated each study separately in sensitivity analyses. CONCLUSIONS Sialorrhea is a relatively common symptom in ALS patients with a comparatively high prevalence. In our study, we found that the prevalence of sialorrhea in ALS patients is relatively higher than the results based on direct questioning or postal survey. Therefore, we deduced that sialorrhea should be evaluated by more complex professional assessment scales to improve the quality of life and improve early prognosis of disease.
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Affiliation(s)
- Yao Wang
- Department of Neurology, (Y.W., X.Y., M.L.) The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China.
| | - Xiaoyu Yang
- Department of Neurology, (Y.W., X.Y., M.L.) The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Qun Han
- Department of Orthopedics, (Q.H.) Xianggong Central Health Center, Linyi, Shandong Province, China
| | - Min Liu
- Department of Neurology, (Y.W., X.Y., M.L.) The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Chang Zhou
- Department of Neurology, (Y.W., X.Y., M.L.) The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China.
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5
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Harbottle J, Carlin H, Payne-Doris T, Tedd HMI, de Soyza A, Messer B. Developing an intrasalivary gland botox service for patients receiving long-term non-invasive ventilation at home: a single-centre experience. BMJ Open Respir Res 2022; 9:9/1/e001188. [PMID: 35190461 PMCID: PMC8862502 DOI: 10.1136/bmjresp-2021-001188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 01/31/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Sialorrhoea is a debilitating symptom in neurological disease and there is a growing literature for the use of intrasalivary gland Botulinum Toxin (botox) injections in its management. However, provision of intrasalivary gland botox remains inconsistent and sialorrhoea is often poorly controlled in motor neuron disease (MND). Sialorrhoea in association with bulbar dysfunction can cause intolerance of non-invasive ventilation (NIV) and respiratory infection, so its treatment is critical within a home ventilation service (HVS). This treatment can also be used to enable tracheostomy cuff deflation to facilitate weaning from ventilation. We report on the outcomes of intrasalivary gland botox in our HVS. Methods In 2015, we set up an intrasalivary gland botox service for patients under our HVS. Under ultrasound guidance, we injected submandibular gland (SMG), parotid gland (PG) or both. Results 109 intrasalivary gland botox procedures were performed in 72 patients. Diagnostic groups included MND 32 Cerebral Palsy 8 and Weaning 14. Glands injected were, SMG (6%), PG (47%) and both (47%). The majority (84%) received the Dysport preparation with mean dose 273 units. 94% were ultrasound guided. 81% of injections resulted in a positive treatment effect, with 47% patients requesting repeat injections. Complications were angioedema (0.9%) and worsening dysphagia (3.7% following SMG injection). Mean survival following treatment was 40 months with 53% patients still alive. Conclusions Intrasalivary gland botox appears effective across a range of neurological conditions requiring long-term NIV with few complications. Dysphagia may be an important complication of SMG injection. A randomised controlled trial may help establish the evidence base.
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Affiliation(s)
- Jessica Harbottle
- School of Medical Education, Newcastle University, Newcastle upon Tyne, UK
| | - Hannah Carlin
- Respiratory Medicine, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Thomas Payne-Doris
- North East Assisted Ventilation Service, Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, UK
| | - Hilary M I Tedd
- Respiratory Medicine, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Anthony de Soyza
- Population Health Science Institutes, Newcastle University, Newcastle upon Tyne, UK
| | - Ben Messer
- North East Assisted Ventilation Service, Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, UK
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6
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Chiò A, Canosa A, Calvo A, Moglia C, Cicolin A, Mora G. Developments in the assessment of non-motor disease progression in amyotrophic lateral sclerosis. Expert Rev Neurother 2021; 21:1419-1440. [PMID: 34554894 DOI: 10.1080/14737175.2021.1984883] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The burden of non-motor symptoms is a major determinant of quality of life and outcome in amyotrophic lateral sclerosis (ALS) and has profound negative effect also on caregivers. AREAS COVERED Non-motor symptoms in ALS include cognitive impairment, neurobehavioral symptoms, depression and anxiety, suicidal ideation, pain, disordered sleep, fatigue, weight loss and reduced appetite, and autonomic dysfunctions. This review summarizes the measures used for the assessment of non-motor symptoms and their properties and recaps the frequency and progression of these symptoms along the course of ALS. EXPERT OPINION Non-motor symptoms in ALS represent a major component of the disease and span over several domains. These symptoms require a high level of medical attention and should be checked at each visit using ad hoc questionnaires and proactively treated. Several instruments assessing non-motor symptoms have been used in ALS. Specific screening questionnaires for non-motor symptoms can be used for monitoring patients during telehealth visits and for remote surveillance through sensors and apps installed on smartphones. Novel trials for non-motor symptoms treatment specifically designed for ALS are necessary to increase and refine the therapeutic armamentarium. Finally, scales assessing the most frequent and burdensome non-motor symptoms should be included in clinical trials.
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Affiliation(s)
- Adriano Chiò
- 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy.,Neurology I, Azienda Ospedaliera Città Della Salute E Della Scienza of Turin, Turin, Italy
| | - Antonio Canosa
- 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy.,Neurology I, Azienda Ospedaliera Città Della Salute E Della Scienza of Turin, Turin, Italy
| | - Andrea Calvo
- 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy.,Neurology I, Azienda Ospedaliera Città Della Salute E Della Scienza of Turin, Turin, Italy
| | - Cristina Moglia
- 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy.,Neurology I, Azienda Ospedaliera Città Della Salute E Della Scienza of Turin, Turin, Italy
| | - Alessandro Cicolin
- 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy.,Sleep Medicine Center, Azienda Ospedaliera Città Della Salute E Della Scienza of Turin, Turin, Italy
| | - Gabriele Mora
- Neurorehabilitation Department, Ics Maugeri Irccs, Institute of Milan, Milan, Italy
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7
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Mahoney CJ, Ahmed RM, Huynh W, Tu S, Rohrer JD, Bedlack RS, Hardiman O, Kiernan MC. Pathophysiology and Treatment of Non-motor Dysfunction in Amyotrophic Lateral Sclerosis. CNS Drugs 2021; 35:483-505. [PMID: 33993457 DOI: 10.1007/s40263-021-00820-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 12/21/2022]
Abstract
Amyotrophic lateral sclerosis is a progressive and fatal neurodegenerative disease typically presenting with bulbar or limb weakness. There is increasing evidence that amyotrophic lateral sclerosis is a multisystem disease with early and frequent impacts on cognition, behaviour, sleep, pain and fatigue. Dysfunction of normal physiological and metabolic processes also appears common. Evidence from pre-symptomatic studies and large epidemiological cohorts examining risk factors for the future development of amyotrophic lateral sclerosis have reported a high prevalence of changes in behaviour and mental health before the emergence of motor weakness. This suggests that changes beyond the motor system are underway at an early stage with dysfunction across brain networks regulating a variety of cognitive, behavioural and other homeostatic processes. The full impact of non-motor dysfunction continues to be established but there is now sufficient evidence that the presence of non-motor symptoms impacts overall survival in amyotrophic lateral sclerosis, and with up to 80% reporting non-motor symptoms, there is an urgent need to develop more robust therapeutic approaches. This review provides a contemporary overview of the pathobiology of non-motor dysfunction, offering readers a practical approach with regard to assessment and management. We review the current evidence for pharmacological and non-pharmacological treatment of non-motor dysfunction in amyotrophic lateral sclerosis and highlight the need to further integrate non-motor dysfunction as an important outcome measure for future clinical trial design.
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Affiliation(s)
- Colin J Mahoney
- Brain and Mind Centre, The University of Sydney, 94 Mallett Street, Camperdown, NSW, Australia.
| | - Rebekah M Ahmed
- Brain and Mind Centre, The University of Sydney, 94 Mallett Street, Camperdown, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - William Huynh
- Brain and Mind Centre, The University of Sydney, 94 Mallett Street, Camperdown, NSW, Australia
| | - Sicong Tu
- Brain and Mind Centre, The University of Sydney, 94 Mallett Street, Camperdown, NSW, Australia
| | - Jonathan D Rohrer
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, UK
| | - Richard S Bedlack
- Department of Neurology, Duke University Hospital, Durham, North Carolina, USA
| | - Orla Hardiman
- Academic Unit of Neurology, Trinity Biomedical Sciences Institute, Trinity College, Dublin, Ireland
| | - Matthew C Kiernan
- Brain and Mind Centre, The University of Sydney, 94 Mallett Street, Camperdown, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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8
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Pearson I, Glasmacher SA, Newton J, Beswick E, Mehta AR, Davenport R, Chandran S, Pal S. The Prevalence and Management of Saliva Problems in Motor Neuron Disease: A 4-Year Analysis of the Scottish Motor Neuron Disease Register. NEURODEGENER DIS 2021; 20:147-152. [PMID: 33902047 DOI: 10.1159/000514615] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/28/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Saliva problems are common and distressing for people with motor neuron disease (pwMND). Despite clinical guidelines for assessment and treatment, management of saliva problems has received little research attention. OBJECTIVE We aimed to investigate the prevalence of saliva problems in pwMND, their association with clinical factors, and their management practice using a highly curated population-based register for motor neuron disease (MND) with 99% case ascertainment. METHODS We conducted an analysis of pwMND diagnosed between January 2015 and October 2019 using the Scottish MND Register (CARE-MND [Clinical, Audit, Research, and Evaluation of MND]). The association between clinical factors and saliva problems was investigated using univariate and multivariable logistic regression; results are reported as odds ratio (OR) and 95% confidence intervals. A survey of health-care professionals involved in the care of pwMND was performed to contextualize the findings. RESULTS 939 pwMND were included. Prevalence of saliva problems was 31.3% (294). Bulbar onset (OR 9.46 [4.7, 19.2]; p < 0.001) but not age, sex, time to diagnosis, or MND subtype were independently associated with the presence of saliva problems in multivariable regression, and 52.7% (155) of those with saliva problems received pharmacological management. The most commonly used medications were hyoscine, amitriptyline, carbocisteine, glycopyrrolate, and atropine. Evidence base (8, 72.7%) and local guidelines (10, 90.9%) were cited as the most important factors influencing treatment decision by survey respondents (n = 11). CONCLUSION Saliva problems are common and associated with bulbar onset MND. A substantial proportion of pwMND with saliva problems did not receive recommended treatments. Future research is required to determine the relative efficacy of individual pharmacological treatments.
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Affiliation(s)
- Iona Pearson
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Stella A Glasmacher
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom.,Anne Rowling Regenerative Neurology Clinic, Royal Infirmary, Edinburgh, United Kingdom
| | - Judith Newton
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom.,Anne Rowling Regenerative Neurology Clinic, Royal Infirmary, Edinburgh, United Kingdom.,Euan MacDonald Centre for Motor Neurone Disease Research, University of Edinburgh, Edinburgh, United Kingdom
| | - Emily Beswick
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom.,Anne Rowling Regenerative Neurology Clinic, Royal Infirmary, Edinburgh, United Kingdom.,Euan MacDonald Centre for Motor Neurone Disease Research, University of Edinburgh, Edinburgh, United Kingdom
| | - Arpan R Mehta
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom.,Anne Rowling Regenerative Neurology Clinic, Royal Infirmary, Edinburgh, United Kingdom.,Euan MacDonald Centre for Motor Neurone Disease Research, University of Edinburgh, Edinburgh, United Kingdom.,Department of Clinical Neurosciences, NHS Lothian, Edinburgh, United Kingdom
| | - Richard Davenport
- Anne Rowling Regenerative Neurology Clinic, Royal Infirmary, Edinburgh, United Kingdom.,Euan MacDonald Centre for Motor Neurone Disease Research, University of Edinburgh, Edinburgh, United Kingdom.,Department of Clinical Neurosciences, NHS Lothian, Edinburgh, United Kingdom
| | - Siddharthan Chandran
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom.,Anne Rowling Regenerative Neurology Clinic, Royal Infirmary, Edinburgh, United Kingdom.,Euan MacDonald Centre for Motor Neurone Disease Research, University of Edinburgh, Edinburgh, United Kingdom.,Department of Clinical Neurosciences, NHS Lothian, Edinburgh, United Kingdom.,UK Dementia Research Institute at University of Edinburgh, Edinburgh, United Kingdom
| | - Suvankar Pal
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom.,Anne Rowling Regenerative Neurology Clinic, Royal Infirmary, Edinburgh, United Kingdom.,Euan MacDonald Centre for Motor Neurone Disease Research, University of Edinburgh, Edinburgh, United Kingdom.,Department of Clinical Neurosciences, NHS Lothian, Edinburgh, United Kingdom.,Department of Neurology, NHS Forth Valley, Larbert, United Kingdom
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9
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Abstract
Many neuromuscular disorders (NMD) are complicated by respiratory failure. These patients are best managed in a multidisciplinary outpatient clinic to provide timely access to the various disciplines they require. The key mainstay of treatment of respiratory failure in patients with NMD is noninvasive ventilation, supported by secretion clearance, speech and language therapy, optimisation of nutrition and the maintenance of mobility. Patients with specific conditions may also require cardiology, neurology, orthopaedics, urology and psychological services. The respiratory NMD multidisciplinary team should also provide access to palliative care, and caregiver health and wellbeing should also be reviewed at clinical reviews. The future of care for the respiratory NMD patient will increasingly involve home services and telehealth and the clinic should be equipped and resourced to deliver these. Although not all health systems will be able to provide all elements of the multidisciplinary team discussed here, this review provides the “ideal” recipe for the adult multidisciplinary team and the evidence base underpinning this from which a clinic can be developed. Care for neuromuscular-related respiratory failure is complex and is best delivered in a multidisciplinary context. The future will increasingly involve home services and telehealth, and their burden needs to be considered when establishing this service.https://bit.ly/33fNsMT
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Affiliation(s)
- Neeraj M Shah
- Lane Fox Respiratory Service, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Lane Fox Clinical Respiratory Physiology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
| | - Patrick B Murphy
- Lane Fox Respiratory Service, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Lane Fox Clinical Respiratory Physiology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
| | - Georgios Kaltsakas
- Lane Fox Respiratory Service, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Lane Fox Clinical Respiratory Physiology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
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10
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Meyer T, Kettemann D, Maier A, Grehl T, Weyen U, Grosskreutz J, Steinbach R, Norden J, George A, Hermann A, Guenther R, Petri S, Schreiber-Katz O, Dorst J, Ludolph AC, Walter B, Münch C, Spittel S. Symptomatic pharmacotherapy in ALS: data analysis from a platform-based medication management programme. J Neurol Neurosurg Psychiatry 2020; 91:783-785. [PMID: 32317400 PMCID: PMC7361015 DOI: 10.1136/jnnp-2020-322938] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/25/2020] [Accepted: 04/01/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Thomas Meyer
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany .,Ambulanzpartner Soziotechnologie APST GmbH, Berlin, Germany
| | - Dagmar Kettemann
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - André Maier
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Torsten Grehl
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Alfried Krupp Krankenhaus, Essen, Germany
| | - Ute Weyen
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Berufsgenossenschaftliches Universitatsklinikum Bergmannsheil, Bochum, Germany
| | - Julian Grosskreutz
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Robert Steinbach
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Jenny Norden
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Annette George
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Hermann
- Department of Neurology, Translational Neurodegeneration Section Albrecht Kossel, Universitätsmedizin Rostock, Rostock, Germany.,Research Site Rostock/Greifswald, DZNE, German Center for Neurodegenerative Diseases, Rostock, Germany
| | - René Guenther
- Department of Neurology, Technische Universität Dresden, Dresden, Germany.,Research Site Dresden, DZNE, German Center for Neurodegenerative Diseases, Dresden, Germany
| | - Susanne Petri
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Johannes Dorst
- Department of Neurology, University of Ulm, Ulm, Germany
| | | | - Bertram Walter
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Münch
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Ambulanzpartner Soziotechnologie APST GmbH, Berlin, Germany
| | - Susanne Spittel
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Ambulanzpartner Soziotechnologie APST GmbH, Berlin, Germany
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Morgante F, Bavikatte G, Anwar F, Mohamed B. The burden of sialorrhoea in chronic neurological conditions: current treatment options and the role of incobotulinumtoxinA (Xeomin®). Ther Adv Neurol Disord 2019; 12:1756286419888601. [PMID: 31819763 PMCID: PMC6883364 DOI: 10.1177/1756286419888601] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/08/2019] [Indexed: 12/11/2022] Open
Abstract
Sialorrhoea is a frequent symptom of neurological diseases (e.g. Parkinson’s
disease, motor neuron disease, cerebral palsy, and stroke) and is defined as
excessive saliva accumulation leading to unintentional loss of saliva from the
mouth. Sialorrhoea increases the overall burden on the patient and their
caregivers, the impact of which can be both physical and psychosocial.
Treatments for sialorrhoea range from lifestyle and behavioural guidance, to
medications, surgery or radiation. Nonpharmacological interventions include
advice on posture, swallowing control, cough management, dietary changes, eating
and drinking techniques, and behavioural modification; however, these
conservative measures may be ineffective for people with progressive
neurological conditions. The pharmacological treatment of sialorrhoea is
challenging because medications licensed for this purpose are limited, but
treatments can include anticholinergic drugs and botulinum toxins. Surgical
treatment of sialorrhoea is typically reserved as a last resort for patients.
IncobotulinumtoxinA (Xeomin®) is the first botulinum toxin type A to receive US
and UK marketing authorization for the symptomatic treatment of chronic
sialorrhoea due to neurological disorders in adults. In this review, we discuss
and compare the frequency and method of administration, location of treatment
delivery, approximate annual costs and main side effects of botulinum toxin and
different anticholinergic drugs. Management of patients with chronic
neurological conditions requires input from multiple specialist teams and thus a
multidisciplinary team (MDT) approach is considered fundamental to ensure that
care is consistent and tailored to patients’ needs. To ensure that adult
patients with neurological conditions receive the best care and sialorrhoea is
well managed, we suggest a potential clinical care pathway for sialorrhoea with
a MDT approach, which healthcare professionals could aspire to.
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Affiliation(s)
- Francesca Morgante
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom; Department of Experimental and Clinical Medicine, University of Messina
| | - Ganesh Bavikatte
- Department of Rehabilitation Medicine, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Fahim Anwar
- Department of Rehabilitation Medicine, Cambridge University Hospital NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Biju Mohamed
- Department of Medicine and Gerontology, University Hospital of Wales, Cardiff, UK
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Dorst J, Ludolph AC, Huebers A. Disease-modifying and symptomatic treatment of amyotrophic lateral sclerosis. Ther Adv Neurol Disord 2017; 11:1756285617734734. [PMID: 29399045 PMCID: PMC5784546 DOI: 10.1177/1756285617734734] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/24/2017] [Indexed: 12/11/2022] Open
Abstract
In this review, we summarize the most important recent developments in the treatment of amyotrophic lateral sclerosis (ALS). In terms of disease-modifying treatment options, several drugs such as dexpramipexole, pioglitazone, lithium, and many others have been tested in large multicenter trials, albeit with disappointing results. Therefore, riluzole remains the only directly disease-modifying drug. In addition, we discuss antisense oligonucleotides (ASOs) as a new and potentially causal treatment option. Progress in symptomatic treatments has been more important. Nutrition and ventilation are now an important focus of ALS therapy. Several studies have firmly established that noninvasive ventilation improves patients' quality of life and prolongs survival. On the other hand, there is still no consensus regarding best nutritional management, but big multicenter trials addressing this issue are currently ongoing. Evidence regarding secondary symptoms like spasticity, muscle cramps or sialorrhea remains generally scarce, but some new insights will also be discussed. Growing evidence suggests that multidisciplinary care in specialized clinics improves survival.
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Affiliation(s)
- Johannes Dorst
- Universitätsklinik Ulm, RKU, Oberer Eselsberg 45, D-89081 Ulm, Germany
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13
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Goutman SA. Diagnosis and Clinical Management of Amyotrophic Lateral Sclerosis and Other Motor Neuron Disorders. Continuum (Minneap Minn) 2017; 23:1332-1359. [DOI: 10.1212/con.0000000000000535] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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McGeachan AJ, Mcdermott CJ. Management of oral secretions in neurological disease. Pract Neurol 2017; 17:96-103. [DOI: 10.1136/practneurol-2016-001515] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2016] [Indexed: 12/12/2022]
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Weikamp JG, Schinagl DAX, Verstappen CCP, Schelhaas HJ, de Swart BJM, Kalf JG. Botulinum toxin-A injections vs radiotherapy for drooling in ALS. Acta Neurol Scand 2016; 134:224-31. [PMID: 26803950 DOI: 10.1111/ane.12559] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Botulinum neurotoxin (BoNT) injections in the salivary glands and radiotherapy (RT) on these glands are commonly used to alleviate severe drooling in patients with amyotrophic lateral sclerosis (ALS). This study compares BoNT type A with RT based on patient-rated evaluations. MATERIALS & METHODS A prospective randomized controlled pilot study to compare RT (n = 10; on the parotid and the posterior part of the submandibular glands) with BoNT-A treatment (n = 10; in the parotid glands only, because of the risk of increasing oropharyngeal weakness) in patients with ALS. The primary outcome was the drooling status (burden of drooling), and our secondary interests were the degree of salivation, global change of drooling after treatment, and level of satisfaction with the treatment and negative experiences. RESULTS There were no statistically significant between-treatment differences for the drooling status after treatment. Only at twelve weeks more saliva reduction was achieved by RT (P = 0.02). Patients treated with RT also described more transient negative experiences (like pain in mandible) directly after treatment. Subgroup analysis showed that patients with very severe dysphagia (no oral intake) were less satisfied and experienced a lower global change of drooling after treatment. CONCLUSIONS This pilot study showed no significant difference in the burden of drooling between the treatments. However, with RT more saliva reduction was achieved, including negative experiences directly after treatment, but without the risk of decreasing oropharyngeal function. In addition, patients with very severe dysphagia do not seem to benefit from either treatment.
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Affiliation(s)
- J. G. Weikamp
- Radboud University Medical Centre; Donders Centre for Neuroscience (DCN); Department of Rehabilitation/Speech-Language Pathology; Nijmegen The Netherlands
| | - D. A. X. Schinagl
- Radboud University Medical Centre; Department of Radiotherapy; Nijmegen The Netherlands
| | - C. C. P. Verstappen
- Canisius Wilhelmina Ziekenhuis; Department of Neurology; Nijmegen The Netherlands
| | | | - B. J. M. de Swart
- Radboud University Medical Centre; Donders Centre for Neuroscience (DCN); Department of Rehabilitation/Speech-Language Pathology; Nijmegen The Netherlands
| | - J. G. Kalf
- Radboud University Medical Centre; Donders Centre for Neuroscience (DCN); Department of Rehabilitation/Speech-Language Pathology; Nijmegen The Netherlands
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McGeachan AJ, Hobson EV, Al-Chalabi A, Stephenson J, Chandran S, Crawley F, Dick D, Donaghy C, Ellis CM, Gorrie G, Hanemann CO, Harrower T, Jung A, Malaspina A, Morrison KE, Orrell RW, Talbot K, Turner MR, Williams TL, Young CA, Shaw PJ, McDermott CJ. A multicentre evaluation of oropharyngeal secretion management practices in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2016; 18:1-9. [PMID: 27579520 DOI: 10.1080/21678421.2016.1221433] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Failure to clear oral secretions can be debilitating for patients with amyotrophic lateral sclerosis (ALS), but the treatment of this symptom is poorly defined and there is no consensus on best practice. The objective of this study was to identify the treatments that are commonly prescribed, and to describe how experienced clinicians manage a patient with treatment resistant symptoms. Twenty-three clinicians were approached, of which 19 from 16 centres across the UK provided case report forms for a total of 119 ALS patients identified as having problematic oral secretions. The use of five anticholinergics, salivary gland botulinum toxin injections, conservative management approaches and carbocisteine were reported. Of the 72 patients who were evaluated following the initiation of a first anticholinergic, 61% had symptomatic improvement. Only 19% of patients achieved symptomatic improvement with the use of an alternative anticholinergic when an initial anticholinergic achieved no symptomatic improvement. Problems with thick and thin secretions often coexisted, with 37% of patients receiving treatment for both types of problem. In conclusion, a variety of treatment options are employed by expert clinicians for problematic oral secretions in ALS patients. The variation in management highlights the need for further prospective research in this area.
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Affiliation(s)
- Alexander J McGeachan
- a Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, & Academic Directorate of Neurosciences, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield
| | - Esther V Hobson
- a Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, & Academic Directorate of Neurosciences, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield
| | - Ammar Al-Chalabi
- b King's College London, Institute of Psychiatry , Department of Clinical Neuroscience , London
| | - Jodie Stephenson
- a Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, & Academic Directorate of Neurosciences, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield
| | | | - Francesca Crawley
- d Department of Neurology , West Suffolk NHS Foundation Trust , Bury St. Edmunds
| | - David Dick
- e Department of Neurology , Norfolk and Norwich University Hospital , Norwich
| | - Colette Donaghy
- f Department of Neurology , Royal Victoria Hospital , Belfast
| | - Cathy M Ellis
- g Motor Neuron Disease Care and Research Centre , Kings College Hospital , London
| | - George Gorrie
- h Institute of Neurological Sciences, Southern General Hospital , Glasgow
| | - C Oliver Hanemann
- i Institute of Translational and Stratified Medicine, Plymouth University Peninsula Schools of Medicine and Dentistry , Plymouth
| | - Timothy Harrower
- j Department of Neurology , Royal Devon and Exeter Foundation Trust Hospital
| | - Agam Jung
- k Department of Neurology , Leeds General Infirmary , Leeds
| | - Andrea Malaspina
- l Centre for Neuroscience and Trauma , Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, & Department of Neurology, Basildon University Hospital , Basildon
| | - Karen E Morrison
- m Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, and Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust , Birmingham
| | - Richard W Orrell
- n Department of Clinical Neuroscience , University College London Institute of Neurology, London, & MND Care and Research Centre, National Hospital for Neurology and Neurosurgery , Queen Square , London
| | - Kevin Talbot
- o Oxford University Nuffield Department of Clinical Neurosciences , John Radcliffe Hospital , Oxford
| | - Martin R Turner
- o Oxford University Nuffield Department of Clinical Neurosciences , John Radcliffe Hospital , Oxford
| | - Timothy L Williams
- p Department of Neurology , Royal Victoria Infirmary , Newcastle-upon-Tyne , and
| | - Carolyn A Young
- q The Walton Centre for Neurology and Neurosurgery , Liverpool , UK
| | - Pamela J Shaw
- a Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, & Academic Directorate of Neurosciences, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield
| | - Christopher J McDermott
- a Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, & Academic Directorate of Neurosciences, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield
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Hobson EV, McDermott CJ. Supportive and symptomatic management of amyotrophic lateral sclerosis. Nat Rev Neurol 2016; 12:526-38. [PMID: 27514291 DOI: 10.1038/nrneurol.2016.111] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The main aims in the care of individuals with amyotrophic lateral sclerosis (ALS) are to minimize morbidity and maximize quality of life. Although no cure exists for ALS, supportive and symptomatic care provided by a specialist multidisciplinary team can improve survival. The basis for supportive management is shifting from expert consensus guidelines towards an evidence-based approach, which encourages the use of effective treatments and could reduce the risk of harm caused by ineffective or unsafe interventions. For example, respiratory support using noninvasive ventilation has been demonstrated to improve survival and quality of life, whereas evidence supporting other respiratory interventions is insufficient. Increasing evidence implicates a causal role for metabolic dysfunction in ALS, suggesting that optimizing nutrition could improve quality of life and survival. The high incidence of cognitive dysfunction and its impact on prognosis is increasingly recognized, although evidence for effective treatments is lacking. A variety of strategies are used to manage the other physical and psychological symptoms, the majority of which have yet to be thoroughly evaluated. The need for specialist palliative care throughout the disease is increasingly recognized. This Review describes the current approaches to symptomatic and supportive care in ALS and outlines the current guidance and evidence for these strategies.
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Affiliation(s)
- Esther V Hobson
- Sheffield Institute for Translational Neuroscience, University of Sheffield, 385a Glossop Rd, Sheffield, S10 2HQ, UK
| | - Christopher J McDermott
- Sheffield Institute for Translational Neuroscience, University of Sheffield, 385a Glossop Rd, Sheffield, S10 2HQ, UK
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Radiotherapy treatment of sialorrhea in patients with amyotrophic lateral sclerosis requiring non-invasive ventilation. J Neurol 2015; 262:1981-3. [DOI: 10.1007/s00415-015-7848-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 07/02/2015] [Accepted: 07/03/2015] [Indexed: 11/27/2022]
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Abstract
PURPOSE OF REVIEW Amyotrophic lateral sclerosis (ALS) is a progressive, incurable and fatal neurodegenerative disease. Few interventions significantly alter the disease course, but many symptomatic treatments exist to improve patients' quality of life. In this review, we describe our approach to symptomatic management of ALS and discuss the underlying evidence base. RECENT FINDINGS Discussion focuses predominantly on recently published articles. We cover management settings, disease-modifying treatment, vitamin D, respiratory management including noninvasive ventilation and diaphragmatic pacing, secretions, nutrition, dysphagia and gastrostomy, communication problems, mobility, spasticity, pain, cognition, depression and emotional lability, fatigue, sleep disturbance, head drop, prevention of deep venous thrombosis and end-of-life issues. SUMMARY Multidisciplinary specialist care appears to improve quality of life and survival. Riluzole remains the only available disease-modifying medication and confers a survival advantage of 2-3 months. Noninvasive ventilation improves quality of life and extends survival by approximately 7 months, at least in patients without severe bulbar problems. Nutrition is an independent prognostic factor; whether gastrostomy improves survival and quality of life remains unclear and further studies are underway. Many other symptomatic treatments appear helpful to individuals in clinic, but further randomized clinical trials are required to provide a more robust evidence base.
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McGeachan AJ, Hobson EV, Shaw PJ, McDermott CJ. Developing an outcome measure for excessive saliva management in MND and an evaluation of saliva burden in Sheffield. Amyotroph Lateral Scler Frontotemporal Degener 2014; 16:108-13. [DOI: 10.3109/21678421.2014.951942] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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