management of dysphagia in ms - excemed · intervención en la disfagia en la em tratamiento d. a....

Management of dysphagia in MS

Marta Renom

Speech and Language Therapist

CEM-CAT (UNeR)

Barcelona

oral phase

pharyngeal phase

oesophageal phase

Normal swallowing

brainstem

cerebellar

cognitive


INTRODUCTION

Dual function: transporting / protecting airway

Dysphagia in MS: 33 to 43% (Calcagno 2002)

Classification

According to:

1. Consistency affected

2. Severity

Solids

Liquids

EDSS ≤ 7.5

EDSS ≥ 8


INTRODUCTION

Classification

According to:

1. Consistency affected

2. Severity mild

moderate

severe


INTRODUCTION

efficacy

nutrition

hydration

safety

penetration

aspiration

Consequences of dysphagia

↑ Morbidity / mortality

↓ Nutrition / hydratation

↓ Quality of life

↓ Independence

↓ Level of participation


INTRODUCTION

Rehabilitation Pharmacological

treatment Enteral

feeding

History taking &

screening

Comprehensive

clinical assessment


ASSESSMENT AND TREATMENT

Instrumental assessment


ASSESSMENT

Clinical observations

Linden 2005 The probability of correctly predicting subglottig penetration from clilnical observations (n=249) (success to predict 2/3)

Voice

Cough

Laryngeal elevation

Posture

Secretions

Palatal gag


ASSESSMENT

Main signs and symptoms

Altered feeding habit

Cough and/or choking

while or after eating and drinking


ASSESSMENT

Other signs and symptoms

Food sticking in throat

Need to repeat the swallowing act

Dyspnoea during or after meals

Weight loss

Recurrent episodes of infections of the upper airways

Episodes of either unexplained fever or pneumonia

DYMUS Questionnaire Bergamashi et al: The DYMUS questionnaire for the assessment of dysphagia in multiple sclerosis.

Journal of the Neurological Sciences 269 (2008) 49-53


ASSESSMENT

Oral anatomy

Sensory-motor assessment

Muscular tone

Movement execution

Functional assessment

Cognitive evaluation

Impact in daily life

Oropharyngeal reflexes

SWAL-QOL / SWAL-CARE

McHorney CA, et al. 2002

Nutritional evaluation

V-VST Clavé et al. 2008

MNA ® Guigoz 2006


ASSESSMENT

Videofluoroscopy

Fiberoptic endoscopic laryngoscopy

Electromyography

Manofluoroscopy

Instrumental assessment

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

Eight-point-penetration-aspiration-scale: Rosenbeck JC, Robins JA, Roecker EB et al. Dysphagia 1996

Supraglottic swallowing

(if silent aspirations)

Repeated swallowing

No evidence-based restitution

method

Diminished pharyngeal

and/or laryngeal

sensation

Smooth

consistency

Turning head to affected side

Tilting head to stronger side

Effortful swallowing

Whistling, sucking, snarlingReduced pharyngeal

contraction

Thin consistencyMendelsohn manoeuvreEx: maximizing extent and timig

of hyoid/laryngeal elevation

Shaker manouvre

Dysfunction of the

upper oesophageal

sphincter

Thickening of

liquids


Turning the head to the

stronger side

Positional, compression and

respiratory support strategies

Pitch / Phonatory exercises

Reduced laryngeal

closure

Enhancing

taste/temperature


Head anteflexion

Stimulation of the faucial pilars

Tongue exercises

Delayed / absent

swallowing reflex

Smooth

consistency

Head anteflexion

Mendelsohn manoeuvre

Tongue exercises

Masako manoeuvre

Impaired tongue base

retraction

Thickening of

liquids

Head anteflexionTongue exercisesReduced lingual control

AdaptationCompensationRestitutionDisturbance

Therapeutic methods of functional swallowing therapy

Enhancing

taste/temperature

Prosiegel M, Schelling A, Wagner-Sonntag E (2004) Dysphagia and multiple sclerosis. Int MS J 11:22-31

Neuromuscular electrostimulation

Verin E, Maltete D, Ouahchi Y, et al.

Submental sensitive transcutaneous electrical stimulation (SSTES)

at home in neurogenic oropharyneal dysphagia: a pilot study

Annals of Physical and Rehabilitation Medicine 54 (2011) 366-375

Domenico A. Restivo, Antonino Casabona , Diego Centonze et al.

Pharyngeal electrical stimulation for dysphagia associated with

multiple sclerosis: A pilot study

Brain Stimulation xxx (2012) 1-6

Intraluminal electrical pharyngeal stimulation

Management of dysphagia in MS REFERENCES

Intervención en la disfagia en la EM

TRATAMIENTO

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Botulinum toxin improves dysphagia

associated with multiple sclerosis

European Journal of Neurology 2011, 18: 486–490

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in MS patients with dysphagia associated with upper

esophageal sphincter hyperactivity

Pharmacological treatment

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dysphagia in multiple sclerosis. J Neurol Sci 269:49-53

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