Management of dysphagia in MS

Transcription

1 Management of dysphagia in MS Marta Renom Speech and Language Therapist CEM-CAT (UNeR) Barcelona

2 Introduction M A N A G E M E N T Assessment Treatment Take-home messages

3 INTRODUCTION Normal swallowing Dual function: transporting / protecting airway oral phase pharyngeal phase oesophageal phase brainstem cerebellar cognitive

4 33 to 43% Management of dysphagia in MS INTRODUCTION Epidemiology in MS Calcagno P, Ruoppolo G, et al (2002) Dysphagia in multiple sclerosis prevalence and prognostic factors. Acta Neurol Scand 105: <6 6-6,5 >6.5 EDSS

5 INTRODUCTION Classification According to: 1. Consistency affected Liquids EDSS Severity Solids EDSS 8

6 INTRODUCTION Classification According to: 1. Consistency affected 2. Severity mild moderate severe

7 INTRODUCTION Consequences of dysphagia Morbidity / mortality Nutrition / hydratation Quality of life Independence Level of participation

8 Introduction M A N A G E M E N T Assessment Treatment Take-home messages

9 ASSESSMENT History taking & screening Comprehensive clinical assessment Instrumental assessment Rehabilitation Farmacological treatment Enteral & others

10 ASSESSMENT Clinical observations Voice Cough Laryngeal elevation Posture Secretions Palatal gag Linden 2005 The probability of correctly predicting subglottig penetration from clilnical observations (n=249) (success to predict 2/3)

11 ASSESSMENT Main signs and symptoms Altered feeding habit Cough and/or choking while or after eating and drinking

12 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

13 ASSESSMENT Bedside screening examination 50 ml water test Pharyngeal sensation Pulse oximetry Prosiegel M, Schelling A, Wagner-Sonntag E (2004) Dysphagia and multiple sclerosis. Int MS J 11:22-31

14 ASSESSMENT History taking & screening Comprehensive clinical assessment Instrumental assessment Rehabilitation Farmacological treatment Enteral feeding?

15 Oral anatomy Management of dysphagia in MS ASSESSMENT Sensory-motor assessment Muscular tone Oropharyngeal reflexes Movement execution Functional assessment Cognitive evaluation Nutritional evaluation Impact in daily life SWAL-QOL / SWAL-CARE McHorney CA, et al. Dysphagia 17: (2002)

16 ASSESSMENT History taking & screening Comprehensive clinical assessment Instrumental assessment Rehabilitation Farmacological treatment Enteral feeding?

17 Videofluoroscopy ASSESSMENT Instrumental assessment Fiberoptic endoscopic laryngoscopy Electromyography Manofluoroscopy Dysphagia outcome and severity scale O Neil KH, Purdy M, Janice F. Dysphagia 1999 Eight-point-penetration-aspiration-scale: Rosenbeck JC, Robins JA, Roecker EB et al. Dysphagia 1996

18 Introduction M A N A G E M E N T Assessment Treatment Take-home messages

19 TREATMENT Goals Risk of aspiration Nutrition / hydratation Quality of life Independence Level of participation

20 TREATMENT History taking & screening Comprehensive clinical assessment Instrumental assessment Rehabilitation Pharmacological treatment Enteral feeding

21 TREATMENT First step Information, awareness, general advise

22 Therapeutic methods of functional swallowing therapy Disturbance Reduced lingual control Impaired tongue base retraction Restitution Tongue exercises Tongue exercises Masako manoeuvre Compensation Head anteflexion Head anteflexion Mendelsohn manoeuvre Adaptation Thickening of liquids Smooth consistency Delayed / absent swallowing reflex Stimulation of the faucial pilars Tongue exercises Supraglottic swallowing Head anteflexion Enhancing taste/temperature Reduced laryngeal closure Positional, compression and respiratory support strategies Pitch / Phonatory exercises Supraglottic swallowing Turning the head to the stronger side Thickening of liquids Dysfunction of the upper oesophageal sphincter Ex: maximizing extent and timig of hyoid/laryngeal elevation Shaker manouvre Mendelsohn manoeuvre Thin consistency Reduced pharyngeal contraction Whistling, sucking, snarling Turning head to affected side Tilting head to stronger side Effortful swallowing Smooth consistency Diminished pharyngeal and/or laryngeal sensation No evidence-based restitution method Supraglottic swallowing (if silent aspirations) Repeated swallowing Enhancing taste/temperature Prosiegel M, Schelling A, Wagner-Sonntag E (2004) Dysphagia and multiple sclerosis. Int MS J 11:22-31

23 Therapeutic methods of functional swallowing therapy Disturbance Reduced lingual control Impaired tongue base retraction Delayed / absent swallowing reflex Reduced laryngeal closure Dysfunction of the upper oesophageal sphincter Reduced pharyngeal contraction Restitution Restitution Tongue exercises Tongue exercises Masako manoeuvre Stimulation of the faucial pilars Tongue exercises Positional, compression and respiratory support strategies Pitch / Phonatory exercises Ex: maximizing extent and timig of hyoid/laryngeal elevation Shaker manoeuvre Whistling, sucking, snarling Compensation Head anteflexion Head anteflexion Mendelsohn manoeuvre Supraglottic swallowing Head anteflexion Supraglottic swallowing Turning the head to the stronger side Mendelsohn manoeuvre Turning head to affected side Tilting head to stronger side Effortful swallowing Adaptation exercises Thickening of liquids Smooth consistency Neuromuscular exercises Enhancing taste/temperature Neuromuscular electrostimulation* Thickening of liquids Mechanical, thermal, gustatory st Thin consistency Smooth consistency Diminished pharyngeal and/or laryngeal sensation * Bogaardt H et al (2009) No evidence-based restitution method Supraglottic swallowing (if silent aspirations) Repeated swallowing Enhancing taste/temperature

24 Therapeutic methods of functional swallowing therapy Disturbance Reduced lingual control Impaired tongue base retraction Delayed / absent swallowing reflex Reduced laryngeal closure Dysfunction of the upper oesophageal sphincter Reduced pharyngeal contraction Diminished pharyngeal and/or laryngeal sensation Restitution Tongue exercises Tongue exercises Masako manoeuvre Stimulation of the faucial pilars Tongue exercises Positional, compression and respiratory support strategies Pitch / Phonatory exercises Ex: maximizing extent and timig of hyoid/laryngeal elevation Shaker manoeuvre Whistling, sucking, snarling No evidence-based restitution method Compensation Compensation Head anteflexion Head anteflexion Mendelsohn manouvre Supraglottic swallowing Head anteflexion Supraglottic swallowing Supraglottic swallowing Turning the head to the stronger side Mendelsohn manoeuvre Turning head to affected side Tilting head to stronger side Effortful swallowing Supraglottic swallowing (if silent aspirations) Repeated swallowing Adaptation Thickening of liquids Smooth posture consistency & techniques Enhancing taste/temperature Thickening of liquids Thin consistency Smooth consistency Enhancing while eating & drinking taste/temperature

25 Therapeutic methods of functional swallowing therapy Disturbance Reduced lingual control Impaired tongue base retraction Restitution Tongue exercises Tongue exercises Masako manouvre Compensation Head anteflexion Environment changes: Head anteflexion Mendelsohn manouvre Adaptation Thickening of liquids Smooth consistency Delayed / absent swallowing reflex Reduced laryngeal closure Dysfunction of the upper oesophageal sphincter Reduced pharyngeal contraction Diminished pharyngeal and/or laryngeal sensation Consistency & volumes Stimulation of the faucial pilars Tongue exercises Positional, compression and respiratory support strategies Pitch / Phonatory exercises Ex: maximizing extent and timig of hyoid/laryngeal elevation Shaker manouvre Whystling, sucking, snarling No evidence-based restitution method Supraglotic swallowing Head anteflexion Supraglottic swallowing Turning the head to the stronger side Taste & temperature Equipment Mendelsohn manouvre Turning head to affected side Tilting head to stronger side Effortful swallowing Supraglottic swallowing Nutrit. & hydrat. intake (if silent aspirations) Repeated swallowing Enhancing taste/temperature Thickening of liquids Thin consistency Smooth consistency Enhancing taste/temperature

26 Environment changes: Therapeutic methods of functional swallowing therapy Disturbance Reduced lingual control Impaired tongue base retraction Restitution food consistency Compensation Tongue exercises Head anteflexion Tongue exercises Masako manouvre hard Head anteflexion Mendelsohn manouvre Adaptation Thickening of liquids Smooth consistency Delayed / absent swallowing reflex Reduced laryngeal closure Dysfunction of the upper oesophageal sphincter Reduced pharyngeal contraction Diminished pharyngeal and/or laryngeal sensation Stimulation of the faucial pilars Tongue exercises Positional, compression and respiratory support strategies Pitch / Phonatory exercises Ex: maximizing extent and timig of hyoid/laryngeal elevation Shaker manouvre Whystling, sucking, snarling soft No evidence-based restitution method Supraglotic swallowing Head anteflexion Supraglottic swallowing purée / pudding honey nectar thin Turning the head to the stronger side Mendelsohn manouvre Turning head to affected side Tilting head to stronger side Effortful swallowing Supraglottic swallowing (if silent aspirations) Repeated swallowing Enhancing taste/temperature Thickening of liquids Thin consistency Smooth consistency Enhancing taste/temperature

27 Therapeutic methods of functional swallowing therapy Disturbance Reduced lingual control Impaired tongue base retraction Restitution Tongue exercises Tongue exercises Masako manouvre Compensation Head anteflexion Head anteflexion Mendelsohn manouvre Adaptation Thickening of liquids Smooth consistency Delayed / absent swallowing reflex Stimulation of the faucial pilars Tongue exercises Supraglotic swallowing Head anteflexion Enhancing taste/temperature Reduced laryngeal closure Positional, compression and respiratory support strategies Pitch / Phonatory exercises Supraglottic swallowing Turning the head to the stronger side Thickening of liquids Dysfunction of the upper oesophageal sphincter Ex: maximizing extent and timig of hyoid/laryngeal elevation Shaker manouvre Mendelsohn manouvre Thin consistency Reduced pharyngeal contraction Whystling, sucking, snarling Turning head to affected side Tilting head to stronger side Effortful swallowing Smooth consistency Diminished pharyngeal and/or laryngeal sensation No evidence-based restitution method Supraglottic swallowing (if silent aspirations) Repeated swallowing Enhancing taste/temperature

28 Security manoeuvres Management of dysphagia in MS TREATMENT Heimlich manoeuvre Assisted cough

29 TREATMENT History taking & screening Comprehensive clinical assessment Instrumental assessment Rehabilitation Pharmacological treatment Enteral feeding

30 TREATMENT Pharmacological treatment Hypersalivation: anticholinergics, botulinum toxin Thick secretions: N-acetylcysteine Hiccup: baclofen + domperidone + proton pump inhibitor Gastroesophageal reflux disease: proton pump inhib. UES dysfunction: botulinum toxin Prosiegel M, Schelling A, Wagner-Sonntag E (2004) Dysphagia and multiple sclerosis. Int MS J 11:22-31

31 TREATMENT History taking & screening Comprehensive clinical assessment Instrumental assessment Rehabilitation Pharmacological treatment Enteral feeding

32 Enteral feeding Management of dysphagia in MS TREATMENT Percutaneous endoscopic gastrostomy (PEG) Nasogastric tube feeding (NTF)

33 Introduction M A N A G E M E N T Assessment Treatment Take-home messages

34 TAKE-HOME MESSAGES Prevalence: relatively high Dysphagia: dangerous consequences Management: early / interdisciplinary Assessment: clinical & instrumental Impact in daily life

35 TAKE-HOME MESSAGES Treatment: Rehabilitative approaches high efficacy Pharmacotherapy for associated symptoms Enteral feeding in severe cases

36 I hope you enjoyed the meal... Thank you for your attention

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

38 REFERENCES Poorjavad M et al (2010) Oropharyngeal dysphagia in multiple sclerosis. Multiple Sclerosis. 16(3) Bogaardt H et al (2009) Use of neuromuscular electrostimulation in the treatment of dysphagia in patients with multiple sclerosis. Ann Otol Rhinol Laryngol. Apr;118(4):241-6