ClinicSpeak: swallowing problems in MS

If you have swallowing problems tell your neurologist or nurse. #ClinicSpeak #MSBlog #MSResearch

"More bad news for those of you who want their reading material to filtered and passed through rose-tinted glasses. The meta-analysis below (combination of studies) shows that more than a third of MSers have swallowing difficulties or dysphagia. I must admit this figure was much higher than I would have expected from clinical practice; but our recent survey done via the blog confirms this figure. Are we missing dysphagia in clinic or is the prevalence going down as we modify the course of MS with DMTs?"

Dysphagia Survey Results from Gavin Giovannoni

"There are two ways to develop dysphagia. Firstly, as part of a clinical attack or relapse and secondly as part of progressive MS as the disease involves the coordination and muscles of swallowing. Swallowing problems occur when MS affects the brain stem. It is a very scary thing not being able to swallow properly and having choking episodes. The latter is a reason for so called aspiration and the development of pneumonia. Pneumonia is one of the commonest cause of death in end-stage MS."

"MS-related dysphagia is typically managed by swallowing therapy, dietary changes and feeding tubes. Swallowing therapy is done by our speech and language therapists (SLT) who use a range of techniques, these include swallowing exercises. Dietary changes are important for example advice about softer foods and thickened fluids that you may find easier to swallow. As a last resort we may have to insert a feeding tube; these are often needed to provide adequate nutrition while you're recovering your ability to swallow from a relapse or when your MS has progressed. A feeding tube also reduces your risk of getting an aspiration pneumonia. Another advantage of a feeding tube is it makes it easier to administer medication. There are two types of feeding tubes; a nasogastric tube – a tube that is passed down your nose and into your stomach and a a percutaneous endoscopic gastrostomy (PEG) tube – a tube that is implanted directly into your stomach. Nasogastric tubes are designed for short-term use and need to be replaced and swapped to the other nostril after about a month. PEG tubes are designed for long-term use and last several months before they need to be replaced."

"Good news; with our treatment target of NEDA we hopefully will prevent ongoing damage to the brain stem or at least delay it by many years. I therefore predict as we improve our management of MS the incidence of dysphagia will drop. Already we know that by simply starting interferon-beta 3 years earlier increases your chance of being alive at 21 years by almost 50%; this figure will be much better with more effective DMTs. The cause of death in the latter study was due to MS in  the majority of cases hence we can extrapolate this to a lower incidence of pneumonia and its main cause dysphagia."

"If you have dysphagia you need to make sure your neurologist and nurse know about it so you can be referred for treatment. Your family and carers also need to be trained to do pharyngeal sweep and the Heimlich manoeuvre to dislodge food in your throat if you choke. Simple things, common sense things, can often prevent a catastrophe."

Epub: Guan et al. Prevalence of dysphagia in multiple sclerosis: a systematic review and meta-analysis. Neurol Sci. 2015 Feb.

Background: Although dysphagia was recognized as a clinical finding in MS as early as 1877, it has not received enough attention yet. With the progress of diagnostic method for dysphagia, there has been a rapid development in estimating the prevalence of deglutition disorder in MS.

Aims: We aimed to conduct a systematic review and meta-analysis of published literature to establish the prevalence of dysphagia in multiple sclerosis. 

Methods: We systematically searched Embase, PubMed databases and Cochrane library from 1980 to August 2014, supplemented by hand searching to identify relevant studies. Of 198 retrieved articles, 15 eligible surveys with a total population of 4,510 met the criteria. 

Results: Twelve studies provided an estimate based on subjective screening test, which proved substantial heterogeneity with a combined prevalence estimate of 36 %. Four studies provided an estimate based on objective measurements (clinical or instrument tools), which were substantial heterogeneity with a pooled prevalence estimate of 81 %. 

Conclusions: The findings confirm that more than one-third of the multiple sclerosis patients are suffering from swallowing difficulties. Therefore, we should be careful to interpret the pooled estimate due to the substantial heterogeneity between studies

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