Emily K. Plowman

Impact of expiratory strength training in amyotrophic lateral sclerosis

Introduction: We evaluated the feasibility and impact of expiratory muscle strength training (EMST) on respiratory and bulbar function in persons with amyotrophic lateral sclerosis (ALS). Methods: Twenty‐five ALS patients participated in this delayed intervention open‐label clinical trial. Following a lead‐in period, patients completed a 5‐week EMST protocol. Outcome measures included: maximum expiratory pressure (MEP); physiologic measures of swallow and cough; and penetration–aspiration scale (PAS) scores. Results: Of participants who entered the active phase of the study (n = 15), EMST was well tolerated and led to significant increases in MEPs and maximum hyoid displacement during swallowing post‐EMST (P < 0.05). No significant differences were observed for PAS scores or cough spirometry measures. Conclusions: EMST was feasible and well tolerated in this small cohort of ALS patients and led to improvements in expiratory force‐generating pressures and swallow kinematics. Further investigation is warranted to confirm these preliminary findings. Muscle Nerve 54: 48–53, 2016

Discriminant ability of the Eating Assessment Tool-10 to detect aspiration in individuals with amyotrophic lateral sclerosis.

Oropharyngeal dysphagia is prevalent in individuals with amyotrophic lateral sclerosis (ALS) leading to malnutrition, aspiration pneumonia, and death. These factors necessitate early detection of at‐risk patients to prolong maintenance of safe oral intake and pulmonary function. This study aimed to evaluate the discriminant ability of the Eating Assessment Tool (EAT‐10) to identify ALS patients with unsafe airway protection during swallowing.

Is There a Role for Exercise in the Management of Bulbar Dysfunction in Amyotrophic Lateral Sclerosis

PURPOSE The role of exercise in the management of people with amyotrophic lateral sclerosis (PALS) is controversial and currently unclear. The purpose of this review article is to review literature examining the impact of limb, respiratory, and oral motor exercise on function, disease progression, and survival in PALS and the transgenic ALS animal model. METHOD A literature review was conducted to examine relevant studies published in peer-reviewed journals between 1960 and 2014. All studies were appraised for quality of research and were assigned a level of evidence, and treatment outcomes were classified as either positive, negative, or neutral. RESULTS A total of 18 exercise-based intervention studies on limb (13), respiratory (3), or speech (2) function were identified. Of the human clinical trials, 6 were experimental and 4 were exploratory. No experimental studies were identified examining the impact of targeted exercise on speech or swallowing function. Mild to moderate intensity limb or respiratory exercise, applied early in the disease, was noted to have a beneficial impact on motor function and survival. CONCLUSION Insufficient data exist to support or refute the role of exercise in the management of bulbar dysfunction in PALS. This represents a critical area of future investigation.

Motor cortex reorganization across the lifespan

UNLABELLED The brain is a highly dynamic structure with the capacity for profound structural and functional change. Such neural plasticity has been well characterized within motor cortex and is believed to represent one of the neural mechanisms for acquiring and modifying motor behaviors. A number of behavioral and neural signals have been identified that modulate motor cortex plasticity throughout the lifespan in both the intact and damaged brain. Specific signals discussed in this review include: motor learning in the intact brain, motor relearning in the damaged brain, cortical stimulation, stage of development and genotype. Clinicians are encouraged to harness these signals in the development and implementation of treatment so as to maximally drive neural plasticity and functional improvements in speech, language and swallowing. LEARNING OUTCOMES Readers will be able to: (1) describe a set of behavioral and neural signals that modulate motor cortex plasticity in the intact and damaged brain; (2) describe the influence of stage of development on plasticity and functional outcomes; and (3) identify a known genotype that alters the capacity for motor learning and brain plasticity.

The evaluation of bulbar dysfunction in amyotrophic lateral sclerosis: survey of clinical practice patterns in the United States

Abstract Objective: Speech and swallowing impairments are highly prevalent in individuals with amyotrophic lateral sclerosis (ALS) and contribute to reduced quality of life, malnutrition, aspiration, pneumonia and death. Established practice parameters for bulbar dysfunction in ALS do not currently exist. The aim of this study was to identify current practice patterns for the evaluation of speech and swallowing function within participating Northeast ALS clinics in the United States. Methods and results: A 15-item survey was emailed to all registered NEALS centres. Thirty-eight sites completed the survey. The majority (92%) offered Speech-Language Pathology, augmentative and alternative communication (71%), and dietician (92%) health care services. The ALS Functional Rating Scale-Revised and body weight represented the only parameters routinely collected in greater then 90% of responding sites. Referral for modified barium swallow study was routinely utilised in only 27% of sites and the use of percutaneous gastrostomy tubes in ALS patient care was found to vary considerably. Conclusions: This survey reveals significant variability and inconsistency in the management of bulbar dysfunction in ALS across NEALS sites. We conclude that a great need exists for the development of bulbar practice guidelines in ALS clinical care to accurately detect and monitor bulbar dysfunction.

Late tracheotomy is associated with higher morbidity and mortality in mechanically ventilated patients

To determine whether the timing of tracheotomy placement impacts ventilation weaning status and mortality.

Respiratory training in an individual with amyotrophic lateral sclerosis

We examined the impact of expiratory muscle strength training on maximum expiratory pressure, cough spirometry, and disease progression in a 71‐year‐old male with amyotrophic lateral sclerosis. Maximum expiratory pressure declined 9% over an 8‐week sham training period, but subsequently improved by 102% following 8 weeks of expiratory muscle strength training. Improvements in cough spirometry and mitigated disease progression were also observed post expiratory muscle strength training. Improvements in maximum expiratory pressures were maintained 6 months following expiratory muscle strength training and were 79% higher than baseline data obtained 301 days prior. In this spinal‐onset amyotrophic lateral sclerosis patient, respiratory training improved subglottic air pressure generation and sequential cough generation.

Elucidating inconsistencies in dysphagia diagnostics: Redefining normal

Abstract Speech–language pathologists (SLPs) are the primary healthcare providers responsible for the evaluation and treatment of dysphagia. Fundamental to this role is the ability to make accurate clinical judgements to distinguish between normal versus disordered swallowing for subsequent treatment planning. In this review, we highlight recent data collected from practising clinicians in the USA that reveal low levels of agreement across clinicians and poor to moderate levels of accuracy for making binary diagnostic ratings (normal vs. disordered). We then propose and discuss barriers that may represent challenges to practising SLP’s understanding of normal swallowing physiology. Proposed barriers include: (1) an educational focus on the disordered system; (2) system 1 processing; (3) complexity of the swallowing system; (4) inability to directly visualise the swallowing process; (5) degree of variability of normal swallowing; and (6) high clinical productivity requirements. This article concludes with suggestions for reducing identified educational and clinical barriers to ultimately improve diagnostic decision-making practices and to benefit patient-related outcomes in dysphagia management.

To Cough or Not to Cough? Examining the Potential Utility of Cough Testing in the Clinical Evaluation of Swallowing

PurposeThe clinical swallowing evaluation (CSE) represents a critical component of a comprehensive assessment of deglutition. Although universally utilized across clinical settings, the CSE demonstrates limitations in its ability to accurately identify all individuals with dysphagia. There exists a need to improve assessment and screening techniques to improve health outcomes, treatment recommendations and ultimately mortality in individuals at risk for dysphagia. The following narrative review provides a summary of currently used validated CSE’s and examines the potential role of cough testing and screening in the CSE.Recent findingsRecent evidence highlights a relationship between objective physiologic measurements of both voluntarily and reflexively induced cough and swallowing safety status across several patient populations. Although more research is needed across a wider range of patient populations to validate these findings; emerging data supports the consideration of inclusion of cough testing during the CSE as an index of airway defense mechanisms and capabilities in individuals at risk for aspiration.SummaryThe sensorimotor processes of cough and swallowing share common neuroanatomical and functional substrates. Inclusion of voluntarily or reflexively induced cough testing in the CSE may aide in the identification of dysphagia and reduced airway protection capabilities.

Reduced pharyngeal constriction is associated with impaired swallowing efficiency in Amyotrophic Lateral Sclerosis (ALS)

Swallowing inefficiency is a prevalent but understudied problem in individuals with Amyotrophic Lateral Sclerosis (ALS). Although reduced pharyngeal constriction has been identified as a mechanism contributing to swallowing inefficiency following stroke, this relationship has not been empirically tested in the ALS population. This study sought to characterize profiles of swallowing efficiency in a sample of ALS patients and investigate relationships between pharyngeal constriction and swallowing efficiency.