Abstract
Dysphagia is common in individuals with amyotrophic lateral sclerosis (ALS) and associated with reductions in quality of life and health-related outcomes. Despite the high prevalence of dysphagia in ALS, functional impairment profiles of swallowing safety and efficiency have not been comprehensively examined. We therefore aimed to determine the relative prevalence of unsafe and inefficient swallowing in a large cohort of individuals with ALS. We further sought to examine the impact of global and bulbar disease progression (Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised "ALSFRS-R" total and bulbar scores, respectively), disease duration, and onset type on swallowing impairment profiles. One hundred individuals with ALS completed a standardized videofluoroscopic swallowing examination Two independent and blinded raters performed validated ratings of safety (Penetration-Aspiration Scale, PAS) and efficiency (Analysis of Swallowing Physiology: Events, Kinematics, and Timing, ASPEKT % residue). Binary classifications of safety (unsafe: PAS ≥ 3), efficiency (inefficient: total residue ≥ 3% of C2-42) and global swallowing status were derived. The ALSFRS-R was completed to derive ALSFRS-R total and bulbar subscale scores. Demographic data (disease duration and onset type) for each participant was also recorded. Descriptives, 2 × 2 contingency tables with Fishers exact test, and independent samples t-tests were performed (α = 0.05). Prevalence of unsafe and inefficient swallowing was 48% and 73%, respectively. Global swallowing profiles were, in rank order: unsafe and inefficient (39%), inefficient but safe (34%), safe and efficient (18%), and unsafe but efficient (9%). There were no differences in global disease progression or disease duration across swallowing impairment profiles. ALSFRS-R bulbar subscale scores were significantly lower in unsafe versus safe swallowers, p < 0.05. Spinal onset patients had a greater proportion of safe swallowers as compared to bulbar onset patients (p = 0.000, Fisher's exact test). Both spinal and bulbar onset patients demonstrated a higher prevalence of inefficient swallowers as compared to efficient swallowers (p = 0.04, Fisher's exact test). Dysphagia was prevalent in this group of individuals with ALS. Approximately half demonstrated safety impairments and two-thirds had impairments in swallowing efficiency. Inefficient swallowing was approximately four times more likely to be the initial functional impairment in patients with one pathophysiologic functional impairment. A longitudinal study is needed to examine the temporal evolution of dysphagia in ALS.
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Acknowledgements
We would like to thank Dr. Catriona Steele of the Swallowing Rehabilitation Research Laboratory for lending her scientific expertise and insight to support this research. This manuscript was (partially) prepared with the use of resources and facilities at the William S. Middleton Memorial Veterans Hospital, Madison WI (GRECC Manuscript 008-2021). The views and content expressed in this article are solely the responsibility of the authors and do not necessarily reflect the position, policy, or official views of the Department of Veterans Affairs, the U.S. Government, or the NIH. This work was based on a dissertation chapter submitted by the first author to the University of Florida in partial fulfillment of requirements for the degree of Doctor of Philosophy.
Funding
This work was supported by National Institute of Neurological Disorders and Stroke (NINDS) Grant Numbers: 1R01 NS100859-01, 5R01NS10859-02S1, and 1F99 NS115339-01.
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Robison, R., DiBiase, L., Ashley, A. et al. Swallowing Safety and Efficiency Impairment Profiles in Individuals with Amyotrophic Lateral Sclerosis. Dysphagia 37, 644–654 (2022). https://doi.org/10.1007/s00455-021-10315-2
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DOI: https://doi.org/10.1007/s00455-021-10315-2