Abstract
Objectives
Swallowing disorders (dysphagia) are common and can incur a negative psychological impact in persons with multiple sclerosis. Mindfulness-Based Cognitive Therapy (MBCT) has the potential to treat dysphagia alongside associated mental health disorders. The purpose of this preliminary trial was to evaluate the efficacy of MBCT combined with diet modification (MBCT-DM) compared to diet modification (DM) alone on swallowing function in persons with multiple sclerosis and dysphagia.
Method
The study design involved a preliminary randomized parallel two-arm trial. Forty-four participants with multiple sclerosis who had dysphagia symptoms were recruited and allocated to MBCT-DM or DM. The primary measure involved comparing the efficacy of the combined intervention (MBCT-DM) to DM alone on dysphagia outcomes. Secondary outcome measures included psychological symptoms, emotional regulation strategies, and level of mindfulness. Outcomes were assessed at baseline and immediately after treatment. We also explored recruitment potential and retention for the MBCT program.
Results
Eighty-five percent of patients with suspected multiple sclerosis demonstrated interest. The first 44 eligible patients who signed consent were included. All completed at least six of the eight MBCT sessions. For the primary and secondary outcomes, all between-group differences favored the MBCT-DM intervention demonstrating decrease of dysphagia (η2 = 0.71) and psychological symptoms, and improvement of emotion regulation strategies, and mindfulness levels (η2 ranging from 0.69 to 0.77).
Conclusions
It is practical to deliver MBCT adjunct to diet modification for the treatment of dysphagia. Such treatment appears to confer physical and psychological benefits. A definitive RCT should be undertaken to confirm these preliminary data.
Preregistration
IRCT.ir registration identifier: IRCT20200521047537N1.
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References
Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review, 30(2), 217–237. https://doi.org/10.1016/j.cpr.2009.11.004
Altman, K. W., Richards, A., Goldberg, L., Frucht, S., & McCabe, D. J. (2013). Dysphagia in stroke, neurodegenerative disease, and advanced dementia. Otolaryngologic Clinics of North America, 46(6), 1137–1149. https://doi.org/10.1016/j.otc.2013.08.005
Ansari, N. N., Naghdi, S., Hasson, S., Valizadeh, L., & Jalaie, S. (2010). Validation of a Mini-Mental State Examination (MMSE) for the Persian population: A pilot study. Applied Neuropsychology, 17(3), 190–195. https://doi.org/10.1002/14651858.CD010783.pub3
Antony, M. M., Bieling, P. J., Cox, B. J., Enns, M. W., & Swinson, R. P. (1998). Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychological Assessment, 10(2), 176. https://doi.org/10.1037/1040-3590.10.2.176
Asghari, A., Saed, F., & Dibajnia, P. (2008). Psychometric properties of the Depression Anxiety Stress Scales-21 (DASS-21) in a non-clinical Iranian sample. International Journal of Psychology, 2(2), 82–102.
Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., Segal, Z. V., Abbey, S., Speca, M., Velting, D., & Devins, G. (2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11(3), 230–241. https://doi.org/10.1093/clipsy.bph077
Bogosian, A., Chadwick, P., Windgassen, S., Norton, S., McCrone, P., Mosweu, I., Silber, E., & Moss-Morris, R. (2015). Distress improves after mindfulness training for progressive MS: A pilot randomised trial. Multiple Sclerosis Journal, 21(9), 1184–1194. https://doi.org/10.1177/1352458515576261
Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84(4), 822–848. https://doi.org/10.1037/0022-3514.84.4.822
Brown, T. A., Chorpita, B. F., Korotitsch, W., & Barlow, D. H. (1997). Psychometric properties of the Depression Anxiety Stress Scales (DASS) in clinical samples. Behaviour Research and Therapy, 35(1), 79–89. https://doi.org/10.1016/S0005-7967(96)00068-X
Browne, R. H. (1995). On the use of a pilot sample for sample size determination. Statistics in Medicine, 14(17), 1933–1940. https://doi.org/10.1002/sim.4780141709
Calcagno, P., Ruoppolo, G., Grasso, M., De Vincentiis, M., & Paolucci, S. (2002). Dysphagia in multiple sclerosis–prevalence and prognostic factors. Acta Neurologica Scandinavica, 105(1), 40–43. https://doi.org/10.1034/j.1600-0404.2002.10062.x
Carlson, L. E. (2012). Mindfulness-based interventions for physical conditions: A narrative review evaluating levels of evidence. International Scholarly Research Notices, 2012(2012), 651583. https://doi.org/10.5402/2012/651583
Coffey, K. A., & Hartman, M. (2008). Mechanisms of action in the inverse relationship between mindfulness and psychological distress. Complementary Health Practice Review, 13(2), 79–91. https://doi.org/10.1177/1533210108316307
Cohen, J. (2013). Statistical power analysis for the behavioral sciences. Academic press.
Cohen, R. M., Weingartner, H., Smallberg, S. A., Pickar, D., & Murphy, D. L. (1982). Effort and cognition in depression. Archives of General Psychiatry, 39(5), 593–597. https://doi.org/10.1001/archpsyc.1982.04290050061012
Dehaghani, S. E., Doosti, A., & Zare, M. (2021). Association between swallowing disorders and cognitive disorders in adults: A systematic review and meta-analysis. Psychogeriatrics, 21(4), 668–674. https://doi.org/10.1111/psyg.12704
Donaldson, C., Lam, D., & Mathews, A. (2007). Rumination and attention in major depression. Behaviour Research and Therapy, 45(11), 2664–2678. https://doi.org/10.1016/j.brat.2007.07.002
Fortin, M., Bravo, G., Hudon, C., Lapointe, L., Almirall, J., Dubois, M.-F., & Vanasse, A. (2006). Relationship between multimorbidity and health-related quality of life of patients in primary care. Quality of Life Research, 15(1), 83–91. https://doi.org/10.1007/2Fs11136-005-8661-z
Ghorbani, N., Watson, P., & Weathington, B. L. (2009). Mindfulness in Iran and the United States: Cross-cultural structural complexity and parallel relationships with psychological adjustment. Current Psychology, 28(4), 211. https://doi.org/10.1007/s12144-009-9060-3
Gross, J. J., & Thompson, R. A. (2007). Emotion Regulation: Conceptual Foundations. In J. J. Gross (Ed.), Handbook of emotion regulation (pp. 3–24). Guilford Press.
Gross, J. J., & John, O. P. (2003). Individual differences in two emotion regulation processes: Implications for affect, relationships, and well-being. Journal of Personality and Social Psychology, 85(2), 348–362. https://doi.org/10.1037/0022-3514.85.2.348
Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress reduction and health benefits: A meta-analysis. Journal of Psychosomatic Research, 57(1), 35–43. https://doi.org/10.1016/S0022-3999(03)00573-7
Hasani, J. (2016). Persian version of the emotion regulation questionnaire: Factor structure, reliability and validity. International Journal of Behavioral Sciences, 10(3), 156–161.
Henry, J. D., & Crawford, J. R. (2005). The short-form version of the Depression Anxiety Stress Scales (DASS-21): Construct validity and normative data in a large non-clinical sample. British Journal of Clinical Psychology, 44(2), 227–239. https://doi.org/10.1348/014466505X29657
Hölzel, B. K., Lazar, S. W., Gard, T., Schuman-Olivier, Z., Vago, D. R., & Ott, U. (2011). How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspectives on Psychological Science, 6(6), 537–559. https://doi.org/10.1177/1745691611419671
Jean, A. (2001). Brain stem control of swallowing: Neuronal network and cellular mechanisms. Physiological Reviews, 81(2), 929–969. https://doi.org/10.1152/physrev.2001.81.2.929
Korostil, M., & Feinstein, A. (2007). Anxiety disorders and their clinical correlates in multiple sclerosis patients. Multiple Sclerosis Journal, 13(1), 67–72. https://doi.org/10.1177/1352458506071161
Kurtzke, J. F. (1983). Rating neurologic impairment in multiple sclerosis: An expanded disability status scale (EDSS). Neurology, 33(11), 1444–1452. https://doi.org/10.1212/wnl.33.11.1444
Ma, S. H., & Teasdale, J. D. (2004). Mindfulness-based cognitive therapy for depression: Replication and exploration of differential relapse prevention effects. Journal of Consulting and Clinical Psychology, 72(1), 31–40. https://doi.org/10.1037/0022-006X.72.1.31
Mann, G. (2002). MASA: The Mann Assessment of Swallowing Ability (Vol. 1). Singular/Thomson Learning.
Martin, R. E., Goodyear, B. G., Gati, J. S., & Menon, R. S. (2001). Cerebral cortical representation of automatic and volitional swallowing in humans. Journal of Neurophysiology, 85(2), 938–950. https://doi.org/10.1152/ajpgi.2001.280.3.G354
Martino, R., & McCulloch, T. (2016). Therapeutic intervention in oropharyngeal dysphagia. Nature Reviews Gastroenterology & Hepatology, 13(11), 665. https://doi.org/10.1038/nrgastro.2016.127
McDonald, W. I., Compston, A., Edan, G., Goodkin, D., Hartung, H. P., Lublin, F. D., McFarland, H. F., Paty, D. W., Polman, C. H., Reingold, S. C., & Sandberg-Wollheim, M. (2001). Recommended diagnostic criteria for multiple sclerosis: Guidelines from the International Panel on the Diagnosis of Multiple Sclerosis. Annals of Neurology: Official Journal of the American Neurological Association and the Child Neurology Society, 50(1), 121–127. https://doi.org/10.1002/ana.1032
Miller, G., Chen, E., & Cole, S. W. (2009). Health psychology: Developing biologically plausible models linking the social world and physical health. Annual Review of Psychology, 60, 501–524. https://doi.org/10.1146/annurev.psych.60.110707.163551
Nathadwarawala, K., Nicklin, J., & Wiles, C. (1992). A timed test of swallowing capacity for neurological patients. Journal of Neurology, Neurosurgery & Psychiatry, 55(9), 822–825. https://doi.org/10.1136/jnnp.55.9.822
Naylor, C., Parsonage, M., McDaid, D., Knapp, M., Fossey, M., & Galea, A. (2012). Long-term conditions and mental health: The cost of co-morbidities. King's Fund.
Sadeghi, Z., Afshar, M., Ebadi, A., Baghban, K., & Qureshi, Z. S. (2020). Swallowing disorder in multiple sclerosis: Modified version of the screening tool. Archives of Rehabilitation, 21(2), 236–255. https://doi.org/10.32598/RJ.21.2.3036.1
Sadeghi, Z., Ghoreishi, Z. S., Flowers, H., Mohammadkhani, P., Ashtari, F., & Noroozi, M. (2021). Depression, anxiety, and stress relative to swallowing impairment in persons with multiple sclerosis. Dysphagia, 36, 902–909. https://doi.org/10.1007/s00455-020-10207-x
Scale, F. C. (2017). Mindfulness-based cognitive therapy for severely fatigued multiple sclerosis patients: A waiting list controlled study. Journal of Rehabilitation Medicine, 49(6), 497–504. https://doi.org/10.2340/16501977-2237
Scalfari, A., Knappertz, V., Cutter, G., Goodin, D. S., Ashton, R., & Ebers, G. C. (2013). Mortality in patients with multiple sclerosis. Neurology, 81(2), 184–192. https://doi.org/10.1212/WNL.0b013e31829a3388
Segal, Z. V., & Teasdale, J. (2018). Mindfulness-based cognitive therapy for depression: Guilford Publications.
Segal, Z. V., Teasdale, J. D., Williams, J. M., & Gemar, M. C. (2002). The Mindfulness-Based Cognitive Therapy Adherence Scale: Inter-rater reliability, adherence to protocol and treatment distinctiveness. Clinical Psychology & Psychotherapy, 9(2), 131–138. https://doi.org/10.1002/cpp.320
Simpson, R., Simpson, S., Ramparsad, N., Lawrence, M., Booth, J., & Mercer, S. W. (2020). Effects of mindfulness-based interventions on physical symptoms in people with multiple sclerosis–A systematic review and meta-analysis. Multiple Sclerosis and Related Disorders, 38, 101493. https://doi.org/10.1016/j.msard.2019.101493
Steele, C. M., Namasivayam-MacDonald, A. M., Guida, B. T., Cichero, J. A., Duivestein, J., Hanson, B., Lam, P., & Riquelme, L. F. (2018). Creation and initial validation of the international dysphagia diet standardisation initiative functional diet scale. Archives of Physical Medicine and Rehabilitation, 99(5), 934–944. https://doi.org/10.1016/j.apmr.2018.01.012
Tassorelli, C., Bergamaschi, R., Buscone, S., Bartolo, M., Furnari, A., Crivelli, P., Alfonsi, E., Alberici, E., Bertino, G., Sandrini, G., & Nappi, G. (2008). Dysphagia in multiple sclerosis: From pathogenesis to diagnosis. Neurological Sciences, 29(4), 360–363. https://doi.org/10.1007/s10072-008-1044-9
Teasdale, J. D., Segal, Z. V., & Williams, J. M. G. (2003). Mindfulness training and problem formulation. Clinical Psychology: Science and Practice, 10(2), 157–160. https://doi.org/10.1093/clipsy.bpg017
Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V. A., Soulsby, J. M., & Lau, M. A. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68(4), 615–623. https://doi.org/10.1037//0022-006x.68.4.615
Verdonschot, R. J., Baijens, L. W., Vanbelle, S., van de Kolk, I., Kremer, B., & Leue, C. (2017). Affective symptoms in patients with oropharyngeal dysphagia: A systematic review. Journal of Psychosomatic Research, 97, 102–110. https://doi.org/10.1016/j.jpsychores.2017.04.006
Vissicchio, N. A., Altaras, C., Parker, A., Schneider, S., Portnoy, J. G., Archetti, R., Stimmel, M., & Foley, F. W. (2019). Relationship between anxiety and cognition in multiple sclerosis: Implications for treatment. International Journal of MS Care, 21(4), 151–156. https://doi.org/10.7224/1537-2073.2018-027
White, L. J., & Dressendorfer, R. H. (2004). Exercise and multiple sclerosis. Sports Medicine, 34(15), 1077–1100. https://doi.org/10.2165/00007256-200434150-00005
World Health Organization. (2008). Atlas: Multiple Sclerosis Resources in the World 2008. https://doi.org/10.1007/s10865-012-9434-0
Wright, A. A., Zhang, B., Ray, A., Mack, J. W., Trice, E., Balboni, T., Mitchell, S. L., Jackson, V. A., Block, S. D., Maciejewski, P. K., & Prigerson, H. G. (2008). Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA, 300(14), 1665–1673. https://doi.org/10.1001/jama.300.14.1665
Acknowledgements
The authors would like to acknowledge the great contribution of the patients who participated in the study.
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ZS: designed and executed the study and contributed to data analysis; wrote the resulting manuscript. ZSG: collaborated on the design and study conceptualization. HF: provided consultation on swallowing assessment and treatment methods relative to the study conceptualization and design; contributed to writing and editing of the manuscript. PM: contributed to the study conceptualization, design, and conduct. MN: contributed to the determination and application of the data analyses.
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Written informed consent was obtained from all patients with approval for a proxy signature from a relative when the patient did not have capacity to sign (in cases of severe dysgraphia due to hand weakness).
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Sadeghi, Z., Ghoreishi, Z.S., Flowers, H.L. et al. Efficacy of Mindfulness-Based Cognitive Therapy Compared to Diet Modification Alone for Dysphagia in Persons with Multiple Sclerosis. Mindfulness 14, 91–100 (2023). https://doi.org/10.1007/s12671-022-02053-9
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DOI: https://doi.org/10.1007/s12671-022-02053-9