Swallowing Safety and Efficiency Impairment Profiles in Individuals with Amyotrophic Lateral Sclerosis

Systematic approach to contextualize findings of flexible endoscopic evaluation of swallowing in neurogenic dysphagia- towards an integrated FEES report

Flexible endoscopic evaluation of swallowing (FEES) is one of the most important methods for instrumental swallowing evaluation. The most challenging part of the examination consists in the interpretation of the various observations encountered during endoscopy and in the deduction of clinical consequences. This review proposes the framework for an integrated FEES-report that systematically moves from salient findings of FEES to more advanced domains such as dysphagia severity, phenotypes of swallowing impairment and pathomechanisms. Validated scales and scores are used to enhance the diagnostic yield. In the concluding part of the report, FEES-findings are put into the perspective of the clinical context. The potential etiology of dysphagia and conceivable differential diagnoses are considered, further diagnostic steps are proposed, treatment options are evaluated, and a timeframe for re-assessment is suggested. This framework is designed to be adaptable and open to continuous evolution. Additional items, such as novel FEES protocols, pathophysiological observations, advancements in disease-related knowledge, and new treatment options, can be easily incorporated. Moreover, there is potential for customizing this approach to report on FEES in structural dysphagia.

Neurogenic Dysphagia

This article provides an overview of neurogenic dysphagia, describing the evaluation and management of swallowing dysfunction in various neurologic diseases. The article will focus on stroke, Parkinson's disease, amyotrophic lateral sclerosis, and multiple sclerosis.

Effect of respiratory training on swallowing function in swallowing disorders: a systematic review and meta-analysis

PURPOSE

To determine the clinical efficacy of different respiratory training interventions on swallowing function in patients with swallowing disorders through the systematic review.

METHODS

We reviewed the literature regarding the application of respiratory training therapy in patients with swallowing disorders, followed by a PRISMA search of published literature in five databases (PubMed, Web of Science, The Cochrane Library, CINAHL and EMBASE) in December 2022. Two reviewers performed study selection, quality evaluation, and risk of bias, followed by data extraction and detailed analysis.

RESULTS

A total of six randomized controlled studies with a total sample size of 193 cases were included. Respiratory training improved swallowing safety (PAS (n = 151, SMD = 0.69, 95% CI - 1.11 to - 0.26, I2 = 36, p < 0.001)) and swallowing efficiency [residual (n = 63, SMD = 1.67, 95% CI - 2.26 to - 1.09, I2 = 23%, p < 0.001)] compared to control groups. The results of the qualitative analysis conducted in this study revealed that respiratory training enhanced hyoid bone movement but had no effect on swallowing quality of life.

CONCLUSIONS

Respiratory training interventions may improve swallowing safety and efficiency in patients with dysphagia. However, the level of evidence is low, and there is a limited amount of research on the effectiveness and physiology of this intervention to improve swallowing function. In the future, there is a need to expand clinical studies, standardize measurement tools, and improve study protocols.

Profiling Number of Swallows per Bolus and Residue in Individuals With Amyotrophic Lateral Sclerosis

PURPOSE

Swallowing efficiency impairments are the most prevalent and earliest manifestation of dysphagia in people with amyotrophic lateral sclerosis (pALS). We aimed to profile number of swallows elicited in pALS across thin liquid, moderately thick liquid, extremely thick liquid, and crackers compared to expected healthy reference data and to determine relationships between degree of pharyngeal residue, number of elicited swallows, and swallowing safety.

METHOD

pALS underwent standardized videofluoroscopic swallowing studies of 10 bolus trials. Trained raters performed duplicate, independent, and blinded ratings to derive Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) efficiency and safety grades and Analysis of Swallowing Physiology: Events, Kinematics, and Timing (ASPEKT) percent total pharyngeal residue. Number of swallows per bolus was quantified (1 = typical, 2 = atypically high, 3 = extremely high). Kruskal-Wallis, Pearson chi-square, and odds ratio analyses were performed at bolus and participant levels.

KEY RESULTS

At the bolus level (N = 2,523), number of swallows per bolus was observed to be, in rank order, as follows: atypically high (49.1%), extremely high (28.5%), and typical (22.4%). Mean number of swallows significantly differed by International Dysphagia Diet Standardisation Initiative level (p < .0001), with a higher number of swallows elicited in pALS for moderately thick versus thin liquids, extremely thick liquids, and crackers, p < .0001. Number of swallows per bolus increased with increasing DIGEST efficiency grades (p < .0001). Positive correlations were observed between ASPEKT percent residue and number of swallows for thin (r = .24) and moderately thick (r = .16) liquids, p < .05. DIGEST efficiency and safety grades were not significantly associated (p > .05).

CONCLUSION AND INFERENCES

pALS demonstrated a higher number of swallows per bolus compared to healthy reference data that may represent a compensation for reductions in swallowing efficiency to clear pharyngeal residue.

Acute Antipsychotic Use and Presence of Dysphagia Among Older Veterans with Heart Failure

OBJECTIVE

Examine whether new antipsychotic (AP) exposure is associated with dysphagia in hospitalized patients with heart failure (HF).

DESIGN

Retrospective cohort.

SETTINGS AND PARTICIPANTS

AP-naïve Veterans hospitalized with HF and subsequently discharged to a skilled nursing facility (SNF) between October 1, 2010, and November 30, 2019.

METHODS

We linked Veterans Health Administration (VHA) electronic medical records with Centers for Medicare & Medicaid (CMS) Minimum Data Set (MDS) version 3.0 assessments and CMS claims. The exposure variable was administration of ≥1 dose of a typical or atypical AP during hospitalization. Our main outcome measure was dysphagia presence defined by (1) inpatient dysphagia diagnosis codes and (2) the SNF admission MDS 3.0 swallowing-related items to examine post-acute care dysphagia status. Inverse probability of treatment weighting was used for risk adjustment.

RESULTS

The analytic cohort consisted of 29,591 Veterans (mean age 78.5 ± 10.0 years; female 2.9%; n = 865). Acute APs were administered to 9.9% (n = 2941). Those receiving APs had differences in prior dementia [37.1%, n = 1091, vs 22.3%, n = 5942; standardized mean difference (SMD) = 0.33] and hospital delirium diagnoses (7.7%, n = 227 vs 2.8%, n = 754; SMD = 0.22). Acute AP exposure was associated with nearly double the risk for hospital dysphagia diagnosis codes [adjusted (adj.) relative risk (RR) 1.9, 95% CI 1.8, 2.1]. At the SNF admission MDS assessment, acute AP administration during hospitalization was associated with an increased dysphagia risk (adj. RR 1.2, 95% CI 1.0, 1.5) both in the oral (adj. RR 1.7, 95% CI 1.2, 2.0) and pharyngeal phases (adj. RR 1.3, 95% CI 1.0, 1.7).

CONCLUSIONS AND IMPLICATIONS

In this retrospective study, AP medication exposure was associated with increased dysphagia coding and MDS assessment. Considering other adverse effects, acute AP should be cautiously administered during hospitalization, particularly in those with dementia. Swallowing function is critical to hydration, nutrition, and medical management of HF; therefore, when acute APs are initiated, a swallow evaluation should be considered.

Nutritional and metabolic factors in amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a complex neurodegenerative disease that is classically thought to impact the motor system. Over the past 20 years, research has started to consider the contribution of non-motor symptoms and features of the disease, and how they might affect ALS prognosis. Of the non-motor features of the disease, nutritional status (for example, malnutrition) and metabolic balance (for example, weight loss and hypermetabolism) have been consistently shown to contribute to more rapid disease progression and/or earlier death. Several complex cellular changes observed in ALS, including mitochondrial dysfunction, are also starting to be shown to contribute to bioenergetic failure. The resulting energy depletion in high energy demanding neurons makes them sensitive to apoptosis. Given that nutritional and metabolic stressors at the whole-body and cellular level can impact the capacity to maintain optimal function, these factors present avenues through which we can identify novel targets for treatment in ALS. Several clinical trials are now underway evaluating the effectiveness of modifying energy balance in ALS, making this article timely in reviewing the evidence base for metabolic and nutritional interventions.

Functional Lingual Pressure Thresholds for Swallowing Safety and Efficiency Impairments in Amyotrophic Lateral Sclerosis

Although reductions in lingual strength are reported in individuals with amyotrophic lateral sclerosis (ALS) that are associated with dysphagia; determination of a functional lingual pressure threshold (FLPT) has not yet been established. The present study therefore sought to identify an FLPT for impaired swallowing safety and efficiency in individuals with ALS.Thirty individuals with ALS completed a standardized videofluoroscopic swallowing examination and maximum anterior isometric lingual pressure testing using the Iowa Oral Performance Instrument. Duplicate, blinded ratings of the validated Penetration-Aspiration Scale (PAS) scores and Analysis of Swallowing Physiology: Events, Kinematics and Timing (ASPEKT) were performed. Binary classifications of safety (unsafe: PAS: ≥ 3) and efficiency (inefficient: ≥ 3% worst total pharyngeal residue) were derived. Descriptives and receiver operating characteristic curve analyses (AUC, sensitivity, specificity) were performed.Unsafe and inefficient swallowing were instrumentally confirmed in 57% and 70% of ALS patients, respectively. Across the entire cohort, the mean maximum lingual physiologic capacity was 32.1 kilopascals ('kPa'; SD: 18.1 kPa). The identified FLPT for radiographically confirmed unsafe swallowing was 43 kPa (sensitivity: 94%, specificity: 62%, AUC 0.82, p = 0.003). FLPT for inefficient swallowing was 46 kPa (sensitivity: 86%, specificity: 56%, AUC = 0.77, p = 0.02).These data provide preliminary FLPT data in a small cohort of individuals with ALS that need to be further investigated in larger cohorts to inform clinical screening practices.

Maximum lingual pressure impacts both swallowing safety and efficiency in individuals with amyotrophic lateral sclerosis

BACKGROUND

Although reduced lingual strength is a confirmed early manifestation of amyotrophic lateral sclerosis (ALS), its functional impact on swallowing remains unclear. We therefore sought to examine relationships between maximum anterior isometric lingual pressure (MAIP) with swallowing safety, swallowing efficiency, and swallowing timing metrics in a large cohort of individuals with ALS.

METHODS

Ninety-seven participants with ALS completed a standardized videofluoroscopic swallowing examination (VF) and lingual pressure testing (Iowa Oral Performance Instrument). Duplicate and blinded ratings of the Penetration-Aspiration Scale (PAS) and Analysis of Swallowing Physiology: Events, Kinematics and Timing (ASPEKT) percent efficiency (%C2-C42 ) and timing (laryngeal vestibule closure (LVC) duration: amount of time (milliseconds, msec) between LVC onset and laryngeal vestibule opening; time-to-LVC: hyoid burst to onset of LVC (msec); and swallow reaction time: interval between bolus passing ramus of mandible and onset of LVC (msec)) were performed across bolus trials. Swallowing safety (safe PAS: 1, 2, 4; unsafe PAS: 3, 5, 6, 7, and 8) and efficiency (inefficient: ≥3% worst total residue) were derived. Statistical analyses including descriptives, binary logistic regressions, and Spearman's rho correlations were performed (α = 0.05).

KEY RESULTS

Mean MAIP was 36.3 kPa (SD: 18.7). Mean MAIP was higher in those with safe swallowing as compared to those who penetrated (mean difference: 12 kPa) or aspirated (mean difference: 18 kPa). Individuals with efficient swallowing demonstrated higher MAIP than those with inefficient swallowing (mean difference: 11 kPa). Binary logistic regression analyses revealed increasing MAIP was significantly associated with a 1.06 (95% CI: 1.03-1.09) and 1.04 (95% CI: 1.01-1.06) greater odds of safe and efficient swallowing, respectively. No relationships were observed between MAIP and swallow reaction time across all bolus trials. Longer time-to-LVC (5 ml thin liquid: rs  = -0.35, p = 0.002; cup sip thin liquid: rs  = -0.26, p = 0.02; moderately thick liquid: rs  = -0.28, p = 0.01) and prolonged LVC duration (cup sip thin liquid, rs  = -0.34, p = 0.003) were associated with lower MAIP.

CONCLUSIONS AND INFERENCES

Reduced lingual strength was confirmed in this group of 97 individuals with ALS that was associated with a diminished ability to effectively transport boluses and aide in laryngeal vestibule closure to prevent entry of material into the airway.

How to increase noninvasive ventilation effectiveness in bulbar amyotrophic lateral sclerosis patients

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease in which the respiratory muscles are also affected, leading to respiratory failure. Bulbar impairment develops in almost all cases during the course of the disease, becoming severe in the late stages of disease. Noninvasive ventilation (NIV) has been shown to increase survival in ALS; however, severe bulbar dysfunction has a negative impact on NIV tolerance and effectiveness. Therefore, certain steps should be taken to improve NIV outcomes in these patients including optimal ventilatory parameters, adequate interface selection, effective respiratory secretion management and control of bulbar symptoms.

Safety and Clinical Benefits of Laryngeal Closure in Patients with Amyotrophic Lateral Sclerosis

This study evaluated the safety of laryngeal closure and post-surgical changes in swallowing function of patients with amyotrophic lateral sclerosis (ALS) and proposed an appropriate surgical strategy for patients with ALS. Clinical and surgical data of 26 consecutive patients with ALS who underwent laryngeal closure at Nagoya University Hospital in Japan between 2003 and 2020 were retrospectively analyzed. Changes in swallowing functions were evaluated before and approximately 1 month post-surgery using Neuromuscular Disease Swallowing Status Scale (NdSSS), and Functional Oral Intake Scale (FOIS). The median operation time was 126 min (range, 51-163 min), and the median intraoperative blood loss was 20 mL (range, 0-88 mL). Among the 26 ALS patients who underwent laryngeal closure, grade 1 (mild) complications occurred in three patients (12%); however, no severe complications were observed. After surgery, 25 patients (96%) maintained the swallowing function and only one patient (4%) had deteriorating NdSSS and FOIS scores. No patients were referred to our hospital due to severe aspiration pneumonia after the surgery. Two patients did not require a feeding tube after the surgery and returned to oral intake. Laryngeal closure may be a safe surgical procedure for preventing chronic aspiration and may also maintain swallowing function of patients with ALS. Further multicenter prospective studies using the gold standard videofluoroscopic swallowing examination are required to support our findings.

Profiles of Dysarthria and Dysphagia in Individuals With Amyotrophic Lateral Sclerosis

PURPOSE

While dysarthria and dysphagia are known bulbar manifestations of amyotrophic lateral sclerosis (ALS), the relative prevalence of speech and swallowing impairments and whether these bulbar symptoms emerge at the same time point or progress at similar rates is not yet clear. We, therefore, sought to determine the relative prevalence of speech and swallowing impairments in a cohort of individuals with ALS and to determine the impact of disease duration, severity, and onset type on bulbar impairments.

METHOD

Eighty-eight individuals with a confirmed diagnosis of ALS completed the ALS Functional Rating Scale-Revised (ALSFRS-R), underwent videofluoroscopy (VF), and completed the Sentence Intelligibility Test (SIT) during a single visit. Demographic variables including disease duration and onset type were also obtained from participants. Duplicate, independent, and blinded ratings were completed using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale and SIT to index dysphagia (DIGEST ≥ 1) and dysarthria (< 96% intelligible and/or < 150 words per minute) status. Descriptive statistics, Pearson chi-squared tests, independent-samples t tests, and odds ratios were performed.

RESULTS

Dysphagia and dysarthria were instrumentally confirmed in 68% and 78% of individuals with ALS, respectively. Dysarthria and dysphagia were associated (p = .01), and bulbar impairment profile distributions in rank order included (a) dysphagia - dysarthria (59%, n = 52), (b) no dysphagia - dysarthria (19%, n = 17), (c) no dysphagia - no dysarthria (13%, n = 11), and (d) dysphagia - no dysarthria (9%, n = 8). Participants with dysphagia or dysarthria demonstrated 4.2 higher odds of exhibiting a bulbar impairment in the other domain than participants with normal speech and swallowing (95% CI [1.5, 12.2]). There were no differences in ALSFRS-R total scores or disease duration across bulbar impairment profiles (p > .05). ALSFRS-R bulbar subscale scores were significantly lower in individuals with dysphagia versus no dysphagia (8.4 vs. 10.4, p < .0001) and dysarthria versus no dysarthria (8.5 vs. 10.9, p < .0001). Dysphagia and onset type (p = .003) and dysarthria and onset type were associated (p < .0001).

CONCLUSIONS

Over half of the individuals with ALS in this study demonstrated both dysphagia and dysarthria. Of those with only one bulbar impairment, speech was twice as likely to be the first bulbar symptom to degrade. Future studies are needed to confirm these findings and determine the longitudinal progression of bulbar impairments in this patient population.

Pharmacokinetics, Bioavailability, and Swallowing Safety With Riluzole Oral Film

Dysphagia is highly prevalent in patients with amyotrophic lateral sclerosis (ALS). Riluzole is a US Food and Drug Administration-approved treatment for ALS. Riluzole oral film (ROF; Exservan™) contains riluzole in a polymer-based film matrix. The ROF is administered by placing on the tongue, where it dissolves and the drug is ingested with the saliva. Two clinical trials assessed the safety and tolerability of the ROF. Bioavailability and pharmacokinetics (PK) were evaluated in an open-label, randomized, single-dose, replicate crossover study of 50 mg of ROF and riluzole 50-mg tablets in 32 healthy volunteers. The second study was a videofluoroscopic swallowing examination conducted with nine patients with ALS before and after receiving a single dose of 50 mg of ROF. The primary outcome was change on penetration-aspiration scale (PAS) scores from pre- to post-dose. Overall, the PK parameters for ROF and riluzole tablets were comparable between treatments and administrations when administered under fasting conditions. Administration of ROF with food resulted in a 15% reduction in area under the curve and a 45% reduction in maximum serum concentration. A total of 44 treatment-emergent adverse events (AEs) were reported in the study; all were mild in severity. No serious AEs were observed and no subjects discontinued due to AEs. In the swallowing study, very little numerical or categorical change was observed following the dose of ROF. No evidence of deterioration of swallowing function was observed post-dose. The ROF was bioequivalent to riluzole tablets, was well tolerated, and had no detrimental effect on swallowing.

Discriminant Ability of the Eating Assessment Tool-10 to Detect Swallowing Safety and Efficiency Impairments

OBJECTIVES/HYPOTHESIS

Quick, sensitive dysphagia screening tools are necessary to identify high-risk patients for further evaluation in busy multidisciplinary amyotrophic lateral sclerosis (ALS) clinics. We examined the relationship between self-perceived dysphagia using the validated Eating Assessment Tool-10 (EAT-10) and videofluoroscopic analysis of swallowing safety and efficiency.

STUDY DESIGN

Prospective, observational, longitudinal study.

METHODS

Individuals with ALS completed the EAT-10 and a videofluoroscopic swallowing study. Duplicate, independent, blinded analyses of the validated Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale were performed to index swallowing safety and efficiency (mild dysphagia: DIGEST ≥ 1, moderate dysphagia: DIGEST ≥ 2). A between-groups analysis of variance with Games-Howell test for post-hoc pairwise comparisons was performed to examine EAT-10 scores across dysphagia severity levels. Receiver operator characteristic curve analysis, area under the curve (AUC), sensitivity, specificity, positive-negative predictive values (PPV, NPV), and odds ratios (OR) were derived.

RESULTS

Four hundred and thirty five paired EAT-10 and DIGEST scores were analyzed. Mean EAT-10 score was 8.48 (95% confidence interval [CI]: 7.63-9.33). Individuals with dysphagia demonstrated higher EAT-10 scores (mild: 4.1 vs. 11.3, moderate: 6.0 vs. 17.5, P < .001). Mean EAT-10 scores increased across DIGEST levels (D0: 4.1, D1: 7.9, D2: 15.1, D3: 20.4, D4: 39.0). For mild dysphagia, an EAT-10 cut score of 3 was optimal: AUC 0.74 (95% CI: 0.69-0.78; sensitivity: 77%; specificity: 53%; PPV: 71%; NPV: 60%; OR: 3.5). An EAT-10 cut score of 7 optimized detection of moderate dysphagia: AUC 0.83 (95% CI: 0.78-0.87; sensitivity: 81%; specificity: 66%; PPV: 39%; NPV: 93%; OR: 8.1).

CONCLUSION

The EAT-10 is an easy-to-administer dysphagia screening tool with good discriminant ability for use in ALS clinics.

LEVEL OF EVIDENCE

2 Laryngoscope, 132:2319-2326, 2022.

Pilot Study of Respiratory-Swallow Coordination in Amyotrophic Lateral Sclerosis

PURPOSE

Amyotrophic lateral sclerosis (ALS) impacts bulbar and respiratory musculature, which may contribute to impaired swallow function (dysphagia) and respiratory-swallow coordination. The purpose of this pilot study was to examine if respiratory-swallow coordination in individuals with ALS was perturbed compared to healthy controls. We further explored relationships between measures of respiratory function and self-reported swallowing outcomes on respiratory-swallow coordination.

METHOD

We employed a cross-sectional design with eight participants with ALS and eight age- and sex-matched healthy participants. Respiratory inductance plethysmography and a nasal cannula were used to capture respiratory-swallow phase patterns during a standardized clinical swallow examination. The advantageous respiratory-swallow phase pattern was defined if exhalation surrounded the swallow (E-E). Spirometry was used to capture indices of respiratory function (forced vital capacity % predicted, peak cough flow [PCF]). Validated questionnaires were used to collect information regarding ALS-related bulbar functional status and swallowing-related concerns.

RESULTS

Compared to the matched healthy cohort, individuals with ALS demonstrated higher rates of non-E-E respiratory-swallow phase patterning and worse bulbar/swallow dysfunction. Group (ALS), swallow tasks, and PCF were significantly associated with respiratory-swallow phase pattern.

CONCLUSIONS

These preliminary findings support altered respiratory-swallow phase patterning in ALS. Future work should employ an instrumental assessment to quantify swallowing physiology and elucidate the relationship between perturbed respiratory-swallow coordination and swallowing function.

Comparison of Validated Videofluoroscopic Outcomes of Pharyngeal Residue: Concordance Between a Perceptual, Ordinal, and Bolus-Based Rating Scale and a Normalized Pixel-Based Quantitative Outcome

PURPOSE

This study compared the concordance between two validated videofluoroscopic pharyngeal residue outcome scales used in clinical and research settings: the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) and the Analysis of Swallowing Physiology: Events, Kinematics and Timing (ASPEKT) percent residue metric.

METHOD

Two trained raters completed independent and blinded videofluoroscopic ratings of both DIGEST efficiency and ASPEKT percent pharyngeal residue outcomes for bolus trials of 5 cc Varibar thin liquid (n = 223), thin liquid comfortable cup sips (n = 223), and 5 cc Varibar thin honey (n = 223). Spearman's rho and Kruskal-Wallis analyses were performed for each bolus type.

RESULTS

Significant associations between DIGEST and ASPEKT pharyngeal residue outcomes were noted for 5 cc thin (r = .54, p < .001), cup sip thin (r = .41, p < .001), and 5 cc thin honey (r = .60, p < .001) bolus trials. ASPEKT percent residue increased across worsening DIGEST efficiency ordinal scale levels, with a main effect for each bolus type. Post hoc analysis revealed significant differences in the ASPEKT percent residue values between each DIGEST pairwise comparison for the thin cup sip bolus trial and for each pairwise comparison except between the moderate-to-severe (less than half vs. majority) ordinal levels for the 5 cc thin and 5 cc honey bolus trials, p < .05.

CONCLUSIONS

Perceptual, ordinal (DIGEST) and quantitative, pixel-based (ASPEKT) videofluoroscopic pharyngeal residue outcomes were associated in this data set of 669 bolus trials. Future research is warranted to confirm these results.

Comparison of Lingual Pressure Generation Capacity in Parkinson Disease, Amyotrophic Lateral Sclerosis, and Healthy Aging

PURPOSE

The tongue plays a key role in bolus propulsion during swallowing, with reduced lingual pressure generation representing a risk factor for impaired swallowing safety and efficiency. We compared lingual pressure generation capacity in people with Parkinson disease (PwPD), people with amyotrophic lateral sclerosis (PwALS), and healthy older adults. We hypothesized that both patient cohorts would demonstrate reduced maximum anterior isometric pressure (MAIP) and regular effort saliva swallow (RESS) pressures compared with healthy controls, with the greatest reductions expected in the ALS cohort.

METHOD

We enrolled 20 PwPD, 18 PwALS, and 20 healthy adults over 60 years of age. The Iowa Oral Performance Instrument was used to measure MAIP, RESS, and lingual functional reserve (LFR, i.e., MAIP - RESS). Descriptive statistics were calculated; between-groups differences were explored using univariate analyses of variance and post hoc Sidak tests with alpha set at .05.

RESULTS

Mean MAIPs for the PD, ALS, and heathy cohorts were 54.7, 33.5, and 47.4 kPa, respectively. Significantly lower MAIP was found in PwALS compared with PwPD and healthy controls. RESS values did not differ significantly across groups. LFR was significantly higher in PwPD versus PwALS and healthy controls.

CONCLUSIONS

Lingual pressure generation capacity and functional reserve were reduced in PwALS, but not in PwPD, beyond changes seen with healthy aging. Both patient cohorts displayed preserved lingual pressure during saliva swallows. Future studies exploring longitudinal changes in tongue pressure generation on isometric and saliva swallowing tasks will be needed to confirm whether tongue pressure measures serve as noninvasive clinical biomarkers of swallowing impairment.

Discriminant ability of the 3-ounce water swallow test to detect aspiration in amyotrophic lateral sclerosis

BACKGROUND

Given the need for quick and accurate dysphagia screening tools to optimize referral workflows and resource utilization in fast-paced multidisciplinary amyotrophic lateral sclerosis (ALS) clinics, we evaluated the discriminant ability of the 3 oz. water swallow test (WST) to detect aspiration in individuals with ALS.

METHODS

A total of 212 paired 3 oz. WST (index test) and standardized videofluoroscopic swallow studies (reference test) were completed in individuals with a confirmed diagnosis of ALS. Blinded raters analyzed swallowing safety using the validated penetration-aspiration scale (PAS; non-aspirator: PAS < 6; aspirator: PAS ≥ 6). Receiver operating characteristic curve analysis, area under the curve (AUC), sensitivity, specificity, and positive and negative predictive values (PPV, NPV) were calculated.

KEY RESULTS

Index test: 78 (36.8%) WSTs were scored as a fail and 134 (63.2%) as a pass.

REFERENCE TEST

Aspiration was confirmed in 67 (31.6%) reference tests with 145 (68.4%) reference tests verified as having no aspiration. Sensitivity and specificity of the 3 oz. WST to detect radiographically confirmed aspiration was 55.2% and 71.7%, respectively (AUC: 0.635, PPV: 47.4%, NPV: 77.6%).

CONCLUSIONS & INFERENCES

In this dataset, the 3 oz. WST did not demonstrate adequate sensitivity or specificity to detect aspiration in people with ALS as a stand-alone dysphagia screening tool.

Use of Pharyngeal High-Resolution Manometry to Evaluate Dysphagia in Adults with Motor Neurone Disease: A Scoping Review

There has been a recent shift towards proactive dysphagia intervention in motor neurone disease (MND) to maintain physiological reserve. Pharyngeal high-resolution manometry (PHRM) can quantify swallowing pathophysiology to inform and evaluate proactive dysphagia intervention. This study aims to explore the current use of PHRM as a dysphagia evaluation in adults with MND. A scoping review based on the Joanna Briggs Framework was completed. Four electronic databases (PubMed, EMBASE, CINAHL and Web of Science core) were searched (inception to March 2021) by two independent researchers. Data were analysed according to (i) PHRM protocol and analysis methods and the feasibility of same, (ii) swallow biomechanics data and (iii) dysphagia intervention effects as measured by PHRM. Six studies with 78 people with MND (PwMND) were included. There was considerable variation in PHRM protocol and analysis methods. Five studies reported a 100% completion rate and three studies reported no adverse events. Swallow biomechanics data were reported across all studies. The effects of sensory stimulation, increased bolus consistency, effortful swallow and cricopharyngeal myotomy were evaluated using PHRM with 20 PwMND across four studies with varying effects. Literature on the use of PHRM in PwMND is limited. Variability in PHRM methods restricts comparison of metrics. PHRM appears to be a feasible tool for PwMND. PHRM can provide novel swallow physiology data in PwMND and quantify discrete effects of compensatory and surgical dysphagia interventions not detectable by videofluoroscopy or FEES. Further research on the effects of proactive dysphagia intervention as measured by PHRM is required.