Botulinum toxin and rehabilitation treatment in inclusion body myositis for severe oropharyngeal dysphagia

Diagnosing and managing dysphagia in inclusion body myositis: a systematic review

OBJECTIVES

Dysphagia is a common debilitating clinical feature of IBM. However, the impact of dysphagia in IBM has been historically overlooked. This study aimed to identify, evaluate and summarize the evidence regarding the assessment and management of dysphagia in persons with IBM undergoing treatment.

METHODS

A systematic review was conducted using a multiengine search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. Eligible studies had to employ an intervention for persons with IBM, report a swallowing outcome and be published in English. Quality assessments of the eligible studies were performed.

RESULTS

Of 239 studies found, 19 met the inclusion criteria. One study was rated as 'fair' and the rest as 'poor' quality, particularly due to the lack of published and validated swallowing assessment procedures and outcome measures. Cricopharyngeal (CP) dysfunction (12/19) was the most commonly reported swallowing abnormality. Interventions for disease management included pharmacological agents (10/19), followed by surgical (3/19), behavioral (1/19) and combined approaches (5/19). Interventions with immunosuppressants, botulinum toxin injection, balloon dilation and/or CP myotomy led to mixed and transient benefits. Few studies examining statins or behavioral therapies (primarily focused on respiratory function) showed no effects for dysphagia.

CONCLUSION

Various interventions have been reported to temporarily improve dysphagia in persons with IBM. However, these findings are based on limited and overall low-quality evidence. This study cautions against the generalization of these findings and emphasizes the need for further systematic research to improve the diagnosis and management of dysphagia in IBM.

Botulinum toxin treatment improves dysphagia in patients with oculopharyngeal muscular dystrophy and sporadic inclusion body myositis

OBJECTIVE

Dysphagia can be troublesome in sporadic inclusion body myositis (sIBM) and oculopharyngeal muscular dystrophy (OPMD), but no established treatment exists. Cricopharyngeal muscle botulinum toxin injection has at case level been reported to be effective. We evaluated safety and efficacy of botulinum toxin injections in the cricopharyngeal muscle in patients with dysphagia due to sIBM or OPMD.

METHODS

Participants were included from our outpatient clinic. Cricopharyngeal constriction was confirmed by laryngoscopy. After EMG confirmation of needle placement in the cricopharyngeal muscle, botulinum toxin A was injected in awake patients. An individualized dose of 5-10 units of botulinum toxin A was applied initially and titrated up a maximum of 3 times. Outcome measures were change in dysphagia questionnaire, timed cold-water swallow test and subjective dysphagia status (worse, unchanged, improved). Due to the need for individualized dosing and a limited number of available patients, an uncontrolled, un-blinded design was used.

RESULTS

Thirteen patients, 3 with OPMD, received at least 1 injection. In the dysphagia questionnaire, all but 2 subjects, none with subjective worsening, improved (p < 0.001). Subjectively, seven felt an improvement, 4 no change and 2 a worsening. No overall change was seen the timed cold-water swallow test. No serious adverse events were observed.

CONCLUSION

Botulinum toxin injection of the cricopharyngeal muscle in patients with OPMD and sIBM had a beneficial effect on dysphagia in most of the treated patients. Two of 13 patients experienced a temporary worsening not reflected in dysphagia score. Limitations are the un-blinded and un-randomized design and subjective assessments methods.

PROSPECTIVE TRIAL REGISTRATION

EudraCT-number: 2014-002210-23.

Clinical therapeutic effects of acupuncture in treating patients with dysphagia after radiotherapy in nasopharyngeal carcinoma: A protocol for systematic review and meta-analysis

BACKGROUND

Dysphagia is a commonly occurring condition in nasopharyngeal carcinoma (NPC) patients after radiotherapy. There has been an increasing number of studies focused on assessing the use of acupuncture to manage dysphagia. Moreover, the quality of the research has gradually increased. The present research will be conducted to systematically evaluate the efficiency and safety of using acupuncture to treat cases of dysphagia after radiation therapy in NPC patients.

METHODS

Literature search will include all potential randomized controlled trials using MEDLINE, Cochrane Library, Web of Science, EMBASE, Chinese National Knowledge Infrastructure, Chinese BioMedical Literature, and WanFang database from their inception to May, 2021 without language or publication status restrictions, to evaluate the efficiency and safety of using acupuncture to treat dysphagia cases following radiation therapy in NPC patients. A couple of independent authors will select related literature, extract data from studies, and estimate this risk in the bias of the selected study articles. In the instance of contrasting opinions, the outcome is mediated through discussion with a different independent author. The data synthesis and statistical analysis will be completed with the RevMan software (version 5.3).

RESULTS

This study will evaluate the efficiency and safety of using acupuncture to treat dysphagia cases after radiation therapy in NPC patients.

CONCLUSION

This study will determine the suitability of acupuncture as an effective and safe intervention for dysphagia in NPC patients after radiotherapy.

ETHICS AND DISSEMINATION

The present study does not need ethical approval.

REGISTRATION NUMBER

May 19, 2021.osf.io/f2cvt. (https://osf.io/f2cvt/).

Impact and Management of Dysphagia in Inflammatory Myopathies

PURPOSE OF REVIEW

Dysphagia is a common symptom in inflammatory myopathies. This review provides an overview on the epidemiology, clinical impact, and management of dysphagia in myositis. Relevant diagnostic tools and treatment strategies are discussed.

RECENT FINDINGS

Dysphagia can occur in any inflammatory myopathy, particularly in inclusion body myositis (IBM). It can lead to malnutrition or aspiration with subsequent pneumonia or even death. Dysphagia can be explored and monitored by patient-reported outcome scales for swallowing. New diagnostic tools such as real-time MRI and oro-pharyngo-esophageal scintigraphy have been studied for assessing dysphagia. Botulinum toxin injection can alleviate dysphagia in IBM. High-dose glucocorticosteroids are considered a first-line treatment for dysphagia in all other myositis subforms. Evaluation of dysphagia in myositis requires thorough clinical workup and appropriate instrumental procedures. Treatment options are available for dysphagia, but controlled trials and consensus on best patient care are required for this important symptom.

The Impact of Dysphagia in Myositis: A Systematic Review and Meta-Analysis

(1) Background: Dysphagia is a clinical hallmark and part of the current American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) diagnostic criteria for idiopathic inflammatory myopathy (IIM). However, the data on dysphagia in IIM are heterogenous and partly conflicting. The aim of this study was to conduct a systematic review on epidemiology, pathophysiology, outcome and therapy and a meta-analysis on the prevalence of dysphagia in IIM. (2) Methods: Medline was systematically searched for all relevant articles. A random effect model was chosen to estimate the pooled prevalence of dysphagia in the overall cohort of patients with IIM and in different subgroups. (3) Results: 234 studies were included in the review and 116 (10,382 subjects) in the meta-analysis. Dysphagia can occur as initial or sole symptom. The overall pooled prevalence estimate in IIM was 36% and with 56% particularly high in inclusion body myositis. The prevalence estimate was significantly higher in patients with cancer-associated myositis and with NXP2 autoantibodies. Dysphagia is caused by inflammatory involvement of the swallowing muscles, which can lead to reduced pharyngeal contractility, cricopharyngeal dysfunction, reduced laryngeal elevation and hypomotility of the esophagus. Swallowing disorders not only impair the quality of life but can lead to serious complications such as aspiration pneumonia, thus increasing mortality. Beneficial treatment approaches reported include immunomodulatory therapy, the treatment of associated malignant diseases or interventional procedures targeting the cricopharyngeal muscle such as myotomy, dilatation or botulinum toxin injections. (4) Conclusion: Dysphagia should be included as a therapeutic target, especially in the outlined high-risk groups.

Exploring the efficacy of the expiratory muscle strength trainer to improve swallowing in inclusion body myositis: A pilot study

Inclusion Body Myositis (IBM) is the most common acquired myopathy in older individuals with more than two thirds of patients experiencing impaired swallowing. There are currently no standardized exercise therapies to improve or sustain swallowing despite good evidence for exercise therapy in limb muscles. Reduced upper esophageal sphincter opening is a common abnormality associated with dysphagia in IBM. This pilot study recruited IBM patients with abnormal upper esophageal sphincter function and dysphagia into an exercise program. It was hypothesized that regular practice using the Expiratory Muscle Strength Trainer (EMST) device would improve hyolaryngeal movement by strengthening suprahyoid musculature and facilitate opening of the upper esophageal sphincter thereby improving swallowing and quality of life. Overall, IBM patients who used the EMST device demonstrated no improvement in swallowing function. Consistent with that result, there was also no change in measures of quality of life. However, further studies are needed to elucidate whether it has a preventative role in the development or progression of dysphagia in IBM as there is a suggestion that patients with a shorter duration of disease may have had some benefit. This research provides pilot data and recommendations that will guide future studies on exercise therapy and swallowing in this area.

New insights into the treatment of myositis

The myositis syndromes include polymyositis, dermatomyositis (DM), necrotizing myopathy, inclusion body myositis (IBM), antisynthetase syndrome and overlap syndromes with myositis. These syndromes mostly occur in middle-aged patients, while juvenile DM occurs in children and adolescents. Patients mostly show a subacute weakness and myalgia in the upper and lower limbs, the diagnosis is based upon these clinical findings in combination with muscle biopsy results and specific serum autoantibodies. In recent years, research achieved a better understanding about the molecular mechanism underlying the myositis syndromes, as well as disease progress and extramuscular organ manifestations, such as interstitial lung disease and association with neoplasias. Treatment mainly consists of glucocorticosteroids and immunosuppressants. IBM is usually refractory to treatments. This review provides an overview of the current standards of treatment and new treatment options like monoclonal antibodies and new molecular therapies and their first results from clinical trials.

Dysphagia in Patients with Sporadic Inclusion Body Myositis: Management Challenges

Dysphagia in inclusion body myositis (IBM) is common and associated with increased mortality and morbidity due to aspiration pneumonia, malnutrition and dehydration. There is currently no consensus on treatment of dysphagia in IBM and outcomes are variable depending on timing of intervention, patient preference and available expertise. There is a paucity of research exploring the pathophysiology of dysphagia in IBM and appropriate investigations. Increased knowledge of the aetiopathogenesis is likely to change the approach to treatment as well as improve the quality of life for patients. This review explores the epidemiology and pathophysiology of dysphagia in IBM and the currently available treatment strategies.

Advances in the early diagnosis and therapy of inclusion body myositis

PURPOSE OF REVIEW

To describe recent advancements in diagnostic and therapeutic approaches to inclusion body myositis (IBM).

RECENT FINDINGS

Our understanding of the implications of anti-cytosolic 5'-nucleotidase 1A autoantibody status in IBM and other diseases is increasing. Muscle imaging using magnetic resonance techniques and ultrasound is increasingly being performed and characteristic patterns of muscle involvement may help with diagnosis. Longitudinal imaging studies are likely to help with monitoring and as an outcome measure in clinical trials. Recent small-scale studies of Arimoclomol and Rapamycin have shown promising results and further investigation of these medications is ongoing. Exercise is likely to form an increasingly important facet of management of patients with IBM, but the optimal type of exercise programme to enrol patients in is not yet determined.

SUMMARY

Antibody testing and muscle imaging results may improve our ability to diagnose IBM and the availability of effective disease modifying treatments targeting novel non-inflammatory pathways could soon become a reality. It remains the duty of those involved in the management of patients with IBM to facilitate involvement in clinical trials and other research studies.

Current Classification and Management of Inflammatory Myopathies

Inflammatory disorders of the skeletal muscle include polymyositis (PM), dermatomyositis (DM), (immune mediated) necrotizing myopathy (NM), overlap syndrome with myositis (overlap myositis, OM) including anti-synthetase syndrome (ASS), and inclusion body myositis (IBM). Whereas DM occurs in children and adults, all other forms of myositis mostly develop in middle aged individuals. Apart from a slowly progressive, chronic disease course in IBM, patients with myositis typically present with a subacute onset of weakness of arms and legs, often associated with pain and clearly elevated creatine kinase in the serum. PM, DM and most patients with NM and OM usually respond to immunosuppressive therapy, whereas IBM is largely refractory to treatment. The diagnosis of myositis requires careful and combinatorial assessment of (1) clinical symptoms including pattern of weakness and paraclinical tests such as MRI of the muscle and electromyography (EMG), (2) broad analysis of auto-antibodies associated with myositis, and (3) detailed histopathological work-up of a skeletal muscle biopsy. This review provides a comprehensive overview of the current classification, diagnostic pathway, treatment regimen and pathomechanistic understanding of myositis.