Voice banking for people living with motor neurone disease: Views and expectations

BACKGROUND

More than 80% of people living with MND (plwMND) develop difficulties with their speech, affecting communication, self-identity and quality of life. Most plwMND eventually use an augmentative and alternative communication device (AAC) to communicate. Some AAC devices provide a synthesized voice for speech, however these voices are often viewed as impersonal and a factor in AAC acceptance. Voice banking creates an approximation of the person's own voice that can be used in AAC and is argued to go some way to preserve a person's identity when natural voice is lost, but there has been little supporting research.

AIMS

To understand what plwMND consider when deciding whether or not to bank their voice, what their expectations are, and the expectations of significant communication partners.

METHODS

Semi-structured interviews were undertaken with plwMND who had either decided to bank their voice or had decided not to. Thematic analysis was used to provide a qualitative analysis of the data.

PROCEDURES

Participants were an opportunistic sample of plwMND within England recruited via an open advert distributed by the MND Association (MNDA).

OUTCOMES AND RESULTS

Twelve plwMND were interviewed with nine significant others. Nine participants had decided to bank their voice and three decided not to. The data suggest 'preserving identity' is the overarching motivation in decision making for voice banking. Participants who decided to voice bank considered it would help to maintain their identity and preserve their social and work networks. Participants deciding not to bank their voice highlighted it could not replace their natural voice or preserve their identity. However, few in either group showed an awareness of how a voice bank is used in AAC, and how communication using AAC is significantly different to natural speech.

CONCLUSIONS AND IMPLICATIONS

This research is the first study of its kind to examine the considerations for decision making around voice banking for plwMND. Preserving identity is central to decision making when considering whether or not to voice bank. However, the reality of using AAC and voice banking for communication is poorly understood. Professionals have a role to provide plwMND with more information about voice banking in the wider context of using AAC for communication. It may be that the process of voice banking itself is seen as a positive act for plwMND, independent of how it is used later. Further research with associated professionals and stakeholders is indicated. What this paper adds What is already known on this subject Voice banking creates an approximation of the person.s own voice that can be used in AAC, and is argued to go some way to preserve a person's identity when natural voice is lost. There is significant and growing interest in voice banking from the MND community, but there has been little supporting research. What this study adds This research is the first study of its kind to examine decision making surrounding voice banking. It shows how preserving identity is critically important in how people deal with a diagnosis of MND. For those choosing to voice bank, it is seen as an effective way of preserving their identity, a way of 'fighting back' and giving a positive psychological benefit. Those deciding against voice banking do not believe it could maintain their identity and cannot bring back the natural voice they once had. Clinical implications of this study The reality of using AAC and voice banking for communication may be poorly understood. It would be helpful for professionals to provide information about voice banking as part of a wider discussion about the range of options for communication as the condition progresses. It is important that this includes the opportunity to listen to a voice bank to support understanding of how it is used in a communication device, and how different it sounds to natural speech.

Permanent lesion to the corticospinal tract after therapy with capecitabine

Capecitabine is an oral fluoropyrimidine used to treat solid tumours such as colorectal and breast cancer. A rare but severe side effect is capecitabine-induced leukoencephalopathy, including bilateral lesion to the corticospinal tract. However, neurological symptoms due to capecitabine treatment are usually reported to be reversible after discontinuation of capecitabine. Here, we present the case of a patient with bilateral degeneration of the corticospinal tract and progressive spastic tetraplegia after chemotherapy with capecitabine mimicking primary lateral sclerosis. Although therapy with capecitabine was ended, symptoms substantially worsened over the following years and the patient finally died from aspiration pneumonia almost 3 years after the application of capecitabine.

Efficacy of the Head Up collar in facilitating functional head movements in patients with Amyotrophic Lateral Sclerosis

BACKGROUND

The Head Up collar is a cervical orthosis designed to be adaptable to a patient's needs using adjustable removable supports. The aim of this study was to characterise the ability of this orthosis to provide head support and facilitate the control of head movements in people living with Amyotrophic Lateral Sclerosis.

METHODS

Thirteen patients (6 females, age range: 45-74 years old, Amyotrophic Lateral Sclerosis Functional Rating Scale range: 13-44) with neck muscle weakness due to Amyotrophic Lateral Sclerosis were enrolled in the study. An additional inclusion criterion was the presence of enough residual muscle strength to enable the performance of the test procedure. Participants were asked to perform a series of head movements with and without wearing the collar. Two parameters (mean angular velocity and ratio of movement coupling) were extracted from recorded angular velocities, to quantify changes in the execution of the movement between the two conditions.

FINDINGS

Participants exhibited different levels of impairment in performing different movements. When wearing the collar self-selected movement velocity was preserved and significant improvement in the control of lateral flexion movement was observed (median ratio of movement coupling value reduced from 1.1 to 0.84, P = 0.013). A lower ratio of movement coupling was also observed in 4 out of 7 individuals that were fitted with anterior supports.

INTERPRETATION

The heterogeneity observed in the level of impairment and residual function highlights the need for personalized interventions. The Head Up was effective in enabling more controlled movements and maintaining the natural velocity of head movement.

Australian family carer responses when a loved one receives a diagnosis of Motor Neurone Disease-"Our life has changed forever"

While the experiences of family members supporting a person with a terminal illness are well documented, less is known about the needs of carers of people with neurological diseases, in particular, Motor Neurone Disease (MND). This paper describes the qualitative data from a large Australian survey of family carers of people with MND, to ascertain their experiences of receiving the diagnosis. The aim of the study was to describe the experiences of family carers of people with MND in receiving the diagnosis in order to inform and improve ways in which the diagnosis is communicated. Anonymous postal surveys were sent to people with MND in Australia and their family carers respectively. The perceived ability/skills of neurologists was assessed using a five-point scale from excellent to poor. Attributes of communication of bad news was measured by the SPIKES protocol. Each survey question invited further written responses. Eight hundred and sixty-four questionnaires were posted to people with MND and their family carers, with assistance from MND associations. One hundred and ninety-six family carers submitted responses, of which 171 (88%) were patient-carer dyads. Analyses were conducted on 190 family carers. Five themes emerged from reading and re-reading written responses: frustrations with the diagnosis; giving information; family carer observations of the neurologist; the setting; and what would have made the diagnosis easier? The delivery of the diagnosis is a pivotal event in the MND trajectory. Satisfaction for patients and their family carers is related to the neurologists showing empathy and responding appropriately to their emotions, exhibiting knowledge and providing longer consultations. Neurologists may benefit from education and training in communication skills to adequately respond to patients' and families' emotions and development of best practice protocols.

'The shock of diagnosis': Qualitative accounts from people with Motor Neurone Disease reflecting the need for more person-centred care

The diagnosis of Motor Neurone Disease (MND) is devastating for people with MND (PwMND) and their families. The objective of this study is to describe the experiences of PwMND in receiving the diagnosis in order to inform a more person-centred approach to communicating such bad news. The design was an anonymous postal survey facilitated by all MND associations across Australia (2014-15). Survey questions centred on the SPIKES protocol for communicating bad news; each question contained an area for written responses, which were thematically analysed for content. Two hundred and forty-eight responses were received from people with MND (29% response rate). Four themes emerged: challenges in being diagnosed with MND; the emotions experienced; the good and the bad; and links to further information and support. Receiving such a diagnosis requires preparation, forethought, sensitive and individualised care on the part of the neurologist, including where and how the diagnosis is given; the supports required; and timing, amounts and sources of giving information. The emotional reactions of the neurologist also caused a lasting impression on those receiving the diagnosis. This study could form the basis for best practice programs implementing a more person-centred approach to caring for PwMND right from the diagnosis stage. The focus needs to shift on the person's values, preferences, psychosocial and existential concerns in the context of the underlying disease experience and the manner clinical practice is delivered.

A comfort assessment of existing cervical orthoses

PURPOSE

Identify location and intensity of discomfort experienced by healthy participants wearing cervical orthoses.

METHOD

Convenience sample of 34 healthy participants wore Stro II, Philadelphia, Headmaster, and AspenVista^® cervical orthoses for four-hour periods. Participants reported discomfort level (scale 0-6) and location.

RESULTS

Participants reported mean discomfort for all orthoses over the four-hour test between 'a little discomfort' and 'very uncomfortable' (mean discomfort score = 1.64, SD = 1.50). Seven participants prematurely stopped tests due to pain and six reported maximum discomfort scores. Significant linear increase in discomfort with duration of wear was found for all orthoses. Significantly less discomfort was reported with Stro II than Headmaster and Philadelphia. Age correlated with greater perceived discomfort. Orthoses differed in the location discomfort was experienced.

CONCLUSION

Existing cervical orthoses cause discomfort influenced by design and duration of wear with orthoses' design the more significant factor. This work informed the design of a new orthosis and future orthoses developments. Practitioner Summary: The purpose of this study was to gain greater knowledge about the discomfort caused by wearing of existing neck orthoses in order to inform the design and development of a new neck orthosis. This study gathers empirical data from a surrogate population and concludes that orthosis design is more influential than the duration of wear.

Brainstem cytokine changes in healthy ageing and Motor Neurone Disease

Neuroinflammation is linked to healthy ageing, but its role in the development of age-related neurodegenerative diseases is unclear. In this pilot study we used a multiplex assay approach to compare 27 cytokines in 6 young adult and 6 ageing control brainstems with those in 6 MND brainstems. We report that healthy ageing is associated with significantly increased brainstem levels of IL-1β, IP-10 and MIP-1β which co-localise immunocytochemically to astrocytes. MND brainstem is also characterised by a general increase in both pro- and anti-cytokine levels, but fails to show the expected age-related increase in MIP-1β and IP-10. This pilot study is the first to show that MND is associated with a failure of specific features of the normal age-related neuroinflammatory process. We suggest that our pilot data indicates that neuroinflammation during healthy ageing may not always be detrimental to motoneuronal survival and that age-related neurodegenerative diseases, such as MND, may instead result from defective neuroinflammation.

Helping families thrive in the face of uncertainty: Strengths based approaches to working with families affected by progressive neurological illness

BACKGROUND

Management of the uncertainty inherent in a diagnosis of a progressive neurological illness is one of the major adjustment tasks facing those affected and their families. A causal relationship has been demonstrated between perceived illness uncertainty and negative psychological outcomes for individuals with progressive neurological illness. Whilst there is a small and promising intervention literature on the use of a range of individually focused strengths based psychological interventions there appears to be little guidance available how clinicians might help those family members of those affected.

OBJECTIVE

To undertake a systematic review of the evidence on the use of strengths based, family focused interventions that target illness uncertainty.

METHODS

A systematic literature search was undertaken using the National Library for Health abstract database.

RESULTS

Five papers were included in the review, only two of which were published in peer reviewed journals. All five reported on strengths based approaches that could be used with families but only two explicitly identified illness uncertainty as a target. Outcome measures were heterogeneous so data could not be aggregated for meta-analysis. The results suggested that these interventions showed promised but the review highlighted a number of methodological issues which mean that the results must be interpreted with caution.

CONCLUSIONS

There is very little evidence of the use of strengths based approaches to helping families manage the uncertainty associated with progressive neurological illness despite it having been identified as a key target for intervention. The review highlights the need for the development of an intervention framework to address this key clinical issue and suggests one model that might show promise.

Family carer perspectives of acute hospital care following a diagnosis of motor neuron disease: a qualitative secondary analysis

OBJECTIVES

The multifaceted nature of the problems faced by someone with motor neuron disease requires a knowledgeable multidisciplinary team approach. Where available, generally, such services are only provided on an outpatient basis, meaning that hospitalised patients are frequently admitted to non-specialist wards where understanding of their needs is limited. Little is known regarding the inpatient care received by patients. Our objective was to address this by exploring the experience of hospitalisation following a diagnosis of motor neuron disease from the perspective of family carers of those diagnosed with the illness.

METHOD

This was a qualitative secondary analysis of pre-existing data from two previously published, separately conducted, qualitative studies. The study involved interview data from 18 bereaved carers and 3 current carers of family members diagnosed with motor neuron disease in Northwest England.

RESULTS

The findings reveal dissatisfaction with the inpatient care received, which impacted negatively not only on patient and carer enthusiasm for future hospital admissions but also on carer bereavement.

CONCLUSIONS

Patients with motor neuron disease have specialist needs that are not always met during hospital admission, particularly to non-specialist units. The inpatient care provided for these patients must be improved as must the knowledge and understanding of the illness among healthcare professionals who treat them.

Factors influencing decision-making in relation to timing of gastrostomy insertion in patients with motor neurone disease

OBJECTIVES

This study aimed to explore the decision-making process leading up to gastrostomy insertion from the perspective of the patients and their informal carers. Gastrostomy feeding is commonly used to support motor neurone disease patients with dysphagia. However, there is no robust evidence to suggest the optimal timing for gastrostomy insertion.

METHODS

Retrospective qualitative exploration using semistructured interviews with paired patients and carers in order to elicit their perceptions in relation to gastrostomy timing.

RESULTS

27 patients consented to the study; of these, 23 underwent a successful gastrostomy. Approximately 3 months following a successful gastrostomy, 10 patients and 8 carers were interviewed. Decision-making in relation to the timing of gastrostomy was described as being a difficult process with individual variations and wishes. A range of factors acted as triggers for taking the decision to proceed with gastrostomy such as prolonged, tiring and effortful meals; the task of food preparation; choking and aspiration; and weight loss. Factors such as the reluctance to give up oral feeding, not realising the potential benefits and negative perceptions of gastrostomy influenced a decision to delay the procedure. A tendency for late insertion was identified despite the opposite advice by health professionals.

CONCLUSIONS

The advice for early insertion does not outweigh the personal perceptions and psychosocial factors for patients and their carers. Understanding the factors which influence decision-making on an individual basis is important for information and care provision by healthcare professionals in aiding patients, and their carers, to make informed decisions in relation to gastrostomy timing.

Delineating the genetic heterogeneity of ALS using targeted high-throughput sequencing

BACKGROUND

Over 100 genes have been implicated in the aetiology of amyotrophic lateral sclerosis (ALS). A detailed understanding of their independent and cumulative contributions to disease burden may help guide various clinical and research efforts.

METHODS

Using targeted high-throughput sequencing, we characterised the variation of 10 Mendelian and 23 low penetrance/tentative ALS genes within a population-based cohort of 444 Irish ALS cases (50 fALS, 394 sALS) and 311 age-matched and geographically matched controls.

RESULTS

Known or potential high-penetrance ALS variants were identified within 17.1% of patients (38% of fALS, 14.5% of sALS). 12.8% carried variants of Mendelian disease genes (C9orf72 8.78%; SETX 2.48%; ALS2 1.58%; FUS 0.45%; TARDBP 0.45%; OPTN 0.23%; VCP 0.23%. ANG, SOD1, VAPB 0%), 4.7% carried variants of low penetrance/tentative ALS genes and 9.7% (30% of fALS, 7.1% of sALS) carried previously described ALS variants (C9orf72 8.78%; FUS 0.45%; TARDBP 0.45%). 1.6% of patients carried multiple known/potential disease variants, including all identified carriers of an established ALS variant (p<0.01); TARDBP:c.859G>A(p.[G287S]) (n=2/2 sALS). Comparison of our results with those from studies of other European populations revealed significant differences in the spectrum of disease variation (p=1.7×10(-4)).

CONCLUSIONS

Up to 17% of Irish ALS cases may carry high-penetrance variants within the investigated genes. However, the precise nature of genetic susceptibility differs significantly from that reported within other European populations. Certain variants may not cause disease in isolation and concomitant analysis of disease genes may prove highly important.

Profound bradycardia associated with NIV removal

A patient with lower-limb onset ALS presented with a one-month history of vasovagal episodes and a one-week history of cough productive of green sputum and lethargy. She was drowsy and in acute on chronic type-two respiratory failure. She responded to non-invasive ventilation, however she suffered recurrent episodes of profound bradycardia on removal of the mask, which gradually resolved over ten days. We have reviewed the literature and offer a potential explanation for these events.