Multiple Sclerosis: Chronicle Immune Disease Analysis

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Multiple Sclerosis (MS) is an incurable, chronic disease of the immune system and central nervous system that commonly affects the brain, optic nerve, and spinal cord with varying degrees of severity. According to an article by Guillamó et. al., MS affects approximately 2.3 million people and is most commonly present in females and young adults. Two primary clinical subtypes of MS have been identified as relapsing-remitting MS (RRMS) and secondary progressive MS (SPMS), with RRMS accounting for more than 80% of MS cases. Symptoms of MS often differ from person to person depending on which nerves are affected, but general symptoms include vision problems, numbness or weakness in one or more limbs, fatigue, and slurred speech. 

Dysphagia is commonly found in individual who have multiple sclerosis. It is found that more than one-third of individuals who have MS also have dysphagia. The severity of the MS symptoms increase, the likelihood of dysphagia increases. Some of the factors that connect dysphagia and MS include dysfunction of the brainstem and cerebellar as a result of the MS. Another factor is paresis of lower cranial nerves. All of these factors contribute to problems with the physiology of swallowing. The facial nerve (CN VII) and trigeminal nerve (CN V) are involved in both chewing and swallowing and when damage in present results in problems with swallowing. 

The different phases of swallowing are impacted differently dependent on the severity of MS. Those with more severe dysphagia had difficulty in both the oral and pharyngeal phases of swallowing. For patients who have MS, there are some features to look out for that could be predictors of dysphagia. Wet phonation, coughing during eating, repeat swallowing, and weight loss are some of the predictors to watch out for in those who have MS. The presence of both MS and dysphagia can negatively impact nutrition and they are at risk for aspiration. Patients also have an increased risk of pneumonia and dehydration. Functional swallowing strategies refer to treatments that are restorative compensatory or adaptive in nature. 

Only one study could be identified in which MS participants with dysphagia were treated using functional swallowing strategies. A study by Calcagno, Ruoppolo, Grasso, Vincentiis, and Paolucci revealed that 100% of participants with mild and moderate dysphagia regained functional deglutition with the use of postural techniques and modification of the quantity, consistency, and speed of food presentation. All participants with severe dysphagia did not benefit from any compensatory strategies or therapy procedures. This study provides level IIa evidence, as this is a controlled study without randomization. 

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Only one study could be identified in which MS participants with dysphagia were treated using drug treatments. Restivo, Marchese-Ragona, Patti, Solaro, Maimone, Zappala, and Pavone examined whether injecting botulinum neurotoxin type A (BoNT/A) into the cricopharyngeal muscle would improve swallowing function. A single BoNT/A injection caused the dysphagia to completely disappear in 10/14 participants, with the remainder of the participants reporting a significant improvement. These results remained for twelve weeks, but all participants experienced the same improvements after being injected every 3-4 months. No adverse side effects were reported or observed. This study provides level IIa evidence, as this is a controlled study without randomization. Surgical treatments have been conducted using vagal nerve stimulation and pharyngeal electrical stimulation. 

Marrosu, Maleci, Cocco, Puligheddu, Barberini, and Marrosu conducted a study in which three participants with MS and symptoms of dysphagia were treated using vagal nerve stimulation. This treatment resulted in a 65% improvement in water intake and a 78% improvement in piecemeal deglutition. This treatment did not yield improvements in swallowing solids. No serious side effects were reported. This study provides level IIa evidence, as this is a controlled study without randomization. Restivo, Casabona, Centonze, Marchese-Ragona, Maimone, and Pavone examined whether electrical stimulation of the pharynx would result in improvements of functional deglutition. The results of the study indicate that improvements were made in the treatment group that received pharyngeal electrical stimulation at a statistically significant level. 

This study provides level Ib evidence, as this is a randomized controlled study. Bogaardt, van Dam, Wever, Bruggeman, Koops, and Fokkens used electrostimulation to stimulate the digastric, mylohyoid, and thyrohyoid muscles. After treatment, 8 participants reported an improvement in drinking water, while the remaining 9 participants remained at the same level as their pre-treatment ratings. Four participants reported an improvement in eating yogurt, while the remainder of the participants did not report any changes after receiving treatment (Bogaardt, 2009). No adverse effects of the treatment were reported, although one participant did describe the treatment as unpleasant. This study provides level IIa evidence, as this is a controlled study without randomization. 

When researching patients with Multiple Sclerosis (MS) and dysphagia, ASHA provided only one article with clinical expertise and zero articles for client perspectives. According to Restivo, dysphagia in patients with MS is prevalent, affecting around 30% - 40% of patients with MS. Dysphagia in patients with MS can be a very dangerous condition, and therefore should be diagnosed at a very early stage. According to Alali, Ballard, and Bogaardt, 66% of individuals with MS and dysphagia experiencing coughing after or during the consumption of food/liquid, 63% reported the feeling of food sticking to their throat, 61% experience throat clearing after eating and/or drinking, and 45% stated they have a decreased desire to eat/drink. 

Due to this, many adults with dysphagia reported having a problem socializing and going out to social gatherings that involved any type of consumption. Management of dysphagia can include two different types of approaches, pharmacological treatment and rehabilitative treatment. Goals of dysphagia rehabilitation aim to reduce aspiration, improve ability to eat and swallow, and optimize nutrition. The first step in managing dysphagia is to inform the client of what happens during swallowing and the importance of controlling voluntary movement as much as possible. 

Additionally, having the client focus on modulation coughing, specific head and neck positioning, consuming highly palatable food, and on creating a “swallow-ready” bolus are all techniques clinicians may use during treatment. Furthermore, compensatory techniques and strengthening and stimulating exercises are also used. The article, ESPEN Guideline Clinical Nutrition in Neurology, lists several clinical expertise recommendations for patients with multiple sclerosis. The first recommends all patients with MS be screened for dysphagia and continue to be screened at regular time intervals, although there is insufficient evidence to recommend exact times of screenings. 

In addition, clinical expertise recommends modified foods and liquids according to the individual’s needs to ensure safe swallowing and feeding. Finally, the article states that because there is insufficient evidence to make recommendations on behavioral treatments for dysphagia for people who have MS, clinicians should follow general recommendations for practices for individuals with dysphagia. The level of evidence for these articles is the following; Multiple Sclerosis, level 4 clinical expertise; Management of Swallowing Disorders in Multiple Sclerosis, level 4 clinical expertise; ESPEN Guideline Clinical Nutrition in Neurology, level 4 clinical expertise.  

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