Dysphagia Screening for Multiple Sclerosis: Adapting and Validating Oropharyngeal Screening

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Introduction

Multiple Sclerosis:

Multiple Sclerosis (MS) defined as a demyelinating disease of the central nervous system (Faezah, 2020)(Printza, 2019). A possibility to be an autoimmune neurological disease (Aghaz, 2018). M.S could involved motor, sensory, cognitive limitations in addition to swallowing and problems in communication (Barrera, 2019)(El-Wahsh, 2019). a long-lasting progressive disease (Solaro, 2019).

MS could be classified as, Relapsing Remitting MS (RRMS), Secondary Progressive MS (SPMS), Primary Progressive MS (PPMS) and Progressive Relapsing MS (PRMS) (Alali, 2018). Moreover, losing the myelin and gliosis formating also justificated this classifing (Moradi, 2017).

Dysphagia:

Any disorder including limited or weakness in the swallowing skills recognized as dysphagia (Elif, 2018). Also any disturbaing for the normal function of swallowing (Maryam, 2017). Both of problems can lead to a severe issues such as aspiration pneumonia, dehydration, malnutrition, and life quality deterioration (Giuseppe, 2018).

Dysphagia mostly accompanied with physical ability and quality of life impacts (Printza, 2018)(Vogel, 2017). Swallowing sometimes called Deglutition, describing the transfering steps of food and liquids (Dalal, 2017).

Oropharyngeal dysphagia (OD) could lead to challenges in life aspects (Bartlett, 2018) and a real impairment in the safety and efficiency (Olga, 2019)(Zahra, 2018). Swallowing process had different stages: the preparatory, the oral, the pharyngeal, and the esophageal stage (Eveline, 2019). Dysphagia is the most common symptom in old people and also in the neurological diseases including multiple sclerosis (Quiros, 2020).

Relation between Multiple Sclerosis and Dysphagia:

Dysphagia nominated as the highly alert and a threatening of life symptom within the multiple sclerosis (MS) population that showed an incidence between 33% and 43% (Elif, 2018).

Dramatically, 37% of the dysphagic people had a variables of severity extended from mild to severe dysphagia as the percentages; mild 50.6%; moderate 29.4%; and severe 20% (Maryam, 2017).

Deeply, people who had diagnised with a neurological diseases could face a fluctuated sitiuations of swallowing disorders among their life (Giuseppe, 2018).

Review Background:

Obviously; in this section, an overview for the literature review of the field of dysphagia screening and assessment with different pulation and neurological disorders.

Printza and others (2019) and Solaro and others (2019) aimed to detect the prevalence, attitudes and quality of life in patients with multiple sclerosis including the prevalence of dysphagia. It recommended to distingwish the swallowing difficulties with MS to confirm the early identification, effective management, prevention of complications.

Dalal and others (2018) reviewed the literature of Multiple Sclerosis which described the definition, types, frequency and symptoms of dysphagia and its impact on the quality of life. 38% of adults with MS had swallowing problems. Further invistegation required to determine whether early intervention for dysphagia can improve the swallowing function.

Alireza et al (2018) and Marissa et al (2019) were estimated and discussed the prevalence of dysphagia in general. the estimation of the general prevalence of dysphagia in MS-affected patients was 43.33%, Although dysphagia is not typically a first sign of MS, it observed in mildly impaired patients with low levels of disability and increased as the disease progress reaching as high as 65% in severely disabled individuals with MS.

Magdalena and others (2020) assessed the prevalence and characteristics of dysphagia in demyelinating diseases using the: DYMUS (DYsphagia in MUltiple Sclerosis), EAT-10 (Eating Assessment Tool) and SDQ (Swallowing Disturbance Questionnaire). The results showed that pharyngeal-stage dysphagia was observed more frequently than oral-stage dysphagia.

Maryam and others (2017) aimed to determine the prevalence of dysphagia in MS and identifying predictors associated with dysphagia. Dysphagia was evaluated using Mann Assessment of Swallowing Ability (MASA). In total, dysphagia was found in 37% of mild to severe dysphagia.

– Measurements of Dysphagia in Multiple Sclerosis.

Sarah and others (2018) developed and validated the Speech pathology-specific questionnaire for 164 persons with Multiple Sclerosis (SMS). This study was fair in results but the weak points were to do the sample collection through online and the participants formal diagnosis of MS.

Eveline and others (2019) aimed to validate the Dutch-language version of the M.D. Anderson Dysphagia Inventory (MDADI) for 178 patients with neurogenic oropharyngeal dysphagia (OD). It was strengthed hence the large sample size. The results of this study showed a validate dysphagia-questionnaire for patients with neurogenic OD.

Dysphagia of Multiple Sclerosis scale (DYMUS), had many studies that had a concentration regarding multi fields of DYMUS:

Firstly; the factor analysis, internal consistency and test–retest reliability were studied by Dalal and others (2017) Or Dalal et al 2017 against the EAT-10 on MS patients.

Additionally, translated it into Farsi by Zahra and others (2018) using Forward-backward method and then confirmatory factor analysis (CFA) was used to examine the construct validity. Internal consistency and test-retest reliability.

Moreover, a Persian version and evaluating the validity and reliability of the test on Southeast Iranian by Faezeh and others (2020) to evaluate the swallowing problems in multiple sclerosis (MS). The results indicated a good reliability and validity for patients with MS.

Furthermore, identifing the frequency and characteristics of dysphagia in multiple sclerosis patients by Sahar and others (2017), the prevalence ranged from 10% to 90% of subjects based on the dysphagia criteria of MS patients.

Elif and others (2018) aimed to support the use of the rapid and easy-use screening test of dysphagia in the early stages for turkish M.S patients.

Therefore, another adapting to Greek by Printza and others (2018) and resulted to valid use of the Greek version of DYMUS for clinical detection of dysphagia in Multiple Sclerosis.

– Other Measurements of Dysphagia.

Olga and others (2019) mentioned that the videofluoroscopy swallowing study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) are the most commonly used instrumental swallowing assessment techniques. It aimed to ensure evidence-based assessment of oropharyngeal dysphagia and to guide future research.

Adam Vogel and others (2017) aimed to designed the Clinical Assessment of Dysphagia in Neuro-degeneration (CADN) at 125 patients with a neurodegenerative disease. It mentioned a good score in specificity and in sensitivity were had been copied.

Kara and Kelly (2018) reviewed available screening tools with an emphasis on the literature that supported their validity and reliability. In addition reviewing the impact of dysphagia on health care costs and patient outcomes. The results revealed that many of the screens were clinician created and are lacking of validation and the incidence of dysphagia post stroke ranged from 37% to 45% using screening techniques, from 51% to 55% using clinical testing, and from 64% to 78% using instrumental testing. Recommending that the ideal screening tool should be easy to administer, inexpensive, and accurate, with consideration of the instrument’s sensitivity, specificity, and both the positive and negative predictive values.

Quiro et al (2020) designed a new scale Oropharyngeal Dysphagia Screening – for Patients and Professionals (ODS-PP) for dysphagia assessment in Spanish people in Spanish language and was translated to english language for publishing scheme, and it was validated and adapted to a large community. It is a new scale with a very strong back ground which allow more people to use it, this scale not using water or food during assessment which take more care about patient safety and more simpler to use by any care giver such as doctors, nurses and others including family related in addition to the patient, also it is very short and takes less than 3 minutes to be finished in comparison to other screening questioners which take more that 10 minutes. An advantage for this scale that it cosiderd as the first test with a high scorse in detecting OD more than EAT-10 scores.

Truly, ODS-PP was the ideal screening tool because it easy to distribute , affordable, and proper, and the higher scores of the sensitivity and specificity. Most tests of dysphagia screening were translated and adapted to many languages and communities, also some of them adapted more than once for the same language.

Accordingly, this reason the current study focused on using a new and valid scale which still not use in many language and in multi areas thus, the ODS-PP was nominated to be used hince it is only the scale in the world up to date which designed in spanish and used in spain only.

Aims of Study:

This study had a general purpose which focused on the Assessment of Dysphagia in Jordanian Arabic Speaking people from Multiple Sclerosis society, while there a specific goals were:

To translate and adapt ODS-PP for testing dysphagia in Arabic population.
To test dysphagia using different instruments ODS-PP and EAT-10 (Arabic version).
To compare the new tool ODS-PP in arabic with EAT-10 for detecting dysphagia in multiple sclerosis
To test dysphagia in Multiple Sclerosis in comparing to people without MS or any disease (Typically Healthy).

Methods:

Participants:

Participants who were part of the study being nominated from the Arabic native speakeing, both genders were included and their ages were more than 18 years old. In addition they were divided by tow groups: group one as a Multiple Sclerosis people and group tow as a Typically Healthy people those with no issues or illnesses. Sample charachteristics are shown in Table 1.

Table 1. Sample’s charateristics.

Sex Age

Male Female Mean Standard deviation Range Total N MOCA

Multiple Sclerosis 12 9 66 40,38-11,35 21-22 21 29,09

Typically Healthy 7 6 64 45,31-12,62 13-29 13 30

Preliminar analysis with Chi Square showed that there were not statistically significant differences between the groups in Sex (χ2(1) = .03, p = .565). Moreover, preliminar analysis using t-test showed there were not statistically significant differences between MS and TH (p=.25). However, for the mental and cognitive status (MOCA) there were statistically significant differences between MS and TH t(32)= -2,143; p=.04

Design and Data Analysis:

Data were collected and the Analyses were assumed using Statistical Package for the Social Sciences (SPSS), version 20. The study followed an ex post facto design. Pearson Chi-Square was used to evaluate the differences between participants in each group – MS and NH – in Sex.

MANOVA – Multivariate Analysis of variance assessed the differences for assessing the screening validity od arabic version of ODS; differences were presented as percentage and 95% confidence interval. T-Test was used to evaluate the differences between participants in each group – MS and NH – in Age.

In addition t-test was used to evaluate the differences between participants in each group – MS and NH – in Mental Cognitive state (MOCA) Statistically significant results when p < ,05.

Instruments:

– The Eating Assessment Tool / EAT-10:

Belafsky (2008) designed the english version and Farahat (2015) was adapted and validated to Arabic language at Eygeptian population. This scale considered as a world wide commonly used, it contains of 10 questions as self report test.

The Eating Assessment Tool is a self-administered, symptom-specific outcome instrument for dysphagia. Appendix 1 showed Arabic EAT-10.

– Oropharyngeal Dysphagia Scale – Profesional and Patients / ODS-PP:

Quire et el and others (2019) developed and validated a new scale for Oropharyngeal Dysphagia (OD) assessment on the spanish people. The test consists of 18 items, organized by 3 scales: Safety, Efficacy, and Others. In most of the items, the Likert scale ranged from 1 = Never to 4 = Very often.

The test had been designed to be completed either by the patient with OD (self-reporting) or the professional caring of patient’s food. Appendix 2 showed Arabic ODS-PP.

– Monterial of Cognitive Abilities / MoCA:

It was created by Nasreddine and others (2004) in English language and the developement to the Arabic version by Tamader and others (2009). The Montreal of Cognitive Assessment (MoCA) had used a breif 30 questiones which can help the health professionals to test the cognitive abilities for people. MoCA is measuring executive functions and multiple cognitive domains Appendix 3 showed Arabic MoCA.

Procedure:

After discussion with the Ethical committee supervisor of the UGR then the approval for this study was obtained.

Firstly, this study was initiated by translating the ODS-PP from spanish to Arabic language and prepared for starting the study. Then an invitations for the people were sent through a professional in speech therapy and an MS organization. Agter that we assigned an appointment for each participant with fixed time and date to collect the data. A consent form was signed for agreement of participating.

During the interview with the participant and his/her family relative, all instructions were explained and the forms were shown to them, immediatley the results collected as:

Step one, the participant completed the MOCA scale in Arabic.
Step tow, the participant completed the ODS-PP scale in Arabic.
Step three, the participants completed the EAT-10 scale in Arabic.
Step four, collecting all results and confirmed the completed forms from all participants.

Results:

MANOVA results have shown that there was a statistically significant effect of Group – Mean Effect, F(4,29) = 4.518; p = .01; η2= .38, sp. = .9, which indicated that the MS group showed higher scores in both tests that the TH group. Results for EAT-10 and ODS-PP were shown in Table 2.

Between subjects analysis showed that there were a statistically significant effect of Group – in each one of the measures.

There were statistically significant differences in the EAT-10 F(1,3030) = 18.526; p < .0001; η2= .37; sp.=.99; the group MS showed higher scores than TH.

There were statistically significant differences in the ODS-PP, total score, F(1,3779) = 13,611; p < .001; η2= .30; sp.=.95; the group MS showed higher scores than TH.

There were statistically significant differences in the ODS-PP category Security F(1,1202) = 12,487; p < .001; η2= .28; sp.=.93; the group MS showed higher scores than TH.

There were statistically significant differences in the ODS-PP category Efficiency F(1,326) = 13,396; p < .001; η2= .30; sp.=.94; the group MS showed higher scores than TH.

There were statistically significant differences in the ODS-PP category Others F(1,76) = 15,907; p < .0001; η2= .33; sp.=.98; the group MS showed higher scores than TH.

Table 2. showed the Results for EAT-10 and ODS-PP .

Measure Group N Mean Standard F p Effect size Observed

deviation power

Total EAT-10 MS 21 19,43 16,18 18.526 .0001 .37 .99

TH 13 0 0

Total ODS-PP MS 21 40,62 21,08 13,61 .001 .30 .95

TH 13 18,92 0,28

Total Security MS 21 22,23 12,41 12,49 .001 .28 .93

TH 13 10 0

Total Eficiency MS 21 11,39 6,24 13,4 .001 .30 .94

TH 13 5 0

Total Others MS 21 7 2,76 15,91 .0001 .33 .98

TH 13 3,92 0,28

Study Concurrent Correlations:

Pearson’s correlation coefficients were calculated for determining the concurrent validity between the ODS-PP and the EAT-10. For these analyses, only results of the group M.S were considered. The correlation matrix was shown in Table 3.

Results showed significant correlations in most of the item’s of the ODS-PP with the EAT-10 test item’s (correlations ranged from r = .574 to r = 901, p = 0.001). There was an exception with the ODS-PP item 18. see table 3 for more details.

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