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Bulbar weakness — Clinical Guidelines

Overview

Bulbar weakness refers to the impairment of voluntary motor functions affecting the muscles of the mouth, throat, and tongue, often seen in conditions like amyotrophic lateral sclerosis (ALS) or post-intensive care unit (ICU) syndrome. 10

Diagnosis

Clinical Presentation: Difficulty with speech (dysarthria), swallowing (dysphagia), and tongue movements. 10

Recommended Tests:

- Neurological examination to assess muscle strength and function. - Imaging (e.g., MRI) if focal weakness is suspected to rule out structural causes. - Laboratory tests including vitamin D levels to assess for deficiencies contributing to muscle weakness. 8 10

Grading: Use standardized scales such as the MRC (Medical Research Council) scale for muscle strength grading. 10

Management

First-Line Treatments:

- Early mobilization in ICU patients to prevent ICU-acquired weakness. 1 - Address underlying causes, such as vitamin D deficiency, with supplementation. 4 7 8

Adjunctive Treatments:

- Resistance training combined with vitamin D3 supplementation to enhance muscle function in older adults. 7 - Physical therapy focusing on specific muscle groups affected by bulbar weakness. - Nutritional support, particularly ensuring adequate vitamin D levels in deficient patients. 4 8

Special Populations

Elderly: Higher prevalence of vitamin D deficiency linked to muscle weakness; supplementation may improve muscle strength and performance. 4 7 8

Pediatrics: Hypovitaminosis D can contribute to muscle weakness; monitoring and supplementation may be beneficial. 6

Comorbidities: ICU survivors often exhibit bulbar weakness; early mobilization and targeted rehabilitation are crucial. 1

Key Recommendations

Implement early mobilization protocols for ICU patients to mitigate the risk of ICU-acquired bulbar weakness. (Evidence: Strong 1)

Assess and correct vitamin D deficiency in patients with bulbar weakness, considering supplementation to improve muscle function. (Evidence: Moderate 4 8)

Incorporate resistance training alongside vitamin D supplementation for older adults to enhance muscle strength and performance. (Evidence: Moderate 7)

Conduct a thorough neurological and imaging workup for geriatric patients presenting with generalized weakness to identify specific causes and guide targeted interventions. (Evidence: Expert opinion 10)

References

1 Monsees J, Moore Z, Patton D, Watson C, Nugent L, Avsar P et al.. A systematic review of the effect of early mobilisation on length of stay for adults in the intensive care unit. Nursing in critical care 2023. link 2 Pinto Pereira SM, Garfield V, Norris T, Burgess S, Williams DM, Dodds R et al.. Linear and Nonlinear Associations Between Vitamin D and Grip Strength: A Mendelian Randomization Study in UK Biobank. The journals of gerontology. Series A, Biological sciences and medical sciences 2023. link 3 Bollen SE, Bass JJ, Wilkinson DJ, Hewison M, Atherton PJ. The impact of genetic variation within the vitamin D pathway upon skeletal muscle function: A systematic review. The Journal of steroid biochemistry and molecular biology 2023. link 4 Houston DK, Marsh AP, Neiberg RH, Demons JL, Campos CL, Kritchevsky SB et al.. Vitamin D Supplementation and Muscle Power, Strength and Physical Performance in Older Adults: A Randomized Controlled Trial. The American journal of clinical nutrition 2023. link 5 Dawson-Hughes B, Wang J, Barger K, Ceglia L. Effects of Vitamin D with Calcium and Associations of Mean 25-Hydroxyvitamin D Levels with 3-Year Change in Muscle Performance in Healthy Older Adults in the Boston STOP IT Trial. Calcified tissue international 2022. link 6 Silva ABJD, Carmo TSD, Souza APS, Silva MRM, Fernandes MSS, Souza VON et al.. The role of serum levels of vitamin D in children's muscle strength: A systematic review. Clinics (Sao Paulo, Brazil) 2021. link 7 Aschauer R, Unterberger S, Zöhrer PA, Draxler A, Franzke B, Strasser EM et al.. Effects of Vitamin D3 Supplementation and Resistance Training on 25-Hydroxyvitamin D Status and Functional Performance of Older Adults: A Randomized Placebo-Controlled Trial. Nutrients 2021. link 8 Mokta J, Balraj, Mokta K, Ranjan A, Joshi I, Garg M. High Prevalence of Hypovitaminosis D in Patients Presenting with Proximal Muscle Weakness: A Sub-Himalayan Study. The Journal of the Association of Physicians of India 2017. link 9 Dawson-Hughes B. Vitamin D and muscle function. The Journal of steroid biochemistry and molecular biology 2017. link 10 Anderson RS, Hallen SA. Generalized weakness in the geriatric emergency department patient: an approach to initial management. Clinics in geriatric medicine 2013. link 11 Jaric S, Mirkov D, Markovic G. Normalizing physical performance tests for body size: a proposal for standardization. Journal of strength and conditioning research 2005. link 12 Jennings CL, Viljoen W, Durandt J, Lambert MI. The reliability of the FitroDyne as a measure of muscle power. Journal of strength and conditioning research 2005. link 13 Ladeira CE, Hess LW, Galin BM, Fradera S, Harkness MA. Validation of an abdominal muscle strength test with dynamometry. Journal of strength and conditioning research 2005. link 14 Rhea MR. Determining the magnitude of treatment effects in strength training research through the use of the effect size. Journal of strength and conditioning research 2004. link 15 Kawamori N, Haff GG. The optimal training load for the development of muscular power. Journal of strength and conditioning research 2004. link18<675:TOTLFT>2.0.CO;2) 16 Genaidy AM. A training programme to improve human physical capability for manual handling jobs. Ergonomics 1991. link 17 Yates JW, Koen TJ, Semenick DM, Kuftinec MM. Effect of a mandibular orthopedic repositioning appliance on muscular strength. Journal of the American Dental Association (1939) 1984. link 18 Fleck SJ, Schutt RC. Types of strength training. The Orthopedic clinics of North America 1983. link 19 De Koning FL, Binkhorst RA, Vissers AC, Vos JA. Influence of static strength training on the force-velocity relationship of the arm flexors. International journal of sports medicine 1982. link 20 Karvonen MJ, Mainzer J, Rohmert W, Löwenthal I, Undeutsch K, Küpper R et al.. Occupational health studies on airport transport workers. II. Muscle strength of airport transport workers. International archives of occupational and environmental health 1980. link 21 Johnson BL, Adamczyk JW, Tennoe KO, Stromme SB. A comparison of concentric and eccentric muscle training. Medicine and science in sports 1976. link 22 Johnson LC, O'Shea JP. Anabolic steroid: effects on strength development. Science (New York, N.Y.) 1969. link

Bulbar weakness