Cricopharyngeal dysfunction in Parkinson's disease: role in dysphagia and response to myotomy

The Effects of Non-Pharmacological Therapies for Dysphagia in Parkinson's Disease: A Systematic Review

BACKGROUND

Parkinson's disease (PD) is currently the second most common degenerative neurological disorder globally, with aspiration pneumonia caused by difficulty swallowing being the deadliest complication. The patient's subjective experience and the safety of swallowing have been the main focus of previous evaluations and treatment plans. The effectiveness of treatment may be attributed to the brain's ability to adapt and compensate. However, there is a need for more accurate assessment methods for dysphagia and further research on how treatment protocols work.

OBJECTIVE

This systematic review was designed to assess the effectiveness and long-term impact of published treatment options for swallowing disorders in patients with PD.

METHODS

In adherence to the Preferred Reporting Items for Reviews and Meta-analysis (PRISMA) guidelines, we conducted a systematic review where we thoroughly searched multiple databases (PubMed, Web of Science, Elsevier, and Wiley) for clinical studies published in various languages until December, 2023. Two reviewers evaluated the studies against strict inclusion/exclusion criteria.

RESULTS

This systematic review included a total of 15 studies, including 523 participants, involving six treatment approaches, including breath training, deep brain stimulation, reduction of upper esophageal sphincter (UES) pressure, transcranial magnetic stimulation, postural compensation, and video-assisted swallowing therapy. Primary outcomes included video fluoroscopic swallowing study (VFSS), fiberoptic endoscopic evaluation of swallowing (FEES), high-resolution pharyngeal impedance manometry (HPRIM), and functional magnetic resonance imaging (fMRI).

CONCLUSION

Treatments that reduce UES resistance may be an effective way to treat dysphagia in PD patients. HRPIM can quantify pressure changes during the pharyngeal period to identify patients with reduced swallowing function earlier. However, due to the limited number of randomized controlled trials (RCTs) included and the high risk of bias in some studies, large-scale RCTs are needed in the future, and objective indicators such as HRPIM should be used to determine the effectiveness and long-term impact of different therapies on dysphagia in PD patients.

Evaluation of oropharyngeal deglutitive pressure dynamics in patients with Parkinson's disease

In Parkinson's disease (PD), oropharyngeal dysphagia is common and clinically relevant. The neurophysiology of dysphagia in PD is complex and incompletely understood. The aim of the study was to determine the changes in oropharyngeal deglutitive pressure dynamics in PD and to correlate these with clinical characteristics including dysphagia and PD severity. In prospective consecutive series of 64 patients with PD [mean age: 66.9 ± 8.3 (SD)], we evaluated dysphagia severity clinically as well as with Sydney Swallow Questionnaire (SSQ) and Swallow Quality-of-Life Questionnaire (SWAL-QOL). PD severity was assessed with Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS). We used high-resolution pharyngeal impedance manometry (HRPIM) to objectively evaluate swallow function and compared data from 23 age-matched healthy controls [mean age 62.3 ± 9.1 (SD)]. Metrics assessed were upper esophageal sphincter (UES), integrated relaxation pressure (IRP), relaxation time (RT), maximum opening (MaxAdm), and pharyngeal intrabolus pressure (IBP) and pharyngeal contractility (PhCI). Mean MDS-UPDRS score was positively associated with dysphagia severity on SSQ and SWAL-QOL. HRPIM in PD compared with controls showed impaired UES relaxation parameters, with shorter RT, and elevated IRP and IBP. MaxAdm was not affected. The overall pharyngeal contractility was significantly higher in PD. Only the IBP and IRP were associated with PD severity and only IBP was significantly associated with dysphagia severity. UES dysfunction leading to increased flow resistance is common in patients with PD and correlates with dysphagia severity. Increased flow resistance may suggest impaired UES relaxation and/or impaired neuromodulation to bolus volume.NEW & NOTEWORTHY In Parkinson's disease, objective assessment of swallow function with high-resolution impedance manometry identifies upper esophageal sphincter dysfunction leading to increased flow resistance.

Electromyographic measures of asymmetric muscle control of swallowing in Parkinson’s disease

Introduction

During the early stages, Parkinson’s disease (PD) is well recognized as an asymmetric disease with unilateral onset of resting tremor with varying degrees of rigidity, and bradykinesia. However, it remains unknown if other impairments, such as swallowing impairment (i.e., dysphagia), also present asymmetrically.

Purpose

The primary aim of this study was to examine muscle activity associated with swallow on the most affected side (MAS) and least affected side (LAS) in persons with PD. A secondary aim was to explore the relationship between differences in muscle activity associated with swallow and subjective reports of swallowing impairment and disease severity.

Methods

Function of muscles associated with swallowing was assessed using surface electromyography placed over the right and left submental and laryngeal regions during three swallows for a THIN and THICK condition. The Swallowing Quality of Life (SWAL-QOL) questionnaire and the Unified Parkinson’s Disease Rating Scale (UPDRS) were collected as measures of subjective swallow impairment and disease severity, respectively.

Results

Thirty-five participants diagnosed with idiopathic PD and on a stable antiparkinsonian medication regimen completed this study. Results revealed no significant mean difference in muscle activity during swallow between the more and less affected side. For the laryngeal muscle region, a significant difference in coefficient of variation between the MAS and LAS was revealed for peak amplitude for the THIN swallow condition. For the laryngeal muscle region, a significant association was revealed between muscle activity and disease severity but not subjective reports of swallowing impairment.

Conclusion

Superficially it appears that swallowing impairment present symmetrical during the early stages of PD, however, our variability data indicates otherwise. These results will be used to inform future studies in specific types of swallowing impairment (i.e., oral dysphagia, pharyngeal dysphagia, and esophageal dysphagia), disease progression, and overall asymmetry.

Gastrointestinal Dysfunction in Parkinson’s Disease: Current and Potential Therapeutics

Abnormalities in the gastrointestinal (GI) tract of Parkinson’s disease (PD) sufferers were first reported over 200 years ago; however, the extent and role of GI dysfunction in PD disease progression is still unknown. GI dysfunctions, including dysphagia, gastroparesis, and constipation, are amongst the most prevalent non-motor symptoms in PD. These symptoms not only impact patient quality of life, but also complicate disease management. Conventional treatment pathways for GI dysfunctions (i.e., constipation), such as increasing fibre and fluid intake, and the use of over-the-counter laxatives, are generally ineffective in PD patients, and approved compounds such as guanylate cyclase C agonists and selective 5-hyroxytryptamine 4 receptor agonists have demonstrated limited efficacy. Thus, identification of potential targets for novel therapies to alleviate PD-induced GI dysfunctions are essential to improve clinical outcomes and quality of life in people with PD. Unlike the central nervous system (CNS), where PD pathology and the mechanisms involved in CNS damage are relatively well characterised, the effect of PD at the cellular and tissue level in the enteric nervous system (ENS) remains unclear, making it difficult to alleviate or reverse GI symptoms. However, the resurgence of interest in understanding how the GI tract is involved in various disease states, such as PD, has resulted in the identification of novel therapeutic avenues. This review focuses on common PD-related GI symptoms, and summarizes the current treatments available and their limitations. We propose that by targeting the intestinal barrier, ENS, and/or the gut microbiome, may prove successful in alleviating PD-related GI symptoms, and discuss emerging therapies and potential drugs that could be repurposed to target these areas.

Cricopharyngeal peroral endoscopic myotomy improves oropharyngeal dysphagia in patients with Parkinson's disease

Background and study aims  Oropharyngeal dysphagia (OPD) is prevalent in patients with Parkinson's disease (PD). Upper esophageal sphincter (UES) dysfunction is an important pathophysiological factor for OPD in PD. The cricopharyngeus (CP) is the main component of UES. We assessed the preliminary efficacy of cricopharyngeal peroral endoscopic myotomy (C-POEM) as a treatment for dysphagia due to UES dysfunction in PD. Patients and methods  Consecutive dysphagic PD patients with UES dysfunction underwent C-POEM. Swallow metrics derived using high-resolution pharyngeal impedance manometry (HRPIM) including raised UES integrated relaxation pressure (IRP), raised hypopharyngeal intrabolus pressure (IBP), reduced UES opening caliber and relaxation time defined UES dysfunction. Sydney Swallow Questionnaire (SSQ) and Swallowing Quality of Life Questionnaire (SWAL-QOL) at before and 1 month after C-POEM measured symptomatic improvement in swallow function. HRPIM was repeated at 1-month follow-up. Results  C-POEM was performed without complications in all (n = 8) patients. At 1 month, there was an improvement in both the mean SSQ (from 621.5 to 341.8, mean difference -277.3, 95 %CI [-497.8, -56.7], P  = 0.02) and SWAL-QOL (from 54.9 to 68.3, mean difference 9.1, 95 %CI [0.7, 17.5], P  = 0.037) scores. Repeat HRPIM confirmed a decrease in both the mean UES IRP (13.7 mm Hg to 3.6 mm Hg, mean difference -10.1 mm Hg, 95 %CI [-16.3, -3.9], P  = 0.007) and the mean hypopharyngeal IBP (23.5 mm Hg to 10.4 mm Hg, mean difference -11.3 mm Hg, 95 %CI [-17.2, -5.4], P  = 0.003). Conclusions  In dysphagic PD patients with UES dysfunction, C-POEM is feasible and enhances UES relaxation and reduces sphincteric resistance to flow during the swallow, thereby improving dysphagia symptoms.

Fluoroscopic Swallowing Examination: Radiologic Findings and Analysis of Their Causes and Pathophysiologic Mechanisms

Dysphagia is a common symptom in the general population, and its prevalence increases with patient age. The deterioration of swallowing function has many acute and chronic causes, including cerebrovascular and neuromuscular diseases, radiation, and surgery. In an elderly population, diagnosis and treatment of swallowing abnormalities is a high priority because it improves the patient's quality of life and helps them to avoid medical complications. Fluoroscopic swallowing examinations and modified barium swallow studies are the most used and most reliable diagnostic procedures to evaluate swallowing disorders. Functional anomalies include disturbances of the oral preparatory, oral propulsory, and pharyngeal phases of swallowing as premature spillage from the mouth, nasal regurgitation, delayed initiation of pharyngeal swallowing, incomplete displacement of the hyolaryngeal complex, abnormal epiglottic tilt, incomplete laryngeal closure, and pharyngeal dysmotilities. Anatomic abnormalities of the pharynx include diverticula, benign strictures, and tumors. The abnormalities diagnosed on the basis of fluoroscopic examination have a variety of treatment strategies, and the choice of treatment depends on the cause of the anomaly and its pathophysiologic characteristics. The radiologist's interpretation of these characteristics is crucial to therapeutic decision making and achieving the best patient outcomes. Online supplemental material is available for this article. ^©RSNA, 2021.

The Effect of Deep Brain Stimulation on Swallowing Function in Parkinson's Disease: A Narrative Review

Unlike appendicular motor symptoms, such as bradykinesia and rigidity, in Parkinson's disease (PD), which have already been reported to respond well to deep brain stimulation (DBS), there is limited literature on the effects of DBS on swallowing function in patients with PD. The field lacks consensus as there are conflicting reports among existing studies regarding whether swallowing function improves or declines following DBS implantation. This narrative review aims to summarize and analyze the studies published on the effect of DBS on swallowing function in patients with PD. We collated studies published up to February 2020 using a comprehensive electronic database search of PubMed, SCOPUS, EMBASE, and the Cochrane Library. Two reviewers independently assessed the studies using strict inclusion and exclusion criteria. The primary literature search yielded 529 relevant papers. After reading their titles and abstracts and assessing their eligibility based on the full-text, we finally included and reviewed 14 publications. Nine of these studies reported positive effects of DBS on swallowing function and four studies showed no significant positive results. The remaining study showed decreased swallowing function after unilateral subthalamic nucleus-DBS surgery. In conclusion, we found that DBS has the potential to improve swallowing function in patients with PD. However, high-quality evidence is lacking. To clearly elucidate the effect of DBS on swallowing function in patients with PD, high-quality randomized controlled trials should be conducted in the future.

Evaluation of the pharynx and upper esophageal sphincter motility using high-resolution pharyngeal manometry for Parkinson's disease

Parkinson's disease (PD) is associated with a high incidence of dysphagia. Aspiration pneumonia due to dysphagia is a major cause of death in patients with PD, and therefore accurately evaluating dysphagia should help improve prognosis. It has been reported that the severity of dysphagia does not always correlate with the Hoehn and Yahr (H&Y) stage for classifying PD severity. However, no reports have quantitatively evaluated the relationship between severity of dysphagia and H&Y stage. High-resolution pharyngeal manometry (HRPM) is a quantitative method that can be used to measure swallowing pressure from the velopharynx to the entry of the upper esophageal sphincter (UES). We used HRPM to measure swallowing pressure in 51 patients with PD. As PD progresses, atrophy and degeneration of the pharyngeal muscles become more pronounced, which contributes to dysphagia. However, thus far there is no quantitative clinical evidence for this pathological change. To evaluate the relationship between severity of underlying PD and dysphagia, patients were categorized by H&Y stage, as follows: stage II in four patients, stage III in 23, stage IV in 14, and stage V in 10. In patients with H&Y stages II, III, IV, and V, the respective velopharyngeal pressures were 179.8 ± 32.5, 157.6 ± 62.2, 172.2 ± 48.9, and 107.4 ± 44.0 mmHg, the mesopharyngeal pressures were 126.8 ± 53.2, 121.6.1 ± 50.4, 142.1 ± 57.8, and 61.4 ± 19.6 mmHg, the residual UES pressure were -8.0 ± 10.8, 10.3 ± 16.1, 16.5 ± 37.9, and 11.2 ± 16.2 mmHg, and the resting UES pressure were 49.5 ± 30.0, 15.8 ± 25.7, 1.85 ± 14.1, and -1.2 ± 12.2 mmHg. Patients with severe PD demonstrated significantly decreased velopharyngeal and oropharyngeal pressures, along with incomplete UES opening and contraction. HRPM can detect subtle abnormalities by quantifying swallowing pressure in patients with PD. Evaluating swallowing pressure with HRPM provides insights into neuromuscular dysfunction that causes abnormal pressure generation during pharyngeal swallowing in patients with PD.

Gastrointestinal dysfunction in the synucleinopathies

Interest in gastrointestinal dysfunction in Parkinson's disease has blossomed over the past 30 years and has generated a wealth of investigation into this non-motor aspect of the disorder, research that has encompassed its pathophysiology, its clinical features, and its impact on quality of life. The question of gastrointestinal dysfunction in the other synucleinopathies has not received nearly as much attention, but information and knowledge are growing. In this review, the current knowledge, controversies, and gaps in our understanding of the pathophysiology of gastrointestinal dysfunction in Parkinson's disease and the other synucleinopathies will be addressed, and extended focus will be directed toward the clinical problems involving saliva management, swallowing, gastric emptying, small intestinal function, and bowel function that are so problematic in these disorders.

Effectiveness of pharmacologic treatment for dysphagia in Parkinson's disease: a narrative review

BACKGROUND

The effectiveness of pharmacological treatment on dysphagia in Parkinson's disease (PD) is debatable. We reviewed the literature for analyzing the effect of pharmacological treatment on the improvement of dysphagia in PD patients.

METHODS

We searched the PubMed database for papers published before June 21, 2020, that evaluated the effect of pharmacologic treatments for improving dysphagia in patients with PD. The following inclusion criteria were applied for the selection of articles: 1) studies performed on patients with dysphagia due to PD, 2) studies where pharmacologic treatment was applied for improvement of dysphagia, and 3) those where follow-up evaluation was performed after the treatment.

RESULTS

The primary literature search yielded 415 relevant papers. After reading their titles and abstracts and assessing their eligibility based on the full-text articles, we finally included nine studies in this review. In five previous studies, the positive effects of dopaminergic drugs on dysphagia were reported, whereas two showed no significant positive results. The remaining two studies showed equivocal results.

CONCLUSION

We found that dopaminergic drugs have some potential to improve dysphagia in patients with PD. However, studies with high-quality evidence are lacking. For the clear elucidation of the effect of dopaminergic drugs on dysphagia in patients with PD, randomized controlled trials with large cohorts and detailed analyses should be conducted in the future.

Autonomic Dysfunction in Parkinson's Disease

Recognition of the importance of nonmotor dysfunction as a component of Parkinson's disease has exploded over the past three decades. Autonomic dysfunction is a frequent and particularly important nonmotor feature because of the broad clinical spectrum it covers. Cardiovascular, gastrointestinal, urinary, sexual, and thermoregulatory abnormalities all can appear in the setting of Parkinson's disease. Cardiovascular dysfunction is characterized most prominently by orthostatic hypotension. Gastrointestinal dysfunction can involve virtually all levels of the gastrointestinal tract. Urinary dysfunction can entail either too frequent voiding or difficulty voiding. Sexual dysfunction is frequent and frustrating for both patient and partner. Alterations in sweating and body temperature are not widely recognized but often are present. Autonomic dysfunction can significantly and deleteriously impact quality of life for individuals with Parkinson's disease. Because effective treatment for many aspects of autonomic dysfunction is available, it is vitally important that assessment of autonomic dysfunction be a regular component of the neurologic history and exam and that appropriate treatment be initiated and maintained.

Cricopharyngeal bar on videofluoroscopy: high specificity for inclusion body myositis

OBJECTIVE

To determine the prevalence and characteristics of the cricopharyngeal bar (CPB), defined as marked protrusion with lacking relaxation and stricture of the upper esophageal sphincter on videofluoroscopy, in patients with inclusion body myositis (IBM).

METHODS

We conducted a case-control study of comprehensive series of adult healthy individuals and consecutive patients with neuropsychiatric disorders aged over 45 (52 versus 2486). A standard videofluoroscopy was performed.

RESULTS

Overall, 47 individuals with CPB were identified. Of the individuals with CPB, 36% were IBM followed by neurodegenerative disorders, muscular disorders, neuromuscular disorders, and others (32%, 21%, 2.1%, and 8.5%, respectively), indicating the heterogeneity of the etiologies. Against muscular disorders, the sensitivity and specificity of the CPB for IBM were 33% (= 17/52; 95% confidence interval [CI], 20-45%) and 96% (= 264/274; 95% CI, 94-99%), respectively. IBM with CPB showed a higher frequency of obstruction-related dysphagia (88% versus 22%, p < 0.001) and severe CPB (76% versus 23%, p < 0.001) than the control with one. The ratio of the upper esophageal distance at the maximum distension at the level of C6 to that of C4 was lower in IBM with CPB than in the controls with one (0.50 versus 0.77, p < 0.001), which suggests the insufficient opening of the upper esophageal sphincter.

CONCLUSION

A CPB could be indicative of IBM. The upper esophagus in IBM with CPB became narrow, like a bottleneck. We provide new perspectives of dysphagia diagnosis by videofluoroscopy, especially for IBM-associated dysphagia, to expand the knowledge on the CPB.

The Effect of High-Frequency Repetitive Transcranial Magnetic Stimulation on Advancing Parkinson’s Disease With Dysphagia: Double Blind Randomized Clinical Trial

We investigate if rTMS has a therapeutic role in the treatment of dysphagia in patients with Parkinson’s disease (PD). Material and Methods. Thirty-three patients with PD and dysphagia were randomly classified with ratio 1:2 to receive sham or real rTMS (2000 pulses; 20 Hz; 90% resting motor threshold; 10 trains of 10 seconds with 25 seconds between each train) over the hand area of each motor cortex (5 minutes between hemispheres) for 10 days (5 days per week) followed by 5 booster sessions every month for 3 months. Assessments included the Unified Parkinson’s Disease Rating Scale part III (UPDRS), Instrumental Activities of Daily Living (IADL), and Arabic–Dysphagia Handicap Index (A-DHI) before, after the last session, and 3 months later. Video-fluoroscopy measures of pharyngeal transit time (PTT) and time to maximal hyoid elevation (H1-H2) were taken before and after the treatment sessions. Results. There were no significant differences between groups. There was a significant improvement on all rating scales (analysis of variance) after real rTMS with a significant time × group interaction. In particular, there was a significant and long-lasting (3 months) effect of time on all subitems of the A-DHI (functional, P = .0001; physical, P = .0001; emotional, P = .02) but not in the sham group. This was associated with significant improvement in H1-H2 ( P = .03) and PTT ( P = .01) during solid swallows in the real rTMS but not the sham group. Conclusion. Real rTMS improves dysphagia in PD as documented by A-DHI scores and by video-fluoroscopy.

Parkinson's Disease and Current Treatments for Its Gastrointestinal Neurogastromotility Effects

PURPOSE OF REVIEW

Gastrointestinal disturbances are seen in nearly all patients with Parkinson's disease and lead to impaired quality of life, affect drug pharmacodynamics, and potentially worsen patient's existing motor fluctuations, leading to further disability. Recent evidence links abnormal accumulations of α-synuclein aggregates in the periphery (gut) as seen in the cortex which causes dysfunctions impacting every level of the gastrointestinal tract from the esophagus, to the stomach, small bowel, colon, and rectum and can even predate the onset of the central neurologic disorder itself. Many treatments exist for the clinical phenotypes that result from the autonomic dysfunction and neuropathy involved in this neurodegenerative disorder. The treatments for the gut dysfunction seen in Parkinson's disease (PD) depend on the specific area of the gastrointestinal tract affected. For dysphagia, behavioral therapies with speech pathology, neuromuscular electrical stimulation, or botulinum toxin injection may be helpful. For gastroparesis, domperidone may serve as an antiemetic while also blunting the hypotensive potential of Levodopa while new treatments such as ghrelin agonists may prove beneficial to help appetite, satiety, gastric emptying in those with constipation, and even improve constipation. Antibiotics such as rifaximin with poor systemic absorption may be used to treat small bacterial overgrowth also found in those with PD while the benefits of probiotics is yet to be determined. Finally, constipation in PD can be a reflection of pelvic floor dyssynergia, slow transit constipation, or both, thus treatments targeting the specific anorectal dysfunction is necessary for better outcomes.

Gastrointestinal Dysfunction in Parkinson's Disease

PURPOSE OF REVIEW

During the past 25 years, there has been an explosion of information regarding the occurrence of gastrointestinal dysfunction in Parkinson's disease. In this review, the clinical features of gastrointestinal dysfunction in Parkinson's disease will be described and information regarding the potential role of the enteric nervous system and the gut microbiome in the genesis of Parkinson's disease will be addressed.

RECENT FINDINGS

Recognition is growing regarding the role that gastroparesis and small intestinal dysfunction may play in Parkinson's disease, especially with regard to erratic responses to anti-Parkinson medication. The presence of enteric nervous system involvement in Parkinson's disease is now well established, but whether the enteric nervous system is the starting point for Parkinson's disease pathology remains a source of debate. The potential role of the gut microbiome also is beginning to emerge. Gastrointestinal dysfunction is a prominent nonmotor feature of Parkinson's disease and dysfunction can be found along the entire length of the gastrointestinal tract. The enteric nervous system is clearly involved in Parkinson's disease. Whether it is the initial source of pathology is still a source of controversy. There also is growing recognition of the role that the gut microbiome may play in Parkinson's disease, but much more research is needed to fully assess this aspect of the disorder.

Alterations in oropharyngeal sensory evoked potentials (PSEP) with Parkinson's disease

Movement of a food bolus from the oral cavity into the oropharynx activates pharyngeal sensory mechanoreceptors. Using electroencephalography, somatosensory cortical-evoked potentials resulting from oropharyngeal mechanical stimulation (PSEP) have been studied in young healthy individuals. However, limited information is known about changes in processing of oropharyngeal afferent signals with Parkinson's disease (PD). To determine if sensory changes occurred with a mechanical stimulus (air-puff) to the oropharynx, two stimuli (S1-first; S2-s) were delivered 500ms apart. Seven healthy older adults (HOA; 3 male and 4 female; 72.2±6.9 years of age), and thirteen persons diagnosed with idiopathic Parkinson's disease (PD; 11 male and 2 female; 67.2±8.9 years of age) participated. Results demonstrated PSEP P1, N1, and P2 component peaks were identified in all participants, and the N2 peak was present in 17/20 participants. Additionally, the PD participants had a decreased N2 latency and gated the P1, P2, and N2 responses (S2/S1 under 0.6). Compared to the HOAs, the PD participants had greater evidence of gating the P1 and N2 component peaks. These results suggest that persons with PD experience changes in sensory processing of mechanical stimulation of the pharynx to a greater degree than age-matched controls. In conclusion, the altered processing of sensory feedback from the pharynx may contribute to disordered swallow in patients with PD.

Gastrointestinal Symptoms in Parkinson Disease: Clinical Aspects and Management

Although it is now generally recognized that the clinical spectrum of Parkinson disease (PD) is broader than its defining motor aspects, its various non-motor symptoms are often not routinely assessed in the clinical setting. As most of these symptoms are amenable to treatment, improved recognition would lead to more comprehensive management of the disease, and ultimately improve the quality of life for PD patients. In an attempt to increase the general awareness of physicians caring for these patients, this article focuses on the clinical manifestations and treatment of the gastrointestinal symptoms most commonly experienced by PD patients, as well as on the gastrointestinal side effects of antiparkinsonian treatments.

Speech pathologist practice patterns for evaluation and management of suspected cricopharyngeal dysfunction

Speech pathologists are often the first professionals to identify signs of a cricopharyngeal (CP) dysfunction and make recommendations for further care. There are many care options for patients with CP dysfunction, but it is unclear how certain interventions are used in practice. A paper-based survey employing two clinical cases involving suspected CP dysfunction (Case 1 with adequate pharyngeal strength and Case 2 with coexisting pharyngeal weakness) was sent to members of American Speech-Language Hearing Association's Special Interest Group 13. Respondents ranked the order of management approaches (swallowing therapy, further evaluation, and referral to another medical professional) and selected specific interventions under each approach that they would recommend for each case. Completed surveys from 206 respondents were entered into analysis. The majority of the respondents recommended swallowing therapy as a first approach for each case (Case 1: 64 %; Case 2: 88 %). The most prevalent swallowing exercises recommended were the Shaker (73 %), effortful swallow (62 %), and Mendelsohn maneuver (53 %) for Case 1 and effortful swallow (92 %), Shaker (84 %), and tongue-hold swallow (73 %) for Case 2. 76 % of respondents recommended a referral for Case 1, while 38 % recommended the same for Case 2. Respondents with access to more types of evaluative tools were more likely to recommend further evaluation, and those with access to only videofluoroscopy were less likely to recommend further evaluation. However, the high degree of variability in recommendations reflects the need for best practice guidelines for patients with signs of CP dysfunction.

Autonomic dysfunction in Parkinson's disease

Growing recognition of the non-motor features of Parkinson's disease (PD) has led to increased awareness of autonomic dysfunction as part of the disease process, not only in advanced disease but also early in its course, sometimes even preceding the development of the classic motor features of PD. Virtually all aspects of autonomic function can become impaired in PD, including cardiovascular, gastrointestinal, urological, sexual and thermoregulatory function. Recognition of the various autonomic abnormalities of PD is important because effective treatment may be available and may measurably improve quality of life for individuals with PD.

Altered pharyngeal muscles in Parkinson disease

Dysphagia (impaired swallowing) is common in patients with Parkinson disease (PD) and is related to aspiration pneumonia, the primary cause of death in PD. Therapies that ameliorate the limb motor symptoms of PD are ineffective for dysphagia. This suggests that the pathophysiology of PD dysphagia may differ from that affecting limb muscles, but little is known about potential neuromuscular abnormalities in the swallowing muscles in PD. This study examined the fiber histochemistry of pharyngeal constrictor and cricopharyngeal sphincter muscles in postmortem specimens from 8 subjects with PD and 4 age-matched control subjects. Pharyngeal muscles in subjects with PD exhibited many atrophic fibers, fiber type grouping, and fast-to-slow myosin heavy chain transformation. These alterations indicate that the pharyngeal muscles experienced neural degeneration and regeneration over the course of PD. Notably, subjects with PD with dysphagia had a higher percentage of atrophic myofibers versus with those without dysphagia and controls. The fast-to-slow fiber-type transition is consistent with abnormalities in swallowing, slow movement of food, and increased tone in the cricopharyngeal sphincter in subjects with PD. The alterations in the pharyngeal muscles may play a pathogenic role in the development of dysphagia in subjects with PD.

The management of gastrointestinal symptoms in Parkinson's disease

The involvement of the autonomic nervous system in Parkinson's disease causes many non-motor symptoms, among which gastrointestinal complaints are prominent. Drooling, dyspepsia, constipation, abdominal pain and fecal incontinence are frequently a source of patient distress. Dysphagia is recognized as causing both discomfort and increased risk of serious complications. Although a diagnosis can often be established based on the reports of patients and/or caregivers, and additional testing is seldom required, these diagnoses are clearly under recognized in clinical practice. These symptoms respond to the same treatment measures used in the general population, although certain drugs with a potential to increase parkinsonian symptoms should be avoided. Increased and early identification of these symptoms can result in a significant improvement in the quality of life of Parkinson's disease patients.

Motility disorders in the patient with neurologic disease

Gastrointestinal symptoms are common in the patient with chronic neurologic disease and may loom large in terms of impact on quality of life and on nutrition and mobility. A knowledge of the range of gastrointestinal disorders associated with a given neurologic disease, together with an understanding of the risks and benefits of various therapeutic options and approaches, should aid gastroenterologists in their efforts to contribute to the care of these patients. In most instances a multidisciplinary team (neurologist/neurosurgeon, gastroenterologist, nutritionist, therapist, specialist nurse) aware of the wishes and needs of the family and their carers and mindful of the nature and the natural history of the underlying disease process are best placed to assess and manage these problems.

Gastrointestinal dysfunction in Parkinson's disease

In recent years, an increasingly detailed picture of gastrointestinal dysfunction in the setting of Parkinson's disease has emerged. Abnormalities of function may occur at virtually all levels of the gastrointestinal tract. Weight loss, dental deterioration, salivary excess, dysphagia, gastroparesis, decreased bowel movement frequency, and anorectal dysfunction all may occur. The pathophysiologic basis for this dysfunction entails both central and enteric nervous system involvement.

Oropharyngeal dysphagia

Although the aging process per se can produce measurable changes in the normal oropharyngeal swallow, these changes alone are rarely sufficient to cause clinically apparent dysphagia. The causes of oropharyngeal dysphagia in the elderly are predominantly neuromyogenic, with the most common cause being stroke. The evaluation of oropharyngeal dysphagia in the elderly involves early exclusion of structural abnormalities, detection of aspiration by videofluoroscopy which might dictate early introduction of nonoral feeding, and exclusion of underlying systemic and neuromyogenic causes that have specific therapies in their own right. Such conditions include Parkinson disease, myositis, myasthenia, and thyrotoxicosis. Management is best delivered by a multidisciplinary team involving physician, speech pathologist, nutritionist and, at times, a surgeon.

Long-lasting effect of a single botulinum toxin injection in the treatment of oropharyngeal dysphagia secondary to upper esophageal sphincter dysfunction: a pilot study

OBJECTIVE

To evaluate the efficacy of botulinum toxin (BTX-A) injection in the cricopharyngeus muscle in patients with neurological dysphagia caused by alteration in the upper esophageal sphincter (UES) opening and with preserved pharyngeal contraction.

MATERIAL AND METHODS

A prospective pilot study was undertaken in 10 patients (7 brain lesions and 3 cervical spinal cord injuries), with a minimum time-lapse of 6 months from neurological lesion to BTX-A injection. Dysfunction of the UES opening and the presence of pharyngeal contraction were diagnosed by videofluoroscopy (VDF) and esophageal manometry (EM). The BTX-A (100 U) injection was guided by endoscopy. Clinical, VDF, and EM follow-ups were carried out at 3 weeks, 3 and 6 months, and at 1 year post-injection.

RESULTS

Prior to treatment, 6 patients were fed by nasogastric tube. VDF showed impairment of the UES opening, residue in pyriform sinuses, and aspiration in all cases. During follow-up, there was a decrease in the number of patients that had aspiration: 3 patients at one year. During swallowing, EM showed a mean UES relaxation of 90% (range: 74.5-100%), residual pressure 3.2 mmHg (range: 0-13 mmHg) and pharyngeal amplitude 52 mmHg (range: 25-80 mmHg). At follow-up, a significant improvement in UES relaxation (98% (89-100%)) and pharyngeal contraction (97 mmHg (35-165 mmHg)) was observed. At 3 months, 6 patients were eating exclusively by mouth.

CONCLUSIONS

One single injection of BTX-A in the UES has long-lasting effectiveness in patients with neurological dysphagia caused by alteration in the UES opening and with pharyngeal contraction. Nevertheless, a randomized control trial should be done to confirm these results and rule out the effect of potential spontaneous improvement of neurological injury.

Neural control of the gastrointestinal tract: implications for Parkinson disease

Disorders of swallowing and gastrointestinal motility are prominent nonmotor manifestations of Parkinson disease (PD). Motility of the gut is controlled both by extrinsic inputs from the dorsal motor nucleus of the vagus (DMV) and paravertebral sympathetic ganglia and by local reflexes mediated by intrinsic neurons of the enteric nervous system (ENS). Both the ENS and the DMV are affected by Lewy body pathology at early stages of PD. This early involvement provides insights into the pathophysiology of gastrointestinal dysmotility in this disorder and may constitute an important step in the etiopathogenesis of Lewy body disease.

Effects of therapy for dysphagia in Parkinson's disease: systematic review

This systematic review explores the effects of dysphagia treatment for Parkinson's disease. The review includes rehabilitative, surgical, pharmacologic, and other treatments. Only oropharyngeal dysphagia is selected for this literature search, excluding dysphagia due to esophageal or gastric disorders. The effects of deep brain stimulation on dysphagia are not included. In general, the literature concerning dysphagia treatment in Parkinson's disease is rather limited. Most effect studies show diverse methodologic problems. Multiple case studies and trials are identified by searching biomedical literature databases PubMed and Embase, and by hand-searching reference lists. The conclusions of most studies cannot be compared with one another because of heterogeneous therapy methods and outcome measures. Further research based on randomized controlled trials to determine the effectiveness of different therapies for dysphagia in Parkinson's disease is required.

Effects of bolus consistency on timing and safety of swallow in patients with Parkinson's disease

Aspiration pneumonia is the leading cause of death in Parkinson's disease (PD) patients. In clinical practice, the videofluoroscopic examination (VFE) is the most common method for evaluation of swallowing disorders. One of the variables manipulated during the VFE is consistency of the bolus. The results of this examination greatly influence the recommendations made by speech-language pathologists regarding swallow therapy and/or intervention. The primary aim of this study was to investigate the effects of bolus consistency on penetration-aspiration (P-A) score and timing of swallow of persons with PD. The videoradiographic images of ten participants with PD swallowing six thin and six pudding-thick boluses were analyzed. Swallow timing and P-A were measured. (i.e., oral transit time, pharyngeal transit time, number of tongue pumps, and P-A score). The results demonstrated various significant differences and relationships among the dependent variables. Implications for further research and clinical practice are discussed.

Risk factors in patients undergoing cricopharyngeal myotomy

Background

Cricopharyngeal myotomy for oropharyngeal dysphagia is designed to improve symptoms, but the operation can result in significant morbidity and even death.

Methods

A retrospective analysis was carried out of all complications and deaths among 253 patients who had cricopharyngeal myotomy performed by a single surgeon.

Results

A single wound infection developed among 15 patients with neurological dysphagia. The same patient subsequently required laryngeal exclusion and tracheostomy. Of 139 patients treated for dysphagia secondary to muscular dystrophy, haematoma formation or infection occurred in four, and eight patients developed postoperative pulmonary complications, four of whom died from respiratory distress syndrome. Two patients with myogenic dysphagia required laryngeal exclusion with a permanent tracheostomy. Infection of the wound or retropharyngeal space was the main problem in 90 patients with a pharyngo-oesophageal diverticulum, affecting 9 per cent of the patients. Fistula was documented in three patients overall (1·2 per cent). Systemic morbidity unrelated to the technique occurred in 26 patients (10·3 per cent).

Conclusion

Pulmonary aspiration and lethal respiratory distress occurred only in patients with myogenic dysphagia. Local infection was the main complication in those with pharyngo-oesophageal diverticulum. Persistent aspiration can lead to laryngeal exclusion or resection with permanent tracheostomy.

Normal swallowing and functional magnetic resonance imaging: a systematic review

Unknowns about the neurophysiology of normal and disordered swallowing have stimulated exciting and important research questions. Previously, these questions were answered using clinical and animal studies. However, recent technologic advances have moved brain-imaging techniques such as functional magnetic resonance imaging (fMRI) to the forefront of swallowing neurophysiology research. This systematic review has summarized the methods and results of studies of swallowing neurophysiology of healthy adults using fMRI. A comprehensive electronic and hand search for original research was conducted, including few search limitations to yield the maximum possible number of relevant studies. The participants, study design, tasks, and brain image acquisition were reviewed and the results indicate that the primary motor and sensory areas were most consistently active in the healthy adult participants across the relevant studies. Other prevalent areas of activation included the anterior cingulate cortex and insular cortex. Review limitations and suggested future directions are also discussed.

Prolonged effect of botulinum toxin injection in the treatment of cricopharyngeal dysphagia: case report and literature review

Cricopharyngeus (CP) muscle spasm can lead to severe dysphagia. Myotomy of the CP muscle was the treatment of choice. Recently, botulinum toxin type A (BtxA) has been used for CP spasm. It usually brings improvement in deglutition but most patients require reinjection in 3-5 months. We report a 35-year-old man who had an arteriovenous malformation hemorrhage in the brain stem resulting in CP spasm and consequently severe dysphagia. He received BtxA injection and deglutition and nutrition remained good one year after treatment. A literature review analyzing 28 patients and our patient showed negative correlations between age and BtxA dose and between age and duration. Efficacy was positively correlated with duration and BtxA dose was positively correlated with pretreatment severity. In conclusion, physicians would use higher doses on patients with more severe cases but use lower doses on older patients. Those who obtained better post-treatment results would enjoy longer effective duration. Thus, the effective duration of the BtxA is multifactorial.

Gastrointestinal dysfunction in Parkinson's disease

There is growing recognition that gastrointestinal dysfunction is common in Parkinson's disease (PD). Virtually all parts of the gastrointestinal tract can be affected, in some cases early in the disease course. Weight loss is common but poorly understood in people with PD. Dysphagia can result from dysfunction at the mouth, pharynx, and oesophagus and may predispose individuals to aspiration (accidental inhalation of food or liquid). Gastroparesis can produce various symptoms in patients with PD and may cause erratic absorption of drugs given to treat the disorder. Bowel dysfunction can consist of both slowed colonic transit with consequent reduced bowel-movement frequency, and difficulty with the act of defecation itself with excessive straining and incomplete emptying. Recognition of these gastrointestinal complications can lead to earlier and potentially more effective therapeutic intervention.

Electrophysiological evaluation of pharyngeal phase of swallowing in patients with Parkinson's disease

We studied the various physiological aspects of oropharyngeal swallowing in Parkinson's disease (PD). Fifty-eight patients with PD were investigated by clinical and electrophysiological methods that measured the oropharyngeal phase of swallowing. All patients except 1 had mild to moderate degree of disability score. Dysphagia was demonstrated in 53% of all patients in whom the test of dysphagia limit was abnormal. All PD patients with or without dysphagia displayed the following abnormalities: (1) the triggering of the swallowing reflex was prolonged probably due to inadequate bolus control in the mouth and tongue and/or a specific delay in the execution of the swallowing reflex; (2) the duration of the pharyngeal reflex time was extremely prolonged due to slowness of the sequential muscle movements, especially those of the suprahyoid-submental muscles; (3) cricopharyngeal muscle of the upper oesophageal sphincter was found to be electrophysiologically normal; and (4) the electrophysiological phenomena in PD patients could not be strongly correlated with the degree of the disability and clinical score of the PD. It was concluded that various motor disorders of PD have considerable influence on oropharyngeal swallowing: hypokinesia, reduced rate of spontaneous swallowing, and the slowness of segmented but coordinated sequential movements rather than any abnormalities in the central pattern generator of the bulbar center. Some compensatory mechanisms in the course of PD may explain the benign nature of swallowing disorder until the terminal stage of the disease. Similarly, the swallowing problems of PD are not only related with the dopamine deficiency; some other nondopaminergic mechanisms may also be involved.

Swallowing disorders in the elderly

Changes that occur as a natural part of senescence in the complex action of deglutition predispose us to dysphagia and aspiration. As the "baby-boomers" begin to age, the onset of swallowing difficulties will begin to manifest in a greater number of our population. Recent advances in the evaluation of normal and abnormal swallowing make possible more precise anatomical and physiological diagnoses. Coupled with an understanding of swallowing physiology, such detailed evaluation allows greater opportunity to safely manage dysphagia with directed therapy and appropriate surgical intervention. The current study is a discussion of the changes that occur in deglutition with normal aging, contemporary evaluation of swallowing function, and some of the common causes of dysphagia in elderly patients.

Efficacy of botulinum toxin A for treatment of upper esophageal sphincter dysfunction

OBJECTIVES

To investigate the efficacy of botulinum toxin A (BTA)-induced chemodenervation of the upper esophageal sphincter (UES) in patients with dysphagia and UES dysfunction.

STUDY DESIGN

Prospective clinical trial in 10 selected patients with pure UES dysfunction.

METHODS

In each patient 30 units of BTA were injected into the UES under brief general anesthesia. Videofluoroscopic swallowing study (VSS) was done and a clinical symptom score was determined before and after treatment.

RESULTS

On VSS relative opening of the UES improved in all patients (mean +/- SD: 47 +/- 14% before versus 71 +/- 24% after treatment; P < .01). Hypopharyngeal retention or laryngeal penetration of barium was significantly reduced in four of seven patients. Clinical symptom scores improved in all patients. One patient was free of symptoms, mild dysphagia persisted in six patients, and moderate dysphagia persisted in three patients.

CONCLUSIONS

Our results support the use of BTA in selected patients with pure UES dysfunction. Its efficacy is limited by the possibility of a persistent structural stenosis of the UES and the risk of BTA diffusion into the larynx or hypopharynx.

Managing late complications of Parkinson's disease

Treatment of parkinsonism becomes more difficult as the disease progresses, and results from increasing neuronal degeneration, side effects from antiparkinsonian medications, or most often, a combination of each. Neurodegenerative parkinson symptoms may result from substantia nigra destruction, or from other areas in the nervous system. These include the cortex (cognitive and psychiatric disorders), brainstem (bulbar abnormalities), intermediolateral cell column (autonomic disturbances), among others. Medication side effects produce motor fluctuations, dyskinesias, delirium, hallucinations, psychosis, orthostatic hypotension, sleep disorders, and a host of other well-recognized complications. This article is divided into sections concerning motor fluctuations, gait difficulty bulbar disturbances, autonomic disturbances, sleep disorders, cognitive disorders, and psychiatric disorders, and is an attempt to provide the reader with strategies for treating common complications in the advanced Parkinson's disease patient.

Clinical manifestations of Parkinson's disease

Although the clinical manifestations of PD remain similar to those described by Parkinson in the nineteenth century, knowledge of associated findings has increased dramatically. The ability to characterize the myriad of findings associated with PD enables clinicians to care better for patients with PD. Knowledge of the associated symptoms as well as the cardinal manifestations allows clinicians to target treatment to specific symptoms and thereby improve the quality of life of those affected with PD.