Dysphagia progression and swallowing management in Parkinson's disease: an observational study

Surface Electromyographic Activity of the Masseter Muscle During Regular and Effortful Saliva Swallows: A Preliminary Study

Biofeedback is a critical component in motor learning of new, complex behaviors such as modifications to swallowing. Surface electromyography (sEMG) is a commonly employed biofeedback tool in swallowing management to assess muscle activity patterns, determine amplitude and duration of swallowing, and train swallowing strategies such as the effortful swallow (EFS) maneuver. The EFS can potentially change multiple physiological components of the swallowing process such as pressure generation and movement of biomechanical structures. The purposes of this study were to determine whether the masseter muscle could differentiate a normal swallow (NS) from an EFS and whether there was a relationship between perceived muscle effort used to swallow and objective measures of muscle activity. Twenty healthy young adults participated in this study. Masseter sEMG peak amplitude and duration were measured across five regular saliva swallows and five effortful saliva swallows. Additionally, participants rated their perceived swallowing effort using a visual analog scale (VAS). Two swallowing conditions, NSs and EFSs were compared with hierarchical models, and repeated measures correlation was used to determine the relationships between the VAS and sEMG peak amplitude. Participants produced swallows with greater masseter sEMG peak amplitude and duration during the EFS. Moreover, a positive correlation was identified between perceived swallowing effort and masseter sEMG peak amplitude. These findings support the potential use of the masseter muscle to differentiate NSs from EFSs and implement the VAS during therapy for tracking patients' performance, particularly in settings with limited access to sEMG.

Behavioural interventions for swallowing in subjects with Parkinson's disease: A mixed methods systematic review

BACKGROUND

Dysphagia is prevalent in subjects with Parkinson's disease (PD). Swallowing intervention to improve or maintain swallowing function is of major importance as dysphagia may considerably impact physical and psycho-social health.

AIMS

A mixed methods systematic review was conducted to summarize and appraise literature reporting (1) effects of behavioural interventions for swallowing in individuals with PD; and (2) participants' perspectives of swallowing interventions.

METHODS & PROCEDURES

Electronic databases were searched systematically in July 2020 for articles published between 2014 and 2020. In addition, studies published between 2000 and 2014 were identified non-systematically through previous reviews. Peer-reviewed quantitative and qualitative research in English or German documenting behavioural interventions for swallowing in individuals with a diagnosis of PD was eligible for inclusion. Participants at all disease stages were included. Behavioural interventions included rehabilitative and compensatory strategies. Studies reporting swallowing outcomes with and without a comparative group were included. For each study, the National Health and Medical Research Council level of evidence was defined. Included studies were critically appraised using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields. An integrated synthesis was performed after separate analysis of effect data and data reflecting participants' experiences. This review was conducted based on published JBI methodology and the guideline from the Preferred Reporting Items for Systematic Reviews and Meta-Analysis system was followed.

MAIN CONTRIBUTION

A total of 33 studies published in English met the inclusion criteria. Thirty-one studies reported quantitative data, one was qualitative and one was mixed methods. Intervention effects on swallowing function, swallowing safety and swallowing-related quality of life were reported for various treatment approaches. Three studies explored how participants perceived the intervention. Overriding themes including subjects' views regarding treatment schedules and levels of effort or comfort associated with the intervention were identified across these studies. Combining evidence of intervention effects and subjects' experiences was possible for one rehabilitative and one compensatory intervention.

CONCLUSIONS & IMPLICATIONS

Beneficial effects of swallowing interventions have been reported; however, most experiments were case studies of variable methodological quality. Randomized-controlled trials with robust methodology to explore treatment effects in larger samples is needed to guide clinical practice. Research reporting subjects' views is scarce. More studies exploring how individuals perceive behavioural interventions for swallowing are necessary to inform clinical decision-making.

WHAT THIS PAPER ADDS

What is already known on the subject Dysphagia is common in individuals with PD. Swallowing intervention is of major importance as dysphagia may negatively affect physical and psycho-social health of subjects with PD. What this study adds Beneficial effects of behavioural interventions for swallowing, including rehabilitative and compensatory strategies, have been reported; however, available data are mostly based on case studies of variable quality. Data on how participants perceive specific behavioural interventions are lacking. Based on the available data, integration of efficacy data and individuals' experiences is limited. What are the clinical implications of this work? Given the current evidence of intervention effects and individuals' views on behavioural treatment strategies, interventions implemented into clinical practice require careful evaluation on a case-by-case basis. More high-quality research is needed to examine interventions' short- and long-term effects in larger samples to guide clinical practice. In addition to studies evaluating intervention effects, research exploring participants' experiences with interventions is required as a foundation for clinical decision-making.

Pathophysiology and Symptomatology of Drooling in Parkinson’s Disease

Drooling can present in patients with Parkinson’s disease (PD), and it is manifested as an excessive pooling of saliva inside the oral cavity. Currently, the exact pathophysiological mechanism of drooling in PD is not yet fully explicated. Thus, it becomes crucial to understand if some clinical characteristics may emphasize drooling or if they are just concomitant. In PD, excessive drooling has been associated with a higher burden of non-motor symptoms, such as cognitive impairment, sleep problems, autonomic dysfunction, constipation and orthostatic hypotension, and of worse severity of motor fluctuations and bradykinesia. PD patients with excessive drooling also showed a reduction of striatal DAT availability at DaTSCAN imaging. Excessive drooling in patients with Parkinson’s cannot be attributed to a single factor but to a mixture of factors, including but not limited to impaired nigrostriatal pathways.

Consensus on the treatment of dysphagia in Parkinson's disease

BACKGROUND

Dysphagia is common in Parkinson's disease (PD). The effects of antiparkinsonian drugs on dysphagia are controversial. Several treatments for dysphagia are available but there is no consensus on their efficacy in PD.

OBJECTIVE

To conduct a systematic review of the literature and to define consensus statements on the treatment of dysphagia in PD and related nutritional management.

METHODS

A multinational group of experts in the field of neurogenic dysphagia and/or Parkinson's disease conducted a systematic evaluation of the literature and reported the results according to PRISMA guidelines. The evidence from the retrieved studies was analyzed and discussed in a consensus conference organized in Pavia, Italy, and the consensus statements were drafted. The final version of statements was subsequently achieved by e-mail consensus.

RESULTS

The literature review retrieved 64 papers on treatment and nutrition of patients with PD and dysphagia, mainly of Class IV quality. Based on the literature and expert opinion in cases where the evidence was limited or lacking, 26 statements were developed.

CONCLUSIONS

The statements developed by the Consensus panel provide a guidance for a multi-disciplinary treatment of dysphagia in patients with PD, involving neurologists, otorhinolaryngologists, gastroenterologists, phoniatricians, speech-language pathologists, dieticians, and clinical nutritionists.

Increased activation of the caudate nucleus and parahippocampal gyrus in Parkinson's disease patients with dysphagia after repetitive transcranial magnetic stimulation: a case-control study

Repetitive transcranial magnetic stimulation (rTMS) has been shown to effectively improve impaired swallowing in Parkinson's disease (PD) patients with dysphagia. However, little is known about how rTMS affects the corresponding brain regions in this patient group. In this case-control study, we examined data from 38 PD patients with dysphagia who received treatment at Beijing Rehabilitation Medicine Academy, Capital Medical University. The patients received high-frequency rTMS of the motor cortex once per day for 10 successive days. Changes in brain activation were compared via functional magnetic resonance imaging in PD patients with dysphagia and healthy controls. The results revealed that before treatment, PD patients with dysphagia showed greater activation in the precentral gyrus, supplementary motor area, and cerebellum compared with healthy controls, and this enhanced activation was weakened after treatment. Furthermore, before treatment, PD patients with dysphagia exhibited decreased activation in the parahippocampal gyrus, caudate nucleus, and left thalamus compared with healthy controls, and this activation increased after treatment. In addition, PD patients with dysphagia reported improved subjective swallowing sensations after rTMS. These findings suggest that swallowing function in PD patients with dysphagia improved after rTMS of the motor cortex. This may have been due to enhanced activation of the caudate nucleus and parahippocampal gyrus. The study protocol was approved by the Ethics Committee of Beijing Rehabilitation Hospital of Capital Medical University (approval No. 2018bkky017) on March 6, 2018 and was registered with Chinese Clinical Trial Registry (registration No. ChiCTR 1800017207) on July 18, 2018.

Effectiveness of fibreoptic endoscopic evaluation of swallowing and dietary intervention during home-visit dental care in older individuals

BACKGROUND

Currently, patients with dysphagia are receiving dietary management that deviates from their original swallowing function.

OBJECTIVE

To evaluate the clinical significance of fibreoptic endoscopic evaluation of swallowing (FEES) and dietary intervention (DI) by multi-professional collaboration during visit care for determining the actual oral intake status in patients with dysphagia.

METHODS

Five hundred and eighteen patients with dysphagia underwent FEES, focusing on the penetration-aspiration scale, and DI. Oral intake status was categorised using the functional oral intake scale (FOIS). FOIS scores at the first visit, after FEES, and at the reassessment were compared.

RESULTS

At the first visit, 34.7% of the patients had an FOIS score of level 1 (no oral intake) and 65.3% had a score of level 2 or higher (capable of oral intake). Following FEES, 7.1% of patients had an FOIS score of level 1, and 44.4% had a score of level 2 with resumption of oral intake. At the reassessment, 489 patients (94.4%) were capable of oral ingestion (FOIS level 2 or higher). There were significant differences between the distributions of FOIS scores at the first visit and following FEES (P < .01) and between those at the first visit and at the reassessment (P < .01). Regarding tube feeding, 17 (5.9%) of 289 patients, who had received tube feeding at the first visit, were completely capable of oral intake following FEES and at the reassessment.

CONCLUSION

Appropriate evaluation of swallowing function using FEES and DI helps to understand the definite swallowing function in patients with dysphagia.

Clinical features associated with drooling in Parkinson's disease

INTRODUCTION

Drooling is characterized by an excessive pooling of saliva in the oral cavity. The exact pathophysiological mechanism of drooling in Parkinson's disease (PD) is not yet fully understood.

OBJECTIVE

To identify the relationship between drooling and other clinical features in people diagnosed with PD.

METHOD

Research on the topic was carried out on the PubMed and ScienceDirect electronic databases. Articles published between March 2015 and March 2020 were selected. Search terms and inclusion and exclusion criteria were previously defined. The articles included met those requirements.

RESULTS

Sixteen articles were included for analysis. The prevalence of drooling varies between 9.26 and 70% and can occur at any stage of the disease. Higher prevalence of drooling is related to disease duration, disease severity, older age, male, levodopa equivalent dose, hypomimia, dysphagia, dysarthria, cognition, sleep, non-dominant tremor, motor fluctuations, bradykinesia, more symmetric pattern, gastrointestinal and urinary problems, sexual dysfunction, obstipation, and orthostatic hypotension. However, it is not related to hallucinations, rapid eye movement sleep behavior disorder, akinetic-rigid PD, mixed, nor dyskinesias.

CONCLUSION

Drooling is not caused by a single factor; it is influenced and related to several clinical features. Some clinical factors participate in the onset of drooling while others are concomitant.

A Systematic Review of the Physiological Effects of the Effortful Swallow Maneuver in Adults With Normal and Disordered Swallowing

Purpose This systematic review summarizes the biomechanical and functional effects of the effortful swallow in adults with and without dysphagia, highlighting clinical implications and future research needs. Specifically, the effects of the effortful swallow on swallowing physiology, safety, and efficiency were identified, as well as the strengths and limitations of current research. Method Recommendations specified by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses were followed. A literature search of three databases and relevant articles cited in the searched studies was performed. Two evaluators independently analyzed the studies for eligibility criteria, and final inclusion of studies was decided by consensus. Evaluators also assessed each study for quality of evidence. Results Twenty-three studies were included in this systematic review. Main findings indicated that the effortful swallow generated greater pressures in the tongue-to-palate, pharynx, upper esophageal sphincter, and esophageal regions. Inconsistent results for hyolaryngeal excursion were reported, as well as for swallowing function. Instructions of the effortful swallow varied greatly across studies. Two of the 23 studies were judged to be of high quality, and the remaining studies were of medium quality based on the quality indicators of this review. Conclusions Biomechanical effects of the effortful swallow included increased pressures in the oral, pharyngeal, and esophageal regions. Future investigations should address the effects of the effortful swallow in individuals with dysphagia and its potential role as a rehabilitative maneuver. Moreover, standardization of the effortful swallow instructions based on its physiological and functional effects is essential.

Implementation of a standardized out-of-hospital management method for Parkinson dysphagia

OBJECTIVE

Our objective is to explore the effectiveness and feasibility of establishing a swallowing management clinic to implement out-of-hospital management for Parkinson disease (PD) patients with dysphagia.

METHOD

Two-hundred seventeen (217) voluntary PD patients with dysphagia in a PD outpatient clinic were divided into a control group with 100 people, and an experimental group with 117 people. The control group was given dysphagia rehabilitation guidance. The experimental group was presented with the standardized out-of-hospital management method as overall management and information and education materials. Rehabilitation efficiency and incidence rate of dysphagia, as well as relevant complications of both groups were compared after a 6-month intervention.

RESULTS

Rehabilitation efficiency and the incidence rate of dysphagia including relevant complications of patients treated with the standardized out-of-hospital management were compared with those seen in the control group. The differences have distinct statistics meaning (p<0.01).

CONCLUSION

Establishing a swallowing management protocol for outpatient setting can effectively help the recovery of the function of swallowing, reduce the incidence rate of dysphagia complications and improve the quality of life in patients with PD.

The Impact of Deep Brain Stimulation on the Quality of Life and Swallowing in Individuals with Parkinson's Disease

Introduction  Deep brain stimulation (DBS) is an established treatment for Parkinson's disease (PD). However, there is little evidence regarding the effect of DBS on dysphagia.

Objective  To assess the swallowing and quality of life of individuals with PD before and after DBS surgery.

Methods  Our sample consisted of people who had undergone DBS surgery in a referral hospital in the state of Rio Grande do Sul, Brazil. The inclusion criteria were a diagnosis of PD and having undergone DBS surgery. A cognitive screening, through a questionnaire about depression and quality of life, was conducted. Evaluations of each patient's swallowing were performed before and after surgery. The assessment consisted of anamnesis, clinical assessment, the Functional Oral Intake Scale, clinical evaluation of swallowing, and the Hoehn and Yahr scale.

Results  The sample included 10 individuals, all male, with a mean age of 57.3 years (±4.7), a mean disease duration of 13.0 years (±2.4), and mean level education of 8.1 years (±4.0). In the clinical evaluation of the swallowing, a significant improvement after DBS was not observed. However, little changes in the signs and symptoms of dysphagia that had a positive impact on the quality of life were observed. Furthermore, there was no relation between the patients' motor subtype and swallowing pre- and post-DBS.

Conclusion  There was an improvement in the quality of life of the patients after DBS. However, the improvement in the clinical signs and symptoms of dysphagia did not cause an overall improvement in the swallowing function.

Benefit from the Chin-Down Maneuver in the Swallowing Performance and Self-Perception of Parkinson's Disease Patients

Aims. To verify the effectiveness of the maneuver application in swallowing therapy with PD. Materials and Method. We performed an open-label trial, with three groups compounds by PD individuals: the experimental group, control group, and orientation group. The study included PD patients with dysphagia. A cognitive screening, through a questionnaire about depression and quality of life, was conducted. Swallowing assessment was performed through (1) fiberoptic endoscopic evaluation of swallowing (FEES); (2) clinical evaluation and Functional Oral Intake Scale (FOIS); and (3) assessment of the quality life related to swallowing (SWALQOL). A therapeutic program, which consisted of chin-down postural maneuver and orientations on feeding, was applied. Both groups (EG and OG) received on-month therapeutic program. Results. A significant improvement in swallowing, evaluated by clinical assessment, was observed in solid (p < 0.001) and liquid (p = 0.022) consistencies in EG when compared to OG and CG. Patients in EG presented improvement in QoL, with the significant difference in comparison with the other groups, about domain frequency of symptoms (p = 0.029) in SWALQOL questionnaire. Conclusion. The postural maneuver chin-down improved swallowing performance and self-perception, but not the laryngeal signs. This trial is registered with registration number NCT02973698.

Gastrointestinal dysfunction in idiopathic Parkinsonism: A narrative review

Currently, gastrointestinal (GI) dysfunctions in Parkinson's disease (PD) are well-recognized problems and are known to be the initial symptoms in the pathological process that eventually results in PD. Many types of PD-associated GI dysfunctions have been identified, including weight loss, nausea, hypersalivation, dysphagia, dyspepsia, abdominal pain, intestinal pseudo-obstruction, constipation, defecatory dysfunction, and small intestinal bacterial overgrowth. These symptoms can influence on other PD symptoms and are the second most significant predictor of the quality of life of these patients. Recognition of GI symptoms requires vigilance on the part of clinicians. Health-care providers should routinely ask direct questions about GI symptoms during office visits so that efforts can be directed at appropriate management of these distressing manifestations. Multiple system atrophy (MSA) and progressive supranuclear palsy are two forms of neurodegenerative Parkinsonism. Symptoms of autonomic dysfunctions such as GI dysfunction are common in patients with parkinsonian disorders. Despite recent progress in the recognition of GI dysfunctions, there are a few reviews on the management of GI dysfunction and GI symptoms in idiopathic Parkinsonism. In this review, the clinical presentation, pathophysiology, and treatment of each GI symptom in PD, MSA, and prostate-specific antigen will be discussed.

Tradução e adaptação cultural do swallowing disturbance questionnaire para o português-brasileiro

RESUMO Objetivo: traduzir e adaptar culturalmente para o português brasileiro o Swallowing disturbance questionnaire (SDQ) para detecção de risco de disfagia em indivíduos com Doença de Parkinson (DP). Métodos: realizou-se tradução para o português, retradução para o inglês, análise de confiabilidade do instrumento, sendo a versão final aplicada aos participantes e realizado o reteste após duas semanas. Selecionou-se os participantes em um ambulatório de distúrbios do movimento de um hospital de referência no Rio Grande do Sul. Incluiu-se indivíduos com diagnóstico de DP. Excluiu-se indivíduos com alteração de linguagem ou audição que impossibilitasse a compreensão do questionário e com diagnóstico de outras doenças neurológicas. Resultados: a amostra foi composta por 23 indivíduos. Os participantes responderam a todas as questões. Não houve eliminação de nenhuma questão. Na análise da confiabilidade teste-reteste o coeficiente de correlação intraclasse do escore final nos dois momentos foi de 0,912 com p<0,001 (95%IC=0,792-0,963), demonstrando que os dados são altamente homogêneos. Na análise por questão, não houve diferença significante entre os dois momentos de aplicação. O valor de α de Cronbach do instrumento foi de 0,63. Conclusão: houve equivalência cultural do SDQ para o português brasileiro, com boa confiabilidade interna do instrumento.

Gut dysfunction in Parkinson's disease

Early involvement of gut is observed in Parkinson’s disease (PD) and symptoms such as constipation may precede motor symptoms. α-Synuclein pathology is extensively evident in the gut and appears to follow a rostrocaudal gradient. The gut may act as the starting point of PD pathology with spread toward the central nervous system. This spread of the synuclein pathology raises the possibility of prion-like propagation in PD pathogenesis. Recently, the role of gut microbiota in PD pathogenesis has received attention and some phenotypic correlation has also been shown. The extensive involvement of the gut in PD even in its early stages has led to the evaluation of enteric α-synuclein as a possible biomarker of early PD. The clinical manifestations of gastrointestinal dysfunction in PD include malnutrition, oral and dental disorders, sialorrhea, dysphagia, gastroparesis, constipation, and defecatory dysfunction. These conditions are quite distressing for the patients and require relevant investigations and adequate management. Treatment usually involves both pharmacological and non-pharmacological measures. One important aspect of gut dysfunction is its contribution to the clinical fluctuations in PD. Dysphagia and gastroparesis lead to inadequate absorption of oral anti-PD medications. These lead to response fluctuations, particularly delayed-on and no-on, and there is significant relationship between levodopa pharmacokinetics and gastric emptying in patients with PD. Therefore, in such cases, alternative routes of administration or drug delivery systems may be required.

The Impact of Dysphagia Therapy on Quality of Life in Patients with Parkinson's Disease as Measured by the Swallowing Quality of Life Questionnaire (SWALQOL)

INTRODUCTION

Dysphagia is a common symptom in Parkinson's disease (PD) and it has been associated with poor quality of life (QoL), anxiety, depression.

OBJECTIVE

The aim of this study was to evaluate the quality of life in individuals with PD before and after SLP therapy.

METHODS

The program consisted of four individual therapy sessions. Each session comprised guidelines regarding food and postural maneuvers (chin down). The Quality of Life in Swallowing Disorders (SWAL-QOL) questionnaire was applied before and after therapy.

RESULTS

The sample comprised of 10 individuals (8 men), with a mean (SD) age of 62.2 (11.3) years, mean educational attainment of 7.5 (4.3) years, and mean disease duration of 10.7 (4.7) years. Thirty percent of patients were Hoehn and Yahr (H&Y) stage 2, 50% were H&Y stage 3, and 20% were H&Y stage 4. Mean scores for all SWAL-QOL domains increased after the intervention period, with significant pre- to post-therapy differences in total score (p = 0.033) and domain 4 (symptom frequency) (p = 0.025). There was also a bias significance for domain 5 (food selection) (p = 0.095).

CONCLUSION

Patients exhibited improvement in swallowing-related quality of life after a SLP therapy program. The earlier in the course of PD, greater the improvement observed after therapy.

Central cholinergic dysfunction could be associated with oropharyngeal dysphagia in early Parkinson's disease

Dysphagia is an important issue in the prognosis of Parkinson's disease (PD). Although several studies have reported that oropharyngeal dysphagia may be associated with cognitive dysfunction, the exact relationship between cortical function and swallowing function in PD patients is unclear. Therefore, we investigated the association between an electrophysiological marker of central cholinergic function, which reflected cognitive function, and swallowing function, as measured by videofluoroscopic studies (VFSS). We enrolled 29 early PD patients. Using the Swallowing Disturbance Questionnaire (SDQ), we divided the enrolled patients into two groups: PD with dysphagia and PD without dysphagia. The videofluoroscopic dysphagia scale (VDS) was applied to explore the nature of the dysphagia. To assess central cholinergic dysfunction, short latency afferent inhibition (SAI) was evaluated. We analyzed the relationship between central cholinergic dysfunction and oropharyngeal dysphagia and investigated the characteristics of the dysphagia. The SAI values were significantly different between the two groups. The comparison of each VFSS component between the PD with dysphagia group and the PD without dysphagia group showed statistical significance for most of the oral phase components and for a single pharyngeal phase component. The total score on the VDS was higher in the PD with dysphagia group than in the PD without dysphagia group. The Mini-Mental State Examination and SAI values showed significant correlations with the total score of the oral phase components. According to binary logistic regression analysis, SAI value independently contributed to the presence of dysphagia in PD patients. Our findings suggest that cholinergic dysfunction is associated with dysphagia in early PD and that an abnormal SAI value is a good biomarker for predicting the risk of dysphagia in PD patients.