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

Adherence of Clinical Practice Guidelines for Oropharyngeal Dysphagia in Parkinson Disease to Trustworthy Standards: A Systematic Survey

Despite the high prevalence and burden of dysphagia in Parkinson disease (PD), the availability and trustworthiness of clinical practice guidelines (CPGs) regarding its assessment and management remains uncertain. The objective of this study is to appraise the quality of CPGs for dysphagia in PD. We searched OVID Medline, Embase, CINAHL and SpeechBite from January 2011 to July 2023 for guidance documents addressing screening, referral, monitoring, assessment, or management of dysphagia in PD. We additionally conducted an informal search of web pages of relevant professional societies and government organizations. Paired reviewers independently screened studies, and for relevant guidance documents, abstracted data and assessed their quality using the National Guideline Clearinghouse Extent of Adherence to Trustworthy Standards instrument. Thirteen CPGs proved eligible. Of these, eight (62%) were developed by professional societies. Overall, CPGs were deemed low quality. Eleven (85%) CPGs reported funding sources, and nine (69%) reported conflicts of interest. Five (35%) guidance documents included a methodologist, four (30%) included patient partners, four (30%) described study selection processes, and two (15%) clearly described relevant benefits and harms. Regarding dysphagia-specific recommendations, less than half of guidance documents met standards for trustworthiness; six (46%) provided a synthesis of available evidence, eight (54%) specified strength of recommendations, and two (15%) articulated unambiguous recommendations. Limited guidance exists regarding screening, monitoring and referral for dysphagia in PD. Existing guidance frequently fails to meet standards for trustworthiness. International, multidisciplinary, evidence-based practice guidelines with adequate methodological and patient partner involvement are needed.

Effects of LSVT LOUD and EMST in individuals with Parkinson's disease: A two arm non-randomized clinical trial

PURPOSE

This study compared the effects of Lee Silverman Voice Treatment and Expiratory Muscle Strength Training on swallow, cough, and voice function in individuals with Parkinson's disease.

METHOD

Fifty-eight individuals with mild-moderate Parkinson's disease (male = 45, M = 69 years, SD = 8) were enrolled in a two-treatment clinical trial and completed four consecutive weeks of either Lee Silverman Voice Therapy or Expiratory Muscle Strength Training. All participants completed standard protocol videofluoroscopic swallow study, spirometry-cough tests, acoustic-voice assessment, and self-rated questionnaires pre- and post-therapy. Data were analysed by masked clinicians using specialised software. Mixed-model repeated measures and t-tests were performed.

RESULT

Lee Silverman Voice Treatment resulted in greater effects in acoustic aerodynamic voice measures (loudness, pitch-range, and aerodynamic-efficiency; p < .05) compared to the Expiratory Muscle Strength Training group. There were significant effects on pharyngoesophageal segment maximum opening (p =.01) following Lee Silverman Voice Treatment. Expiratory Muscle Strength Training resulted in significantly greater change in maximum hyoid displacement (Hmax; p = .04) and decreased Hmax duration (p < .01) compared to Lee Silverman Voice Therapy group. No cough measures and self-reported questionnaires significantly differed between groups with both groups improving post-treatment.

CONCLUSION

Both Lee Silverman Voice Therapy and Expiratory Muscle Strength Training improved specific swallow efficiency and airway defence capacity despite differences in task and therapeutic dose. Only Lee Silverman Voice Thearpy improved vocal intensity. Both treatments are feasible options for individuals with mild-moderate Parkinson's disease.

Vocal and tongue exercise in early to mid-stage Parkinson disease using the Pink1-/- rat

Vocal and swallowing deficits are common in Parkinson disease (PD). Because these impairments are resistant to dopamine replacement therapies, vocal and lingual exercise are the primary treatment, but not all individuals respond to exercise and neural mechanisms of treatment response are unclear. To explore putative mechanisms, we used the progressive Pink1-/- rat model of early to mid-stage PD and employed vocal and lingual exercises at 6- and 10-months of age in male Pink1-/- and wild type (WT) rats. We hypothesized that vocal and lingual exercise would improve vocal and tongue use dynamics and increase serotonin (5HT) immunoreactivity in related brainstem nuclei. Rats were tested at baseline and after 8 weeks of exercise or sham exercise. At early-stage PD (6 months), vocal exercise resulted in increased call complexity, but did not change intensity, while at mid-stage (10 months), vocal exercise no longer influenced vocalization complexity. Lingual exercise increased tongue force generation and reduced relative optical density of 5HT in the hypoglossal nucleus at both time points. The effects of vocal and lingual exercise at these time points are less robust than in prodromal stages observed in previous work, suggesting that early exercise interventions may yield greater benefit. Future work targeting optimization of exercise at later time points may facilitate clinical translation.

A systematic review of behavioural therapies for improving swallow and cough function in Parkinson's disease

PURPOSE

This systematic review evaluated the efficacy of therapeutic interventions on improving swallow, respiratory, and cough functions in Parkinson's disease (PD).

METHOD

A PRISMA systematic search was implemented across six databases. We selected studies reporting pre- and post-assessment data on the efficacy of behavioural therapies with a swallow or respiratory/cough outcome, and excluded studies on medical/surgical treatments or single-session design. Cross-system outcomes across swallow, respiratory, and cough functions were explored. Cochrane's risk of bias tools were utilised to evaluate study quality.

RESULT

Thirty-six articles were identified and further clustered into four treatment types: swallow related (n = 5), electromagnetic stimulation (n = 4), respiratory loading (n = 20), and voice loading (n = 7) therapies. The effects of some behavioural therapies were supported with high-quality evidence in improving specific swallow efficiency, respiratory pressure/volume, and cough measures. Only eleven studies were rated with a low risk of bias and the remaining studies failed to adequately describe blinding of assessors, missing data, treatment adherence, and imbalance assignment to groups.

CONCLUSION

Behavioural therapies were diverse in nature and many treatments demonstrated broad cross-system outcome benefits across swallow, respiratory, and cough functions. Given the progressive nature of the condition, the focus of future trials should be evaluating follow-up therapy effects and larger patient populations, including those with more severe disease.

Tongue Acupuncture to Treat Dysphagia in Patients with Parkinson's Disease: A Randomized Controlled Trial

Objective

Parkinson's disease (PD) is a chronic degenerative disease that lacks specific treatment. The incidence of dysphagia in patients with PD is 35%-82%. Dysphagia not only affects nutritional intake but also leads to pneumonia, even asphyxia. This study explored the efficacy of tongue acupuncture for treating dysphagia in patients with PD.

Materials and Methods

From March 2021 to June 2023, 64 patients with PD-related dysphagia were chosen from Qingdao Central Hospital and the Affiliated Hospital of Qingdao Binhai University, both in Qindao, Shandong, China. The patients were divided into a tongue acupuncture group (n = 32) and a control group (n = 32). The control group was treated with a VitalStim® 5900 Swallowing Disorder Therapeutic Instrument (CA, USA), and the tongue acupuncture group had tongue acupuncture at Juquan (Ex-HN-10) and Haiquan (Ex-HN-11). Swallowing function and nutritional conditions were compared between the 2 groups after all treatments.

Results

The total clinical effective rate in the tongue acupuncture group was higher than that of the control group (P < 0.05). The proportion of grade 1 and grade 2 of the 5-scaled Kubota drinking-water test in the tongue acupuncture group was significantly higher than that in the control group (78.13 % versus 31.26 %; P < 0.05), and the proportion of grade 3, grade 4, and grade 5 was significantly lower than that in the control group (21.87 % versus 68.74 %; P < 0.05). After tongue acupuncture, levels of body mass index, upper-arm circumference, triceps skinfold thickness, hemoglobin, serum albumin, and prealbumin were significantly higher than those in the control group (P < 0.05) and the incidence of complications caused by PD was significantly lower than that in the control group (P < 0.05).

Conclusions

Treatment of dysphagia in PD by tongue acupuncture significantly improved swallowing function and nutritional level, and decreased the incidence of complications.

Dysphagia treatments in Parkinson's disease: A systematic review and meta-analysis

BACKGROUND

The majority of patients with Parkinson's disease (PD) develop oropharyngeal dysphagia during the course of their disease. However, the efficacy of dysphagia treatments for these patients remains controversial. Therefore, we conducted this systematic review and meta-analysis to evaluate treatment efficacy based on the evidence from randomized controlled trials (RCTs).

METHODS

Five electronic databases were systematically searched from inception date to April 2022. Two reviewers independently extracted and analyzed the data. The outcome measures were changes in swallowing-related characteristics based on instrumental swallowing assessments.

KEY RESULTS

An initial search identified 187 RCT studies of relevance. After screening, nine studies with a total sample size of 286 were included in the meta-analysis. The pooled effect size for all dysphagia treatments compared with control comparators was significant and medium (SMD [95% CI] = 0.58 [0.22, 0.94], p = 0.001; I2  = 50%). Subgroup analysis revealed a significant and medium pooled effect size for stimulation treatments (brain stimulation, peripheral neurostimulation and acupuncture) (SMD [95% CI] = 0.54 [0.15, 0.92]; p = 0.006; I2  = 22%). Specifically, the effect sizes for the single RCTs on neuromuscular stimulation (SMD [95% CI] = 1.58 [0.49, 2.86]; p = 0.005) and acupuncture (SMD [95% CI] = 0.82 [0.27, 1.37]; p = 0.003) were significant and large.

CONCLUSIONS AND INFERENCES

Our results showed that overall, dysphagia treatments, particularly stimulation treatments, can potentially benefit PD patients. However, given the limited number of small RCTs for each type of treatment, the evidence remains weak and uncertain. Further large-scale, multicenter RCTs are warranted to fully explore their clinical efficacy in the PD population.

Electrokinesiographic Study of Oropharyngeal Swallowing in Neurogenic Dysphagia

Electrokinesiographic study of swallowing (EKSS) can be useful for the assessment of patients with suspected or overt neurogenic dysphagia. EKSS consists of multichannel recording of the electromyographic (EMG) activity of the suprahyoid/submental muscle complex (SHEMG), the EMG activity of the cricopharyngeal muscle (CPEMG), and the laryngopharyngeal mechanogram (LPM). The LPM is an expression of the mechanical changes that the laryngopharyngeal structures undergo during the pharyngeal phase of swallowing. This method allows detailed evaluation of the magnitude, duration and temporal relations of the different events that characterize oropharyngeal swallowing, and thus in-depth exploration both of physiological deglutition mechanisms and of pathophysiological features of swallowing in neurogenic dysphagia. Furthermore, EKSS can guide dysphagia treatment strategies, allowing identification of optimal solutions for single patients. For instance, CPEMG recording can identify incomplete or absent relaxation of the upper esophageal sphincter during the pharyngeal phase of swallowing, thus suggesting a therapeutic approach based on botulinum toxin injection into the cricopharyngeal muscle. More recently, the 'shape' of SHEMG and the reproducibility of both SHEMG and LPM over repeated swallowing acts have been implemented as novel electrokinesiographic parameters. These measures could be valuable for straightforward non-invasive investigation of dysphagia severity and response to dysphagia treatment in clinical practice.

Effects of behavioural swallowing therapy in patients with Parkinson's disease: A systematic review

PURPOSE

A previous 2014 systematic review outlining the treatment effects of swallowing therapies in Parkinson's disease (PD) demonstrated a lack of well-designed randomised controlled studies. This current review presents and evaluates the latest evidence for behaviour swallowing therapies for PD-related dysphagia to enhance speech-language pathologists' evidence-based decision-making around treatment choices.

METHOD

A systematic review of articles published in English and Korean was conducted from January 2014 through June 2020 using the electronic databases PubMed, Embase, and Cochrane Library. Two authors independently searched the literature and differences after the search were settled following discussion and consensus. Identified studies were evaluated for quality with the ABC rating scale and critical appraisal criteria.

RESULT

Eight studies after initial search and three additional studies which met our original criteria but were not freely available, or published after the initial search period were also included. Eleven studies included the following treatments: biofeedback therapy (N = 1), respiratory-swallow coordination training (N = 2), neuromuscular electrical stimulation (NMES) (N = 1), expiratory muscle strength training (EMST) (N = 2), intensive exercise-based swallowing program (ISP) (N = 1), chin-down strategy (N = 2), Lee Silverman Voice Treatment (N = 1), and therapeutic singing (N = 1).

CONCLUSION

Most of the behavioural therapies improved swallowing function in PD. Treatments that enhanced airway function globally demonstrated positive effects on swallow function as did intensive, targeted swallowing treatment. However, the chin-down strategy did not show a significant effect on swallowing measured by flexible endoscopic evaluations of swallowing. EMST detraining effects implied a need to design maintenance training in PD. In the future, well-designed randomised controlled trials are needed to consolidate the effects of these therapies.

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.

Rate of Hospitalizations and Underlying Reasons Among People with Parkinson's Disease: Population-Based Cohort Study in UK Primary Care

BACKGROUND

Hospitalization in Parkinson's disease (PD) is associated with reduced quality of life, caregiver burden and high costs. However, no large-scale studies of rate and causes of hospitalizations in patients with PD have been published.

OBJECTIVE

To investigate the rate and reasons for hospitalization and factors associated with hospitalization among people with PD compared to the general population.

METHODS

We examined rate and causes of admission in PD patients and matched controls in The Health Improvement Network from 2006 to 2016. Multivariable Poisson regression was used to explore the effects of age, gender, social deprivation, urbanicity and practice geographic location on hospitalization.

RESULTS

In the longitudinal data from 9,998 newly diagnosed individuals with PD and 55,554 controls without PD aged ≥50 years, 39% of PD patients and 28% of controls were hospitalised over a median follow-up of 5.1 years. The adjusted incidence rate ratio (IRR) of hospitalization in PD compared to controls was 1.33 (95% CI:1.29-1.37) and rose with increased follow-up duration. Hospitalization rate was overall higher in the older age groups, but the adjusted IRR of hospitalization compared to controls was highest in the youngest age group. PD patients were more often admitted with falls/fractures, infections, gastrointestinal complications, PD, dementia, psychosis/hallucinations, postural hypotension, electrolyte disturbances, stroke and surgical procedures and slightly less often due to hypertension.

CONCLUSION

People with PD have an increased hospitalization rate compared to controls, particularly in the younger age groups, and it increases with longer disease duration. The complications of motor and non-motor features of PD are amongst the main reasons for admission, some of which could be managed preventatively to avoid admissions.

Effectiveness of Interventions for Dysphagia in Parkinson Disease: A Systematic Review

PURPOSE

Dysphagia is a common sequela of Parkinson disease (PD) and is associated with malnutrition, aspiration pneumonia, and mortality. This review article synthesized evidence regarding the effectiveness of interventions for dysphagia in PD.

METHOD

Electronic searches were conducted in Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and speechBITE. Of the 2,015 articles identified, 26 met eligibility criteria: interventional or observational studies with at least five or more participants evaluating dysphagia interventions in adults with PD-related dysphagia, with outcomes measured using videofluoroscopic swallowing study (VFSS), fiberoptic endoscopic evaluation of swallowing (FEES), or electromyography (EMG). Risk of bias (RoB) was evaluated using the Evidence Project tool and predetermined criteria regarding the rigor of swallowing outcome measures.

RESULTS

Interventions were classified as follows: pharmacological (n = 11), neurostimulation (n = 8), and behavioral (n = 7). Primary outcome measures varied across studies, including swallowing timing, safety, and efficiency, and were measured using VFSS (n = 17), FEES (n = 6), and EMG (n = 4). Critical appraisal of study findings for RoB, methodological rigor, and transparency showed the majority of studies failed to adequately describe contrast media used, signal acquisition settings, and rater blinding to time point. Low certainty evidence generally suggested improved swallow timing with exercises with biofeedback and deep brain stimulation (DBS), improved safety with DBS and expiratory muscle strength training, and improved efficiency with the Lee Silverman Voice Treatment and levodopa.

CONCLUSIONS

Studies with lower RoB and greater experimental rigor showed potential benefit in improving swallowing efficiency but not safety. Further research investigating discrete changes in swallowing pathophysiology post-intervention is warranted to guide dysphagia management in PD.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.17132162.

Machine learning based analysis of speech dimensions in functional oropharyngeal dysphagia

BACKGROUND AND OBJECTIVE

The normal swallowing process requires a complex coordination of anatomical structures driven by sensory and cranial nerves. Alterations in such coordination cause swallowing malfunctions, namely dysphagia. The dysphagia screening methods are quite subjective and experience dependent. Bearing in mind that the swallowing process and speech production share some anatomical structures and mechanisms of neurological control, this work aims to evaluate the suitability of automatic speech processing and machine learning techniques for screening of functional dysphagia.

METHODS

Speech recordings were collected from 46 patients with functional oropharyngeal dysphagia produced by neurological causes, and 46 healthy controls. The dimensions of speech including phonation, articulation, and prosody were considered through different speech tasks. Specific features per dimension were extracted and analyzed using statistical tests. Machine learning models were applied per dimension via nested cross-validation. Hyperparameters were selected using the AUC - ROC as optimization criterion.

RESULTS

The Random Forest in the articulation related speech tasks retrieved the highest performance measures (AUC=0.86±0.10, sensitivity=0.91±0.12) for individual analysis of dimensions. In addition, the combination of speech dimensions with a voting ensemble improved the results, which suggests a contribution of information from different feature sets extracted from speech signals in dysphagia conditions.

CONCLUSIONS

The proposed approach based on speech related models is suitable for the automatic discrimination between dysphagic and healthy individuals. These findings seem to have potential use in the screening of functional oropharyngeal dysphagia in a non-invasive and inexpensive way.

The Frequency of Atypical and Extreme Values for Pharyngeal Phase Swallowing Measures in Mild Parkinson Disease Compared to Healthy Aging

Purpose Dysphagia is thought to be prevalent and a leading cause of morbidity and mortality in people with Parkinson disease (PwPD). The aim of this study was to compare the frequencies of atypical and extreme values for measures of swallowing physiology in PwPD and in an age- and sex-matched cohort of healthy adults. Atypical and extreme values were defined, respectively, as values falling in the 25% and 5% tails of the reference distribution for healthy adults under age 60 years. Method A standard videofluoroscopy (VF) protocol was performed in 17 adults with mild PD and 17 age- and sex-matched healthy adults using 20% w/v liquid barium ranging from thin to extremely thick consistency. Blinded VF analysis was performed according to the Analysis of Swallowing Physiology: Events, Kinematics and Timing Method. Frequencies for atypical and extreme values were tabulated by cohort and compared using odds ratios. Results Increased frequencies of atypical values (> 25%) were seen in the PwPD for prolonged swallow reaction time, prolonged time-to-laryngeal-vestibule-closure (LVC), and poor pharyngeal constriction. However, these findings were also observed in the healthy controls. The PwPD showed significantly higher odds of atypical values for narrow upper esophageal sphincter (UES) diameter on thin liquids, a short hyoid-burst-to-UES-opening interval on extremely thick liquids, and prolonged time-to-LVC, LVC duration, and UES opening duration on multiple consistencies. The frequencies of extreme values failed to show any significant cohort differences for any parameter. Conclusions In this study, a group of people with mild PD did not show clear evidence of swallowing impairments distinct from the changes seen in a healthy age-matched control group when odds ratios were used to compare the frequencies of atypical values between PwPD and the control group; only a few parameters showed significant differences. These were findings of significantly higher frequencies in PwPD of prolonged LVC and UES opening duration. Supplemental Material https://doi.org/10.23641/asha.15032241.

Fidelity in Behavioral Interventions for Oropharyngeal Dysphagia in Parkinson's Disease: A Systematic Review

Measuring fidelity of delivery and engagement in the methods of a trial helps us to understand whether planned interventions were effective. Treatment fidelity is critical in proving that change in study outcomes is due to the intervention itself and not to variability in its implementation or measurement. Existing reviews of oropharyngeal dysphagia (OD) interventions for Parkinson's disease (PD) have not systematically scrutinized fidelity within clinical trials. This study aimed to examine treatment fidelity in behavioral interventions for OD in PD and provide information about the reliability of existing study findings on behavioral interventions. All published and unpublished randomized controlled trials (RCTs) regarding behavioral interventions for OD in PD were sought. A comprehensive search of eight electronic databases was performed from inception to January 2019 and updated in April 2020. Gray literature was explored to minimize publication bias. No language or date restrictions were applied. Data were extracted by two independent reviewers with a third mediator. The National Institutes of Health Behavior Change Consortium Treatment Fidelity checklist was used to assess fidelity. From the 4998 references identified, eight studies met the inclusion criteria. Behavioral interventions in the included studies varied. The level of treatment fidelity was rated as low across all studies included in the review. The review concluded that low levels of treatment fidelity adherence in RCTs on dysphagia interventions in PD undermine the interpretation of the validity and reliability of study findings along with successful replication of these interventions in research and clinical practice.

Effectiveness of expiratory flow acceleration in patients with Parkinson's disease and swallowing deficiency: A preliminary study

OBJECTIVES

Parkinson's disease (PD) causes dysfunction both to swallowing and to the cough mechanism. Oropharyngeal dysphagia is the main cause of pneumonia, due to silent aspiration of food and saliva. Pneumonia is the leading cause of death in PD. Different strategies exist to reduce the risk of inhalation and associated lung infections, but evidence of their efficacy is still unclear. The aim of this preliminary study was to investigate if adding an expiratory flow acceleration (EFA®) technique to standard therapy (ST) for dysphagia can reduce the incidence of bronchopulmonary infections and improve quality of life, respiratory function parameters, cough, and airways encumbrance perception.

MATERIALS AND METHODS

Twenty-five patients with PD were randomized to two groups: ST vs. ST + EFA. Patients were re-assessed at 30, 180 and 360 days from start of treatment. The primary outcome was the incidence of respiratory exacerbations together with quality of life score (PDQ-39). Secondary outcomes were changes in respiratory function tests, cough capacity (CPEF), perceived health status (Euro-QOL-VAS), cough, and upper airways encumbrance perception evaluated by visual numeric scale (VNS).

RESULTS

Twenty patients concluded the study (10 each group). Albeit the difference was not significant, less respiratory infections, symptoms, hospital admissions and medical visits were found in the study group. Furthermore, there was a significant difference in cough effectiveness measured with the peak cough expiratory flow (PCEF) and other spirometry parameters (FEV₁, FVC), and also in specific and generic health-related quality of life measures (PDQ-39, Euro-QoL-VAS).

CONCLUSION

The results of this preliminary study support the use of EFA® technology in Parkinson's patients with dysphagia to reduce the risk of respiratory complications. Nevertheless, further studies are needed in a larger, more representative sample to definitively confirm the usefulness of this technique in PD patients.

The effects of spaced transcranial Direct Current Stimulation combined with conventional dysphagia therapy in Parkinson's disease: A case report

Parkinson's disease (PD) is a neurodegenerative disease of the central nervous system that is characterized by a set of motor and non-motor symptoms. Impaired swallowing or dysphagia is one relatively common motor symptom in patients with PD. We investigated whether neuroplasticity induction by spaced transcranial Direct Current Stimulation (tDCS) combined with conventional swallowing therapy leads to long-lasting effects on swallowing ability in patients with PD. We present a case of a 61-year-old male PD patient with dysphagia. Conventional Swallowing Therapy (CDT) combined with tDCS (bilateral anodal, 1 mA, 20 min, 10 online sessions, twice daily with a 20 min interval in between for five days over two weeks) was applied over the pharyngeal motor cortex. Our findings suggest that anodal tDCS combined with CDT is feasible, safe, and well-tolerated, and leads to a clinically relevant improvement of swallowing functions.

A comprehensive review of the diagnosis and treatment of Parkinson's disease dysphagia and aspiration

INTRODUCTION

Bulbar dysfunction is common in Parkinson's disease (PD) with more than 80% of affected individuals developing dysphagia during the course of the disease. Symptoms can begin in the preclinical stage and individuals may remain clinically asymptomatic for years. Furthermore, patients may be unaware of swallowing changes, which contributes to the difference between the prevalence of self-reported dysphagia and deficits identified during instrumental evaluations. Dysphagia is underrecognized and contributes to the development of aspiration pneumonia which is the leading cause of death in PD. Dysphagia in PD is complex and not completely understood. Both dopaminergic and nondopaminergic pathways likely underpin dysphagia.

AREAS COVERED

This comprehensive review will cover the epidemiology, pathophysiology, clinical evaluation, and expert management of dysphagia and aspiration in patients with PD.

EXPERT OPINION

A multidisciplinary team approach is important to properly identify and manage PD dysphagia. Regular clinical screenings with objective instrumental assessments are necessary for early detection of dysphagia. Studies are needed to better understand the mechanism(s) involved in PD dysphagia, establish markers for early detection and progression, and develop evidence-based treatment options.

The Effect of Cranial Nerve Stimulation on Swallowing: A Systematic Review

This systematic review summarizes published studies on the effect of cranial nerve stimulation (CNS) on swallowing and determines the level of evidence of the included studies to guide the development of future research on new treatment strategies for oropharyngeal dysphagia (OD) using CNS. Studies published between January 1990 and October 2019 were found via a systematic comprehensive electronic database search using PubMed, Embase, and the Cochrane Library. Two independent reviewers screened all articles based on the title and abstract using strict inclusion criteria. They independently screened the full text of this initial set of articles. The level of evidence of the included studies was assessed independently by the two reviewers using the A-B-C rating scale. In total, 3267 articles were found in the databases. In the majority of these studies, CNS was used for treatment-resistant depression or intractable epilepsy. Finally, twenty-eight studies were included; seven studies on treatment of depression, thirteen on epilepsy, and eight on heterogeneous indications. Of these, eight studies reported the effects of CNS on swallowing and in 20 studies the swallowing outcome was described as an adverse reaction. A meta-analysis could not be carried out due to the poor methodological quality and heterogeneity of study designs of the included studies. These preliminary data suggest that specific well-indicated CNS might be effective in reducing OD symptoms in selective patient groups. But it is much too early for conclusive statements on this topic. In conclusion, the results of these studies are encouraging for future research on CNS for OD. However, randomized, double-blind, sham-controlled clinical trials with sufficiently large sample sizes are necessary.

Systematic Review of Behavioral Therapy to Improve Swallowing Functions of Patients With Parkinson's Disease

Decreased swallowing function is a common and main cause of malnutrition and aspiration pneumonia in patients with Parkinson's disease. The aims of this systematic review were to summarize and qualitatively analyze the studies that have been published on behavioral therapies for improving swallowing functions in patients with Parkinson's disease. Studies published from January 2000 to December 2015 were identified via electronic database searches using Ovid-MEDLINE, Ovid-EMBASE, the Cochrane Library, and 8 Korean databases. Two reviewers independently evaluated the studies using inclusion criteria. Nine studies were included, of which 6 evaluated rehabilitation technique studies and 3 evaluated compensatory strategies. The 9 studies were evaluated qualitatively using a methodology checklist of the Scottish Intercollegiate Guideline Network, according to which all of the studies had acceptable quality. The available data on the effects of rehabilitation techniques and compensatory strategies remain insufficient. Further randomized controlled studies should be done to investigate the effect of behavioral therapy on improving swallowing functions in patients with Parkinson's disease.

Research-based Updates in Swallowing and Communication Dysfunction in Parkinson Disease: Implications for Evaluation and Management

PURPOSE

Individuals with Parkinson disease (PD) present with complex and variable symptoms, with recent findings suggesting that the etiology of PD extends beyond the involvement of just the basal ganglia. These symptoms include significant impairments in the speech and swallowing domains, which can greatly affect quality of life and therefore require therapeutic attention. This research-based update reviews the neurophysiological basis for swallowing and speech changes in PD, the effectiveness of various types of treatments, and implications for symptom evaluation and management.

CONCLUSION

The mechanisms responsible for swallowing and speech symptoms in PD remain largely unknown. Dopaminergic medication and deep-brain-stimulation do not provide consistent benefits for these symptoms suggesting a non-dopaminergic network is involved. Importantly, evidence suggests that symptoms of dysphagia and hypokinetic dysarthria may be early indications of PD, so it is critical to investigate the cause of these changes.

Inpatient Enhanced Multidisciplinary Care Effects on the Quality of Life for Parkinson Disease: A Quasi-Randomized Controlled Trial

OBJECTIVES

To compare the effects of inpatient enhanced multidisciplinary care (EMC) and multidisciplinary rehabilitation (MR) on the symptoms and quality of life (QOL) of patients with Parkinson disease (PD) and to clarify the relation between reduction in symptoms and the improved QOL.

METHODS

This study was a quasi-randomized controlled (alternate allocation), assessor-blinded, single-center study. We recruited 80 patients with idiopathic Parkinson disease, Hoehn and Yahr stage 2 to 4, on stable medication. Patients were included in an EMC or MR group. Both rehabilitation programs were performed for 8 weeks (17 h/wk). Main outcome measures were Parkinson's Disease Questionnaire-39 and Unified Parkinson's Disease Rating Scale.

RESULTS

The EMC induced significant improvements in QOL compared to MR. We found that body axis symptoms (rising from a chair, posture, postural stability, falling, and walking) as well as nonmotor symptoms (depression) in patients with PD were relieved by the inpatient EMC.

CONCLUSIONS

Enhanced multidisciplinary care for patients with PD appears to be effective in improving the QOL. The improvement in motor and nonmotor symptoms, including depression, may contribute to the improved QOL.

Changes in Timing of Swallow Events in Parkinson's Disease

OBJECTIVES:

The prevalence of Parkinson's disease (PD) increases as the population ages. Dysphagia and subsequent aspiration pneumonia are common causes of morbidity and mortality in those with PD. To maximize the benefit of swallowing therapy, protocol design should be based on an understanding of the physiologic swallowing deficits present in the PD population. The aim of this study was to compare the timing of swallow events in a cohort of patients with PD with that in normal age-matched control subjects to characterize variations in the coordination of structural displacement and bolus movement that may contribute to dysphagia.

METHODS:

This retrospective study included 68 adults with diagnoses of PD. Liquid bolus swallows during modified barium swallow studies were analyzed and compared with those from an age- and sex-matched cohort of 48 adults without PD.

RESULTS:

Patients with PD were significantly slower in initiating and completing airway closure. Hyoid elevation was prolonged in this patient population.

CONCLUSIONS:

Patients with PD demonstrate slower initiation of airway closure and a delay in relaxation of hyoid elevation during swallow. Delays increased with larger boluses. These findings may be related to impaired pharyngeal sensation and increased muscular rigidity. The results of this study will be helpful in guiding swallow therapy for patients with PD.

Home-Based Orolingual Exercise Improves the Coordination of Swallowing and Respiration in Early Parkinson Disease: A Quasi-Experimental Before-and-After Exercise Program Study

Introduction: The coordination of swallowing and respiration is important for safety swallowing without aspiration. This coordination was affected in Parkinson disease (PD). A noninvasive assessment tool was used to investigate the effect of an easy-to-perform and device-free home-based orolingual exercise (OLE) program on swallowing and respiration coordination in patients with early-stage PD.

Materials and Methods: This study had a quasi-experimental before-and-after exercise program design. Twenty six patients with early-stage PD who were aged 62.12 ± 8.52 years completed a 12-week home-based OLE program. A noninvasive assessment tool was used to evaluate swallowing and respiration. For each patient, we recorded and analyzed 15 swallows (3 repeats of 5 water boluses: 1, 3, 5, 10, and 20 mL) before and after the home-based OLE program. Oropharyngeal swallowing and its coordination with respiration were the outcome measures. The frequency of piecemeal deglutition, pre- and post-swallowing respiratory phase patterns, and parameters of oropharyngeal swallowing and respiratory signals (swallowing respiratory pause [SRP], onset latency [OL], total excursion time [TET], excursion time [ET], second deflexion, amplitude, and duration of submental sEMG activity, and amplitude of laryngeal excursion) were examined.

Results: The rate of piecemeal deglutition decreased significantly when swallowing 10- and 20-mL water boluses after the program. In the 1-mL water bolus swallowing trial, the rate of protective pre- and post-swallowing respiratory phase patterns was significantly higher after the program. For the parameters of oropharyngeal swallowing and respiratory signals, only the amplitude of laryngeal excursion was significantly lower after the program. Moreover, the volume of the water bolus significantly affected the SRP and duration of submental sEMG when patients swallowed three small water bolus volumes (1, 3, and 5 mL).

Conclusion: The home-based OLE program improved swallowing and its coordination with respiration in patients with early-stage PD, as revealed using a noninvasive method. This OLE program can serve as a home-based program to improve swallowing and respiration coordination in patients with early-stage PD.

Characterization of oromotor and limb motor dysfunction in the DJ1 -/- model of Parkinson disease

Parkinson disease (PD) is devastating to sensorimotor function that includes cranial/oromotor and limb motor deficits. However, the onset, progression, and neural correlates of PD-related dysfunctions are poorly understood. To address this gap, we used a genetic rat model of PD, DJ1 -/-, and hypothesized that motor deficits would manifest early in the disease process, be progressive in nature, and be related to pathologies in brainstem structures associated with sensorimotor function. The present study compares homozygous DJ1 -/- male rats to age-matched wild type controls. Progressive cranial sensorimotor function (ultrasonic vocalizations and tongue motor performance) and limb motor function (tapered balance beam) was analyzed at 2, 4, 6, and 8 months of age. Additionally, tyrosine hydroxylase cell counts were performed in the locus coeruleus and correlated to behavioral measures. We found that compared to wild type controls, DJ1 -/- show deficits in ultrasonic vocalizations as well as oromotor (tongue) deficits that were progressive. Overtime, DJ1 -/- rats cross a tapered balance beam with significantly decreased speed of traversal. Additionally, in the DJ1 -/-, tyrosine hydroxylase positive cells in the locus coeruleus are significantly reduced and are negatively correlated to oromotor behaviors. Characterizing the DJ1 -/- model of PD provides important foundational work necessary to define behavioral and early-onset biomarkers that parallels early-stage PD pathology in humans.

Characterization of early-onset motor deficits in the Pink1-/- mouse model of Parkinson disease

In Parkinson disease (PD), a complex neurodegenerative disorder that affects nearly 10 million people worldwide, motor skills are significantly impaired. However, onset and progression of motor deficits and the neural correlates of these deficits are poorly understood. We used a genetic mouse model of PD (Pink1-/-), with phenotypic similarities to human PD, to investigate the manifestation of early-onset sensorimotor deficits. We hypothesized this mouse model would show early vocalization and gross motor dysfunction that would be progressive in nature. Pink1-/- mice, compared to wild type (WT) controls, were evaluated at 2, 3, 4, 5, and 6 months of age. To quantify deficit progression, ultrasonic vocalizations and spontaneous locomotor activity (cylinder test and pole test) were analyzed. Although somewhat variable, in general, Pink1-/- mice produced significantly more simple calls with reduced intensity as well as a larger percentage of cycle calls compared to WT counterparts. However, there were no significant differences in duration, bandwidth, or peak frequency for any of the ultrasonic call types between genotypes. Pink1-/- mice showed a significant impairment in limb motor skills with fewer hindlimb steps, forelimb steps, and rears and lands in the cylinder test compared to WT. Additionally, Pink1-/- mice took significantly longer to turn and traverse during the pole test. Immunohistochemical staining showed no significant difference in the number of tyrosine hydroxylase (TH) positive cells in the substantia nigra or density of TH staining in the striatum between genotypes. These data suggest the Pink1-/- mouse model may be instrumental in defining early motor biomarkers of PD in the absence of nigrostriatal dopamine loss.

Considerations for general anaesthesia in Parkinson's disease

Parkinson's disease is a common neurodegenerative disorder in the elderly which when present has a significant influence on surgical management. These patients necessitate additional perioperative and anaesthetic considerations across disease specific domains as well as in relation to the respiratory and cardiovascular systems. This brief review focuses on the factors which contribute to perioperative morbidity, including the use of medications that may exacerbate symptoms or adversely interact with treatments for Parkinson's disease. Recommended dosing practices to reduce complications during hospitalisation are covered. In addition, recent concerns regarding anaesthetic exposure in early childhood as a risk factor for the development of Parkinson's disease are discussed in light of data from animal models of anaesthetic neurotoxicity and epidemiological studies.

Deep Brain Stimulation in Parkinson's Disease: New and Emerging Targets for Refractory Motor and Nonmotor Symptoms

Parkinson's disease (PD) is a progressive neurodegenerative condition characterized by bradykinesia, tremor, rigidity, and postural instability (PI), in addition to numerous nonmotor manifestations. Many pharmacological therapies now exist to successfully treat PD motor symptoms; however, as the disease progresses, it often becomes challenging to treat with medications alone. Deep brain stimulation (DBS) has become a crucial player in PD treatment, particularly for patients who have disabling motor complications from medical treatment. Well-established DBS targets include the subthalamic nucleus (STN), the globus pallidus pars interna (GPi), and to a lesser degree the ventral intermediate nucleus (VIM) of the thalamus. Studies of alternative DBS targets for PD are ongoing, the majority of which have shown some clinical benefit; however, more carefully designed and controlled studies are needed. In the present review, we discuss the role of these new and emerging DBS targets in treating refractory axial motor symptoms and other motor and nonmotor symptoms (NMS).

Why do clinicians choose the therapies and techniques they do? Exploring clinical decision-making via treatment selections in dysphagia practice

PURPOSE

Speech-language pathologists (SLPs) are assumed to use evidence-based practice to inform treatment decisions. However, the reasoning underpinning treatment selections is not well known. Understanding why SLPs choose the treatments they do may be clarified by exploring the reasoning tied to specific treatments such as dysphagia interventions.

METHOD

An electronic survey methodology was utilised. Participants were accessed via the gatekeepers of two national dysphagia special interest groups representing adult and paediatric populations. Information was elicited on the dysphagia therapies and techniques used and on the reasoning for using/not using therapies. Data was analysed using descriptive and non-parametric statistics.

RESULT

The survey had a 74.8% response rate (n = 116). Consensus in both treatment selections and reasoning supporting treatment decisions was evident. Three favoured interventions (texture modification, thickening liquids, positioning changes) were identified. The reasoning supporting treatment choices centred primarily on client suitability and clinician knowledge. Knowledge reflected both absent knowledge (e.g. training) and accumulated knowledge (clinical experience).

CONCLUSION

Dysphagia practice appears highly-defined, being characterised by group consensus regarding both preferred treatments and the reasoning underpinning treatment selections. Treatment selections are based on two core criteria: client suitability and the SLPs experience/knowledge. Explicit scientific reasoning is less influential than practice-centric influences.

Sleep Stage Coordination of Respiration and Swallowing: A Preliminary Study

Swallowing is an important physiological response that protects the airway. Although aspiration during sleep may cause aspiration pneumonia, the mechanisms responsible have not yet been elucidated. We evaluated the coordination between respiration and swallowing by infusing water into the pharynx of healthy young adults during each sleep stage. Seven normal subjects participated in the study. During polysomnography recordings, to elicit a swallow we injected distilled water into the pharynx during the awake state and each sleep stage through a nasal catheter. We assessed swallow latency, swallow apnea time, the respiratory phase during a swallow, the number of swallows, and coughing. A total number of 79 swallows were recorded. The median swallow latency was significantly higher in stage 2 (10.05 s) and stage 3 (44.17 s) when compared to awake state (4.99 s). The swallow latency in stage 3 showed a very wide interquartile range. In two subjects, the result was predominantly prolonged compared to the other subjects. There was no significant difference in the swallow apnea time between sleep stages. The presence of inspiration after swallowing, repetitive swallowing, and coughing after swallowing was more frequent during sleep than when awake. This study suggests that the coordination between respiration and swallowing as a defense mechanism against aspiration was impaired during sleep. Our results supported physiologically the fact that healthy adult individuals aspirate pharyngeal secretions during sleep.

Dysphagia in Parkinson's Disease

More than 80 % of patients with Parkinson's disease (PD) develop dysphagia during the course of their disease. Swallowing impairment reduces quality of life, complicates medication intake and leads to malnutrition and aspiration pneumonia, which is a major cause of death in PD. Although the underlying pathophysiology is poorly understood, it has been shown that dopaminergic and non-dopaminergic mechanisms are involved in the development of dysphagia in PD. Clinical assessment of dysphagia in PD patients is challenging and often delivers unreliable results. A modified water test assessing maximum swallowing volume is recommended to uncover oropharyngeal dysphagia in PD. PD-specific questionnaires may also be useful to identify patients at risk for swallowing impairment. Fiberoptic endoscopic evaluation of swallowing and videofluoroscopic swallowing study are both considered to be the gold standard for evaluation of PD-related dysphagia. In addition, high-resolution manometry may be a helpful tool. These instrumental methods allow a reliable detection of aspiration events. Furthermore, typical patterns of impairment during the oral, pharyngeal and/or esophageal swallowing phase of PD patients can be identified. Therapy of dysphagia in PD consists of pharmacological interventions and swallowing treatment by speech and language therapists (SLTs). Fluctuating dysphagia with deterioration during the off-state should be treated by optimizing dopaminergic medication. The methods used during swallowing treatment by SLTs shall be selected according to the individual dysphagia pattern of each PD patient. A promising novel method is an intensive training of expiratory muscle strength. Deep brain stimulation does not seem to have a clinical relevant effect on swallowing function in PD. The goal of this review is giving an overview on current stages of epidemiology, pathophysiology, diagnosis, and treatment of PD-associated dysphagia, which might be helpful for neurologists, speech-language therapists, and other clinicians in their daily work with PD patients and associated swallowing difficulties. Furthermore areas with an urgent need for future clinical research are identified.

An Incidental Finding of a Radiopaque Pill following Cervical Spinal Surgery in a Parkinson's Disease Patient

There are previous reports of the identification of radiopaque medications on abdominal X-rays or computed tomography (CT). We describe an interesting case of the incidental identification of a radiopaque medication on cervical spinal CT following cervical spinal surgery. A sixty seven-year-old male patient with Parkinson's disease (PD) visited our emergency center with a C5-6 dislocation and fracture. Surgery was performed with open reduction and pedicle screw fixation through the posterior approach. No abnormal events occurred during the perioperative period. However, a radiopaque incidental foreign body in front of the C6 vertebrae was found on a cervical spinal CT and X-rays that were performed as routine examinations on postoperative day 3. After 6 hours, we performed gastrofibroscopy (GFS) but were unable to find anything. Therefore, we checked all of his medications related to the neck and check X-ray again. One enteric-coated pill he had taken exhibited strong radiodensity. Although our patient underwent an unnecessary GFS, every spinal surgeon should keep in mind that radiopaque pills can appear similar to spinal instruments on X-ray and CT. In addition, we should also know the associated dysphagia is a possible cause of the delayed passage of medicine in PD with or without cervical osteophytes.

Swallowing and pharyngo-esophageal manometry in obstructive sleep apnea

Introduction

Objective

Methods

Results

Conclusion

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.

Orofaryngeale slikstoornissen bij de ziekte van Parkinson

OROPHARYNGEAL SWALLOWING DISORDERS IN PARKINSON'S DISEASE

Parkinson's disease is one of the most common and best studied neurodegenerative diseases. The typical motor features, like hypokinesia and rigidity are also seen in chewing and swallowing, but this 'hypokinetic dysphagia' is a complaint that generally occurs in the later stages of the disease. However, consequences as choking on liquid or food and very slow eating and drinking can contribute to a decrease of the quality of life and in combination with decreased coughing capacity cause aspiration pneumonia. Hypokinetic dysphagia can also contribute to drooling, but hypomimia is the best predictor of that complaint. Several validated questionnaires are available in Dutch to assess dysphagia complaints and their severity. The behavioural treatment consists of compensatory techniques, like adapting head posture to avoid liquid aspiration. But also training exercises can be helpful to overcome hypokinesia, similar to talking louder to overcome hypokinetic speech. Medical treatment, either with levodopa or deep brain surgery in general does not provide clinical improvement of swallowing.

Development and evaluation of buccal films impregnated with selegiline-loaded nanospheres

Poor peroral therapeutic efficiency of selegiline is primarily due to the extensive hepatic metabolism and hence the need for an alternative route of administration. The present study is based on evaluation of a buccal film which is impregnated with selegiline nanospheres to enhance the systemic bioavailability. Selegiline-loaded nanospheres prepared using poly(lactide-co-glycolide) was embedded into buccal films (F₁-F₄) with varying polymer composition [hydroxypropyl methylcellulose and eudragit]. The developed films were evaluated for their physicomechanical properties, hydration, mucoadhesive strength, in vitro drug release and ex vivo permeation in order to identify the ideal system suitable for further development. In vivo studies were carried out on rabbits to assess the comparative pharmacokinetics profile of the selected buccal film with oral solution. Preliminary studies indicated that the prepared films exhibited excellent physical properties, adequate mucoadhesive strength and moderate hydration. In vitro drug release data of the buccal films (F₁, F₂ and F₃) showed distinct profiles. Permeation studies indicated higher steady-state flux from film F₃ (p < 0.0001) when compared to film F₂. In-vivo results of film (F₃) demonstrated significant increase in absorption (p < 0.0001), C_max (∼1.6-fold), T_max, AUC_0-α (∼3-fold, p < 0.0001) and improved bioavailability, when compared to control. This study concludes that the buccal delivery of selegiline using the developed buccal film (F₃) would be a promising alternative approach for the treatment of Parkinson's disease.

Treatment effects for dysphagia in Parkinson's disease: a systematic review

BACKGROUND

Dysphagia remains a common problem in Parkinson's disease (PD). Previous systematic reviews on therapy effects for oropharyngeal dysphagia in PD have shown a lack of evidence. In the past 5 years several placebo or sham-controlled trials with varying results have been published.

OBJECTIVE

The aim of this systematic literature review is to summarize and qualitatively analyze the published studies on this matter.

METHOD(S)

Studies published up to December 2013 were found via a systematic comprehensive electronic database search using PubMed, Embase, and The Cochrane Library. Two reviewers independently assessed the studies using strict inclusion criteria.

RESULT(S)

Twelve studies were included and qualitatively analyzed using critical appraisal items. The review includes rehabilitative (exercises, electrical stimulation, bolus modification etc.) and pharmacologic treatment. Some well-designed controlled trials were included. However, none of the included studies fulfilled all criteria for external and internal validity. A meta-analysis was not carried out as most of the studies were not of sufficient quality to warrant doing so.

CONCLUSION

Expiratory Muscle Strength Training (EMST) and Video-Assisted Swallowing Therapy (VAST) may be effective dysphagia treatments solely or in addition to dopaminergic therapy for PD. However, these preliminary results warrant further investigation concerning their clinical applicability, and further research should be based on randomized sham-controlled trials to determine the effectiveness and long-term effects of different therapies for dysphagia in PD.

Analysis of the level of Dysphagia, anxiety, and nutritional status before and after speech therapy in patients with stroke

INTRODUCTION

 The rehabilitation in oropharyngeal dysphagia evidence-based implies the relationship between the interventions and their results.

OBJECTIVE

 Analyze level of dysphagia, oral ingestion, anxiety levels and nutritional status of patients with stroke diagnosis, before and after speech therapy.

METHOD

 Clinical assessment of dysphagia partially using the Protocol of Risk Assessment for Dysphagia (PARD), applying the scale Functional Oral Intake Scale for Dysphagia in Stroke Patients (FOIS), Beck Anxiety Inventory (BAI) and the Mini Nutritional Assessment MNA(®). The sample consisted of 12 patients, mean age of 64.6 years, with a medical diagnosis of hemorrhagic and ischemic stroke and without cognitive disorders. All tests were applied before and after speech therapy (15 sessions). Statistical analysis was performed using the chi-square test or Fisher's exact test, McNemar's test, Bowker's symmetry test and Wilcoxon's test.

RESULTS

 During the pre-speech therapy assessments, 33.3% of patients had mild to moderate dysphagia, 88.2% did not receive food orally, 47.1% of the patients showed malnutrition and 35.3% of patients had mild anxiety level. After the therapy sessions, it was found that 33.3% of patients had mild dysphagia, 16.7% were malnourished and 50% of patients had minimal level of anxiety.

CONCLUSION

  There were statistically significant evolution of the level of dysphagia (p = 0.017) and oral intake (p = 0.003) post-speech therapy. Although not statistically significant, there was considerable progress in relation to the level of anxiety and nutritional status.