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

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.

Gastrointestinal involvement in Parkinson's disease: pathophysiology, diagnosis, and management

Growing evidence suggests an increasing significance for the extent of gastrointestinal tract (GIT) dysfunction in Parkinson's disease (PD). Most patients suffer from GIT symptoms, including dysphagia, sialorrhea, bloating, nausea, vomiting, gastroparesis, and constipation during the disease course. The underlying pathomechanisms of this α-synucleinopathy play an important role in disease development and progression, i.e., early accumulation of Lewy pathology in the enteric and central nervous systems is implicated in pharyngeal discoordination, esophageal and gastric motility/peristalsis impairment, chronic pain, altered intestinal permeability and autonomic dysfunction of the colon, with subsequent constipation. Severe complications, including malnutrition, dehydration, insufficient drug effects, aspiration pneumonia, intestinal obstruction, and megacolon, frequently result in hospitalization. Sophisticated diagnostic tools are now available that permit more detailed examination of specific GIT impairment patterns. Furthermore, novel treatment approaches have been evaluated, although high-level evidence trials are often missing. Finally, the burgeoning literature devoted to the GIT microbiome reveals its importance for neurologists. We review current knowledge about GIT pathoanatomy, pathophysiology, diagnosis, and treatment in PD and provide recommendations for management in daily practice.

Behavioural Interventions in People with Oropharyngeal Dysphagia: A Systematic Review and Meta-Analysis of Randomised Clinical Trials

Objective: To determine the effects of behavioural interventions in people with oropharyngeal dysphagia. Methods: Systematic literature searches were conducted to retrieve randomized controlled trials in four different databases (CINAHL, Embase, PsycINFO, and PubMed). The methodological quality of eligible articles was assessed using the Revised Cochrane risk-of-bias tool for randomised trials (RoB 2), after which meta-analyses were performed using a random-effects model. Results: A total of 37 studies were included. Overall, a significant, large pre-post interventions effect size was found. To compare different types of interventions, all behavioural interventions and conventional dysphagia treatment comparison groups were categorised into compensatory, rehabilitative, and combined compensatory and rehabilitative interventions. Overall, significant treatment effects were identified favouring behavioural interventions. In particular, large effect sizes were found when comparing rehabilitative interventions with no dysphagia treatment, and combined interventions with compensatory conventional dysphagia treatment. When comparing selected interventions versus conventional dysphagia treatment, significant, large effect sizes were found in favour of Shaker exercise, chin tuck against resistance exercise, and expiratory muscle strength training. Conclusions: Behavioural interventions show promising effects in people with oropharyngeal dysphagia. However, due to high heterogeneity between studies, generalisations of meta-analyses need to be interpreted with care.

Impact of the Chin-Down Posture on Temporal Measures of Patients With Dysphagia: A Pilot Study

Purpose The chin-down position is a commonly prescribed posture by health care professionals to alleviate the symptoms of dysphagia. Yet, how the technique influences swallowing physiology lacks clarity. Our goal was to examine the impact of the postural technique on patients with various medical conditions and swallowing impairments. Method Temporal and functional measures were examined with videofluoroscopy in the chin-down and neutral head position on 15 patients. Also, timing differences between head positions were examined to determine the presence of improvement during the chin-down posture. Results The primary finding was chin-down posture swallows prolonged the elapsed time between when the prematurely spilled bolus entered the pharynx relative to swallow onset compared to the neutral head position (p = .006). Also, no improvement in airway protection was found when performing the postural technique. Conclusions The chin-down posture may benefit patients with specific swallowing impairments. However, the general use of the technique for all patients who experience swallowing difficulty might be negligent and could potentially have adverse or no effect on patient outcomes. Future studies examining patients with the same pathophysiology are needed to understand the benefit of the chin-down posture based on swallowing impairment.

Effect of Chin-down-plus-larynx-tightening maneuver on swallowing function after minimally invasive esophagectomy: A randomized controlled trail

Background

The incidence of swallowing abnormality was high after minimally invasive esophagectomy (MIE) for esophageal cancer (EC). Few reports, however, focused on interventions for dysphagia after esophagectomy.

Aim

The purpose of this research was to estimate the effect of Chin‐down‐plus‐larynx‐tightening maneuver on swallowing function for patients receiving esophagectomy.

Method

This was a 2‐arm, parallel‐group, single‐blind randomized clinical trial, performed in patients suffered from EC from November 2018 to January 2020. Patients were randomly assigned to the intervention group (IG) or the control group (CG). The participants in CG received routine care, and the IG received Chin‐down‐plus‐larynx‐tightening maneuver during feeding. The incidence of choking cough, swallowing function, and dietary outcomes were evaluated before and after intervention for 7 days.

Results

A total of 237 EC cases were enrolled and randomized to the IG (n = 118) or CG (n = 119). There was no significant difference between the two groups in terms of demographic and clinical characteristics. Postoperative choking cough occurred in 5 of 118 cases (4.24%) in IG and 18 of 119 cases (19.4%) in CG, the differences showed statistically significant (P < .001). The analysis showed that the participants in the IG compared with the CG have more total caloric intake of 24 hours and higher K/R (the ratio of calories oral achieved to total calories required of body) significantly from D1 to D7 of intervention (P < .05).

Conclusion

The findings suggest that the Chin‐down‐plus‐larynx‐tightening maneuver can improve swallowing function recovery and oral total food intake and calories in EC patients undergoing MIE.

Interventions to promote oral nutritional behaviours in people living with neurodegenerative disorders of the motor system: A systematic review

BACKGROUND & AIMS

Weight loss is common in people with neurodegenerative diseases of the motor system (NDMS), such as Parkinson's disease and Amyotrophic Lateral Sclerosis, and is associated with reduced quality of life, functional ability and survival. This systematic review aims to identify interventions and intervention components (i.e. behaviour change techniques [BCTs] and modes of delivery [MoDs]) that are associated with increased effectiveness in promoting oral nutritional behaviours that help people with NDMS to achieve a high calorie diet.

METHODS

Eight electronic databases including MEDLINE and CINAHL were searched from inception to May 2018. All interventions from included studies were coded for relevant BCTs and MoDs. Methodological quality of studies was assessed using the Cochrane risk of bias tool.

RESULTS

Fourteen studies were included. Of these, eight studies reported interventions to assist with swallowing difficulties and six studies reported interventions targeting dietary content. Beneficial effects in managing swallowing difficulties were observed with video assisted swallowing therapy, lung volume recruitment and swallowing management clinics with outpatient support. In contrast, studies reporting effectiveness of chin down posture, use of thickened liquids and respiratory muscle training were inconclusive. Positive effects in interventions targeting dietary content included the use of food pyramid tools, individualised nutritional advice with nutritional interventions, electronic health applications, face-to-face dietary counselling and high fat, high carbohydrate and milk whey protein supplements. Individualised nutritional advice with weekly phone contact did not appear to be effective. Most frequently coded BCTs were 'instructions on how to perform the behaviour', 'self-monitoring' and 'behavioural practice/rehearsal'. Most commonly identified MoDs were 'human, face-to-face' and 'somatic therapy'. However, the robustness of these findings are low due to the small number of studies, small sample sizes and large between-study variability.

CONCLUSIONS

Despite the limited evidence, these findings may help inform the development of more effective interventions to promote oral nutritional behaviours in people with NDMS. However, further research is needed to demonstrate which interventions, or intervention components, yield most benefit.

Chin-down-plus-larynx-tightening maneuver improves choking cough after esophageal cancer surgery

Background

Esophageal cancer patients can benefit from dissection of the recurrent laryngeal nerve (RLN) lymph node (LN); however, this procedure increases the risk of RLN injury. After nerve injury, many complications can occur, including choking cough, which can affect patients' quality of life. This study examined the effectiveness of the chin-down-plus-larynx-tightening maneuver for improving choking cough after radical thoracic esophageal cancer surgery.

Methods

Sixty-two patients with resectable thoracic esophageal cancer presented with choking cough, hoarseness or vocal cord paralysis after radical operations. Twenty-two patients who choked on water were guided to swallow 1 mL of warm water using a chin-down-plus-larynx-tightening maneuver. Choking cough relief results and their relationships with clinical factors were analyzed.

Results

No correlation was found between the occurrence of post-operative choking cough and gender, age, surgical method, hoarseness, vocal cord fixation type, vocal cord fixation, or glottal closure. Multivariate regression analysis revealed no independent risk factors associated with choking cough. Choking cough was completely relieved in 17 of 22 (77.3%) patients. Fifteen of 19 (78.9%) patients with choking cough and hoarseness, and 2 of 3 patients with only choking cough reported complete relief when they tried the new maneuver. The chin-down-plus-larynx-tightening maneuver was more effective for males than for females.

Conclusions

The chin-down-plus-larynx-tightening maneuver significantly relieved choking cough; thus, this maneuver can aid in managing choking cough after radical thoracic esophageal cancer surgery.