Running head: DYSPHAGIA IN PARKINSONS DISEASE

Characteristics and Management of Dysphagia in Patients with Parkinsons Disease

Margaret Pawlowski
University of Wisconsin-Whitewater

DYSPHAGIA IN PARKINSONS DISEASE

Parkinsons disease (PD) is a progressive neurologic disease that is caused by a

deterioration of the substantia nigra, the structure in the brain that controls production of
dopamine, and impairs body movement (Rosenbeck & Troche, 2013). Dopamine is essential for
basal ganglia functioning, which controls the initiation and coordination of body movement.
Depletion of dopamine in patients with PD results in bradykinesia, rigidity, resting tremor,
postural instability, and overall motor decline, of which all impact swallowing function
(Rosenbeck & Troche, 2013). More than 80% of individuals with PD experience dysphagia and
although PD alone is not fatal, dysphagic complications resulting from PD can be. Furthermore,
aspiration pneumonia is the leading cause of death in patients with PD (Troche et al., 2010) and
aspiration is frequently noted in patients with PD, even those who report no complaints of
dysphagia. Dysphagia in PD is characterized by differences during the oral, pharyngeal, and
esophageal phases of swallowing, and behavioral treatments are most frequently recommended
for management of dysphagia in patients with PD.
Dysphagia may be observed in patients with PD during the oral, pharyngeal, and
esophageal phases of swallowing, however swallowing difficulties most often associated with
PD occur during the oral and pharyngeal phases. Abnormalities during the oral phase of
swallowing are often the first indication of dysphagia in patients with PD. Patients may exhibit
limited excursion of the mandible resulting in increased time spent during the oral preparatory
phase (Tjaden, 2008). To compensate, patients with PD may exhibit tongue pumping, a
repetitive rocking motion of the tongue, which is considered to be a significant indication of PD.
Tongue pumping is a forward and backward motion of the tongue that is inefficient and
prevents a bolus from traveling from the oral cavity to the pharynx with ease (Tjaden, 2008).
Many patients with PD also report xerostomia because of reduced saliva production caused by

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levodopa, a common pharmaceutical drug used for treatment of PD. Although a reduction in
saliva is commonly observed in patients with PD, another characteristic of dysphagia during the
oral phase is drooling because of a reduction in the frequency of reflexive swallows (Tjaden,
2008). Other characteristics of dysphagia in the oral phase of patients with PD include lingual
tremor, piecemeal deglutition, and residue post-swallow (Rosenbeck & Troche, 2013), all
impacting the efficiency of swallowing function.
Differences in the pharyngeal phase of swallowing are also frequently noted in patients
with PD. Some patients exhibit a delay in pharyngeal swallow initiation. A reduction in
pharyngeal wall contraction and posterior tongue base retraction is often observed in patients
with PD, which results in residue in the vallecuae and pyriform sinuses (Tjaden, 2008),
increasing the risk of aspiration. Impaired laryngeal closure is also often observed in patients
with PD which leads to impaired coughing, a function that is essential for clearing the airway of
boluses and foreign materials (Tjaden, 2008). Other characteristics of dysphagia in the
pharyngeal phase of swallowing in patients with PD include deficient epiglottic positioning, slow
laryngeal elevation and excursion, and penetration (Rosenbeck & Troche, 2013). Complications
during the oral and pharyngeal phases of swallowing contribute to an increased risk of aspiration
in patients with PD.
Parkinsons disease is also know to cause differences in the esophageal phase of
swallowing, however according to Leopold and Kagel (1997), characteristics of pharyngoesophageal dysfunction in patients with PD are not well established because most studies in this
area have included small sample sizes of patients. A study conducted by Leopold & Kagel
(1997) of 69 patients with PD reported dysmotility of delayed transport, stasis, reverse
peristalsis, and tertiary contractions as the most common abnormalities during the esophageal

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phase of swallowing. The same study found the most common abnormalities related to LES
functioning were slowed closure of the LES, delayed esophageal emptying, non-optimal
esophageal alignment, and gastroesophageal reflux (Leopold & Kagel, 1997).
There is greater emphasis on behavioral treatments for dysphagia management in patients
with PD because pharmacological treatments recommended for patients with PD more
consistently effect limb motor symptoms with less effect on speech and swallowing (Tjaden,
2008). Luchesi, Kitamura, and Mourdo (2013) looked at what compensatory and rehabilitative
behavioral interventions were most frequently recommended for patients with PD in a
longitudinal study. The study included 24 patients with PD in swallowing management
programs at an outpatient clinic over a five year span. The most frequently recommended
maneuvers recommended to patients were bolus effect (20 patients), bolus consistency (19
patients), multiple swallows (19 patients), chin-tuck (16 patients), and tongue strengthening
exercises (16 patients). Other more frequently recommended techniques were vocal exercises
(12 patients), tongue control (10 patients), and effortful swallow (10 patients) (Luchesi et al.,
2013). Compensatory interventions such as chin-tuck and thickened liquids are usually
recommended for patients with PD in order to protect the airway because of the high rate of
aspiration in the population with PD. Tongue strengthening and tongue control exercises are
also recommended because of the abnormal tongue movements observed in patients with PD.
The effortful swallow maneuver is recommended frequently as to improve posterior movement
of the tongue base which is often stiff and slow in patients with PD (Luchesi et al., 2013). This
study provided information regarding which interventions are most often recommended for
patients with PD, but did not provide evidence of the efficacy of such techniques as they relate to
the population with PD.

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Compensatory strategies are frequently recommended for treatment of dysphagia because

they provide immediate effect, yet little research exists demonstrating the effectiveness of
various compensatory strategies in patients with PD. Logemann et al. (2008) designed a study
that aimed to identify which of 3 common treatments for reduction of aspiration on thin liquids
was most effective. They compared chin-tuck posture, nectar-thick liquids, and honey-thick
liquids in patients with dementia and PD. A total of 711 patients participated in this study, of
whom 360 were diagnosed with PD. Prior to the study, all patients participated in a
videofluorographic swallow study (VFSS) to assess swallowing function. Next, all patients
participated in a research VFSS to determine eligibility for this study. Eligibility criteria
consisted of aspiration on one or more trial swallows during the research VFSS (Logemann et
al., 2008). After meeting eligibility criteria, all patients received each intervention in randomly
assigned orders. For the chin-tuck posture, patients were told to touch their chin to the front of
their neck and were given three swallows of 3ml of thin liquid from a spoon and three swallows
of thin liquid from a cup filled with 6oz of water. For both thickened liquids interventions,
patients were given the same amounts of liquid to swallow in the same manner (Logemann et al.,
2008).
This study compared the immediate results of using three commonly recommended
techniques for management of dysphagia in patients with PD. Results from this study identified
honey-thick liquids as the most successful intervention for patients with PD, followed by nectarthick liquids, and then chin-tuck posture, although results varied among all participants
(Logemann et al., 2008). It should also be noted that nearly half of all participants did not
receive any benefit from any of the 3 interventions, which implies that the effectiveness of
different interventions varies among patients and that not one treatment will necessarily be

DYSPHAGIA IN PARKINSONS DISEASE

effective in all patients with PD. These results highlight the importance of introducing multiple
compensatory strategies to patients with PD during the VFSS in order to determine which
strategy or combination of strategies will be most effective for each individual patient.
Interestingly, the severity of PD did not impact the results, therefore suggesting that the use of
compensatory strategies may not be limited by severity of the disease.
Patient preference is an important factor when recommending treatment for dysphagia.
One-hundred and eighty-eight patients with PD without coexisting dementia were given the
opportunity to rate each intervention according to what they thought was most pleasant or easy to
follow. The majority of these participants rated chin-tuck and nectar-thick liquids more
favorably than honey-thick liquids (Logemann et al., 2008), although the honey-thick
intervention showed to be the most effective at reducing aspiration. Although honey-thick
liquids demonstrated the greatest overall effectiveness, most patients in this study rated the chin
tuck-position as most favorable. When selecting therapeutic interventions, it is important to take
patient preference under consideration to increase the likelihood of patient compliance and to
support a greater quality of life.
Aspiration pneumonia is the primary cause of death in patients with PD and is thought to
be caused by decreased elevation and excursion of the hyolaryngeal complex (Troche et al.,
2010). There is little documented research establishing effective behavioral treatments for
improving this function. Expiratory muscle strength training (EMST) is a treatment that has
been used to improve functioning of muscles used in breathing, coughing, and speaking. Troche
et al., (2010) studied the use of EMST as a rehabilitative treatment for improving swallowing
function and reducing aspiration in a group of 60 patients with PD over a 4-week intervention
period. To meet eligibility criteria for this study, patients had to be between ages 55 and 85, met

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the UK Brain Bank diagnostic criteria for PD, reported some degree of swallowing
abnormalities, remained on the same medications for PD throughout the study, and scored at
least 24 on the Mini-Mental State Examination (Troche et al., 2010).
Participants were randomly assigned to an active treatment or a sham treatment group.
The EMST device used a calibrated, one-way, spring-loaded valve to mechanically overload the
expiratory and submental muscles (Troche et al., 2010, 1913). The sham treatment group used
an identical but non-functioning EMST device so that participants and clinicians were blind to
treatment randomization. Clinicians visited the participants weekly and reminded them how to
properly use their device in order to complete daily treatment trials independently. Participants
were instructed to wear nose clips, take a deep breath, hold their cheeks lightly, and blow as hard
as they could into the device (Troche et al., 2010). Patients completed 5 sets of 5 repetitions on 5
out of 7 days each week.
Two outcomes were measured in this study: swallow safety and physiologic measures of
swallowing. The PA scale was used to measure safety of swallowing during the baseline
measure and after the intervention period had ended. There was no difference between the
treatment and sham group during the baseline measure. The average PA scale score in the
treatment group improved by .57, and the treatment group average score post-treatment was 1.23
points lower than the sham group (2.07 compared to 3.30) (Troche et al., 2010), indicating a
significant improvement in the EMST treatment group compared to the sham treatment group.
Examiners also measured duration of hyoid movement pre- and post-treatment. Duration of
hyoid movement was measured on digital recordings using the Digital Swallowing Workstation
as patients swallowed ten 5-mL of thin liquids. After the intervention period, results showed that
there was no improvement in hyoid movement in the EMST treatment group, however hyoid

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movement decreased significantly in the sham treatment group (by .76 seconds) (Troche et al.,
2010) demonstrating maintenance of function in the EMST treatment group and a decrease of
function in the sham treatment group.
The EMST treatment group ultimately performed significantly better than the sham
treatment group on measures of swallowing safety and physiologic measures of swallowing after
the intervention period had ended, indicating promise for future use of EMST as a rehabilitative
intervention for patients with PD. Similar to findings in the study by Logemann et al., (2008),
patient severity of PD did not impact patient outcomes although it should also be noted that the
participants in this study had only mild to moderately impaired swallowing, and the results may
have differed if patients with more severe dysphagia had participated. As stated earlier, patient
preference is an important consideration for patient compliance and quality of life when
recommending treatment for dysphagia. Both the EMST and sham treatment groups in this
study rated improvements in quality of life relating to swallowing after the intervention period
had ended, therefore implying that the EMST treatment was not perceived unfavorably by the
participants. Conclusions from this study suggest promising implications for use of EMST as a
rehabilitative technique for dysphagia in patients with PD and that EMST treatment does not
interfere with quality of life in patients.
More than 80% of individuals with PD experience dysphagia. PD is a progressive
neurologic disease affecting movement of the body that is known to impact all phases of
swallowing. Behavioral treatments are most frequently recommended for management of
dysphagia in patients with PD, however to date, there is limited research on different
interventions as they specifically relate to dysphagia in the population with PD. Chin-tuck and
thickened liquids are compensatory strategies frequently recommended for patients because they

DYSPHAGIA IN PARKINSONS DISEASE

protect the airway and reduce risk of aspiration, although outcomes associated with these
interventions vary on a patient by patient basis. It should not be assumed that one intervention
will be successful for all patients, so various compensatory strategies should be attempted during
the VFSS in order to determine which will be most beneficial to each patient. EMST is a
rehabilitative technique that shows promising implications for improving swallow safety in
patients with PD, and was rated favorably by patients who used it. When selecting interventions
for management of dysphagia, it is important to take patient preference under consideration, as
this will promote better patient compliance and better quality of life. There is no evidence of a
connection between severity of PD and severity of dysphagia (Tjaden, 2008) and in support of
this, both studies previously addressed noted that severity of PD did not affect overall outcomes
of intervention, implying that use of management techniques for dysphagia in patients with PD is
not limited by disease severity.

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References
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Research, 51(1), 173-183.
Luchesi, K. F., Kitamura, S., & Mouro, L. F. (2013). Management of dysphagia in Parkinson's
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