Dysphagia (2010) 25:207–215
DOI 10.1007/s00455-009-9244-x
ORIGINAL ARTICLE
Immediate Effects of Thermal–Tactile Stimulation on Timing
of Swallow in Idiopathic Parkinson’s Disease
Julie Regan Æ Margaret Walshe Æ W. Oliver Tobin
Received: 17 January 2009 / Accepted: 21 July 2009 / Published online: 26 August 2009
Ó Springer Science+Business Media, LLC 2009
Abstract Oropharyngeal dysphagia frequently presents in
people with idiopathic Parkinson’s disease (IPD). Clinical
sequelae of dysphagia in this group include weight loss and
aspiration pneumonia, the latter of which is the leading cause
of hospital admissions and death in IPD. Thermal–tactile
stimulation (TTS) is a sensory technique whereby stimula-
tion is provided to the anterior faucial pillars to speed up the
pharyngeal swallow. The effects of TTS on swallowing have
not yet been investigated in IPD. The aim of this study was to
investigate the immediate effects of TTS on the timing of
swallow in a cohort of people with IPD and known oropha-
ryngeal dysphagia. Thirteen participants with IPD and known
dysphagia attended for videofluoroscopy during which
standardised volumes of liquid barium and barium paste were
administered preceding and immediately subsequent to TTS.
The immediate effects of TTS on swallowing were examined
using oral, pharyngeal, and total transit times and pharyngeal
delay times as outcome measures. TTS significantly reduced
median pharyngeal transit time on fluids (0.20 s, 95%
CI = 0.12–0.28, p = 0.004) and on paste (0.3 s, 95%
CI = 0.08–0.66, p = 0.01). Median total transit time was
J. Regan (&)
SLT Department, Adelaide and Meath Hospital, Tallaght,
Dublin 24, Ireland
e-mail: julie.regan@amnch.ie
M. Walshe
School of Clinical Speech & Language Studies,
Trinity College Dublin, Dublin 2, Ireland
W. O. Tobin
Department of Neurology, Adelaide and Meath Hospital,
Tallaght, Dublin 24, Ireland
W. O. Tobin
Trinity College Dublin, Dublin 2, Ireland
also reduced on fluids (0.48 s, 95% CI = 0.00–1.17, p =
0.049) and on paste (0.52 s, 95% CI = 0.08–1.46, p =
0.033). Median pharyngeal delay time was reduced on fluids
(0.20 s, 95% CI = 0.12–0.34, p = 0.002). TTS did not sig-
nificantly alter median oral transit time on either fluid or paste
consistency. TTS significantly reduced temporal measures of
the pharyngeal phase of swallowing in the IPD population.
Significant results may be attributed to the role of sensory
stimulation in improving motor function in IPD, with
emphasis on the impaired glossopharyngeal and vagus nerves
in this population. It is still unclear whether these findings
will translate into a clinically beneficial effect.
Keywords Oropharyngeal dysphagia
Idiopathic
Parkinson’s disease
Thermal–tactile stimulation

Sensory stimulation
Immediate effects
Deglutition

Deglutition disorders
Idiopathic Parkinson’s disease (IPD) is a common pro-
gressive neurological disease estimated to affect 100–180
per 100,000 of the population (between 6 and 11 people per
6000 of the general population in the UK), with an annual
incidence of 4–20 per 100,000 [1]. The condition is thought
to manifest itself clinically after the pathology already has
reached an advanced stage [2, 3], and pathological features
have been described at initial, intermediate, and advanced
stages of the disease process [4]. Hallmark pathological
features of IPD include damage to specific subnuclei of the
pars compacta in the substantia nigra, with destruction of
neuromelanin-laden projection neurons [2, 4–7], associated
with hallmark features of tremor, rigidity, akinesia, and
postural instability [1]. Of interest from a dysphagia view-
point, specific areas of extranigral damage that have been
identified in IPD include the dorsal motor nucleus of the
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208 J. Regan et al.: Immediate Effects of Thermal–Tactile Stimulation on Timing of Swallow in IPD
glossopharyngeal and vagal nerves and the adjoining inter-
mediate reticular zone [8–11]. This glossopharyngeal and
vagus nerve damage has been identified as a factor con-
tributing to dysphagia and impaired cough response in this
diagnostic group [12].
The reported prevalence of oropharyngeal dysphagia in
IPD has varied from 75% [13, 14] to 100% [15]. Prevalence
rates depend on definitions used and the diagnostic method
employed [16]. However, the percentage of individuals who
complain of or recognise a swallowing problem is much
smaller [13, 14, 17, 18]. The association between severity of
dysphagia and stage of IPD is inconsistent in the literature
[13, 19–21]. Dysphagia in IPD has been described for all
phases of the swallow [13, 22]. In the oral phase, features
include repetitive tongue pumping [23–25], difficulty with
bolus formation [26], impaired mastication [25, 27], pre-
mature spillage of material into the pharynx, and residue
post swallow on the tongue surface and in the valleculae [22,
28]. Pharyngeal phase features of dysphagia in IPD include
pharyngeal reflex delay [13, 22], limited pharyngeal peri-
stalsis [22, 25], and reduced posterior motion of the tongue
base leading to residue in both the valleculae and pyriform
sinuses after swallowing [25, 28]. Sensory impairment at the
pharyngeal phase, including silent aspiration, has also been
reported in this diagnostic group [14, 29].
Regarding the clinical sequelae of dysphagia, pneumonia
has been reported to be the leading cause of death in the late
stages of IPD [30]. In fact, the most common reason for
admission to an acute hospital setting in the IPD population
is chest infection [30, 31] or pneumonia [30], presumably
because of aspiration. Weight loss has been associated with
IPD, with dysphagia highlighted as being one of several
possible causes [32]. From a psychosocial viewpoint, the
impact of dysphagia on the quality of life of both people
with IPD and their carers has been highlighted [33].
The effects of surgical treatments such as pallidotomy and
subthalamic nucleus deep brain stimulation (DBS-STN) on
swallowing and speech of IPD appears to be either limited or
negative [34–39]. Effects of levodopa on swallowing in IPD
is also uncertain [40, 41], with the suggestion that dysphagia
in IPD is not due to dopamine deficiency in isolation [40].
This is supported by the identified extranigral damage to
glossopharyngeal and vagal nerves in IPD [4]. Subsequently,
management of dysphagia in IPD to date has consisted of
behavioural intervention changes such as chin-down pos-
tural strategies [22, 42, 43] and diet modification [44, 45].
Nevertheless, a marked proportion of people with IPD do not
benefit from either chin-down posture or thickened fluids in
eliminating aspiration [46]. Furthermore, thickening fluids
can lead to dehydration and urinary tract infections [47].
Thickening fluids has been found to eliminate aspiration
more frequently than the chin-down posture in IPD [46],
although individuals with IPD have been found to prefer
123
using postural changes over thickening fluids [46]. Research
therefore continues to investigate behavioural means to
improve swallow safety and efficiency in IPD. However,
interventions need to be considered with reference to the
underlying neuropathophysiology and nature of dysphagia
observed in IPD.
Thermal–tactile stimulation (TTS) is a technique
employed by clinicians to target a delayed pharyngeal
swallowing reflex. By providing sensory stimulation via a
cold probe to the anterior faucial arches, sensitivity within
the oral cavity is purported to be heightened, leading to a
more rapid triggering of the pharyngeal swallow upon
presentation of a bolus [48–51]. The anterior faucial arches
contain sensory fibres innervated by the glossopharyngeal
nerve [48–51]. Sensation is therefore transmitted via the
glossopharyngeal nerve which synapses at the level of the
nucleus tractus solitarius in the dorsal region of the
brainstem [51]. The historical popularity of TTS among
dysphagia clinicians has been due to pioneering investi-
gative research exploring the immediate and the long-term
effects of TTS in both heterogeneous and stroke popula-
tions [48–51]. More recent studies have demonstrated the
role of sensory (thermal, chemical, electrical) stimulation
in modifying swallow behaviour [52, 53].
To our knowledge, the short- or long-term effects of
TTS have not been investigated in IPD. It is suggested here
that individuals with IPD presenting with dysphagia may
be candidates for TTS to speed up swallowing. Braak et al.
[4] describe the extranigral pathological damage to the
dorsal motor nucleus in the medulla oblongata, which
controls both the glossopharyngeal and vagus nerves, in
IPD [4]. The impact of this cranial nerve damage on
swallowing in IPD has already been described [12]. It is
hypothesised that by providing sensory stimulation to the
anterior faucial arches, which contain sensory receptors to
the glossopharyngeal nerve, the damaged motor output
may be primed to produce a more prompt and efficient
swallow. The aim of this study is to investigate the effects
of TTS on the timing of swallow function in IPD. Our
a priori hypothesis is that TTS will reduce swallowing
times in patients with IPD.
Methodology
This was a phase 1 study of treatment effect [54]. A within-
subject design was used as participants acted as their own
controls. This design was used to control for extraneous
variables such as age, stage of disease, severity of dysphagia,
time of day, as well as presence or absence of dyskinesia,
‘‘on/off’’ phenomenon, and type or dosage of medication.
Approval from a local research ethics committee (St. James
Hospital, Adelaide and Meath, incorporating the National
J. Regan et al.: Immediate Effects of Thermal–Tactile Stimulation on Timing of Swallow in IPD 209

Children’s Hospital Research Ethics Committee) was Table 1 Participants’ demographic and staging characteristics
obtained before conducting this study. (N = 15)
Participant Gender Age Stage of Severity of
Participants (years) IPDa dysphagiab

1 F 66 4 5
During the recruitment period, 24 people with a diagnosis
2 M 63 4 4
of IPD were referred from the local neurology service for
3 M 67 4 5
swallow assessment in a single acute hospital setting.
4 M 79 5 1
Criteria for inclusion in the study consisted of (1) a
5 F 74 5 5
confirmed diagnosis of IPD, (2) medical stability as judged
6 M 75 3 6
by the referring neurologist, (3) presence of oropharyngeal
7 F 70 3 6
dysphagia determined at bedside examination and associ-
8 M 65 4 3
ated with the diagnosis of IPD, (4) presence of pharyngeal
9 F 60 2 6
reflex delay as observed during videofluoroscopy, and (5)
ability to give written consent. A pharyngeal reflex delay 10 F 75 4 4
was defined as the time taken from bolus head arrival at the 11 F 73 4 3
point where the shadow of the lower edge of the mandible 12 M 70 3 5
crosses the tongue base until laryngeal elevation indicating 13 F 71 3 4
the onset of the pharyngeal swallow [22]. 14 F 74 3 4
Exclusion criteria included (1) parkinsonism secondary 15 M 66 2 5
to causes other than IPD, (2) history of stroke or transient a
Stage as rated by Hoehn & Yahr rating scale [55]
ischaemic attack (TIA), (3) history or presence of trache- b
Severity of dysphagia as rated by Dysphagia Outcome and Severity
ostomy tube placement, (4) dysphagia from a cause other Scale [56]
than IPD as determined by chart review and consultation
with referring neurologist, (5) absence of pharyngeal reflex medications on the day of the study to ensure they were
delay on videofluoroscopy, and (6) an inability to give ‘‘on,’’ i.e., receiving full clinical benefit from their medi-
written consent. cations at the time of the procedure. In keeping with pre-
Fifteen participants (age range = 60–79 years, mean vious studies [48–51], liquid barium and barium paste were
age = 70 years, SD = 5.263), 7 men (age range = 63– the two consistencies chosen for the investigation. A 5-ml
79 years, mean age = 69 years, SD = 5.794) and 8 women bolus was chosen for the study protocol. This volume was
(age range = 60–75 years, mean age = 70 years, SD = chosen to reduce the risk of aspiration from an ethical
5.097), were eligible for inclusion in the study (Table 1). All perspective, and also because oropharyngeal delays have
participants had been reviewed by a member of the local been found to be greater with small boluses [51]. A 5-ml
neurology team and had fulfilled the clinical criteria for IPD syringe was used to measure liquid and paste volumes to
(UK Parkinson’s Disease Society Brain Bank’s clinical ensure bolus quantities were accurate both before and after
criteria) subsequent to a clinical assessment and prior to administration of TTS.
being referred to speech and language therapy services. Participants were required to swallow two separate
Patients were recruited from both an inpatient ward (n = 2) volumes of liquid barium before administration of TTS and
and an outpatient clinic (n = 13). The level of a partici- outcomes were to be derived from the second swallow.
pant’s clinical disability related to IPD was established by This was to allow for a warm-up effect, as many individ-
independent medical physicians using the Hoehn and Yahr uals with neurological impairment tend to have a greater
rating scale [55]. This scale ranges from Stage I being the pharyngeal delay on the first swallow of a substance but
mildest level of disability such as unilateral involvement, to improve on the second swallow [48]. When possible, par-
Stage V, the most severe level of disability. This rating was ticipants were requested to self-feed from a plastic dis-
made by the referring medical staff who were familiar with posable cup when swallowing fluids. Where participants
the study subjects and with the scale. The Dysphagia Out- were unable to self-feed, the administrator assisted feeding
come and Severity Scale (DOSS) [56] was selected to the participant both before and after TTS. Mode of feeding
measure severity of dysphagia within the participant group. did not change within individual participant examinations.
Participants were advised to swallow all of the contents of
Procedure the cup to ensure standardisation of volumes.
To administer TTS, a Thermo-StimTM (Luminaud,
When obtaining written consent, participants were Mentor, OH) implement was employed (Fig. 1). This
requested to schedule timing of antiparkinsonian implement has been designed specifically for TTS.

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210 J. Regan et al.: Immediate Effects of Thermal–Tactile Stimulation on Timing of Swallow in IPD

Fig. 1 Thermo-StimTM (with

permission of Luminaud, Inc.,
Mentor, Ohio, USA)

Weighing 2.53 oz. (72 g) and being 9.5 in. (24 cm) long,
this is a durable stainless-steel device that is said to retain
cold temperatures. This instrument has been used suc-
cessfully in clinical practice at the study site. A ther-
mometer was placed alongside the Thermo-Stim in crushed
ice to calibrate the temperature for purposes of replication.
The temperature of the crushed ice within a plastic con-
tainer ranged from 0 to 3°C. This was held for 30 s. A
maximum time lapse of 6 s occurred between removal of
the Thermo-Stim from the crushed ice and its application to
faucial arches. This was to avoid the temperature of the
probe from rising [57]. After the second swallow of liquid
barium, the participant was asked to open his/her mouth.
The researcher vertically rubbed the left and then the right
anterior faucial arch firmly, five times each side, with the
Thermo-Stim implement.
Once the TTS was administered, participants were then
immediately given another 5-ml bolus of liquid barium to
swallow. The time between TTS and presentation of the
next bolus was 6 s or less. The same protocol was repeated
for barium paste.
videofluoroscopy studies were conducted using a Siemens
AXIOM Artis dMP multipurpose C-arm X-ray system with
dynamic flat detector (30 cm 9 40 cm). Images were
recorded for later slow motion and millisecond frame-by-
frame analysis (frame rate = 25 frames/s) using a Video
South Panasonic DVC Pro digital video recorder and 14-in.
high-resolution monitor and a high-quality clip-on micro-
phone. Procedures were recorded onto a Panasonic DVC
Pro 66L AJ-P66LP videotape. During the radiographic
study, participants were instructed to sit on a standard chair
while lateral plane views were recorded. The fluoroscopic
tube was focused on the lips anteriorly, the pharyngeal wall
and the cervical vertebrae posteriorly, the hard palate
superiorly, and the bifurcation of the airway and the
esophagus inferiorly [22].
As per previous studies [48–51], temporal measures
were selected to establish an alteration in swallow function
post TTS. Oral transit time (OTT), pharyngeal transit time
(PTT), total transit time (TTT), and pharyngeal delay time
(PDT) were selected to measure for change subsequent to
TTS (Table 2).

Outcome Measures Preparation of Data for Analysis

A videofluoroscopic study of the oropharyngeal swallow Thirteen of 15 participants attending for videofluoroscopy
was chosen to establish swallow transit times preceding provided temporal measures before and after TTS on both
and subsequent to TTS for all participants. The liquids and barium paste. Two participants did not open

Table 2 Definitions of temporal measures of swallowing

Temporal measure Definition

Oral transit time (OTT) Time elapsed from beginning of backward movement of the bolus until the bolus head passes the landmark
where the base of the tongue meets the ramus of the mandible [22]
Pharyngeal transit time (PTT) Time elapsed from when the bolus passes the landmark where the back of the tongue meets the ramus of the
mandible until it passes through the upper oesophageal sphincter [22]
Total transit time (TTT) Sum of oral and pharyngeal transit times [22]
Pharyngeal delay time (PDT) Time taken from the bolus head arrival at the point where the shadow of the lower edge of the mandible crosses
the tongue base until laryngeal elevation indicating the onset of the pharyngeal swallow [22]

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J. Regan et al.: Immediate Effects of Thermal–Tactile Stimulation on Timing of Swallow in IPD
their mouths sufficiently to allow for stimulation of the
faucial arches across both consistencies. Therefore, data
from only 13 participants were included in the analysis.
To ensure accuracy of the temporal measures obtained,
videofluoroscopy recordings were analysed at normal
speed, in slow motion, and frame-by-frame as many times
as considered necessary for confident judgment by the first
author, who has extensive experience with videofluoros-
copy analysis. When analysing videofluoroscopy studies,
the rater was blinded to the identity of participant, IPD
staging, and dysphagia severity rating. Temporal measures
were obtained for the second swallow preceding TTS and
the first swallow post TTS for each of the two
consistencies.
Measurement of Reliability
Intrajudge test–retest reliability was assessed 1 month post
completion of initial data analysis. A random sampling of
20% of the total number of examinations (n = 3) took
place. The random sample was selected by an independent
clinician who was not involved in the research project.
During the reanalysis of the studies, the rater was blinded
to the identity of participants and whether the swallows
being analysed were recorded before or after the adminis-
tration of TTS. Temporal measures were re-evaluated from
the sample examinations both before and after TTS on two
consistencies (Table 3).
Three independent clinicians, who were not involved in
the study, analysed a representative sample (20%) of vid-
eofluoroscopy studies to measure interjudge reliability.
Each judge had certified postgraduate training in dysphagia
and at least 5 years of experience in analysing videofluo-
roscopy procedures. When measuring the specified temporal
measures (OTT, PTT, TTT, PDT) on both consistencies, the
independent clinicians were blinded to whether the studies
they were measuring were recorded before or after TTS.
Once the independent examiners completed their analyses,
temporal measures obtained were compared to the temporal
measures obtained by the first author. Pearson’s (r) para-
metric test of correlation (two-tailed) was used to establish
intrarater and interrater agreement.
Table 3 Median reduction in temporal measures post TTS
Fluids (n = 13)
Median reduction (s) Confidence interval
OTT 0.36 -0.12 to 0.92
PTT 0.20 0.12 to 0.28
TTT 0.48 0.00 to 1.17
PDT 0.20 0.12 to 0.34
*Median reduction is significant at 0.05 level
211
Statistical Analysis
Because the data were not normally distributed, the Wil-
coxon’s signed rank test was used to compare median
swallowing times between pre and post TTS. A p value of
less than 0.05 was considered statistically significant.
Results are reported as median differences between the
groups, along with 95% nonparametric confidence inter-
vals. All statistical calculations were carried out using R
version 2.8.1 [58].
Results
Statistical analysis demonstrated that TTS significantly
reduced pharyngeal transit time (median reduc-
tion = 0.20 s, 95% CI = 0.12–0.28, p = 0.004) and pha-
ryngeal delay time (median reduction = 0.20 s, 95%
CI = 0.12–0.34, p = 0.002) on fluid consistency. There
was also a significant reduction in total transit time (median
reduction = 0.48 s, 95% CI = 0.00–1.17, p = 0.04977)
on fluids. TTS did not significantly reduce median oral
transit time on fluids (median reduction = 0.36 s, 95%
CI = -0.12 to 0.92, p = 0.124) (Table 3).
On barium paste consistency, pharyngeal transit time
(median reduction = 0.30 s, 95% CI = 0.08–0.66,
p = 0.011) and total transit time (median reduc-
tion = 0.52 s, 95% CI = 0.08–1.46, p = 0.033) were
reduced by TTS. Pharyngeal delay time was not affected
on paste consistency (median reduction = 0.12 s, 95%
CI = -0.14 to 0.40, p = 0.196). Oral transit time also was
not significantly reduced by TTS on paste consistency
(median reduction = 0.42 s, 95% CI = -0.04 to 1.06,
p = 0.062) (Table 3).
In terms of descriptive statistics, 93% (97/104) of tem-
poral measures of swallowing obtained post TTS were
changed, while 7% (7/104) remained unchanged post
stimulation. Of the 93% temporal measures changed fol-
lowing TTS, 81% (79/97) were reduced in time post
stimulation. Pharyngeal transit times were reduced in 85%
(11/13) of participants on both fluids and barium paste.
Total transit times were reduced in 69% (9/13) of
Paste (n = 13)
p Median reduction (s) Confidence interval p
0.124 0.42 -0.04 to 1.06 0.062
0.004* 0.30 0.08 to 0.66 0.011*
0.049* 0.52 0.08 to 1.46 0.033*
0.002* 0.12 -0.14 to 0.40 0.196
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212 J. Regan et al.: Immediate Effects of Thermal–Tactile Stimulation on Timing of Swallow in IPD

Table 4 Percentage of change

% Decreased % Increased % Unchanged
in timing of swallow post TTS
post TTS post TTS post TTS
in IPD
Fluids
Oral transit time 69% (9/13) 31% (4/13) 0% (0/13)
Pharyngeal transit time 85% (11/13) 8% (1/13) 8% (1/13)
Total transit time 69% (9/13) 23% (3/13) 8% (1/13)
Pharyngeal delay time 92% (12/13) 0% (0/13) 8% (1/13)
Barium paste
Oral transit time 62% (8/13) 23% (3/13) 15% (2/13)
Pharyngeal transit time 85% (11/13) 8% (1/13) 8% (1/13)
Total transit time 77% (10/13) 23% (3/13) 0% (0/13)
Pharyngeal delay time 69% (9/13) 23% (3/13) 8% (1/13)

Table 5 Measures of reliability

Intrarater Significance (p) Inter-rater Significance
agreement (r) agreement

Videofluoroscopy 1 0.994* C0.000 0.660* 0.005

Videofluoroscopy 2 0.903* C0.000 0.974* C0.000
* Correlation is significant at Videofluoroscopy 3 0.983* C0.000 0.846* C0.000
the 0.01 level (2-tailed)

participants on fluids and in 77% (10/13) of participants on
barium paste. Pharyngeal delay times were reduced in 92%
(12/13) of participants on fluids and in 69% (9/13) of
participants on barium paste. Oral transit time decreased in
69% (9/13) of participants on fluids and in 62% (8/13) of
participants on barium paste (Table 4). Data obtained were
deemed to have good intrarater and interrater reliability
(Table 5).
Discussion
This was a phase 1 study of treatment effect to determine if
TTS has merit when used in a specific clinical population
with known dysphagia [54]. Limitation to surgical, phar-
maceutical, and behavioural management of dysphagia in
IPD justifies research in this area. The results of this study
indicate that TTS significantly reduced pharyngeal transit
time, total transit time, and pharyngeal delay time during
swallowing in this IPD population.
In this study, the temporal measure most significantly
reduced by TTS was pharyngeal delay time (PDT) on fluids
(p = 0.002). This finding is in keeping with the original
purpose of TTS which is to speed up the involuntary
pharyngeal swallow. Shortening the PDT during swallow-
ing would be of major clinical benefit given the hallmark
pharyngeal reflex delay observed in IPD on fluid consis-
tency, which can frequently lead to aspiration before the
swallow [13, 22]. TTS also significantly shortened pha-
ryngeal transit time on both fluids (p = 0.004) and barium
paste (p = 0.011) in this participant group. While it may be
assumed that shorter or decreased pharyngeal transit times
are associated with a safer and a more efficient swallow in
IPD, this requires more study. However, shorter pharyngeal
transit times observed during videofluoroscopy have been
significantly correlated with reduced risk of aspiration
pneumonia in stroke populations [59]. In contrast to pha-
ryngeal phase response to TTS, the technique had no effect
on oral transit time on both consistencies. This disparity
reflects the difference in neurological control of the oral
and pharyngeal phases of swallowing. The oral stage is
voluntary and controlled by higher cortical areas [52, 53].
Meanwhile, afferent branches of the glossopharyngeal
nerve targeted in TTS control the pharyngeal phase of
swallowing which is involuntary and influenced by the
brainstem [52, 53].
The findings from this study suggest that TTS may have
a role in altering the timing of the pharyngeal phase of
swallowing in IPD. However, the question remains as to
how a sensory stimulation technique such as TTS might
effect change when the efferent apparatus is damaged.
While the triggering of the pharyngeal swallow was for-
merly regarded as being a pure reflex, it is now recognised
as being a complex sensorimotor process [52]. The act of
swallowing relies heavily on sensory input as food or drink
passing through the oropharynx engages afferent branches
of the trigeminal, glossopharyngeal, and superior laryngeal
nerves [60, 61]. Input from these cranial nerves is then
conveyed to the dorsal brainstem pattern generator for
swallowing [60, 61]. As sensorimotor interdependency for
swallowing becomes better understood, dysphagia treat-
ment is concentrating on targeting preserved properties of

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the central and peripheral nervous system to rehabilitate
neurogenic dysphagia. Therefore, if neurological damage
occurs to the efferent swallowing system, the afferent
system can be manipulated to alter motor output for
swallowing [60, 61]. This can be done by application of
stimulation (e.g., air pulse, electrical, vibratory, thermal, or
gustatory) to the faucial arches, one of the regions of the
oral cavity and pharynx that have been identified as being
indirect projections to the brainstem swallowing pathway,
to improve pharyngeal swallowing [62]. Sensory stimula-
tion has been proven to improve swallowing in people with
dysphagia post stroke [63]. A neuropathological basis for
the use of sensory stimulation to improve swallowing in
Parkinson’s disease is evident, as damage to the dorsal
motor root of glossopharyngeal and vagus nerves is
observed pathologically from the early clinical stages of
the disease [4].
In the minority of cases, temporal measures of swal-
lowing increased post TTS. This variation in temporal
measures to dysphagia treatment has been observed in
other TTS research [48]. It may indicate the presence of
some independent variable that causes an increase or
decrease in temporal measures of swallowing post TTS.
Potential factors include varying sensory thresholds within
the participant group [63, 64]. Cranial nerves involved in
evoking the pharyngeal phase of swallowing require a
previously described code [63, 64]. They need to be acti-
vated repeatedly and with a certain frequency [63, 64].
Perhaps the different degrees of dorsal motor root damage
across the various stages of IPD may influence the amount
of sensory stimulation required to improve the pharyngeal
swallow [4].
Future Research
In time, future research may determine the longer-term
effect of TTS on swallowing in IPD. First, the treatment
protocol for investigating the immediate effects of TTS in
IPD should be refined in a phase 2 study. Issues to consider
include the measurement of the temperature of the TTS
probe itself as opposed to measuring the crushed ice sur-
rounding the probe. While measurement of ice surrounding
the probe lends itself to transferability of findings, probe
measurement would more accurately monitor the level of
thermal stimulation being administered. The effect of tac-
tile versus thermal–tactile stimulation on the parameters of
swallowing also requires examination using a neutral
temperature probe in a control group. It is possible that the
outcomes obtained in this study might have been solely due
to the mechanical or ‘‘tactile’’ stimulation and that the
temperature of the probe may have not contributed to the
observed effect.
213
In terms of outcome measures, this study focused solely
on the effects of TTS on the timing of swallow in IPD.
However, the relationship between the timing of swal-
lowing and swallow safety/efficiency in IPD warrants
exploration before TTS is advocated as a viable short-term
dysphagia treatment in IPD. In future research, the pene-
tration–aspiration scale [65] may determine if TTS reduces
aspiration, while previously utilised rating scales [66] may
be used to evaluate the effect of TTS on valleculae/pyri-
form residue in people with IPD. Furthermore, use of
multiple-outcome measures across several domains,
including oral intake, weight, recurrent respiratory infec-
tions, and length of hospital stay, should be used in future
research. Once these various issues outlined here are
addressed, questions regarding the longer-term effects of
this sensory stimulation technique may be posed.
Conclusion
The prevalence of dysphagia and its clinical sequelae in
IPD indicate that an alternative dysphagia intervention is
urgently required. TTS is a dysphagia treatment that
requires little clinician training and few resources and has
few known contraindications across clinical populations.
Despite this, there has been a recent inclination to dismiss
TTS as a dysphagia treatment option due to the limited
evidence base available. Use of TTS can be justified neu-
ropathologically in IPD and the findings from this study
indicate that TTS can have a role in short-time optimisation
of the swallow in this clinical group. We suggest that TTS
has potential as a treatment option and should be examined
in more specific homogeneous populations while control-
ling for the factors suggested above to produce positive
clinical outcomes.
Acknowledgments The authors thank the 15 people with IPD who
participated in this study, the three speech and language therapists in
AMNCH who provided reliability data, and Dr. Justin Kinsella,
Neurology Department, AMNCH, who aided in the statistical analysis
of data.
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Julie Regan BSc, MSc
Margaret Walshe PhD, MSc
W. Oliver Tobin MRCPI
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