September 11, 2019
Greetings from the University of Wisconsin-Madison. I would like to share some research and thoughts with you on swallowing problems and Parkinson disease (PD). A myth is that swallowing problems don’t occur until later stages of the disease process. However, we are learning that simply is not true. Dysphagia, or disordered swallowing, may be one of the first signs of PD. As you may know by now, PD affects people in very different ways. So, some people may have early dysphagia, some people late. This is why attempts to correlate disease severity with dysphagia have been unsuccessful.
Dysphagia can manifest in many different ways. Most commonly in PD, people have difficulty chewing solid foods, getting the swallow started, ‘pumping’ movements with the tongue, multiple swallows per mouthful (even if it is small), food/liquid going down the wrong pipe (we call that aspiration), trouble coordinating breathing and swallowing, a weak cough, and feelings of food getting stuck in the throat or chest.
These difficulties can range from mild to severe and the consequences range from having to limit eating/drinking certain foods/liquids, having to modify food/liquids, having to perform maneuvers while swallowing, or sometimes tube feedings. There are many ways to treat dysphagia. This is typically done by a medical team under the leadership of a speech-language pathologist and physician. Our goal to increase awareness and have a pro-active approach to dysphagia so that we can avoid restricting what people eat and recommending tube feedings. We think that with early identification and treatment, this can be achieved in most cases!
Corinne A. Jones, PhD, CCC-SLP and I recently published a paper where we examined differences in swallow physiology and patient’s perceptions of swallow changes in the early stages of PD. To do this, we recruited patients in the early stages of PD and age-matched controls. I should note that people were on their typical medications.
To measure swallow physiology, we used two instruments. The first is video fluoroscopy-a moving x-ray. A person ingests food/liquid mixed with barium and we can measure the movement of structures, as well as how safe and efficient the swallow is. This is the most common tool that is used clinically. Although this is a robust tool, it does have some issues with reliability of measures and doesn’t necessarily have the ability to assess subtle changes to swallow physiology. However, it remains one of the best diagnostic tools we have to assess swallow dysfunction. The second is high resolution manometry. This is a cutting edge tool that uses a catheter that is inserted through the nose and swallowed into the esophagus. The catheter has an array of pressure sensors and measures pressure and timing of swallow events. This tool allows us to make more precise and quantifiable measurements of swallowing activity.
We also used a clinically-validated patient-reported quality of life tool called The Sydney Swallow Questionnaire. This is a 30-item questionnaire that asks about perceptions of swallowing difficulty.
Not surprisingly, with videofluoroscopy, we didn’t find evidence of overt swallow dysfunction. This means swallowing was ‘relatively’ normal in persons with early PD compared to age-matched controls. However, using high resolution manometry, we found early differences in swallow physiology in persons with early PD compared to controls. One of the most interesting findings was that there was a lot of abnormal variability in swallowing patterns in those with PD. Typically, when a person swallows measured amounts of water, that person swallows in the same way each time. However, those with PD had much more within-person variability. We think that this early variability in swallowing could be a hallmark feature of PD.
Also, patients self-reported swallowing issues on the questionnaire. In particular, persons with PD reported significant difficulty with swallowing saliva. These patients came in stating they had no swallowing issues. This underscores the very important need to ask the right kinds of questions and use a validated questionnaire to determine if there are early swallowing differences.
So, what does this all mean? Well, we think there are early changes to swallowing function with PD. And we also think if you ask the right questions and use the right tools, you can pick up on these differences. But, differences don’t necessarily mean swallowing is dysfunctional to the degree that it affects the health and safety of the patient. However, this could mean that dysphagia is on the horizon. As such, we feel that it is important to not only pay attention to swallowing, but to advocate for yourself and make sure this is discussed with your neurologist early and often. If you or your physician (or your partner) suspect that you might have dysphagia, get a referral to a speech-language pathologist for a swallowing evaluation.
Dysphagia affects nutrition, hydration, quality of life, and health status. In fact, the leading cause of death in PD is a complication from dysphagia-aspiration pneumonia. So it is important that we are aware that this is yet another part of PD. And let’s not forget about the esophagus (food pipe)! Often reduced motility, spasm, or reflux can be the first signs of a problem. Below is a list of signs/symptoms of dysphagia.
List of signs/symptoms of dysphagia:
1. Difficulty chewing solids.
2. Not eating certain foods any more.
3. Trouble getting the swallow started (especially with tongue movements).
4. Coughing when eating or drinking.
5. A ‘wet’ or gurgly voice when/after eating or drinking.
6. Difficulty swallowing saliva.
7. Frequent drooling.
8. Food or liquid getting ‘stuck’ in the throat.
9. A feeling or sensation in your throat or chest.
10. Chest infections such as pneumonia.
11. Weight loss.
12. Weak cough.
2. Not eating certain foods any more.
3. Trouble getting the swallow started (especially with tongue movements).
4. Coughing when eating or drinking.
5. A ‘wet’ or gurgly voice when/after eating or drinking.
6. Difficulty swallowing saliva.
7. Frequent drooling.
8. Food or liquid getting ‘stuck’ in the throat.
9. A feeling or sensation in your throat or chest.
10. Chest infections such as pneumonia.
11. Weight loss.
12. Weak cough.
Remember, the person with PD may not notice these signs, so it is best to err on the side of caution and ask. Once a proper evaluation has been performed, then a management plan can be put in place to prevent further complications and perhaps rehabilitate the swallow. Remember, eating and drinking are part of what makes life pleasurable, so please make sure to stay healthy!
References:
Multimodal swallowing evaluation with high-resolution manometry reveals subtle swallowing changes in early and mid-stage Parkinson disease: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4816667/
Dr. Michelle Ciucci’s Website: http://ciuccilab.wixsite.com/main
University of Wisconsin-Madison Swallow Clinic: https://www.uwhealth.org/voice-swallow/voice-and-swallowing/11279
Michelle R Ciucci, PhD, CCC-SLP presented at the Fourth World Parkinson Congress in Portland, OR.
She currently serves as an Associate Professor in the Department of Communication Sciences and Disorders and the Department of Surgery-Otolaryngology and the Neuroscience Training Program at the University of Wisconsin-Madison.
Ideas and opinions expressed in this post reflect that of the author(s) solely. They do not necessarily reflect the opinions of the World Parkinson Coalition®
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