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- DOI 10.18231/j.ijoas.2023.011
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Dysphagia following parkinson’s - A case study
- Author Details:
-
Kritika Arora
-
Dipti Gupta *
-
Puranjit Kar
-
Abhay Nagpal
-
Gurubax Singh
Kritika Arora
Dipti Gupta *
Introduction
Dysphagia is a medical condition that affects the ability to swallow properly. Acc. to Jeri A (1998)][1] “Dysphagia is a medical condition characterized by difficulty or discomfort in swallowing”. The common symptoms of dysphagia include coughing or choking while eating, feeling like food stuck in the throat or chest, regurgitation of food or liquids, pain while swallowing, recurring pneumonia or respiratory infections. Dysphagia is of different types (oral preparatory, oral dysphagia, pharyngeal dysphagia, esophageal dysphagia) depending on the signs and symptoms. The SLP has a major role in diagnosing and treating only the oral preparatory, oral and pharyngeal dysphagia.
Dysphagia can affect people of all ages from infants to the elderly however elderly suffer more from this condition. Due to lack of epidemiological studies on dysphagia, the incidence and prevalence of dysphagia is limited. Acc. to National foundation of swallowing disorders, Patel et al (2018) the incidence and prevalence of dysphagia is estimated acc.to different (i) settings – acute and chronic geriatric care (68%) followed by general hospitals (30%) and (ii) diseases - Parkinson’s disease (90%), head and neck cancer (48%), stroke (27%), dementia (15%) and endotracheal intubation (5-10%).[2] It can be brought on by a wide range of conditions, including neurological disorders, gastrointestinal disorders, progressive diseases (such as Parkinson's disease and amyotrophic lateral sclerosis), iatrogenic causes (such as tracheostomy, radiation therapy, and chemotherapy), as well as other or related conditions like structural abnormalities, respiratory disorders, head and neck cancer, aging, etc. It is a severe disorder that can cause aspiration pneumonia, dehydration, and dehydration.[1] Diagnosis includes a thorough evaluation of anatomical structures, imaging tests and swallowing studies. Treatment options may include lifestyle modifications, medications or surgery, swallowing therapy to improve swallowing functions.
Case Presentation
A 72-year-old man who had been having trouble swallowing and aspirating for the past few months was admitted to the hospital's tertiary care unit. He claimed that he felt like food was becoming caught in his throat and that he needed to swallow several times to clear it. Due to his trouble swallowing, he lost a lot of weight over a short period of time.
Medical history
The patient had a history of hypertension, diabetes (type II) and Parkinson’s disease. Patient took amlodipine and syndopa for hypertension and dopamine deficiency respectively. Patient also had no history of stroke, gastrointestinal disorders, respiratory conditions or head and neck surgeries.
Clinical examination
On physical examination, patient appeared to have a drooping posture along with weakness in upper and lower limbs. His vital signs were within normal limits. Examination of the head and neck showed no abnormalities. Cranial nerve examination Revealed signs shown in Table 1. On speech and language evaluation the following results were obtained–
Oral Peripheral Motor Examination Revealed the Following Results.
Lips – The patient demonstrated weak lip closure and strength during pucker and whistle tasks.
Dentition – The patient had missing teeth and uses dentures
Tongue – The patient had difficulty protruding the tongue beyond the lips and demonstrated reduced strength during protrusion, elevation, retraction and lateralization.
Palate – The patient exhibited inadequate elevation and reduced mobility of the soft palate during the phonation of ‘ahh’ and also had reduced strength during the nasal consonant ‘n’ production.
Jaw – The patient had adequate jaw opening and closing range of motion but demonstrated reduced strength during jaw lateralization and protrusion tasks.
Larynx – The patient had delayed laryngeal elevation during swallowing along with weak cough reflex.
The vegetative skills of the patient such as blowing, sucking, chewing, biting and coughing were also affected.
Overall, the oral peripheral motor examination results revealed reduced strength and coordination of the muscles involved in swallowing, contributing to dysphagia.
Cranial nerve examination
Following nerves were discovered to be impacted during investigation of the cranial nerves involved in swallowing, which led to weakening in the muscles they innervate and ultimately affected movements of the parts these muscles innervate ([Table 1]).
|
Cranial Nerve |
Responses |
|
Trigeminal |
Inadequate jaw pressure |
|
|
Jaw movements affected (lateralization and against resistance) |
|
|
Impaired chewing |
|
|
Weakness of temporalis and masseter muscle |
|
Facial |
Poor lip seal |
|
|
Alternate motion of lips (ee, oo) affected |
|
|
Smile, pucker unable to perform |
|
|
Puffing of cheeks affected |
|
|
Facial muscle weakness |
|
Glossopharyngeal |
Reduced soft palate elevation |
|
|
Reduced gag reflex |
|
|
Pharyngeal constrictor weakness |
|
Vagus |
Abnormal movement of vocal folds during phonation |
|
Hypoglossal |
Restricted range of motion of the tongue movements (lateralization, protrusion, elevation retraction, against resistance) all affected |
Speech assessment
The FDA (Frenchay Dysarthria Assessment) and Apraxia Battery for Adults (ABA-2) were administered to rule out the possibility of speech deficits and apraxia component in the patient. No abnormality was detected in Apraxia Battery for Adults (ABA-2).
Franchay’s dysarthria assessment
Administration of FDA revealed the presence of hypokinetic dysarthria (Parkinson’s disease) which was further confirmed by looking for the confirmatory signs which are shown in[Table 2].
|
Bradykinesia |
Present |
|
Akinesia |
Present |
|
Rigidity |
Present |
|
Gait |
Festinating Gait |
|
|
(Shuffling, Small Baby Steps) |
|
Posture |
Stooped Posture |
|
|
(Forward Bent) |
|
Facial Expression |
Masked Face |
|
Extremities |
Flexed Elbows, Arms and Knees |
Four finger test revealed
The finger developed by jeria A. Logemann.[1] placing the finger on the submandibular region, finger on thyroid bone, on thyroid cartilage.
The patent is Introduced to swallow.
The four finger test developed by Jeri A. Logemann[2] includes placing the first finger on the submandibular region, second finger on hyoid bone, third & fourth fingers on the thyroid cartilage.
The mann asessment of swallowing ability (MASA)
It is an instrument designed for bedside evaluation for patients with swallowing issues. It measures 24 different areas to gauge a patient’s swallowing abilities. On administration of MASA on the patient the total score obtained was 140 out of 200 which reveals moderate dysphagia. The Masa score for individual domain is shown in [Table 3].
|
Domain |
Scoring |
Explanation |
|
Alertness |
8 |
Drowsy – Fluctuating Awareness / Alert Level |
|
Cooperation |
10 |
Cooperative |
|
Auditory Comprehension |
10 |
No Abnormality Detected |
|
Respiration |
10 |
No Evidence of Abnormality |
|
Respiratory Rate for Swallow |
3 |
Patient can a achive nasal breathing for short period |
|
Dysphasia |
5 |
No Abnormality Detected |
|
Dyspraxia |
5 |
No Abnormality Detected |
|
Dysarthria |
2 |
Speech Unintelligible |
|
Saliva |
5 |
No Abnormality Detected |
|
Lip Seal |
2 |
Incomplete Closure or Limited |
|
Tongue Movement |
4 |
Minimal movement |
|
Tongue Strength |
2 |
Gross Weakness |
|
Tongue Coordination |
5 |
Gross Incoordination |
|
Oral Prepration |
6 |
Minimal Chew |
|
Gag |
4 |
Diminished Bilaterally |
|
Palate |
4 |
Minimal Movement (Nasal Air Escape) |
|
Bolus Clearance |
8 |
Significant Clearance, Minimal Residue |
|
Oral Transit |
8 |
Delay Greater Than 1 Sec |
|
Cough Reflex |
5 |
Strong Reflexive Cough |
|
Voluntary Cough |
5 |
Attempt Inadequate |
|
Voice |
6 |
Hoarse, difficulty with pitch and volume control |
|
Trache |
10 |
No Trache Required |
|
Pharyngeal Phase |
8 |
Laryngeal Elevation Restricted |
|
Pharyngeal Phase |
5 |
Coughing Triggered After Swallow |
Instumental Evaluation
Endoscopic evaluation
Endoscopic evaluation reveals that epiglottis, bilateral valleculae, aryepiglottic folds, pyriform sinuses were normal with bilaterally swollen vocal cords.
Electroglottography
Vocal fold irregularity and a compromised contact quotient are both revealed by electroglottography.
Provisional diagnosis
The detailed subjective and objective assessment revealed moderate dysphagia of pharyngeal type. The provisional diagnosis made was hypokinetic dysarthria with dysphagia
Treatment
The main objective of treatment was to restore oral feeding while continuously ensuring appropriate nutrition and hydration as well as safe swallowing. The management strategies included therapeutic and compensatory treatment strategies. The compensatory treatment methods are those that regulate food flow and get rid of symptoms like aspiration in the patient while not necessarily altering the swallowing physiology.
Postural adjustments – This involves looking for the best head and neck position that results in no symptoms of aspiration while tilting patient head to different positions during swallowing. In this case chin tuck position was found out to be the best position that led to no symptoms of aspiration and the patient was instructed to swallow in the same way and position.
Modifying volume and speed of food presentation – patient had a weakened pharyngeal swallow and required two or more swallows per bolus to clear the remaining residue. The patient had a habit of engulfing the food bolus too quickly resulting in collection of food residue in the pharynx thus causing aspiration. Thus, the patient was instructed to simply take small quantity of a food item, chew the bolus properly at a slower rate, thereby eliminating any risk of aspiration.
The therapy procedures included
Oral control and oral & pharyngeal range of motion exercise – various oral motor control exercises were demonstrated which included, range of motion and resistance exercises of the tongue, lip and jaw; range of motion of pharyngeal exercises (vocal fold adduction exercises)
Swallowing maneuvers – Mendelsohn and masako maneuvers were administered on the patient. The goal of Mendelsohn maneuver is to increase the extension and duration of the laryngeal elevation thereby increasing the duration and width of the cricopharyngeal opening. The patient was instructed to first perform the maneuver with saliva and then with the bolus. Similarly, the goal of masako maneuver is to achieve complete movement of pharyngeal constrictors and strengthen the base of the tongue to improve swallowing in Parkinson’s disease patient. These were the two maneuvers that the patient was instructed to perform in both therapy and at home as a part of home training.
Results
[Table 4], [Table 5] shows the post therapy outcomes of the patient after applying customized intervention plan.
|
Pre-Therapy |
Post Therapy |
Percentage Achieved |
|
Prior Patient was not able to |
Now the patient is able to |
|
|
Elevate, protrude, lateralize, retract tongue |
Elevate, protrude, lateralize, retract tongue |
Accuracy attained – 60-70% |
|
Hold a position of articulators |
Can hold the articulators in different position |
Accuracy attained –70% |
|
Reduced range of motion of the articulators |
Adequate range of motion of articulators |
Accuracy attained – 70-75% |
|
Affected movement against resistance |
Able to resist the articulators against external force applied to some extent |
Accuracy attained – 50-60% |
|
Palatal movements |
|
|
|
Significant Hyper nasality |
|
|
|
|
Enhanced palatal movements |
Accuracy attained – 60% |
|
|
No significant change |
Accuracy attained – 10-20% |
|
Pre – Therapy |
Post- Therapy |
|
Masa Score – 140 |
Masa Score – 169 |
|
Severity – Modrerate |
Severity – mild |
|
Aspiration & Choking While Swallowing |
No Aspiration & Choking While Swallowing |
|
Cough During Or After Meal |
Significantly Reduced |
Discussion
Parkinson’s disease is becoming more frequent as the global human population is aging [Tysnes (2017, August)].[3] In Parkinson’s disease, dysphagia is very common with serious and negative consequences for physical health and quality of life [Smith].[4] Today, the most common treatment for dysphagia focuses on changing the texture of the diet, although there are other techniques aimed at improving the quality of life of the patients suffering from dysphagia. [Troche].[5]
This case study highlights different therapeutic techniques which were used during management. It greatly emphasized on compensatory procedures as well as swallowing maneuvers to treat the signs and symptoms of the patient. Use of MASAKO and Mendelsohn maneuver eliminated aspiration and swallowing difficulty. Hence this study rationalizes the importance of swallowing maneuvers along with lifestyle modifications in treating patients with dysphagia.
Like this study, preceding studies verified that use of appropriate swallowing maneuvers and compensatory strategies in dysphagia management lead to enhancement of swallowing functions such as reduction of aspiration in patients with Parkinson’s disease.
Felix et.al. emphasized the implementation of swallowing maneuvers such as the Mendelsohn and Masako and postural adjustments to be used as therapeutic techniques for oropharyngeal dysphagia in patients with Parkinson’s disease.[6]
Argolo et.al. investigated the effect of motor swallowing exercises, on swallowing dynamic, quality of life and swallowing complaints in Parkinson’s disease and found that these exercises may reduce the swallowing disorders in Parkinson’s disease patients and impact positively on the quality of life and swallowing complaints in individuals with Parkinson’s disease.[7]
In his case study, which was designed to examine the impact of concurrently applying postural techniques and EMST on the enhancement of swallowing, author Byeon reported that the use of postural methods and expiratory muscular strengthening training (EMST) as a part of intervention for dysphagia in patients with Parkinson's disease resulted in significant improvements in swallowing.[8]
The effects of using the tactics, such as compensatory strategies and swallowing maneuvers, mentioned in the chosen papers support an improvement in the ability to swallow functions in Parkinson's disease patients.[9] Similar outcomes were attained in this case study, where the patient received the same therapy approaches and had a noticeable increase in their ability to swallow. This case study thus emphasizes the significance of adopting compensatory techniques and swallowing maneuvers as a part of the treatment in managing individuals who have dysphagia caused due to Parkinson's disease.
Source of Funding
None.
Conflict of Interest
None.
References
- JA Logemann. The Evaluation and Treatment of Swallowing Disorders. Curr Opin Otolaryngol Head Neck Surg 1998. [Google Scholar]
- DA Patel, S Krishnaswami, E Steger, E Conver, MF Vaezi, MR Ciucci. Economic and survival burden of dysphagia among inpatients in the United States. Dis Esophagus 2018. [Google Scholar]
- OB Tysnes, A Storstein. Epidemiology of Parkinson's disease. J Neural Transmission 1996. [Google Scholar]
- SK Smith, H Roddam, H Sheldrick. Rehabilitation or compensation: time for a fresh perspective on speech and language therapy for dysphagia and Parkinson's disease?. Int J language Commun Dis 2012. [Google Scholar]
- MS Troche, CM Sapienza, JC Rosenbek. Effects of bolus consistency on timing and safety of swallow in patients with Parkinson's disease. Dysphagia 2008. [Google Scholar]
- VN Felix, SM Corrêa, RJ Soares. A therapeutic maneuver for oropharyngeal dysphagia in patients with Parkinson's disease. Clinics 2008. [Google Scholar]
- N Argolo, M Sampaio, P Pinho, A Melo, AC Nóbrega. Do swallowing exercises improve swallowing dynamic and quality of life in Parkinson's disease?. Neuro Rehabili 2013. [Google Scholar]
- H Byeon. Effect of simultaneous application of postural techniques and expiratory muscle strength training on the enhancement of the swallowing function of patients with dysphagia caused by parkinson's disease. J Physical Ther Sci 2016. [Google Scholar]
- RL Liria, JP Egeda, FA Vega-Ramírez, JM Aguilar-Parra, RT Ramos, MJ Morales-Gázquez. Treatment of Dysphagia in Parkinson’s Disease: A Systematic Review. Int J Environ Res Public Health 2020. [Google Scholar]
- Introduction
- Case Presentation
- Medical history
- Clinical examination
- Cranial nerve examination
- Speech assessment
- Franchay’s dysarthria assessment
- Four finger test revealed
- The mann asessment of swallowing ability (MASA)
- Instumental Evaluation
- Electroglottography
- Treatment
- Results
- Discussion
- Source of Funding
- Conflict of Interest