Running head: PARKINSONS DISEASE AND ITS EFFECTS ON SWALLOWING

Parkinsons Disease and its Effects on Swallowing

Lauren Normoyle
University of Wisconsin-Whitewater

PARKINSONS DISEASE AND ITS EFFECTS ON SWALLOWING

Parkinson's Disease and its effect on Swallowing

Parkinsons disease (PD) is a chronic, progressive neurodegenerative disease that
currently affects about one million people in the United States (Hou & Lai, 2008). Pathology
results reveal neurodegeneration of dopamine neurotransmitters in the substantia nigra of the
basal ganglia (Carranza, Snyder, Shaw, & Zesiewicz, 2013). There is no known cause for the
dopamine deficiency; however, there are current theories suggesting the etiology may be due to
genetics and environmental factors. Clinical symptoms are believed to occur years after neuronal
degeneration begins (Argolo, Sampaio, Pinho, Melo, & Nbrega, 2013). The most common
known clinical symptoms of PD include bradykinesia, rigidity, resting tremor, and postural
instability (Rosenbek & Troche, 2013). These symptoms are known as the cardinal symptoms of
PD. There are many other symptoms of PD that can be under recognized, such as dysphagia,
dementia, depression, autonomic dysfunction, sleep disorders, and sensory disturbances
(Carranza, Snyder, Shaw, & Zesiewicz, 2013). Even though these symptoms can be under
recognized, they can have a major impact on a patients quality of life. A speech-language
pathologist (SLP) plays a major role in a patient life over the course of his or her illness because
most individuals will experience speech, voice, and swallowing disorders. Dysphagia can be
dangerous if it is not properly attended to and can lead to aspiration pneumonia. Fox et al.
(2008), states aspiration pneumonia occurs in 95% of PD patients making it the leading cause of
death. An SLPs primary concern for patients with PD is the presence of dysphagia in the oral,
pharyngeal, and esophageal swallowing phases. It is essential to know how PD may affect a
patients typical swallow in order to provide proper intervention to ensure safety and highest
quality of life.
Oral Phase

PARKINSONS DISEASE AND ITS EFFECTS ON SWALLOWING

The oral phase of swallowing is composed of the oral preparatory phase and the oral
transit phase. The oral preparatory phase is responsible for voluntary control of the bolus, lip
closure to prevent anterior spillage, lowering of the velum and elevation of the tongue base to
prevent posterior spillage, and salivary production to assist food manipulation, transport, and
digestion (Matsuo & Palmer, 2013). It is common for patients with PD to have impairments in
each component of the oral preparatory phase. When characteristics of the oral preparatory phase
are impaired you will see labial bolus leakage, lingual tremor, slowed or limited mandibular
function, piece-meal deglutition, and pre-swallow spill (Rosenbek & Troche, 2013).
The oral transit phase is responsible for elevation of the anterior portion of the tongue
against the hard palate, soft palate elevation and posterior tongue base flattens in order to
transport bolus into pharynx (Matsuo & Palmer, 2013). When characteristics of the oral transit
phase are impaired you will see lingual pumping, delayed swallow triggering, and post-swallow
residue (Rosenbek & Troche, 2013). Lingual pumping reveals a rocking-like motion of the
tongue during bolus manipulation occurring when the patient was unable to lower the tongue
base to propel the bolus posteriorly into the pharynx. Impairments in the oral phase may be due
to decreased tongue strength, tongue control, and/or sensory disturbance. Even though the airway
is not within the oral cavity, oral phase dysphagia can lead to aspiration in many ways; therefore
it is important for an SLP to know how PD can affect each phase of the swallow.
Pharyngeal Phase
The pharyngeal phase of swallowing begins once the head of the bolus crosses the
anterior faucial pillars. The pharyngeal phase is responsible for involuntary control of the bolus,
soft palate elevation to close the nasopharynx by innervation of the levator and tensor veli
palatini, posterior movement of tongue base against posterior pharyngeal wall creating pressure

PARKINSONS DISEASE AND ITS EFFECTS ON SWALLOWING

forcing the bolus inferiorly, and airway protection. Airway protection involves superior and
anterior movement of the hyolaryngeal complex, true vocal fold closure, false vocal fold closure,
aryepiglottic fold closure, and epiglottic inversion (Belafsky & Lintzenich, 2013).
Patients with PD typically exhibit impairments in the pharyngeal phase of swallowing
such as slow pharyngeal transit, abnormal/delayed contraction of the pharyngeal transit, coating
of the pharyngeal walls with bolus material, deficient epiglottis positioning, decreased epiglottic
positioning, decreased epiglottic range of motion, stasis in the vallecula and pyriform sinuses,
slow laryngeal elevation and excursion, penetration, aspiration, and upper esophageal sphincter
discoordination (Rosenbek & Troche, 2013, p. 396-397). According to Troche et al. (2014),
delayed laryngeal elevation and excursion and impaired reflex cough are due to decreased
sensory. For example, a sensory impairment may lead to delayed initiation of swallow; therefore,
decreased airway protection. In addition, if a patient with decreased sensory aspirates he or she
will not produce the reflex cough needed to expel the unwanted bolus. Troche et al. (2014)
implemented a study in which participants wore a face mask and delivered capsaicin to elicit a
reflex cough. The results revealed that the patients with more severe dysphagia were less likely
to respond to capsaicin with a reflex cough. This is important for clinicians to take into
consideration when determining the safest diet for the patients because if a patient provides no
reflex cough then it may lead to silent aspiration. Oral phase dysphagia and pharyngeal phase
dysphagia are the two most common types of dysphagia with patients with PD (Sapir, Ramig, &
Fox, 2007). Therefore, it is essential for an SLP to be aware of how PD can affect each phase of
the swallow.
Esophageal Phase

PARKINSONS DISEASE AND ITS EFFECTS ON SWALLOWING

While it is not in the scope of practice for an SLP to treat esophageal phase dysphagia, it
is important to recognize and know when dysphagia may be occurring in the esophagus in order
to refer patients to a gastrointestinal physician. The esophageal phase of swallowing is
responsible for moving food through the esophagus into the stomach by movement known as
peristalsis (Miller, 2013). Patients with PD commonly have impaired opening of the upper
esophageal sphincter and an abnormality in typical peristalsis movement. Studies reveal motor
abnormalities in the esophagus, including aperistalsis and diffuse esophageal spasm, were found
in 73% of 22 patients with PD (Sapir, Ramig, & Fox, 2007).
Respiration
In addition to examining impairments during each swallowing phase, patients with PD
have the potential to develop respiratory dysfunction. According to Silverman et al. (2006),
respiratory symptoms develop as a result of motor dysfunctions. Respiratory function is
important for swallowing, as well as speech, voice, and protective mechanisms. Coughing is a
protective mechanism because if a patient potentially aspirates he or she can cough in order to
expel the unwanted bolus. Silverman et al. (2006) states, strengthening respiratory muscles can
decrease respiratory symptoms through expiratory muscle strength training program (EMST).
Treatment
According to Troche, Brandimore, Okun, Davenport, & Hegland (2014), Dysphagia
often is considered an inevitable consequence of PD (p. 1297). Therefore, it is important to have
intervention plan in place in order to maintain current levels of functioning and quality of life.
The purpose of swallowing treatment for patients with PD is to protect the airway. Two
researched intervention plans for patients with PD that have and are currently being researched
include EMST and Lee Silverman Voice Treatment (LSVT).

PARKINSONS DISEASE AND ITS EFFECTS ON SWALLOWING

Some studies suggest that cough function should be included in order to voluntarily eject
material that enters the airway. As mentioned previously, researchers found that patients with PD
have a decreased sensation, which causes absence of a reflex cough. Silent aspiration is
aspiration without a reflex cough response (Troche et al., 2014). Research has found that
treatment for reflex cough may be to elicit a voluntary cough. However, patients need to be able
to generate enough energy in order to generate a cough. The purpose of EMST is to provide high
intensity exercise for a short period of time and will increase the ability to generate maximum
expiratory pressure needed in order to cough. EMST is performed by using a pressure-threshold
device that provides a consistent pressure load for expiration. Using these devices, participants
must overcome a threshold load by generating an expiratory pressure sufficient to open a springloaded valve (Silverman et al., 2006, p. 73).
LSVT is a known treatment developed for patients with PD for targeting voice during
speech production. However, studies have proven that LSVT improved swallowing by increasing
orofacial function relevant to swallowing (Sapir, Ramig, & Fox, 2007). For example, increased
tongue force will improve swallowing by increasing bolus control and creating pressure during
oral transit time in order to send bolus into the pharynx.
There are many other types of treatment that have been identified to improve swallowing
safety and improve cough effectiveness such as verbal cueing, swallowing rehabilitation
exercises, and bolus modification (Rosenbek & Troche, 2013). An SLP must choose the
appropriate intervention plan for each individual patient.
Conclusion
PD is one of many progressive, neurodegenerative diseases that an SLP will have on his
or her caseload. Bradykinesia, rigidity, resting tremor, and postural instability are the cardinal

PARKINSONS DISEASE AND ITS EFFECTS ON SWALLOWING

symptoms of PD. However, dysphagia is very common in patients with PD. As mentioned
previously, Troche et al. (2014) states, dysphagia is to be anticipated at some point after being
diagnosed with PD. Dysphagia can lead to aspiration and possibly lead to death if not properly
treated. Patients with PD could experience dysphagia at any phase of the swallow. Oral phase
and pharyngeal phase dysphagia are the two most common types seen in patients with PD. Even
though an SLP does not provide treatment for esophageal phase dysphagia, it is essential to
recognize in order to refer patients to the appropriate physician. All swallowing phases could
lead to aspiration; therefore, it is important for an SLP to be able to identify and know how to
provide intervention for patients with PD.

PARKINSONS DISEASE AND ITS EFFECTS ON SWALLOWING

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