B.J.M. de Swart

Prevalence of oropharyngeal dysphagia in Parkinson's disease: a meta-analysis.

Dysphagia is a potentially harmful feature, also in Parkinsons disease (PD). As published prevalence rates vary widely, we aimed to estimate the prevalence of oropharyngeal dysphagia in PD in a meta-analysis. We conducted a systematic literature search in February 2011 and two independent reviewers selected the papers. We computed the estimates of the pooled prevalence weighted by sample size. Twelve studies were suitable for calculating prevalence rates. Ten studies provided an estimate based on subjective outcomes, which proved statistically heterogeneous (p < 0.001), with a pooled prevalence estimate with random effect analysis of 35% (95% CI 28-41). Four studies provided an estimate based on objective measurements, which were statistically homogeneous (p = 0.23), with a pooled prevalence estimate of 82% (95% CI 77-87). In controls the pooled subjective prevalence was 9% (95% CI 2-17), while the pooled objective prevalence was 23% (95% CI 13-32). The pooled relative risk was 3.2 for both subjective outcomes (95% CI 2.32-4.41) and objective outcomes (95% CI 2.08-4.98). Clinical heterogeneity between studies was chiefly explained by differences in disease severity. Subjective dysphagia occurs in one third of community-dwelling PD patients. Objectively measured dysphagia rates were much higher, with 4 out of 5 patients being affected. This suggests that dysphagia is common in PD, but patients do not always report swallowing difficulties unless asked. This underreporting calls for a proactive clinical approach to dysphagia, particularly in light of the serious clinical consequences.

Dysphagia in spinal muscular atrophy type II More than a bulbar problem

Objective: In patients with spinal muscular atrophy (SMA) type II, feeding problems and dysphagia are common, but the underlying mechanisms of these problems are not well defined. This case control study was designed to determine the underlying mechanisms of dysphagia in SMA type II. Methods: Six children with SMA type II and 6 healthy matched controls between 6.4 and 13.4 years of age were investigated during swallowing liquid and solid food in 2 different postures using surface EMG (sEMG) of the submental muscle group (SMG) and a video fluoroscopic swallow study (VFSS). Results: The VFSS showed postswallow residue of solid food in the vallecula and above the upper esophageal sphincter (UES), which can be responsible for indirect aspiration. Better results in swallowing were achieved in a more forward head position. These findings were supported by the sEMG measurements of the SMG during swallowing. Conclusions: Dysphagia in spinal muscular atrophy type II is due to a neurologic dysfunction (lower motor neuron problems from the cranial nerves in the brainstem) influencing the muscle force and efficiency of movement of the tongue and the submental muscle group in combination with a biomechanical component (compensatory head posture). The results suggest an integrated treatment with an adapted posture during meals and the advice of drinking water after meals to prevent aspiration pneumonias.

Problems with Eating and Drinking in Patients with Unilateral Peripheral Facial Paralysis

Patients with facial paralysis not only suffer from asymmetry of the face, but also from problems with eating and drinking. To demonstrate that these patients have many problems with activities such as eating and drinking, we examined 17 outpatients with a unilateral peripheral facial paralysis for the presence of problems in these functions. To collect data, all patients completed a questionnaire concerning the problems they had directly following onset of the paralysis and at the moment of this study. In addition, they were examined to determine the severity of the paralysis, the problems with eating and drinking, their experiences regarding impairments and disabilities, and the compensatory behavior. The result of the study is a portrayal of problems and conscious or unconscious compensations. Furthermore, we concluded that the Sunnybrook Facial Grading System score does not predict the number of problems in eating and drinking, the number of compensations, and the emotional impact. Significant correlations are found only between various scores on Visual Analog Scales and the number of compensatory actions. Patients differ in how they experience the extensive problems due to the facial paralysis and in the extent to which they are successful in adaptation. Consulting a speech therapist for treatment of functional problems is a meaningful adjunct to regular therapy. The treatment of deglutition disorders can be best based upon the detailed information of the questionnaire and the examination of eating, drinking, and compensatory behavior.

Myotonia and flaccid dysarthria in patients with adult onset myotonic dystrophy

Background: Myotonia and weakness are the most important components of dysarthric speech in myotonic dystrophy. Objective: To specify and quantify possible defects in speech execution in patients with adult onset myotonic dystrophy. Methods: Studies on speech production were done on 30 mildly affected patients with myotonic dystrophy. Special attention was paid to myotonia. Because muscle activity can result in a decrease of myotonia, speech characteristics were measured before and after warm up. The possibility that warming up causes increased weakness was also assessed. Results: As with other motor skills, a warm up effect was found in speech production, resulting in an increase in repetition rate and a decrease in variability of repetition rate. Signs of fatigue did not occur. Conclusions: Warming up is valuable for patients with myotonic dystrophy in reducing the influence of myotonia on speech production.

Speech Pathology Interventions in Patients with Neuromuscular Diseases: A Systematic Review

Purpose: A systematic review was conducted to summarize and evaluate the literature on the effectiveness of speech pathology interventions in adults with neuromuscular diseases. Method: Databases searched included the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, EMBASE, PsycINFO and PubMed. A total of 1,772 articles were independently screened on title and abstract by 2 reviewers. Results: No randomized controlled trials or clinical controlled trials were found. Four other designs were included. Only one study on oculopharyngeal muscle dystrophy (OPMD) appeared to have sufficient methodological quality. There is evidence indicating that correction of head position in patients with OPMD improves swallowing efficiency (level III evidence). Conclusion: Despite 1,772 studies, there is only evidence of level III regarding the effectiveness of speech pathology interventions in patients with OPMD. Recommendations for future research are given.

The Radboud Dysarthria Assessment: Development and Clinimetric Evaluation.

Objective: In the absence of an adequate dysarthria assessment in the Netherlands, we developed the Radboud Dysarthria Assessment (RDA). This article describes its development and clinimetric evaluation. Patients and Methods: Forty-three patients were assessed with the RDA. The recording forms were subjected to exploratory factor analysis and estimation of internal consistency. The self-evaluation questionnaire was tested for internal consistency and the severity scale for intra- and inter-rater reliability. Construct validity of the severity scale and questionnaire was determined by relating them to the Speech Handicap Index (SHI), Dutch sentence intelligibility assessment (NSVO-Z), and category fluency task. Results: Exploratory factor analysis extracted 4 factors (articulation, resonance, phonation, respiration/prosody) yielding an explained variance of 70.3%. Each factor showed good internal consistency (Cronbach’s α: 0.89–0.91). The self-evaluation questionnaire showed excellent internal consistency (Cronbach’s α: 0.90). Intra-class correlation coefficients of the severity scale (0.85–0.86) showed good reliability. The severity scores and self-evaluation questionnaire correlated substantially to strongly with the SHI (rs = 0.40 and 0.80) and substantially with the NSVO-Z (rs = –0.65 and –0.52). Conclusions: The RDA is a valid and reliable tool, but further investigation is needed to demonstrate whether this instrument can successfully support speech-language therapists in correctly diagnosing the type of dysarthria.

Author reply to "Oropharyngeal dysphagia in Parkinson's disease: Comments on paper by Kalf et al." by Boot & Chaudhuri

Dear Editor,WehavereadthecommentbyBootandChaudhurionourpaper[1] and highly appreciate their input on this topic. Oropharyngealdysphagia is poorly indexed in databases, so the risk of missingrelevant studies is indeed present. However, we believe that wedid not fail to include key papers which could have led to anotheroutcome of our meta-analysis.While systematically searching for eligible papers for thisreview, we were well aware of the NMSQuest being the new stan-dard of screening for non-motor symptoms in Parkinson’s disease(PD), with an item on swallowing. In fact, we included two studiesusing NMSQuest [2,3] in our meta-analysis, which added signifi-cantly to the overall prevalence rate because of their populationsize.In our first search strategy, we used “deglutition disorders”, theMESH term – which includes “swallowing disorders”–to identifystudies with data on swallowing disorders or dysphagia. We rana second search including “non-motor” as a search term, in orderto find prevalence studies using NMSQuest or SCOAP-AUT. Weincluded the NMSQuest study by Martinez-Martin et al. [2],because this study was explicitly done to report prevalence ratesof non motor symptoms using the NMSQuest, while precedingNMSQuest-studies focussed on the development and validation ofthe instrument.InthissecondsearchwealsofoundtheNMSS-studytheauthorsrefer to in their comment [4], but we did not include this study inour meta-analysis, because it focuses on the psychometric charac-teristics of the instrument, instead of reporting prevalence rates.Finally,wedidmissthestudydemonstratingthenondeclarationof non motor symptoms to health professionals [5]. The dysphagiaprevalence rate in this study was 27% and if included in the meta-analysis, it would have had a small lowering effect on the pooledprevalence rate of 35% based on subjective outcomes. Interestingly,37% of the patients in this study who had scored positive on the‘swallowing’ item had not previously discussed their complaintwith a healthcare professional. This underreporting justifies theroutinely use of questionnaires like NMSQuest and timely referralto a speech-language therapist, as we advocated in our conclusion.References