Christine M. Sapienza

Strength-Training Exercise in Dysphagia Rehabilitation: Principles, Procedures, and Directions for Future Research

AbstractDysphagia rehabilitation, historically, has focused a great deal on various compensations during swallowing to prevent aspiration and/or improve safety and efficiency. Exercise, in general, has been a part of the dysphagia rehabilitation landscape. However, heightened discussions in the field regarding best practices for exercise training, particularly strengthening, raise more questions than answers. The intent of this paper is to (1) explore the overriding principles of neuromuscular plasticity with regard to strength training, (2) evaluate how current exercise-training interventions in dysphagia rehabilitation correspond to these principles, and (3) postulate directions for future study of normal and disordered swallowing and determine how to incorporate these principles into dysphagia rehabilitation.

Aspiration and swallowing in Parkinson disease and rehabilitation with EMST: A randomized trial

Objective: Dysphagia is the main cause of aspiration pneumonia and death in Parkinson disease (PD) with no established restorative behavioral treatment to date. Reduced swallow safety may be related to decreased elevation and excursion of the hyolaryngeal complex. Increased submental muscle force generation has been associated with expiratory muscle strength training (EMST) and subsequent increases in hyolaryngeal complex movement provide a strong rationale for its use as a dysphagia treatment. The current studys objective was to test the treatment outcome of a 4-week device-driven EMST program on swallow safety and define the physiologic mechanisms through measures of swallow timing and hyoid displacement. Methods: This was a randomized, blinded, sham-controlled EMST trial performed at an academic center. Sixty participants with PD completed EMST, 4 weeks, 5 days per week, for 20 minutes per day, using a calibrated or sham, handheld device. Measures of swallow function including judgments of swallow safety (penetration–aspiration [PA] scale scores), swallow timing, and hyoid movement were made from videofluoroscopic images. Results: No pretreatment group differences existed. The active treatment (EMST) group demonstrated improved swallow safety compared to the sham group as evidenced by improved PA scores. The EMST group demonstrated improvement of hyolaryngeal function during swallowing, findings not evident for the sham group. Conclusions: EMST may be a restorative treatment for dysphagia in those with PD. The mechanism may be explained by improved hyolaryngeal complex movement. Classification of evidence: This intervention study provides Class I evidence that swallow safety as defined by PA score improved post EMST.

Impact of expiratory muscle strength training on voluntary cough and swallow function in Parkinson disease.

BACKGROUND Cough provides high expiratory airflows to aerosolize and remove material that cannot be adequately removed by ciliary action. Cough is particularly important for clearing foreign particles from the airway in those with dysphagia who may be at risk for penetration/aspiration (P/A). Expiratory muscle strength training (EMST) was tested to improve cough and swallow function. METHODS Ten male participants, diagnosed with Parkinson disease (PD), with videofluorographic evidence of penetration or with evidence for aspiration of material during swallow of a thin 30-mL bolus, completed 4 weeks of an EMST program to test the hypothesis that EMST would improve cough and/or swallow function. Measured parameters from an airflow waveform produced during voluntary cough, pre-EMST and post-EMST, included inspiration phase duration, compression phase duration (CPD), expiratory phase peak flow (EPPF), expiratory phase rise time (EPRT), and cough volume acceleration (VA) [ie, the EPPF/EPRT ratio]. The swallow outcome measure was the degree of P/A during the swallow task. RESULTS There was a significant decrease in the duration of the CPD and EPRT; the decrease in EPRT resulted in a significant increase in cough VA. Significant decreases in the P/A scores were found posttraining. CONCLUSIONS The results demonstrate that EMST is a viable treatment modality for a population of participants with PD at risk of aspiration.

The Relationship Between Quality of Life and Swallowing in Parkinson’s Disease

Few studies exist in the literature investigating the impact of idiopathic Parkinsons Disease (IPD) on swallow‐related quality of life. We therefore aimed in this project to: (1) evaluate swallow‐specific quality of life in IPD; (2) delineate potential relationships between IPD duration and severity with swallow‐specific quality of life; (3) investigate relationships between swallow‐specific quality of life and general health‐related quality of life; and (4) investigate relationships between swallow‐specific quality of life and depression. Thirty‐six patients diagnosed with IPD with and without dysphagia filled out self‐report assessments of the SWAL‐QOL, Parkinsons Disease Questionnaire‐39 (PDQ‐39), and Beck Depression Inventory (BDI). A series of Mann Whitney U tests were performed between non‐dysphagic and dysphagic groups for the total SWAL‐QOL score and the 10 SWAL‐QOL domains. Spearmans Rho correlation analyses were performed between the SWAL‐QOL and (1) PDQ‐39; (2) Hoehn and Yahr stage; (3) PD disease duration; (4) UPDRS “on” score; and (5) the BDI. The dysphagia swallowing group reported significant reductions compared to the non‐dysphagic group for the total SWAL‐QOL score (P = 0.02), mental health domain score (P = 0.002) and social domain score (P = 0.002). No relationships existed between swallow‐specific quality of life and disease duration or severity. Significant relationships existed between swallow‐specific quality of life and general health‐related quality of life (rs =−0.56, P = 0.000) and depression (rs = −0.48, P = 0.003). These exploratory data highlight the psychosocial sequelae that swallowing impairment can have in those with IPD and suggest a possible association between swallowing, social function, and depression.

Effects of Bolus Consistency on Timing and Safety of Swallow in Patients with Parkinson’s Disease

Aspiration pneumonia is the leading cause of death in Parkinson’s disease (PD) patients. In clinical practice, the videofluoroscopic examination (VFE) is the most common method for evaluation of swallowing disorders. One of the variables manipulated during the VFE is consistency of the bolus. The results of this examination greatly influence the recommendations made by speech-language pathologists regarding swallow therapy and/or intervention. The primary aim of this study was to investigate the effects of bolus consistency on penetration-aspiration (P-A) score and timing of swallow of persons with PD. The videoradiographic images of ten participants with PD swallowing six thin and six pudding-thick boluses were analyzed. Swallow timing and P-A were measured. (i.e., oral transit time, pharyngeal transit time, number of tongue pumps, and P-A score). The results demonstrated various significant differences and relationships among the dependent variables. Implications for further research and clinical practice are discussed.

Implications of expiratory muscle strength training for rehabilitation of the elderly: Tutorial.

With age, physical functions decline, which influences respiratory performance. One of the physical changes associated with aging is sarcopenia, a reduction in muscle strength and power. Sarcopenia has been extensively studied in the elderly with regard to limb function but less with regard to respiratory function. Elderly individuals experience reduced muscle mass and strength in respiratory musculature, which may hinder the ability to generate adequate expiratory driving force for both ventilatory and nonventilatory activities. Increasing expiratory muscle strength may enhance an elderly individuals ability to generate and maintain the expiratory driving force critical to cough, speak, and swallow. Previous studies demonstrate that expiratory muscle strength training (EMST) improves ventilatory and nonventilatory functions. This paper discusses the potential impact that EMST can have on the rehabilitation of respiratory muscle decline, particularly in the elderly. This tutorial reviews an EMST paradigm, its physiological underpinnings, and its potential outcomes.

Research Priorities in Spasmodic Dysphonia

Objective To identify research priorities to increase understanding of the pathogenesis, diagnosis, and improved treatment of spasmodic dysphonia. Study Design and Setting A multidisciplinary working group was formed that included both scientists and clinicians from multiple disciplines (otolaryngology, neurology, speech pathology, genetics, and neuroscience) to review currently available information on spasmodic dysphonia and to identify research priorities. Results Operational definitions for spasmodic dysphonia at different levels of certainty were recommended for diagnosis and recommendations made for a multicenter multidisciplinary validation study. Conclusions The highest priority is to characterize the disorder and identify risk factors that may contribute to its onset. Future research should compare and contrast spasmodic dysphonia with other forms of focal dystonia. Development of animal models is recommended to explore hypotheses related to pathogenesis. Improved understanding of the pathophysiology of spasmodic dysphonia should provide the basis for developing new treatment options and exploratory clinical trials. Significance This document should foster future research to improve the care of patients with this chronic debilitating voice and speech disorder by otolaryngology, neurology, and speech pathology.

Respiratory and laryngeal measures of children during vocal intensity variation

Simultaneous aerodynamic, acoustic, and kinematic measurements from the laryngeal and respiratory systems were made in order to study mechanisms for changing vocal intensity. Aerodynamic and acoustic measures include an approximation of open quotient, maximum flow declination rate, alternating glottal airflow, estimated tracheal pressure, sound pressure level, and fundamental frequency. Respiratory measures included lung volume, rib cage, and abdominal displacements. Adults were used as a comparison group to twenty 4-year-olds and twenty 8-year-olds. Laryngeal and respiratory results indicate that speech production differences between the children and adults are based both on size and function. For example, childrens absolute anteroposterior diameters of the rib cage are smaller than adults, but their rib cage movement is larger and encompasses a different range during speech breathing. Since children are functionally different than adults, age specific speech production models need to be developed.

Effect of expiratory muscle strength training on elderly cough function

Age-related loss of muscle strength, known as sarcopenia, in the expiratory muscles, along with reductions in lung elastic recoil and chest wall compliance decreases the intrathoacic airway pressure as well as expiratory flow rates and velocity, greatly impacting an elderly persons ability to generate the forces essential for cough. This study examined the effects of a 4-week expiratory muscle strength training (EMST) program on maximum expiratory pressure (MEP) and cough function in 18 healthy but sedentary elderly adults. MEP significantly increased after the EMST program from 77.14+/-20.20 to 110.83+/-26.11cmH(2)O. Parameters measured during reflexive coughs produced by capsaicin challenge, indicated that compression phase duration significantly decreased (from 0.35+/-0.19 to 0.16+/-0.17s), peak expiratory flow rate decreased (from 4.98+/-2.18 to 8.00+/-3.05l/s) and post-peak plateau integral amplitude significantly increased (from 3.49+/-2.46 to 6.83+/-4.16l/ss) with the EMST program. EMST seems to be an effective program to increase the expiratory muscle strength in the sedentary elderly, which contribute to an enhanced cough function.

Voluntary Cough Production and Swallow Dysfunction in Parkinson ’ s Disease

Cough is important for airway clearance, particularly if penetration/aspiration of foreign material occurs during swallow. Measures of voluntary cough production from ten male participants with stage II–III Parkinson’s disease (PD) who showed no videofluorographic evidence of penetration/aspiration (Group 1) were examined and compared with those of ten male participants with stage II–III PD who showed videofluorographic evidence of penetration/aspiration (Group 2). The degree of penetration/aspiration was expertly judged from the videofluorographic examinations of the participants’ sequential swallow of a thin, 30-cc bolus. Measured cough parameters included inspiratory phase duration, inspiratory peak flow, compression phase duration, expiratory peak flow, expiratory rise time, and cough volume acceleration. Results indicated significant group differences for the majority of cough measures, except for inspiratory phase duration and inspiratory peak flow. A modest relationship existed between voluntary cough parameters and penetration/aspiration scores. Decreased ability to adequately clear material from the airway with voluntary cough may exacerbate symptoms resulting from penetration/aspiration, particularly for those with neurodegenerative disease. Measurement of voluntary cough may be useful for the evaluation of airway clearance ability.