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Abstract

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 study's 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.

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DISCLAIMER

The contents of this manuscript do not represent the views of the Department of Veterans Affairs or the United States Government. This material is based on work supported in part by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Rehabilitation Research and Development Service.

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Information & Authors

Information

Published In

Neurology®
Volume 75Number 21November 23, 2010
Pages: 1912-1919
PubMed: 21098406

Publication History

Received: February 15, 2010
Accepted: August 9, 2010
Published online: November 22, 2010
Published in print: November 23, 2010

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Disclosure

Dr. Troche reports no disclosures. Dr. Okun serves on scientific advisory boards for the Dystonia Medical Research Foundation and the National Parkinson Foundation and also the Medical Advisory Board for the Tourette Syndrome Association; has received funding for travel and speaker honoraria from Medtronic, Inc. prior to 2010; has served/serves on the editorial boards of Neurology and Parkinsonism and Related Disorders; is a founder of the COMPRESS software used for deep brain stimulation (DBS) screening and has filed patents regarding double lead DBS, DBS targeting, and COMPRESS; receives royalties from the publication of Ultimate Neurology Review (DEMOS, 2007), Parkinson's Disease (Manson, 2009), and Deep Brain Stimulation for Neurological and Psychiatric Diseases (Humana Press, 2009); serves as Medical Director of the National Parkinson Foundation and as a member of the Ask the Expert Forum; and has received research support from Medtronic, Inc. (devices and training fellowship grants), the NIH (PI R21NS072897, PI R34MH080764 ), the University of Florida Foundation, the Parkinson Alliance, the Michael J. Fox Foundation, and the National Parkinson Foundation. Dr. Rosenbek serves on the editorial board of the Journal of Medical Speech Language Pathology; and receives royalties from the publication of Dysphagia and Movement Disorders (Plural Publishing, 2009) and Encyclopedia of Rare Dysphagias (Plural Publishing, 2010). Ms. Musson reports no disclosures. Dr. Fernandez serves on scientific advisory boards for EMD Serono, Inc. and Biogen Idec; serves as Medical Editor of the Movement Disorders Society Web Site; is a founder of the COMPRESS software used for deep brain stimulation (DBS) screening and has filed patents regarding double lead DBS, DBS targeting, and COMPRESS; has received royalties from the publication of Ultimate Review for the Neurology Boards (Demos Publishing, 2006 and 2010), A Practical Approach to Movement Disorders (Demos Publishing, 2007), Clinician's Desk Reference on Parkinson Disease (Manson Publishing, 2009), and Parkinson's Disease: A Guide to Patient Care (Springer Publishing, 2009); served as a member of the Ask The Doctor Forum; has received research support from AstraZeneca, Forest Laboratories, Inc., Novartis, Solvay Pharmaceuticals, Inc., Teva Pharmaceutical Industries Ltd., the NIH/NINDS (U10 NS53381-01 [PI]), the Huntington Study Group, the Movement Disorders Society, the Parkinson Study Group, the Society of Progressive Supranuclear Palsy, the Michael J. Fox Foundation, and the National Parkinson Foundation. Dr. Rodriguez has served on speakers' bureaus for Allergan, Inc., Valeant Pharmaceuticals International, Solstice Neurosciences, Inc., Teva Pharmaceutical Industries Ltd., Boehringer Ingelheim, and SCHWARZ PHARMA; and receives research support from Merz Pharmaceuticals, LLC and Ipsen. Ms. Romrell, Ms. Pitts, and Dr. Wheeler-Hegland report no disclosures. Dr. Sapienza serves on a scientific advisory board for and has potential royalty interest in Aspire Products, LLC; has received speaker honoraria from the American Speech-Language-Hearing Association; serves as an Associate Editor of Logopedics and Phoniatrics; receives royalties from the publication of Voice Disorders (Plural Publishing, Inc., 2009); and receives research support from the US Veterans Administraion, the NIH (NIDCHD HD046903-01A112/0 [PI]), CurePSP, and the Michael J. Fox Foundation.

Authors

Affiliations & Disclosures

M.S. Troche, PhD
From the University of Florida (M.S.T., M.S.O., J.C.R., H.H.F., R.R., J.R., T.P., K.M.W.-H., C.M.S.), Gainesville; and Brain Rehabilitation Research Center (M.S.T., J.C.R., N.M., T.P., K.M.W.-H., C.M.S.), Malcom Randall VAMC Gainesville, Gainesville, FL.
M.S. Okun, MD
From the University of Florida (M.S.T., M.S.O., J.C.R., H.H.F., R.R., J.R., T.P., K.M.W.-H., C.M.S.), Gainesville; and Brain Rehabilitation Research Center (M.S.T., J.C.R., N.M., T.P., K.M.W.-H., C.M.S.), Malcom Randall VAMC Gainesville, Gainesville, FL.
J.C. Rosenbek, PhD
From the University of Florida (M.S.T., M.S.O., J.C.R., H.H.F., R.R., J.R., T.P., K.M.W.-H., C.M.S.), Gainesville; and Brain Rehabilitation Research Center (M.S.T., J.C.R., N.M., T.P., K.M.W.-H., C.M.S.), Malcom Randall VAMC Gainesville, Gainesville, FL.
N. Musson, MA
From the University of Florida (M.S.T., M.S.O., J.C.R., H.H.F., R.R., J.R., T.P., K.M.W.-H., C.M.S.), Gainesville; and Brain Rehabilitation Research Center (M.S.T., J.C.R., N.M., T.P., K.M.W.-H., C.M.S.), Malcom Randall VAMC Gainesville, Gainesville, FL.
H.H. Fernandez, MD
From the University of Florida (M.S.T., M.S.O., J.C.R., H.H.F., R.R., J.R., T.P., K.M.W.-H., C.M.S.), Gainesville; and Brain Rehabilitation Research Center (M.S.T., J.C.R., N.M., T.P., K.M.W.-H., C.M.S.), Malcom Randall VAMC Gainesville, Gainesville, FL.
R. Rodriguez, MD
From the University of Florida (M.S.T., M.S.O., J.C.R., H.H.F., R.R., J.R., T.P., K.M.W.-H., C.M.S.), Gainesville; and Brain Rehabilitation Research Center (M.S.T., J.C.R., N.M., T.P., K.M.W.-H., C.M.S.), Malcom Randall VAMC Gainesville, Gainesville, FL.
J. Romrell, PA-C
From the University of Florida (M.S.T., M.S.O., J.C.R., H.H.F., R.R., J.R., T.P., K.M.W.-H., C.M.S.), Gainesville; and Brain Rehabilitation Research Center (M.S.T., J.C.R., N.M., T.P., K.M.W.-H., C.M.S.), Malcom Randall VAMC Gainesville, Gainesville, FL.
T. Pitts, PhD
From the University of Florida (M.S.T., M.S.O., J.C.R., H.H.F., R.R., J.R., T.P., K.M.W.-H., C.M.S.), Gainesville; and Brain Rehabilitation Research Center (M.S.T., J.C.R., N.M., T.P., K.M.W.-H., C.M.S.), Malcom Randall VAMC Gainesville, Gainesville, FL.
K.M. Wheeler-Hegland, PhD
From the University of Florida (M.S.T., M.S.O., J.C.R., H.H.F., R.R., J.R., T.P., K.M.W.-H., C.M.S.), Gainesville; and Brain Rehabilitation Research Center (M.S.T., J.C.R., N.M., T.P., K.M.W.-H., C.M.S.), Malcom Randall VAMC Gainesville, Gainesville, FL.
C.M. Sapienza, PhD
From the University of Florida (M.S.T., M.S.O., J.C.R., H.H.F., R.R., J.R., T.P., K.M.W.-H., C.M.S.), Gainesville; and Brain Rehabilitation Research Center (M.S.T., J.C.R., N.M., T.P., K.M.W.-H., C.M.S.), Malcom Randall VAMC Gainesville, Gainesville, FL.

Notes

Address correspondence and reprint requests to Dr. Michelle S. Troche, PO Box 117420, University of Florida, Gainesville, FL 32611[email protected]
Study funding: Supported by the VA Rehab R&D (B3721R to C.S.) and the Michael J. Fox Foundation (00056150).

Author Contributions

Statistical analysis was conducted by Dr. Troche, Dr. Wheeler-Hegland, and Dr. Sapienza.

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