parkinsonpotilaan · pdf fileorofaryngeaalisen dysfagian insidenssi parkinsonin taudissa...

PARKINSONPOTILAAN DYSFAGIA

Taina Kannosto-Blomqvist

Puheterapeutti FL

Tyks

PARKINSONIN TAUTI

bull Ikaumlaumlntyneiden tauti (1100 gt70v)

bull Presbyfagian mukanaan tuomat

lisaumlongelmat huomioitava

Taina Kannosto-Blomqvist 2842017

OROFARYNGEAALISEN DYSFAGIAN INSIDENSSI PARKINSONIN TAUDISSA

Stroudley ampWalsh1991 Fuh et al1997 Leopold amp Kagel 1997 Potulska et al2003

70 ndash 100


PARKINSONIN TAUTIIN LIITTYVAumlN DYSFAGIAN RISKIT

Parkinsonlaumlaumlkitys ei siihen useinkaan tehoa

bull Aiheuttaa aspiraatiota joka bull Aiheuttaa keuhkokuumetta joka bull On parkinsonpotilaiden yleisin kuolinsyy bull MUUT RISKIT

ndash Vajaaravitsemus ndash Tukehtumisriski


Parkinsonism Relat Disord 2015 Sep21(9)1082-6

Incidence and mortality trends of aspiration pneumonia in Parkinsons disease in the United States 1979-2010

Akbar et al

bull Long-term (32-year) trends revealed a nearly 10-fold increase in incidence of AsPNA in PD (04 in 1979 49 in 2010)

bull Our data suggest that PD patients are living longer have slightly more AsPNA but a lower mortality than was seen in past decades


J Neurol Neurosurg Psychiatry 2012 Jun83(6)607-11

Ten year survival and outcomes in a prospective cohort of new onset Chinese Parkinsons disease patients

Auyeung M Tsoi TH Mok V Cheung CM Lee CN Li R Yeung E

171 new onset PD patients were recruited

bull After a mean follow-up of 113plusmn26 years 50 (29) patients died

bull 83 (49) developed dementia

bull 81 (47) had psychosis and

bull 103 (60) had sensory complaints

bull Postural hypotension was found in 58 (34) patients

bull 101 (59) had falls

bull 102 (60) had dysphagia

bull 148 (87) had freezing of gait

bull 117 (68) had speech disturbances

bull 46 (27) were institutionalised whereas 54 (32) lived independently

bull Dementia older onset and postural instability gait disorder were independent predictors of death

bull 10 years into PD a significant proportion of patients developed dopa resistant motor and non-motor features


IKAumlAumlNTYNYT POTILAS HEIKENTYNYT PROTEIININSAANTI ndash RISKITEKIJAumlT

geriatrian prof Rainer Wirth (BochumSaksa)

bull Dysfagia bull Huonot hampaat bull Laumlaumlkityksen sivuvaikutukset bull Ruuansulatuskanavan sairaudet bull Muu sairaus bull Heikentynyt maku- ja hajuaisti bull Dementia bull Masennus bull Koumlyhyys ja sosiaalinen eristaumlytyneisyys bull Ruuan ravintoarvo heikko bull Heikentynyt janon ja naumllaumlntunne


VAJAARAVITSEMUKSEN NOIDANKEHAuml Volkert 1989 (muokattu)


LAIHTUMINEN Mov Disord 2006 Nov21(11)1824-30

Body weight in patients with Parkinsons disease Bachmann CG Trenkwalder C

SYITAuml

bull Dysfagia

bull Hajuaistin heikentyminen

bull Heikentynyt kaumlsien toimintakyky

bull Pureskeluvaikeudet

bull Suolen hidastuminen

bull Depressio

bull Pahoinvointi

bull Laumlaumlkityksen aiheuttama ruokahaluttomuus

bull Lisaumlaumlntynyt energiantarve (jaumlykkyys ja tahattomat liikkeet)

PUNNITSEMINEN KERRAN KUUSSA TAumlRKEAumlAuml Taina Kannosto-Blomqvist 2842017

IKAumlAumlNTYNYT JATAI VUODEOSASTOPOTILAS

Huomioitava

bull Ravitsemustilan arviointi

bull Nielemiskyvyn arviointikonsistenssimuutokset

bull Suuhygienia (mm klooriheksidiinin kaumlyttouml)

Vrt Claveacute ym Minimal Massive Intervention


TAUDIN VAIKEUSASTEEN ARVIOINTI

bull Unified Parkinsonrsquos Disease Rating Scale (UPDRS) (Fahn et al 1987)

bull Hoehn and Yahr scale (Hoehn MM Yahr MD Parkinsonism onset progression and mortality Neurology 1967 17427ndash42)


Hoehn and Yahr scale bull Stage 1 - In this stage symptoms are on just one

side of the body bull Stage 2 - As the disease progresses there are

symptoms on both sides of the body but balance is not yet impaired

bull Stage 3 - In the third stage balance impairment and disability has begun

bull Stage 4 - In stage four the disability is severe but the person still can stand and walk without help

bull Stage 5 - In the final stage the person cannot walk or stand and must remain in bed or a wheelchair


Unified Parkinsonrsquos Disease Rating Scale

(UPDRS) Variety of categories including

bull Depression intellectual impairment motivation bull Activities of daily living including swallowing speech

cutting food dressing hygiene walking and handwriting

bull Motor skills including facial expression tremor posture walk speech and rigidity

bull Each area is divided into functions and each function is rated on 0 to 4 scale with 0 being normal and 4 representing significant problems There is a total of 199 possible points with 0 meaning no disability and 199 being total disability


Unified Parkinsonrsquos Disease Rating Scale (UPDRS) NIELEMINEN (7)

NIELEMINEN

0 = normaalia

1 = tukehtumiseen viittaavaa harvoin

2 = tukehtumiseen viittaavaa silloin taumllloumlin

3 = tarvitsee pehmeaumln ruuan

4 = tarvitsee NMLn tai PEGn


Unified Parkinsonrsquos Disease Rating Scale (UPDRS) SYLJENERITYS (6)

SYLJENERITYS

0 = normaalia

1 = suussa lievaumlsti kohonnut syljen maumlaumlrauml ehkauml youmlnaikaista sylkivuotoa

2 = syljen maumlaumlrauml kohtalaisesti kohonnut ehkauml vaumlhaumlistauml sylkivuotoa

3 = huomattavasti sylkeauml ja joskus sylkivuotoa

4 = runsasta sylkivuotoa tarvitsee jatkuvasti nenaumlliinaa sen pyyhkimiseen


DYSFAGIAN KEHITTYMINEN PARKINSONPOTILAILLA

bull Yli puolella potilaista voidaan instrumentaalisin keinoin todeta dysfagia vaikka subjektiivisesti eivaumlt sellaista koe (Manor et al2007)

bull Parkinsonin taudin ensioireista vaikeaan dysfagiaan n 130 kkssa (10-11v)

(Muller et al 2001)


OROFARYNGEAALISEN DYSFAGIAN OIREET PARKINSONPOTILAILLA

Logemann JA Evaluation and treatment of swallowing disorders Austin Pro-Ed 1998

Heikentynyt liike orofarynksissauml ndash Kielen kanta

ndash Nielun seinaumlmaumlt

ndash Kurkunpaumlauml ja kieliluu

Keskeinen loumlydoumls syljen ruuan tai juoman RESIDUAALI JAumlAumlMAuml jota potilas ei useinkaan itse tunne



bull Boluksen siirtymaumlaika nielutasolla on pidentynyt

bull Nielemisrefleksi on myoumlhaumlssauml

bull Nielun lihaksiston peristaltiikka (kurojat) on heikentynyttauml

bull UESn avautuminen on rajoittunutta cricopharyngeus ei relaksoidu normaalisti (akalasia)

bull Nielemislihaksiston dyskoordinaatio (kielen pumppaus)

bull Kieliluun liike yloumls eteenpaumlin on rajoittunutta

bull Epiglottiksen kallistuskulma pienentynyt


VFG-loumlydoumlkset Nagaya M et alNagoya J Med Sci 67 2004

2125 poikkeavuutta syoumlmisessaumlnielemisessauml

Tauti jo pidemmaumllle edennyt (Hoehn and Yahr taso 3 tai enemmaumln) levodopa otettu 90-120min sitten

ORAALINEN VAIHE poikkeavia 21

bull 521 ruokajaumlaumlmaumlauml suussa nielemisen jaumllkeen

bull 1621 bolus siirtyi hallitsemattomasti nielutasolle

bull 2021 bolus siirtyi osa kerrallaan nielua kohti

FARYNGEAALINEN VAIHE poikkeavia 20

bull 1720 jaumlaumlmaumlauml valleculissa

bull 1320 jaumlaumlmaumlauml piriformiksissa

bull 1320 aspiraatiota (nesteellauml mutta ei hyyteloumlllauml)

Leuan laskeminen tai supraglottinen nieleminen eivaumlt auttaneet aspiraation vaumlhentaumlmisessauml vain hyyteloumlmaumliseen siirtyminen auttoi estaumlmaumlaumln aspiraation


MEKANORESEPTORIT

bull Suun ja nielun limakalvolla

bull Nopeasti adaptoituvia

bull Aistivat herkaumlsti paineen muutoksia ja nielemiseen liittyvaumlauml lihasten liikettauml

HEIKENTYNEET PARKINSONDYSFAGIASSA


Int J Lang Commun Disord 2015 Sep-Oct50(5)659-64

Swallowing disorders in Parkinsons disease impact of lingual pumping

Argolo N Sampaio M Pinho P Melo A Noacutebrega AC

bull Lingual pumping (LP) is a repetitive involuntary anteroposterior movement of the tongue on the soft palate that is executed prior to transferring the food bolus to the pharynx

bull 69 PD patients VFG

bull LP was associated with the unstable intra-oral organization of the bolus the loss of bolus control the pharyngeal retention of food and food entering the airway

bull This abnormal movement was found to be more prevalent with food of thicker consistencies


Spontaneous swallowing during all-night sleep in patients with Parkinson disease in comparison with healthy control

subjects Uludag IF Tiftikcioglu BI Ertekin C SLEEP 201639(4)847ndash854

bull A total of 21 patients with PD and 18 age-matched healthy controls were included in the study

bull video-EEG 12-channel recording was used including the electromyography (EMG) of the swallowing muscles nasal airflow and recording of vertical laryngeal movement using a pair of EEG electrodes over the thyroid cartilage

bull The new finding was the so-called salvo type of consecutive SS(spontaneous saliva swallows) in one set of swallowing The amount of coughing was significantly increased just after the salvo SS

bull We define a novel type of swallowing pattern we termed salvo swallowing which is characterized by a burst of four or more consecutive spontaneous swallows within a single swallow event We showed that salvo swallows are increased in PD The salvo type swallowings were frequent in 15 of 21 patients with PD The mean number of swallows in one salvo swallowing was 81 plusmn 125 in patients with PD


Spontaneous swallowing during all-night sleep in patients with Parkinson disease in comparison with healthy control subjects

Uludag IF Tiftikcioglu BI Ertekin C SLEEP 201639(4)847ndash854

COUGH AND SALVO SWALLOWING

bull Cough after salvo swallowing were all significantly increased in patients with PD (P lt 0001)

bull A higher incidence of coughing may indicate that the swallowing material can be transmitted into the airway during deglutition

bull However many individuals with PD can have silent aspiration without awareness especially in sleep and there is no cough response to airway aspiration probably because of a reduced sensitivity in the laryngopharynx

bull It may be expected that apneic events in sleep are increased in PD


What is the mechanism of salvo type of SS

bull If we can focus on the pathophysiological mechanism of dysphagia in PD we can find some clue for the mechanism

bull Logemann (Logemann JA Evaluation and treatment of swallowing disorders San Diego CA College-Hill Press 1983) was the first to describe the oscillating anterior-posterior movements of the tongue and these movements may repeat many times before the swallow that is triggered by the sufficient tongue-driving force Excessive tongue pumping movements have also been described by Murry and Carrau (Murry T Carrau RL Clinical manual for swallowing disorders San Diego CA Singular Thomson Learning 2001)

bull They reported that these motor behaviors were more prevalent in liquid than in semisolids and solids

bull Weak pharyngeal contractionsqueeze and impaired pharyngeal peristalsis have been reported along with delays in triggering of the pharyngeal phase of swallowing that resulted in spillage and pooling of the bolus in valleculae or piriform muscle



Leow LP Mechanisms of airway protection in ageing and Parkinsonrsquos disease University of Canterbury 2007) Leow reported that individuals in PD may repetitively pump the tongue to advance the bolus from anterior to posterior in an attempt to trigger sensory receptors for pharyngeal swallowing

bull Patients with PD had sensory loss at the base of the tongue in comparison with their healthy counterparts and it was concluded that tongue-pumping behavior seen in patients with PD may also be related to sensory loss

Mu L Sobotka S Chen J et al Parkinson disease affects peripheral sensory nerves in the pharynx J Neuropathol Exp Neurol 201372614ndash23

Mu L Sobotka S Chen J et al Altered pharyngeal muscles in Parkinson disease J Neuropathol Exp Neurol 201271520ndash30

bull The pharyngeal sensory nerves and branches of glossopharyngeal and vagal nerves are directly affected by the pathological process (α-synucleopathy) in PD

bull Thus insufficient sensory input in the oropharyngeal mucosae may be the reason for the salvo type swallow of saliva that accumulated in the mouth and the pharyngeal spaces


Does botulinum toxin injection in parotid glands interfere with the swallowing dynamics of Parkinsons disease patients

Noacutebrega AC Rodrigues B Melo A Clin Neurol Neurosurg 2009 Jun111(5)430-2

bull Sixteen patients with diurnal sialorrhea were selected and evaluated during the on period by a standardized questionnaire and swallowing videofluoroscopy before and 30 days after ultrasound-guided BT-A injection into the parotid glands

RESULTS bull A decrease in sialorrhea was observed in all studied patients Silent laryngeal

penetration was observed in three patients and silent aspiration was observed in two of them There were no changes in swallowing dynamics when comparing patients before and after BT-A parotid injection (p=1) suggesting similar levels of dysphagia in the two measurements

CONCLUSION bull BT-A injection into parotid glands does not interfere with the oropharyngeal

swallowing dynamics of PD patients


Eur Neurol 201370(1-2)42-5 doi 101159000348571 Epub 2013 May 23

Impact of cognitive dysfunction on drooling in Parkinsons disease Rana AQ Khondker S Kabir A Owalia A Khondker S Emre M

bull 314 potilasta

bull Drooling is caused by impaired swallowing and it can have a significant impact on the quality of life However it is still unclear whether cognitive dysfunction could exacerbate drooling We wanted to examine if any relationship existed between drooling and dementia in PD patients

bull still unclear whether cognitive dysfunction could exacerbate drooling


Eur Neurol 201267(5)312-4 doi 101159000336054 Epub 2012 Apr 20 Impact of progression of Parkinsons disease on drooling in various ethnic groups

Rana AQ Yousuf MS Awan N Fattah A

bull Drooling or sialorrhea is a common non-motor symptom of Parkinsons disease (PD) and is reported by 35-75 of patients Drooling is primarily due to impaired swallowing rather than hypersecretion of saliva In this study we examined the prevalence of drooling in PD and its relation to various factors such as age stage of disease gender and ethnicity

bull 307 potilasta

bull 123 (40) patients exhibited drooling No correlation between age and development of drooling was observed However gender was found to be a significant factor in developing sialorrhea Males are twice as more likely to develop sialorrhea than females In addition drooling becomes more prevalent with disease progression Hoehn and Yahr stage 4 patients being the most at risk Ethnicity and immigration status have no relationship in developing drooling


Parkinsonism Relat Disord 200814(3)243-5 Epub 2007 Sep 24

Is drooling secondary to a swallowing disorder in patients with Parkinsons disease Noacutebrega AC Rodrigues B Torres AC Scarpel RD Neves CA Melo A

bull Sixteen PD patients with diurnal drooling were assessed using a modified barium swallowing with videofluoroscopy and a drooling score

bull Changes in the oral stage of swallowing were seen in 100 of the patients and in the pharyngeal stage in 94 of the patients The results showed a correlation between the drooling scale score and the level of dysphagia (-0426 plt005) Patients with the worst dysphagia had the worst drooling


SYLKIVUODON HOITO

bull Various symptomatic treatments are available aiming either to reduce saliva production (botulinum toxinanticholinergics or radiotherapy over the salivary glands) or to improve the quality and frequency of swallowing

bull Sialorrhea in PD is thought to be caused by impaired or infrequent swallowing rather than hypersecretion Oral medications botulinum toxin injections surgical interventions radiotherapy speech therapy and trials of devices may be used to treat sialorrhea in PD but few controlled trials have been published


SYLJEN HALLINNAN PARANTAMINEN

EPDA (European Parkinsonacutes Disease Association) Changes in posture and swallowing can help to improve saliva control You may find the following suggestions useful

bull Try to sit upright

bull Keep your head up so that saliva flows to the back of your throat where it can be swallowed

bull Make a conscious effort to swallow saliva often Using a special badge or button or brooch that bleeps discretely to remind you to swallow may help with this

bull Drink more often so saliva is lsquowashed downrsquo with fluids

bull Avoid sugary foods as these encourage saliva to develop

bull Reducing your intake of dairy products can help to reduce mucus production

bull If you suffer from dry mouth and your swallowing reflex is good suck on sweets ice chips or chew gum to encourage saliva production

bull Clean teeth and mouth regularly particularly after meals to guard against infections that can result from stale saliva


EPDA (European Parkinsonacutes Disease Association) HUULTEN SULKUHARJOITTEITA

These simple exercises can help to improve lip seal For each exercise hold your lips in position for a count of four then relax and try to repeat at least five times

bull Close your lips as tightly as you can

bull Hold a wide smile

bull Hold your lips as if you are going to kiss someone or blow a whistle

bull Hold your lips together as if smoking a pipe

bull Try sitting for five minutes with a lolly stick or pen held between your lips and swallow every 30 seconds

bull Strongly swallow your saliva throughout the day


KURLAAVA AumlAumlNI rdquoWET VOICErdquo

Dysphagia 2014 Oct29(5)610-52014 Jul 8 Wet voice as a sign of penetrationaspiration in Parkinsons disease does testing

material matter Sampaio M Argolo N Melo A Noacutebrega AC

bull perceptual vocal quality that is commonly used as an indicator of

penetration andor aspiration in clinical swallowing assessments and bedside screening tests

bull Speech therapists rated the presence or absence of wetness and other voice abnormalities Two binary endpoints of FEES were selected for comparison with an index test low penetration (LP) and low penetration andor aspiration (LPASP) The accuracy of wet voice changed according to the testing material in PD patients Overall the specificity of this indicator was better than its sensitivity and the wafer cookie and yogurt drink yielded the best indices Our data show that wet voice is clearly indicative of LP or LPASP in PD patients in case of positive test However in the case of a negative result the wet voice test should be repeated or combined with other clinical tests to include or exclude the risk of LP or LPASP


Botulinum toxin A for drooling in Parkinsons disease A pilot study to compare submandibular to parotid gland injections

Kalf et al Parkinsonism amp Related Dis 2007 Volume 13 Issue 8 Pages 532ndash534

bull Drooling is a common and incapacitating problem in Parkinsons disease (PD) Treatment with botulinum neurotoxin (BoNT) into the parotid glands seems beneficial Injection of the submandibular glands may also be effective since these produce 70 of the daily unstimulated saliva We randomly allocated patients to BoNT injections into the submandibular glands or the parotid glands

bull Within-group improvements were significant for the submandibular group but not for the parotid group Between-group differences showed a trend towards superiority for the submandibular group Injecting the submandibular glands instead of the parotid glands seems a promising approach and larger studies are justified


Neurogastroenterol Motil 2017 Jan29(1)

Esophageal dysfunction in different stages of Parkinsons disease

Suttrup I Suttrup J Suntrup-Krueger S Siemer ML Bauer J Hamacher C Oelenberg S Domagk D Dziewas R Warnecke T

bull 65 PD patients divided into three groups early [HampY I+II n=21] intermediate [HampY III n=25] and advanced stadium [HampY IV+V n=19]

bull Manometry

bull Minor impairment of the esophageal body was present in 95 of participants and throughout all disease stages with pathological findings especially in peristalsis and intrabolus pressure

possibly reflects α-synucleinopathy in the enteric nervous system

bull No clear association was found between the occurrence of oropharyngeal dysphagia and esophageal impairment


Bischoff-Grethe A Crowley MG Arbib MA Movement inhibition and next sensory state prediction in the basal ganglia In Graybiel AM DeLong MR Kitai ST editors The Basal

Ganglia VI Kluwer AcademicPlenum Publishers New York 2002

bull The inability of the sensorimotor regions of the basal ganglia cerebral cortex and other associated regions to receive accurate afferent input may account for errors in the initiation timing and range of swallow movements

bull The fact that individuals with PD often exhibit abnormally increased muscle tone and rigidity may reflect a tendency of the central nervous system to remain in a state of movement preparation while awaiting the arrival of the afferent signal resulting in a delayed or aberrant transition to movement execution

In later stages of PD this tendency may increase as the ability to initiate a swallow becomes more impaired


YSKIMINEN Decreased Cough Sensitivity and Aspiration in Parkinson Disease

TrocheMS et al CHEST 2014 146(5)1 294- 1299

bull Aspiration pneumonia is a leading cause of death in people with Parkinson disease (PD) The pathogenesis of these infections is largely attributed to the presence of dysphagia with silent aspiration or aspiration without an appropriate cough response

bull to test reflex cough thresholds and associated urge-to-cough (UTC) ratings in participants with PD with and without dysphagia

bull 20 Parkinsonpotilasta kapsaisiiniaerosoli inhaloituna

TULOKSET

bull UTC ratings and total number of coughs produced at 200 m M capsaicin were significantly influenced by dysphagia severity but not by general PD severity age or disease duration Increasing levels of dysphagia severity resulted in significantly blunted cough sensitivity

UTC ratings may be important in understanding the mechanism underlying

morbidity related to aspiration pneumonia in people with PD and dysphagia

YSKIMISKYVYN KUNTOUTUS


Parkinsonism Relat Disord 2014 Nov20(11)1226-30

Comparison of voluntary and reflex cough effectiveness in Parkinsons disease

Wheeler Hegland K Troche MS Brandimore AE Davenport PW Okun MS

bull Cough serves to eject material from the lower airways and can be produced voluntarily (on command) and reflexively in response to aspirate material or other airway irritants Voluntary cough effectiveness is reduced in PD however it is not known whether reflex cough is affected as well

bull 20 Parkinsonpotilasta kapsaisiini-inhalaatio TULOKSET bull Significant differences were found for peak expiratory flow rate (PEFR) and

cough expired volume (CEV) between voluntary and reflex cough Specifically both PEFR and CEV were reduced for reflex as compared to voluntary cough

Cough PEFR and CEV are indicative of cough effectiveness in terms of the ability to remove material from the lower airways Differences between these two cough types likely reflect differences in the coordination of the respiratory and laryngeal subsystems Clinicians should be aware that evaluation of cough function using voluntary cough tasks overestimates the PEFR and CEV that would be achieved during reflex cough in patients with PD


Arch Phys Med Rehabil 2016 Mar97(3)413-20 doi 101016japmr201510098 Epub 2015 Nov 6

Measurement of Voluntary Cough Production and Airway Protection in Parkinson Disease Silverman EP Carnaby G Singletary F Hoffman-Ruddy B Yeager J Sapienza C

bull To examine relations between peak expiratory (cough) airflow rate and swallowing

symptom severity in participants with Parkinson disease (PD) N=68

bull potential relations among disease severity swallowing symptom severity and peak expiratory (cough) airflow rate

TULOKSET

bull Participants with early stage PD demonstrated little to no swallowing symptoms and had the highest measures of peak expiratory (cough) airflow rate In contrast participants with the most severe swallowing symptoms also displayed the lowest measures of peak expiratory (cough) airflow rate

Relations existed among PD severity swallowing symptom severity and peak expiratory (cough) airflow rate in participants with PD Peak expiratory (cough) airflow rate may eventually stand as a noninvasive predictor of aspiration risk in those with PD

particularly those with later stage disease Inclusion of peak expiratory (cough) airflow rates into existing clinical swallowing assessments may increase the sensitivity and predictive validity of these assessments


Voluntary Cough Production and Swallow Dysfunction in Parkinsonrsquos Disease

PittsTet al Dysphagia 2008 September 23(3) 297ndash301

bull 10 Parkinsonpotilasta VFG puheterapeuttiarviot penetraatioaspiraatiosta pneumotachograph connected to a spirometer

bull The results from this study indicated that those with PD with known swallow dysfunction as defined by degree of penetrationaspiration during a sequential swallow have impaired voluntary cough

bull Siis nielemisen heikentyessauml myoumls yskimiskyky heikkenee samalla

bull It is known that subcortical lesions like that in PD could be interrupting the cortical pathways necessary to facilitate a coordinated cough response

bull Braak et al found lesions beginning in PD stage I in the dorsal motor group (within the medulla oblongata) that controls the glossopharyngeal and vagus nerves which allow for the activation of swallowing and the laryngeal activation for cough

bull The locations of lesions on sites that control both swallow and a portion of cough may be a factor that dictates changes to both the swallow and cough function in PD


Mov Disord 2011 Jan26(1)138-41

Silent saliva aspiration in Parkinsons disease Rodrigues B Noacutebrega AC Sampaio M Argolo N Melo A

bull We investigated the frequency and characteristics of saliva SLPSA in PD

patients with daily drooling (Group A) and in individuals without PD or daily drooling (Group B)

bull Both groups were evaluated by fiberoptic endoscopic evaluation of swallowing (FEES) after dyeing the oral cavity with blue dye The oropharynx was assessed for the presence of the stasis of saliva and sensitivity was tested by direct tactile stimuli

bull PD patients (n = 28) and controls (n = 18) were evaluated We observed silent aspiration of saliva in 107 and silent laryngeal penetration of saliva near the vocal folds in 286 of Group A however none of these events was observed in Group B Sensitivity in the epiglottis and posterior wall of the hypopharynx was decreased in 892 of Group A and in 333 of Group B whereas in the aryepiglottic folds and interarytenoid area a decrease in sensitivity was observed in 928 and in 444 of Groups A and B respectively

bull Silent aspiration and laryngeal penetration of saliva are common features in PD patients with daily drooling The presence of hypoesthesia of the laryngeal structures and the lack of protective reflexes in such patients may play a major role in the mechanisms of SLPSA


Usefulness of the Simplified Cough Test in Evaluating Cough Reflex Sensitivity as a Screening Test for Silent Aspiration

Ji Young Lee MD Don-Kyu Kim MD Kyung Mook Seo MD Si Hyun Kang MD Ann Rehabil Med 201438(4)476-484

bull The cough latency was more significantly prolonged in the healthy elderly group than in the healthy young group (plt0001) and in the dysphagic elderly group than in the healthy elderly group (plt0001)


Mov Disord 2008 Apr 1523(5)676-83

Subthalamic nucleus deep brain stimulation improves deglutition in Parkinsons disease Ciucci MR Barkmeier-Kraemer JM Sherman SJ

bull Purpose to examine the effects of subthalamic nuclei (STN) DBS on the oral and pharyngeal stages of deglutition in individuals with Parkinsons Disease (PD)

bull Stimulation of the STN may excite thalamocortical or brainstem targets to sufficiently overcome the bradykinesiahypokinesia associated with PD and return some pharyngeal stage motor patterns to performance levels approximating those of normal deglutition

bull But the degree of hyoid bone excursion and oral stage measures did not improve


Interdiscip Neurosurg 2016 Sep53-5 Tailored deep brain stimulation optimization for improved airway protective outcomes in

Parkinsons disease Troche MS Brandimore AE Hegland KW Zeilman PR Foote KD Okun MS

bull There is no consensus regarding the effects of deep brain stimulation (DBS) surgery on swallowing outcomes in Parkinsons disease (PD) No prospective studies have compared airway protective outcomes following DBS to the subthalamic nucleus (STN) versus globus pallidus interna (GPi) A recent retrospective study described swallowing outcomes pre- and post-STN vs GPi DBS in a cohort of 34 patients with PD

bull The results revealed that the patients who received GPi DBS maintained their swallowing function post-DBS while those in the STN group significantly worsened in swallowing safety As DBS surgery becomes a common management option in PD it is important to understand the impact of DBS on airway protective outcomes especially given that aspiration pneumonia is the leading cause of death in this population We present a case report in which optimizing DBS settings with the goal of improving laryngeal function resulted in immediate improvements to swallowing safety


Comparison of dysphagia before and after deep brain stimulation in Parkinsons disease

Silbergleit et al 2012 Movement Disorders

bull Fourteen subjects with advanced PD underwent videofluorographic swallowing studies prior to bilateral DBS of the subthalamic nucleus (STN) and at 3 and 12 months postprocedure

bull data suggest that bilateral STN-DBS does not substantively impair swallowing in PD In addition it may improve motor sequencing of the oropharyngeal swallow for solid consistencies (which are known to provide increased sensory feedback to assist motor planning of the oropharyngeal swallow) Subjects with advanced PD who are undergoing DBS may perceive significant improvement in swallowing ability despite the lack of objective improvements in swallowing function


Parkinsonism Relat Disord 2016 Jul28100-6

Levodopa responsiveness of dysphagia in advanced Parkinsons disease and reliability testing of the FEES-Levodopa-test

Warnecke T Suttrup I Schroumlder JB Osada N Oelenberg S Hamacher C Suntrup S Dziewas R

bull We evaluated the effect of oral levodopa application on dysphagia in advanced PD patients with motor fluctuations

bull In 15 PD patients (mean age 7193 plusmn 829 years mean disease duration 1433 plusmn 594 years) with oropharyngeal dysphagia and motor fluctuations endoscopic swallowing evaluation was performed in the off state and on state condition following a specifically developed protocol (FEES-levodopa-test) The respective dysphagia score covered three salient parameters i e premature spillage penetrationaspiration events and residues each tested with liquid as well as semisolid and solid food consistencies An improvement of gt30 in this score indicated levodopa responsiveness of dysphagia

bull Severity of swallowing dysfunction in the off state varied widely The lowest dysphagia score was 15 points (dysphagia without any aspiration risk) The highest dysphagia score was 84 points (dysphagia with aspiration of all consistencies) Seven patients showed a marked improvement of dysphagia in the on state condition Eight PD patients did not respond


Dysphagia 2010 Sep25(3)216-20 doi 101007s00455-009-9245-9 Epub 2009 Aug 13 The impact of dysphagia on quality of life in ageing and Parkinsons disease as measured by the

swallowing quality of life (SWAL-QOL) questionnaire Leow LP Huckabee ML Anderson T Beckert L

bull This prospective cross-sectional study evaluated the impact of dysphagia on quality of

life in healthy ageing and in subjects with Parkinsons disease (PD) using the Swallowing Quality of Life (SWAL-QOL) questionnaire Sixteen healthy young adults (8 males mean age = 251 years) and 16 healthy elders (8 males mean age = 728 years) were recruited Thirty-two subjects with idiopathic PD (mean age = 685 years) were recruited from a movement disorders clinic The severity of PD was staged using the Hoehn and Yahr scale Results revealed that elders experienced symptoms of dysphagia more frequently than young adults but the overall SWAL-QOL scores were not significantly different

bull Subjects with PD who experienced dysphagia reported greatly reduced QOL and significant differences were found in all but one subsection of the SWAL-QOL Disease

progression detrimentally impacts QOL with subjects in later-stage PD experiencing further reduction in the desire to eat difficulty with food selection and prolonged eating duration These features which increase with disease severity

bull are likely to impact negatively upon nutritional status which is already under threat from PD-related dysphagia


Brain 2013 Mar136(Pt 3)726-38

Evidence for adaptive cortical changes in swallowing in Parkinsons disease

Suntrup S Teismann I Bejer J Suttrup I Winkels M Mehler D Pantev C Dziewas R Warnecke T

bull 10 dysphagic and 10 non-dysphagic patients with Parkinsons disease and a healthy control group during self-paced swallowing

bull Compared with healthy subjects a strong decrease of cortical swallowing activation was found in all patients It was most prominent in participants with manifest dysphagia

bull Non-dysphagic patients with Parkinsons disease showed a pronounced shift of peak activation towards lateral parts of the premotor motor and inferolateral parietal cortex with reduced activation of the supplementary motor area This pattern was not found in dysphagic patients with Parkinsons disease

bull We conclude that in Parkinsons disease not only brainstem and basal ganglia circuits but also cortical areas modulate swallowing function in a clinically relevant way

bull The results point towards adaptive cerebral changes in swallowing to compensate for deficient motor pathways Recruitment of better preserved parallel motor loops driven by sensory afferent input seems to maintain swallowing function until progressing neurodegeneration exceeds beyond the means of this adaptive strategy resulting in manifestation of dysphagia


PARKINSONIN TAUTIIN LIITTYVAumlN DYSFAGIAN PATOFYSIOLOGIA

bull Aiemmin hyvin heikosti tunnettu

bull Selvaumlauml korrelaatiota dysfagian vaikeusasteen ja sairauden keston tai kehon muiden motoristen haumlirioumliden ei ole todettu siksi epaumlilty onko myoumls ei-dopaminergisten verkostojen haumlirioumltauml mukana

bull Taumlmauml selittaumlisi miksi suurella osalla potilaista dysfagiaoireisto ei lievity dopamiinilaumlaumlkityksellauml vaikka muu motorinen oireisto lievittyy


Hunter PC Crameri J Austin S et al Response of parkinsonian swallowing dysfunction to dopaminergic stimulation J Neurol Neurosurg Psychiatry 1997 63579ndash83 [PubMed 9408096]

Leopold NA Kagel MC Pharyngo-esophageal dysphagia in Parkinsonrsquos disease Dysphagia 1997

1211ndash8 [PubMed 8997827]

Sapir S Ramig L Fox C Speech and swallowing disorders in Parkinson disease Curr Opin Otolaryngol Head Neck Surg 2008 16205ndash10 [PubMed 18475072]

bull Anti-PD drugs and surgical interventions (pallidotomy thalamotomy and deep brain stimulation) which have been shown to be efficacious for the treatment of the primary clinical features affecting the limb function in PD do not produce consistent or positive effects in the treatment of the dysphagia These findings suggest that oropharyngeal dysphagia in PD may not be linked solely to a reduction in basal ganglia dopamine activity Some investigators suggested that other neurotransmitter systems or some other non-dopaminergic mechanisms may also be involved

(Mu et al 2012)



bull Parkinsonin taudissa hermosolujen runko-osaan kertyy alfasynukleiini nimistauml proteiinia Taumlmauml on yksi Parkinsonin taudin neuropatologisista tunnusmerkeistauml

bull Normaalisti alfasynukleiini on liukoinen proteiini joka on kaikilla ihmisillauml osa solujen normaalia toimintaa Tuntemattomasta syystauml Parkinsonin taudissa alfasynukleiinista tulee liukenematon tai se sakkautuu ja muodostaa pallon muotoisia Lewyn kappaleita

bull Liukenemattoman alfasynukleiinin kertyminen dopamiinihermosoluihin voi heikentaumlauml solun normaaleja toimintoja


α-Synuclein Pathology and Axonal Degeneration of the Peripheral Motor Nerves Innervating Pharyngeal Muscles in

Parkinsonrsquos Disease Mu et al J Neuropathol Exp Neurol 2013 February 72(2) 119ndash129

(+Mu et al Altered Pharyngeal Muscles in Parkinson Disease J Neuropathol Exp Neurol 2012 June 71(6) 520ndash530)

ldquothis study is the first to demonstrate α-synuclein pathology in the peripheral motor nerves innervating the pharynx in PDrdquo

bull Postmortem-tutkimus 10 Parkinsonpotilasta 4 kontrollia

bull Tutkittiin paumlaumlasiassa vagusta (CN X) nieluhaarat

bull Kaikilla Parkinsonpotilailla havaittiin alfasynukleiinisakkautumia kontrolleilla ei





bull Our studies showed that some nerve fibers of the pharyngeal plexus innervating the pharyngeal constrictors and cricopharyngeal sphincter undergo degeneration in PD

bull We detected Lewy pathology in the nerves forming the pharyngeal plexus Specifically α-synuclein aggregates were identified in cervical X nerve Ph-X cervical superior sympathetic ganglion and sympathetic trunk in PD

bull Axonal degeneration of the pharyngeal motor nerves could be responsible for denervation atrophy of the pharyngeal muscle fibers

bull PD subjects with dysphagia had a higher density of α-synuclein aggregates in the nerves studied as compared with those without dysphagia

bull Involvement of the peripheral motor nervous system controlling the pharynx in PD is most likely a major factor leading to the oropharyngeal dysphagia that is commonly seen in patients with PD

bull These findings suggest that oropharyngeal dysphagia in PD may not be caused solely by a reduction in basal ganglia dopamine activity


Airway Somatosensory Deficits and Dysphagia in Parkinsonrsquos Disease

Michael J Hammer Caitlin A Murphy and Trisha M Abrams J Parkinsons Dis 2013 3(1) 39ndash44

bull 18 PD participants and 18 healthy controls participated in this study and underwent endoscopic assessment of airway somatosensory function endoscopic assessment of swallow function and clinical ratings of swallow and disease severity

bull PD participants exhibited abnormal airway somatosensory function and greater swallow impairment compared with healthy controls

bull Swallow and sensory deficits in PD were correlated with disease severity

bull Swallow deficits were correlated with sensory function

bull PD participants reported similar self-rated swallow function as healthy controls suggesting an association between impaired sensory function and

poor self-awareness of swallow deficits in PD

For controls interestingly sensory detection thresholds and self-reported swallow deficits were negatively correlated However this finding makes sense because better airway sensory detection would logically be associated with a greater awareness of swallow difficulty




bull The present results and this clinical observation suggest that swallow impairments in PD may be related to impaired somatosensory function and that swallow and airway sensory function may degrade as a function of disease severity

bull Therefore the basal ganglia and related neural networks may play an important role to integrate airway sensory input for swallow-related motor control

bull Furthermore the airway deficits observed in PD suggest a disintegration of swallow-related sensory and motor control


The Coordination of Breathing and Swallowing in Parkinsonrsquos Disease

Gross et al Dysphagia (2008) 23136ndash145

bull When compared to the healthy control group those with Parkinsonrsquos disease swallowed significantly more often during inhalation and at low tidal volumes (tidal volume=lepohengitysvolyymi sisaumlaumln ja ulos)

bull The Parkinsonrsquos participants also exhibited significantly more postswallow inhalation for both consistencies (pudding and cookie)




bull Impaired coordination between breathing and swallowing in IPD patients is likely to have a negative effect on swallowing

bull Accurate coordination between breathing and swallowing could be the key to swallowing safety in PD because sufficient subglottic air pressure is easiest to generate at higher tidal volumes


Respiratory-Swallowing Coordination and Swallowing Safety in Patients with Parkinsonrsquos Disease

Troche et al Dysphagia 2011 September 26(3) 218ndash224

The purpose of this study was to determine if individuals with Parkinsonrsquos disease (PD) demonstrate abnormal respiratory events when swallowing thin liquids

bull 39 individuals with PD were administered ten trials of a 5-ml thin liquid bolus

bull VFG nasal cannulaPAS-score

FINDINGS expiration was the predominant respiratory event (864) before and after swallowing apnea The data revealed no differences in our cohort versus the percentages of post-swallowing events reported in the literature for healthy adults

bull BUT Individuals with decreased swallowing safety as measured by the PndashA scale were more likely to inspire after swallows and to have shorter swallowing apnea duration - may be related to the delay in triggering the swallowing reflex

bull The occurrence of inspiratory events after a swallow and the occurrence of shorter swallowing apnea durations may serve as important indicators during clinical swallowing assessments in patients at risk for penetration or aspiration with PD


PARKINSONPOTILAILLE TARKOITETUT KYSELYLOMAKKEET

bull the Munich dysphagia test for Parkinsonacutes disease (Simons et al 2014) ndash Ks httpwwwmdt-parkinsonde

bull Swallowing disturbance questionnaire for detecting dysphagia in patients with Parkinsonacutes disease (Manor et al 2007) ndash httpsstanfordhealthcareorgcontentdamSHCfor-patients-

componentrehabilitationdocsmbstheswallowingdisturbancequestionnaire-1pdf


YHTEENVETO PARKINSONDYSFAGIASTA Riippuen dysfagian vaikeusasteesta heikentyvaumlt bull Huulion sulku

bull Pureskelu

bull Sensorinen feedback suusta ja nielusta

bull Kielen propulsio

bull Glossopalataalinen sulku

bull Nielaisurefleksin ajoitus

bull Kurkunpaumlaumln ja kieliluun nousuliike

bull Nielun peristaltiikka

bull Hengitysteiden sulkumekanismit ja yskiminen

bull Ruokatorven ylemmaumln sulkijan avautuminen

bull Ruokatorven motiliteetti

bull Hengityksen ja nielemisen koordinaatiorytmitys


YHTEENVETO PARKINSONDYSFAGIASTA

Pitkaumllle edennyt dysfagia koskee kaikkia nielemisen vaiheita ja em fysiologisista muutoksista seuraa

bull Syoumlminen on hidasta ja tehotonta

bull Syoumlminen vaatii ponnistelua

bull Syoumlminen ja juominen vaumlhenee

bull Syljenhallinta heikkenee

bull Ruuan kakomista (huom hotkijat)

bull Limottumista

bull Infektioriski hengitysteissauml kasvaa


KUNTOUTUS riittaumlvaumln aikaisin bull Kompensaatiokeinot konsistenssimuutokset syoumlmistekniikka

asento manoumloumlverit bull Nielemistekniikan kohentaminen (effortful swallow + mahd

visual feedback VitalStim ja FEES-video) bull Yskimiskyvyn (ja hengityksen) parantaminen ja yllaumlpito bull LSVT bull MDTP bull IOPI Medical (isotonic exercise protocols with use of special

tongue bulbs) bull EMST150 (calibrated expiratory muscle strength trainer) bull NMES (neuromuscular electrical stimulation)

ndash VitalStim Phagenyx

bull Cricopharyngeuksen operointimyotomia dilataatio jatai botuliini-injektiot


Parkinsonin taudin kaumlypauml hoito-suositus 1015 PUHETERAPIA

bull Aumlaumlnen voimakkuuden heikkeneminen on yleinen mutta huonosti tiedostettu oire Parkinsonin taudissa Parkinsonin tautiin kehitetty spesifinen aumlaumlniterapia (Lee Silverman -aumlaumlniterapiaLSVT) saattaa parantaa aumlaumlnenvoimakkuutta ja -laatua tehokkaammin kuin pelkkauml hengityksen harjoittaminen ja tulos on mitattavissa vielauml 2 vuoden kuluttua [198ndash202] C Terapiamuodolla saattaa olla vaikutusta myoumls ilmeikkyyden parantumiseen [198ndash202] C

bull LSVT parantanee myoumls nielemistauml suun ja kielen tyven motoriikan parantuessa [198ndash202] C

ndash LSVTtauml on kaumlytetty myoumls DBSn asentamisen jaumllkeen heikentyneen puheen kuntoutuksessa Tulokset ovat kuitenkin olleet vaihtelevia ja kokemukset asiasta ovat taumlssauml potilasryhmaumlssauml vielauml vaumlhaumliset [252 253]

ndash Aumlaumlnihieronnan (voice massage) hyoumldystauml ei ole tutkimusnaumlyttoumlauml

bull Puheterapeutin asiantuntemuksesta voi olla apua myoumls nielemisvaikeuksien arvioinnissa ja hoidossa


Dysfagian diagnosointi ks Kotisivut

suomentanut Taina Kannosto-Blomqvist

(INFORMAATIO TARKOITETTU POTILAALLE TAI HAumlNEN LAumlHEISELLEEN)

Syoumlmisen ja nielemisen vaikeus voi vaikuttaa ravinnonsaantiisi ja syoumlmistapaasi ja voi aiheuttaa haumlpeaumlauml ja hermostumista Se voi myoumls vaikuttaa sosiaaliseen elaumlmaumlaumlsi ja johtaa vajaaravitsemukseen ja heikentyneeseen terveydentilaan


EPDA Mikaumlli huomaat omassa tai laumlheisesi syoumlmis- tai nielemiskyvyssauml ongelmia on taumlrkeaumlauml ottaa yhteyttauml laumlaumlkaumlriin joka tekee laumlhetteen puheterapeutille

Puheterapeutti arvioi nielemiskyvyn Tarkkaile seuraavia oireita

bull Nielemisessauml on epaumlroumlintiauml

bull Ruokaa takertuu kurkkuun tai sitauml jaumlauml suuhun nielemisen jaumllkeen

bull Tukehtumisen tunne syoumldessauml

bull On nieltaumlvauml monta kertaa samaa suuannosta

bull Nielty ruoka ajautuu nenaumlaumln

bull Ruuan pureskelu on vaikeaa

bull Ruokaa nousee takaisin suuhun nielemisen jaumllkeen

bull Yskittaumlauml nielemisen aikana tai sen jaumllkeen

bull Kurkkua joutuu selvittelemaumlaumln aumlaumlni on kaumlheauml

bull Aumlaumlnen laadussa on muutos ja nielemisen jaumllkeen aumlaumlni on kurlaava

bull Kurkussa tai rinnassa on kipua syoumldessauml

bull Refluksi naumlraumlstys

bull Nielemisen aikana otettava usein juomaa jotta saa nieltyauml ruuan

bull Syoumlminen kestaumlauml kauan voi olla ettauml ruokaa jaumlauml syoumlmaumlttauml

bull Ruokahalu on heikko ruuasta kieltaumlytymistauml

bull Paino putoaa tahattomasti

bull Keho kuivuu nestettauml ei saa tarpeeksi

bull Toistuvat hengitystieinfektiot tai keuhkokuumeet


EPDA Puheterapeutin arviointitestaus sisaumlltaumlauml

bull Sairaushistorian ja laumlaumlkityksen laumlpikaumlyminen

bull Kognitiivisen kyvyn arviointi

bull Syljenhallinnan arviointi

bull Suualueen rakenteen ja toiminnan arviointi (huulet kieli leuka posket)

bull Suualueen tunnon arviointi

bull Kurkunpaumlaumln toiminnan arviointi (aumlaumlnentuotto)

bull Nielemisrefleksien testaaminen

bull Nielemisen testaaminen eri koostumuksilla


LUETTAVAA

bull Suttrup I Warnecke T Dysphagia in Parkinsonrsquos Disease Dysphagia 2016 3124ndash32

ndash review-artikkeli hyvauml yleiskatsaus taumlmaumlnhetkisestauml tiedosta

bull Epidemiologia ja kliininen merkitys

bull Dysfagian patofysiologia

bull Dysfagian diagnosointi

bull Hoito


LUETTAVAA

Atypical Parkinsonism Laura Purcell Verdun MA CCCSLP 2016 bull PSP bull CBD bull MSA Kannattaa lukea netistauml


LUETTAVAA

bull Oropharyngeal dysphagia in older persons ndash from pathophysiology to adequate intervention a review and summary of an international expert meeting

Rainer Wirth Rainer Dziewas Anne Marie Beck Pere Claveacute Shaheen Hamdy Hans Juergen Heppner Susan Langmore Andreas Herbert Leischker Rosemary Martino Petra Pluschinski Alexander Roumlsler Reza Shaker Tobias Warnecke Cornel Christian Sieber and Dorothee Volkert

Clinical Interventions in Aging 2016 11 189ndash208


Suomen Parkinson-liitto ryn esite VASTASAIRASTUNEEN PARKINSONPOTILAAN OPAS 2014

(neurologi Anna-Maria Kuopio)

bull rdquoUsein parkinsonpotilas valittaa lihasheikkoutta mutta varsinaista heikkoutta ei voida todeta Lihasheikkouden tunne johtuu siitauml ettauml lihasten kyky suorittaa jatkuvia ja tiheaumlsti toistuvia lihassupistuksia on heikentynyt Naumlin ollen jaksottaisen liikesuorituksen automaattinen toteuttaminen kaumly vaikeaksi Esimerkiksi kun kaumlttauml panee nopeasti vuoronperaumlaumln nyrkkiin ja avaa liike muuttuu kerta kerralta kankeammaksi Hetkellisen voimaa vaativan lihasliikkeen suorittaminen kyllauml onnistuu mutta voiman yllaumlpitaumlminen ja liikkeen toistaminen ei onnistukaan yhtauml helpostirdquo

bull rdquoMyoumls kielen ja nielun lihakset toimivat hitaammin ja kankeammin mikauml voi aiheuttaa puheen muuttumisen hiljaisemmaksi epaumlselvemmaumlksi ja vivahteettomammaksirdquo

oppaassa ei kaumlsitellauml dysfagiaa lainkaan

MITEN ASIAAN VOITAISIIN VAIKUTTAA


MIHIN KLIINISEN SEKAuml PERUSTUTKIMUKSEN

TULISI KOHDISTUA TULEVAISUUDESSA SuttrupampWarneke (2016)

VAumlHINTAumlAumlN 3 OSA-ALUETTA

1 Parkinsondysfagian kehittymisen ja patofysiologian ymmaumlrtaumlminen ndash SEURANTATUTKIMUKSIA

2 Validien ja standardoitujen seulontametodien ja kliinisten arviointimenetelmien kehittaumlminen Parkinsondysfagian kaikkien aspektien varhaiseksi toteamiseksi

3 Satunnaistetut kontrolloidut tutkimukset hoito- ja kuntoutusmenetelmien vaikuttavuudesta potilaan elaumlmaumlnlaatuun tai keuhkokuumeen vaumlhentaumlmiseen


PARKINSONIN TAUTI

bull Ikaumlaumlntyneiden tauti (1100 gt70v)

bull Presbyfagian mukanaan tuomat

lisaumlongelmat huomioitava




70 ndash 100









Akbar et al





























SYITAuml

bull Dysfagia





bull Depressio

bull Pahoinvointi





Huomioitava

























NIELEMINEN

0 = normaalia







SYLJENERITYS

0 = normaalia









(Muller et al 2001)































MEKANORESEPTORIT





















































bull 314 potilasta







bull 307 potilasta








SYLKIVUODON HOITO








































bull Manometry
















TULOKSET



















TULOKSET


























Mov Disord 2008 Apr 1523(5)676-83































Brain 2013 Mar136(Pt 3)726-38



















(Mu et al 2012)


































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA





















70 ndash 100









Akbar et al





























SYITAuml

bull Dysfagia





bull Depressio

bull Pahoinvointi





Huomioitava

























NIELEMINEN

0 = normaalia







SYLJENERITYS

0 = normaalia









(Muller et al 2001)































MEKANORESEPTORIT





















































bull 314 potilasta







bull 307 potilasta








SYLKIVUODON HOITO








































bull Manometry
















TULOKSET



















TULOKSET


























Mov Disord 2008 Apr 1523(5)676-83































Brain 2013 Mar136(Pt 3)726-38



















(Mu et al 2012)


































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA


























Akbar et al





























SYITAuml

bull Dysfagia





bull Depressio

bull Pahoinvointi





Huomioitava

























NIELEMINEN

0 = normaalia







SYLJENERITYS

0 = normaalia









(Muller et al 2001)































MEKANORESEPTORIT





















































bull 314 potilasta







bull 307 potilasta








SYLKIVUODON HOITO








































bull Manometry
















TULOKSET



















TULOKSET


























Mov Disord 2008 Apr 1523(5)676-83































Brain 2013 Mar136(Pt 3)726-38



















(Mu et al 2012)


































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA












































SYITAuml

bull Dysfagia





bull Depressio

bull Pahoinvointi





Huomioitava

























NIELEMINEN

0 = normaalia







SYLJENERITYS

0 = normaalia









(Muller et al 2001)































MEKANORESEPTORIT





















































bull 314 potilasta







bull 307 potilasta








SYLKIVUODON HOITO








































bull Manometry
















TULOKSET



















TULOKSET


























Mov Disord 2008 Apr 1523(5)676-83































Brain 2013 Mar136(Pt 3)726-38



















(Mu et al 2012)


































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA




















Huomioitava

























NIELEMINEN

0 = normaalia







SYLJENERITYS

0 = normaalia









(Muller et al 2001)































MEKANORESEPTORIT





















































bull 314 potilasta







bull 307 potilasta








SYLKIVUODON HOITO








































bull Manometry
















TULOKSET



















TULOKSET


























Mov Disord 2008 Apr 1523(5)676-83































Brain 2013 Mar136(Pt 3)726-38



















(Mu et al 2012)


































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA






































NIELEMINEN

0 = normaalia







SYLJENERITYS

0 = normaalia









(Muller et al 2001)































MEKANORESEPTORIT





















































bull 314 potilasta







bull 307 potilasta








SYLKIVUODON HOITO








































bull Manometry
















TULOKSET



















TULOKSET


























Mov Disord 2008 Apr 1523(5)676-83































Brain 2013 Mar136(Pt 3)726-38



















(Mu et al 2012)


































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA




















SYLJENERITYS

0 = normaalia









(Muller et al 2001)































MEKANORESEPTORIT





















































bull 314 potilasta







bull 307 potilasta








SYLKIVUODON HOITO








































bull Manometry
















TULOKSET



















TULOKSET


























Mov Disord 2008 Apr 1523(5)676-83































Brain 2013 Mar136(Pt 3)726-38



















(Mu et al 2012)


































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA






















(Muller et al 2001)































MEKANORESEPTORIT





















































bull 314 potilasta







bull 307 potilasta








SYLKIVUODON HOITO








































bull Manometry
















TULOKSET



















TULOKSET


























Mov Disord 2008 Apr 1523(5)676-83































Brain 2013 Mar136(Pt 3)726-38



















(Mu et al 2012)


































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA
















































MEKANORESEPTORIT





















































bull 314 potilasta







bull 307 potilasta








SYLKIVUODON HOITO








































bull Manometry
















TULOKSET



















TULOKSET


























Mov Disord 2008 Apr 1523(5)676-83































Brain 2013 Mar136(Pt 3)726-38



















(Mu et al 2012)


































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA


































































bull 314 potilasta







bull 307 potilasta








SYLKIVUODON HOITO








































bull Manometry
















TULOKSET



















TULOKSET


























Mov Disord 2008 Apr 1523(5)676-83































Brain 2013 Mar136(Pt 3)726-38



















(Mu et al 2012)


































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA






















bull 307 potilasta








SYLKIVUODON HOITO








































bull Manometry
















TULOKSET



















TULOKSET


























Mov Disord 2008 Apr 1523(5)676-83































Brain 2013 Mar136(Pt 3)726-38



















(Mu et al 2012)


































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA
























SYLKIVUODON HOITO








































bull Manometry
















TULOKSET



















TULOKSET


























Mov Disord 2008 Apr 1523(5)676-83































Brain 2013 Mar136(Pt 3)726-38



















(Mu et al 2012)


































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA























































bull Manometry
















TULOKSET



















TULOKSET


























Mov Disord 2008 Apr 1523(5)676-83































Brain 2013 Mar136(Pt 3)726-38



















(Mu et al 2012)


































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA






























TULOKSET



















TULOKSET


























Mov Disord 2008 Apr 1523(5)676-83































Brain 2013 Mar136(Pt 3)726-38



















(Mu et al 2012)


































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA
































TULOKSET


























Mov Disord 2008 Apr 1523(5)676-83































Brain 2013 Mar136(Pt 3)726-38



















(Mu et al 2012)


































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA








































Mov Disord 2008 Apr 1523(5)676-83































Brain 2013 Mar136(Pt 3)726-38



















(Mu et al 2012)


































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA












































Brain 2013 Mar136(Pt 3)726-38



















(Mu et al 2012)


































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA





























(Mu et al 2012)


































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA



















































































bull Pureskelu



















bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA


























bull Limottumista





















































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA





































































LUETTAVAA






bull Hoito


LUETTAVAA



LUETTAVAA



















LUETTAVAA



LUETTAVAA



















LUETTAVAA



















parkinsonpotilaan · pdf fileorofaryngeaalisen dysfagian insidenssi parkinsonin taudissa...

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