**5. Management of dysphagia in patients with Parkinson's disease**

been considered sufficiently important to warrant study by clinicians and researchers. In a prospective study of 101 PD patients, neurologists failed to identify the presence of depression, anxiety, and fatigue in over 50% of patients and the presence of sleep disturbance in 40% [26].

**4. Clinical features and diagnosis of dysphagia in Parkinson's disease**

individual [27].

182 Seminars in Dysphagia

muscle system [29, 30].

swallowing disorders.

airways [31].

efficient therapeutic approach [27].

sialorrhea, and reduced tongue movements [21].

Oropharyngeal dysphagia in PD may limit or preclude safe oral feeding, reducing the patient's full capacity in society and resulting in social, psychological, and economic problems for the

One of the first reports of parkinsonian dysphagia was in 1817 by James Parkinson, who described a typical case of PD with weight loss, difficulty in swallowing solids and liquids,

In 1983, Longemann proposed the videofluoroscopic swallowing study (VFSS) as a means of assessing the dynamics of swallowing. Parkinsonian VFSS [27] can show specific impairments, such as those in the oral pharyngeal and esophageal phases. In the oral phase, these include orofacial tremor, difficulty forming a cohesive food bolus, prolonged swallowing time, limited tongue and mandibular excursion during mastication, and the presence of repetitive antero‐ posterior movements of the tongue during bolus propulsion (lingual festination). Pharyngeal phase impairments include delayed pharyngeal response with consequent stasis in the valleculae and piriform sinuses, with the risk of laryngeal penetration and aspiration, and impairment of pharyngeal muscle contraction and cricopharyngeal function [28]. Impairments in the esophageal phase of swallowing include reduced peristalsis and reduced transit time. All of these disturbances occur together with the traditional motor symptoms of PD (brady‐ kinesia and rigidity) as a result of degeneration of the autonomic nerve system and voluntary

The incidence of swallowing disorders in PD varies from 50% to 100% of patients. Another characteristic reported in studies of dysphagia in PD is that it may be present without symp‐ toms, making it difficult to identify the condition early and, consequently, to plan a more

Interestingly, many patients who do not complain of feeding difficulties report having eliminated certain types of food that caused them swallowing difficulties, often restricting themselves to food with a purée consistency. Some patients report weight loss associated with

As a result of swallowing disturbances, parkinsonian patients may present with tracheal aspiration (entry of material into the airway), which is generally asymptomatic and known as silent aspiration. Tracheal aspiration related to swallowing is a major cause of morbidity and mortality in PD, suggesting a reduction in voluntary mechanisms that protect the upper Treatment of PD has traditionally been pharmacologic and was revolutionized by the discov‐ ery that levodopa is able to penetrate the blood--brain barrier and be converted to dopamine in the central nervous system. However, the effect of pharmacologic treatment on oral communication and swallowing is still controversial.

Drug treatment appears to have little effect on speech and swallowing disturbances compared with the major effect it has on motor symptoms in the trunk and limbs. In a study on voice and swallowing, when patients were asked about the effects of medication, all reported clear improvements in general physical symptoms, but only three out of twenty-four patients reported improvements in oral communication and swallowing symptoms. This suggests that both dysarthrophonia and dysphagia are related to dysfunction of nondopaminergic neuronal pathways [27].

Although the subject of much controversy in the past, the value of speech therapy has been confirmed in several objective studies [29-31]. The effects of speech therapy on voice and swallowing were analyzed in a study, which showed that there was a 100% improvement in symptoms after therapy, particularly increased sphincteric action of the larynx [27].

Speech therapy for parkinsonian dysphagia includes exercises to increase mobility of oro‐ pharyngeal and laryngopharyngeal structures involved in mastication and swallowing, specific techniques to improve formation and propulsion of the bolus, and maneuvers that increase airway protection during swallowing. In cases of severe dysphagia, speech language pathologists work with compensatory strategies such as modifications in bolus consistency and viscosity and postural maneuvers [31].

In 1987, Lorraine Olson Raming and Carolyn Mead developed an effective treatment program for individuals with PD voice tremor. The technique is known as LSVT (Lee Silverman Voice Treatment) and was named after the first patient who received the treatment (Lee Silverman). The basic principle used in this approach involves increasing vocal effort to enable patients to speak louder. An important study reported significant improvements in swallowing in patients who received LSVT treatment. Temporal measurements such as oral and pharyngeal transport time, duration of contact between the base of the tongue and the pharynx and duration of velopharyngeal closure and laryngeal elevation were taken. There was a 51% improvement in dysphagia after LSVT [32].

Biofeedback is a technique that uses visual or auditory references and electromyography, mirrors or other tools to show physiological events to the patient. It is used to enhance learning by means of exteroceptive systems, which replace inadequate proprioceptive signals, to improve voluntary motor control, to provide more specific, faster sensory information and to facilitate motor relearning. Visual information can compensate for sensorimotor loss by allowing individuals to assimilate lost or altered information and reduce body asymmetry by reestablishing a central motor program that takes into account position and movement [32,33].

Doppler sonar has been investigated as a method for assessing swallowing [34]. The feasibility of using this method as an aid to the assessment of swallowing and the benefits it brings have been confirmed in recent studies. The use of Doppler sonar to provide biofeedback of swal‐ lowing in PD patients not only helps them understand the swallowing process and how they can influence it, but also enables them to derive satisfaction from performing an activity over which they previously seemed to have no control.
