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Calderone A, Militi D, Cardile D, Corallo F, Calabrò RS, Militi A. Swallowing disorders in cerebral palsy: a systematic review of oropharyngeal Dysphagia, nutritional impact, and health risks. Ital J Pediatr 2025; 51:57. [PMID: 39985076 PMCID: PMC11846443 DOI: 10.1186/s13052-025-01903-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/09/2025] [Indexed: 02/24/2025] Open
Abstract
Cerebral palsy (CP) is a permanent disorder affecting movement and posture due to nonprogressive brain issues, often leading to various sensory, cognitive, and musculoskeletal challenges. Among these complications, oropharyngeal dysphagia (OPD) is prevalent, impacting up to 85% of children with CP and resulting in significant nutritional deficits. This systematic review aims to explore the prevalence and types of OPD in CP patients, its effects on nutritional status, and its associated health complications, emphasizing the need for thorough assessment and intervention to mitigate risks. The review adheres to PRISMA guidelines, searching five major databases (PubMed, Web of Science, Embase, Cochrane Library, and Scopus) without time range restrictions to capture studies addressing swallowing disorders and their impact on nutritional status in CP. This review has been registered on Open OSF (n) 3KUQX. Individuals with CP often experience swallowing impairments, including delayed pharyngeal transit and aspiration. Research indicates that 81.5% of kids with CP suffer from dysphagia, commonly associated with reduced motor skills and general health. Moreover, as a result of these swallowing difficulties, nutritional complications may occur, with elevated levels of gastroesophageal symptoms causing malnutrition and growth delays, which require thorough evaluations and personalized interventions for successful treatment. Tools like the Videofluoroscopic Swallowing Study were identified as primary methods for evaluation, but assessment remains limited by methodological inconsistencies. This systematic review underscores the significant health impacts of OPD in children with CP, which affects nutrition and overall well-being. Future research should address the need for standardized evaluation methods and effective interventions to balance nutritional needs with practical mealtime strategies.
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Affiliation(s)
- Andrea Calderone
- IRCCS Centro Neurolesi Bonino-Pulejo, Via Palermo, C.da Casazza, S.S. 113, Messina, 98124, Italy
| | - David Militi
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, Messina, 98125, Italy
| | - Davide Cardile
- IRCCS Centro Neurolesi Bonino-Pulejo, Via Palermo, C.da Casazza, S.S. 113, Messina, 98124, Italy
| | - Francesco Corallo
- IRCCS Centro Neurolesi Bonino-Pulejo, Via Palermo, C.da Casazza, S.S. 113, Messina, 98124, Italy
| | - Rocco Salvatore Calabrò
- IRCCS Centro Neurolesi Bonino-Pulejo, Via Palermo, C.da Casazza, S.S. 113, Messina, 98124, Italy.
| | - Angela Militi
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, Messina, 98125, Italy
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Wang P, Chen X, Chen M, Gao L, Xiong B, Ji C, Shen Q, Shen Y, Wu S, Pan Y, Li J, Wang B, Luo W. Dysphagia Pattern in Early to Moderate Parkinson's Disease Caused by Abnormal Pharyngeal Kinematic Function. Dysphagia 2024; 39:905-915. [PMID: 38319366 DOI: 10.1007/s00455-024-10672-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/15/2024] [Indexed: 02/07/2024]
Abstract
Airway invasion is common in patients with Parkinson's disease (PD) and can cause serious complications. However, a PD-related dysphagic pattern has not been clearly elucidated. In this study, 53 patients with early to moderate PD were enrolled to undergo a videofluoroscopic study of swallowing evaluation (VFSS) and a battery of neuropsychological assessments. A set of VFSS variables (three visuoperceptual, nine temporal, and six spatial) were measured. The main effects of bolus viscosity and volume on airway invasion were calculated. Statistical analyses were performed to determine key kinematic factors of airway invasion for swallowing each bolus type. Airway invasion frequency was significantly higher for liquid boluses (liquid vs. pudding P < 0.001; liquid vs. honey P = 0.006). Laryngeal vestibule closure reaction time (LVCrt) was the key kinematic factor of airway invasion for 3 ml liquid swallow (P = 0.040), anterior displacement of hyoid bone was the key kinematic factor for both 5 ml and 10 ml liquid swallows (P = 0.010, 0.034, respectively). Male sex and advanced Hoehn and Yahr stage were significantly related to reduced anterior displacement of hyoid bone. These results reveal the dysphagic pattern related to PD, demonstrating that prolonged LVCrt and reduced anterior displacement of hyoid bone are two crucial kinematic factors contributing to airway invasion during the liquid swallow. In addition, hyoid bone dysfunction was correlated with disease severity and male sex. Our findings warrant further investigation of the pathophysiological mechanism of dysphagia in PD and would guide clinical intervention.
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Affiliation(s)
- Ping Wang
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China
- Department of Rehabilitation, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xinhui Chen
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China
| | - Miao Chen
- Department of Neurology, Zhuji Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Leilei Gao
- Department of Rehabilitation, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bing Xiong
- Department of Rehabilitation, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Changmeng Ji
- Center for Rehabilitation Assessment and Therapy, Zhejiang Rehabilitation Medical Center, Hangzhou, China
| | - Qian Shen
- Department of Rehabilitation, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuanqing Shen
- Department of Rehabilitation, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Sheng Wu
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China
| | - Yanhong Pan
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China
| | - Jinhui Li
- Department of Rehabilitation, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bo Wang
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China.
| | - Wei Luo
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China.
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Yoon J, Baek S, Jang Y, Lee CH, Lee ES, Byun H, Oh MK. Malnutrition and Associated Factors in Acute and Subacute Stroke Patients with Dysphagia. Nutrients 2023; 15:3739. [PMID: 37686771 PMCID: PMC10489833 DOI: 10.3390/nu15173739] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 08/18/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023] Open
Abstract
Most patients with stroke suffer from complications and these include dysphagia. Dysphagia can cause malnutrition, and malnutrition affects prognosis and recovery. However, there is a lack of accurate studies on the nutritional status of stroke patients with dysphagia and its associated factors in different phases of stroke. This study retrospectively investigated 620 stroke patients who underwent a videofluoroscopic swallowing study (VFSS) due to dysphagia, from March 2018 to February 2021. The study aimed to evaluate the nutritional state and associated factors of malnutrition in acute and subacute stroke patients with dysphagia. Serum albumin and percentage of current weight to ideal weight were used to determine nutritional status. Malnutrition was observed in 58.9 and 78.9% of acute and subacute stroke patients. Exact logistic regression analysis revealed that old age and high penetration-aspiration scale score were significantly associated factors for malnutrition in patients with acute stroke. Old age, stroke history, bilateral hemiplegia, high modified Rankin score, low Korean Mini-Mental State Examination, pneumonia, and high functional dysphagia score were significantly associated factors for malnutrition in patients with subacute stroke. Patients with these associated factors in each phase of stroke require active nutritional assessment and care to decrease the risk of malnutrition.
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Affiliation(s)
- Jiyong Yoon
- Department of Rehabilitation Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Changwon Hospital, Changwon 51472, Republic of Korea; (J.Y.); (S.B.); (Y.J.); (C.H.L.)
| | - Soyeong Baek
- Department of Rehabilitation Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Changwon Hospital, Changwon 51472, Republic of Korea; (J.Y.); (S.B.); (Y.J.); (C.H.L.)
| | - Yunjeong Jang
- Department of Rehabilitation Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Changwon Hospital, Changwon 51472, Republic of Korea; (J.Y.); (S.B.); (Y.J.); (C.H.L.)
| | - Chang Han Lee
- Department of Rehabilitation Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Changwon Hospital, Changwon 51472, Republic of Korea; (J.Y.); (S.B.); (Y.J.); (C.H.L.)
| | - Eun Shin Lee
- Department of Rehabilitation Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Institute of Medical Science, Gyeongsang National University, Jinju 52727, Republic of Korea;
| | - Hayoung Byun
- Department of Rehabilitation Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju 52727, Republic of Korea
| | - Min-Kyun Oh
- Department of Rehabilitation Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Institute of Medical Science, Gyeongsang National University, Jinju 52727, Republic of Korea;
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Barbiera F, Cosentino G, La Seta F, Vetrano E, Murmura B, Avenali M, Alfonsi E, Tassorelli C. A narrative review on the role and main findings of the Videofluoroscopic Study of Swallowing in Parkison's disease. LA RADIOLOGIA MEDICA 2023; 128:27-34. [PMID: 36565409 DOI: 10.1007/s11547-022-01581-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 12/13/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE Dysphagia is a common symptom in patients with Parkinson's disease (PD), though it may go undiagnosed until severe complications arise. Dysphagia can be suspected on a clinical basis, but an instrumental assessment is mandatory to confirm its presence and evaluate pathophysiological aspects and severity of the swallowing impairment. Aim of this review is to inform the clinician and the radiologist on the importance and the main radiological findings of the Video-Fluoroscopic-Swallow-Study (VFSS) in patients with PD starting from the most recent literature data on the topic. MATERIALS AND METHODS Databases analysis identified 98 papers (January 2000/October 2022) of which 55 were excluded after reading title, abstract and full-text. After evaluation of the selected articles and their references 7 additional papers were added. RESULTS Fifty papers were reviewed to answer the following four main questions: Should VFSS be routinely used to screen dysphagia? Compared to other diagnostic tools, what is the role of VFSS in PD patients with suspected dysphagia? What are the main VFSS findings and technical expedients ? What is the role of VFSS in the choice of the best treatment strategy ? CONCLUSIONS VFSS represents a gold standard technique in the diagnostic evaluation of dysphagia in PD, having a fundamental role in the identification of patients with high risk of aspiration pneumonia and also being extremely helpful to guide to the choice of treatment strategies for dysphagia.
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Affiliation(s)
- Filippo Barbiera
- Azienda Sanitaria Provinciale Agrigento - UO Complessa Radiologia Distretto Ag 2 Sciacca Ribera, Presidio Ospedaliero Di Sciacca (AG), Via Pompei, 92019, Sciacca (AG), Italy.
| | - Giuseppe Cosentino
- Department of Brain and Behavioral Sciences, University of Pavia, Via Mondino 2, 27100, Pavia, Italy
- Translational Neurophysiology Research Unit, IRCCS Mondino Foundation, Via Mondino, 2, 27100, Pavia, Italy
| | - Francesco La Seta
- Azienda Ospedaliera Ospedali Riuniti Villa Sofia Cervello Palermo, UO Complessa Radiologia PO "Vincenzo Cervello", Via Trabucco, 180, 90146, Palermo, Italy
| | - Elena Vetrano
- Azienda Sanitaria Provinciale Agrigento - UO Complessa Radiologia Distretto Ag 2 Sciacca Ribera, Presidio Ospedaliero Di Sciacca (AG), Via Pompei, 92019, Sciacca (AG), Italy
- Department of Biomedicine, Neuroscience and Advanced Diagnostic, University of Palermo, Institute of Radiology, 90127, Palermo, Italy
| | - Bruno Murmura
- Azienda Sanitaria Provinciale Agrigento - UO Complessa Radiologia Distretto Ag 2 Sciacca Ribera, Presidio Ospedaliero Di Sciacca (AG), Via Pompei, 92019, Sciacca (AG), Italy
| | - Micol Avenali
- Department of Brain and Behavioral Sciences, University of Pavia, Via Mondino 2, 27100, Pavia, Italy
- Neurorehabilitation Unit, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Enrico Alfonsi
- Translational Neurophysiology Research Unit, IRCCS Mondino Foundation, Via Mondino, 2, 27100, Pavia, Italy
| | - Cristina Tassorelli
- Department of Brain and Behavioral Sciences, University of Pavia, Via Mondino 2, 27100, Pavia, Italy
- Neurorehabilitation Unit, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
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Expanding Rehabilitation Options for Dysphagia: Skill-Based Swallowing Training. Dysphagia 2022; 38:756-767. [PMID: 36097215 PMCID: PMC10182941 DOI: 10.1007/s00455-022-10516-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/17/2022] [Indexed: 11/03/2022]
Abstract
Over the past four decades, our understanding of swallowing neural control has expanded dramatically. However, until recently, advances in rehabilitation approaches for dysphagia have not kept pace, with a persistent focussing on strengthening peripheral muscle. This approach is no doubt very appropriate for some if not many of our patients. But what if the dysphagia is not due to muscles weakness? The purpose of this clinical manuscript is to reflect on where we have been, where we are now and perhaps where we need to go in terms of our understanding of swallowing motor control and rehabilitation of motor control impairments. This compilation is presented to clinicians in the hope that suggesting approaches "outside the box" will inspire clinicians to focus their attention "inside the box" to ultimately improve rehabilitation and long-term outcomes for patients with dysphagia.
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Dilmaghani S, Atieh J, Khanna L, Hosfield EA, Camilleri M, Katzka DA. Severity of dysphagia is associated with hospitalizations and mortality in patients with Parkinson's disease. Neurogastroenterol Motil 2022; 34:e14280. [PMID: 34628711 DOI: 10.1111/nmo.14280] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/11/2021] [Accepted: 09/27/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Aspiration pneumonia is the commonest cause of hospitalizations and death in patients with Parkinson's disease (PD). Among these patients, the relationships between severity of dysphagia, hospitalizations for related complications, and death are not robustly defined. Our aim was to characterize the relationship between PD-related oropharyngeal dysfunction and clinically relevant outcomes. METHODS Retrospective cohort study of 312 patients with PD at a tertiary center who underwent videofluoroscopic swallow studies conducted by expert therapists between 2010 and 2015. Level of swallowing function was represented using the 7-point Functional Oral Intake Scale (FOIS) (7 = normal function). Significance and relative risk calculations utilized Poisson regression. Time to composite outcome of first hospitalization or death was summarized using Kaplan-Meier curve with log-rank test. KEY RESULTS One hundred thirty eight patients had a recorded FOIS score. The prevalence of oropharyngeal dysfunction was 76.1%. The median duration of follow-up was 26.8 months. In multivariate analyses, patients with FOIS 5 (RR = 2.01 [95% CI: 1.22, 3.32]), FOIS 3 (RR = 2.78 [95% CI: 1.75, 4.40]), and FOIS 1 (RR = 2.50 [95% CI: 1.49, 4.20]) were significantly associated with increased risk of hospitalization or death compared to FOIS 7 after co-variate adjustments. GERD was also associated with a significant increased risk of hospitalization or death (RR = 1.28 [95% CI: 1.01, 1.64]). Time to first hospitalization or death was shorter in patients with lower FOIS scores (p < 0.00005). CONCLUSIONS AND INFERENCES Severity of oropharyngeal dysphagia, as measured by the FOIS, is associated with poorer survival and shorter time to hospitalization for dysphagia-related complications, pneumonia, or death in PD.
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Affiliation(s)
- Saam Dilmaghani
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Rochester, Minnesota, USA
| | - Jessica Atieh
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Rochester, Minnesota, USA
| | - Lehar Khanna
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Rochester, Minnesota, USA
| | - Emily A Hosfield
- Division of Speech Pathology, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Rochester, Minnesota, USA
| | - David A Katzka
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Rochester, Minnesota, USA
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Ku PKM, Wang K, Vlantis AC, Tang EWK, Hui TSC, Lai R, Yeung ZWC, Cho RHW, Law T, Chan SYP, Chan BYT, Wong JKT, van Hasselt A, Tong MCF. Oro-pharyngo-esophageal radionuclide scintigraphy predicts aspiration pneumonia risk and associated survival in post-irradiated nasopharyngeal carcinoma patients. Laryngoscope Investig Otolaryngol 2022; 7:170-179. [PMID: 35155795 PMCID: PMC8823181 DOI: 10.1002/lio2.704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 10/28/2021] [Accepted: 11/16/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To demonstrate that oro-pharyngo-esophageal radionuclide scintigraphy (OPERS) not only detects tracheobronchial aspiration after swallowing, but also quantifies the amount of aspiration and subsequent clearance. METHODS Data collected between 2014 and 2019 were reviewed for aspiration pneumonia at 12 and 24-months after OPERS. The predictive value for aspiration pneumonia on flexible endoscopic evaluation of swallowing (FEES), videofluoroscopic swallowing study (VFSS), and OPERS, and the overall survival of patients with or without aspiration were determined. RESULTS Thirty-seven patients treated with radiotherapy for nasopharyngeal carcinoma (NPC) were reviewed. The incidence of aspiration detected on FEES, VFSS, and OPERS was 78.4%, 66.7%, and 44.4%, respectively. Using VFSS as a gold standard, the sensitivity and specificity of OPERS for aspiration was 73.7% and 100%. The positive and negative predictive values for aspiration were 100% and 66.7%, respectively, with an overall accuracy of 82.8%. A history of aspiration pneumonia was one factor associated with a higher chance of subsequent aspiration pneumonia within 12 months (odds ratio: 15.5, 95% CI 1.67-145.8, p < .05) and 24 months (odds ratio: 23.8, 95% CI 3.69-152.89, p < .01) of the swallowing assessment. Aspiration detected by OPERS was a significant risk factor for future aspiration pneumonia at 12 and 24 months respectively. Significantly, better survival was associated with an absence of aspiration on OPERS only, but not on FEES or VFSS. CONCLUSION OPERS predicts the safety of swallowing, the incidence of subsequent aspiration pneumonia, and the survival prognosis in post-irradiated NPC dysphagia patients. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Peter K. M. Ku
- Department of Otorhinolaryngology—Head and Neck SurgeryUnited Christian Hospital and Tseung Kwan O HospitalNew TerritoriesHong Kong
- Department of Otorhinolaryngology, Head and Neck SurgeryThe Chinese University of Hong Kong, Prince of Wales HospitalShatinNew TerritoriesHong Kong
| | - Ki Wang
- Department of Imaging and Interventional RadiologyPrince of Wales HospitalShatinNew TerritoriesHong Kong
| | - Alexander C. Vlantis
- Department of Otorhinolaryngology, Head and Neck SurgeryThe Chinese University of Hong Kong, Prince of Wales HospitalShatinNew TerritoriesHong Kong
| | - Evelyn W. K. Tang
- Department of Imaging and Interventional RadiologyPrince of Wales HospitalShatinNew TerritoriesHong Kong
| | - Thomas S. C. Hui
- Department of Otorhinolaryngology—Head and Neck SurgeryUnited Christian Hospital and Tseung Kwan O HospitalNew TerritoriesHong Kong
| | - Ronald Lai
- Department of Otorhinolaryngology—Head and Neck SurgeryUnited Christian Hospital and Tseung Kwan O HospitalNew TerritoriesHong Kong
| | - Zenon W. C. Yeung
- Department of Otorhinolaryngology—Head and Neck SurgeryUnited Christian Hospital and Tseung Kwan O HospitalNew TerritoriesHong Kong
| | - Ryan H. W. Cho
- Department of Otorhinolaryngology—Head and Neck SurgeryUnited Christian Hospital and Tseung Kwan O HospitalNew TerritoriesHong Kong
| | - Thomas Law
- Department of Otorhinolaryngology, Head and Neck SurgeryThe Chinese University of Hong Kong, Prince of Wales HospitalShatinNew TerritoriesHong Kong
| | - Simon Y. P. Chan
- Department of Speech TherapyPrince of Wales HospitalShatinNew TerritoriesHong Kong
| | - Becky Y. T. Chan
- Department of Speech TherapyPrince of Wales HospitalShatinNew TerritoriesHong Kong
| | - Jeffrey K. T. Wong
- Department of Imaging and Interventional RadiologyPrince of Wales HospitalShatinNew TerritoriesHong Kong
| | - Andrew van Hasselt
- Department of Otorhinolaryngology, Head and Neck SurgeryThe Chinese University of Hong Kong, Prince of Wales HospitalShatinNew TerritoriesHong Kong
| | - Michael C. F. Tong
- Department of Otorhinolaryngology, Head and Neck SurgeryThe Chinese University of Hong Kong, Prince of Wales HospitalShatinNew TerritoriesHong Kong
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A multinational consensus on dysphagia in Parkinson's disease: screening, diagnosis and prognostic value. J Neurol 2021; 269:1335-1352. [PMID: 34417870 PMCID: PMC8857094 DOI: 10.1007/s00415-021-10739-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/01/2021] [Accepted: 08/02/2021] [Indexed: 11/25/2022]
Abstract
Background Parkinson’s disease (PD) is a neurodegenerative disorder characterized by a combination of motor and non-motor dysfunction. Dysphagia is a common symptom in PD, though it is still too frequently underdiagnosed. Consensus is lacking on screening, diagnosis, and prognosis of dysphagia in PD.
Objective To systematically review the literature and to define consensus statements on the screening and the diagnosis of dysphagia in PD, as well as on the impact of dysphagia on the prognosis and quality of life (QoL) of PD patients.
Methods A multinational group of experts in the field of neurogenic dysphagia and/or PD conducted a systematic revision of the literature published since January 1990 to February 2021 and reported the results according to PRISMA guidelines. The output of the research was then analyzed and discussed in a consensus conference convened in Pavia, Italy, where the consensus statements were drafted. The final version of statements was subsequently achieved by e-mail consensus.
Results Eighty-five papers were used to inform the Panel’s statements even though most of them were of Class IV quality. The statements tackled four main areas: (1) screening of dysphagia: timing and tools; (2) diagnosis of dysphagia: clinical and instrumental detection, severity assessment; (3) dysphagia and QoL: impact and assessment; (4) prognostic value of dysphagia; impact on the outcome and role of associated conditions. Conclusions The statements elaborated by the Consensus Panel provide a framework to guide the neurologist in the timely detection and accurate diagnosis of dysphagia in PD. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10739-8.
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From DYMUS to DYPARK: Validation of a Screening Questionnaire for Dysphagia in Parkinson's Disease. Dysphagia 2021; 37:824-830. [PMID: 34264379 PMCID: PMC9345821 DOI: 10.1007/s00455-021-10332-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 06/22/2021] [Indexed: 11/05/2022]
Abstract
Dysphagia is a common debilitating symptom in people with Parkinson’s Disease (PD), adequate screening of swallowing disorders is fundamental. The DYMUS questionnaire has shown very good characteristics for the screening of dysphagia in Multiple Sclerosis, and it might also prove useful for screening dysphagia in PD. The primary aim was to test and validate the DYMUS questionnaire in PD patients. This is an observational multicentric study involving 103 patients affected by PD. All subjects filled in the DYMUS and the Eating Assessment Tool (EAT-10) questionnaires. A subgroup of patients (n = 53) underwent a fiber-optic endoscopic evaluation of swallowing (FEES) and their dysphagia was scored by means of the Dysphagia Outcome Severity Scale (DOSS). DYMUS showed a relatively high level of internal consistency (Cronbach’s alpha 0.79). A significant positive correlation was found between the DYMUS and the EAT-10 scores (p < 0.001), while a negative correlation was found between the DYMUS and the DOSS scores (p < 0.001). DYMUS showed a good sensitivity and specificity compared to FEES for detecting dysphagia (area under the curve: 0.82, p < 0.001). The ROC curve analysis showed that a DYMUS score ≥ 6 represents a reliable cut-off for the risk of dysphagia. The DYMUS questionnaire proved to be a reliable screening tool to detect dysphagia in patients suffering from PD. It is easy to understand, it can be self-administered and therefore adequate for adoption in the clinical practice with the more convenient name of DYPARK.
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10
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Chang MC, Kwak S. Videofluoroscopic Swallowing Study Findings Associated With Subsequent Pneumonia in Patients With Dysphagia Due to Frailty. Front Med (Lausanne) 2021; 8:690968. [PMID: 34291064 PMCID: PMC8287055 DOI: 10.3389/fmed.2021.690968] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/14/2021] [Indexed: 11/13/2022] Open
Abstract
Dysphagia in frailty or deconditioning without specific diagnosis that may cause dysphagia such as stroke, traumatic brain injury, or laryngeal pathology, has been reported in previous studies; however, little is known about which findings of the videofluoroscopic swallowing study (VFSS) are associated with subsequent pneumonia and how many patients actually develop subsequent pneumonia in this population. In this study, we followed 190 patients with dysphagia due to frailty or deconditioning without specific diagnosis that may cause dysphagia for 3 months after VFSS and analyzed VFSS findings for the risk of developing pneumonia. During the study period, the incidence of subsequent pneumonia was 24.74%; regarding the VFSS findings, (1) airway penetration (PAS 3) and aspiration (PAS 7 and 8) were associated with increased risk of developing pneumonia, and (2) the functional dysphagia scale (FDS) scores of the patients who developed subsequent pneumonia were higher than those of the patients who did not develop subsequent pneumonia. Our study findings might assist clinicians in making clinical decisions based on the VFSS findings in this population.
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Affiliation(s)
| | - Soyoung Kwak
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, South Korea
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Abstract
The purposes of this study were to compare poststroke liquid swallowing methods by including a cup and a straw in videofluoroscopic swallowing studies (VFSS) and to test the hypothesis that increased aspiration would be observed with the cup compared to the straw. Eighty-five poststroke patients who had undergone VFSS using a spoon, cup, and straw were included. Penetration-aspiration scale and functional dysphagia scale (FDS) were used for assessment. These scores did not differ significantly between the cup and the straw. Higher FDS scores were found with the cup than with the straw in patients who had penetration/aspiration with both the cup and the straw and with the cup only. However, FDS scores did not differ significantly between the cup and the straw in patients who had penetration/aspiration with the straw only. Although advantages of the straw over the cup were clear, some patients showed penetration/aspiration only with the straw.
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12
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Usefulness of the Modified Videofluoroscopic Dysphagia Scale in Choosing the Feeding Method for Stroke Patients with Dysphagia. Healthcare (Basel) 2021; 9:healthcare9060632. [PMID: 34071752 PMCID: PMC8226657 DOI: 10.3390/healthcare9060632] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The Videofluoroscopic Dysphagia Scale (VDS) is used to predict the long-term prognosis of dysphagia in patients with strokes. However, the inter-rater reliability of the VDS was low in a previous study. To overcome the mentioned limitations of the VDS, the modified version of the VDS (mVDS) was created and clinically applied to evaluate its usefulness in choosing the feeding method for stroke patients with dysphagia. METHODS The videofluoroscopic swallowing study (VFSS) data of 56 stroke patients with dysphagia were collected retrospectively. We investigated the presence of aspiration pneumonia and the selected feeding method. We also evaluated the correlations between the mVDS and the selected feeding method, and between the mVDS and the presence of aspiration pneumonia after stroke. Univariate logistic regression and receiver operating characteristic analyses were used in the data analysis. RESULTS The inter-rater reliability (Cronbach α value) of the total score of the mVDS was 0.886, which was consistent with very good inter-rater reliability. In all patients with dysphagia, the supratentorial stroke subgroup, and the infratentorial stroke subgroup, the mVDS scores were statistically correlated with the feeding method selected (p < 0.05) and the presence of aspiration pneumonia (p < 0.05). CONCLUSIONS The mVDS can be a useful scale for quantifying the severity of dysphagia, and it can be a useful tool in the clinical setting and in studies for interpreting the VFSS findings in stroke patients with dysphagia. Further studies with a greater number of patients and various stroke etiologies are required for more generalized applications of the mVDS.
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Zhou W, Zhang WJ, Zhao GQ, Li K. Bone cement implantation syndrome during hip replacement in a patient with pemphigus and Parkinson’s disease: A case report. World J Clin Cases 2021; 9:3342-3349. [PMID: 34002143 PMCID: PMC8107892 DOI: 10.12998/wjcc.v9.i14.3342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/22/2021] [Accepted: 03/03/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Bone cement implantation syndrome (BCIS) is characterized by hypotension, arrhythmia, diffuse pulmonary microvascular embolism, shock, cardiac arrest, any combination of these factors, or even death following bone cement implantation.
CASE SUMMARY An 80-year-old patient with pemphigus and Parkinson’s disease underwent total hip replacement under spinal subarachnoid block and developed acute pulmonary embolism after bone cement implantation. The patient received mask mechanical ventilation with a continuous intravenous infusion of adrenaline (2 μg/mL) at a rate of 30 mL/h. Subsequently, the symptoms of BCIS were markedly alleviated, and the infusion rate of adrenaline was gradually reduced until the infusion was completely stopped 45 min later. The patient was then transferred to the Department of Orthopedics, and anticoagulation therapy began at 12 h postoperatively. No other complications were observed.
CONCLUSION This is a rare case of BCIS in a high-risk patient with pemphigus and Parkinson’s disease.
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Affiliation(s)
- Wei Zhou
- Department of Anesthesiology, Tongde Hospital of Zhejiang Province, Hangzhou 310012, Zhejiang Province, China
| | - Wen-Jing Zhang
- Department of Anesthesiology, China Japan Union Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Guo-Qing Zhao
- Department of Anesthesiology, China Japan Union Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Kai Li
- Department of Anesthesiology, China Japan Union Hospital of Jilin University, Changchun 130021, Jilin Province, China
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Kwon M, Lee JH. Oro-Pharyngeal Dysphagia in Parkinson's Disease and Related Movement Disorders. J Mov Disord 2019; 12:152-160. [PMID: 31556260 PMCID: PMC6763715 DOI: 10.14802/jmd.19048] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/15/2019] [Indexed: 12/11/2022] Open
Abstract
Oro-pharyngeal dysphagia is a common symptom in patients with Parkinson’s disease (PD) and related disorders, even in their early stage of diseases. Dysphagia in these patients has been underdiagnosed, probably due to poor the self-awareness of the conditions and the underuse of validated tools and objective instruments for assessment. The early detection and intervention of dysphagia are closely related to improving the quality of life and decreasing the mortality rate in these patients. The purpose of this paper is to give an overview of the characteristics of dysphagia, including the epidemiology, pathophysiology, and clinical symptomatology, in patients with PD compared with other parkinsonian disorders and movement disorders. The management of dysphagia and future research directions related to these disorders are also discussed.
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Affiliation(s)
- Miseon Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Hong Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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15
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Borders JC, Brates D. Use of the Penetration-Aspiration Scale in Dysphagia Research: A Systematic Review. Dysphagia 2019; 35:583-597. [PMID: 31538220 DOI: 10.1007/s00455-019-10064-3] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/04/2019] [Indexed: 12/12/2022]
Abstract
The penetration-aspiration scale (PAS) is an 8-point scale used to characterize the depth and response to airway invasion during videofluoroscopy. Though widely used in the field of deglutition, there is a lack of consensus regarding the statistical properties of the scale. In order to better understand the state of the literature and the statistical use of the PAS, a systematic review was undertaken to descriptively examine trends in statistical and reporting practices of the PAS since its inception. Online databases were searched for studies citing the original PAS article, which yielded 754 unique articles. Of these, 183 studies were included in the review. Results showed inconsistencies in the statistical use of the scale; 79 studies treated the PAS as ordinal, 71 as categorical, and 49 as interval. Ten types of categorizations were identified. Reporting of power analyses (9%), as well as inter- (26%) and intra-rater (17%) reliability, was uncommon. Among studies that administered multiple bolus volumes or consistencies, 55% reported PAS analyses at the participant/group level only. This review confirms the existence of discrepancies in the statistical treatment of the PAS. A lack of consensus among researchers limits comparisons between studies. The approach to handling this scale dictates the statistical tests used, potentially affecting results and interpretations. Consistent application of statistically sound approaches to PAS analyses is vital for the future of deglutition research.
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Affiliation(s)
- James C Borders
- Department of Otolaryngology, Boston Medical Center, Boston, MA, USA.
| | - Danielle Brates
- Department of Communication Sciences and Disorders, New York University, New York, NY, USA
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Iwaki H, Tagawa M, Iwasaki K, Kawakami K, Nomoto M. Comparison of zonisamide with non-levodopa, anti-Parkinson's disease drugs in the incidence of Parkinson's disease-relevant symptoms. J Neurol Sci 2019; 402:145-152. [DOI: 10.1016/j.jns.2019.05.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 04/22/2019] [Accepted: 05/23/2019] [Indexed: 10/26/2022]
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The Modified Barium Swallow Impairment Profile as a Predictor of Clinical Outcomes of Admission for Pneumonia or Choking in Dysphagic Patients with Parkinson’s Disease. Dysphagia 2019; 34:896-903. [DOI: 10.1007/s00455-019-09986-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 02/06/2019] [Indexed: 11/26/2022]
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18
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Su CM, Kung CT, Chen FC, Cheng HH, Hsiao SY, Lai YR, Huang CC, Tsai NW, Lu CH. Manifestations and Outcomes of Patients with Parkinson's Disease and Serious Infection in the Emergency Department. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6014896. [PMID: 30417011 PMCID: PMC6207881 DOI: 10.1155/2018/6014896] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 10/01/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Several comorbidities contribute to an increased risk of infections in Parkinson's disease (PD) as the disease progresses. However, few studies have examined the correlation between sepsis and PD. AIM The aim of this study is to disclose the presentation and outcome of serious infection in patients with PD in the emergency department. METHODS This retrospective cohort study enrolled patients with PD who had serious infection and were admitted to the emergency department between January 2007 and December 2013. For clinical comparison, we compared the clinical features, laboratory data, and outcomes with those of age- and sex-matched patients who had serious infection but not PD. RESULTS There were a total of 1,200 episodes of infected PD patients and 2,400 age- and sex-matched infected patients without PD as disease controls. PD patients had fewer comorbidities and lower severity of infectious disease but longer hospital stays than control group patients. The incidences of respiratory tract and urinary tract infections were higher in PD patients. The levels of inflammatory and organ dysfunction biomarkers in PD were lower and compatible with the severity of infectious disease. A total of 86 (7.2%) infected PD patients died during the 28-day admission compared to 339 (14.1%) in non-PD patients. Serum C-reactive protein, bandemia, and lactate could be used to predict mortality in infected PD patients. CONCLUSIONS In infected patients with PD, respiratory and urinary tract infections were the two most common infectious sources. Empiric therapy based on experience could treat both respiratory and urinary tract infections. Early diagnosis and treatment are essential for survival.
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Affiliation(s)
- Chih-Min Su
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Chung Shan Medical University, School of Medicine, Taiwan
| | - Chia-Te Kung
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Fu-Cheng Chen
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsien-Hung Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Chung Shan Medical University, School of Medicine, Taiwan
| | - Sheng-Yuan Hsiao
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Biological Science, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Yun-Ru Lai
- Department of Biological Science, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chin-Cheng Huang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Nai-Wen Tsai
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Cheng-Hsien Lu
- Department of Biological Science, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Neurology, Xiamen Chang Gung Memorial Hospital, Xiamen, Fujian, China
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Tomita S, Oeda T, Umemura A, Kohsaka M, Park K, Yamamoto K, Sugiyama H, Sawada H. Video-fluoroscopic swallowing study scale for predicting aspiration pneumonia in Parkinson's disease. PLoS One 2018; 13:e0197608. [PMID: 29874285 PMCID: PMC5991364 DOI: 10.1371/journal.pone.0197608] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 05/04/2018] [Indexed: 11/30/2022] Open
Abstract
Introduction A number of video-fluoroscopic swallowing study (VFSS) abnormalities have been reported in patients with Parkinson’s disease (PD). However, the most crucial finding of subsequent aspiration pneumonia has not been validated fully. We conducted a retrospective and case-control study to determine the clinically significant VFSS findings in this population, and to propose a practical scale for predicting aspiration pneumonia in patients with PD. Methods We enrolled 184 PD patients who underwent VFSS because of suspected dysphagia. The patients who developed aspiration pneumonia within six months of the VFSS were assigned as cases and the patients without aspiration pneumonia at six months were designated as controls. Logistic regression analysis was performed to determine the prognostic VFSS features based on the data of swallowing 3 mL of jelly, which were used to make a PD VFSS scale (PDVFS). The validity of the new PDVFS was evaluated by ROC analysis. Additionally, we used the survival time analysis to compare time to death between groups, stratified by the PDVFS score. Results Twenty-five patients developed aspiration pneumonia. Among the previously-proposed VFSS features, mastication, lingual motility prior to transfer, aspiration, and total swallow time were identified as significant prognostic factors. We combined these factors to form the PDVFS. The PDVFS score ranges from 0 to 12, with 12 being the worst. ROC analysis revealed 92% sensitivity and 82% specificity at a cutoff point of 3. The higher PDVFS group showed shorter time-to-death than the lower PDVFS group (log rank P = 0.001). Conclusion Our newly developed VFSS severity scale (based on jelly swallowing) for patients with PD was easy to rate and could predict subsequent aspiration pneumonia and poor prognosis in patients with PD.
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Affiliation(s)
- Satoshi Tomita
- Clinical Research Center and Department of Neurology, Utano National Hospital, Kyoto, Japan
| | - Tomoko Oeda
- Clinical Research Center and Department of Neurology, Utano National Hospital, Kyoto, Japan
| | - Atsushi Umemura
- Clinical Research Center and Department of Neurology, Utano National Hospital, Kyoto, Japan
| | - Masayuki Kohsaka
- Clinical Research Center and Department of Neurology, Utano National Hospital, Kyoto, Japan
| | - Kwiyoung Park
- Clinical Research Center and Department of Neurology, Utano National Hospital, Kyoto, Japan
| | - Kenji Yamamoto
- Clinical Research Center and Department of Neurology, Utano National Hospital, Kyoto, Japan
| | - Hiroshi Sugiyama
- Clinical Research Center and Department of Neurology, Utano National Hospital, Kyoto, Japan
| | - Hideyuki Sawada
- Clinical Research Center and Department of Neurology, Utano National Hospital, Kyoto, Japan
- * E-mail:
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A Significant Association of Malnutrition with Dysphagia in Acute Patients. Dysphagia 2017; 33:258-265. [DOI: 10.1007/s00455-017-9855-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 10/04/2017] [Indexed: 02/07/2023]
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21
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Non-oral dopaminergic therapies for Parkinson's disease: current treatments and the future. NPJ PARKINSONS DISEASE 2016; 2:16023. [PMID: 28725704 PMCID: PMC5516582 DOI: 10.1038/npjparkd.2016.23] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/07/2016] [Accepted: 08/25/2016] [Indexed: 12/30/2022]
Abstract
Dysfunction of the gastrointestinal tract has now been recognized to affect all stages of Parkinson’s disease (PD). The consequences lead to problems with absorption of oral medication, erratic treatment response, as well as silent aspiration, which is one of the key risk factors in developing pneumonia. The issue is further complicated by other gut abnormalities, such as small intestinal bacterial overgrowth (SIBO) and an altered gut microbiota, which occur in PD with variable frequency. Clinically, these gastrointestinal abnormalities might be associated with symptoms such as nausea, early-morning “off”, and frequent motor and non-motor fluctuations. Therefore, non-oral therapies that avoid the gastrointestinal system seem a rational option to overcome the problems of oral therapies in PD. Hence, several non-oral strategies have now been actively investigated and developed. The transdermal rotigotine patch, infusion therapies with apomorphine, intrajejunal levodopa, and the apomorphine pen strategy are currently in clinical use with a few others in development. In this review, we discuss and summarize the most recent developments in this field with a focus on non-oral dopaminergic strategies (excluding surgical interventions such as deep brain stimulation) in development or to be licensed for management of PD.
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