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DOI 10.1007/s00455-012-9406-0
ORIGINAL ARTICLE
Received: 26 September 2011 / Accepted: 12 March 2012 / Published online: 27 May 2012
Springer Science+Business Media, LLC 2012
123
Methods
This study was approved by the Human Research Ethics
Committee of Health Science Center of the Federal University of Pernambuco (Of. No. 334/2008).
Subjects
The experimental group comprised 15 subjects (7 men)
with PD, aged 4581 (mean = 63) years, Original Hoehn
and Yahr (HY) Scale [17] IIII, and SWAL-QOL (a
questionnaire to evaluate quality of life in swallowing)
6496 (mean = 77). Fifteen healthy individuals (3 men)
aged 4782 (mean = 63) years and SWAL-QOL 8099
(mean = 91) served as the control group.
The study was done at the Parkinsons Patient Care Service and at the Clinical Neurophysiology Laboratory of the
Clinical Hospital of the Federal University of Pernambuco,
Brazil, from October 2008 to May 2009. The patients were
invited to participate in the study during consultation. The
inclusion criteria of individuals with PD were the following:
(1) diagnosis of idiopathic PD; (2) normal dental elements or
well-adapted dental prosthesis; and (3) being in stage I, II, or
III of the disease, according to the HY Scale [17]. Individuals
with cognitive deficits (screened with the mini-mental test)
and/or risk of bronchoaspiration (screened with the SWALQOL) were excluded from the study. The individuals of the
control group were generally the companions of the PD
patients. All participants signed an informed consent form.
Recordings
The electrical activity of muscles was recorded using disposable self-adhesive electrodes (Meditrace 200) fixed to
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2.
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Measurement Procedure
The onset of swallowing was considered to be when the
sEMG activity rose clearly above the background activity
preceding. The end of swallowing was scored when the
EMG activity returned to levels of background activity. The
difference between the beginning and end of swallowing
determines the duration of sEMG activity during swallowing. Only boluses that were swallowed with a single swallow
were compared to make sure we compared swallowing of
similar volumes.
Normal
(%)
10
54
20
80
20
73
10
73
20
Kappa
\0.001*
0.47
\0.001** 0.60
\0.001*
0.73
\0.001** 0.53
Data Analysis
Data were tabulated in Microsoft ExcelTM spreadsheets
(Microsoft Corp., Redmond, WA, USA) and analyzed
using Medicalc statistical software (MedCalc Software,
Mariakerke, Belgium). For the swallowing condition, the
variables studied were amplitude (lV) and duration (in
seconds). For the free-drinking condition, the variables
studied were time to drink and number of swallows necessary to drink the full volume.
Data were summarized as means and standard deviations. For the swallowing conditions, two-way (2 groups by
2 volumes or consistencies) mixed-model ANOVA models
were used for comparing the amplitudes and durations of
sEMGs during (1) swallowing of 10 and 20 ml of water,
(2) swallowing of 5 and 10 ml of yogurt, and (3) swallowing of 10 ml of water and yogurt. For the drinking
condition a Students t test was used to compare the time
each group took to drink 100 ml of water and the MannWhitney test was used to compare the number of swallows.
Statistical significance was considered if p B 0.05.
Results
Swallowing Condition
Volume (ml)
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Single swallow
Parkinson
Water
Yogurt
Normal
n
14
10
2.2 (0.6)
1.7 (0.3)
20
2.9 (0.8)
2.2 (0.6)
4.0 (1.7)
2.1 (0.4)
15
10
3.5 (1.2)
2.5 (0.7)
12
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and PD subjects. Durations were significantly longer during swallowing of 10 ml of yogurt than an equal volume of
water, in both normal and PD subjects.
Amplitudes
Table 3 shows the amplitudes of the sEMG during the
swallowing conditions. Amplitudes were not significantly
different between normal and PD subjects for any tested
volume or consistency. Amplitudes were significantly larger during swallowing of 20 ml of water than for swallowing 10 ml, but were not significantly different during
swallowing of 10 and 5 ml of yogurt, in both normal and
PD subjects. Amplitudes were significantly larger during
the swallowing of 10 ml of yogurt than an equal volume of
water, in both normal and PD subjects.
Drinking (Sequential Swallowing) Condition
Table 4 shows the time (in seconds) and the number of
swallows the normal and PD subjects took to drink 100 ml
of water. The table also shows the estimated average volume of water per swallow (in milliliters), calculated by
dividing 100 ml by the number of swallows each subject
Table 3 Amplitudesrms (lV) of the sEMG during swallowing of 10
and 20 ml of water and 5 and 10 ml of yogurt
Single swallow
Condition
Volume (ml)
Parkinsons
Normal
17 (7)
19 (8)
14
Discussion
Multiple Peaks and Piecemeal Deglutition
Most PD subjects and some normal subjects presented two or
more peaks of the sEMG during swallowing. This was most
obvious during the swallowing of 20 ml of water. Ertekin
et al. [13] recorded suprahyoid sEMG during swallowing of
increasing volumes of water. For volumes above 20 ml,
normal subjects tended to divide the bolus into two or more
parts; this is called piecemeal or in-parts deglutition.
This volume (20 ml) is known as the dysphagia limit,
which is reduced in PD patients [13, 14, 19].
The multiple peaks we observed probably represent
piecemeal deglutition. In the normal subjects multiple
peaks occurred mainly during the swallowing of 20 ml of
water and 10 ml of yogurt (both in 20 % of the subjects),
whereas in the DP patients it occurred in 50 and 80 % of
the subjects during the swallowing of 10 and 20 ml of
water, respectively, and in 70 % during the swallowing of
either 5 or 10 ml of yogurt.
Duration
Water
Yogurt
10
20
23 (9)
22 (7)
5
10 l
23 (8)
22 (9)
4
4
23 (7)
25 (8)
15
12
Time to drink
100 ml (s)
No. of swallows
Normal controls
12 (5)
5 (47)
Parkinsons disease
23 (13)
7 (411)
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PhD
MSc
Amdore G Asano
MSc
PhD
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