Uses Of Botulinum Toxin In Parkinsons Disease
You most likely know that Botulinum toxin is used for cosmetic purposes to decrease wrinkles. Prior to being used in this way, Botulinum toxin was used for medical purposes to control abnormal movements. In the right hands, it can be a very effective measure to control a variety of problems related to PD.
Description Of The Condition
Parkinson’s disease is a progressive degenerative disorder of the nervous system that results from death of dopaminegenerating cells in the basal ganglia in the brain . Motor symptoms affecting movement are the cardinal features of PD, but are typically accompanied by a range of nonmotor symptoms that may include disturbances in speech, cognition, and mood, and may affect swallowing, sleep, and autonomic body functions such as regulation of blood pressure and temperature, and saliva control .
Drooling, which generally refers to an involuntary loss of saliva , is a common problem for people with PD. Drooling in the literature is also frequently termed dribbling, hypersalivation, ptyalism, and sialorrhoea . Anterior drooling, which describes visible loss of saliva from the mouth, is distinct from posterior drooling where saliva spills into the pharynx .
Why Do Parkinsons Patients Cough While Swallowing Food
When a small particle of food goes into the wind-pipe, we gag & start coughing vigorously to throw the particles out. These are called the Gag and Cough reflexes.
Food can go into the wrong pipe often in Parkinsons patients . Therefore they frequently cough while swallowing food.
But the condition becomes even more problematic in advanced Parkinsons disease.
In advanced Parkinsons disease, there may be no coughing even when particles are entering the windpipe. This is dangerous!
Thus, particles of food may repeatedly go into the lungs of Parkinsons patients without them noticing it. This is called Silent Aspiration.
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Is Difficulty Swallowing Common In Parkinsons Disease
Many patients with Parkinsons disease may complain of difficulty swallowing. The medical term for swallowing difficulty is Dysphagia.
In milder cases, you may just have the feeling that food gets stuck in your throat. Some patients may report that they have a feeling of their throat closing when they try to swallow.
In more severe cases, you may tend to choke on your food if you try to swallow it too quickly.
Why Does Parkinsons Disease Cause Drooling
Saliva is produced by small glands around our mouth, called Salivary glands.
It is a common misconception that Parkinsons patients have drooling because they are producing too much saliva. In fact, multiple studies have shown that most Parkinsons patients produce less saliva.
Our salivary glands continuously produce saliva, even when we are not eating.
Normally, we automatically swallow this saliva, through small gulps that we dont even notice.
But in Parkinsons disease, there is a marked decrease in all automatic movements, including automatic swallowing.
Therefore, saliva accumulates in the mouth. When the mouth is full, it drips out. We call this Drooling.
Lets talk about treatment
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Criteria For Considering Studies For This Review
Types of studies
We will include all published and unpublished randomized controlled trials and quasiRCTs. Relevant trials for this review will be those with at least one group receiving BoNT with the aim of reducing or eliminating drooling, and one group receiving a placebo or no treatment, with concurrent enrolment and followup of the BoNT and controltreated groups. We will exclude crossover trials as the period of washout of BoNT is not established. Crossover trials are defined as trials in which each participant is randomized to a sequence of interventions . We will consider quasiRCTs as eligible for inclusion due to the potentially small number of RCTs in this area. As described in the Cochrane Handbook for Systematic Reviews of Interventions, quasiRCTs will be defined as trials where the method of allocation is not considered to be strictly random, for example allocation by alternation or date of birth . We will not apply any language limits or date restrictions to our searches for trials.
Types of participants
Types of interventions
We will consider all trials that involve delivery of BoNT injections into one or more of the major salivary glands . This intervention can be delivered with or without ultrasound guidance. It must be administered by a trained medical professional. We will include trials that involve all BoNT serotypes, commercial brands, dosages, injection sites, and all administration schedules. We will make the following comparisons:
A Exercises To Improve Swallowing Difficulty :
A speech-swallow therapist evaluates how your muscles move while swallowing. They can teach you important exercises to improve swallowing difficulty and prevent Aspiration.
Speech therapists specially trained in Parkinsons can teach you exercises such as Expiratory Muscle Strength Training or Lee Silverman Speech Therapy or LOUD therapy.
These specialized training sessions are tremendously helpful in improving voice. But these exercises also make swallowing easier.
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Risk Factors For Drooling In Pd
If susceptibility to anterior drooling is not related to hypersalivation, other factors must be at work. Suggested candidates have been dysphagia, oro-facial rigidity/hypomimia, lingual bradykinesia, cognitive status, male gender and more advanced disease stage.23,24,28,31,39,43,50,51 Individuals with non-tremor dominant PD phenotypes were at higher risk of drooling.31,52 The precise contribution of these factors remains unsettled. The uncertainty rests partly on general issues above regarding why estimates of drooling prevalence and flow rates exist, but variability in individual profiles of impairment and disability also contributes.
Susceptibility of males probably relates to greater absolute flow rate when body mass and gland sizes are not controlled for though not all studies have found a male predominance.23,24,29 Relationship to greater disease severity likely reflects increased rigidity, poorer cognitive status and more marked dysphagia of later stages, and, in as far as medications may alter the picture, higher medication dependency.21
L-dopa can influence variables in swallowing efficiency,3,58 and thus indirectly change drooling. Currently, dysphagia study outcomes do not afford sufficient evidence to conclude a positive, neutral or negative effect of possible swallowing changes on sialorrhoea.
Swallowing Exercises Can Be Very Helpful To Improve Your Swallowing
After a formal swallow assessment, swallowing therapy sessions can be designed for you, involving exercises tailored to the specific parts of your mouth and throat that are causing the swallowing problem. Sessions may involve practicing compensatory swallowing strategies with various types of foods in order to maximize safety and efficiency while swallowing.
During swallow therapy, recommendations may include:
- Best feeding techniques
- Exercises to strengthen oral and throat muscles
- Compensatory techniques to assist in safe swallowing
- Oral and mouth care techniques
- Appropriate food selection and ways to modify food texture
- Safe positioning strategies
Different Types Of Botulinum Toxin
There are eight different botulinum toxin species that occur in nature. There are only two however, that are produced commercially Botulinum toxin A and B.
The commercially available products are:
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Prevalence Associated Factors And Negative Impacts Of Drooling In Pd
Due to the lack of a standard definition and criteria for diagnosing drooling in PD patients, estimates of prevalence vary. Previous studies showed that prevalence ranged from 10 to 84% . Various tools such as the Unified Parkinson’s Disease Rating Scale part II Scales for Outcomes in PD for Autonomic Symptoms PD non-motor symptoms questionnaire and different types of screening questionnaires were used to screen drooling. The factors associated with drooling have been reported. However, results vary among studies and the conclusion remains unclear. Factors possibly associated with drooling were severity of PD , male gender , aging , hallucinations , duration of PD , the sum of the scores of UPDRS part II and III greater than 28 points, dysarthria, dysphagia, orthostatic hypotension, and a history of using antidepressants . Drooling during PD can have negative impact for both patients and caregivers. Many negative physical sequelae were reported to follow the course of drooling such as perioral dermatitis, poor oral hygiene, bad breath, increased amount of intra-oral occult bacteria, eating and speaking difficulty, and an increased rate of respiratory tract infection from silent aspiration of saliva . Psychosocially, drooling PD patients showed poor quality of life , i.e., social embarrassment and increasing emotional distress . In addition, drooling patients affected their caregivers by increasing their burden, depression and anxiety, and reducing their QoL .
Botulinum Toxin For Treatment Of Dystonia Sialorrhea And Tremor In Parkinsons
Being happy doesnt mean that everything is perfect. It means that youve decided to look beyond the imperfections. Gerard Way
Rules for Happiness: something to do, someone to love, something to hope for. Immanuel Kant
Introduction: I have a new friend with Parkinsons. He has always been very active and genuinely enjoys playing golf. However, he has a hard time controlling dystonia, which has hindered much of his daily exercise. This got me thinking, and it leads me to the topic of this blog post. The goal is to describe how botulinum toxin works, allowing someone with Parkinsons and bothersome dystonia some regular relief. Botulinum toxin is also used to treat excessive drooling and even the Parkinsons tremor in some clinical studies.
If you want to live a happy life, tie it to a goal, not to people or objects. Albert Einstein
Success is not the key to happiness. Happiness is the key to success. If you love what you are doing, you will be successful. Albert Schweitzer
Given at the end of the post are some references/literature for anyone interested in the original study/review.
The happiness of your life depends upon the quality of your thoughts. Marcus Aurelius
Dystonia on its own is a movement disorder, and it occupies the number three slot in terms of the number of cases of movement disorders. Dystonia is a frequent component of Parkinsons. It is estimated that between 50-60% of PwP have some first-hand experience with dystonia.
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Efficacy Of Botulinum Toxin For Treating Sialorrhea In Neuromuscular Conditions
- 1Department of Neurology, University of Missouri, Columbia, MO, United States
- 2Assistant Professor of Neurology, Department of Neurology, University of Missouri, Columbia, MO, United States
Background: Drooling related to bulbar weakness and dysfunction is a common concern in patients with neuromuscular disease. While there are numerous medications to manage sialorrhea, they are often limited by side effects and lack of efficacy. Botulinum toxin has shown to benefit ALS patients in a few studies, but there is scant data on the benefit in other neuromuscular conditions.
Objective: To assess the effectiveness of Botulinum toxin in reducing sialorrhea in patients with various neuromuscular disease.
Design/Methods: 25 patients with documented neuromuscular illness and concern for drooling was followed for 6 weeks after Botulinum toxin injection. These patients had one of the following diagnoses: Duchenne muscular dystrophy , myotonic dystrophy , oculopharyngeal muscular dystrophy , inclusion body myositis , primary lateral sclerosis , amyotrophic lateral sclerosis , spinal muscular atrophy type 2 and 3 , spinal-bulbar muscular atrophy , and Becker’s muscular dystrophy . A subjective drooling scale and drooling thickness score was calculated on these patients prior to the injection and 4 and 6 weeks after the injection. Botulinum toxin 2030 units were injected into bilateral parotid gland and submandibular gland .
Slow Muscles Carrying Food To Your Stomach
Parkinsons may also slow down the muscles carrying food down into your stomach. Food moving slowly down your food pipe to your stomach can make you feel full up. But once it arrives at your stomach you realise youre still hungry. By this time the food on your plate may have gone cold and be unappealing.
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Data Collection And Analysis
Selection of studies
We will merge search results using reference management software, remove duplicate records of the same report, and import the results into Covidence, a webbased systematic review software platform . In Covidence two review authors will independently examine titles, abstracts and key words identified from the literature search. The results of this search will be categorised as either ‘yes’, ‘no, or ‘maybe’ relevant. If it is unclear from titles and abstracts whether a study should be included, we will obtain full texts of these trial reports for further examination. We will resolve disagreement about selection of studies by consensus discussion. We will list those studies excluded in the ‘Characteristics of excluded studies table. FH will retrieve full texts of relevant and potentially relevant reports and link multiple reports of the same study. Two authors will independently examine the full texts for compliance with eligibility criteria. We will contact study authors for further information, where appropriate, to clarify study eligibility. The review team will not be blinded to information about study authors, institutions, journal of publication, or results. We will resolve any disagreements through discussion.
Data extraction and management
Assessment of risk of bias in included studies
Measures of treatment effect
Unit of analysis issues
Dealing with missing data
Assessment of heterogeneity
0% to 40%: might not be important.
Mechanisms For Drooling Disturbance In Pd
Patient reports of too much saliva in my mouth suggest hypersalivation as a cause. However, saliva production appears unchanged or even depressed in PD, indicating excessive salivation is not a crucial factor.26,3840,4547
Decreased salivary flow may relate to dysautonomia in PD. Hyposecretion may arise from medications common in PD.20,21,36 Altered reaction to stimulation, from reduced olfactory and other sensory triggers, may also play a role.48 Hou et al49 conducted a fMRI investigation to examine basal ganglia functional connectivity in drug-naïve people with PD who did or did not drool. Those with sialorrhea showed significantly reduced functional connectivity of putamen within bilateral sensorimotor cortices, superior and inferior parietal lobules and areas in the right occipital and temporal lobes.
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How Do You Know If You Or Your Loved One Has A Problem With Swallowing
Swallowing difficulties can start very subtly and initially not be obvious to either the person with PD or their loved ones. There are signs to look out for before swallowing difficulty becomes overt . Some of the signs you should pay attention to include:
- Slow rate of eating people with difficulty swallowing may slow down their eating in order to avoid coughing or choking
- Fatigue during eating or decreased enjoyment of food
- A sensation that food is sticking in the throat
- Coughing or excessive throat clearing during eating
- Difficulty in swallowing pills
- Unexplained weight loss people with difficulty swallowing may reduce their consumption in an attempt to eat without coughing or choking
- Change in dietary habits people with difficult swallowing may alter their diet in order to avoid foods that cause difficulty. This may not be a choice made consciously
- Diagnosis of a pneumonia this could be caused by aspiration, or entry of a foreign substance into the airway
If you think there might be a swallowing issue, it is important to speak with your doctor about it. There are steps you can take to properly assess the situation and improve your swallowing function. This can in turn reduce your risk of choking, make eating more enjoyable, and lessen the chances of unwanted weight loss and/or other discomforts.
Eating Swallowing And Saliva Control
Some people with Parkinsons may find they have problems with eating, swallowing and controlling their saliva.
This information looks at the issues you may face, explains why they happen and what help is available.
Eating is a social activity and problems that affect chewing and swallowing can have a big impact on how much you enjoy meal times. For example, some people with Parkinsons have told us that they feel self-conscious or embarrassed while eating because of their symptoms.
Its important to look out for symptoms related to difficulties with eating and swallowing. These can develop slowly over time and you may not notice them, so family, friends or carers should know what to look out for too.
If youre not able to swallow properly, you may experience:
- inability to clear food from the mouth
- food sticking in the throat
- a gurgly voice
- coughing when eating or drinking
- choking on food, liquid or saliva
- problems swallowing medication
- discomfort in the chest or throat
These things can lead to a number of long-term problems, including:
Talk to your GP as soon as you can if you have problems with eating or swallowing they may refer you to specialists who can help.
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Oral Dysfunction In Parkinsons: Swallowing Problems And Drooling
Two common and distressing problems that can develop in Parkinsons disease are swallowing dysfunction and drooling. I want to help you better understand these issues and learn what you can do to improve them so read on!
Thank you to Christine Sapienza, PhD, CCC-SLP and Bari Hoffman Ruddy, PhD, CCC-SLP for providing some of the material below.
If You Have Swallowing Difficulty What Can Be Done
In some cases, swallowing function varies in response to dopamine medication doses, much like other aspects of motor function. Therefore, if swallowing becomes problematic, an increase in dopaminergic medications can be tried. In addition, make sure you undergo a swallow evaluation when you are in the ON state.
Even before a formal swallow study, you can take steps to increase the efficiency of your swallow. These include:
- Sit upright during all eating and drinking, even when taking pills
- Tilt the head slightly forward, not backward, as you swallow
- Take small bites of food, chew thoroughly, and do not add any more food until everything from the first bite has been swallowed
- Take small sips of liquid
- Concentrate while moving the food backward in the mouth with the tongue
- Double swallow if the food did not go down completely with the first swallow
- Sometimes taking a sip of liquid between bites of food can help to wash the food down
- If eating is very tiring, try several smaller meals spaced out during the day instead of three large meals.
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