“It does not do to dwell on dreams and forget to live.” J.K. Rowling, Harry Potter and the Sorcerer’s Stone
“May you live every day of your life.” Jonathan Swift
Introduction: Along the way to the diagnosis of Parkinson’s, you may have to undergo several different kinds of tests to help your physician(s) learn what actually is going on with your physiology and neurological network. Remember there is neither a blood test nor a genetic marker evaluation to provide a diagnosis of Parkinson’s. Therefore, the clinical exams I will describe are sometimes done to exclude other disorders and to further implicate Parkinson’s. My Neurologist says the most helpful thing is the actual patient interview (History and Physical) since most people with Parkinson’s have a characteristic set of signs and symptoms.
These posts (a series of 5 procedures) are purely descriptive/informational but they are important to describe because they can be kind of intimidating and nerve-racking to undergo (just in case any of these tests are suggested by your physician team). Let me be clear, I am not recommending any of these procedures for you (I’m a basic scientist not a physician). Interestingly, my Neurologist was involved only in the MRI and sleep study, which were done after my diagnosis of Parkinson’s. The other procedures were done before my diagnosis as we (another group of very talented physicians) were trying to sort out what was wrong. These are the procedures:
Part 1 describes the Barium Swallow test;
Part 2 gives an overview of Magnetic Resonance Imaging (MRI);
Part 3 highlights Polysomnography, which is a sleep study;
Part 4 presents Electromyography (EMG), which measures nerve/muscle interactions;
Part 5 characterizes Transradial Cardiac Catheterization and Angiography.
What causes someone to have difficulty in swallowing (dysphagia)? Dysphagia is the medical term used to describe someone with difficulty or discomfort from swallowing; it is harder or takes longer to get food, liquid or pills from your mouth to your stomach. Dysphagia usually means something is not working properly in your mouth, pharynx or esophagus. Dysphagia typically occurs in older adults, and in people with brain or nerve injuries or disease. There are two broad pathological categories that cause dysphagia: disorders that affect the nerves and muscles of the throat and esophagus; and disorders that interfere/ block the throat and esophagus. WebMD has a very nice overview of the many causes of dysphagia (please click here).
“I may not have gone where I intended to go, but I think I have ended up where I needed to be.” Douglas Adams, The Long Dark Tea-Time of the Soul
What is a barium swallow study? How does a barium swallow study work? Barium swallow remains the primary clinical evaluation of dysphagia. Like the more familiar substance calcium, barium is also an alkaline earth metal with a +2 charge. When the compound barium sulfate is dissolved in water, it forms a thick chalky paste that absorbs X-rays, which is the basis of the barium swallow study. A barium swallow uses X-rays (radiographic) to examine the pharynx (back of mouth and throat) and the esophagus (a hollow tube that connects the back of the mouth to the stomach). Barium coats the lining of the pharynx and esophagus to make them visible when exposed to X-rays (electromagnetic energy that is used to visualize various internal organs). The combination of barium/ X-ray gives the radiologist a ‘movie’ (Fluoroscopy) to watch the movement of barium through the upper gastrointestinal tract.
The left panel above shows the orientation of the pharynx and esophagus between the back of the mouth and stomach, respectively; and in the middle and right panels show the result of a normal barium swallow study in a static X-ray.
For the procedure, you will be both horizontal and vertical on an imaging platform with the other body parts shielded and protected from the X-rays. You will be asked to drink a barium solution with the consistency of a milkshake. Barium actually has very little flavor. Additionally, I was given barium pills to simulate pill ingestion. Furthermore, I was also given barium mixed into applesauce and barium coated on top of graham crackers to simulate different types of textured food while you chew and swallow. The coolest thing is you actually get to see the results in real time as you swallow the various forms of barium. Besides the radiology people, I also had a speech pathologist present who specialized in dysphagia. The only difficulty in dealing with the barium swallow study was the constipation that occurred from ingestion of barium. For a more comprehensive overview of the barium swallow study (please click here) and see references cited at the bottom.
The image above is a barium (solution) swallow study and the resulting x-ray ‘movie’.
“It may be unfair, but what happens in a few days, sometimes even a single day, can change the course of a whole lifetime…” Khaled Hosseini ,The Kite Runner
What is the relationship of dysphagia to Parkinson’s? One of the earliest presenting features of my Parkinson’s was a swallowing defect, which occurred several years before my diagnosis. Interestingly, dysphagia can occur at any stage of Parkinson’s. Signs and symptoms of a swallowing problem go from mild to severe and typically present as follows: coughing/throat clearing while eating/drinking; trouble swallowing certain foods or liquids; and having a feeling that food is getting stuck in the back of your throat. Anyone with a swallowing defect clearly needs to be seen by a speech pathologist and your neurologist, which would likely include a barium swallow study.
“Life is like riding a bicycle. To keep your balance, you must keep moving.” Albert Einstein
Useful reference material: there is a lot of material on the Internet to read regarding dysphagia, barium swallow, and dysphagia in Parkinson’s. However, I found the following to be very useful in learning about swallowing defects in Parkinson’s:
-Barium Swallow (from the University of Rochester Medical Center describing all the aspects of barium swallow, to view it click here);
-Dysphagia (from WebMD with a nice overview of dysphagia, please click here).
-Upper Gastrointestinal Examination [from the Lahey Clinic in Boston with a very nice overview (text/visual) of the upper GI exam, to view it click here];
–Parkinson Disease: Speech and Swallowing (from the National Parkinson Foundation, an informative and well-written pamphlet);
-Swallowing and Parkinson’s Disease (from the U.S. Veterans Administration, an interesting presentation describing dysphagia in Parkinson’s, to view it click here).
“I wanted a perfect ending. Now I’ve learned, the hard way, that some poems don’t rhyme, and some stories don’t have a clear beginning, middle, and end. Life is about not knowing, having to change, taking the moment and making the best of it, without knowing what’s going to happen next. Delicious Ambiguity.” Gilda Radner
Cover photo credit: http://www.pachd.com/free-images/napa/napa-07.jpg
Pharynx and esophagus d: https://sites.google.com/a/mtlstudents.net/wallace-davis-digestive/_/rsrc/1429639718932/home/pharynx-and-esophagus/normal-pharynx-esophagus-anatomy-lg-bdy.jpg?height=320&width=200
Normal barium swallow X-ray image: http://images.radiopaedia.org/images/501264/edcd492f95768c4dcd045283fe7845.jpeg
Barium swallow gif-movie: By Normaler_Schluck-00.jpg (and others): Hellerhoffderivative work: Anka Friedrich (talk) – 34 files:Normaler_Schluck-00.jpg[…]Normaler_Schluck-33.jpg, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=15333554