Parkinson's Disease

Parkinson's Disease

Speech and Voice 

Up to 90% of persons with PD will experience voice and speech symptoms [1, 2]. The motor symptoms such as slowed movement and rigidity that are experienced in other parts of the body due to basal ganglia dysfunction also affect the motor movements of voice and speech.

The profile of speech symptoms most typical in PD is termed 'hypokinetic dysarthria' [3] and is characterized by decreased vocal intensity, reduced articulatory precision, reduced pitch variation perceived as monotone speech, and hypophonia (hoarse, breathy voice). Speech rate may be slowed (although persons may also experience rapid rushes of speech). Overall, there is a reduction in speech intelligibility. Additionally, due to sensorimotor changes, a person with PD may not be able to detect changes in their own voice. Their friends and family may be finding it more difficult to understand them, but the person with PD has the sensation that they are "yelling" to achieve a voice that is loud enough for others to understand them. 

The progression of communication symptoms differs between individuals; some persons experience no or minimal reduction in their functional communication skills, or not until the later stages of the course. It is advisable to consult with an S-LP early in the course of PD. Such consultation will give you accurate information to make informed decisions with. Moreover, when intervention is provided early, greater gains can be achieved in less time, worsening symptoms may be delayed, and functional speech is maintained longer.

Treatment Options

Non-Intensive Speech/Voice Treatment

Treatment programs are developed based on the specific needs of individuals. A treatment plan can be developed to improve vocal volume, vocal quality, speech clarity, and breath support for speech. Dosage of treatment may be one or two 60-minute appointments per week with daily home practice.

LSVT (Lee Silvermen Voice Treatment) LOUD Treatment 

LSVT LOUD is an intensive treatment protocol developed for persons with Parkinson's disease. Outcomes typically include improvements in breath support, volume, speech clarity, vocal strength, pitch range, facial expression, and confidence.

It is critical that those considering LSVT LOUD treatment are able to commit to the minimum dosage:

  4 consecutive days per week (60 minute sessions)

  over 4 consecutive weeks

  over 30 days

This is the minimum dosage required to achieve the outcomes expected from LSVT LOUD. Some people - such as those who have more severe symptoms - may require more than 16 sessions. The days between S-LP-led sessions involve homework and carryover tasks to ensure that treatment gains are made and maintained outside of the treatment room. The breakdown of the schedule is:

   Each week:

  • 4 days - 60 minutes of daily treatment with S-LP plus 10 minutes of home                        practice plus carryover activities

  • 3 days - daily home practice twice a day for 15 minutes each plus carryover activities

 

Carryover activities are 'assignments' in which clients intentionally apply new skills to real life situations. An example for someone who has been having trouble talking on the phone would be calling a relative and maintaining a loud enough voice for the entire conversation.

Completion of daily homework is required and is necessary in order to see an improvement in your daily speech outside of the treatment room. On treatment days there is an additional 10 minutes of home practice. On days when you don't have a treatment session, homework consists of two periods of 15-minute practice. 

At about 6 months post-treatment (ranges from every 3-12 months depending on the stage of PD and severity of voice symptoms) there is a follow-up visit scheduled, and for every 6 months after that. If tune-up sessions are required at any point, they can be arranged at that time. 

In order to maintain the gains your make during treatment, you will need to continue to practice for 10 minutes a day.

There is certainly a level of commitment required, but it's worth it!!

 

For more information about this treatment, please visit: 

https://www.lsvtglobal.com/LSVTLoud

In this video, a gentleman shares his experience with LSVT LOUD:

https://youtu.be/OcQQuiO-FbY

Before initiating treatment, a laryngeal exam should be completed by an Ear Nose and Throat medical specialist ('otolaryngologist'). Your doctor can make this referral. 

Pamela Coulter is a LSVT LOUD Certified Clinician. For a list of certified clinicians, visit: 

https://www.lsvtglobal.com/clinicians

Voice Amplification

 

Many people find it beneficial to use a device to amplify their voice when in groups and noisy situations. Shoreline's clients may borrow an amplifier to see if this would be beneficial before purchasing one.

 

Augmentative Communication

 

Take advantage of text-based systems to supplement your speech and be understood.

Caregiver Training

 

Learn how to support your spouse, family member, or client with PD to maximize their success when communicating.

Download pdf.

Assessment

Assessment may include the following:

  • analysis of your voice (e.g., loudness, quality, and pitch range)

  • analysis of your speech (e.g., intelligibility)

  • screening of cognitive skills required for communication (e.g., attention, memory, language, visuospatial skills)

  • evaluation of the impact of speech changes on your daily life and your family

  • discussion of your goals for intervention

  • identification lifestyle factors contributing to voice issues

  • case history

  • oral mechanism exam (examination of oral structures required for speech)

  • evaluation of candidacy for treatment 

  • prognosis for improvement with treatment

  • review of reports from other professionals (ENT, audiologist, family doctor, neurologist)

  • hearing screening

Please bring the following to your appointment or send them ahead of time. If you do not have access to these reports, please just bring the name/contact information of the health professional who provided the service. With your consent Shorleine will be able to request these reports on your behalf.

  • results of any recent hearing test

  • copy of report from laryngeal exam by an ENT medical specialist

  • list of medications

  • medical history (if you have a history of cardiac disease or surgery, medical clearance will be required before starting voice treatment)

  • copy of report from neurologist 

Before initiating treatment, a laryngeal exam should be completed by an Ear Nose and Throat (ENT) medical specialist ('otolaryngologist'). Your doctor can make this referral. For a laryngeal exam, the ENT (or specially trained S-LP) will place a scope in your mouth so that they can look down your throat to your vocal folds. This scope only goes to the back of your mouth. In some cases, a flexible scope may need to be passed through your nose to your throat. Topical anesthetic will be used to make this more comfortable. From this position, your vocal folds can also be viewed. The ENT/S-LP will discuss this with your before starting the procedure. The laryngeal exam is important in order to identify or rule out any structural reason for the voice changes you are experiencing (e.g., nodules).

A laryngeal exam may involve a laryngoscopy and stroboscopy. The videos below demonstrate what this typically involves.

Laryngoscopy and Stroboscopy to Examine the Vocal Cords (video)

University of California, Irvine

Department of Otolaryngology 

Fiberoptic Laryngoscopy with Dr. Hermsen (video)

McFarland Clinic

Dr. Derek Hewitt: What is Videostroboscopy? (video)

Yavapai Regional Medical Center

Rigid Videostroboscopy Procedure (video)

Swallowing and Neurological Rehabilitation, LLC

Stuttering

Many people with PD develop 'neurogenic stuttering' [4]. These persons may or may not have stuttered as children. 

Treatment

Persons with PD who stutter can improve speech fluency with treatment. Treatment focuses on acquiring increased control over speech through fluency enhancing strategies and stuttering modification. Fluency enhancing strategies take advantage of what is known to be associated with decreased stuttering incidence by reducing motor demands to make it less likely that you will stutter. Stuttering modification techniques are those that can be applied by a person to regain control during a stuttering episode and release the stutter to move forward with speaking.

Assessment

Assessment may include the following:

  • analysis of your speech (e.g., intelligibility)

  • speaking tasks to measure frequency and severity of stuttering and to characterize the nature of the stutter

  • evaluation of secondary behaviours (behaviours that develop in response to stuttering)

  • evaluation of impact of stuttering on your daily life (work, family, etc.)

  • exploration of emotional and cognitive responses to stuttering 

  • screening of cognitive skills required for communication (e.g., attention, memory, language, visuospatial skills)

  • discussion of your goals for intervention

  • case history

  • oral mechanism exam (examination of oral structures required for speech)

  • evaluation of candidacy for treatment 

  • prognosis for improvement with treatment

  • review of reports from other professionals (ENT, audiologist, family doctor, neurologist)

  • hearing screening

 
 
 

Cognitive-Linguistic Changes

Most persons with PD, over the course of the condition, will experience reduced cognitive ability to some extent. Some people will experience cognitive-linguistic symptoms without a diagnosis of dementia, others will develop mild cognitive impairment (MCI), while as many as 80% will eventually receive a diagnosis of Parkinson's disease dementia (PDD) [5]. Subtle changes in cognition may actually be reported subjectively by persons before the development of motor symptoms and diagnosis [6]. 

 

Cognitive-linguistic symptoms often reported by people with PD include reduced verbal fluency (word finding), informativeness and length of utterances, comprehension of complex grammar, conversation management (e.g., staying on topic), and reading ability [7-9]. 

Treatment

 

Although there is some research demonstrating cognitive training can improve skills in working memory, processing speed, and executive functioning in persons with mild to moderate PD [10], this area of research is still developing. ​More reports on cognitive rehabilitation for persons with PD are becoming available [10], but not necessarily in linguistic skills such as verbal fluency and comprehension. 

Strategy-based treatment may be helpful in improving functional cognitive skills (e.g., use of strategies to retain information read) [11], but this is another area that needs to be further explored in research. 

 

In treatment, persons with PD can develop useful strategies to compensate for linguistic-cognitive changes (e.g., word finding difficulties). Furthermore, a trial of cognitive training can determine whether an individual may benefit from this approach to improve and/or maintain linguistic-cognitive abilities.

Assessment

Assessment may include the following:

  • speaking, listening, and reading tasks that will be analyzed by the S-LP

  • identification and characterization of areas of strength and difficulty

  • evaluation of impact of symptoms on your daily life (work, family, etc.)

  • screening of cognitive skills required for communication (e.g., attention, memory, language, visuospatial skills)

  • discussion of your goals for intervention

  • case history

  • evaluation of candidacy for treatment 

  • prognosis for improvement with treatment

  • review of reports from other professionals (ENT, audiologist, family doctor, neurologist)

  • hearing screening

 

PD Communication Group

Learn about our Communication Group for people with Parkinson's disease here.

 

We have spaces available in this group at the present. To learn more, contact us

 
PD group poster.png
 

More Information on Parkinson's Disease

Parkinson Canada

http://www.parkinson.ca/

 

LSVT Global

https://www.lsvtglobal.com/

 

Parkinson’s Foundation

http://parkinson.org/

University of California San Francisco – Memory and Aging Center

https://memory.ucsf.edu/parkinson-disease-dementia

Johns Hopkins Medicine - Parkinson Disease and Dementia

https://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/parkinsons_disease_and_dementia_134,50

"What is Parkinson's Disease?"

Michael J. Fox Foundation

https://www.youtube.com/watch?v=cRLB7WqX0fU

"Raising Your Voice with Parkinson's"

Lee Health

https://www.youtube.com/watch?v=HhfZ6wb1nHc

"Communication Changes in Parkinson's Disease"

Nick Miller

https://pn.bmj.com/content/17/4/266

Citation: Miller, N. (2017). Communication changes in Parkinson's disease. Practical Neurology, 2017, 266-274. doi:10.1136/practneurol-2017-001635

Local

Parkinson Canada - Dartmouth/Halifax Support Group

https://www.parkinson.ca/support-groups/dartmouth-halifax/

Research: LSVT LOUD

List of research studies conducted on LSVT LOUD: 

https://blog.lsvtglobal.com/research/loud-reference/

Research: Comparisons Between Different Treatment Approaches for PD

Sackley, C. M., Smith, C. H., Rick, C. E., Brady, M. C., Ives, N., Patel, S., . . . Clarke, C. E. (2018). Lee Silverman Voice Treatment versus standard speech and language therapy versus control in Parkinson's disease: a pilot randomised controlled trial (PD COMM pilot). Pilot and Feasibility Studies, 4(30), 1-10. https://doi.org/10.1186/s40814-017-0222-z

 

Herd, C. P., Tomlinson, C. L., Deane, K. H. O., Brady, M. C., Smith, C. H., Sackley, C. M.,, & Clarke, C. E. (2012). Speech and language therapy for speech problems in Parkinson's disease. Cochrane Database of Systematic Reviews, 2012(8). doi: 10.1002/14651858.CD002814.pub2

 

References on This Page

[1] Müller, J., Wenning, G. K., Verny, M., McKee, A., Chaudhuri, K. R., Jellinger, . . . Litvan, I. (2001). Progression of dysarthria and dysphagia in postmortem-confirmed Parkinsonian disorders. Archives of Neurology, 58, 259–264. Retrieved from https://jamanetwork.com/journals/jamaneurology

[2] Miller, N., Allcock, L., Jones, D., Noble, E., Hildreth, A. J., & Burn, D. J. (2007). Prevalence and pattern of perceived intelligibility changes in Parkinson's disease. Journal of Neurology Neurosurgery and Psychiatry, 78, 1188–1190. doi:10.1136/jnnp.2006.110171

[3] Duffy, J. (2012). Motor Speech Disorders: Substrates, differential diagnosis, and management (3rd ed.). Toronto: Mosby.

[4] Goberman, A. M., Blomgren, M., & Metzger, E. (2010). Characteristics of speech disfluency in Parkinson disease. Journal of Neurolinguistics, 23, 470-478. doi:10.1016/j.jneuroling.2008.11.001

[5] Buter, T. C., van den Hout, A., Matthews, F. E., Larsen, J. P., Brayne, C., & Aarsland, D. (2008). Dementia and survival in Parkinson disease: A 12-year population study. Neurology, 70, 1017-1022. https://doi.org/10.1212/01.wnl.0000306632.43729.24

[6] Postuma, R. B., Aarsland, D., Barone, P., Burn, D. J., Hawkes, C. H., Oertel, W., & Ziemssen, T. (2012). Identifying prodromal Parkinson's disease: Pre-motor disorders in Parkinson's disease. Movement Disorders, 27, 617–626. doi:10.1002/mds.24996.

[7] Schalling, E., Johansson, K., & Hartelius, L. (2017). Speech and communication changes reported by people with Parkinson's disease. Folia Phoniatrica et Logopaedica, 69(3), 131–141. https://doi.org/10.1159/000479927

[8] Ash, S., Jester, C., York, C., Kofman, O. L., Langey, R., Halpin, A., ... Grossman, M. (2017). Longitudinal decline in speech production in Parkinson's disease spectrum disorders. Brain and Language, 171, 42–51. doi:10.1016/j.bandl.2017.05.001

[9] Colman, K. S., Koerts, J., Stowe, L. A., Leenders, K. L., & Bastiaanse, R. (2011). Sentence comprehension and its association with executive functions in patients with Parkinson's disease. Parkinsons Disease, 2011, 1-15.  http://dx.doi.org/10.4061/2011/213983

[10] Leung, I. H. K., Walton, C. C., Hallock, H., Lewis, S. J. G., Valenzuela, M., & Lampit, A. (2015). Cognitive training in Parkinson’s disease: A systematic review and meta-analysis. Neurology, 85, 1843-1851. doi:10.1212/WNL.0000000000002145

[11] Foster, E. R., Spence, D., & Toglia, J. (2018). Feasibility of a cognitive strategy training intervention for people with Parkinson’s disease. Disability and Rehabilitation, 40, 1127-1134. doi:10.1080/09638288.2017.1288275

Shoreline Speech Therapy

Paddlers Cove Professional Centre

300 Prince Albert Rd., Suite 215, Dartmouth, NS, B2Y 4J2

info@shoreline-speech.com

phone (902) 405-7858 or (902) 219-3065 

fax (902) 704-5444

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