Parkinson’s Disease
Role of Speech Language Pathology
Dr. Mariam H Syeda
Speech-Language Pathologist
MBBS, CCC-SLP
Ziauddin College of Speech Language
Therapy
Cognition
Voice
swallow
language
speech
Speech Language Pathology
Areas Affected in Parkinson’s
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Voice
Speech
Swallow
Cognition
Outline
• Area Affected in PD
– Symptoms
– Causes
– Evaluation/Treatment
– Tips to take home
• Available Resources – ZCSLT
• Projects
VOICE
Voice symptoms
• Voice Quality
– Hoarse or breathy
– caused by the vocal folds not firmly meeting in a
regular rhythm or closing pattern (bowing of vocal
folds)
Voice symptoms
• Loudness
– Reduced loudness
• Evidence suggests breakdown in patient’s sensory
processing
– “My wife is hard of hearing.”
• Inaccurate sense of vocal effort
– “It feels shouting.” like I am shouting.
• Individuals with PD “overhear” themselves
Voice symptoms
• Pitch:
– Speech has very little melody or pitch variation.
– Monotone pitch (decreased up and down
movement of the larynx)
– can be hard to listen to because it is the inflection
of speech that keeps listeners involved in a
conversation
– lacks liveliness, can be boring to listen to and
sometimes it is misunderstood.
Evaluation
• Informal
– Recordings
– Voice tasks
• Formal
– DRS (Dr. Speech)
– Virtual Voice Trainer
Treatment
• Traditional Voice Therapy
• Specific voice rehabilitation programs
– LSVT
• Voice evaluation/treatment software
– DRS
Lee Silverman Voice Treatment (LSVT)
• Intensive voice treatment program:
– Designed to teach an individual with PD to
improve functional intelligible oral communication
by increasing vocal loudness
• Treatment Duration:
– 16 intensive individual sessions, 4x/week
– Maintenance: 6 to 12 months (daily practice)
Lee Silverman Voice Treatment
• Theory:
– Model of Intention:
– When subjects speak with intent, their speech
was observed as slower and louder with better
articulation and increased quality.
– “Think Loud, Think Shout”
LSVT
Outcomes
• Improvements subsequent to LSVT treatment
have included changes in
– facial expression (Spielman, Borod, & Ramig,
2003),
– speech intensity (Ramig et al., 1995),
– vocal cord adduction (Smith et al., 1995) and
– sub-glottal air pressure (Ramig & Dromey, 1996).
– Positive improvements in swallowing
(Sharkawi et al 2002)
LSVT
Cognitive Perspective
– LSVT is not a cognitively demanding intervention
approach (Sapir & colleagues, 2003).
• Some individuals with PD present with symptoms of
dementia (Sapir & colleagues, 2003).
• may have difficulty completing multi-step tasks (Yorkston,
Miller, & Strand, 2004).
• LSVT  simple intervention tasks that are motivating to
the individual (Yorkston, Miller, & Strand, 2004).
Dr. Speech
• Dr. Speech is a comprehensive real-time
speech and voice assessment and training
software system
• It helps to teach, reinforce, document and
report speech production in various animated
tasks.
• 6 components, each targeting a different
function
DRS – Dr. Speech
• This game-like tool;
Provides immediate visual feedback to the client
on their performance
Is versatile and has unique features
Enables a quick review of the graphical display or
statistical data of the client’s performance.
Provide real-time recording and playback help
maximize the client’s therapy.
6 Components of DRS
Voicing
Onset
Voicing
Phonetic
Exercise
Maximum
Phonation
Time
(MPT)
Pitch
Loudness
Tips to improve…..
Quality
• ❑ Try to produce a sharp sound while
producing voice
• ❑ Keep the loudness level of the voice up by
pushing air from the abdomen.
• ❑ Practice speech drills and lip/tongue
strengthening exercises
• ❑ avoid excessive coughing, throat clearing or
yelling.
• ❑ Protect the vocal folds by keeping the home
air moist (humidifier)
Tips to improve…..
Loudness
Take a big breath before beginning to speak.
Use short sentences/phrases
Use abdominal muscles when yelling/screaming
Maintain good posture
Open mouth behavior when speaking
Tips to improve…..
Pitch
• Question- Statement Contrast:
• When making a statement, start the sentence
at a slightly higher pitch, and bring it down at
the end
– I am not going home. ➷
• When asking a question, start lower and raise
the pitch at the end.
– I am not going home? ➹
Tips to improve…..
Pitch
• ❑ Emphasize important words by increasing
the pitch when they are said.
– Turn right at the signal
• ❑ When reading the speech practice material,
draw arrows to aid in indicating when to
change the pitch.
• ❑ Practice pitch changes when singing. Try to
exaggerate the pitch range when singing.
SPEECH
Speech Characteristics
• Hypokinetic Dysarthria
• Fast Rate of Speech
– Sometimes people with PD experience “rushes” of
speech –
• very rapid speech
• And an uneven tempo.
– Speech becomes difficult to understand.
• Unclear Speech
– individual speech sounds are not made clearly or
precisely  speech sounds “slurred”
Speech characteristics
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Hypokinetic Dysarthria:
Monopitch
Monoloudness
Reduced stress
Short phrases
Variable rate
Short rushes of speech
Imprecise consonants
Cause of unclear speech:
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Decreased mouth opening
Slow and imprecise lip movements
Slow and imprecise tongue movements
Poor ability to move the tongue and lips
together in a way that is coordinated and
rapid enough to be able to produce all of the
speech sounds clearly
Speech Evaluation
• Oro-motor Examination
• Speech Assessment Batteries
• DRS –
– Quantitative data
Therapy for Clear Speech
• Conventional speech
therapy exercises
• DRS
• Delayed Auditory
Feedback (DAF)
– Rate of speech
• Voice Amplifiers
Speech Exercises
• lip strength and
flexibility exercises
• tongue strength and
flexibility exercises
Example…
Purse lips, pucker and say OOO…
Example…
Blow air through straw while putting
up cheeks as much as possible.
Clear Speech
Tips
• Before starting to speak, swallow all excess
saliva in the mouth.
• Say all sounds clearly and firmly – exaggerate
the sounds and do not leave any sounds of
any words out.
• Start by practicing single words, then two and
three word phrases, short sentences and
paragraphs
Clear Speech
Tips
• Pause between words
• keep the vocal loudness up until the end of
the sentence
• Try making a fist when speaking, or pushing
• use shorter sentences
• Simplify the message for the listener
• Speak at a slightly slower than normal rate
• Do not strain to say every word perfectly
SWALLOW
Swallowing
• Oral Phase
• Pharyngeal Phase
• Esophageal Phase
• Swallowing
Dysphagia
• A disorder of swallowing
• common consequence of PD, with reports of
40% to 100% of patients in the later stages
experiencing symptoms like
– ❑ Slow rate of eating.
– ❑ Fatigue during eating.
– ❑ Food “sticking” in the throat.
– ❑ Coughing or choking on food or liquid.
– ❑ Difficulty in swallowing pills.
• May lead to aspiration pneumonia
Effects of PD on swallowing
Oral
• typical repetitive, AP rolling pattern in lingual propulsion of the bolus (rockingrolling motion)
• excessive tongue pumping movements
• anterior loss due to poor lip seal
• Posterior spillage
pharyngeal
• delays in the triggering of the pharyngeal phase
• Larygeal elevation and closure incomplete
• impaired pharyngeal motility
• deficient epiglottic retroflexion
• laryngeal penetration/aspiration , pooling/residue in sinuses
esophageal
• incomplete UES relaxation and reduced UES opening during swallowing
• stasis of bolus  aspiration after swallow
• These behaviors were more prevalent in liquid
than in semi-solids or solids.
Effects of PD on Cough Reflex
• desensitization of pharyngeal, laryngeal or
tracheal mucosa
–  resulting in failure to clear substances from the
upper airway
– thought to be the result of impairment to the
sensory components of the vagus and
glossopharyngeal nerves.
• This may account for the high incidence of
– silent aspiration
– aspiration pneumonia
Evaluation
• Evaluation
– Informal
• Bedside Swallow
Evaluation
– Formal
• Modified Barium Swallow
Treatment
• Treatment
– Compensatory strategies
– Diet modification
• Liquids are the toughest
• Pureed diet is easier
– Therapeutic strategies
– VitalStim Therapy
• Neuromuscular electrical
stimulation for
Swallowing
CONSISTENCY
EXAMPLES
Thin liquid
Milk, fruit juice
Thick liquid
Soup, milkshake
Puree
Yogurt, custard
Soft solid
Mashed potato,
porridge, khichdi
Hard solid
Biscuits, chappati,
toast, salads
VitalStim
 Neuromuscular
Electrical Stimulation
for Dysphagia
 Proven safe (the only
FDA approved device
for swallow)
 Remarkably successful
 ZCSLT has the only
certified VitalStim
provider in Pakistan
Dysphagia management
Safe Swallow
Tips
• Eat only those consistencies that have been
recommended as being safe
• Sit upright at 90 degrees
• Stay upright for at least 30 mins after taking
anything by mouth
• Chin tuck – when swallowing
• No distractions
ZIAUDDIN COLLEGE OF SPEECH
LANGUAGE THERAPY
 Evaluation & Therapy for all areas in PD:
 Voice
 Swallow
 Speech
 Cognition
 Sessions
- One-on-one & Group
- Each is session is for 30-45 mins
NEW PROJECTS
VitalStim Therapy
Modified Barium Swallow
Study
VOICE & SWALLOW LAB
Video Stroboscopy Unit
Digital Swallowing Station