On December 11th PMD Alliance hosted a webinar on Parkinson’s and Speech as part of the wHolistic series.  In this very informative hour CCC-SLP, Nicole Herndon, spoke about why speech changes occur with PD as well as treatment options and strategies for both the speaker and listener to improve communication.

You can watch this webinar here.  

This is a follow up to Ms. Herndon’s August 2020 webinar for PMD Alliance on Swallow Dysfunction in Parkinson’s Disease, which can be viewed here.  

Of course, the Stanford Parkinson’s Community Outreach Program has pages of information about Parkinson’s speech and swallowing, including home exercises to maintain speech enunciation, cadence, and volume.

Speech and Swallowing

Speech & Voice Therapy

Speech and Voice Exercises for home use

And now, on with my notes…

– Denise

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PMD Alliance
Parkinson’s and Speech
December 11, 2020

Moderator: Indu Subramanian, MD, person with Parkinson’s

Speaker: Nicole Herndon, CCC-SLP

Ms. Herndon works at a neurological treatment center in Florida on a multidisciplinary team with physical and occupational therapists.  She is working both in-person and virtually with patients.  

She became aware of speech issues when her grandfather fell and incurred a head injury, which affected his speech.  As a result, she pursued a career in speech therapy.

In August 2020 Ms. Herndon spoke for the PMD Alliance on swallowing issues in PD.

Today’s Topics

• Background
• Speech changes in PD
• Speech changes in atypical parkinsonism
• Treatment / Strategies
• Concluding remarks

Speech

• The power of expressing of communicating thoughts by speaking.
• Exchange of spoken words

Poll

• Have you received speech therapy?
  • Yes. I’ve addended speech therapy sessions – 53%
  • Yes. Only for speech evaluation – 6%
  • No – 41%

Speech

• Includes coordination of 4 subsystems
  • Respiratory – lungs, diaphragm
  • Phonatory – vocal cords, voice box / larynx
  • Articulatory – mouth, tongue, jaw
  • Resonatory – air through nasal cavity (n, m vs. b, k)
• Discoordination – hyperkinetic movements/dyskinesia can throw off coordination

Speech changes in PD

• Impacts as many as 90% of people w/PD – the degree of impact varies, depending on how long one has had PD.  The first several years after diagnosis tend to have less impact on speech than later in the disease process.
  • Hypokinetic dysarthria includes:
    • Reduced breath support for speech
    • Reduced volume – hallmark of speech issues in PD, results from reduced breath support
    • Hoarse or breathy vocal quality
    • Short rushes of fast speech or faster speech, overall – can result in loss of clarity
    • Reduced clarity
    • Monotone – less inflection
    • Hypernasal resonance
    • Stuttering – new onset of stuttering or reemergence of stuttering from childhood

Why do these speech changes happen?

• Hypokinesis – reduced movement of the mouth
• Rigidity – limits breath support, postural stooping compresses chest cavity
• Neural changes

Articulation – how we produce sounds

• Lower amplitude and velocities of movements of the articulators (lips and jaw, possibly the soft pallet)
• When saying, “Make me a Hong Kong cookie,” sometimes the more nasal tones linger a bit longer than needed
• Let’s try…
  • Jaw: 
    • “aw” vs “ee” – your jaw should drop with the “aw” sound, but not the “ee” sound
  • Lips:
    • “oh” vs “ee” – your lips should pucker with the “oh” sound, but pull back for the “ee” sound
    • “sh vs “s” – your lips should push forward somewhat for the “sh,” but pull back for the “s” sound
    • “b” vs “v” – your lips should touch for the “b,” and your top teeth touch your bottom lip with vibration for the “v” sound

Speech Breathing – breathing for speech is quick intake of breath and slow exhalation w/speech articulation.  This is different from the regular inhale and exhale of sedentary breathing.  However, in those with Parkinson’s:

• Increased variability compared to age-matched controls
  • In those with PD one phrase may have a typical speech breath pattern but with the next phrase the breath pattern changes and there is not enough airflow to support end of the sentence, volume fades, and you may not be heard or understood.
• Rely more on abdominal breathing to change lung volume
• Smaller rib cage volume initiations
• Overall less contribution of the rib cage to overall lung volume change
  • In those without PD there is flexibility of the musculature around the ribcage.  Breaths tend to be regular with some ‘springing’ action at the top of the breath to push the air out of the lungs.
  • In those with PD the intake of a regular breath is less than that of someone without PD and without the ‘springing’ action, engagement of the musculature around the ribcage is required to exhale fully.
• Let’s try… (rubber band demo of this ‘springing’ action)
  • Speech therapy may focus on expanding the ribcage on the inhale, rather than engaging musculature around the ribcage to exhale fully.  This is more effective and uses less energy.

Perception of speech changes in PD

• Perceptions of speech changes often do not match auditory – perceptual findings
  • Person with PD may say, “My wife says I’m not speaking up, but I think the problem is her hearing.”
  • Person with PD may say, “When people can’t hear me, I speak up.  It feels like I’m shouting, but they say it doesn’t sound I’m shouting.”
• Difficulty regulating volume and knowing what an appropriate volume is.  The thing is your air volume is changing so slowly your brain adapts so, over time your brain perceives your new quiet volume as being normal, even though you can hardly be heard by others.

Speech changes in atypical parkinsonism

• Progressive Supranuclear Palsy (PSP)
  • Hypokinetic dysarthria
  • Mixed hypokinetic and Spastic Dysarthria (slow rate of speech, strained-strangled vocal quality)
  • Speech-language variant: apraxia of speech
• Multiple System Atrophy (MSA)
  • MSA-P (parkinsonism): hypokinetic dysarthria
  • MSA-C (cerebellar): mixed hypokinetic and Ataxic Dysarthria (imprecise articulation, slow rate of speech, intermittent hypernasal resonance, excess and equal stress, variable inflection)
• Dementia with Lewy Bodies (DLB)
  • Hypokinetic dysarthria
• Corticobasal Degeneration (CBD)
  • Hypokinetic dysarthria
  • Apraxia of Speech

Speech & PD Medication – do PD meds improve speech?

• Inconclusive for levodopa therapy – clinically people with PD will say both meds help speech and not

Speech & Deep Brain Stimulation (DBS)

• Dysarthria is less responsive to DBS than global motor limb dysfunction.  Don’t expect any improvement of speech with DBS.
• STN DBS target:
  • Speech intelligibility has a poor response to STN stimulation
• GPi DBS target: Variable results
  • Studies have shown an improvement of speech relative to baseline, no change, or worsening of speech
• Due to its lesion-like effects, there is still a risk of speech worsening
  • If so, changes typically occur in severity, type of dysarthria, and vocal quality
  • With recognition of this stimulation effect on speech can be ameliorated with programming adjustments.

Treatment – Hypokinetic dysarthria

• Remediation
  • Programs & Trainings
• Compensatory
  • Voice amplifier
  • Augmentative-Alternative Communication (AAC)
• Communication Strategies
  • Speaker
  • Listener

Remediation

• Lee Silverman Voice Treatment – LSVT Loud
  • Increases:  Loudness, Intonation, Voice Quality, and Clarity
  • Slows:  Speaking rate
  • Four 1-hour sessions/week for 4 weeks; one-on-one training (intensive program)
  • Home exercises for carryover from clinic to home
  • Maintenance exercises for continued benefits – if you don’t use it, you lose it, for all these programs!!!
  • Link
• SPEAK OUT! 
  • Increases:  Loudness, Perception of voice function
  • About 12 speech therapy sessions (less intensive)
  • Includes speech and cognitive exercises
  • Home exercises for carryover
  • Maintenance exercises for continued benefit
  • LOUD Crowd (group therapy)
• SpeechVive
  • Increases:  Loudness, Length of utterance, Clarity, Intonation
  • Wearable speech device that fits over one ear, like a hearing aid
  • Uses multi-talker babble to elicit the Lombard reflex (when you are in a louder environment, you speak louder to talk over the background noise)
  • Some evidence that the effect lingers for a while after taking off the device
  • More insurances covering this recently as durable medical equipment, including the VA
• Expiratory Muscle Strength Training (EMST150 devise by Aspire, LLC, and Threshold PEP device by Philips)
  • Preliminary evidence that it may help with speech breathing, cough, and swallow function
• Other options
  • Voice Amplifier examples
    • Pocketalker (Williams Sound)
    • Spokeman (KEC Innovations)
    • Chattervox
  • Augmentative-Alternative Communication (AAC) – rarely needed by those with PD
    • Low and high-tech options if you have difficulty speaking
    • Looks like ipad or windows surface Pro with different language options on them

Communication Strategies

• This webinar explains why communication breaks down between those with PD and others.
• Communication Strategies for Optimal Success – 9/17/2019, Speaker: Angela Roberts, PhD
• Link
  • A couple reasons communication breaks down, include:
    • Others speak over the person with PD
    • The conversation moves too quickly for the person with PD to jump in

Speaker Strategies

• Face-to-face – masks complicate seeing what someone is saying and muffle voice volume
• Reduced background noise / distractions
• Get attention of listener prior to speaking – avoids making you repeat yourself
• Provide context – if someone isn’t understanding what you’re saying, back up and give them the subject
  • When you hear, “What did you say?” back up and give them the context.  
  • For example: “Dinner, what do you want for dinner?”
• Fill in information listener did not hear / understand
  • Instead of repeating the whole thing ask, “What did you hear?”  Then, fill in the missing information.
  • That way, you will make sure the information is correct.

“SLOP” strategies

• S = Slow down and improve clarity.  
  • Sometimes, people know they are speaking too fast, but don’t know how to slow down.  Over-articulation is a good way to slow down (see O below).
• L = Loud
  • Speech Breath
    • Taking a deeper breath at the beginning of each sentence and let it out as you’re speaking
    • Be a bit more dramatic – if you feel as though you’re overdoing it, your effort probably about right
    • Helps improve loudness
    • Maintenance of loudness so the ends of your sentences don’t fade away
    • Can improve vocal quality with more air across the voice box
    • Try this – inhale deeply before each sentence.  Be sure to let the air out while you’re speaking.  Inhale again if you have more to say.  Note: Some people are not aware that they are holding their breath while they speak and exhaling after speaking.  Others try to keep talking when they are out of air, but they can no longer be heard.
      • “Today is a beautiful day.”
      • “Please put the groceries in the refrigerator.”
• O = Over-articulation – Larger movements of ‘articulators’ while speaking; focus on precision of each syllable.  This helps improve clarity / precision (improve “mumbling”) and helps slow rate of speech.
  • Focus on larger movements of ‘articulators’ while speaking
  • Focus on precision of each syllable
• P = Pausing for more frequent breaths – inhale again if you have more to say.
  • Some people try to keep speaking when they are out of air, but they can no longer be heard/understood.

Listener Strategies

• Face-to-face
• Reduced background noise / distractions
• Let listener know what you did or did not hear / understand
  • Say, “I heard you want something specific for dinner.  What was that?”  So, the person with PD doesn’t have to repeat everything.
  • This helps reduce fatigue for the person with PD
  • Can help reduce frustration and the number of times the person with PD says, “Oh, never mind.”
• Confirm / summarize what you heard
• Give speaker time to respond
  • If they are in the middle of a task, they may need a minute to stop what they’re doing and form a reply
  • They may need a minute to gather better breath support
  • They may actually answer you before you repeat yourself, reducing frustration for both of you

Conclusion

• Recommend a formal speech evaluation by speech-language pathologist
  • Baseline evaluation to see where you’re starting
  • Annual re-evaluation to see progress or decline and recommend further therapy
• Individualized speech therapy – make sure therapy recommended matches what’s needed
  • Programs / trainings, compensatory strategies, communication strategies

Questions?
Q. With hearing aids you hear yourself as louder than others may hear you.  How to deal with that issue?
A. Your volume may still be reduced so you still need to focus on the effort behind your speech.  You can use the Decibel X Sound Level Meter (or another decibel meter) on your smart phone.  Put it a one or two feet away from your mouth and shoot for 65-70 decibels, which will be a good conversational level.  You can also record yourself using your smart phone.  Play it back and listen to hear if you fade at the end of a sentence, or what’s going on with your speech.

Q. Have you heard of impaired speech from the Duopa pump?
A. The Duopa pump can cause dyskinesias which could result in a strained vocal quality because it’s hard to get a good deep breath before speaking.
Dr. Subramanian says the Duopa pump is nowhere near where speech is produced.  It is more likely to be the effect of too much or too little medication, which can affect speech.  DBS can affect speech as a side-effect of the stimulation, depending on the location of the electrodes.

Q. How do you choose which type of speech therapy program is best for you?  Attendee did the SPEAK OUT! program and it has helped her immensely.  She does SPEAK OUT! maintenance with a friend.
A. Both LSVT and SPEAK OUT! have the same concept behind them.  LSVT has a bit more research because it was developed 20 years earlier.  LSVT is intense and requires a commitment to 4 hours per week for 4 weeks.  SPEAK OUT! is a bit more flexible.  I present both that and SPEAK OUT! and let the person with PD and their care partner decide which works best for their schedule and level of commitment.

LSVT Loud has about 10,000 clinicians and SPEAK OUT! has about 2500.  Both programs require certification of clinicians.  Both websites have clinician finders.

LSVT Loud has e-loud tele-health.  This was available prior to covid.  For both programs you must find a clinician licensed to work in the state where you live.  

Q. Tell us about the cognitive exercises that go with speech therapy, like with SPEAK OUT!.
A. Cognition changes over time with PD so you can never go wrong with any cognitive exercises, even if you don’t feel any cognitive loss.  Dual tasking, like doing your breathing exercises while counting or naming items in a category is efficient use of your time and good for your brain.

Q. SpeechVive is in one ear.  Can you use it with hearing aids?  Would you get the same Lombard effect if you put in an ear bud playing instrumental music?
A. You can use one hearing aid on one side and SpeechVive in the other ear.  There’s a certain time of day when you train with the SpeechVive.  Put the SpeechVive in your ear with less hearing loss.  SpeechVive clinicians can help you figure this out.

You must have an evaluation with a clinician to see if you will benefit from SpeechVive before ordering it, because it is durable medical equipment.  
It is different from just putting instrumental music in your ear with an ear bug.  SpeechVive uses indistinguishable speech, rather than music, because music can be distracting.  Indistinguishable speech uses less mental effort than music.  It is also not too loud.  Too loud music can further injure your hearing.

Q. For someone in assisted living during lockdown for 9 months with no speech therapy, what are the chances speech will improve with therapy now?
A. You can read aloud to practice the SLP strategies you learned prior to lockdown.  Singing or humming, even counting and practicing phrases you say often using the SLP strategies you learned, like breath support, over-articulation, etc.  These can all be done at home.

Sample sentences people frequently say to use for practice:”How are you today?””Have you seen my glasses?””What’s for dinner?””I need to go to the bathroom.”

Remember, if you don’t use it, you lose it!!!

SLP can be expensive, so using videos and practice options can be a great way to get a taste of these programs before they commit.

Q. For those who live alone, do you have feedback ideas for speech, since they don’t have anybody to provide feedback.
A. Record yourself on your smart phone or with a tape recorder and listen to it back.  Use the Decibel X app (or another app) to get feedback.  Use it about 2 feet away and shoot for about 70 decibels.

Q. If you live alone, how much should you practice?
A. Daily, 10-15 minutes.  But take every moment, like phone calls, to practice.  You can even talk through the steps as you do mundane tasks, like watering your plants, adjusting your thermostat, washing your hands, etc.  Make a point to talk with your neighbors.

Q. What about singing for breath support?
A. Yes! that is good practice.  There are many PD singing groups across the country, like PD Sing for Life and Orange County Tremble Clefs, or you can just join your church choir.  As long as you’re using your voice and focusing on your breath, you’re on the right track.

Music and the brain / cognitive maintenance for those with PD is terrific.  Find something you enjoy and do it!

Q. How to make it as easy as possible to be articulate.
A. Be sure your teeth or partials are in properly and secured.  Don’t have gum in your mouth when trying to talk.  Address excess saliva with your neurologist.  Focus on precision of enunciating each syllable while speaking.