In late March, the American Parkinson Disease Association (APDA) hosted a webinar on speech with speech-language pathologist Lisa Sommers. Lisa described the changes — sometimes subtle –in breath support, voice production, speed and accuracy, inflection of voice, facial expressions and swallowing. She noted that about 90% of people with Parkinson’s Disease (PD) will experience these kinds of changes in communication.
Speech-language pathology (SLP) services have been proven to be effective for those with PD. They often start with an evaluation from an otolaryngologist to visualize the vocal cords, and can focus on improvements to volume, quality of voice, clarity and rate of speech and fluency. The ultimate goal is to improve functional, everyday communication with a minimum of cognitive effect.
To treat dysphagia, a modified barium swallowing study (MBSS) might be used, which is a moving x-ray of the swallow. This can help identify what specifically is causing swallowing issues and can help SLPs find the appropriate individualized treatment for the patient.
For more resources on these topics, see these webpages on the Stanford Parkinson’s Community Outreach website:
- Speech and swallowing symptoms
- Speech/voice therapy (including at-home exercises)
- Speech/voice exercise classes and videos
The webinar recording can be found on the APDA’s YouTube channel here.
Please see below for notes on the March 25th webinar.
– Joëlle Kuehn
Speakers: Lisa Sommers, speech-language pathologist, UMass Amherst
Webinar Host: American Parkinson Disease Association (APDA)
Webinar Date: March 25, 2021
Summary by Joëlle Kuehn, Stanford Parkinson’s Community Outreach
Communication changes common with PD:
- About 90% of people with PD will experience changes in communication
- Changes can be very subtle and can fluctuate; can occur early in the disease process
- Areas affected:
- Breath support
- Voice production (soft voice, sometimes quality is hoarse, breathy or harsh)
- Speed and accuracy (reduced clarity)
- Inflection of voice
- Reduced facial expressions (can cause people to seem depressed or disinterested when they actually are not)
- Sensory disconnect – people feel that they aren’t communicating differently, it feels the same as before, and do not notice that they have an issue (“I’m not the one that is too soft, my spouse just needs a hearing aid”).
- Medications have shown to be effective with many motor changes like bradykinesia, but have not shown to be effective with the speech, voice, and swallowing changes associated with PD.
Cognitive changes impact communication:
- Cognitive changes are not uncommon and are highly variable from person to person
- Frustrating and with emotional consequences
- Common areas affected:
- Some types of memory (especially when learning new information)
- Executive functions
- Visuospatial functions
- Generalized complaint of “bradyphrenia” (slowed thinking processes)
- Depression, anxiety, apathy, sleep issues can play a role, and should be treated
- An often ignored and significant contributor is hearing loss
- There is a really close connection
- Develops gradually over time, but it greatly impacts everyday life and can add barriers to an active lifestyle
- These things can make it hard to keep up with PT sessions
Swallowing and PD:
- Dysphagia is the medical term for a swallowing disorder
- Swallowing changes in PD are very common
- Often, people wait too long before they bring it to a doctor
- Changes associated with PD can affect every stage of the swallow
- Changes occur because of decreased force of movement, decreased range of motion, slowness of movement and a decreased ability to adapt to changes in volume and consistency of foods and liquids, as well as changes in reflexes involved in swallowing and airway protection
- Dysphagia has real health consequences for people with PD – weight loss (they take a lot longer to eat so they eat less), reduced quality of life (stop going out to eat) and aspiration pneumonia
- Dysphagia can also be linked to social isolation
- There are also effective treatments possible
Speech-language pathology (SLP) services:
- Excellent evidence of the effectiveness of SLP services for PD
- Services usually start with an evaluation from an otolaryngologist (deferred during COVID) to visualize the vocal folds
- Order from the physician can read: “Speech-language pathology evaluation and treatment”
- The diagnosis of PD should be on the order as well
- No matter the frequency of days per week, services generally involve intensive effort from the person with PD
- Services to change communication focus on the voice as the target for improvements in:
- Quality of voice
- Clarity of articulation
- Rate of speech/fluency
- Inflection of the voice
- Facial expressiveness
- The ultimate goal: Improve functional, everyday communication with a minimum of cognitive effort
- Most people with PD require periodic re-evaluations and a need for re-enrollment in individualized therapy over the course of the disease
- Different therapy approaches like LSVT (Lee Silverman Voice Treatment – Loud for Life) and Speak Out! (Loud Crowd) have carryover programs
Swallowing evaluation and treatment:
- Physician’s order for “Dysphagia evaluation and treatment”
- “Bedside” evaluation of the swallow
- Modified Barium Swallow Study (MBSS)
- Moving x-ray of the swallow
- Like to do it early for people with PD to have a baseline
- Treatment: develop individualized plan for every person
- LSVT LOUD
- Expiratory Muscle Strength Training
- Compensatory strategies
- Changes in posture and positioning
- Modifications of diet
- Maintain nutrition and hydration
- Look at on/off periods
Question & Answer:
Question: Is a modified barium swallow test the same as a barium swallow test?
Answer: A barium swallow looks from the esophagus down through the rest of the GI tract. A modified barium swallow is looking at what is happening from the lips to the esophagus once it opens up and lets the food down, and will have a speech language pathologist and a radiologist there for the procedure. A barium swallow will only have a radiologist.
Question: Can you explain the difference between voice therapy, speech therapy, and language therapy?
Answer: Our field is called speech-language pathology, but some people call us speech therapists or clinicians. We can address things outside of speech and language like voice and swallowing. There are voice teachers who have more of a musical background but those people don’t have specialty training for PD or the training of a speech-language pathologist.
Question: If my husband is going to choke on something, should I be taking a review class in first aid?
Answer: I’d recommend going to a speech-language pathologist so they can help you specifically for your husband because there are different kinds of choking, and getting extra help is best. CPR is a great idea but you want to go to a specialist.
Question: What could an exercise look like for swallowing problems?
Answer: A lot of swallowing exercises are targeting what might be going wrong. Sometimes we work on something and get a modified barium swallow and find something different. After we see what works because some tips can be worse for others. Examples are a breath hold, pitch glide, or a chin tuck. They’re not always easy to do, so we teach those strategies and practice them.