Parkinson's Disease Clinic & Research Center

Speech and Swallowing Therapy

Speech & Communication Problems

in Parkinson's Disease

Although a disturbance in speech (also known as dysarthria) is not always associated with Parkinson's disease, it is sometimes impaired in mid-to late stages of the disease and in some persons, can pose a significant handicap. The speech disorder is characterized by a soft voice, with low volume and breathy, harsh voice quality. There may be reduced stress and intonation, making the speech sound 'monotonous' in tone. Articulation is usually less precise and often sounds rushed, with short but rapid utterances. Some persons complain that they have a problem with 'fluency' or stuttering, especially at the beginning of a sentence. Along with the speech disturbance, there may be a reduction in facial expression which adds to the perception of 'monotonous speech'. These symptoms may impair communication with friends, family, and colleagues at work.

Not all people with Parkinson's disease are aware that their voice is softer or that they are not speaking distinctly. This seems to be part of the problem in Parkinson's - the internal self-monitoring or self-calibration system is 'off' so the person doesn't make automatic adjustments in his/her speech, much as a deaf person would not be capable of doing this.

Treatment of speech problems
Over the years, a number of speech therapy programs have been developed to improve speech and communication. Unfortunately, most of these have not shown good long-term results. The one exception is the Lee Silverman Voice Treatment program, or LSVT. This program has undergone extensive research and development and has demonstrated good outcomes. In fact, 80% of patients who have this treatment report significant improvement - with 64% reporting that their voice is better than before treatment one year later! The goal of therapy is to increase loudness, which, in turn, improves clarity of speech and increases melody or inflection over the sentence.

The Lee Silverman Voice Treatment program is a 4 week, intensive voice therapy program, covered by most insurance companies, including Medicare. For an appointment to discuss the program at UCSF, call 415- 885-7700. Alternatively, a listing of all LSVT- trained speech pathologists in the country can be found on their website http://www.lsvt.org/main_site.htm

Some general suggestions that help some people with their voice/speech problem include the following:

• Face your listener when speaking.
• Express yourself in short, concise sentences.
  
• Take a breath before speaking and pause between phrases to take another breath.
  
• Exaggerate pronunciation, particularly of consonants.
  
• Pretend the listener is hard of hearing.

Voice treatment is most effective in the early and middle stages of Parkinson's. When a direct therapy technique is no longer helpful, some people with Parkinson's disease benefit from assistive devices such as amplification equipment, "communication boards," or computerized speech generating devices that may be used to communicate even when natural speech is difficult to understand.

Swallowing Problems in Parkinson's Disease

Although some people with Parkinson's disease will continue to eat normally throughout the course of the disease, many will develop difficulty chewing or swallowing. Early symptoms of difficulty in swallowing (also called "dysphagia") are of food sticking in the throat or of liquids "going the wrong way". For some, chewing may become more difficult or there may be difficulty in getting the swallow "started." Food may stick in the throat and esophagus. Later, the swallowing problem may become so severe that a diet change is required.

Some suggestions that have helped people with Parkinson's disease eat better include:

• Eat your meal after the Parkinson's medication has taken effect, usually 1 hour after taking the medication(s).
• Ensure that there is adequate time to eat
• Eat food that has been cut in small pieces-don't hesitate to ask a companion to cut up meat or foods.
• Try using "easy grip utensils."
• After swallowing food, swallow again 2 or 3 times to help all the food clear the throat.
• Drink liquids carefully. Thicker liquids may be easier for you to swallow without choking.
  

Swallowing problems should be reported to your doctor. In some circumstances referral to a speech pathologist may be recommended. Often the speech pathologist can provide strategies to make swallowing easier and avoid choking. In some instances, the specialist may use procedures to visualize a person's swallowing such as fluoroscopy (using x-rays) or laryngoscopy (using a flexible tube that goes through the nose to the throat). Exercises to strengthen the muscles used in swallowing are sometimes helpful.

Excess saliva is another common problem in Parkinson's disease. In most cases, the problem is not one of having too much saliva, but rather of not swallowing often enough. If the automatic reflex that causes us to swallow our saliva once every minute or two is not operational, saliva builds up in the mouth until it leaks out and the person notices drooling. This can be very embarrassing, of course. Once the problem is brought to the attention of the individual with Parkinson's disease, it can sometimes be alleviated by developing a habit of consciously swallowing every few minutes. Swallowing can be further stimulated by carrying a bottle of water and taking a sip every few minutes. If that does not help, a speech-language pathologist may recommend a more structured therapy program. Occasionally, botox injection to the salivary glands will reduce the saliva excreted by these glands for a few months.

For help with your speech, voice, and swallowing problems, ask your doctor for a referral to a speech-language pathologist. This person will be the most qualified professional to work with your problem. The American Speech-Language Hearing Association certifies speech-language pathologists. More information can be found at: www.asha.org. Don't wait till it is too late - prevention is the key to managing speech and swallowing problems.