Parkinson’s Disease

1. Parkinson’s Disease Role of Speech Language Pathology Dr. Mariam H Syeda Speech-Language Pathologist MBBS, CCC-SLP Ziauddin College of Speech Language Therapy

2. Speech Language Pathology

3. Areas Affected in Parkinson’s • Voice • Speech • Swallow • Cognition

4. Outline • Area Affected in PD • Symptoms • Causes • Evaluation/Treatment • Tips to take home • Available Resources – ZCSLT • Projects

5. Voice

6. 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)

7. 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

8. 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.

9. Evaluation • Informal • Recordings • Voice tasks • Formal • DRS (Dr. Speech) • Virtual Voice Trainer

10. Treatment • Traditional Voice Therapy • Specific voice rehabilitation programs • LSVT • Voice evaluation/treatment software • DRS

11. 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)

12. 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”

13. 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)

14. 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).

15. 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

16. 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.

17. 6 Components of DRS

18. 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)

19. 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

20. 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? ➹

21. 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.

22. Speech

23. Speech Characteristics • HypokineticDysarthria • 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”

24. Speech characteristics • HypokineticDysarthria: • Monopitch • Monoloudness • Reduced stress • Short phrases • Variable rate • Short rushes of speech • Imprecise consonants

25. Cause of unclear speech: • 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

26. Speech Evaluation • Oro-motor Examination • Speech Assessment Batteries • DRS – • Quantitative data

27. Therapy for Clear Speech • Conventional speech therapy exercises • DRS • Delayed Auditory Feedback (DAF) • Rate of speech • Voice Amplifiers

28. Speech Exercises • lip strength and flexibility exercises • tongue strength and flexibility exercises

29. Example… Purse lips, pucker and say OOO…

30. Example… Blow air through straw while putting up cheeks as much as possible.

31. 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

32. 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

33. swallow

34. Swallowing Swallowing • Oral Phase • Pharyngeal Phase • Esophageal Phase

35. 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

36. Effects of PD on swallowing • These behaviors were more prevalent in liquid than in semi-solids or solids.

37. 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

38. Evaluation • Evaluation • Informal • Bedside Swallow Evaluation • Formal • Modified Barium Swallow

39. Treatment • Treatment • Compensatory strategies • Diet modification • Liquids are the toughest • Pureed diet is easier • Therapeutic strategies • VitalStim Therapy • Neuromuscular electrical stimulation for Swallowing

40. VitalStim Dysphagia management • 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

42. 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

43. Ziauddin college of speech language therapy

44. Evaluation & Therapy for all areas in PD: • Voice • Swallow • Speech • Cognition • Sessions • One-on-one & Group • Each is session is for 30-45 mins

45. NEW projects

46. VitalStim Therapy Modified Barium Swallow Study

47. VOICE & SWALLOW LAB Video Stroboscopy Unit Digital Swallowing Station