Parkinson’s and SpeechSpeech-Language Pathologist
UF Health Rehab Center at the Norman Fixel Institute for Neurological Diseases
12/11/2020
Gainesville, Florida
3. Speech changes in atypical Parkinsonism
4. Treatment / Strategies
communicating thoughts by speaking.
Exchange of spoken words.
A. Yes. I’ve attend/attended speech therapy sessions.
B. Yes. Only for speech evaluation.
C. No.
Impacts as many as 90% of people with PD
Hypokinetic dysarthria
Reduced volume
Short rushes of fast speech or faster rate
Reduced clarity
Stuttering
(Duffy, 2013; Logemann et al., 1978; Müller et al., 2001; Tjaden, 2008)
Why?
Impacts as many as 90% of people with PD
Hypokinetic dysarthria
1. Hypokinesia
2. Rigidity
(Caligiuri, 1989; Goberman & Coelho, 2002; De Letter et al. 2007a)
Why?
Articulation
Lower amplitude and velocities of movements of articulators (lips and jaw)
Let’s try…
Speech Breathing
Rely more on abdominal breathing to change lung volume
Smaller rib cage volume initiations
Less contribution of rib cage to overall lung volume change
Let’s try…
(Solomon & Hixon, 1993; Huber et al., 2003; Huber & Darling-White, 2017)
Perception of speech
changes in PD
perceptual findings
Difficulty regulating volume
(Fox & Ramig, 1997; Ho, Bradshaw, Iansek, & Alfredson, 1999; Kwan & Whitehill., 2011)
Speech changes in atypical parkinsonism
Progressive Supranuclear Palsy (PSP)
Multiple System Atrophy (MSA)
Dementia with Lewy bodies (DLB)
Hypokinetic dysarthria
Apraxia of Speech
(Kluin et al., 1996; Müller et al., 2001; Rusz et al., 2015)
• Imprecise articulation
• Strained-strangled vocal quality
Speech & PD Medication
(Wolfe et al., 1975; Skodda et al., 2010; Jiang et al., 1999; De Letter et al., 2007a; Sanabria et al., 2001;
Ho et al., 2008; Kompoliti et al., 2000)
Inconclusive for levodopa therapy.
Speech & Deep Brain Stimulation (DBS)
Dysarthria is less responsive to deep brain stimulation than global motor limb dysfunction.
STN:
GPi DBS: 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.
(Chiu et al., 2020; Gross et al., 1997; Krause et al., 2001; Pinto et al., 2004; Skodda, 2012; Tsuboi et al., 2015)
Treatment – Hypokinetic dysarthria
Home exercises for carryover
Loudness
Intonation
Speaking rate
(Mahler et al., 2015; Ramig, Sapir, Countryman, et al., 2001; Ramig, Sapir, Fox, et al., 2001, Ramig et al., 2018)
Home exercises for carryover
LOUD Crowd® (group therapy)
Loudness
the Lombard reflex
Threshold PEP (Philips)
Pocketalker/dp/B003IQN8WA
voice-amplifier
Provide context
“SLOP” strategies
S = Slow
L = Loud
O = Over-articulation
“SLOP” strategies
S = Slow
L = Loud
O = Over-articulation
Over-articulation
• Helps to improve clarity/precision (improve
“mumbling”)
“SLOP” strategies
S = Slow
L = Loud
O = Over-articulation
breaths
Taking a deeper breath at the beginning of each sentence
• Helps to improve loudness
Listener Strategies
Let the listener know what you did not hear/understand
Confirm/summarize what you heard
Conclusion
language pathologist
Baseline evaluation
Annual re-evaluation
communication strategies.
References 1. Behrman, A., Cody, J., Elandary, S., Flom, P. & Chitnis, S. (2020). The effect of SPEAK OUT! And The Loud Crowd on dysarthria due to Parkinson’s
disease. American Journal of Speech-Language Pathology, 29(3), 1448-1465.
2. Caligiuri, M P. “The influence of speaking rate on articulatory hypokinesia in parkinsonian dysarthria.” Brain and language vol. 36,3 (1989): 493-502.
3. Chiu, S. Y., Tsuboi, T., Hegland, K. W., Herndon, N. E., Shukla, A. W., Patterson, A., Almeida, L., Foote, K. D., Okun, M. S., & Ramirez-Zamora, A.
(2020). Dysarthria and Speech Intelligibility Following Parkinson's Disease Globus Pallidus Internus Deep Brain Stimulation. Journal of Parkinson's
disease, 10(4), 1493–1502.
4. Darling-White, M. & Huber, J. (2017). The impact of expiratory muscle strength training on speech breathing in individuals with Parkinson’s disease: A
preliminary study. American Journal of Speech-Language Pathology, 26(4), 1159-1166.
5. De Letter, M, Santens, P, De Bodt, M, Van Maele, G, Van Borsel, J, & Boon, P. (2007a). The effects of levodopa on respiration and word intelligibility in
people with advanced Parkinson’s disease. Clin Neurol Neurosurg, 109, 495–500.
6. Duffy, J. (2013). Motor speech disorders: Substrates, differential diagnosis, and management (3rd edition ed.). St. Louis: Elsevier Mosby.
7. Forrest K, Weismer G, Turner GS. (1989). Kinematic, acoustic, and perceptual analyses of connected speech produced by Parkinsonian and normal
geriatric speakers. J Acoust Soc Am., 85, 2608– 2622.
8. Fox, C. & Ramig, L. (1997). Vocal sound pressure level and self-perception of speech and voice in men and women with idiopathic Parkinson disease.
American Journal of Speech-Language Pathology, 6(2), 85-94.
9. Goberman, A. M., & Coelho, C. (2002). Acoustic analysis of parkinsonian speech I: speech characteristics and L-Dopa
therapy. NeuroRehabilitation, 17(3), 237–246.
10. Gross, C., Rougier, A., Guehl, D., Boraud, T., Julien, J., & Bioulac, B. (1997). High-frequency stimulation of the globus pallidus internalis in Parkinson's
disease: A study of seven cases. Journal of Neurosurgery , 87 (4), 491-498.
11. Huber, J. & Darling-White, M. (2017). Longitudinal changes in speech breathing in older adults with and without Parkinson’s disease. Seminars in
Speech and Language, 38(3), 200-209.
12. Huber JE, Stathopoulos ET, Ramig LO, Lancaster SL.(2003) Respiratory function and variability in individuals with Parkinson’s disease: Pre- and post-
Lee Silverman Voice Treatment. Journal of Medical Speech-Language Pathology, 11(4), 185–201.
13. Huber, J., Stathopoulos, E., Sussman, J., Richardson, K., Matheron, D., & Snyder, S. Changes to Speech Production after SpeechVive Treatment in
Individuals with Parkinson’s Disease [abstract]. Mov Disord. 2019; 34 (suppl 2). https://www.mdsabstracts.org/abstract/changes-to-speech-production-
after-speechvive-treatment-in-individuals-with-parkinsons-disease/. Accessed December 7, 2020.
14. Ho, AK, Bradshaw, JL, & Iansek, R. (2008) For better or worse: the effect of levodopa on speech in Parkinson’s disease. Mov Disord, 23, 575–580.
15. Ho AK, Bradshaw JL, Iansek R, Alfredson R. Speech volume regulation in Parkinson's disease: effects of implicit cues and explicit instructions.
Neuropsychologia. 1999 Dec;37(13):1453-60.
16. Jiang, J, Lin, E, Wang, J, & Hanson, D. (1999). Glottographic measures before and after levodopa treatment in Parkinson’s disease. Laryngoscope, 109,
1287–1294.
17. Kompoliti, K, Wang, QE, Goetz, CG, Leurgans, S, & Raman, R (2000). Effects of central dopaminergic stimulation by apomorphine on speech in
Parkinson’s disease. Neurology, 54, 458–462.
18. Kluin, K., Gilman, S., Lohman, M., & Junck, L. (1996). Characteristics of the dysarthria of multiple system atrophy. Archives of Neurology, 53(6), 545-8.
References 19. Krause, M., Fogel, W., Heck, A., Hacke, W., Bonsanto, M., Trenkwalder, C., et al. (2001). Deep brain stimulation for the treatment of Parkinson's
disease: Subthalamic nucleus versus globus pallidus internus. Journal of Neurology, Neurosurgery, and Psychiatry , 70 (4), 464-70.
20. Kwan LC, Whitehill TL. Perception of speech by individuals with Parkinson's disease: a review. Parkinsons Dis. 2011;2011:389767.
21. Logemann, J., Fisher, H., Boshes, B., & Blonsky, E. (1978). Frequency and cooccurence of vocal tract dysfunctions in the speech of a large sample of
Parkinson patients. Journal of Speech and Hearing Disorders , 43, 47-57.
22. Mahler, L. Ramig, L., & Fox, C. (2015). Evidence-based treatment of voice and speech disorders in Parkinson disease. Current Opinion in
Otolaryngology & Head and Neck Surgery, 23(3), 209-215.
23. Miller N, Allcock L, Jones D, Noble E, Hildreth AJ, Burn DJ. Prevalence and pattern of perceived intelligibility changes in Parkinson’s disease. J Neurol
Neurosurg Psychiatry 2007;78:1188–1190
24. Müller J., Wenning G.K., Verny M., McKee, A., Chaudhuri, K.R., Jellinger, K., Poewe, W., Litvan, I. (2001). Progression of Dysarthria and Dysphagia in
Postmortem-Confirmed Parkinsonian Disorders. Arch Neurol, 58(2):259–264.
25. Patel, B., Legacy, J., Hegland, KW., Okun, M., & Herndon, N. A comprehensive review of the diagnosis and treatment of Parkinson’s disease dysphagia
and aspiration. Expert Review of Gastroenterology & Hepatology, 2020. 14(6): 411-424.
26. Pinto, S., Ozsancak, C., Tripoliti, E., Thobois, S., Limousin-Dowsey, P., & Auzou, P. (2004). Treatments for dysarthria in Parkinson's disease. The
Lancet Neurology , 3 (9), 547-56.
27. Ramig L, Sapir S, Countryman S, et al. Intensive voice treatment (LSVT1) for individuals with Parkinson disease: a two-year follow-up. J Neurol
Neurosurg Psychiatry 2001; 71:493–498.
28. Ramig L, Sapir S, Fox C, Countryman S. Changes in vocal intensity following intensive voice treatment (LSVT1) in individuals with Parkinson disease: a
comparison with untreated patients and age-matched controls. Mov Disord 2001; 16:79–83.
29. Ramig, L., Halpern, A., Spielman, J., Fox, C., & Freeman, K. (2018). Speech treatment in Parkinson’s disease: Randomized controlled trial (RCT).
Movement Disorders, 33(11), 1777-1791.
30. Rusz, J., Bonnet, C., Klempí, J., Tykalová, T., Baborová, E., Novotny, M., Rulseh, A., & Rika, E. (2015). Speech disorders reflect differing
pathophysiology in Parkinson’s disease, progressive supranuclear palsy and multiple system atrophy. Journal of Neurology, 262(4), 992-1001.
31. Sanabria, J, Ruiz, PG, Gutierrez, R, Marquez, F, Escobar, P, Gentil, M, & Cenjor, C. (2001). The effect of levodopa on vocal function in Parkinson’s
disease. Clin Neuropharmacol, 24, 99–102.
32. Sapir S, Ramig LO, Fox CM. Intensive voice treatment in Parkinson’s disease: Lee Silverman Voice Treatment. Expert Rev Neurother 2011;11:815–830.
33. Skodda S. (2012). Effect of deep brain stimulation on speech performance in Parkinson's disease. Parkinson's disease, 2012, 850596.
34. Skodda, S., Visser, W., & Schlegel, U. (2010). Short- and long-term dopaminergic effects on dysarthria in early Parkinson’s disease. Journal of Neural
Transmission, 117(2), 197-205.
35. Solomon NP & Hixon TJ. (1993). Speech breathing in Parkinson’s disease. J Speech Hear Res., 36, 294–310.
36. Stathopoulos, E.T., Huber, J.E., Richardson, K., Kamphaus, J., DeCicco, D., Darling, M., Fulcher, K., and Sussman, J.E. (2014). Increased vocal
intensity due to the Lombard effect in speakers with Parkinson’s disease: Simultaneous laryngeal and respiratory strategies. Journal of Communication
Disorders, 48, 1-17 (PMID: 24438910). doi: 10.1016/j.jcomdis.2013.12.001
disease, 6(4), 811-819.
38. Tjaden, K. (2008). Speech and swallowing in Parkinson’s disease. Topics in Geriatric Rehabilitation, 24(2), 115-126.
39. Tsuboi, T., Watanabe, H., Tanaka, Y., Ohdake, R., Yoneyama, N., Hara, K., Nakamura, R., Watanabe, H., Senda, J., Atsuta, N., Ito, M., Hirayama, M.,
Yamamoto, M., Fujimoto, Y., Kajita, Y., Wakabayashi, T., & Sobue, G. (2015). Distinct phenotypes of speech and voice disorders in Parkinson's disease
after subthalamic nucleus deep brain stimulation. Journal of neurology, neurosurgery, and psychiatry, 86(8), 856–864.
40. Walsh, B. & Smith, A. (2012). Basic parameters of articulatory movements and acoustics in individuals with Parkinson’s disease. Movement Disorders,
27(7), 843-850.
41. Wolfe, VI, Garvin, JS, Bacon, M, & Waldrop, W. (1975). Speech changes in Parkinson’s disease during treatment with L-dopa. J Commun Disord, 8,
271–279.
Thank You