Parkinson’s and Speech

Nicole Herndon, MS, CCC-SLP

Speech-Language Pathologist UF Health Rehab Center at the Norman Fixel Institute for Neurological Diseases

12/11/2020 Norman Fixel Institute for Neurological Diseases Gainesville, Florida Today’s Topics

1. Background 2. Speech changes in PD 3. Speech changes in atypical Parkinsonism 4. Treatment / Strategies 5. Conclusion Speech

 The power of expressing or communicating thoughts by speaking.  Exchange of spoken words. Poll

 Have you received speech therapy?

A. Yes. I’ve attend/attended speech therapy sessions.

B. Yes. Only for speech evaluation.

C. No. Speech

 Includes coordination of 4 subsystems  Respiratory  Phonatory  Articulatory  Resonatory

Retrieved from: https://www.the-scientist.com/features/why-human- speech-is-special--64351 Speech changes in Parkinson’s disease

Impacts as many as 90% of people with PD  Hypokinetic dysarthria  Reduced breath support for speech  Reduced volume  Hoarse or breathy vocal quality Why?  Short rushes of fast speech or faster rate  Reduced clarity  Monotone  Hypernasal resonance  Stuttering

(Duffy, 2013; Logemann et al., 1978; Müller et al., 2001; Tjaden, 2008) Speech changes in Parkinson’s disease

Impacts as many as 90% of people with PD  Hypokinetic dysarthria

1. Hypokinesia Why? 2. Rigidity

(Caligiuri, 1989; Goberman & Coelho, 2002; De Letter et al. 2007a) Articulation

 Lower amplitude and velocities of movements of articulators (lips and jaw)  Let’s try…  Jaw:  “ah” vs “ee”

 Lips:  “oh” vs “ee”  “sh” vs “s”  “b” vs “v”

(Forrest et al., 1989; Walsh & Smith, 2012) Speech Breathing

 Increased variability compared to age-matched controls  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

 Perceptions of speech changes often do not match auditory- 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) Ataxic dysarthria • Imprecise articulation  Hypokinetic dysarthria  Mixed hypokinetic and spastic dysarthria • Slow rate of speech  SL variant: apraxia of speech • Intermittent hypernasal  Multiple System Atrophy (MSA) resonance  MSA-P: hypokinetic dysarthria • Excess and equal stress  MSA-C: mixed hypokinetic and ataxic dysarthria • Variable inflection  Dementia with Lewy bodies (DLB) Spastic dysarthria

 Hypokinetic dysarthria • Slow rate of speech  Corticobasal Degeneration (CBD) • Strained-strangled vocal  Hypokinetic dysarthria quality  Apraxia of Speech

(Kluin et al., 1996; Müller et al., 2001; Rusz et al., 2015) Speech & PD Medication

 Inconclusive for levodopa therapy.

(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) Speech & Deep Brain Stimulation (DBS)

 Dysarthria is less responsive to deep brain stimulation than global motor limb dysfunction.  STN:  Speech intelligibility has a poor response to STN stimulation.  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

 Remediation  Programs & Trainings  Compensatory  Voice Amplifier  Augmentative-Alternative Communication (AAC)  Communication Strategies  Speaker  Listener Treatment – Hypokinetic dysarthria

 Lee Silverman Voice Treatment - LSVT Loud™ (https://www.lsvtglobal.com/LSVTLoud)

Loudness Intonation Speaking rate Vocal quality Clarity

 Four 1-hour sessions/week for 4 weeks; one-on-one  Home exercises for carryover  Maintenance exercises for continued benefits

http://parkinsonsecrets.com/blog/2020/10/24/ndt9mequsp3zr5xeni838gb0r0x0h5

(Mahler et al., 2015; Ramig, Sapir, Countryman, et al., 2001; Ramig, Sapir, Fox, et al., 2001, Ramig et al., 2018) Treatment – Hypokinetic dysarthria

 SPEAK OUT! ® (https://www.parkinsonvoiceproject.org/OurSpeechTherapyProgram)

Loudness Perception of voice function

 ~12 speech therapy sessions  Includes speech and cognitive exercises  Home exercises for carryover  Maintenance exercises for continued benefit  LOUD Crowd® (group therapy)

(Behrman et al., 2020; Levitt et al., 2015) Treatment – Hypokinetic dysarthria

 SpeechVive (https://www.speechvive.com)  Wearable speech device that uses multi-talker babble to elicit the Lombard reflex

Loudness Length of utterance Clarity Intonation

(Huber et al., 2019; Stathopoulos et al., 2014) EMST150 device (Aspire, LLC) Expiratory Muscle Strength Training Threshold PEP (Philips)

 Preliminary evidence that it may help with speech breathing

(Image taken from Patel et al., 2020)

(Darling & Huber, 2017) Other options

 Voice Amplifier

Pocketalker (Williams Sound) Spokeman (KEC Innovations) Image retrieved from: https://www.amazon.com/Williams-Sound-PKT-D1- Chattervox® Pocketalker/dp/B003IQN8WA Image retrieved from: https://www.harc.com/products/chattervox- voice-amplifier

 Augmentative-Alternative Communication (AAC)

 Low and high-tech options Communication Strategies

https://www.parkinson.org/Living-with-Parkinsons/Resources-and- Support/PD-ExpertBriefings-Webinars/Archives Speaker Strategies

 Face-to-face  Reduced background noise/distractions  Get attention of listener prior to speaking  Provide context  Fill in information listener did not hear/understand “SLOP” strategies

 S = Slow  L = Loud  O = Over-articulation  P = Pausing for more frequent breaths “SLOP” strategies

 S = Slow  L = Loud  O = Over-articulation  P = Pausing for more frequent breaths

Over-articulation Larger movements of ‘articulators’ while speaking; focus on precision of each syllable. • Helps to improve clarity/precision (improve “mumbling”) • Helps to slow down rate “SLOP” strategies

 S = Slow  L = Loud  O = Over-articulation  P = Pausing for more frequent breaths

Speech Breath Taking a deeper breath at the beginning of each sentence • Helps to improve loudness • Maintenance of loudness • Can help improve vocal quality Listener Strategies

 Face-to-face  Reduced background noise/distractions  Get attention of listener prior to speaking  Let the listener know what you did not hear/understand  Confirm/summarize what you heard  Give speaker time to respond Conclusion

 Recommend a formal speech evaluation by speech- language pathologist  Baseline evaluation  Annual re-evaluation  Individualized speech therapy  Programs / trainings, compensatory strategies, communication strategies. References

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Nicole Herndon, MS, CCC-SLP

E-mail: [email protected]