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. 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