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Dr. Mahler

Speech Clinician Moderators
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Dr. Mahler last won the day on February 27 2014

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About Dr. Mahler

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  • Birthday 01/01/1970

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  1. apps for speech rate

    The cause of speech and voice changes in People with PD results from motor and sensory changes. Apps can be very useful but may not fully address the cause of the communication disorder so the benefits may not generalize to functional communication. I would still recommend that you seek the advice of a speech-language pathologist in person for a plan individualized to your needs. Sincerely, Leslie Mahler, PhD, CCC-SLP
  2. apps for speech rate

    There is acoustic software that can calculate rate but there is an easier way to calculate rate. Read a passage for 1-2 minutes. Find a stable/representative 15 seconds and then count the number of syllables and multiply by 4. That will give you the number of syllables/minute and you can compare over time. Have you tried increasing loudness to normal loudness levels? That technique has been shown to reduce rate as well. Sincerely, Dr. Mahler
  3. Swallowing and Parkinson's

    Some individuals with PD may have a safe swallow but one that is less "efficient". That can result in reduced ability to manage secretions. Although needing suction to control the flow sounds like a significant problem with saliva control. It is possible that exercises to swallow with more effort could improve this situation. You will need to see a speech-language pathologist in person to determine if this is an appropriate option for you. Please write again if you have any further questions. Sincerely, Dr. Mahler
  4. LSVT Loud

    Dear DB, Thank you for your feedback about LSVT LOUD. I have a couple things to add to your description. One is that it is not a one size fits all program. It is true that the treatment protocol is 16 individual one-hour sessions administered 4 times a week for 4 weeks BUT the goals and the materials are customized to each individual. Another thing to bear in mind is that research from neuroscience has taught us that behaviors change before neural control of those behaviors. The goal of LSVT LOUD is for people with PD to be more successful communicators after the treatment is completed. There are changes in voice and speech behaviors that can occur early in the treatment but they need to be practiced many times to maintain long-term carryover and generalization to communication outside of the clinical environment. I am glad that you received the treatment before speech was a significant problem for you and that it was a success. I like your thinking that now you have techniques to use in the future as well. One of the keys to using those techniques successfully is to practice for 10 minutes every day and be sure you are using normal loudness throughout the day. Sincerely, Leslie Mahler
  5. Swallowing and Parkinson's

    Dear NN, Thank you for understanding that I cannot diagnose without seeing the patient in person. The information provided in this correspondence is not a substitute for medical or professional care. DH should seek the advice of his physician or other qualified health provider with questions regarding a medical condition and treatment. It sounds like there are multiple factors to consider in the case of DH. Like many people with PD, he was diagnosed in his 70's and like many people in their 70's, PD is often not the only factor to consider when trying to evaluate and make recommendations to treat speech and swallowing disorders. DH definitely needs an evaluation with a speech-language pathologist to address each of your important concerns. Here are some thoughts about the different components individually: The trigeminal nerve is important for speech and swallowing in several ways. It innervates muscles that elevate and close the jaw and provides sensation for the front part of the tongue. Therefore treatment for trigeminal neuralgia could definitely have an impact on speech (imprecise articulation) and swallowing (reduced control of the food in the oral stage). Therefore, it would be important for the SLP who treats him to know what the impact of those treatments were prior to his diagnosis of PD earlier this year. There are different types of PD. There is idiopathic PD and there are Parkinson Plus syndromes. Idiopathic PD does not typically progress so rapidly that there are noticeable changes in 5 months. Therefore, DH's physician needs to know about the noticeable deterioration in tremor, balance, cognition, and word-finding. The debate about "excess saliva" has a long history with the general opinion that people with PD do not actually produce more saliva but swallow less frequently and when they do swallow the swallow is weaker and less efficient giving the appearance of excess saliva. Exercises may be able to improve the swallow efficiency. I am curious about the description of "blocked" speech. Is that physical or is it trying to find the right word or a combination? The answer to that would be important for treatment recommendations. There has been research examining the link between pesticides and PD. To my knowledge, the link between Agent Orange and PD is not clear. However, if DH was in Vietnam that means that DH should be eligible to receive services from the VA, which provides speech-language pathology services. Swallowing disorders can occur at any time in PD although swallowing disorders are typically more severe as the disease progresses. I really don't know if his breathing will be restricted. It does not seem like a silly concern and you must have some reason for asking. This is a medical question for the doctor. If you see any signs of shortness of breath or difficulty getting his breath, then call the doctor immediately. In the meantime, I suggest practicing safe swallow guidelines: General Safe Swallow Recommendations: Eat sitting upright – in a chair is preferable – even for swallowing pills Eat slowly – take small bites and sips of liquid If DH has difficulty making the food go down or clearing the liquid, then swallow effortfully for each swallow and/or swallow twice. Watch the quality of foods that DH east to make sure they are high in nutrition. When swallowing is difficult, people tend to eat less, which makes what they eat even more important. Consult with a dietician or nutrition specialist for specific diet recommendations. Eat smaller more frequent meals throughout the day so you don’t get too fatigued during a meal. Be sure to stay hydrated – drink plenty of water and decaffeinated beverages. I hope this information helps. Please write again if you have further questions. Sincerely, Dr. Mahler
  6. Swallowing and Parkinson's

    Lonnise, It sounds like you have been doing a lot of research since your husband received his diagnosis. I am glad that you included a post to the NPF forums in your search for information. There is significant heterogeneity among people diagnosed with PD. Therefore, I can respond to your questions about swallowing and PD in a general way but encourage your husband to seek an evaluation with a speech-language pathologist who specializes in PD for recommendations specific to his needs. People with PD often have swallowing problems. I described some of the causes earlier in this email thread. A hiatal hernia can also cause swallowing changes such as those you described in your email. For example, frequent throat clearing and increased coughing can be associated with this diagnosis. Therefore, the swallowing changes your husband is experiencing are probably a combination of the hiatal hernia and PD. There are exercise programs to improve swallowing that may benefit your husband and I recommend that he begin as soon as possible. Therefore, in answer to your question, when you see the movement disorders specialist, ask that doctor to write a script for evaluation and treatment of speech and swallowing from a speech-language pathologist. Please write again if you have any additional questions. Sincerely, Dr. Mahler
  7. Swallowing problem and tracheostomy secreations

    Your father's swallowing disorder must be significant if he is have difficulty managing his own secretions and aspiration caused pneumonia that required the placement of a tracheostomy tube. It is impossible for me to say what should come next without seeing your father in person. Is he receiving swallowing therapy at the present time? If he is, ask the speech-language pathologist what the goals are and whether there is an expectation that your father could recover enough swallowing ability to eventually remove the tracheostomy tube. The speech-language pathologist in charge of his case will be able to tell you what to do next. If he is not receiving swallowing therapy, then you could request a referral to a speech-language pathologist who is experienced in treating people with PD. I wish you and your father the best. Sincerely, Dr. Mahler
  8. vocal exercise during playing a sport

    Shouting during physical exercise is sometimes part of the game and is fine but it won't take the place of speech and voice exercises that target normal loudness and speech that is easy to understand in conversation. I am glad that your speech and swallowing are "ok" in your perception but it would be better if you had an evaluation with a speech-language pathologist (SLP) who is an expert in speech and swallowing tell you that. The SLP could teach you about speech and swallowing changes associated with PD and discuss possible future treatment options. I have had many patients come to me for an evaluation who thought they were "ok" and I had a different assessment. Together we worked out a plan for treatment that was mutually acceptable. As someone with EOPD, you want to learn speech and swallowing exercises that will maintain your function for as long as possible for work and social participation. You have important things to say and the goal is to have people understand you easily. Please write again if you have any further questions. Sincerely, Dr. Mahler
  9. Swallowing and Parkinson's

    Your father's swallowing disorder must be significant if he is have difficulty managing his own secretions and aspiration caused pneumonia that required the placement of a tracheostomy tube. It is impossible for me to say what should come next without seeing your father in person. Is he receiving swallowing therapy at the present time? If he is, ask the speech-language pathologist what the goals are and whether there is an expectation that your father could recover enough swallowing ability to eventually remove the tracheostomy tube. The speech-language pathologist in charge of his case will be able to tell you what to do next. If he is not receiving swallowing therapy, then you could request a referral to a speech-language pathologist who is experienced in treating people with PD. I wish you and your father the best. Sincerely, Dr. Mahler
  10. Swallowing and Parkinson's

    The muscles of swallowing can be affected in the same was as limb muscles in people with PD. Rigidity, weakness, bradykinesia, and tremor can be present in muscles of the mouth and throat and that can cause changes in swallowing safety. The onset of swallowing disorders varies by individual but eventually, 90% of people with PD will have a swallowing disorder. This means it is very important to discuss any changes in swallowing, or unexplained weight loss, or more frequent coughing during meals with your physician. Those symptoms could indicate that you need a full swallowing evaluation with a speech-language pathologist. Thank you for writing with this important question. Please send a follow-up questions if you would like further information. Sincerely, Dr. Mahler
  11. Voice Problems

    Thank you for writing with this important question. People's communication needs change as PD progresses. It is good to hear that your husband benefited from treatment 3 years ago and it is possible that similar strategies could help again. However, it would be best practice to get a referral for an evaluation with a speech-language pathologist to assess your husband's current communication and swallowing. This will be covered by insurance. If strategies to increase loudness are still appropriate then some number of tune-up sessions may be sufficient. Patients do not always need to repeat the entire 16 sessions. In the meantime, it is a good idea to carry on with the homework exercises he was taught in LSVT LOUD. Please write again if you have any further questions. Sincerely, Leslie Mahler, PhD, CCC-SLP
  12. Voice Problems

    Thank you for writing with this important question. Speech problems are very common in people with Parkinson disease! It has been reported that as many as 89% of people with PD have trouble with their speech or voice. The most common difficulties include reduced vocal loudness, monotone, mumbled articulation and a hoarse or breathy sounding voice. Unfortunately, the medications that can be so helpful for improving limb movement don’t always have a positive effect for movement of speech muscles and increasing intelligibility. That is why people who have PD and communication difficulties need behavioral speech treatment. It is great that you are pursuing speech therapy and I want to describe research that supports specific treatment interventions. LSVT LOUD is currently the most researched treatment of speech disorders for people with PD. Development of LSVT LOUD began in the late 1980’s at a time when no behavioral speech treatments had been identified to ameliorate speech impairment for people with PD. Initial data reported in 1988 by Ramig and colleagues established the LSVT LOUD treatment protocol. Initial studies to develop LSVT LOUD methods provided the foundation for examining the mechanisms of change following treatment. Vocal sound pressure level (vocSPL) is the primary outcome variable because decreased loudness is a key perceptual features of hypokinetic dysarthria associated with PD. LSVT LOUD has been evaluated in research studies demonstrating statistically significant therapeutic effects in voice and speech with long-term maintenance up to two years post-treatment. In addition to increasing vocal vocSPL, there have been distributed effects of training increased loudness to more precise articulation, increased pitch variation, improved coordination of respiration and phonation, greater facial expression, and preliminary evidence demonstrated improved swallow function. LSVT LOUD consists of exercises to train increased amplitude of speech (increased vocSPL) as well as training individuals to monitor vocal loudness to learn the internal cue for scaling amplitude of speech production to achieve normal loudness during treatment tasks. Increased vocSPL serves as a single motor organizing theme for multiple speech production subsystems that may be impaired. LSVT LOUD is unique in comparison to existing treatment paradigms because the mode of treatment delivery is intensive and requires high effort consistent with theories of motor learning that drive activity-dependent changes in neural plasticity for long-term carryover and generalization of skill acquisition. That means the therapy must be administered four times a week for four weeks for a total of 16 individual treatment sessions in one month. In addition, LSVT LOUD is unique because it includes calibration activities to addresses sensory and internal cueing deficits that can be barriers to carryover and generalization of treatment effects for people with PD. Calibration refers to teaching the patient to recognize the internal sensory cue for normal loudness so they will use normal loudness consistently in communication situations outside the treatment room. It sounds like the treatment you have experienced is targeted to increase loudness but may not be a standardized approach. I recommend treatment that is supported by the literature. Ask your therapist for the available research on the approach being used with you. Please write again if you have any additional questions. Sincerely, Dr. Mahler
  13. Swallowing and Parkinson's

    Thank you for writing with this interesting question. Speech is sometimes referred to as an "overlaid" function. That means that the muscles used for swallowing and speech overlap. Therefore, it is not surprising that if a person is having difficulty with speech, then they might also have difficulty with swallowing or vice versa. There are a number of reasons why swallowing can be "difficult" for a person with PD and it is important for the health care team to understand these issues. Appropriate treatment techniques to address swallowing disorders in PD need to address the motor and sensory components. Dysphagia can occur in all stages of swallowing in people with PD. Typical changes associated with the oral phase of swallowing can include: Reduced tongue strength => tongue and/or palatal residue Reduced anterior to posterior tongue coordination and lateralization => decreased bolus formation & transport Lingual rocking during bolus formation Lingual tremor Prolonged ramplike posture Piecemeal deglutition (El Sharkawi et al., 2001; Volonte, Porta, & Comi, 2002; Hunter et al., 1997; Bushmann et al., 1989; Robbins et al., 1986) Typical changes associated with the pharyngeal phase of swallowing include: Delayed pharyngeal response Delayed triggering of the swallow reflex Impaired motility with residue in valleculae and pyriform sinuses Penetration and/or aspiration (El Sharkawi et al., 2001; Leopold & Kagel, 1997 ; Potulska et al., 2003; Robbins et al., 1986) Aspiration before the swallow may occur as a result of premature material spilling over the tongue base with and reduced vocal fold closure. Aspiration after the swallow may occur secondary to significant amounts of pharyngeal residue that is aspirated when respiration is resumed (Robbins et al., 1986) or incoordination of breathing and swallowing (Gross et al., 2008). Please write again if you have additional questions. Sincerely, Leslie Mahler
  14. Literature for swallowing strengthening

    Without seeing you in person, it is hard for me to determine what exercises are best suited to improve your "swallow issues". I have not read any studies supporting the movements that you have described for improving swallowing in people with PD. Changes in swallowing are frequently found in people with PD. It has been reported that as many as 95% of people with PD have dysphagia (Bird, Woodward, Gibson, Phyland, & Fonda, 1994; Logemann, Blonsky & Boshes, 1975; Potulska, Friedman, Krolicki & Spychala, 2003). When dysphagia is present it has a negative impact on quality of life by interfering with the ability to take medications, maintain hydration and nutrition, and may result in aspiration pneumonia. Pneumonia is one of the leading causes of death in PD (Beyer, Herlofson, Arsland, & Larson, 2001; D’Amelio, Ragonese, Morgante, Reggio, Callari, Salemi & Savettieri, 2006). Even when there are no difficulties with swallowing, mealtimes can be effortful for people with PD possible causing them to fatigue easily and eat less. Muscle rigidity, weakness and bradykinesia that are present in the limbs can also affect all phases of swallowing (Robbins et al. 1986; Labuszewski & Lidsky, 1979). In addition, sensorimotor abnormalities may reduce the person’s awareness of symptoms of dysphagia. Some Symptoms of swallowing disorders called, “dysphagia” may include: Frequent coughing during meals Coughing while drinking liquids or taking pills A wet gurgly sounding voice quality Recent unexplained weight loss Recent diagnosis of pneumonia Difficulty making the food “go down” Which symptoms are you experiencing? There are a number of reasons why swallowing can be "difficult" for a person with PD. The reason you need to get a referral for an evaluation with a speech- language pathologist (SLP) is so that they can identify the unique causes of the swallowing difficulty for you as an individual. The evaluation usually consists of an examination of the muscles for chewing and swallowing and then possibly a modified barium swallow study if the SLP suspects a problem in the pharyngeal stage of the swallow, which is more difficult to observe directly. When the evaluation is done the SLP should be able to describe your swallowing problems, the underlying physiology causing the problems, your risk for aspiration, and treatment strategies that appropriately address the cause of the problems. Although people with PD share a common etiology there may still be heterogeneity within the population regarding the cause of swallow problems. There are a number of reasons why swallowing can be "difficult" for a person with PD and it is important for the health care team to understand these issues. Appropriate treatment techniques to address swallowing disorders in PD need to address the motor and sensory components. Common treatment approaches for swallowing deficits in PD include: Modifying bolus flow with postures Maneuvers to improve airway protection or airway clearance Alterations in diet consistency Sensory stimulation Exercises to improve swallow function Alterations in feeding environment I recommend that you get a referral for a swallowing evaluation with a speech-language pathologist to learn what can be done to maximize swallow safety and oral intake in addition to consulting about specific diet recommendations. Sincerely, Leslie Mahler, PhD, CCC-SLP
  15. Difficulty understanding my husband

    Thank you for writing with this important question. Speech problems are very common in people with Parkinson disease! It has been reported that as many as 89% of people with PD have trouble with their speech or voice. The most common difficulties include reduced vocal loudness, monotone, mumbled articulation and a hoarse or breathy sounding voice. Unfortunately, the medications that can be so helpful for improving limb movement don’t always have a positive effect for movement of speech muscles and increasing intelligibility. That is why people who have PD and communication difficulties need behavioral speech treatment. The experience of having difficulty finding the right words may also be common for people with Parkinson's disease particularly as the disease progresses. Both of these can have a negative impact on quality of life and I am glad that you wrote to learn more about it. The difficulties initiating speech and slower thinking are similar to difficulties in limb movements with delayed initiation and slowness of movement. Bradykinesia is the term typically used to describe this slowed initiation of movement. The underlying cause of some of speech and voice difficulties has multiple sources: • Reduced vocal fold adduction • Reduced mouth opening • Decreased dynamic modulation of muscles of articulation • Mismatch between the person’s perception of their loudness during communication and actual levels of loudness Many times there is also a mismatch between the person’s perception of their loudness during communication and actual level of loudness and understandability just as the one you reported. For example, someone with PD may think people in their family need hearing aids when in fact it is the person with PD who is speaking too softly to be easily understood. No wonder you thought you needed a hearing aid. Unfortunately, the medications that can be so helpful for improving limb movement don’t always have a positive impact on bradykinesia for movement of speech muscles. That is why people who have communication difficulties as a result of PD need behavioral speech treatment. Research has shown that the homework component of treatment is critical for long-term success and carryover outside of the clinical environment. The good news is that speech treatment may help your husband. I recommend that you speak to your physician and get a referral to a speech-language pathologist (SLP). Find an SLP who is experienced in treating communication deficits associated with PD. That person will do an evaluation to determine how much of your difficulty is due to changes in speech motor control and how much may be caused by changes in cognitive/linguistic abilities. The significant memory changes that you described in your email are of concern so soon after diagnosis and is something that should e evaluated specifically. I hope this information helps and that you will seek an evaluation soon to get started on improving your communication skills. Please write again if you have any additional questions. Sincerely, Dr. Mahler
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