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SkeeterElf

Difficulty pronouncing words and swallowing issues

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SkeeterElf    32

I was diagnosed with PD back in January 2013.  I have had issues with slurred speech and now seem to be having troubles with getting some words out.  I have also had issues with both chewing and swallowing foods. 

 

I have discussed these symptoms with my neurologist and I get the feeling that these symptoms are nothing to be too concerned about but I am concerned about it.  I'm certain that the symptoms are related to my Parkinson's and was wondering if seeing a Speech Therapist could help with both speech issues and swallowing issues.  

 

I cut my food up into very small pieces therefore I don't have any real problems with choking.  I can only take small pills because I do choke, gag and throw up in my attempts at trying to swallow certain sized pills.  I've even tried breaking them up into halves and quarters but still have difficultly in swallowing them.  I can not drink out of a cup or glass without the use of a straw or I drool or dribble the drink onto my clothing.

 

So can seeing a Speech Therapist help with any of the above listed symptoms/issues that I have?  If so, do I go through my neurologist for a referral to see a Speech Therapist or can I call and schedule an appointment on my own.  

 

Thank you in advance for your assistance and advice regarding my symptoms.  

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Dr. Mahler    19

Dear SkeeterElf,

 

Thank you for writing with this important question.  Of course speech and swallow changes are important and you should follow-up.  Your physician may not be aware of the extensive literature about the efficacy of speech and swallow interventions to help people with PD.  You will need a prescription for speech/swallow evaluation and treatment from a physician.  Below is some information about the incidence of speech and voice disorders in people with PD and why we recommend early referral for evaluation and treatment.

 

 

Incidence of speech and voice disorders in people with PD

Nearly 90% of people with PD will develop speech disorders during the course of the disease, which can have a negative impact on functional communication contributing to decreased quality of life for people with PD and their families.  Speech disorders associated with PD are most commonly characterized by one or a combination of the following speech impairments; reduced vocal loudness; a breathy or harsh voice quality; imprecise consonants and distorted vowels; and reduced voice pitch inflections or monotone voice collectively called hypokinetic dysarthria. 

 

Voice and speech deficits in people with PD include reduced vocal fold adduction and asymmetrical patterns of vocal fold vibration; reduced neural drive to laryngeal muscles; poor reciprocal suppression of laryngeal and respiratory muscles; and a reduction in respiratory muscle activation patterns, all of which contribute to the perceptual feature of significantly decreased loudness in people with PD. 

 

Origin of speech disorders in people with PD

Over the last 25 years we have learned a lot about the neuroscience of PD, which has led to an increased understanding of the underlying neurophysiology associated with changes in voice and speech.  It is well established that the symptoms of PD are associated with alterations in basal ganglia circuitry due to a decrease in dopamine that affects motor and sensory systems   Recent research suggests that these changes begin before the onset of PD symptoms and therefore, before the diagnosis of PD by a neurologist. Therefore, it is recommended that patients receive LSVT LOUD at diagnosis or soon after to obtain the maximum benefit from the treatment for the greatest possible length of time.

 

Pharmacological and neurosurgical approaches for people with PD have not demonstrated as consistent or significant impact on voice and speech disorders in people with PD.  Therefore, a behavioral speech intervention for people with PD is needed to effectively improve voice and speech disorders. 

 

Please write again if you have additional questions or concerns.

 

Sincerely,

Dr. Mahler

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Dr. Mahler    19

Dear SkeeterElf,

 

Here is more information about the impact of PD on swallowing.  I can't assess your problem online but if you feel you are experiencing swallowing problems at this time, then follow up soon before you experience any potential health consequences as a result of swallowing problems.  You also need a physician referral for a swallowing evaluation.

 

Swallowing and PD

 

Changes in swallowing are frequently found in 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”

 

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.

 

Sincerely,

Dr. Mahler

 

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swva    81

I am newly diagnosed but I have noticed difficulty swallowing certain foods. Apples and other things that have solids and juices seem to cause me to get strangled.

I have also noticed some type of stutter where I will repeat a word either at the beginning or in the middle of a sentence.

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Dr. Mahler    19

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 that 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.

 

Raw fruits and vegetables are typically more difficult to chew and swallow.  Cooked fruits and vegetables are easier.  If you are finding it effortful to finish a meal then you want to manage your food consistencies so that you don't tire yourself with chewing and still have good muscle control for swallowing foods safely.  Chopping foods or eating cooked fruits and vegetables help accomplish this goal.

 

Please write again if you have any further questions.

 

Sincerely,

Dr. Mahler

 

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SkeeterElf    32

I will request a referral for a Speech Language Pathologist next week.  I do not have to much difficulty eating and swallowing soft foods but most meats are not my menu anymore because it does take so much effort to cut it up int small enough pieces and swallow it.  It does tend to tire me out just eating.  Taking pills is very difficult. What exactly does a Barium Swallow Test entail.  When and if they do opt to do barium swallow will they allow me to use a straw if there are liquids involved?  I can not drink straight out of a cup anymore without it coming out of my mouth or by drooling.  I am interested to learn more about this test.

 

What should I  do if my neurologist doesn't feel it necessary to refer me to a SLP - should I ask my primary care physician then?

 

Thank you for all the information you have supplied me with.  I didn't realize that the symptoms could lead to such serious issues if not taken care of.  I merely thought it was something that came with having PD and that I was just going to have to live with it. 

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Dr. Mahler    19

Dear SkeeterElf,

 

Voice and speech symptoms have been reported to occur very early in the diagnosis of PD and models of the physiology suggest that changes in the nervous system underlying voice and speech disorders begin long before the onset of symptoms and the actual diagnosis of PD.  Therefore, it is recommended that people with PD receive a referral to a speech-language pathologist at diagnosis or soon after to obtain the maximum benefit from recommendations and treatment for the greatest possible length of time. It is further recommended that each patient receive a laryngeal evaluation by an otolaryngologist prior to initiation of treatment as part of best practice to confirm a diagnosis of voice changes secondary to PD and eliminate the possibility of vocal fold pathology other than that associated with PD such as GERD or unilateral vocal fold paralysis. 

 

Most neurologists who specialize in movement disorders such as PD know the potential for the development of speech and swallowing problems and I would not expect resistance to requesting an evaluation.  The speech-language pathologist will give an expert opinion on the status of your individual speech and swallowing abilities and give you information about treatment possibilities for you to make the decision about what is right for you.

 

Sincerely,

Dr. Mahler

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Nailtatt    57

I have speaking issues when the meds are wearing off or not working very well. I stutter and get stuck on words. Very frustrating and embarrassing. Fortunately the meds, for the most part, stop it all together and I can speak clearly. I assume this is "normal" for PD people? I have heard and read a lot about not being able to speak loudly, but not much about the issue I deal with. My volume is good even in my off times.

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Dr. Mahler    19

Dear Nailtatt,

 

Thank you for writing with your question about your speech issues related to stuttering.  It is understandable that this could be frustrating and embarrassing.  It sounds like this might be “festinating” speech rather than stuttering per se.  Festinating speech, also called palilalia, can be a challenge for communication.  The phenomenon usually reflects bilateral basal ganglia pathology and is typically associated with more advanced PD.  Benke & Butterworth (2001) reported that palilalia is a speech disorder that probably reflects damage to motor circuits that stop an action.  Palilalia is characterized by repetition of syllables or words with gradually increasing rate and decreased loudness.  This means that people with palilalia may also have difficulty speaking at normal loudness and using normal pitch variation in speech.  Treatment is recommended to help the individual with palilalia to be more understandable.  A speech-language pathologist should be able to determine if repetitive speech is palilalia in an evaluation and determine the most appropriate treatment approach.

 

I recommend you seek a referral to a speech-language pathologist from your neurologist or physician soon.  The lack of ability to communicate clearly and understandably can be very frustrating and has a negative impact on quality of life.

 

Sincerely,

Leslie Mahler, PhD, CCC-SLP

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