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SSmithvi    0

Hi, my 92-year-old father has advanced Parkinson's disease, and he is having more and more difficulty talking which is really disconcerting, because I had to relocate for work and I can no longer communicate with him on the telephone.  We had to wean him off of Sinemet due to serious side effects, so the only medication that he takes regularly now is clonazepam.  He takes a 1/2 pill every other night.  He also takes Atrovent via a nebulizer when needed for excessive drooling and mucus in his throat.  However, my mom says he does not drool much anymore, so mucus does not seem to be the problem.  When he had bad days and had difficulty speaking, we treated him by giving him an Atrovent treatment, some mucinex and have him suck on some ice or sugarless candy.  However, since mucus does not seem to be the problem now, I wanted to know what you suggest.  I know our options are limited.  We have a caretaker, and I told my mom to make sure she continues to give him some vocal exercises, as there are no speech therapists in the area trained to help people with Parkinson's, but is there anything else we can do?  I read that some people get collagen injections, but I don't think my mom would go for that, and I don't think there is any ENT in the area that is trained to do that.  Also, if he is not drooling much anymore, does it make sense to continue his Atrovent treatment?  All of his food is pureed, but I know that he could still have food stuck in his throat due to the slow down in his ability to swallow.  I am at a loss as to what to do at this point.  I would appreciate any advice you can offer? 

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Dr. Mahler    19

The question that you are asking seems more of a medical question so I would refer you to a physician for information about how the medications might be affecting his speech and swallowing.  Treatment is considerably more challenging in the advanced stages of PD but could possibly still be helpful.  Only an individual evaluation with a speech-language pathologist who is experienced in treatment people with PD can provide the appropriate feedback for you father.  He is fortunate to have you as an advocate.

 

Sincerely,

 

Leslie Mahler

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Cinder    3

I have had several appointments with a speech pathologist.  My therapy was basically yelling and holding that note for a period of time at a certain decibel level.  I found this to be extremely embarrassing and cannot find a time or space to do it.  Does this really work?  Am I shortchanging myself?

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Dr. Mahler    19

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

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ljharper62    4

Hello Doctor Mahler,

 

My husband was diagnosed about 5 years ago and went through the LSVT Loud program 3 years ago which helped immensely for awhile. Now two years later he really needs to have some additional help with his speech. Unfortunately our medical insurance does not cover the therapy and the cost is too great for us to be able to pay for it out of pocket again. 

 

Is it still helpful if we start working on some of the exercises that were given to him at the time? I believe we have most of the practice sheets. Are there any other things we can work on at home to help him out?

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Dr. Mahler    19

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

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