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Speech & Swallowing Problems

People with Parkinson’s (PD) may notice changes in or difficulty chewing, eating, speaking or swallowing. These changes can happen at any time, but tend to increase as PD progresses. Just as PD affects movement in other parts of the body, it also affects the muscles in the face, mouth and throat that are used in speaking and swallowing.

Beyond producing the sounds of speech, PD symptoms like a frozen or masked face can make it harder to communicate the emotions that go along with what you are saying. Others may misinterpret this as a lack of interest in the conversation or aloofness. In addition, some people with PD struggle to find words, and so they may speak slowly. And in other cases, PD causes people to speed up their speech, so much that it may sound like stuttering.

The term for swallowing difficulty is dysphagia. It affects the mechanics of swallowing and quality of life. Many people become frustrated or embarrassed and isolate themselves from social activities, such as dining with friends or family. More importantly, dysphagia can lead to malnutrition, dehydration and aspiration (when food or liquid “goes down the wrong pipe”). Aspiration, which can be silent, (a person does not cough or choke) can lead to aspiration pneumonia — the leading cause of death in PD. Thus, it is important to ensure that people with PD can eat safely.

Answer the below questions to help you figure out if you have a speech, voice or swallowing problem. If many of these statements apply to you, visit a speech-language pathologist (SLP) especially if these changes begin to limit your life.

How do I know if I have a speech or voice problem?

  • My voice makes it difficult for people to hear me.
  • People have difficulty understanding me in a noisy room. 
  • My voice issues limit my personal and social life. 
  • I feel left out of conversations because of my voice.
  • My voice problem causes me to lose income.
  • I have to strain to produce voice.
  • My voice clarity is unpredictable.
  • My voice problem upsets me.
  • My voice makes me feel handicapped.
  • People ask, "What's wrong with your voice?"

How do I know if I have a swallowing problem?

  • I have recently lost weight without trying.
  • I tend to avoid drinking liquids.
  • I get the sensation of food being stuck in my throat.
  • I tend to drool.
  • I notice food collecting around my gum line.
  • I tend to cough or choke before, during or after eating or drinking
  • I often have heartburn or a sore throat.
  • I have trouble keeping food or liquid in my mouth. 

How are swallowing problems treated?

The first step to addressing swallowing issues is to speak to a neurologist about getting an evaluation performed by a SLP. This professional will take a medical history and interview the person with PD about eating and swallowing.

This is typically followed by either a video X-ray or an endoscopic examination, so the medical specialist can observe the swallowing process as an individual sips liquid and eats food, as these substances flow from the mouth, down the throat and esophagus, to the stomach. With these tests it is possible to see where the trouble is occurring and to recommend therapies.

Follow the recommendations of the swallowing specialist, which may include the following:

  • Exercise and Swallow Hard. Just as exercise can ease other PD-related movement difficulties, it can also help with swallowing. The Lee Silverman Voice Technique® (LSVT®) helps a person exaggerate speaking and swallowing. Working with an SLP on an individualized program helps the person to swallow hard and move food from the mouth down the throat.
  • Expiratory Muscle Strength Training. This therapy strengthens respiratory muscles, improves cough and swallowing and reduces aspiration.
  • Change in food. Modifying liquids and solids can help. For people who find liquids get into the airway, liquids may need thickening. Taking bigger or smaller bites or sips or pureeing solid foods may help. First get an evaluation, so the SLP can recommend how to modify food and liquid.

Additionally, people with PD tend to swallow less often and less completely. As a result, 70 percent have too much saliva, which often pools in their mouth. Sucking on hard candy, preferably sugarless, can stimulate swallowing and provide temporary relief from drooling. An effective treatment, available by prescription, is atropine eye drops taken on or under the tongue. Adjusting anti-PD medications may also make it easier to swallow. In addition, medical conditions unrelated to PD can lead to difficulty swallowing. Your doctor may diagnose swallowing difficulties with a modified barium swallow test.

How are speech problems treated?

There are many options to help improve your speech. A speech-language pathologist (SLP) can help you pick the right approaches for you. Speech-language pathologists are trained health care professionals who specialize in evaluating and treating people with speech, swallowing, voice, and language problems.

Ask your doctor for a referral to a speech-language pathologist. It is also important to contact your health insurance company to find out what therapy and procedures are eligible for reimbursement and to find a list of SLPs covered by your plan. Finally, visit a SLP who has experience treating people with PD. Call the free Parkinson’s Foundation Helpline at 1-800-4PD-INFO (473-4636) for help locating a speech-language pathologist in your area.

The Lee Silverman Voice Treatment

The Lee Silverman Voice Treatment (LSVT®) is the first speech treatment for PD proven to significantly improve speech after one month of treatment.

  • Exercises taught in the LSVT method are easy to learn and typically have an immediate impact on communication.
  • Improvements have been shown to last up to two years following treatment.
  • LSVT methods have also been used with some success in treating speech and voice problems in individuals with atypical PD syndromes such as multiple-system atrophy (MSA, formerly known as Shy-Drager syndrome) and progressive supranuclear palsy (PSP). 

LSVT® Guidelines

  • Must be administered four days a week for four consecutive weeks.
  • On therapy days, perform LSVT exercises one other time during the day. On non-therapy days, perform LSVT exercises two times a day.
  • Once you complete the four-week LSVT therapy, perform LSVT exercises daily to maintain your improved voice.
  • Schedule six-month LSVT re-evaluations with your specialist to monitor your voice.
  • If available in your area, participate in a speech group whose focus is on thinking loud.
  • A Digital Sound Level Meter can help you monitor voice volume. Place the meter at arm distance to perform the measurement. Normal conversational volume ranges between 68-74dB.

Collagen injections

Collagen injections have been used in the treatment of voice and speech impairment in PD:

  • Contact a recommended Ear, Nose and Throat (ENT) doctor for this type of treatment.
  • Collagen injections build up vocal folds that do not close completely while talking.
  • Procedure involves injecting collagen directly into the vocal folds.
  • Collagen effect typically lasts six months then must be re-injected.
  • Some people have reported improvement in their voice.

Assistive Communication Devices

When fatigue or other illness make it difficult to use your normal voice, an assistive communication device is helpful.

  • A personal amplification device is the device most often used by people with PD.
  • Other communication devices range from hand-made communication boards to computerized equipment.
  • A SLP can recommend an appropriate device.
  • Speech Easy is an FDA-approved feedback device used for stuttering. It is a small electronic device worn on the ear (similar to a hearing aid). People with problems in verbal fluency and stuttering usually benefit from this device. 

If you have any questions about speech problems, please visit the Talk to a Speech Clinician forum, where a team of experts answer questions regarding speech and people with Parkinson's.

Tips for Coping with Speech Difficulties

  • Exercise your voice by reading out loud or singing every day.
  • Drink enough water, avoiding shouting and rest your voice when it is tired.
  • Train your voice like an actor—sit and stand with good posture, do exercises for articulation, breathing and projecting the voice.
  • Get feedback from friends and family members about how others perceive your speech —develop a cue or code word you can use in public to make you focus on speaking clearly.
  • If you have soft speech, use tools such as a voice amplifier (microphone), placed on your shirt, and on the telephone (this device may help with soft speech, but not for mumbling/stuttering speech). Ask an occupational therapist (OT) about other tools.
  • Make eye contact with the person to whom you are speaking.
  • Reduce background noise.
  • Socialize in small groups or one-on-one.
  • If you experience a facial masking, use “feeling” words to communicate your emotions (“I feel happy, sad, excited,” or "I agree”). Use practice physical gestures to help convey emotions.
  • Determine which times of day your speech is best. Plan social engagements around those times.

Even in the early stages of PD, many report that their voices are too soft, causing others to ask them to repeat themselves. Other people with PD may have a gruff or hoarse quality to their voice. Try these strategies:

  • Take a breath before you start to speak.
  • Pause between phases to take in another breath.
  • Express your ideas in short, concise sentences.
  • Speak louder than you think is necessary.
  • Do not shout over noise when you talk.
  • Rest your voice when it is tired.
  • Reduce throat clearing or coughing. Try a hard swallow.
  • Reduce or eliminate heartburn.
  • If the air is dry in your home, use a humidifier.

Page reviewed by Dr. Chauncey Spears, Movement Disorders Fellow at the University of Florida, a Parkinson’s Foundation Center of Excellence.

 
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