In a high majority of people with Parkinson's, the disease also takes a toll on speech. The repercussions can be devastating as patients, unable to communicate clearly, withdraw from social interaction. A form of speech rehabilitation called LSVT compensates by training Parkinson's patients to talk more loudly.
How to recognize voice and speech problems
Parkinson's disease can impair muscles of the voice box, throat, mouth, tongue, and lips. Subtle changes may happen early, with the person's voice becoming softer and flat in tone, making it hard to hear. In advanced stages of Parkinson's, speech may become unintelligible.
Let the neurologist know if you notice these symptoms:
- Talking in a monotone, with little inflection in pitch
- Reduced speech volume
- Breathy or hoarse voice
- Mumbled speech, imprecise articulation
- Difficulties initiating speech
- Hesitant, sometimes stuttering speech
- Short, fast rushes of speech
How voice and speech troubles can harm a person's well-being
Parkinson's patients experience a sensory processing glitch in the brain that leaves them unable to detect that they're speaking quietly. Unaware of the problem, they are likely to feel frustrated at being asked to constantly re peat themselves. They may even complain that their spouse needs a hearing aid.
Parkinson's disease also often causes a loss of facial expressiveness. That change, combined with a soft, monotone voice, can lead family and friends to think the patient is "just depressed, apathetic, bored, disinterested -- whereas the person inside feels quite alive," says Cynthia Fox, a speech-language pathologist and researcher at the National Center for Voice and Speech in Denver.
The upshot is that others stop engaging patients in conversation. They may come to feel ignored, and such patients often give up, says Fox. They drop job responsibilities that require a lot of phone talk, and they avoid dining out because restaurant noise further drowns out their voices. "It's a real blow to self-confidence," says Fox.
What are the treatment options?
The standard Parkinson's drugs don't always work well for speech impairment. Although some people find that levodopa improves their communication, others don't. Deep brain-stimulation surgery has also produced inconsistent results for relieving speech difficulties.
The best strategy is drug therapy paired with speech therapy. Traditionally, speech-language experts trained patients to concentrate on multiple, separate aspects of voice and speech, such as breathing properly, articulating well, increasing volume, and slowing down the rate of speech. But even though patients sounded better inside the treatment room, the benefit typically vanished once they walked out the door and reverted to usual habits.
In 1987, however, University of Colorado speech-language researcher Lorraine Olson Ramig devised the Lee Silverman Voice Treatment, the first speech treatment tailored for Parkinson's disease. (It was named after a Parkinson's patient whose family funded the research). Small studies have found that LSVT produces lasting improvements.
How LSVT differs from traditional speech treatments:
- LSVT is much more intensive, requiring four rigorous one-hour sessions a week -- and daily voice homework exercises -- for one month.
- It attempts to overcome the sensory processing deficit that affects speech in Parkinson's. For example, by recording patients' voices and playing them aloud, the therapist can convince them before treatment that their voices are weak.
- A patient focuses on a single goal -- boosting loudness with maximal ef fort -- rather than thinking about several aspects of voice and speech production at once.
How LSVT retrains vocal loudness
When prompted with just one cue of "Speak loudly!" or "Think loud!", Parkinson's patients automatically take in a deeper breath, open their mouth more for better resonance and articulation, and increase volume. All aspects of speech production strengthen together, says Fox, who, together with Ramig, cofounded a company called LSVT Global.
LSVT doesn't train patients to actually yell or scream, although to them it may feel disconcertingly as though that's what they're doing. "A huge piece of the treatment is to teach them that what feels very funny to them, and maybe too loud, is act ually within normal limits," says Fox.
Each workout session starts with many repetitions of sustained "aaaahhhs" at normal, high, and low pitch, followed by repetitions of 10 everyday phrases or sentences. Over weeks, the therapist trains patients to build a healthy, louder voice to use first with individual words, phrases, and sentences, and then building up to continuous reading and conversational speech.
How long the benefits last:
Studies of LSVT show that in conversation, patients' voices grow louder by about 5 to 6 decibels, which makes a big difference to a listener's ability to hear them. A study published in 2001 found that some of the gains from LSVT persist for two years. Ideally, patients keep up voice exercises to maintain benefits. Occasional tune-up therapy visits may be needed.
Where someone with Parkinson's can go for speech therapy
A neurologist or hospital should be able to refer patients to a speech therapist, where treat ments are usually covered by health insurers. The American Speech-Language-Hearing Association maintains a searchable directory of practitioners at www.asha.org/findpro/ .
To find a certified LSVT therapist in your area, check the directory at the nonprofit LSVT Foundation or its spin-off company LSVT Global . LSVT Global's eLOUD service offers Internet delivery of the speech treatment via standard webcam technology. The firm is developing a computer program that lets patients do some speech sessions at home.
What you can do to help someone with Parkinson's communicate better
Encourage them to seek speech therapy early on so that they can remain active at working, socializing, and enjoying life. Fox recommends treatment as soon as problems develop, because once speech impairment starts discouraging someone from conversing, the inactivity may accelerate the speech deterioration.
You can give important positive feedback to Parkinson's patients the about how much clearer their voice sounds after receiving treatment. These tips can also help when chatting with them:
- Cut background noise. Turn off the TV, close the windows, and choose quiet restaurants when eating out.
- Talk face-to-face. Reading their lips will help.
- Try to be patient. Let them answer questions and finish sentences themselves. Cognitive changes in Parkinson's disease can slow thinking processes and hinder recall of the words they want to say.
- Keep encouraging them to speak. Repeat the parts of a sentence that you understood, then ask them to say the full sentence again more slowly. Have them spell words you didn't catch.
When speech exercises alone aren't enough
The speech therapist may also recommend a variety of assistive devices, such as a small personal microphone system to amplify a soft voice. For patients who are able to use a computer, communicating via e-mail can be a satisfying way to stay connected with friends and family. For the advanced Parkinson's patient who can't speak at all, one option is a computerized device that speaks aloud the phrases the person types in.
For more information:
The National Parkinson Foundation's brochure, Parkinson's Disease: Speech and Swallowing, can be downloaded from its free publications page.
The Cleveland Clinic offers communication tips in its article " Speech Therapy for Parkinson's Disease ."
Learn more about Lee Silverman Voice Treatment at the LSVT Foundation website.