1. Speech and Swallowing in Parkinson’s Disease Prepared by Fauzia Shah Speech Therapist AKUH Presented by Haroon Basheer

2. Introduction  Parkinson’s is a slowly progressive neurological movement disorder caused by a degeneration of dopamine producing cells.  Hypokinetic dysarthria is reduced movement of the muscles of speech and swallowing.  Researches say about 89% of people will have speech and voice symptoms.

3. Introduction (Cont…..)  Speech symptoms affecting.  Respiration (breathing).  Phonation (voice production).  Articulation.

4. Introduction (Cont…..)  Other symptoms associated with PD:  Dysphagia.  Drooling.  Progressive difficulty with writing.  Decreased facial expressions.

5. Voice Handicap Index (Cont…..) FUNCTIONAL  My family has difficulty hearing me when I call them.  I use the phone less often than I would like to.  My voice problem restricts my personal and social life.

6. Voice Handicap Index (Cont…..) PHYSICAL  I run out of air when I talk.  The sound of my voice varies through out the day.  I use a great deal of effort to speak.

7. Voice Handicap Index (Cont…..) EMOTIONAL  I am tense when talking to others.  I find that other people do not understand my voice problem.  I feel annoyed when people ask me to repeat. Source: VHI: The American Journal of Speech Language Pathology.

8. Caregiver Concerns  I have difficulty hearing / understanding my Parkinson's partner when he / she speaks.  My Parkinson's partner does not talk as much as in the past.  He / she does not attend social functions as frequently as in the past.  He / she clears his / her throat more often.  He / she suspects that I need a hearing aid.

9. Speech Symptoms  Overall loudness level is reduced.  Rate of speech: too slow or too fast.  Difficulty initiating speech, or inappropriate pauses.  Voice is usually tremulous and monotonous.  Hoarse /breathy vocal quality.  Articulatory effort is reduced or imprecise.

10. Breathing Improper breathing patterns:  Use short breaths  Hold breath while attempting to speak. Try speaking loud by counting in one breath:  1 -- 2 --3  1 -- 2– 3---4  1 – 2—3—4—5………..10

11. Breathing (Cont…..) Strategies to improve breath support for loud voice:  Take a deep breath (inhale).  Slowly exhale and say the vowels ‘ah’ or ‘ee’  Try to hold the sound for 15-20 seconds.. (Repeat 3 times with a 1-2 minutes rest after each try).  Repeat 3-4 times a day.

12. Vocal Quality Breathy vocal quality can result from weakened vocal fold closure. Strong closure is necessary for the vibration that produces sound.

13. Vocal Quality (Cont…..) increase loudness and vocal quality: Sit, stand or lie down. Put both palms together. Take a deep breath and exert pressure into your palms. Exert air into a vocal grunt. Sustain the grunt until the air supply is gone. Source: The source of Dysarthria Lingiuisystems,Inc

14. Exercises to improve pitch variation or monotone speech 1, 2, 3, 4, 5 1 2 3 4 5 6 Source: Working with Dysarthric Clients, Communication Skill Builders 1, 2, 3, 4, 5, 6, Count and gradually decrease the volume. Count and gradually increase the volume. Count with decrease and increase the volume.

15. Articulation Slow and imprecise lip movements. Slow and imprecise lip movements. Slow and imprecise tongue movements. Slow and imprecise tongue movements. Imprecise speech sounds. Imprecise speech sounds.

16. Strategies to improve speech Practice lip/tongue exercises. Practice lip/tongue exercises. Reduce the speed. Reduce the speed. Use short phrases. Use short phrases. Exaggerate the sounds and do not leave any sounds of any words out. Exaggerate the sounds and do not leave any sounds of any words out. Close lips firmly for b, p, m sounds. Close lips firmly for b, p, m sounds. Try to explode the sounds t, d, k, g. Try to explode the sounds t, d, k, g. Pause between the words, keeping the vocal loudness up until the end of the sentence. Pause between the words, keeping the vocal loudness up until the end of the sentence. I Want a Glass of Water

17. Tactile voicing

18. Cheek Puff/ Lip Purse

19. Smile Exercise 1

20. “O” Exercise

21. Lateral Tongue Stretch

22. Tongue Tip Movement

23. Straight Tongue Stretch

24. Speech practice 10 Functional words and phrases for daily practice: 10 Functional words and phrases for daily practice: Hello.Yes / No Hello.Yes / No Good-bye.Thank you. Good-bye.Thank you. How are you?I am okay. How are you?I am okay. Come here please. Get the phone. Come here please. Get the phone. Where is the paper? Where is the paper? I am not feeling well. I am not feeling well.

25. Improving communication Improving communication Noise: turn down television or radio. Noise: turn down television or radio. Lighting: make sure the lights are turned on in the room. Lighting: make sure the lights are turned on in the room. Maintain eye contact with the speaker. Maintain eye contact with the speaker. Distance: stand or sit close to the speaker to help you hear what is said. Distance: stand or sit close to the speaker to help you hear what is said. Writing: Keep writing materials accessible at all times. Writing: Keep writing materials accessible at all times. Pointing systems: notebook, pictures, words, alphabet boards for daily needs. Pointing systems: notebook, pictures, words, alphabet boards for daily needs.

26. Primary problems in swallowing I feel weak and tired often. I feel weak and tired often. I have recently an unintentional loss of weight. I have recently an unintentional loss of weight. It takes me longer to eat than other people. It takes me longer to eat than other people. I pocket food on either side of my mouth. I pocket food on either side of my mouth. I cough before, during after swallow. I cough before, during after swallow. I choke or gag when I drink liquids. I choke or gag when I drink liquids.

27. Primary problems in swallowing (Cont…..) I have thick or excess saliva or phlegm. I have thick or excess saliva or phlegm. I drool sometimes. I drool sometimes. Food sticks in my throat. Food sticks in my throat. Figuring out what I can or can not eat is a problem for me. Figuring out what I can or can not eat is a problem for me. I am afraid of choking when I drink liquids. I am afraid of choking when I drink liquids. Source: A strategic guide for speaking and swallowing, American Parkinson's Disease Association Inc. Source: A strategic guide for speaking and swallowing, American Parkinson's Disease Association Inc.

28. Disorders of swallowing Difficulty initiating a swallow. Difficulty initiating a swallow. Unexplained weight loss. Unexplained weight loss. Pocketing/pooling of food or saliva. Pocketing/pooling of food or saliva. Cough/choking during or after swallowing. Cough/choking during or after swallowing. Change in voice or speech. Change in voice or speech. Nasal /oral regurgitation Nasal /oral regurgitation Drooling. Drooling. Excessive secretions. Excessive secretions. Recurrent pneumonia. Recurrent pneumonia.

29. Safe swallowing strategies Sit upright during all meals, even when taking pills Sit upright during all meals, even when taking pills Tilt the head slightly forward, not backward as you swallow. Tilt the head slightly forward, not backward as you swallow. Take small bites, sips of water. Chew thoroughly and swallow before taking the next bite Take small bites, sips of water. Chew thoroughly and swallow before taking the next bite Double swallow, or take a sip of water between bites of food to wash it down. Double swallow, or take a sip of water between bites of food to wash it down. Oral and mouth care. Oral and mouth care.

30. Safe swallowing strategies (Cont…..) Diet consistencies: Thickened liquids. Thickened liquids. Pureed / blenderized. Pureed / blenderized. Soft Soft