Speech, Voice & Parkinson’s Q&A with John Dean

Speech and Voice in Parkinson's Q&A

We recently hosted a webinar with speech-language pathologist John Dean. You can get access to the recording here. We received so many questions during the session that we weren’t able to answer them all; so, John was kind enough to do some written Q&A for us.

“When is a good time to start speech therapy?”

It’s much better to maintain function than to try to restore it. An overly broad metaphor that I like to make is that I prefer to change my oil rather than replace my engine. I don’t think it’s quite that stark in Parkinson’s, but the reality is that people who soon after diagnosis start to exercise regularly (including voice exercise and other things related to speech) have better long-term outcomes and a better quality of life.

Also, listen to Kathleen Donohue talk about why you need a speech therapist.

“As a care partner, what can I do to help with mumbling and slurred speech during my partner’s OFF periods?”

OFF periods are when medications aren’t working and symptoms reappear. While it’s not ideal to ask your loved one to increase their effort when they are OFF, you might consider using a portable speaker to improve intelligibility. Here’s one option I recommend.  (Note: I have no affiliation with any of these manufacturers and make no guarantees about any specific device. Always do your research and make use of Amazon’s generous return policy if you don’t get what you want the first time.)

You can also share with your person living with Parkinson’s that the best thing someone can do as a proactive measure to help mumbling and slurred speech during OFF periods is to train their speech muscles regularly (10-20 minutes max). Doing this will create a “reserve” that can be used during OFF times.

“When I’m tired, my voice sounds quieter, slurred, and sloppy, and I often choke on food and end up coughing. What is happening?”

There are a few reasons this may be happening:

#1 – Medication timing

Although there’s no real evidence that using medications is going to improve overall intelligibility, it often improves the speed of production and range of motion of the structures involved in producing speech (known as the articulators). So, when your medication is not providing its maximum effect, it may be more difficult to get those articulators into place in a timely way, and that probably gives the perception of slurring. Add any fatigue or tiredness to that equation and the problem could become quite pronounced.

It’s also possible that just the opposite situation is the culprit. On occasion, too much medication can also make speech a little distorted and slurry.

If you can, note when these issues are occurring in relation to medication timing as well as the time of day. Many people report having more issues with their speech later in the day when they are more fatigued. You might even make a couple of recordings on your phone so you can hear and compare.

Your speech issues might improve with speech therapy, but it also may require some additional tweaking of your medications (or their timing) with your doctor.

#2 – Deep Brain Stimulation (DBS)

If you have had DBS, particularly recently, slurred speech is something that can occur. It can be difficult, though, to address events directly caused by DBS. In those situations, connect with your doctor to see if there are any options that can provide relief.

On top of that, working with a speech therapist will help you strengthen your voice to be as strong as possible. Optimally, you’d work with them at different times in your medication cycle so that you can experience the issue with your therapist while it’s happening and identify techniques to maximize performance.

Additionally, as I mentioned before, by doing regular voice and speech exercises, you will maintain more “reserve” that you can call upon when you are tired.

#3 – Swallowing

Choking on food and coughing is a pretty clear indication that there is a swallowing problem going on. Your body coughs to prevent food particles and liquid from getting into your airway where they could lead to an infection (known as aspiration pneumonia). Discuss this with your doctor right away, and get a referral to a speech-language pathologist for treatment. You need to start strengthening that musculature and get smart about the way you eat in order to minimize the risk of getting an infection in your lungs.

Watch this video about aspiration pneumonia with Kathleen Donohue.

And this one on what aspiration looks like in the throat.

“Does slurring that follows Deep Brain Stimulation eventually improve?”

If this issue is being caused by DBS, it’s possible that the slurring may continue to be somewhat chronic in the absence of any kind of changes in programming. There is no harm in giving it a little bit of time to see how things settle, depending on how long you’ve had your DBS, but you should alert your doctor or whoever programs the device to let them know that it’s a problem. In a perfect world, you would work with somebody as a part of an interdisciplinary team that includes a speech-language pathologist. I would invite that SLP to sit in on a programming session, particularly if they have a relationship with you and they know how your speech is supposed to sound.

That being said, speech therapy can be effective post-DBS. Dr. Ramig and her colleagues performed a study at the University of Colorado that showed significant benefits in using LSVT after DBS in approximately 50% of the individuals who were in the study. This matches with my experience working with the same types of individuals.

“I often experience a problem with phlegm build up in my throat, which restricts my voice clarity. Do you suggest doing anything aside from clearing your throat to help that?”

I don’t recommend clearing your throat because when you clear your throat, you slam the vocal folds together and cause irritation, which inflames those tissues and hinders voice production. These structures are very small and have the general consistency of the inside of your cheek; so, slamming them together aggressively is counterproductive.

Rather, I recommend you make an /h/ sound as if firmly and clearly saying the word “ha”. Then,  follow that with a swallow. That may provide some clearance while reducing irritation to the vocal folds. Only when the phlegm does not resolve entirely should you take the next step and actually clear your throat.

I think it’s also a good idea to speak with your doctor to see if there any options for clearing out some of that phlegm. If it’s related to an allergy, there may be some over-the-counter inhalable meds that can provide relief. Always consult a doctor first because some medications can dry out the vocal folds, making them more susceptible to injury and even cause mental slowing.

“I’ve had Parkinson’s for a year and my voice has become increasingly raspy. It seems that I am constantly clearing my throat. Is this Parkinson’s related?  Is there anything I can do to alleviate it?”

You may be getting into a vicious cycle. Throat clearing is what we often refer to as “abusive” behavior. I urge you to work with a speech therapist, even if that initially needs to occur online. At the same time, I would consider working with an ear, nose, and throat doctor.

Whether it’s reflux that’s influencing your vocal folds or other issues related to vocal production, you might need some periods of rest while addressing the throat clearing issue and then initiate some speech therapy to strengthen the voice so you can get rid of the raspiness.

“What can I do to prevent or lessen the voice issues that come with Parkinson’s?”

Everything in Parkinson’s is a use-it-or-lose-it proposition, or more accurately, use-it-and-improve-it. Your voice is no exception.

The first order of business is to find a speech-language pathologist who specializes in Parkinson’s and start working with them. As I mentioned during the webinar, you will want a long-term relationship with that clinician (as well as a physical therapist, occupational therapist, and social worker) if you’re able to find one. After that, the trick is to find ways to use your voice every day to keep everything in motion. Even if you don’t get the chance to talk as much during COVID restrictions, make the commitment to use your voice every day.

“Do you have any suggestions to reduce swelling in the throat?”

Swelling in the throat could be caused by a range of different issues so it’s impossible to diagnose it from afar. I recommend having a conversation with an ear, nose, and throat doctor and preferably someone who has imaging equipment such as a camera that goes into your nose so they can take a video of what they see. It sounds scary but it’s not that bad; I’ve had it done many times to address my own issues related to GERD.

“Are there exercises I can do to help alleviate stuttering?”

Stuttering can be quite a challenge sometimes. Some of the traditional tools that a speech-language pathologist might use with a child that has developmental stuttering issues may not be as effective for stuttering that shows up much later in life (referred to in the research literature as acquired stuttering).

In the latter situation, most of the interventions I use involve relaxing the system and increasing airflow in order to produce loud clear speech without excessive effort. Excessive effort can exacerbate fluency issues. To find what’s right for you, work with your speech-language pathologist.

Stuttering can also be related to a change in medication or DBS programming (especially if the DBS is relatively new). So, if you are able to identify something like that, start by seeing if that is possibly the culprit by having a discussion with your doctor and/or DBS programmer. If you can address it, that may be the most effective way to deal with the problem.

Another thing to consider is a technology known as delayed auditory feedback. This approach takes your speech sounds and feeds it back into your ear with a little bit of lag. It has a very remarkable and robust effect on some kinds of stuttering. In particular, I find it most effective with something referred to as palilalia, or festinating speech. This is essentially a speech version of the small shuffling steps you sometimes see in individuals in the later stage of Parkinson’s. When I see it, usually someone starts off with speech that is somewhat normal and intelligible but continues to pick up speed as they go along. A quick test is to count from 1 to 10. Often, the first several numbers are okay and then the remaining digits move faster and faster. Delayed Auditory Feedback is particularly effective for those kinds of issues, but it is important to note that it’s more of a prosthetic than a treatment. When it’s on, it’s effective, but when it is off, that benefit is gone.

There are some dedicated devices that can be purchased for this purpose. The one I feel comfortable suggesting is SpeechVive. It has been developed by a speech therapist specializing in Parkinson’s and has recently received clearance for Medicare reimbursement, making it a much more affordable option for many. They even have an app if you want to download it and try it out to see if it’s effective before considering a purchase. (Note: The folks at SpeechVive do not specifically claim to improve stuttering, but the device may help certain individuals while also possibly increasing volume.)

“Can singing help with voice and speech issues?”

Singing can be very effective and fun. Whether that’s in a Parkinson’s choir or maybe a choir in your community or at your church, it’s a nice bit of social engagement plus regular voice and breath training. There are even some online choirs. One example is the work that Judi Spencer is doing with the World Parkinson’s Coalition. If that’s something you enjoy, I would definitely take a closer look.

You can also do karaoke in the comfort of your home by doing a YouTube search for your favorite song name, then adding, “AND karaoke”. There are also karaoke apps that give you almost unlimited access and will even record your performance. The caveat with those apps is that they often require in-app purchases to unlock the songs you actually want to listen to. Be cautious about committing to buying items on those platforms.

“I have an easier time singing than talking sometimes. What is the reason for this?”

Singing, and music, in general, bypasses a lot of the damaged areas of the basal ganglia. Couple this with the emotional attachment we often have while singing and it may explain better output. However, it’s also possible that you’re simply not putting in as much effort during your speech, but that effort scales up automatically while you’re singing something you enjoy. If you work with a speech therapist, do exercises that strengthen the vocal folds and during the course of your treatment, you will also come to understand the amount of effort necessary to produce clear speech.

“How do I get more sound from my diaphragm? My sound is very nasally, especially when I sing.”

I addressed the issue of diaphragmatic performance in another part of this Q&A, so I’ll refer you there.

Nasality is not something I expect in an individual with Parkinson’s, although, it is Parkinson’s, so anything is possible. I would work with your physician to make sure there are no other factors at play. It may be worth getting a referral to an ear, nose, and throat doctor so that they can look down there with a scope.

“What is a dual-task exercise and what are its benefits?”

Dual-Task Training is an approach that my wife Josefa Domingos and I do with our clients. We incorporate movement, voice, and cognition into nearly every exercise we do. So, whether she’s teaching a program more focused on physiotherapy or I’m teaching one more focused on speech, we still incorporate all three areas into it. In our mind, not only is this the most efficient way to exercise by incorporating many different elements, it’s engaging and challenging so that our people keep coming back to it over time. We also try to build activities that replicate common daily challenges that many people with Parkinson’s experience.

“How would you modify your dual-task exercises for people with PD dementia?” 

To do the kind of dual-task exercises we normally do in a group setting with people who are less impaired would be extremely frustrating to someone dealing with dementia. And often their frustration can lead to anger and other very unhealthy outcomes.

That doesn’t mean that we never do dual tasking with someone with dementia, but we don’t do it as much in a group environment. It must be carefully calibrated to their specific abilities and needs.

Occasionally, when we do an exercise that combines many different components, it is possible to have someone dealing with poor cognition or even dementia to simply focus on one component in isolation, such as saying the answers out loud in a clear voice. That provides some of the benefits and allows participation. However, it’s a case-by-case basis because the overall goal of incorporating dual tasks is to make it more engaging and salient.

When we teach classes, we try to calibrate to the levels of the people who are attending. Sometimes it’s a little easier in the speech version that I teach because most of it is seated and a little less intensive, but that’s not a guarantee.

“Do the  dual-task activities get increasingly difficult?”

Here’s a version I did for a private class last year. Take a look and see if you can follow along. I hope you enjoy it.

“My swallowing is poor because of my horrendous posture. What can I do about that?”

Posture is often under-recognized as a correctable component of swallowing function. In fact, one of the best continuing education programs I’ve ever done, from the Occupational Therapy Association of America, included a very solid discussion about positioning and posture and its role in swallowing. Having optimal posture allows gravity to do the work while avoiding other issues such as drooling or food spilling from the front of the mouth. It’s not information that was emphasized during my training 16 years ago, but it’s something I definitely focus on during intervention.

To address your posture, your physical therapist (PT) and occupational therapist (OT) would be a good place to start.

“Are there strengthening or other exercises you can do to overcome this postural issue? Or is it the result of some kind of dystonia such as camptocormia or Pisa syndrome?”

I might point you to some basic lengthening breath exercises to improve posture (aka Pilates). However, to really address that, you need to have a physical therapist help you lengthen muscles that may be chronically contracted and/or strengthen underused or overextended muscles in order for them to provide better support.

The caveat is that if this is dystonia, (abnormal muscle contraction), it may not be completely correctable by exercise. In that case, you may need to escalate to additional treatment, working with your movement disorder specialist, who may use a careful placement of botulinum toxin to provide some relief.

“How do I know if my mom has early signs of swallowing issues? Loud swallow? Chewing pills?”

Let me distill the basics into a couple of key areas.

Unexplained weight loss and/or unexplained infection can be key indicators of a swallowing problem. The weight loss is likely due to a lowered ability to eat food in a timely fashion, resulting in lower calorie intake overall. It can also be caused by changes in the absorption of food, which will need to be addressed by your physician. Fortunately, assessing weight changes is a common practice at most visits these days but if not, don’t hesitate to mention it to your doctor.

An unexplained infection could be an indication that food and liquid particles are getting into your lungs and causing issues. This is a pretty significant problem that must be addressed, or it could lead to very serious consequences.

Issues with swallowing pills is often an early indicator of someone dealing with a swallowing problem. It’s a good reason to work with a speech-language pathologist to address the underlying issues and strengthen the musculature. This is definitely a situation where early intervention is going to be way more effective than later attempts; so, don’t delay.

As a side note, I typically recommend people take their pills with soft foods such as applesauce or chewed up banana. That makes it much easier to swallow and the excess moisture also improves transit into the stomach. I would be cautious about doing this with yogurt, cottage cheese, or other items that have a significant amount of protein because that can interfere with the absorption of levodopa in some individuals.

The presence of drooling can be a harbinger of potential swallowing problems and research seems to point towards a higher risk of swallowing issues in people presenting with this problem early on. Again, this is a situation in which I would recommend early intervention in order to maintain function rather than trying to address it after more serious issues are at play.

Notably, individuals who have the kind of Parkinson’s that doesn’t occur with a tremor, referred to as a “rigid akinetic” phenotype, are also at somewhat higher risk of swallowing problems over time. These individuals typically have more midline or axial issues, meaning that the problems are occurring in the center of their body rather than on the limbs. So, this typically results in more issues related to balance. The structures involved with swallowing and digestion are also located axially, which is why they are also at higher risk for swallowing dysfunction.

Loud swallowing might be an indication, but it would be hard to definitively say unless I saw it being accompanied by a “struggle” behavior (meaning the individual takes a lot of effort to swallow). Interestingly, the use of an “effortful swallow” is actually one of the first techniques I might recommend in treatment. So, if you work with me, your swallowing might actually get louder before it gets quieter. 🙂

“Do LSVT LOUD exercises help with swallowing?  If not, what can you do?”

LSVT LOUD actually does have a pilot study that showed some benefit for swallowing dysfunction and while it can’t hurt, I would try to find more specific exercises to address that issue.

As I’ve mentioned in other responses, I think if you are having swallowing problems, it’s very important to work directly with a speech-language pathologist.

“Does low motility of the esophagus impact speech?”

I’m not sure that poor esophageal motility is going to directly affect voice production unless there is significant reflux making its way all the way up to the vocal folds (known as laryngopharyngeal reflux).

What I suspect is more likely, if you are experiencing significant issues with motility, is that those issues are probably occurring in many other parts of the body and that could be responsible for the poor function of the speech mechanisms.

One thing I think everyone with Parkinson’s should remember is that whatever can be visibly or audibly observed in someone with Parkinson’s, whether that is a slow movement, muscle stiffness, quieter voice, or facial masking, is also occurring in places you can’t observe as easily.

Fortunately, a high-intensity speech therapy approach such as LSVT LOUD or SPEAK OUT can be very valuable in improving performance. I would start by working with a speech clinician with training in one (or optimally, both) of these approaches.

“Sometimes I feel out of breath when I speak.  Can speech therapy help with that?”

Often, when people with Parkinson’s go to their ear, nose, and throat doctor for imaging, they find that their vocal folds don’t close all the way. Your doctor might even refer to you as having “bowed vocal folds.” That means that every time you speak, a lot of air is leaking in a very inefficient way. That could require a lot more effort to get adequate sound production.

This is exactly what programs such as LSVT LOUD and SPEAK OUT are designed to address. Also, of course, I recommend working with a speech-language pathologist.

“What is spasmodic dysphonia?”

It’s in the family of movement disorders (as is ataxia, dystonia, Huntington’s, tics, and Tourette’s syndrome, among others) but is not typically associated with Parkinson’s. Essentially, in the most common version, adductor spasmodic dysphonia results in the inability to adequately “apply the brakes” to the muscles associated with voicing and other speech production. As a result, when they activate, they activate with full force, resulting in pressed industry information. It would be as if you replaced a dimmer switch with a standard on-off light switch. All of the gradients of speech effort and concomitant performance are largely gone. So, when someone dealing with spasmodic dysphonia starts to speak, the muscles engage too fully, resulting in the very halted, pressed speech.

Speech therapy is not particularly effective for this issue, although there are some techniques related to relaxing phonation effort that may benefit from working with a speech therapist. However, most individuals I know dealing with this issue ultimately work with a physician who provides botulinum toxin to reduce the strength of the musculature and provide some improvement. This relief is not permanent and ongoing shots throughout the course of the disease process will likely be necessary, but it does provide some immediate benefits.

“After aerobic exercise, I am not tired, but my voice is hoarse. Is that fatigue or maybe dryness?”

Hydration will certainly be critical, however, it’s possible that you may be working out to a point where you are overdoing it a bit and fatiguing yourself. Perhaps you can have a consult with your physical therapist to identify the optimal levels of exercise.

“What about tongue exercises? Are they worth the time?”

That was something that was in the process of becoming less popular when I was in graduate school. I would say that it’s largely fallen out of vogue within our profession, primarily because it doesn’t seem to produce significant improvements that apply to actual eating. When you think about it, when you are getting ready to eat food, sticking out your tongue and/or moving it from side to side aren’t activities you would do during a mealtime.

My swallowing inventions usually focus much more on optimizing real-time environment and food and swallow practice. I suspect most clinicians you encounter will be the same way. That doesn’t mean there can’t be some benefit for some basic tongue strengthening, but I’ll leave it to your speech therapist to guide you.

“I have bad teeth which makes it hard to eat and swallow. I also have atrial fibrillation and not enough breath. What can you tell me about that?”

I don’t have much to contribute about the atrial fibrillation, but the issues with your teeth are not uncommon. There are certain classes of medications that can exacerbate dry mouth which makes the teeth more susceptible to decay. There may be some mouth moisturizers that can ameliorate that somewhat, but I don’t see an excellent solution unless your doctor can modify the medications to address it. I think it would be worth having a good conversation with your dentist as well to see if they have any solutions. Easy chew cookbooks and recipes can provide some tasty and easy to prepare ideas.

I’ve given a presentation on a number of occasions about ways to modify your diet that doesn’t include puréeing your favorite foods.

One of the key takeaways specific to your situation would be to incorporate a slow cooker for meal preparation. It is particularly good for meats such as ribs as well as preparing pulled pork and other meals. Freshly baked squash is also another excellent healthy option that might not have as much protein for those dealing with protein/levodopa absorption concerns.

If you do a little bit of digging, you should be able to find a range of recipes that are easier to eat but still tasty. One of our pandemic favorites has been quesadillas with fresh avocado and salsa. Not only is that soft and easy to eat, but it’s eaten easily with your hands, which can also help make mealtimes a little simpler.

Specific to providing dental care, I would point you to your favorite occupational therapist. They have extensive expertise with modifying daily tools to make them more effective. Of course, the easy low hanging fruit is to incorporate an electric toothbrush, but a good OT will give you a range of options. Nancy Hillmer, one of my favorite occupational therapists specializing in Parkinson’s, has been featured on the Foundation’s website and might have some good recommendations.

Also, watch this video on daily oral health with Kathleen Donohue.

“Does speech therapy include working on facial expression?”

Facial masking and the loss of facial expression often associated with Parkinson’s is a very difficult issue. I’ve heard many, many people complain over the years about the way that interferes with their social interactions, particularly with people who don’t know them well.

I do not recall any research that convinces me that exercising facial muscles will restore facial expression back to its previous level of performance. There’s nothing wrong with doing facial exercises to maintain mobility and extend the range of motion, but the best way to improve this issue is actually to improve your overall function with regular aerobic exercise. That’s going to make the most significant gains.

In short, it’s not going to harm you to do exercises, of course, but I’m not certain that it’s going to provide the results you’re looking for. At a bare minimum, I would spend some time in front of a mirror to get a better sense of what you are putting out to the people you interact with on a daily basis.

One thing I’ve observed with facial masking is that it also reduces the range of total expression which sometimes amplifies negative facial expressions. This first came onto my radar after an anecdote from someone in a working environment that kept getting reprimanded by their supervisor. Digging into the situation a bit, it wasn’t simply because the loss of facial expression made it seem like they were consistently disgruntled at work (although that did not help). Rather, whenever the individual with Parkinson’s was even a little dissatisfied, the facial masking amplified that in a way that made it difficult for them to hide any dissension. This can have very serious ramifications in a work environment. Again, I would recommend a little bit of work in front of the mirror to see what you’re putting out in the world. Then, if you feel comfortable doing so, I always believe educating people about facial masking is an important step in helping them understand and easing your stress.

My husband is having difficulty processing group conversation, and lately he can’t process when I speak to him.  Sometimes I have to repeat/rephrase 2-3 times. Is there help for this?”

From my limited information, it’s difficult to identify what the issue is. Here are a couple of different places to look.

First, be sure that you remove any additional distractions when you communicate. Of course, background sounds such as a television or radio are easy to eliminate but sometimes simply having too much visual activity in the background can be an additional source of distraction. Along those lines, be careful about being in front of a window or other light source as being backlit can make it difficult for him to see your eyes and lips when you are speaking.

Second, I would look towards any hearing loss. It would definitely be worth visiting an audiologist for an assessment. Often hearing issues (and vision issues) can cause deficits that may mimic cognitive issues, in addition to exacerbating any existing cognitive problems. Addressing that with a hearing aid (and updated glasses) may provide a nice benefit with no additional effort on your part (aside from paying for the devices).

On occasion, I might also encounter someone dealing with a central auditory processing disorder, although that’s not very common. An audiology assessment could also help uncover this issue and provide some possible ways to improve the problem.

“How do I get more sound out of my diaphragm?”

Specific to Parkinson’s, you might want to try a threshold breath trainer such as the EMST 150. If you have used that in the past but found it too difficult, they have released a new version with less intensity. There are versions of resistive trainers that may provide some benefit as well, but in my experience, they must be coupled with a device for measuring an output or it’s simply too easy for the user to not use enough effort and therefore not get benefits. The EMST 150 has Parkinson’s specific information (although that specific research relates to the strengthening of muscles under the chin, known as submental muscles, not the diaphragm).

Any type of bodywork that includes breath work, such as tai chi or yoga, may also be beneficial. Pilates, which incorporates a different kind of breathing approach for their exercises, is my personal favorite, though it may require a lot of modifications for someone living with Parkinson’s.

“Why do I yawn when I try to do vocal exercises?”

If you’re doing your voice exercises well, you are opening your mouth into a large, stretched out position which might look like a yawn. And it’s pretty well-known that you can make other people yawn simply by yawning yourself; so, I imagine that you are mimicking some of the actions and feelings associated with yawning and your body just kicks in on its own.

“Any advice for the problem of drooling into face coverings?”

This is definitely an issue for our times, truly…

First, let me say that drooling (which you will see referred to as sialorrhea in scientific literature) is rather common in Parkinson’s. However, researchers have identified that an individual with Parkinson’s produced no more additional saliva than anyone else, so it is primarily an attention and management issue. Attention is one of the key cognitive changes associated with Parkinson’s. When addressing drooling in a clinical setting, my focus is primarily to bring your attention to it. I do this by using a form of “spaced retrieval therapy” during which I encourage you to swallow at regular intervals (usually somewhere between two and three minutes) in order to manage the saliva better.

That’s often all it takes, and it can be very effective, especially if you address it early on. However, if it is not effective, there are a couple of other options.

Your physician might administer botulinum toxin to some of the salivary glands in your mouth to reduce their production. That can be extremely effective and can be performed as needed over time (the toxin only maintains effect for several months at a time so it must be continued). There may be other medications your doctor might also consider as a more effective approach.

If you need a quick bit of help, perhaps when you’re going to be in a public environment or you’re getting to the end of your current medication cycle, I sometimes use a swallow prompting app that beeps to provide a reminder for you to swallow your saliva. It can be particularly discrete and effective when paired with a bluetooth earpiece. You might experiment with that. However, if you haven’t seen a speech-language pathologist for this drooling issue, I would start there.

“Could you address memory loss and lack of motivation in connection with Parkinson’s?”

Memory loss can happen in Parkinson’s, particularly in someone dealing with Parkinson’s disease dementia (PDD) or Lewy body dementia (LBD). However, more often, individuals with Parkinson’s may have issues with executive function and most pointedly, attention. So, what might look like a memory loss is actually someone who was not able to attend to the activity and later on is unable to recall.

We incorporate quite a bit of attention training into our dual-task exercise activities. Not only does changing these activities into “dual-task” exercises provide specific benefits, but it also is engaging in a way that helps you practice for a longer time and more regularly. I would encourage you to look at some of the free exercise programs we have been producing online to get a feel for what that looks like.

There are also exercises that you can do specifically for improving attention (although I will very pointedly say that most brain training platforms haven’t shown very robust results in that respect).

Finally, as you may have guessed, aerobic exercise also has significant benefits for attention and everybody living with Parkinson’s should incorporate regular aerobic exercise into the routine.

“Does Medicare cover speech therapy?”

Medicare does provide reimbursement for speech therapy services, and it is often the preferred pay source for many facilities and clinicians nationwide because it’s so reliable. Recently, they relaxed guidelines and provided coverage for speech therapy online, but my understanding is they are not planning to do that when the pandemic is over. I think that’s an opportunity for activism, as I believe it’s a terrible idea to make access to proper care more difficult for people living with Parkinson’s. I’ll leave it to the Foundation to organize that advocacy, but I will definitely join in their cause as will many other clinicians (including physical and occupational therapists, who have also been cleared to receive funding for telehealth interventions during the pandemic).

“Do you have any speech to text software recommendations?”

Dragon Systems NaturallySpeaking is the best option for performance and features. I have been using it since version 2 in the late 90s (it is now up to version 15). It’s also the software that was the basis for my research at the University of Cincinnati (on the effects of long-term voice function with speech recognition software).

“What specifications do you recommend for voice amplifiers?”

I recommend a wired unit over a wireless one because the quality of the audio production seems to be better. Also, wireless units seem to break down over time. That doesn’t mean you can’t find a solution with a wireless mic, but I just haven’t found one that does a good job and that also lasts over the long-term.

Amplifiers with a headset microphone that fits over the ear are what I like best. I have experimented over time with some microphones that clip onto the lapel, and while they can be a little more discreet, positioning can be problematic. Being able to place the microphone very close to your mouth is important for optimal performance

Regarding speaker selection, a floor-standing speaker is probably more than you need. Most of the ones I see being used effectively are about the size of a box of raisins and almost all of them come with a rechargeable battery that will last for hours per charge.

“Are there any apps that help with speech and voice issues?”

There are some interesting apps out there but nothing replaces interventions with a speech therapist or an ongoing maintenance class.  Bla Bla Bla is a fun tool for playing with the voice (and it’s free). The Voice Trainer is an app from the Netherlands that’s designed for use with a particular approach called Pitch Limited Voice Therapy. In general, I’m hesitant to tell someone to download an app and start using it without the approval of their clinician; so, talk to your clinician first!

This post is part of the Live Well Today webinar Speech, Voice, and Parkinson’s.

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