From time to time over my 35 years of working with people with Parkinson’s disease, a patient will say something that stops me in my tracks: “I hate to exercise.” Now, when someone is referred for Physical Therapy, they fully expect to be asked to exercise. But Speech Therapy? That’s a different story — and it’s worth exploring what we really mean when we use that word.

Let’s Start With What Exercise Actually Is

Most of us picture planned, structured, repetitive physical activity — running, swimming, lifting weights, yoga. And that’s not wrong. But there’s a broader definition worth considering: any physical or mental activity designed to improve overall health, or to strengthen the skills needed to perform a functional activity.

That second definition matters, because it opens the door to something called skills training.

Think of skills training as the targeted practice of specific neuromuscular movements and cognitive processes — moving a person from conscious, effortful execution toward something more automatic and natural. I often use golf as an example with my patients. You might work with a coach on your swing, your posture, your form. You practice at the range. But eventually, you have to take all of that onto an actual golf course — different clubs, different terrain, unpredictable conditions. The goal isn’t just to practice the skill in isolation; it’s to transfer it to real life. And that takes time, deliberate repetition, and meaningful feedback.

When Speaking Suddenly Requires Effort

Here is something I’d like every person with Parkinson’s to hear, because I think it’s important: for most of your life, you never had to think about how to speak. You paid attention to what you were saying and who you were talking to — but the actual mechanics of speaking, how loud, how fast, how clearly — none of that required your conscious attention. It happened automatically.

The same was true for countless other movements throughout your day. Reaching for a glass. Bending to pick something up. Chasing the dog to the door. Even though those movements require strength, balance, and muscle coordination, they didn’t demand your focused attention.

That is, until Parkinson’s disease changed the equation.

In Parkinson’s disease, the loss of the brain chemical dopamine disrupts a system that neuroscientists call automaticity — the brain’s ability to carry out well-learned or habitual movements without conscious oversight. When automaticity breaks down, movement no longer flows. Walking slows. Arm swing diminishes. Some individuals experience freezing of gait, where the feet feel momentarily locked to the floor.

And speech? Speech is movement. The same breakdown in automaticity that affects walking also affects talking.

This is why many people with Parkinson’s find that their voice gradually becomes softer (a symptom called hypophonia), their speech rhythm changes, or words come out rushed or slurred. What used to be effortless now requires deliberate attention — every single time.

Because the brain must essentially “manually override” the disrupted automatic systems of the basal ganglia, the demand on attention and cognitive resources becomes enormous. Think of it like a backup generator that kicks in when the power goes out. It can keep some lights on — but it can’t run the entire house. The brain simply doesn’t have unlimited capacity to consciously manage walking, talking, and swallowing all at once. For many people with Parkinson’s, the daily mental effort required just to communicate can feel like one more invisible burden of the disease.

And the consequences reach far beyond the mechanics of speech. Communication difficulties are consistently linked to decreased participation in conversation, social withdrawal, and an increased risk of isolation.(1) They affect relationships — particularly with care partners, who may find themselves working harder to keep communication exchanges on track, and who, at a deeper level, may experience a quiet but profound loss of one of the most important ways they stay connected to the person they love.

So What Can Speech Therapy Do?

Following an evaluation — which includes an assessment of motor speech and swallowing symptoms, as well as tools designed to capture your own perception of the problem — a therapy plan is developed that is specific to you.

Depending on your needs, therapy will likely include some element of exercise in the traditional sense: strength and endurance training for the voice. This typically involves vocalizing at a high level of effort — think of it as weight training without the weights. The “load” placed on the vocal muscles during effortful voicing helps build strength over time. In some cases, a respiratory muscle training device — a small handheld resistance tool — may also be recommended. Research introduced over 30 years ago demonstrated that the breathing muscles can be strengthened much like the muscles of the arms and legs. Stronger breathing muscles can help overcome some of the rigidity caused by Parkinson’s, improve breath support for speech, and enhance the coordination needed for safe swallowing.

But strengthening is only part of the picture.

Skills training is where much of the real work happens.

Behavioral approaches such as LSVT LOUD use high-effort exercises to increase vocal intensity, targeting both the respiratory and laryngeal systems. Importantly, LSVT LOUD also addresses a perceptual challenge that is central to Parkinson’s: the mismatch between how loud a person thinks they are speaking and how quietly they are actually coming across. By using cues like “think loud,” the approach helps individuals internalize what it feels like to speak at a more functional level of loudness.

Another approach, Speak OUT!, focuses on engaging the part of the brain that governs voluntary, intentional movement. Through a hierarchy of skill-based activities, patients learn to speak with intent — deliberate, focused attention applied each and every time they communicate.

Research supports the benefit of both approaches. That said, there are no well-controlled studies of either in individuals with moderate to advanced disease or with Parkinson’s-related cognitive impairment, which means these protocols may need to be thoughtfully adapted for some patients.

Bridging the Gap: Feedback in the Real World

One of the most persistent challenges in speech therapy — for any condition, but especially for Parkinson’s — is what happens once a patient leaves the therapy room. Without the therapist present, without the cues, without the structured environment, many people find it difficult to transfer what they’ve been practicing into everyday conversation.

External feedback plays a crucial role in overcoming this gap. It helps a learner reach their goal more efficiently, reinforces their sense of what they’re capable of, and increases the likelihood that they’ll repeat the performance on their own.

The Hi-VOLT® Voice-on-Light Bracelet is a voice-activated feedback tool designed to support independent home practice. By setting a target for loudness and providing immediate feedback when that target is met, it helps patients feel the level of effort required to produce a strong enough voice for daily conversation — while also building the strength and endurance needed to sustain it. Because it’s worn on the wrist, it can be used during physical therapy, Rock Steady Boxing, or any other exercise program, making it easy to pair vocal practice with the movement activities already built into a patient’s routine.

“But I Still Hate to Exercise”

Back to my patient. When someone tells me they hate to exercise, I listen — because I understand exactly what they mean. If a personal trainer told me I had to run every day to improve my aerobic capacity, I’d be genuinely disappointed. I might do it for a while out of obligation, but long-term? Unlikely. But if that same trainer told me I could bike, or dance, or take a brisk daily walk? Sign me up.

My job as a therapist is to explain — clearly and honestly — how motor speech and swallowing symptoms are affecting daily life, and to provide a strong rationale for the treatments I recommend. For a patient who is hesitant, I’ll often suggest starting small: let’s pick one or two exercises most likely to make a measurable difference, and commit to two weeks of therapy and home practice. After that, we reassess. In my experience, once a relationship is established and early progress begins to show, reluctance often softens into engagement.

Speech therapy is never — and should never be — a one-size-fits-all endeavor. Even when research demonstrates benefit for a particular method, that doesn’t mean it’s the right fit for every person. Those with more advanced disease or cognitive changes may need adapted protocols and will likely benefit from continued external cueing beyond the therapy room.

The Case for Early Referral

At a recent Parkinson’s support group meeting, I asked for a show of hands: how many people in the room had received speech therapy? Out of ten individuals, only one raised their hand.

I wish I could say that surprised me. But I’ve asked that question at every seminar and support group I’ve ever attended, and the result is almost always the same.

The literature confirms what I see in practice: up to 89% of individuals with Parkinson’s experience speech disorders, yet only an estimated 3–4% receive intervention. The gradual, insidious onset of symptoms likely contributes to under-reporting — if changes come on slowly enough, they can be easy to dismiss or overlook. And because Parkinson’s is classified as a movement disorder, the clinical focus often defaults to mobility and walking, with physical therapy referrals following more naturally than speech therapy referrals.

Yet evidence suggests that early enrollment in speech therapy can improve motor speech and swallowing function — and may even slow the progression of symptoms, though this has not yet been specifically studied.

Financial barriers are real too. Insurance coverage, co-payments, and the demands of intensive therapy protocols can limit access for many patients. In those situations, hybrid approaches — combining guided home practice with periodic clinical visits — can offer a meaningful alternative. The Voice Aerobics family of products was developed with exactly this in mind: tools and programs that patients can use independently, before, during, or after formal therapy, to build awareness of their voice and stay engaged in their own care in a way that feels approachable — even fun.

NEW!! Education Modules Hosted by Parkinson Wellness Recovery (PWR!)

I am honored to be contributing an educational webinar to the new multidisciplinary Education Module series hosted by Parkinson Wellness Recovery (PWR!), founded by Dr. Becky Farley — physical therapist, neuroscientist, and Parkinson exercise specialist. These modules are designed to help PTs, OTs, and exercise specialists work more effectively alongside speech-language pathologists in support of people with Parkinson’s. Details and registration information are linked below.

(1) Roberts, Angela, et al. Speech Dysfunction, Cognition, and Parkinson’s Disease. Prog Brain Res. 2022; 269(1): 153–173.

My Mission: To enlist individuals in their treatment, and help them express their personality & spirit through voice. To educate and empower. Mary Spremulli, MA, CCC-SLP * FiTOUR® Group Exercise Instructor * Certified End of Life Specialist (CEOLS) * Voice Aerobics® A Whole Body Approach to Voice Practice

Voice Aerobics the heART and Science of Voice Practice