Most of our behavioral speech and voice treatment approaches for patients with Parkinson’s disease (PD) depend on a conscious response from patients to self-monitor some aspect of speech production such as vocal intensity (loudness) or speech rate. Patients are usually cued by the therapist with recommendations such as  “think loud,” or “say it with intent.” These cues which are provided by the speech pathologist throughout treatment carry the the expectation that the patient will eventually internalize the cue and be able to employ a new conscious technique when in conversation.

However, not unlike some voice therapy patients without a diagnosis of Parkinson’s, improvements attained in the therapy setting may fail to generalize outside of the therapy room to everyday conversation, leading some researchers to point to associated problems of cognitive-perceptual deficits.

When discussing their speech problems, PD patients often say to me: “it’s not automatic,” and, in fact, they are exactly right. Loss of the automaticity of speech coupled with cognitive changes can result in patients who are “willing” but not “able” to do all that is expected of them when communicating in the complexity and demand of everyday conversation. A spouse or other family member who observes the PWP (Person with Parkinson’s) in therapy may also be frustrated when the performance before the therapist is not occuring at home, leading to the conclusion that the PWP is “just not trying.”

A study by voice researchers of healthy subjects[i] found that when speech practice contained tasks viewed as having a “low level of cognitive load,” such as reciting days of the week or months, individuals were more easily able to devote some of their attention to self-analysis and self-monitoring aspects of voice and speech production. This type of attention and cognitive activation is thought to play a role in the inhibition of old habits and facilitation of new motor patterns.

In contrast, spontaneous speech, also called novel speech or voluntary speech, refers to newly created, extemporaneous utterances; similar to what is required for participation in conversation. Such speech is assumed to involve a larger amount of communicative effort and attention to content than rote speech and this type of effort can easily distract patients from maintaining dual focus of attention on both content and some aspect of their speech and voice behavior they are trying to modify. The study authors concluded that patients attending behavioral voice therapy may have a better chance of successfully adopting new behaviors in exercises with a low degree of distraction due to content.

Better understanding of the relationship between cognitive load and speech-language planning/production is an important consideration when developing a treatment plan for individuals with speech and voice impairment related to Parkinson’s disease. Patients who have already have been identified as having some memory or other cognitive problems may  struggle  with self-monitoring of speech as the cognitive demands increase, and alternatives to conventional speech therapy, such as a speech device intervention may be a more realistic and satisfying option.

Voice Aerobics® Tools for Home Practice

Hi-VOLT® 4 PD is a 27 minute audio recording of guided voice practice. It is designed to be used with the Hi-VOLT® voice-on-light a calibrated feedback tool, designed to help patients feel the effort required to maintain a loud enough voice for every day conversation.

Voice Aerobics® DVD, is a recorded version of a 57- minute voice and exercise program developed in 1999, for patients to use before, during, or after formal speech therapy.  This whole body voice strengthening program is guided, and focuses on posture, breathing, and voice. It’s FUN, it’s EASY, and when surveyed, patients reported increased awareness about breathing and voice use. The full program can be purchased or rented for as little as $5.99(US).

Device Interventions

Speech Vive is a device intervention based on the research of Jessica Huber, PhD, SLP, while at Purdue University. The device is fitted to one ear, and delivers babble noise, which in turn elicits the Lombard effect, causing users to speak louder over the background noise. Some users experience an instantaneous effect in loudness and speech clarity. Research conducted by Dr Huber found that when using the SpeechVive, Parkinson’s patients used breathing patterns similar to the non Parkinson’s control group, suggesting that for many Parkinson’s patients the speech mechanism is still capable of being used normally, and speech problems may be more attributable to a cognitive-perceptual dis-connect.

[i] Cognitive  Load in Voice Therapy Carry-over Exercises. / Iwarsson, Jenny; Morris, David Jackson; Balling, Laura Winther. Journal of Speech, Language, and Hearing Research, Vol. 60, No. 1, 2017, p. 1-12.

Therapy is NOT Magic

Therapy is not magic. There is nothing magical or supernatural about what speech-language pathologists do, rather, therapy is largely hard work on the part of patients, with a constant re-clarification of goals, mine and theirs. In fact there may be no more important question for the patient then “what are your goals from therapy?” “What is the outcome you hope to achieve?” Aligning expectations with abilities can help therapists design a treatment approach that is best for the individual, and with a disease like Parkinson’s that causes symptoms that change over time, treatment options should also change, and include any evidence-based treatment that is available that might help an individual.

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 Certified End of Life Specialist Training (CEOLS) * FiTOUR® Group Exercise Instructor 

                   Voice Aerobics® A Whole Body Approach to Voice Practice

 Voice Aerobics the heART and Science of Voice Practice