A new patient asked: “am I coming to see you to find out how bad my voice is?” “NO,” I replied, “you’re coming to find out how good it could be!”
Research has shown us that vocal behavior is hierarchically organized and that different speech activities engage cerebral networks in unique combinations. For example, speech that is repeated and speech that is read aloud seem to require the least amount of attention or effort, and these sorts of tasks have been associated with remarkable voice and speech improvements as compared with spontaneous speech, in persons with Parkinson’s disease (PD). Reading aloud, therefore, can be a great way to practice when the focus is only on speech production. But when mental energy and focus on speech production must be shared with, the mental energy of processing novel information, formulating thoughts and tolerating interruptions, all aspects of conversational speech, speaking may feel daunting and fatiguing to some individuals with Parkinson’s disease.
Researchers have shown that when voice patients were required to speak on a specific subject and at the same time self-monitor some aspect of voice that they were trying to change, modify, or improve, the degree of cognitive effort could easily distract the patient from maintaining dual focus of attention on both content and some aspect of voice production. This is an important consideration when choosing the most appropriate therapy approach for a patient, as it must be tailored to their individual motor speech symptoms, cognitive strengths or weaknesses, motivation and self-efficacy, and any other sensory loss such as hearing or vision which may impact learning.
For years I have witnessed the breakdown many patients experience when attempting to internalize a cue or self-monitor speech outside of the structure of therapy. Spouses or carepartners often express frustration when they observe the patient speaking louder and clearer in therapy, only to revert back to their low or mumbled voice once in the car or back home. Factoring into all of this as well, can be the on/off effects some patients may have in response to their Parkinson’s medications, or other non-motor symptoms such as general fatigue or anxiety.
Conversation is demanding, and expecting patients to give attention to perceptual and sensorimotor aspects of speech, cognitive-linguistic aspects of communication, emotional content, and pragmatic aspects of conversation such at eye contact and turn-taking may spell failure and frustration for many patients, who are otherwise motivated to improve the way they communicate.
At the onset of any out-patient speech therapy, it’s important to be thinking about a discharge plan. Thirty days of speech therapy can simply not be the end point for most patients with Parkinson’s disease, and a plan for discharge must include an honest assessment of what a patient is willing and able to do from a physical and congitive aspect, taking into account their primary communication partners and communicative environment, which will be very different for a patient living in the community v/s one living in an ALF.
After therapy maintenance programs such as Voice Aerobics® and the LOUD Crowd® can provide PD patients with an opportunity to continue to practice and strengthen their ability to attend to the sensori-motor aspects of speech production AND the cognitive-linguistic demands of communication in a safe and supportive setting.
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Device interventions such as SpeechVive are becoming more readily available and offer individuals with Parkinson’s an instant improvement in speech volume and clarity, while reducing cognitive load. Below is a voice sample of a patient of mine during an initial evaluation.
The patient is 57 yo with a diagnosis of PD for 22 years. He underwent bilteral deep brain stimulation in 2012, and although he is pleased with the improvement in walking and other motor symptoms, he has experienced a decline in speech, which is reduced in volume and clarity.
Voice tasks were performed initially without any cueing, and then repeated using the Hi-VOLT® light for feedback, and a single cue: “speak loud enough to activate the light.” Tasks were repeated a third time while the patient wore the SpeechVive device in one ear. An increase in vocal intensity and speech clarity was noted while reading the Rainbow passage with a 6dB increase in loudness using the Hi-VOLT® light and a 4dB increase in loudness using the SpeechVive. (when programmed, the SpeechVive is designed to yield a 3dB increase in SPL).
With daily use of the SpeechVive, this patient will likely experience even more improvement in speech clarity. For patients with cognitive impairment, a device intervention can eliminate the need for self-monitoring of speech and speech therapy sessions can focus on cognitive-linguistic aspects of communication or other bothersome symptoms, such as dysphagia (swallowing difficulty).
My MissionTo 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 * Voice Aerobics® A Whole Body Approach to Voice Practice
Voice Aerobics the heART and Science of Voice Practice