Dyskinesia (uncontrolled involuntary movements that can look like fidgeting or swaying of arms, legs, oral-facial, or trunk muscles) are unfortunately a common experience for individuals with Parkinson’s disease (PD). Dyskinesia are associated with long term use of Levodopa, and research has indicated that, dyskinesia can occur in approximately 50% of patients by 5 years and nearly 90% of patients by approximately 10 years of treatment. Dyskinesia have been associated with impaired activities of daily living, increased risk of falls, increased health care utilization, and increased strain on care providers.
Dyskinesia affecting the trunk and respiratory muscles are less apparent, and hence, may be less reported or under-recognized, and yet, may have a marked effect on speech breathing and the co-ordination of breathing and swallowing. Irregular breathing patterns because of fluctuating dopamine levels may contribute to reduced co-ordination of breathing and swallowing leading to mistimed swallows and aspiration, and irregular breathing patterns may cause some hyperventilation or dizziness and contribute to a patient’s sense of anxiety.
A recent study in the Journal of Speech, Language, and Hearing Research (JSLHR) reported evidence of restrictive lung defect, weakness of both inspiratory and expiratory muscles, and an abnormally high prevalence of OSAS (obstructive sleep apnea) or nocturnal oxygen desaturation associated with Parkinson’s disease. In addition, the study investigators reported a more pronounced cough disability in PD patients with moderate-to-severe dysarthria (a motor speech impairment). Abnormal posture constricting the rib cage could further contribute to both respiratory and voice impairments.[i]
Most patients with Parkinson’s will benefit from speech and swallowing interventions, but first and foremost, they must be optimally medicated, including addressing side effects that may be related to medication use. Speech-language pathologist need to be aware of the contribution of dyskinesia to speech and swallowing symptoms the patient may be reporting. Timing of medication and on/off symptoms may have a marked impact on testing and treatment, including pulmonary function testing, and hence, results may not always accurately represent a patient’s best or worse performance.
Speech-language pathologist and other therapists who treat patients with Parkinson’s disease must be astute observers and help patients identify and document episodes of dyskinesia which may be related to medication, and which may be contributing to the patient’s speech and swallowing, or other motor symptoms.
Expecting a patient to use their voice in a normal fashion when involuntary muscle activity is being imposed on the system will only result in frustration for the patient and therapist. My own experience has been that patients are frequently unaware of their dyskinesia, perhaps because they acclimate to the abnormal movement. Instead, they report associated symptoms: “I can’t catch my breath,” or “I run out of breath when I speak, “ and only when they see themselves on video do they comment on the dyskinesia. Therapists treating PD patients can help with management by documenting symptoms and reporting these to the patient’s neurologist.
It is increasingly being recognized that respiratory dysfunction even in pre-motor stages should be considered as a part of Parkinson’s disease itself rather than a different problem. If patients are sent for pulmonary function testing, it is important that pulmonologist be aware that breathing problems in PD patients may be a direct consequence of disease progression, dopaminergic stimulation, or associated with levodopa-induced diaphragmatic dyskinesia. The presence of other dyskinesia more commonly seen in PD, such as trunk, face, or limbs, should alert physicians to the presence of diaphragmatic dyskinesia in patients complaining of shortness of breath.[ii]
[i] Voice Alterations, Dysarthria, and Respiratory Derangements in Patients with Parkinson’s Disease. https://doi.org/10.1044/2022_JSLHR-21-00539
[ii] Respiratory dysfunction in Parkinson’s disease: a narrative review Andrea D’Arrigo, Stefano Floro, Francesca Bartesaghi, Chiara Casellato, Giuseppe Francesco Sferrazza Papa, Stefano Centanni, Alberto Priori, Tommaso Bocci ERJ Open Research 2020 6: 00165-2020; DOI: 10.1183/23120541.00165-2020
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The Hi-VOLT® voice-activated Feedback Tool for Speech Practice
The Hi-Volt® is a calibrated, voice-activated feedback tool that may help some patients perform speech practice more efficiently and help them feel the effort they need to use to generate a loud enough voice for some strengthening to occur. Frequently, it is introduced during speech therapy treatment, with a single cue: “speak loud enough to activate the light.” At home, the patient can use the Hi-VOLT® during their speech practice, or, because the light is housed within a bracelet, use it during physical therapy as an external cue for loudness when counting exercise reps. To purchase or learn more visit the homepage: https://voiceaerobicsdvd.com/
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