This month I had the opportunity to provide two community lectures on the topic of Swallowing and Parkinson’s disease. Following my presentation/s I was struck by the number of people  with Parkinson’s (PWP) who came up to me to ask a question who have never been referred for a speech or swallowing assessment, despite an apparent speech or voice problem, a complaint of drooling, or a report of  a symptom such as food “sticking” in their throat.

Why, I wonder, are some neurologists still waiting until Parkinson’s patients are symptomatic to refer for speech and swallowing evaluations and treatment?

With 80% of people with Parkinson’s reported to have swallowing problems, and 90% speech and voice changes, early referral for assessment and treatment should be a part of the standard of care. Although Carbidopa in its various forms may provide improvement in motor symptoms of PD, it has not been shown to have that same direct beneficial effect on speech and swallowing, and so, behavioral interventions and swallowing and speech exercises specifically directed at symptoms are necessary.

Do You Have a Swallowing Problem?

Research tells us that PWP are not often reliable in reporting swallowing symptoms, and there may be several reasons for this. PWP may not recognize that certain symptoms, such as drooling, do in fact represent a change to the swallowing mechanism, and may also be associated with “silent aspiration” (saliva, food or liquid getting into the airway without triggering a reflexive cough). Other individuals may acknowledge that they frequently cough when drinking or eating, but don’t associate this behavior with dysphagia ( a swallowing problem), and so fail to report this to their physician.

What are you waiting for?

 A patient says: “I don’t think I need therapy yet” “my speech is not that bad”

I am fortunate to work with a local physician who refers most of his patients newly diagnosed with Parkinson’s or related disease diagnosis for a speech and swallowing consult. But, when I contact a patient to schedule an appointment, from time to time, I am met with the comment: “I don’t think I need speech therapy yet, my speech is not that bad.”

I will often ask: “what symptoms are you waiting for?”, as I may already detect the tell tale signs of speech decline such as : low volume, monotone pitch, or a rate that is faster or slower than normal.

But, my job is not to convince someone that they have a problem, rather, it is to educate them about the benefits of early speech and swallowing treatment  that may include  exercises which  if begun early, may improve or delay the progression of symptoms.

I have learned over the years,  that education about a chronic disease or its treatments isn’t a onetime event, and that it may take time for an individual to “wrap their head around a particular diagnosis.” Disease education, if it is going to be effective, has to begin early and be ongoing. When someone has a progressive neurodegenerative disease like Parkinson’s, PSP, or a related diagnosis, symptoms and subsequent needs will change throughout the course of the disease, and periodic re-assessment and treatment is going to be likely. 

Early referral to a speech-language pathologist for evaluation and treatment can provide patients and their families with an ally who will accompany them on their journey and who, in addition to providing treatment, can serve as an advocate providing disease education, support and resources.

Frequently Asked Questions About Speech Therapy

Does Medicare pay for this? Medicare pays for speech and swallowing therapy which is deemed medically necessary, and so yes, speech therapy is a covered service. However, if you have a Medicare Advantage plan, be aware that your upfront cost-savings may be found on the back end by way of high co-pays. I have had patients who have a  $50 co-pay for specialists’ services, and those patients often self-limit treatment or discharge prematurely because of cost. Medicare may pay later in hospital costs due to falls, aspiration pneumonia, or other symptom related injuries or illness.

Do I need a prescription? Unlike physical and occupational therapists, speech-language pathologists do not require a physician prescription to treat, so you can self-refer, however, if services are billed to Medicare, they will require a physician signature to the plan of care.

Can I go to your private practice while receiving Home Health? You cannot receive services from an out-patient provider (PT, OT, or speech), even if they come to your home, while you are under a Home Health plan of care. Be sure your Home Health agency discharges you from their care before seeking out-patient therapy. If you are receiving Home Health services and your doctor has ordered physical and speech therapy, be sure the agency you are working with has staffing to adequately provide both services at the frequency you require.

I have a prescription for PT and Speech, can I do both? Yes, you can do simultaneous speech therapy and physical or occupational therapy, but I usually recommend doing one or the other if the treatment is for symptoms related to Parkinson’s. If, for example, you are enrolled in LSVT BIG and LSVT® LOUD, you are going to have home practice with both, and you may soon feel overwhelmed and not do one or the other. It may be helpful to have an assessment with a physical therapist and a speech-language pathologist and based on assessment findings, the therapists may be able to help you prioritize a therapy schedule. If, for example, you have a swallowing issue that needs attention, then that may be the priority.

Can I self-pay? As a Medicare provider, I am obligated to bill Medicare, so, no, if you are seeing a PT, OT, or Speech therapist who bills Medicare, you cannot do private pay. That is the law. If you are below the Medicare age, then yes, you can do private pay. If you are below the Medicare age and have a commercial payer such as Blue Cross or Aetna, many do not contract with private practice therapists, so, you must check with your payer to see if out-of network benefits are available. You may also have a high deductible which needs to be met or co-payments you will be responsible for.

Can I do therapy over the computer? Speech therapy provided via the computer is also referred to as telepractice, telehealth, or telerehab. There are a number of programs, including LSVT® LOUD, which have been researched using a telepractice model of delivery. Medicare, however, does not yet pay for speech therapy via telepractice, so this will be an out-of pocket expense. Additionally, the therapist working with you must be licensed in their state and also the state where you reside.

Interested in Telepractice or Online Coaching?   

Some people may find it difficult to attend speech therapy due to the distance they live from a provider. For those individuals, telepractice might be an option to investigate. Visit my private practice page and learn more about online coaching and telepractice services available. I hold a speech-language pathology license in Florida, North Carolina, and Ohio.


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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