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What is Parkinson's Disease?

Degenerative disease of middle age
Marked degenerative changes & dopamine deficiency in substantia nigra
Either idiopathic (primary) or symptomatic (secondary)


Who 1st described PD?

James Parkinson in 1817


Primary/Idiopathic PD

No known cause
Where most research is done


Secondary/Symptomatic PD

Arises from another neurological impairment: drugs, trauma, etc. (Muhammad Ali-basal ganglia trauma)
Theories of cause: Pesticides, genetics, etc.


Extrapyramidal System

Consists of basal ganglia, lateral to internal capsule
Contributes to control of posture, tone, & facilitation of movement:
-automaticity of walking/running
-cooperation of independent movements of extremities
-freedom of movement
-suppress unwanted, involuntary movements (tremor)


Prevalence/Incidence of PD

1.5 million in US
1 in every 100 over age of 75
6 million worldwide
25.6 per 100,000 per year
2020=40 million worldwide
50-60,000 will be diagnosed this year
Becoming more prevalent esp. b/c people are living longer
Research shows we can slow progression & improve QOL through therapy


Who gets PD?

More common in males (slightly)
Typical age of onset: 55-60
African Americans & Asians are less likely than Caucasians to develop
Early vs. Late Onset
Earlier in life tends to have quicker progression than later in life onset


Pathological Findings & PD

Loss of pigmented, dopaminergic neurons in the SNpc
50-60% cell death at diagnosis
70-80% loss of DA terminals at diagnosis
Proceeds diagnosis ~5-6 years


#1 1st sx of PD

Loss of smell


Motor Circuit through Basal Ganglia

Basal Ganglia-thalmo-cortico circuit
Cortical drive is overall under-scaled & timing scales are inconsistent
Cortical drive to periphery
BG controls all cortical drive to motor output


Incomplete activation=

inconsistent output=timing issues (akinesia)


PD has ____ amplitudes of movements



____ in inhibition so there's a _____ in movement

Increase; Decrease


PD characterized by...

Postural instability


2 Types of Rigidity

Cogwheel rigidity
Lead pipe rigidity


Cogwheel Rigidity

Jerky, ratchet-like resistance to passive movement as muscles alternately tense & relax
Will mostly see weird posturing


Lead Pipe Rigidity

Sustained resistance to passive movements



Can be unilateral or bilateral (usually start unilateral & move bilateral)
Medications can help (significant side effect is dyskinesias)
Is present in 70% of Pts
Resting vs. action--resting with this
Increases with distress/fatigue
Fluctuations are very common
Energy conservation & decreasing anxiety important



rhythmic movements (essential tremor, Huntington's)



When they're doing an activity; more rhythmic



Decreased movement/amplitude
Freezing: sudden break or block in movement



Absence of movement: presents a deficit in preparatory phase of movement control & can be related to rigidity (counting, rhythmical, music)--designs hard for them, visual cues can help, laser pointers, can have it in their speech too


PD is an ____ disorder

Decreased amplitude; arms, speech
amplitude of what they go to do decreases


Common Motor Sx's Related to

Inadequate scaling of motor output
Inadequate time signals


Common Motor Sx's of PD at Time of Diagnosis

Bradykinesia, gait hypokinesia, resting tremor, micrographia, hypophonia, stooped posture, decreased dexterity, masked face


Common Motor Sx's of PD at Time of Referral

Generalized weakness, akinesia, festinating gait (walk forward/stooped, shuffle as they go/speed up), freezing episodes, postural instability, rigidity, adaptive responses (weakness, contractures, decreased aerobic capacity), dysphagia


Common Speech & Voice Sx's and PD

Harsh, breathy phonation; monopitch; monoloud; decreased intensity; excessive pausing; short rushes of speech; variably fast & slow AMR's; reduced ROM of musculature; alternating fast & rates of artic; imprecise consonant & vowel production; masked facies; decreased intonation


Sensory Deficiencies in PD

Lack of awareness across body & space
Decreased ability to internally cue or trigger movements themselves: due to decreased activation of the SMA
For therapy: Show them in mirror or record them-recalibrate system


Parkinson's Plus

Axial rigidity is more prominent with less in extremities
More backwards lean
PT tx limited info for prevention as w/ idiopathic PD
Focus on QOL
Present like PD but not



Abnormal posturing or tone
Increased output to muscle (so much tone); can be result of PD


Multiple system atrophy (MSA)

Progressive, idiopathic degenerative process beginning in adulthood
Pt's present with various degrees of parkinsonism, autonomic failure, cerebellar dysfunction, & basal ganglia signs that are poorly responsive to levadopa or dopamine agonists
(1st sx's look like PD pt, but will progress much more rapidly)


Progressive supranuclear palsy (PSP)

Pt develops bradykinesia, rigidity, dysarthria, dysphagia, & dementia, as in Pt's w/ idiopathic PD
Tremor is rare, Pt has severe postural instability
Axial rigidity appears to be more prominent than limb rigidity
Occular paresis (vertical gaze palsy) and gait instability are cardinal signs


Telltale sign of PSP

Don't have vertical gaze--can't track up & down
"PD version of ALS"--cognitive deficits, AAC, if early enough can do LSVT


Diffuse Lewy body disease (DLBD)

Progressive neurodegenerative disorder characterized by presence of parkinsonian sx's & neuropsychiatric disturbances commonly accompanied by dementia
Progressive dementia often first & predominant sx
(the worst—mostly caused Lewy body dementia—very progressive—must have cognitive sign be first sign—quick)—can’t tell unless upon autopsy for sure—OCD, other psychiatric disturbances


How many stages of speech d/o's in PD?

5; UPDRS (is a ranking system for PD)


Stage 1 of Speech Disorders in PD

No detectable impairment


Stage 2 of Speech Disorders in PD

Detectable impairment; effective communication decreased


Stage 3 of Speech Disorders in PD

Decreased speech intelligibility


Stage 4 of Speech Disorders in PD

Less speech; low intelligibility; less talking


Stage 5 of Speech Disorders in PD

Speech is rare


Stages of PD Speech Disorders & Typical Tx Stage 1

Confirm the stage and educate


Stages of PD Speech Disorders & Typical Tx Stage 2

Environment, context, partner (educating)


Stages of PD Speech Disorders & Typical Tx Stage 3

Target intelligibility, communication repair


Stages of PD Speech Disorders & Typical Tx Stage 4

Supplementation (Anne doesn't enroll in tx, talks about AAC)


Stages of PD Speech Disorders & Typical Tx Stage 5



When should PD Pt's enroll in tx?

Sooner rather than later
Tx is most successful in earlier stages
Sensory impairment isn't as bad earlier & may be able to calibrate easier
Research demonstrates that early intervention slows progression of disease process


___% of PD pts need speech therapy



Lee Silverman Voice Treatment Development

In Scottsdale, AZ
Lorie Gramig & Cynthia Fox


LSVT Definition

Intensive speech therapy tx program targeting high frequency for improved calibration & maintenance of therapy


LSVT Targets

All subsystems of speech production: Respiration, Phonation, Articulation, Resonance


Treatment Paradigm for LSVT (& PD)

PD is disease of amplitude
Instead of targeting subsystems of speech & voice production, target is amplitude, aka vocal loudness


To target vocal loudness...

Intensive, high effort delivery in order to achieve calibration/generalization


Vocal amplitude

Loudness targets an improvement in this in all areas of speech production: lungs, VFs, articulators, facial movements


By cueing PD Pts to think loud...

You aren't cueing to talk loud but to think loud in order for them to be able to speak with a voice that is WNL
They have to think loud so their sensory feedback is wrong so they are at normal loudness


Loudness facilitates ___

Improved VF closure, increased opening of the vocal tract, & increased movement of the tongue, lips, & jaw with only 1 cognitive target


Treatment Techniques

Complete a full voice assessment
Assess Stimulability & enroll in tx if appropriate


LSVT Protocol

4 sessions (50-60 minutes), 4 days a week, for 4 weeks (16 sessions)
Research being completed for 2x/wk for 8 weeks and it's effectiveness
Very strict protocol


LSVT Materials

Stop watch, Sound Level Meter, Tuner


Eval for PD

Case history
Cognitive screening/assessment (depending on team, may not be necessary)
Motor speech & voice assessment
Dysphagia assessment (if necessary, need modifieds with these pt's, not fees)


Evaluating Cognition

Montreal Cognitive Assessment
Informal assessment

Not MMSE for outpatient


Evaluating Speech & Voice Materials

Voice/video recorder
SPL meter (sound pressure level meter)--always use same one w/ same pt-arms length away
Words, sentences, & paragraphs for reading
Tuner (for pitch)


Evaluating Speech & Voice Procedure

Determine respiratory pattern
MPT & counting from 1-__ on a single breath to measure coordination of respiration & phonation
Determine pitch range by going up a scale
Measure Pt's loudness at baseline during MPT & paragraph reading
Rate vocal characteristics during paragraph reading or convo (harshness, hoarseness, etc.)
Intelligibility testing: Quick Assessment for Dysarthria or Assessment of Intelligibility of Dysarthric Speech
Stimulability Testing: Are they stimulable for tx, specifically LSVT if appropriate?



Can they follow models/cues?-- "do what I do"
do they use your intonation, inflection, etc.


ENT Eval

Important to have instrumental assessment of VFs & their structure & function
Develop a relationship w/ an ENT in order to have an interdisciplinary approach to voice tx
Instrumental not necessary for stage 1: if they start getting hoarseness, send to ENT before tx


Max duration of sustained vowel phonation

Target duration of phonation efficiency, adduction of VFs, coordination of respiration & phonation
Have Pt say "ah" for as long as they can in a loud, strong voice (8-10x--wears them out; 10x at home)
Important to model for the pt and cue; as tx progresses, models & cues are reduced to facilitate calibration
Exercising voice


Maximum Fundamental Frequency Range (Pitch Extension)

Improve range of motion in cricothyroid, rescale amplitude of phonatory output for speech
Have pt say "ah" at normal pitch & then extend to high pitch (15 reps)
Have pt say "ah" at normal pitch & then extend to low pitch (15 reps)
No hyperfunction (maybe only 1 note)
“Think loud; be loud”
“I may be talking to you while you do this. Keep going until I cut you off.”


Maximum Functional Speech Loudness

Assist in carryover & maintenance, trains, cues, & calibrates pt to use good vocal amplitude for speech production
Pt generate 10 functional phrases uses in everyday life (assists in carryover): read phrases targeting Loud voice 5x's; make sure to have pt's separate each utterance, do not read as a list--not functional-will affect loudness-short rushes of speech in PD anyway (not how they say it)


Hierarchical Speech Loudness Task

Allows Pts to systematically progress into normal loudness at conversation
Always doing conversation: functional
Eval: Always have them fill out Voice Handicap Index: self-report questionnaire: voice impairment from their perspective


Week 1: Hierarchical Speech Loudness Tasks

words/phrases, short simple conversation


Week 2: Hierarchical Speech Loudness Tasks

sentences/reading, short simple conversation


Week 3: Hierarchical Speech Loudness Tasks

reading (paragraphs-interested from home or clinician-supplied)/conversation


Week 4: Hierarchical Speech Loudness Tasks



LSVT LOUD Tx Activities

It's impt to monitor pts & avoid pressed voice, closed mouth, tight/raised shoulders, facial grimacing, poor posture, poor head positioning
Give pts daily tasks to complete at home with carryover exercises: assignments given for home practice include daily activities done in tx session & activities to promote calibration (greetings, voice mail, talking on phone, talking to staff outside of tx room)
Model what they’re doing wrong and what they should do
Modeling really works
When they’re not in therapy, they’re doing home work twice a day, when they are, they’re doing it once a day


Is Pt calibrated?

Measure speech in conversation, during cognitive tasks
Pt spontaneous speech, self-generated speech will be louder
Pt & families will report improved communication
Friends & acquaintances will give feedback to pts
Daily habits change & pts talk more



Review w/ pt that they must continue their exercise program & practice at home
Follow-up in 6 months (want to slow progression): 1 or 2 "tune-up sessions"; more severe pts may need more frequent follow-up
Pts complain that pets hate homework exercise



Same paradigm applied to movement
PD is a disease of amplitude so Big targets big movement to improve gait, balance, & functional mobility
Research is being completed on dual target of Big & Loud during one tx session with a Pt



combining big and loud at the same time because physical movement improves cognition and speech/laryngeal movement


Deep Brain Stimulation

Device like a pacemaker sends electrical pulses to targeted parts of the brain
Proven to increase daily "on" time by 6 hours
Proven to reduce daily dyskinesia by about 3-4 hours per day
Based on how bad dyskinesias are
If pt doesn’t have dyskinesias and get this, better outcome than pt who already has them


DBS & Speech Pathology

Little research supporting improvement in speech after DBS
Most research states no impact or negative impact on speech
Some research states 17-30% of STN implantations will have speech/language side effects
Activa is DBS therapy (speech is one of top 4 side effects)
Maybe increased word-finding difficulties


Possible Side Effects & DBS

Increased rate of speech, jaw, posterior tongue dystonia, velopharyngeal dysfunction, increased effort, decreased vocal intensity


Speech Implications of DBS

Longitudinal study found that speech was relatively unaffected by STN-DBS
Another found that bilateral & right stimulation were perceived as no significant change; left was perceived as having significant deterioration in prosody, artic, & intelligibility (quieter voice)
Fewer studies on Gpi (globus pallidus): 1 study demonstrated improved speech in 1 but hypophonia in another
Effects on speech are largely dependent on DBS programming
Research demonstrates a sig. relationship b/t increased amplitude & frequency & worse intelligibility
Often Pts have to choose which sx is worse & have the system programmed based on their goals



quieter voice


SLP's Role in DBS Tx

Important to eval speech & swallowing abilities prior to surgery
After surgery, may need to assess on & off stimulation to determine best level of function
Neurologist may set several different programs so that pt can switch program when necessary
Research overwhelmingly states that individual is greater than whole when it comes to outcomes; too much variability b/t pts to determine common effect
Treat each pt individually & determine best course of action; assess each subsystem b/c each subsystem can be affected differently


Why Not LSVT?

Some PD Pts have hyperfunctional voice d/o's as well
Some Pts have dystonia
Some Pts have too severe of breathing impairments


Traditional Voice Tx for PD

Diaphragmatic breathing
Relaxation & Stretching for cervical muscles & other muscles for speech production: relaxation of muscles used for voicing & speech; consists of stretching & movement of muscles to reduce tightness & tension
Laryngeal massage
Pacing boards (not very functional)


Diaphragmatic breathing

Coordination of respiration & phonation is important aspect for speech
Many pt's use clavicular, thoracic, or a combination when breathing: impt for pts to use full lung capacity
Begin in supine position & progress to standing then sitting while taking away cues
Eventually achieve calibration of technique
Pts with PD often have issues with BP (have to be aware of it with moving around (sitting, standing, laying down)



Sudden breaks or blocks in movement