Ask an Expert: Registered Speech-Language Pathologist Sherri Zelazny Discusses Common Speech and Swallowing Problems in People with Parkinson’s

Sherri Zelazny is a Registered Speech-Language Pathologist with more than 35 years of experience and clinical expertise in voice evaluation and treatment. She has a long history of involvement with the Parkinson’s community as a clinician providing Lee Silverman Voice Treatment® for Parkinson’s for more than 20 years. She was the Vice President (now Honourary Member) of the Wisconsin Chapter of the American Parkinson Disease Association. She joined the Board of Directors in November 2012. Sherri also contributed significant time and energy to piloting the Society's Communication and Swallow program in 2014 and continues to present this program. She is Past-President of Speech and Hearing BC (2017-2019).

What are some of the common speech and communication problems in Parkinson’s disease? What about swallowing problems? What impact do these issues have on daily living?

The most common communication difficulty that people with Parkinson’s disease (PD) experience is low vocal volume or soft voice. Other communication changes can include hoarseness, mumbling, vocal tremor, and changes in speaking rate. Hypokinetic dysarthria is the diagnostic term used to identify communication problems typical of Parkinson’s disease.

The most obvious signs of swallowing problems are coughing and choking; these issues can occur during or after eating or drinking. Other less obvious symptoms may include trouble swallowing pills, difficulty chewing, slower eating, avoidance of certain foods, drooling, fatigue with eating, difficulty starting the swallow, or recurrent lung infections. Dysphagia is the term used to describe swallowing disorders.

Changes in communication and swallowing often emerge before a formal diagnosis of Parkinson’s disease. Early identification, evaluation, and treatment can help manage symptoms and maintain quality of life. We take our ability to communicate and eat for granted, including expressing our wants and needs, telling people we love them, and enjoying a meal with family and friends. Problems with communication and swallowing interfere with quality of life and daily wellbeing.

We know that more than 80% of people with PD will experience communication and/or swallowing challenges at varying levels of severity. A qualified Registered Speech-Language Pathologist (RSLP) can help evaluate, treat, and improve communication and swallowing safety to improve quality of life.

What role does a Registered Speech-Language Pathologist have in treating communication and swallowing difficulties in people with Parkinson’s?

Registered Speech-Language Pathologists (RSLP) provide behavioural evaluation and treatment for symptoms related to hypokinetic dysarthria and dysphagia. Treatment for communication and swallowing disorders for Parkinson’s disease can be very effective. Patient participation is crucial, as it is in any therapy exercise program, as is early identification and treatment. For better outcomes, early contact with an RSLP is important.

You are certified in Lee Silverman Voice Treatment® (LSVT®), one of the “gold standard” treatments for Parkinson’s. What makes LSVT® so effective when compared to other therapies?

Scientifically validated over the last 30 years with research funding from the National Institutes of Health and other organizations, LSVT LOUD® is the only speech treatment with level one evidence, the highest level of evidence, for people with Parkinson's. Published outcomes on LSVT LOUD® have documented:

Increased vocal loudness
Improved articulation and speech intelligibility
Improved intonation
Improvements in facial expression
Changes in neural functioning related to voice and speech

LSVT LOUD® is a standardized treatment protocol that is customized to the unique communication goals of each client. It can result in improvements in clients across a range of disease severities and communication impairments.

The dosage of LSVT LOUD® is consistent with principles of neuroplasticity including “Use it or Lose it and Use it and Improve it!” It is administered in an intensive manner to challenge the impaired system.

What day-to-day activities can people with Parkinson’s do to strengthen their communication and swallowing abilities?

Some general tips for improved communication:

Talk LOUDER!
Look at the people you are talking to
Talk in a quiet location
Plan conversations for when you have more energy
See a Registered Speech-Language Pathologist for voice exercises

After participating in therapy with a Registered Speech-Language pathologist, there may be group voice activities appropriate for you that will help you continue practicing voice exercises, ensuring you maintain your progress.

Some general tips for swallowing safety:

Focus on eating; do not talk or do something else at the same time
Take small bits and sips, one at a time
Chew your food well
For each bite or sip you take, swallow two times
Be careful using straws. The liquid can come in too fast making it difficult to swallow safely
A spoonful of mashed bananas can help pills go down. Try one pill at a time
If you notice coughing or throat clearing during or after eating, tell your doctor
See a Registered Speech-Language Pathologist for swallowing exercises

Any activities that involve using your voice and swallowing muscles can help to keep the muscles active. Singing (on your own, karaoke, with a choir, or with a program such as SongShine) is great. Staying social, talking on the phone, talking with your family, and reading aloud are all activities that will keep those muscles moving.

The best exercise for swallowing is swallowing. Just like the general recommendation for physical exercise for people with Parkinson’s disease, talking, singing, and swallowing are all forms of exercise that can benefit your communication and swallowing abilities!

What advice would you give someone who cannot, for whatever reason, access the services of a Registered Speech-Language Pathologist? Are there any self-guided treatments available?

This is a very difficult question to answer. In short, there are no self-guided treatments for communication and swallowing challenges in Parkinson’s disease. We would like everyone to have access to the services that mediate communication and swallowing problems in PD and improve quality of life. The best personalized care will be provided by a qualified Registered Speech-Language pathologist after a comprehensive evaluation. Because British Columbia's Medical Services Plan (MSP) does not cover outpatient rehabilitation outside of programs offered in hospital and at movement disorder clinics, it limits access to important services. Currently, services are available through movement disorder clinics across the province and private speech-language pathology providers. If you have extended benefits that cover “speech therapy,” you may be able to submit receipts from private service providers for reimbursement within the limits of your benefits. Swallowing evaluations and RSLP recommendations are always covered through MSP with a referral from a physician to your health authority.

Parkinson Society BC (PSBC) has been instrumental in improving access to services by funding speech pathologist positions in the Kelowna, Victoria, Nanaimo, and Vancouver movement disorder clinics. It is important that all people diagnosed with Parkinson’s disease have contact with the movement disorder clinic closest to them for the best access to available services.

PSBC’s Communication and Swallow Workshops are also offered around British Columbia to help people better understand and identify hypokinetic dysarthria and dysphagia, explain importance of early evaluation and treatment, and introduce initial voice and swallowing exercises. The next Communication and Swallow Workshop is taking place on Saturday, September 16 at Lambrick Park Church in Victoria.

Are there any assistive devices that can support communication and swallowing in people with Parkinson's disease?

There are devices available, such as The Voice Aerobics Hi VOLT® Voice-on-Light Bracelet (which requires the user to wear the bracelet on their wrist; once their vocal volume reaches a sufficient level, the bracelet's light turns on, providing instant feedback) and SpeechVive (which utilizes an automatic brain response called the Lombard Effect, prompting louder speech as surrounding noise levels increase). These devices help individuals increase vocal volume. There are also various smartphone apps to help measure loudness and guide voice exercises, as well as reminding you to swallow. Additionally, there is respiratory muscle strength training that has shown effectiveness for communication and swallowing. Candidacy for benefitting from any of these devices should be determined after evaluation with a Registered Speech-Language Pathologist.

How do you assess and monitor the progression of communication and swallowing difficulties in Parkinson's disease? Does treatment change as the disease progresses?

The Radboud Oral-Motor Inventory (downloadable here) is a great way to self-monitor the status of communication and swallowing concerns and changes that may occur over time. Treatment is always customized to the unique communication and swallowing goals of each person. Early contact with a Registered Speech-Language Pathologist will help direct treatment over time based on disease progression in each person.

Are there surgical or medication treatments for speech and swallowing challenges for people with Parkinson’s?

So far, there are no surgical or medication treatments for communication and swallowing challenges. Having your medication regime optimized for your symptoms is best and will allow you to do all communication and swallowing exercises to the best of your ability. If communication or swallowing symptoms worsen with a medication change, be sure to tell your doctor as soon as possible.

How can healthcare providers help address the emotional and social aspects of communication and swallowing challenges?

Early referral to a qualified Registered Speech-Language Pathologist is the most important step. If you have been diagnosed with Parkinson’s disease, you are a candidate to benefit from services offered by a RSLP. Prompt attention to communication and swallowing challenges helps to maintain quality of life, including communicating with loved ones, working, enjoying meals with others, and socializing. From a much larger lens, we all need to advocate for access to publicly-provided allied healthcare services with the Ministry of Health for people with Parkinson’s disease.

This content was published in the Fall 2023 edition of our quarterly magazine, Viewpoints. The content was accurate as of this publication date.

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