On the occasion of European Speech and Language Therapy Day, marked today, March 6th, we share an opinion piece from Therapist Helena Santos, Coordinator of Speech Therapy at the Lisbon Unit of CNS – Campus Neurológico. In it, she explains the most common speech and swallowing changes in Parkinson’s disease and when one should seek the support of a speech therapist.
Parkinson’s Disease (PD) has a visible face, easily identifiable by all (tremor, slowed movements, shuffling steps), yet, like other neurological conditions, its impact is felt in various capacities and functions. Today, I highlight two: communication and safe eating without compromising nutritional and hydration status. Although these may not be the first functions that come to mind when thinking of PD, changes in these areas are diverse and very common. Their consequences are crucial for the quality of life of people with this condition and their families or caregivers.
Managing these changes, along with others associated with this condition, requires a multidisciplinary team, which includes a speech therapist. Speech therapy, as a profession, is well-known and publicized for its role in specific areas such as childhood speech and communication difficulties or those arising from events like strokes. However, in other domains, like neurodegenerative diseases such as PD, the speech therapist’s contribution is still not widely known. Due to this lack of awareness and the difficulty in accessing qualified professionals, individuals with these conditions often seek therapy late or not at all.
It is important to understand how PD interferes with these functions and how a speech therapist can help.
Why does PD interfere with communication?
Among the most common changes in PD are those related to speech. The voice becomes softer, sometimes hoarse or breathy, and speech sounds become less distinct. People move their jaw, lips, and tongue less, making speech less understandable to others. Speech becomes slower or too fast, and the tone becomes monotonous, making it difficult to convey different emotions through speech. In extreme cases, it may be challenging to discern the person’s communicative intention. To make matters more challenging, these changes are often accompanied by a perception defect; individuals with PD may not realize they have these issues. They may be unaware that their voice has significantly lowered in volume, making it difficult for others to understand, even if there’s no hearing loss. This communication breakdown can lead to misunderstandings, causing the individual with PD to become less communicative and more isolated over time.
Regarding swallowing, how does PD affect a person’s ability to eat?
Swallowing refers to the ability to safely transport saliva, liquids, and food from the mouth to the stomach. Safe transport means that these substances do not deviate from their usual path and enter the airways. This is called dysphagia.
In people with PD, early signs of swallowing changes often include increased saliva in the mouth, tablets getting stuck, and coughing/choking with saliva, liquids, and dry or granular solids. Initially, these incidents may occur infrequently, perhaps once or twice a week, and may be dismissed or not reported to healthcare professionals. As the disease progresses, swallowing difficulties become more frequent and involve a wider variety of foods, making eating more challenging and less safe. This can result in reduced food intake, weight loss, muscle mass loss, worsened motor functions, and increased frailty. Additionally, as dysphagia worsens, the risk of food entering the airway and causing aspiration pneumonia increases. Beyond health implications, swallowing changes diminish the pleasure of eating and disrupt the social aspect of meals.
What can be done? How can we minimize the impact of these changes on the quality of life of those with PD and their close ones?
Speech therapy intervention generally falls into two categories: improving function and introducing/adapting strategies to facilitate communication and maintain safe eating.
For speech improvement, evidence suggests intensive intervention programs where individuals with PD undergo almost daily sessions for several weeks. An example is the Lee Silverman Voice Treatment (LSVT), which, while focusing on voice training, has shown positive results in other speech subsystems.
Similarly, for swallowing, intensive programs focusing on specific swallowing aspects (coordination of breathing and swallowing, muscle strength involved in swallowing, laryngeal elevation) have a positive impact and improve this function. This allows individuals with PD to maintain a less restrictive oral diet.
However, not everyone can access intensive programs. In certain situations or disease stages, a less frequent but longer-lasting program might be more appropriate. As with walking, speech and swallowing functions require the coordinated effort of a wide range of muscles. Regular exercise appears beneficial for people with PD. However, maintaining regular exercise without guidance can be challenging and demotivating. Therefore, I believe that, like walking, speech and swallowing functions should be regularly exercised, and close follow-up by a speech therapist not only helps maintain practice consistency but also allows for early detection of new changes and program adjustments.
Is exercise enough? Are there other ways to help? What can be done before seeing the results of exercise?
As previously mentioned, speech therapy intervention is not solely focused on exercises. An essential component of this professional’s work is the introduction and adaptation of strategies or tools that facilitate communication and enhance the safety of oral feeding.
From the outset, it’s crucial for the speech therapist to teach strategies to the individual with PD, as well as their family members or caregivers, to facilitate communication. These strategies can focus on behaviors both parties adopt when communicating (e.g., encouraging the person with PD to speak louder, having face-to-face conversations) or on controlling the communication environment (e.g., whenever possible, making the communication environment quieter by eliminating unnecessary noise like the television or car radio). Sometimes, these strategies may not be sufficient to improve communicative functionality, and it’s up to the speech therapist to help identify the most suitable tools, adapt them to the individual’s communication needs and contexts, and train their use. An example of such a tool is a voice amplifier, a device designed to amplify the voice, making it easier for others to hear what the person with PD wants to convey. This is just one possibility. The most important thing is to find a solution that works for that individual and their close ones, resulting in increased communicative functionality without becoming a burden for those involved, making its use more facilitating.
Helena Santos
Coordinator of the Speech Therapy Team Lisbon
Unit of CNS – Campus Neurológico