Understanding Parkinson’s disease as a dynamic, individualized, and specialized disease is important prior to creating a treatment plan. There are many ways to accomplish a deeper knowledge of the population being affected by PD. To get started, read last week’s post for a list of resources and recommendations.

Speech-language pathologists (SLPs) directly treat many symptoms that co-occur with Parkinson’s disease (PD). The list includes changes in voice, fluency, swallowing, and cognitive processes related to memory and executive functions. There is limited information that provides direct instruction on interventions specific to PD but knowledge of the characteristics of the disease guides us to accurate differential diagnosis and meaningful treatment.

Research Based Voice Treatment for People with Parkinson’s Disease

Listening to our patient’s needs, identifying functional goals, and completing continuing education courses is a solid starter pack to being an informed therapist but does not eliminate the need to know the research. There are two research-based voice therapy protocols created for people with PD. Both programs require clinicians to pay for training and a certification prior to using the outlined approaches.

LSVT LOUD®, created by the Lee Silverman Voice Treatment, is provided in 16 sessions with strict guidelines on implementing the program as the research indicates will provide the best outcomes. The program includes 4 days of voice therapy each week for 4 consecutive weeks. The primary motto is “Think LOUD” and the program uses a hierarchy of exercises in high repetition to increase the patient’s sensory perception of their own voice as well as the patient’s ability to maintain increased loudness (and actual decibel levels) in functional communication.

SPEAK OUT!®, created by Parkinson Voice Project, is provided in 12 sessions with a focus on their motto “Speak with Intent”. Frequency of delivery is flexible although the recommended model is 3 days a week for 4 weeks. The program includes cognitive exercises integrated into the voice program. Similar to LSVT LOUD®, the outcomes are based on high repetition and daily practice. SPEAK OUT!® provides the clinician and patient free materials and a daily exercise book that arrives via mail to assist the therapy sessions. The results focus on achieving a sensory shift in the person with PD to encourage intentional use of their voice during functional communication.

Without a certification in one of the mentioned protocols, all clinicians treating patients with PD maintain an obligation to provide a therapeutic approach using evidence-based practice. Research informs clinicians on best practices for treatment of hypophonia related to neurodegenerative diseases. Below are five areas that produce informed and outcome-driven treatment plans with associated studies. If you prefer to listen rather than read, the March 10^th episode of Speech Uncensored is where I discuss these five areas in more detail.

1. Set clear expectations in therapy from start to finish. This should include goal-setting.
   Article: Rosenbek, J. C. (2017). Mind Over Motor. The ASHA Leader, 22(3), 44–49.
2. Use high repetition in all exercises for best outcomes. Aiming to achieve 10/10 on a given task is no longer an adequate standard, especially when learning a new skill.
   Article: Liotti, L.O. Ramig, D. Vogel, P. New, C.I. Cook, R.J. Ingham, J.C.Ingham, P.T. Fox. (2003).Hypophonia in Parkinson’s disease. Neurology, 60 (3) 432-440; doi: 10.1212/WNL.60.3.432.
3. Therapy tasks and homework should be functional to see meaningful results (and your patients will thank you for not making them name 25 zoo animals).
   Article: MacPherson, M. K. (2019). Cognitive Load Affects Speech Motor Performance Differently in Older and Younger Adults. Journal of Speech, Language, and Hearing Research. 62(5), 1258-1277; doi: 10.1044/2018\_JSLHR-S-17-0222.
4. Consider the cognitive load you are placing on the patient during each step of their progress and other factors that may influence their ability to access your instructions.
   Article: Watson, G. S., & Leverenz, J. B. (2010). Profile of Cognitive Impairment in Parkinson’s Disease. Brain pathology (Zurich, Switzerland), 20(3), 640–645.
5. We know there is limited carryover in novel settings and this informs how we assign homework tasks and carryover tasks from the start of therapy. It is never too early to start practicing outside of the therapy room.
   Article: Kelm-Nelson, C. A., Brauer, A. F., & Ciucci, M. R. (2016). Vocal training, levodopa, and environment effects on ultrasonic vocalizations in a rat neurotoxin model of Parkinson disease. Behavioural Brain Research, 307, 54–64.

Leave your favorite resources for the PD population in the comments below!