Guidelines for Speech-Language Therapy in Parkinson’s Disease

By: Hanneke Kalf, Bert de Swart, Marianne Bonnier-Baars, Jolanda Kanters,
Marga Hofman, Judith Kocken, Marije Miltenburg, Bas Bloem, Marten Munneke 

With respect to Parkinson’s disease, speech-language pathology focuses on three domains:

• difficulty with speech: hypokinetic dysarthria and the influence of cognitive impairments on language comprehension, language use and communication skills
• difficulty with chewing and swallowing: dysphagia, choking and slow chewing and swallowing
• difficulty with controlling saliva: drooling or dribbling of saliva

For the rehabilitation of persons with Parkinson’s disease (PwP), Morris & Iansek have described a theoretical model which has been met with positive experiences in large Parkinson’s centers abroad. This model consists of the following five basic assumptions:

1. “Normal movement is possible in Parkinson’s disease; what is required is appropriate activation. The skilled therapist is able to determine the most effective methods to activate normal movement.
2. Complex movements need to be broken down into smaller components. This is to avoid motor instability and to take advantage of increased amplitude at the beginning of movement sequences.
3. Each component of a task needs to be performed at a conscious level. Conscious attention appears to bypass the basal ganglia and restore movement towards normal.
4. External cues may be used to initiate and maintain movement and cognitive processes. Visual, auditory or proprioceptive cues may be used. Cues indicate the appropriate movement size and appear to activate attentional motor control mechanisms.
5. Simultaneous motor or cognitive tasks are to be avoided. This is because the more automatic task is not executed properly and only the task demanding attention is satisfactorily completed.”

These assumptions are also relevant in speech-language treatment.

 Evaluation and treatment of limitations in speech:

Subtle changes in a patient’s speech and cognition can have a large impact on the degree to which the patient feels comfortable with speaking (already early in the disease) (3). This underscores the importance of early referral and timely attention from a speech-language pathologist (SLP).

The current speech-language treatment techniques related to hypokinetic dysarthria focus on an intensive stimulation of the intensity of the speech, over a period of at least four weeks. This kind of approach is specific for PD, because it puts demands on the – to a certain extent – normal motor skills by activating and stimulating them with cues. Various studies (4) have shown the value of this approach for patients with Parkinson’s disease.

PwPs vary significantly with respect to the severity of the disease, physical and cognitive capacity, dysarthric features and expectations regarding verbal communication. This means that the treatment to improve intelligibility can range from a one-time consultation with recommendations to intensive treatment of at least three sessions per week over the course of at least four weeks, to periodic consultations with a focus on supervising and instruction of caregivers (conversational partners). The treatment of communication disorders resulting from cognitive deterioration and language impairments is limited to recommendations and specific modifications. A physician, referring a patient with PD may expect that an SLP with experience in PD is capable of evaluating whether, and in what way, treatment is worthwhile and carrying out this treatment.

Evaluation and treatment of limitations to swallowing:

Choking, slowness of chewing and other typical swallowing problems in PD can be worrisome and a burden to the patient and his caregivers (5). After an efficient assessment, SLPs who have experience with the treatment of dysphagia related to PD are capable of providing adequate exercises, modifications, cues and movement strategies. The treatment that follows will generally consist of a one-time session or a short treatment period, if necessary in the domestic setting.

Evaluation and treatment of limitations in saliva control:

Drooling is an unpleasant problem that appears primarily in the later phases of the disease. SLPs experienced in the treatment of drooling can determine the severity of the problem and to what extent it can be treated. Treatment generally consists of either one-time recommendations or a short treatment period, when needed in the domestic setting. If speech-language therapy is ineffective, the SLP will refer the PwP back to the neurologist for medical treatment (e.g. injections with botulinum-neurotoxin).”

Full guidelines can be found at:

http://www.parkinsonnet.info/media/14829977/dutch_slp_guidelines-final.pdf