Guidelines for Speech-Language Therapy in Parkinson’s Disease

Kalf, H., de Swart, B., et al. (2011).

Nijmegen (The Netherlands); Miami (FL): ParkinsonNet (The Netherlands); National Parkinson Foundation, 1-137.

This guideline provides recommendations for speech-language pathology management of Parkinson's disease. It includes recommendations for the evaluation and treatment of communication, dysphagia, and saliva control. Recommendations are based on systematically searched scientific literature to the extent possible and based on expert opinion when evidence was lacking.

Nederlandse Vereniging voor Logopedie en Foniatrie (The Netherlands)

<p>For individuals with Parkinson's disease, it is recommended that the treatment results be determined by:</p> <ul> <li>objectively evaluating the intensity of the spontaneous speech with a dB meter or video recording;</li> <li>subjectively evaluating the dysarthria and intelligibility during spontaneous speech with the [Therapy Outcome Measures] TOM scales; [and]</li> <li>discussing with the patient and caregivers the extent to which the initial treatment goals have been achieved" (Level 3 Recommendation, Class C Evidence; p. 76).</li> </ul>

Group treatment should be considered if warranted for individuals with dysarthria and communication problems secondary to Parkinson's disease (Level 4 Recommendation, Class D Evidence).

Diet modification using thickened liquids can be used for individuals with Parkinson's disease if difficulty swallowing fluids is observed. It is recommended that the clinician determine "whether smaller volumes and/or thicker consistencies are sufficient for preventing choking on fluids" (Level 3 Recommendation, Class B Evidence).

For patients using medication that has an impact on speech (e.g., levodopa), consider waiting to initiate speech-language treatment until after the medication has been well regulated. Also consider the patient's <em>on</em> and <em>off</em> periods during treatment (Level 2 Recommendation, Class B Evidence).

Patients with dysphagia secondary to Parkinson's disease should&nbsp;receive education and counseling by the SLP to identify signs of aspiration and safe swallow techniques (Level 3 Recommendation, Class D Evidence).

Treatment with PLVT/LSVT is recommended for patients with Parkinson's disease and hypokinetic dysarthria when the following criteria are met: <br /> <ul> <li><span style="color: #333333;">voice quality (loudness, clarity, and pitch) can be sufficiently stimulated,</span></li> <li><span style="color: #333333;">there is an intrinsic motivation to practice intensively (based on the severity of the problem and the expectations of the communicative performance),&nbsp;</span></li> <li><span style="color: #333333;">the patient is (cognitively) able to learn a new technique, and </span></li> <li><span style="color: #333333;">the patient has enough energy to practice intensively (Level 4 Recommendation, Class C Evidence; p. 18).</span></li> </ul> Additional considerations include: <br /> <ul> <li><span style="color: #333333;">completing a trial treatment period, practicing with the assistance of a caregiver as a co-therapist, </span></li> <li><span style="color: #333333;">following-up 6 to 12 months after initial treatment, and </span></li> <li><span style="color: #333333;">recommending PLVT/LSVT techniques with less intensity if warranted and caregiver training to cue patients as necessary (Level 4 Recommendation, Classes C and D Evidence).</span></li> </ul>

"It is recommended to evaluate the spontaneous speech of a [person with Parkinson's disease] PwP by assessing common speech features, such as breathing, phonation, articulation, resonance and prosody. In the interpretation, it is important to know whether the patient has been observed during an <em>on</em> period or an <em>off</em> period" (Level 4 Recommendation, Class D Evidence; p. 57).

Assessment and treatment of drooling should be completed and the SLP should identify causes of drooling and implement behavioral strategies to reduce or eliminate problems (Level 4 Recommendation, Class D Evidence). Caregivers should be included in treatment especially when external cueing strategies are provided (Level 4 Recommendation, Class D Evidence).

Individuals with hypokinetic dysarthria and dysphagia secondary to Parkinson's disease may benefit from Lee Silverman Voice Treatment to improve swallowing function. Reassessments should be completed after treatment is provided (Level 3 Recommendation, Class C Evidence).

<p>In order to maximize efficiency, it is recommended that the clinical dysarthria evaluation be limited to:</p> <ul> <li>an evaluation of spontaneous/unstimulated speech; and</li> <li>an evaluation of the stimulability of various speech features using maximum performance tests&nbsp;(Level 4 Recommendation; Class D Evidence; p. 56).</li> </ul>

It is recommended to audio or video record the spontaneous speech for each patient with Parkinson's disease in order to establish a baseline and to provide feedback regarding dysarthria. Intensity of speech should be recorded with a dB meter (Level 3 Recommendation; Class C Evidence).

<p>The SLP should actively involve the caregivers in treatment of dysarthria and communicative slowness. The caregiver can assume the role of:</p> <ul> <li>a co-therapist during intensive PLVT or LSVT; or</li> <li>a trained conversational partner, using cues to facilitate speech or cognitive-communication abilities&nbsp;(Level 4 Recommendation, Class D Evidence).</li> </ul>

<p>The following interventions are recommended as applicable for individuals with Parkinson's disease:</p> <ul> <li>use of chin tuck to prevent aspiration (Level 3 Recommendation, Classes B and C Evidence); and</li> <li>use of effortful swallow&nbsp;(Level 3 Recommendation, Class C Evidence).</li> </ul>

In addition to involvement of a speech-language pathologist, it is recommended that patients with Parkinson's disease and dysphagia receive multidisciplinary treatment in collaboration with a dietitian, nurse, and occupational/physical therapist (Level 4 Recommendation, Class D Evidence). Caregivers also play an active role in dysphagia treatment (Level 4 Recommendation, Class D Evidence).

Individuals with severe dysarthria secondary to Parkinson's disease who have useful hand-arm function should receive SLP advice and supports for the use of augmentative and alternative communication (Level 4 Recommendation, Class D Evidence).

<p>For individuals with Parkinson's disease, swallowing assessment should include:</p> <ul> <li>assessment of swallowing function during spontaneous drinking of single and consecutive sips of various volumes (Level 2 Recommendation, Class B Evidence);</li> <li>assessment of swallowing function during meal time&nbsp;(Level 2 Recommendation, Class B Evidence); and</li> <li>assessment using videofluoroscopy or fiberoptic evaluation of swallowing to determine pharyngeal dysphagia and aspiration of food (Level 3 Recommendation, Class C Evidence).</li> </ul>

<p>For individuals with Parkinson's disease, it is strongly recommended that the stimulability of the intensity and quality of speech be evaluated using:</p> <ul> <li>automatic speech tasks;</li> <li>maximum phonation time; and</li> <li>pitch range and calling.</li> </ul> <p>Additionally, it is important to note whether the patient was evaluated during an <em>on</em> period or <em>off</em>&nbsp;period&nbsp;(Level 4 Recommendation, Class D Evidence).</p>

<p>The following should be considered when evaluating individuals for swallowing impairments secondary to Parkinson's disease:</p> <ul> <li>the patient's history of oropharyngeal dysphagia (e.g., specific problems with swallowing, slow eating); and</li> <li>a patient/caregiver-reported standardized questionnaire (to be completed&nbsp;before assessment)&nbsp;(Level 4 Recommendation; Class D Evidence).</li> </ul>

Pitch Limiting Voice Treatment or Lee Silverman Voice Treatment is strongly recommended for individuals with a hypokinetic dysarthria secondary to Parkinson's disease if intensive treatment is indicated (Levels 1, 2, and 3 Recommendations, Classes A and B Evidence; p. 65].

"The SLP should consider rating the severity of the effects of dysarthria on the intelligibility and communicative effectiveness according to the Dutch version of the intelligibility subscale of the Therapy Outcomes Measures (TOM)" (Level 3 Recommendation, Class C Evidence; p. 55).

<p>If treatment techniques such as Pitch Limiting Voice Treatment or Lee Silverman Voice Treatment are insufficient for individuals with dysarthria secondary to Parkinson's disease consider:</p> <ul> <li>the use of a pacing board or metronome; and/or</li> <li>the use of a portable amplification system&nbsp;(Level 4 Recommendation, Class D Evidence)</li> </ul>

SLP treatment techniques (i.e., isolated exercises for respiration, voice, oral motor function or articulation) are not recommended due to their limited consistent improvement in intelligibility with individuals with hypokinetic dysarthria (Level 4 Recommendation, Class D Evidence).

<p>When conducting a review of the patient's speech history, the speech-language pathologist should:</p> <ul> <li>consider the patient's impairment at the functional, activity, and participation level;</li> <li>consider the patient's impairment with respect to speech and language;</li> <li>consider the communication experiences of the patient as well as conversational partners and/or caregivers; and</li> <li>consider having the patient complete a standardized questionnaire prior to the first session&nbsp;(Level 4 Recommendation, Class D Evidence).</li> </ul>

The SLP should recommend a videolaryngostroboscopy by an otolaryngologist for individuals with hypokinetic dysarthria and suspected vocal fold pathology unrelated to PD (Level 4 Recommendation, Class D Evidence; p. 62).