Parkinson's Voice and Swallowing: Why Train The Breathing Muscles?

One of the first things speech-language pathologists learn during their education is the concept that voice and swallowing are a part of a "shared system", referred to as the aerodigestive tract.  Like a cast of stage actors, muscles of respiration, the larynx ( voice box), and the oral-pharynx ( mouth and throat) participate in an exquisite performance of  breathing, speaking, and swallowing.

When speaking, the airstream from our lungs passes through the vocal folds and the vibration that occurs creates voice.  Our tongue, lips and  the shape of our mouth further modify the airstream into recognizable speech.We are always using the breath going out, exhalation, for speech. During swallowing, the demand changes so that when we  swallow, we  actually hold our breath,  so that food or liquid is prevented from entering into our airway. We have learned from the swallowing research that the momentary breath hold also happens during  the breath out , exhalation, creating an opportunity after the swallow  for the exhaled breath to sweep away any particles of food or liquid that may have become stalled in our mouth or throat.

                              

Upper aerodigestive tract - Image courtesy of Passy-Muir Inc.

               

All day long, without our instruction our bodies perform these shared functions. And, like many functions in our body, this performance goes on daily, seemingly effortlessly, until or unless the process is stressed by illness or disease.

 Respiration, in particular, always demands our attention. Most of us have had the experience of trying to talk while walking or climbing stairs. Not easy, and when our breathing is stressed this way, we always choose to "catch our breath" before completing our thought.  Similarly, when laughing and talking during a meal, we may mistime our swallow with a breath, and the result is a vigorous coughing episode as we proclaim "something went down the wrong pipe!"

 For individuals with a medical diagnosis of Parkinson's disease, COPD or other neurogenic or neuromuscular problems, reduced strength or efficiency of the respiratory muscles can result in reduced voice loudness and an increased number of  mistimed episodes of choking when eating or drinking, threatening the health of their lungs. Strategies for strengthening the respiratory muscles, therefore, should be incorporated into swallowing and voice therapy programs and should be considered when designing a home exercise program.

Respiratory muscle training can include:

Instruction in diaphragmatic breathing and purse lip breathing which can help you to take deeper and slower breaths.

 Expiratory muscle training using a device.

EMST 150 Expiratory muslce strength trainer

BREATHER Respiratory muscle trainer

                                                              

Strategies to improve your ability to "hold" your breath when swallowing.

A home program such as Voice Aerobics which can be performed independently and heightens awareness about the use of diaphragmatic breath support for voice.

Parkinson’s and your voice: How Many Ways Can You Say Exercise?

Esercizio, ejercicio, ubung, Упражнение, Yùndòng, l'exercice, ekusasaizu

“Exercise Protects Brain in New Studies: Two new studies  add to the mountain of research indicating that physical activity in older people keeps their brains active and healthy as well. Both were reported at the Alzheimer's Association International Conference on Alzheimer's Disease, with simultaneous publication online in Archives of Internal Medicine :(Primary source: Archives of Internal Medicine Source reference:Larson E "Brains and aging" Arch Int Med 2011; DOI: 10.1001/archinternmed.2011.273.)”

So, once again, researchers, it seems , have come forward to inform us of what we most likely already know, and that is: exercise can benefit the brain. A suggestion was made that clinical research should now focus on "ways to change behavior" so that exercise becomes habitual in middle and late life. As someone who happens to be in mid-life, and works with many patients in late life, I would suggest that the earlier in life and as soon after a diagnosis of a chronic disease has been made, a prescription for exercise should be given. But, exercising the muscles involved in speech and swallowing can be a bit more elusive, as we are generally talking about small muscle groups that because of their placement in our anatomy, do not lend themselves well to  treadmills and cybex machines.

Within the field of speech-language pathology,  there is ongoing interest among researchers as to what role exercise may have in delaying or abolishing  speech, voice or swallowing symptoms that  result from injury or disease. Depending on a patient’s symptoms, specific exercise may focus on strengthening the tongue, respiratory muscles  and/or muscles of the larynx ( voice box). Patients may be instructed in a variety of exercises designed to strengthen the swallowing or voice mechanism, however, since the optimal recommendation for most types of exercise designed to improve these functions are still under investigation, the specific type, number of trials and repetitions may vary from therapist and setting .

The Lee Silverman Voice Treatment Method (LSVT®), is one type of voice therapy offered to patients with Parkinson’s  and which, as a result of their research, is delivered via a very specific protocol  Adherence to this delivery method is important and may help to reduce some of the variation mentioned above, and provide a more predictable result. At the conclusion of LSVT ® treatment, however, and without continuous feedback, it may remain difficult for some patients to judge if they are continuing to exercise and use their voice with an adequate amount of intensity to maintain improvements they have achieved in therapy. So, researchers are now developing various sorts of measuring devices to help therapist and patients monitor muscle strength changes and continued voice use outside of the therapy setting.

If you have been given voice, speech and/or swallowing exercises to perform, it is important that you complete them in the prescribed fashion. ( For ex: 10x’s 3x’s a day 5 times/week). It is also important that you and your therapist discuss whether it is expected that your condition will improve and remain stable after a course of  therapy which includes exercise or if you will be required to continue some regimen of exercise for the remainder of your life in order to retain the improvements or minimize further decline. If changes or decline in memory are also a component of your particular medical diagnosis, it may be beneficial to ask your therapist if the prescribed exercises are available in a recorded format. Or, better, yet, have your therapist or a family member record you while performing your voice and swallowing exercises, so that  you are able to perform them independently.

A group exercise class such as Voice Aerobics™ may help you retain improvements achieved in formal therapy and help you remain motivated and focused on improving or preserving  posture, breath support, and voice use.

 

Parkinson’s and Your Voice: The essence of you

essence n. The intrinsic or indispensable properties that serve to characterize or identify something

This week I had the opportunity to participate in the Northeast Ohio Activities Professionals (NOAAP) conference.  The conference title was “Cultivating Culture Through Wellness,” and  topics  included: stress management, therapeutic dancing,  and the power of touch . Spending a day in such a fun and nurturing environment made me realize why I am often drawn to the activities professionals at the skilled nursing facility where I occasionally work . A group of individuals, who are creative, artistic, and fun, seemed a good fit for an introduction to Voice Aerobics ™.

One of the most interesting and entertaining speakers of the morning was an aromotherapist. She talked about the therapeutic properties of essential oils, and their predating the development of most pharmaceuticals so widely used in our culture. She spoke about the role of scents and smell in activating the limbic system of the brain, evoking memories emotions, and mood. With dramatic flair, she discussed the Latin derivative for the word “essential” or “essence”, and while doing so, made me begin to think about voice, as the essence of the individual spirit.

The day following the  NOAAP conference, and after speaking to a Parkinson’s support group,  I  gave further thought  to why the essence of an individual  is so linked to their voice. Similar to a scent  that evokes a quick memory of a person or place, the sound of one’s voice seems to also evoke reactions and responses from us that are quick and visceral. Beyond the message of the words, we respond and react to the pitch, the timbre, the tone, and when there is the absence of one’s voice due to illness or injury, it can make us feel abandoned, and  that a body, alone, will somehow not do.

Parkinson’s classification as a movement disorder draws a great deal of attention to managing the physical symptoms such as tremor and stiffness. This is understandable since on a day to day basis mobility issues can be problematic for individuals with the diagnosis. But if movement is improving, and voice fading, than the essence  of the individual is also beginning to  fade. The husband who is walking next to his wife, but now with words that are inaudible, is fading from the relationship.

It is no wonder then, that improving or in some instances helping to restore voice, has become for me my work and my mission.  The need to discover and develop ways to preserve and strengthen voice that are fun was reinforced to me this week as I moved, hummed, and played among the activity therapists. Preserving and improving voice as the essence  of who we are ,I hope was the take home message to those who attended the Parkinson’s support group meeting, with a call to take action.

Birthday Blues

Next week I celebrate another birthday. I vaguely remember a time in my childhood when the anticipation of a birthday and all that it entailed brought great excitement. But since turning 40, a decade ago, it seems that birthdays only bring the blues. Like uninvited guests, a family of demons seems to move into my home for several weeks. They are loud and obnoxious, and with names like Regret and Disappointment, they  crowd my space. They occupy my thinking, steal pleasure from my  day to day activities, and create a gnawing feeling in the pit of my stomach. Intellectually, I know that I invite them in the day I begin to conduct my annual life in review and  dwell on the "should of", "could of," and "would ofs"  of my life thus far. I go through my mental list and I check off, one by one, all of the dreams unacted on, opportunities not taken, and goals not achieved .It is no wonder, that after several weeks of this daily mental diet, I am filled with the blues. 

 I suspect, that an impending birthday would seem to most like a ridiculous, and self-indulgent reason for someone to be sad, but, I'm afraid it is just my twist on the kind of stinking thinking that we all indulge in from time to time. The kind of thinking, believe it or not, that is common to people in the helping professions who like to give, but can't receive. The blues might also be a common occurrence for carepartners who are too tired, too overwhelmed, and too guilty to ask for help.

I will eventually shake this blue  mood I am in. My birthday, the trigger event for my stink fest will pass. More importantly, I am working to re-focus my thinking  on what I still want and what is still possible for my life, and cultivating a mindset to receive it. To help with making the shift, I am re-reading a book I purchased a few months ago: the power of receiving by Amanda Owen.

If you are someone like me, whose tendency has been to spend more time in life dwelling upon what you want than how to receive it, this book might be for you.

                                      Mary one year old.....

Parkinsons and Voice: Why You Need Green Eggs and Ham

This week I was touched by an early birthday present I received from my friend, Kate Kelsall. The gift was a talking book, recorded by Kate. Kate writes a great blog: Shake, Rattle, and Roll, in which she shares her day to day experiences in living with Parkinson's Disease (PD), a diagnosis she has had now for 15years. Kate is also active in her community of Denver, and co-hosts a DBS ( Deep Brain Stimulation) support group. So, in part, because of her work with patients and families in the support group, Kate has been bothered by Parkinson's related changes in her speech and voice that have occurred over the years. From time to time, since meeting  Kate a couple of years ago , I have provided some voice coaching.

In addition to a frequently "too soft" voice, Kate has also been bothered by the loss of expression in her voice. Her home answering machine has a recorded message from a number of years ago, and when I hear Kate's voice on the machine, the descriptive words that come to mind  are: "sweet, and lilting and expressive."  Return of that "expression" has been one of Kate's speech goals this past year. A suggestion I made to her some time back was that she begin to read children's books. In particular, I am a fan of Dr. Seuss, the original rapper, as his books and poems are filled with so much fun rhythm and rhyme.

I do not like that Sam- I- am
Do you like green eggs and ham?
I do not like them Sam-I-am
I do not like green eggs and ham!

And, so, Kate, approaching her speech and voice practice like she approaches most things in her life began  a daily ritual of reading aloud. She has pushed her voice through the calisthenics of daily training. Pitch up, then down, softer and louder, adding facial expressions for emphasis and interest, all the little nuances of speech that came much more easily and automatically before a diagnosis of PD. But the book I received in the mail this week, "On The Night You Were Born,", is the real testimonial of her hard work. The message of the words, of course, touch my heart, but it's really Kate's voice that brings those words alive, and if I didn't know better, I would think it was the same voice on her home answering machine!

You have brains in your head.
You have feet in your shoes.
You can steer yourself in any direction you choose.
You’re on your own.
And you know what you know.
You are the guy who’ll decide where to go.
~ Dr Seuss

visit Kate's blog: http://katekelsall.typepad.com/