Where would you be without your voice?

Editor’s note: This important guest post is by Cara Bryan. Bryan is a licensed speech language pathologist and LSVT certified clinician in private practice in Tampa. I know her work first hand. She is very good. More about Bryan is appended to her post. Gil Thelen

Parkinson disease (PD) has one of the highest rates of communication difficulties among progressive neurological diseases.

Bet you didn’t know that. It’s not a conversation staple at support group meetings, much less during visits with your neurologist

It’s treatable with speech therapy services using the LSVT LOUD approach.

Consider the case of the “Professor.”

Professor was the former Dean of a University English Department. He was in his early 50s and had been diagnosed with PD within the past two years.

He was referred by his neurologist for speech therapy. Professor presented with slouched posture, shallow breathing, and vocal strain when speaking.

He spoke quickly and whispered without any inflection. His face appeared flat and expressionless. His conversational loudness measured between 48-56 dB, which is significantly below the normal 65-75 dB level in a quiet room at a 3-ft distance.

Professor explained that he had recently had to step down as dean because he could not meet demands. His true passion was teaching, and he was extremely close to losing that job too.

He explained that he had significant difficulty making himself heard in his classroom. Professor described his previous self as outgoing, garrulous, “never met a stranger” kind of person.

Now students frequently asked for repetition and clarification. At times he had difficulty obtaining and maintaining their attention.

All the desks were moved close to the front of the classroom. He started using amplification but didn’t like it. He tried strategies for more student involvement and less lecture time. But he was exhausted trying to adapt to his communication decline.

Professor’s impaired communication extended beyond the classroom into all aspects of his life: Being heard over the phone, in noisy restaurants, at home with his wife and two teenage children, ordering in the drive-thru line, etc.

He reported withdrawing from conversations, avoiding speaking, and speaking significantly less. He nearly ceased socializing and was becoming more home bound.

Professor admitted to symptoms of depression, feelings of poor self-worth. Professor’s difficulty being heard was affecting his persona, his sense of self, and his livelihood. He was a spectator to life.

Approximately 80-90% of individuals with PD have or will have difficulty communicating. Common symptoms include a quiet voice (nonfunctional loudness), vocal hoarseness, strain and/or breathiness, fast rate of speech, monotone-sounding speech and stammering.

Often stooped posture and shallow breath support further impair the ability to communicate. Word-finding deficits and loss of thought process during conversations can occur in tandem.

Persons with PD are often NOT the first to realize they are speaking differently. This is due to the neurological phenomenon known as sensorimotor misperception, which is a hallmark symptom of PD. Sensorimotor misperception is a mismatch between what a person self-perceives and the corresponding muscle movement.

Shuffled gait, quiet voice, mumbled speech, shallow breath, and small handwriting are examples of common small muscle movements in PD

In other words, if a person with PD perceives his/her voice to be of “normal” loudness, the brain sends corresponding messages for small muscle movement to produce speech/voice.

Often the person with PD reports “my spouse is hearing impaired.” In reality (and regardless of the spouse’s hearing acuity), the voice is measurably soft. Many persons with PD experiencing communication difficulties are able to produce normal loudness levels given clinical guidance, high effort and conscious thought.

Professor’s quiet, nonfunctional communication was treated with a protocol of speech therapy called LSVT LOUD. Designed specifically for people with PD, LSVT LOUD targets sensorimotor misperception by re-calibrating a person’s perception of required physical effort for appropriate loudness. The LSVT LOUD approach strives to elicit best quality voice with controlled loudness on “Ahhh.”

The mechanics of good quality loud vocal production include upright posture, relaxed, deep inhalation, and loud voicing using exhalation without straining the throat muscles.

Professor completed several loud Ah’s with clinician coaching and modeling for good quality voicing. He was instructed to maintain an effort level of 8 out of 10 (10 being the highest possible) during the exercises to assist with his physical awareness and loudness level.

Using this approach, the first time Professor repeated the clinician-modeled loud voice, he echoed the sound perfectly. Moments before the loud “Ah,” Professor’s voice had been whispered. To combat monotone sounding speech, a series of ascending and descending pitches were repeated with loud, good quality “Ahhh.”

The LSVT LOUD approach continues through a hierarchy of speech tasks across a 4-week time period of 16, one-hour sessions. The aggressive treatment protocol serves to reduce the amount of physical effort and ultimately automate “normal” conversational loudness.

Upon completion of speech therapy using LSVT LOUD, Professor improved his vocal loudness and quality to normal. He was acutely aware of the required effort for his “new normal” loudness.

He was immediately successful in the classroom and throughout his daily communication. His mood and outlook improved significantly. His face was expressive when he spoke. He was successfully participating and initiating conversations. He rarely had difficulty making himself heard. He was socializing. Professor reported he had found his voice again, and by doing so regained himself. He taught for many years after.

The LSVT LOUD approach allowed Professor to return to himself and maintain employment. Professor is one example of a common experience of people with PD. Successful communication is directly correlated to one’s personality, the sense of belonging, self-esteem, livelihood, pastime, interpersonal skills, EVERYTHING. People with PD should be aware that with speech therapy services, they can fight to maintain their voice.


About Cara Bryan

Cara has lived in Tampa since 2003. Cara is busy with her husband and two children. She sings in the church choir, performs solo work, exercises, enjoys her children’s sports and activities, and is an avid Carolina Tar Heel fan.  

Cara received her master’s degree from the University of Iowa in speech-language pathology and her undergraduate degree from The University of North Carolina at Chapel Hill in music-vocal performance and linguistics. 

Her special interests include vocal rehabilitation of those with Parkinson disease, professional voice users, vocal cord dysfunction, and chronic cough. As a young child, Cara was exposed to Parkinson disease with her paternal grandmother and developed a calling to help those with the disease.

Bryan is in private practice. She can be reached at carabryan@gmail.com and 813-728-6601.




3 thoughts on “Where would you be without your voice?”

  1. Gil, Thank you so much for this info. Also, Thanks so much for all you are doing for Parkinson’s.

    John Sent from my iPad



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