Introduction
In this course, I won’t be able to cover every possible treatment that can be used for Parkinson’s or any other type of neurological disorder like ALS, multiple sclerosis, TBI, or stroke. However, I will discuss the construction around therapy for people with dysarthria. I will also review a few examples of therapy as well.
How do we decide who might benefit from therapy? How do we make therapeutic recommendations? I like to consider how much the dysarthria is affecting someone's activities or their participation in everyday activities. For example, a person might have an impairment; they might have low vocal intensity or a fast rate of speech but we have to decide whether therapy is right for them based on that impairment. Is it really impacting their everyday life? It's important as clinicians to remember that what we estimate the effect of that impairment is may be different from what the client estimates the effects are and what the family’s estimates are. Sometimes the client and the family don't even agree. So it's always a good idea to ask the client and the spouse or other family members what they estimate to be the effects of the impairment.
I also look at what is happening in the person's environment and with the communication partners. Not only to determine if treatment would help the person but to determine what might be the prognosis of therapy and what my plan might be. Environmental factors and communication partners should be considered as targets for therapy.
The Goal of Treatment
When starting therapy it’s important to think about what the goal is. Often with Parkinson's or with dysarthria, the goal is to reduce impairment but not usually to get the person to normal speech production. Someone who has ALS or MS or Parkinson's is never going to have normal speech production again. They continue to degenerate and so our goal might be, for example, to compensate. How can we maximize what these patients have left to get the most communication and the most effective communication for them? Sometimes these compensations are behavioral compensations, things the person will do differently. Sometimes patients use devices or prosthetics and in many ways, we underuse those kinds of prosthetics in people with dysarthria.
We also need to think about adjusting. Sometimes we get to a point with a patient where we can no longer help them compensate. In that instance, we need to adjust so that the environment is more supportive for their ability to communicate. For a patient who will eventually lose their ability to communicate, someone with ALS for example, we want to plan for that when making our long-term therapy plan. We want to think about how long it might be until we get there. Again, not only do we want to think about what we are going to do in each treatment session but how do we envision their therapy long term.
Basic Management Approaches
I’d like to discuss some basic management approaches instead of specific ones.
Prosthetic Management
I already mentioned prosthetic management and I define this as the use of any device. That could be a high-tech device, a low-tech device, or it could even be a piece of paper in some cases. It could be a palatal lift prosthesis that helps lift a weak, flaccid velum for better velopharyngeal closure. It could be an AAC device to replace speech or to supplement speech. Boards or books can be used to help people who have communication break down or need a choice when they are in a noisy environment and can't be heard. Pacing boards are used to help a person externally cue themselves to slow their rate. Wearable devices include voice amplifiers like the Chattervox, delayed auditory feedback devices like the SpeechEasy, and the device that was developed in my lab called the SpeechVive is for people with Parkinson's disease.
Behavioral Management
Behavioral management can be speaker-oriented. How am I going to help the speaker either improve their function or teach them how to compensate better? As an SLP, I need to be communication-oriented as well. For example, working with listeners, common care partners, common communication partners or the environment. Allowing people to ask for things or request in ways that don't entirely depend on verbal communication.
Counseling and Support
Counseling and support is always part of our behavioral management but it deserves some discussion. This is one of the most important things that SLPs bring to the medical model. It allows us the time to talk to patients about their dysarthria, their disease, the prognosis, what might be coming for them in the short term and the long term and how they can really maintain their communication. It allows us to make that deep connection with our patients.
Severe Patients
Understanding the categories of severity level for dysarthria can help to plan therapy. The severe patient is someone who really can’t communicate verbally. In therapy, we want to primarily establish a means of communication which will most likely be alternative communication. When we're making AAC plans and selecting devices or input methods, we want to think about whether the person will degenerate or are they likely to get better. We also want to plan for a device that we can morph around their changing needs.
We want to do some patient and family education so they understand what's happening and how it's likely to change. We want to observe their environment and set up some ways for them to interact better. That may mean changing their room a bit. For example, adding switches allow people to request or to call from one room to another. This is helpful for a person who can’t raise the intensity of their voice to yell for help. There are call buttons that can be worn so that if the person falls, they can contact someone right away to help them and rather than waiting for somebody to come by.
Moderate Patients
Moderate patients use speech for communication but they have intelligibility problems. Their intelligibility problems could be significant or a little more moderate but the goal is to maximize their intelligibility. We can do that by working on compensatory strategies like slowing the rate of speech. We know that makes people easier to understand and a bit more intelligible. Prosthetic devices can also maximize intelligibility at this point.
Mild Patients
I don’t see too many patients with mild dysarthria in my therapy practice. But, I am always happy when I do because they are still intelligible and I can really help them maximize their communication. For example, they might be less efficient or find speaking fatiguing. But, I can help with efficiency and creating natural voice. I can find ways to help them participate more and reduce some of the withdrawal that is occurring as the disorder gets worse.
Guidelines for Management
Some of these guidelines might be similar to what you are already doing with your patients. However, there might be some that are different, particularly for people with dysarthria.
When to Start
We want to management early rather than waiting. I have had many patients come to me and they have had the disease for ten year and they are very difficult to understand. They fatigue when they talk. They are starting to decondition - not that it takes a lot of strength to speak - but they do decondition. If we start treatment early, we can make a big impact. We might be able to slow the degeneration of their speech, not their whole disease, but at least their speech. It’s very important to intervene before they start having some maladaptive strategies because those actually make speech worse. By working with them early, we're able to help them identify beneficial compensations from not so beneficial compensation. So, begin as soon as a patient is medically stable and they have the attention, the motivation, the cognition to participate.
Collect Baseline Data
I always collect baseline data and to some extent, we all do this. The initial evaluation can be used to gather some baseline data. We want to ask the patient how does the disorder, or whatever is happening, impact their communication. Ask how they are they responding to what's happening with their communication.
Be sure to inventory the patient's needs and goals. What is motivating them to come to therapy? What are their daily speaking environments like? Who do they tend to talk to? Which of those environments and listeners are really beneficial to the patient? In which of those cases is communication more successful and in which of those cases is communication less successful? That really gives us an idea of what we want to work on, how we might use the environment and listeners in other directed therapy and how to make an impact on this patient.
Additionally, if we want to our clients to do specific tasks in therapy, we need to get a baseline on those tasks as well. That will help to know how they're getting better when it's time to change tasks. For example, I may think a task is going to be great for a patient but when we try it, it doesn’t work. So, getting baseline data is important.
Compensation
I try to talk to my patients. First, I watch them and listen to them to see if I can identify some compensatory strategies that they're using successfully. I also ask them, "Do you feel like you're doing anything different now that your speech has changed? What kinds of things might you be doing to make your speech better? What do you think makes this environment or this listener a more successful communicative environment for you than another listener or environment?" These questions help make the client conscious of what kind of compensatory activities they are using and encourages the use of successful compensatory strategies.
One of the benefits of working with adults, and often we are working with adults when we have someone with dysarthria, is that we can really make them aware of what they are doing. We can talk about communication in a “meta” way to help them be better judges of what they're doing and better online adaptors to environments.
Maladaptive Behaviors
We definitely want to reduce behaviors that are not beneficial to improving communication. In my experience, there are two types. One is a strategy where the individual is trying to compensate and just the choice they've made is not a great one. We might see that with people who have some poor laryngeal valving and they will squeeze the super laryngeal structures. However, doing that can actually result in a worse vocal quality and sometimes damage the larynx. So, hyperfunction can be a maladaptive strategy to hypofunction. The second type is when a client has a strategy that worked quite well at an earlier stage of the disorder but because they've gotten better (or worse) that strategy is no longer a great choice.
Specificity of Training
Continuing on with treatment paradigms and treatment characteristics, I want to talk about specificity of training. This is a pretty common way to think about treatment - we want to train to our ultimate task. That means if we want to get better at speech, we practice speech. If we want to get better at swallowing, we practice swallowing. This is true even when using non-speech tasks. For example, if we have a patient who really can't produce speech or they're not at a point where they're ready to use only speech to communicate then we want to use non-speech tasks that mimic speech as much as possible. We can even try some mental practice even though actual motor movement is going to be much better. There's no substitute for real practice.
Instruction
We all provide instruction and cueing. Both are important in speech therapy but I think it's important that we always consider other modes than just the verbal-auditory mode. We often say to our patients, “This is what I want you to do.” But using a visual and tactile modality as well really helps patients to hone in on what we want. A lot of times when I teach students, I tell them to think back to when they didn't know what a larynx was and to remember that oftentimes our patients have never heard of that term. They aren't clear where the voice comes from or they don't think about how they breathe, what their lips are doing or their tongue is doing. Getting our clients to really think about that, see it, and feel it can be important.
Self-learning is also critical. Self-learning has been shown in many studies to assist with retention. For example, if we want someone to judge a therapeutic outcome in physical therapy, sometimes it's best to let the client figure out how to achieve some of the goals. We may want to use less direct instruction and less specific instruction. Instead of telling them, "Take a deep breath. Really close your larynx and produce a loud voice." You say, "Try to make that stronger. How can you make that sound better to me?" Rather than giving them particular instructions (e.g. make sure your tongue is in a particular spot) you ask, “How do you make that sound clearer?” That allows them to play around a bit and think through it on their own. Learning is really trial and error and we need to allow our patients to do some of that as well
Feedback
Feedback is important and comes in many forms. Sometimes we use regular, immediate feedback where every single trial we tell them immediately whether that trial was successful or not. There is definitely a faster rate of acquisition of skill or learning with immediate feedback, but we need to fade it to less regular feedback for better retention. As we move from learning to maintenance in therapy or on a particular skill, we will start to alter our feedback schedules.
It's also important to think about who's giving the feedback. Many times it is the clinician, but it's really important that the client give themselves feedback because we aren't going to be with them every day when they're talking. They have to be able to think about what they did, judge it and make an accurate judgment on what they should do differently the next time.
Group therapy can also be very useful if you can get reimbursed for it. It’s a great modality because it gives other-provided feedback. It’s not just the clinician or the spouse, it's another person who has the same disorder helping that person understand how their speech or a particular task was perceived.
Finally, biofeedback, or instrumental feedback, can be helpful. Feedback can be as simple as a sound level meter to show a person how loud they are. Those can be really helpful for having someone achieve a goal and, in turn, they can feel what that goal feels like. But we don't want to have that feedback there all the time. Having that kind of biofeedback there for too long causes the patient to become reliant on it and then they can't internalize the behavior. They stop thinking about what it felt like to achieve the goal and are depending on this external biofeedback to achieve the goal.
