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Mary Spremulli, MA, CCC-SLP Discusses Exercise and Voice

By Patrick LoSasso

I’d like to send a special thanks to speech-language pathologist, Mary Spremulli,MA,CCC-SLP, for her invaluable assistance in the writing of this article.

Is it possible for your body to learn new behaviors even if you have Parkinson’s Disease?

Although Parkinson’s is an extremely difficult disease and often times a devastating diagnosis, there are strategies that makes things better, provide hope and allow you to continue to thrive with a better quality-of-life.


Parkinson’s is a neurologically degenerative disease that attacks nerve cells in an area of the brain called the basal ganglia and the substantia nigra where dopamine is produced. Dopamine is a critical neurotransmitter that facilitates movement and is in increasingly small supply if you have Parkinson’s.

But there is evidence that new neuro pathways can be created allowing you to again perform tasks that have become difficult.

This article is part one of a two week series where I will feature ways that you can, for lack of a better phrase, trick the disease and encourage your body to learn new behaviors.

Please note that before beginning any new exercise, even voice related, you should first check with your doctor.

How to improve the volume of your voice when you have Parkinson’s:

Parkinson’s disease can effect the the voice of the individual in many ways. One of the common symptoms that can occur is a quiet or soft voice according to the Parkinson’s Disease Clinic and Research Center at the University of California, San Francisco.

Although difficulty with speech is not always associated with Parkinson’s disease, estimates are that 70%-90% of persons with PD will develop speech abnormalities over the course of the disease, and in fact, a change in speech may be one of the first symptoms. The speech disorder is often characterized by:

    • soft voice
    • less precise articulation
    • problem with ‘fluency’ or stuttering, especially at the beginning of a sentence when it may be difficult to start speaking quickly

Alternatively, individuals may complain of rapid bursts of speech. There may also be a loss of inflection leading to a monotonous sounding voice often accompanied by a reduction in facial expression.

These symptoms may impair communication both at work and at home. Hypokinetic dysarthria(HKD) is the broad term for the speech disturbance experienced by persons with Parkinson’s disease.

Some studies show that Dopamine replacement which is used to improve motor symptoms may yield some benefit in speech production for some, and for others, no particular benefit. Similarly, following DBS placement(Deep Brain Stimulation), some patients may experience a decline or change in speech production.

Current strategies to improve ‘quiet voice.’

Speech-language pathologist working with  patients with Parkinson’s use methods to address the dysarthria like the LSVT(R) Loud program. According to LSVT(R)Global:
LSVT LOUD improves vocal loudness by stimulating the muscles of the voice box (larynx) and speech mechanism through a systematic hierarchy of exercises. Focused on a single goal “speak LOUD!” – the treatment improves respiratory, laryngeal and articulatory function to maximize speech intelligibility. The treatment does not train people for shouting or yelling; rather, LSVT LOUD uses loudness training to bring the voice to an improved, healthy vocal loudness with no strain.
Another approach  to maintaining improvement from speech therapy, is to join singing group such as the Tremble Clefs.

Tremble Clefs is a nation-wide program for people with Parkinson’s and their care partners. The Tremble Clefs Program establishes singing groups in which individuals share in a joyful activity with therapeutic results and work toward a common goal.

Auditory masking

A strategy I find extremely intriguing is a technique called auditory masking, which happens if the perception of a sound is altered by hearing another sound.

Here is the concept.

As we speak, we are conditioned overtime to hear our voice at a consistent or regulated volume. Auditory Masking (delivering sound such as white noise or babble played in one’s ear) elicits the Lombard effect.

By suppressing the individuals ability to hear their own voice, without prompting they speak louder as they try to overcome the background noise loud enough to get the proper auditory feedback. The results are immediate.

In the video accompanying this article, I am assisted by my client Leonard who has Parkinson’s and struggles with a soft voice. I am handing him cards from my Memory Cards Plus which is a game I have created that introduces brain challenges that you attempt to solve while exercising.

Memory Cards Plus employs well known principals for improving cognition, attention span and memory. I’m asking Leonard to name the image he sees on the cards. I also ask him just speak. Notice the volume of his voice?

Leonard is exhibiting a typical and extremely common presentation of a Parkinson’s soft voice.

Now, notice what happens when I put headphones on Leonard and ask him to attempt to speak over the music. The change is immediate. [REFER TO ACCOMPANYING VIDEO]

So, how does a person with Parkinson’s employ this technique and turn it into a practical strategy to increase the volume of voice? Obviously we can’t walk around with headphones blarring music.

I asked speech-language pathologist, Mary Spremulli, MA, CCC-SLP, creator of Voice Aerobics(R) her thoughts on auditory masking.
Most patients do not recognize that they are speaking louder until or unless they hear or see themselves on audio or videotape. For this reason, I incorporate auditory masking into my intitial evaluation of patients, as it is a quick and easy way to demonstrate stimulability (the ability to speak louder and clearer).

When I review the video with the patient and his or her spouse, it’s an important first step in goal setting, and a visual reminder that they can speak better.

This way, as we embark on speech and voice therapy, we have a nice visual reminder of our target or goal. There have been a few patients that do not respond to auditory masking, and I’m not sure the reason for this, although I usually ask about their hearing.

We don’t really know if auditory masking alone will yield a training effect, although there is some suggestions of this from the work of researcher, Dr. Jessica Huber at Purdue.

Dr. Huber’s research investigating the effect of auditory masking in Parkinson’s has led to an invention called the SpeechVive(TM), a small ear piece, similar to a Bluetooth, that delivers a masking noise, eliciting louder and clearer speech.

Another device intervention, Speech Easy(R)PD or  FLuency Coach uses delayed auditory feedback (DAF), and this can have an effect of slowing or normalizing the rate of speech for individuals who speak too fast or have stuttering like dysfluencies.

Finally, there is iParkinson’s, an app, developed by Thomas Kehoe, owner of Casa Futura Technologies, himself a stutterer. iParkinson’s is an inexpensive option for patients or therapists wanting to investigate the effect of auditory masking and DAF before investing in a device.

While traditional speech and voice therapy, such as LSVT(R) Loud would always be my first option with patients diagnosed with HKD, there are many patients with Parkinson’s and Parkinsonism, who, for a variety of reasons, do not seem to generalize improvement noted in the therapy room to everyday conversation, and for those persons, device interventions will be a welcome addition to our treatment tools.

(Mary Spremulli,MA,CCC-SLP, owns a private speech-language pathology practice, and is also creator of Voice Aerobics®, a Whole Body Voice Strengthening Program created for persons with Parkinson’s and related diagnosis. Visit her website  or blog to learn more about programs and products available to support voice use.
Patrick’s Suggestion with the Consultation of the Speech Therapist:

First, as with any skill, you must practice. Here is how to proceed. Put on a set of headphones with your favorite music and turn it up moderately. It will be incredibly helpful if you have your friend or spouse film this effect with their phone or video camera so that you can see the difference.

This will demonstrate to you what type of wonderful volume you are truly capable of delivering by providing valuable video feedback.

While listening to the music through headphones, pick up a magazine, a newspaper, or a book of poems, anything you like, and speak the text so that you can hear your voice over the music. You can also try singing along with the music – that might be fun as well

Be sure to be careful not to attempt this for longer than a few minutes and be sure not to push your voice to the point of discomfort.

As you proceed, pay close attention to the physiological experience required to talk or sing at this volume. Experience it. It does indeed take more effort to project and achieve this volume, but trust that that is likely how hard you should be working every day and how loud you should be speaking in normal conversation.

There are not yet documented studies that prove this practice will transfer into a consistent louder volume, but my guess is, there soon will. As an example of empirical evidence that demonstrates its value, I’ve seen it work for many of my clients.

Practice with the headphones on, and then remove the headphones and see if you can match the volume by attempting to duplicate the physiological experience and effort you just put forth.

Joking with my clients, I often tell them they need to go home and yell at their significant other. Many times, this is just the trick to get them to speak at an acceptable level that allows for good conversation.

Come back next week for part two of how to trick the disease and make your Parkinson’s symptoms better. Stay positive, keep moving, and I will see you at the gym!

In Part 2 I’ll show you how to make a simple adaptation to your walker which will improve your gait by increasing the amplitude of your stride and reduce freezing.


USE AT YOUR OWN RISK: Content in Patrick LoSasso’s website is for informational purposes only. Consult a physician before performing this or any exercise program. After consulting with your physician, it is your responsibility to evaluate your own medical and physical condition, and to independently determine whether to perform, use or adapt any of the information contained here. Any exercise program has an inherent risk of injury. By voluntarily undertaking any exercise displayed herein, you assume the risk of any resulting injury.


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