Shake, Rattle and Roll: Power Up Your Voice and Body

Photo of Mary Spremulli with her therapy dog, Franki

Voice Aerobics™ was created by speech and language pathologist, Mary Spremulli, MA, CCC-SLP. It is an exercise program focusing on breath support, posture and vocal function exercises for improved vocal performance.

I was delighted to conduct the following email interview with Mary:

Kate: What attracted you to working with Parkinson’s patients in the area of speech/voice treatment?

Mary: I have always enjoyed working with children and adults with motor and speech disorders. More than 20 years ago when working in pediatrics, I became certified in Neurodevelopmental Treatment, also referred to as NDT. One of the underlying principles of that treatment is that "normal and abnormal cannot co-exist." Based on that understanding, I would incorporate treatment approaches that included techniques to minimize or extinguish the abnormal patterns that were interfering with the more normal expression of movement, voice, speech or swallowing.

When I relocated to Florida in 1989, I began to work with primarily an adult population, including individuals with voice, motor and speech problems from Parkinson's, stroke, and other neurological events. That theory from NDT still applied, and I realized that if someone's goal was "better" or more "normal" speech, then we needed to work together to minimize the interference from the abnormal. Using Parkinson's speech as an example, there may be a number of things that are interfering, such as tremor, too fast of rate, weak voice or hoarseness. We attempted to identify the feature that was causing the most interference and minimize that by strengthening some other aspect of the speech, voice, or respiratory system.

I became certified in the Lee Silverman Voice Treatment® (LSVT) technique in 1997. Dr Lorraine Ramig and her colleagues associated with this program have published an impressive body of research describing its benefit. In my opinion, if someone has been newly diagnosed with Parkinson’s, this is the ideal time to consider the LSVT.

I realize that I may not have answered your actual question. I find that I am attracted to working with individuals with Parkinson’s, in particular, because over the last 15 years or so, I have met so many interesting patients, whose voice and speech changes from Parkinson's really misrepresent the person behind the voice. I can think of many individuals who on first meeting have weak, monotone voices. As we begin to work together, I discover that they are often intelligent, witty individuals, who were teachers, CEO's of companies, athletes, yet their true personalities are beginning to be lost inside their bodies. So, if I can help them to strengthen their system to minimize further physiological changes and to re-capture the spirit of who they are, then, that's fun and rewarding for me. I have audiotapes of patient's first and last sessions, and you can hardly believe that they are the same person talking.

Kate: What are the biggest speech and voice challenges faced by those with Parkinson’s?

Mary: Oh, wow, well, you know that answer better than me, Kate.

I would have to say that one of the biggest challenges is the insidious or sneaky nature of the speech and voice changes. Unlike someone who has had a stroke where the changes in speech are quite sudden, the changes that come about with Parkinson's are slow and gradual. For the persons with Parkinson’s they don't really seem to realize how bad their speech may have actually become.

The LSVT people talk about the need for those with Parkinson’s to become "re-calibrated," and I do think that this is at the heart of the program, but, also the greatest challenge. Even when Parkinson’s patients hear themselves producing better and louder voices, it doesn't feel natural to them. We humans seem quite drawn to the familiar, and even when we don't like some aspect of our behavior, it can be difficult to change.

The other challenge is that the individual with Parkinson’s must realize that even when a formal program of therapy of any sort has been completed, that is not really the end. Parkinson's is still in the background of their lives, sneaking around, and changing the way muscles behave, and so individuals have to make a LIFETIME commitment to exercise. In that regard, with or without Parkinson’s, if a commitment to exercise was easy, our gyms would be overflowing with members, and of course, that is not the case.

Kate: What additional speech and voice problems have you observed in those with Deep Brain Stimulation (DBS) for Parkinson’s? Have you been able to develop some unique techniques to help your patients deal with these problems?

Mary: This year in particular, perhaps because more patients are being considered for DBS, I seem to have seen a lot of patients with undesirable changes in speech or swallowing following DBS, usually after a second placement. I have had several patients with changes in swallowing. An evaluation of swallowing function should probably be conducted before DBS as a baseline, and then needs to be repeated, to include some instrumental evaluation such a video-swallow study conducted by a speech pathologist and radiologist.

The other problems I have seen are changes in rate of speech (too fast) or an increase in stuttering-like speech patterns. These last two problems are tough to address, and I am like the mad scientist, with all kinds of gadgets and gismos in my office, experimenting with what might work. I have had some patients who have had some success with a metronome for pacing to reduce a too rapid rate. I have also been experimenting with white noise masking, which for a few people has yielded instant improvement in volume.

The reduction of tremor with DBS is nothing less than miraculous for many patients, so, I guess the tradeoff of changes in speech and/or swallowing are going to have to be ones they make. I would just like neurologists and neurosurgeons to listen to their patients, when they tell them something has changed, and refer them to a speech pathologist for some help.

Kate: In your DVD, Voice Aerobics™, you combine physical exercise with speech/voice exercises. What led you to develop this combination?

Mary: I began the live classes back in 1999, as an after therapy program for individuals who had completed the LSVT. The patients knew that they needed to keep exercising, and I wanted to provide them with some tools to keep them motivated.

It seemed natural to combine movement with voice, and now that I have done this for so long, it's hard for me to just do vocal function exercises without some body movement. Since repetition of a behavior is the surest way to establish a new habit, I have also tried to tie the voicing and movement with things we do all day long, so that, for example, every time an individual gets out of their lazy boy, or up from the toilet seat, they would couple it with a "yaah" as we do in the video. I have read at least one study, where that type of speech "self-cueing," when used with individuals with Parkinson’s, actually increased the smoothness and speed of movement.

Did I mention that I'm also a dancer at heart? If you were beginning to learn the waltz, it would just be easier to count the steps out loud: one, two, three, one, two, three, and soon you would be gliding around the room, and internalizing the tempo.

Kate: Do you have any advice about voice and speech for those newly diagnosed with PD?

Mary: The best advice I can give, in addition to taking your medications as prescribed, is to begin a voice exercise program. Frequently, I receive a request from a local neurologist to contact a person for therapy, and in doing so, the person will say: "I don't think my speech is that bad, yet." GRRRRR!!!!! If they wait until the day of the "yet," they will already be in trouble.

Recently I have watched a few episodes of the Biggest Loser, and I compare some of those folks to the persons who want to wait for their speech, voice, or swallowing to get worse. I would ask: Do you think it would have been easier for those contestants to lose weight when they were only 10 pounds overweight, than waiting until they were 250 pounds overweight? Well, it's the same thing really. If you are fit, your larynx is healthy, and you aren't having any particular speech, voice, or swallowing problems "yet," then you are the PERFECT candidate for a program.

Voice Aerobics™ can also be a good program for those reluctant individuals who don't want to enroll in therapy. They can begin training the muscles, heightening their awareness of the connection between posture and breathing and voice, and hopefully preserve your their function for as long as possible.

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For more information on Voice Aerobics™, view the website at:

http://www.voiceaerobicsdvd.com