A 65-year-old male began experiencing a slight, unremitting resting tremor of both hands. Soon after the onset of this symptom he developed
mild difficulty with gait, speech, and swallowing, which prompted a complete medical examination. Although a diagnosis was reserved at that
time, a drug therapy program was prescribed that included a mixture of trihexyphenidyl (Artane) and carbidopa-levodopa (Sinemet) tablets
(25/250 mg.) four times a day. Initially, this program resulted in modest improvement; however, these effects were not sustained, and
symptoms gradually worsened over a two-year period. The patient was admitted to the clinic for comprehensive reevaluation.

ID of likely language limitations: I looked up Artane and Sinemet on www.rxlist.com, and it described them both as medications used to treat Parkinson’s Disease, or Parkinson’s like symptoms. Since this patient also showed common progressive symptoms of Parkinson’s (difficulty with gait, speech, and swallowing) and since he was prescribed these particular medications, I am going to address language limitations often linked with Parkinson’s Disease.

When researching for the language limitations of Parkinson’s, I had a difficult time because there was a bit of conflicting information. In terms of speech therapy, Parkinson’s is primarily a disease that effects speech/voice characteristics and swallowing. It seems that language limitations are debatable, and some argue that they are often mainly side effects of Parkinson’s-associated dementia that appears in approximately 1/3 of the people with the disease rather than the actual disease itself.

Language limitations that are present may be a result of frontal lobe dysfunction due to a reduction in dopamine levels used in the particular cortical networks involved in memory and attention. This change could result in difficulties with the following: concept formation, word generation, sentence processing, slowness in memory activities, and self-monitoring the patient’s own language behavior. Other language limitations that could manifest might include: inappropriate silences, reduced spontaneous verbalizations, difficulty producing and understanding syntactically complex sentences, dysgraphia (a disturbance in the ability to write; the patient may write very small letters and use inappropriate spacing), naming difficulties, lexical selection errors, and paralinguistic limitations (gestures, facial expression) due to muscle rigidity.

As previously mentioned, approximately 1/3 of Parkinson’s patients will develop dementia. Dementia patients all demonstrate language deficits, and they are proportional to the patient’s mental function. Since dementia is a disruption of cognitive function, in communication it would additionally involve processing, storing and retrieving data. Substitutions and anomia are more evident as dementia progresses and patients may have difficulty maintaining a topic in conversation because they may say unrelated and seemingly meaningless phrases. Also, comprehension and memory become significantly impaired as the dementia progresses making the patient increasingly disoriented to time and place.

When doing this research, I found a site that was extremely helpful that might interest some of you. It is the site of the National Parkinson Foundation and has some very valuable information. You can find it at www.parkinson.org. It has a great search engine for all sorts of information on the disease. For all the other speech therapists in-training out there in particular, a great place from this site for information regarding anatomy, assessment, memory, swallowing, and intervention techniques can be found at http://www.parkinson.org/sp3.htm.

Kelli Black

ID of likely speech limitations: Since this patient seems to present with Parkinson’s disease, it is likely that he will also present with hypokinetic dysarthria. Parkinsonism is the major etiological factor associated with this dysarthria. Some of the common speech problems associated with hypokinetic dysarthria include: a slow speaking rate with intermittent burst of rapid-fire articulation, monopitch, monoloudness, reduced stress, abnormally long pauses, imprecise consonants, a harsh or breathy vocal quality and short phrases. Hypokinetic dysarthria is also the only dysarthria in which an increased rate of speech in contextual situations may be one of the symptoms. When hypokinetic dysarthria occurs in
Parkinson’s disease, rigid mumbling and non-prosodic speech can also be characteristics.

Laura Dunlap and Amy Edwards

ID of likely swallowing limitations: The following comments are based on the Parkinson-like symptoms of the patient. It is expected that the patient may experience difficulty in all three stages of the swallow. Keep in mind that these symptoms are suggestive of a generative disease and that the swallowing difficulties may increase with the progression of the disease. In the oral stage, the patient may experience difficulty moving the bolus into the pharynx. A repetitive anterior-posterior rolling pattern may appear often. Over time, the function of the tongue will be reduced to limited or incomplete movement. When the swallow is begun, the bolus is held in normal position, but the posterior portion of the tongue frequently may not lower and the bolus will be rolled anteriorly. This motion may continue until a sufficient anterior-posterior tongue movement is able to propel the bolus over the posterior of the tongue. Muscle rigidity may also be present in the tongue! muscles along with the limited range of movement. Appropriate lip closure may show weakness as well as limited movement of the mandible. A delayed trigger during the pharyngeal swallow (maybe 2 to 3 seconds) can be expected. Velar elevation may be weakened or limited. The contraction of the pharyngeal wall and posterior motion of the base of the tongue can be expected to be reduced and even limited as the disease progresses. After each swallow, residual bolus may be located in the valleculae and pyriform sinuses. The inversion of the epiglottis may be weak and later it may become incomplete. The patient may also experience aspiration of residual material. In the more advanced stages of the disease, the patient will probably experience incomplete laryngeal elevation and laryngeal closure. Also, a resting tremor may be seen affecting the control of the tongue and head movement. Over time, it can be expected that the entire! swallowing mechanism will become limited or even absent.

Sarah Goodwin

ID of likely limitations in basic ADL's: This 65-year-old male may experience widespread difficulties as a result of the tremor in his hands, and difficulty with gait. The largest contributing factor that would limit functional movements needs for basic ADLs, including dressing, bathing, grooming, feeding, and toileting, is the resting tremor. While this may not compromise his ability to accomplish some gross movements, it will give him problems with fine motor movements. For example, during dressing he may have difficulty buttoning, zipping, tying shoelaces or drawstrings. Oral hygiene may also be compromised, as well as grooming activities such as shaving, and hair combing. He may not be able to open bottles or hold soap during bathing. The tremor would also create trouble when he is trying to direct a spoon toward his mouth and keep food on it at the same time. He may also present with difficulties in toilet hygiene. The gait difficulty would cause safely issues during bathing, if he takes showers, and create a general risk of increased falls during transfers or functional mobility.

Emily Cobble

ID of likely limitations in complex ADL's: Even with the limited amount of background information, I do believe that this 65 year old man would experience difficulty with advanced or "complex ADL's. I will assume that he is living on his own and was not dependent on a wife or a family member to care for him. In this case, he would have to do his own household maintenance, household cleaning, meal preparation and cooking, money management, shopping, medication as well as set up and follow a medication routine, and find transportation if he is not driving. His
household maintenance can include mowing the lawn, cleaning out gutters, raking leaves, painting, and washing the outside windows. Many categories fall under household maintenance. He may now experience difficulty with caring for the exterior of his home and the yard maintenance due the tremors in his hands and his unsteady gait. The different types of terrain (gravel, grass, and dirt) may be on an incline and can contribute to his unsteady gait. Due to his tremors he may have difficulty starting the lawnmower, climbing a ladder to clean out his gutters, or even holding onto a rake. With his household maintenance he may have difficulty opening his laundry detergents and dishwasher detergents, folding clothes, ironing his clothes, holding onto the vacuum, sweeping his floors and even making his bed. He may have difficulty walking around his home due to his unsteady gait. It may be too challenging to sweep, walk, and hold onto the broom all at one time. If he does not have a dishwasher he may have difficulty holding onto the soapy dishes due to the tremors which has worsened over the two year period. It may now be unsafe for him to prepare food in his kitchen. Due to the tremors and unsteady gait he may walk or trip into the stove or drop a hot dish. He may also now have a special diet due to his swallowing difficulties and he may be required to puree his food. This man may not be able to hold onto his utensils or open jars of food in order to do the necessary meal prep. For his money management this man may have difficulty writing a check or holding onto a pen due to the tremors. When handling coins he may drop them easily. This can also cause problems when balancing a checkbook or even opening a check to receive his social security. His unsteady gait may make it difficult for him to walk out to his mailbox to either receive or send off his mail. This man may have difficulty shopping for clothes or groceries if he is unable to walk down the aisles. Even if he were to ride on the scooters his hands may not allow for him to operate the scooter or grab items on the shelves with out dropping them. Items can easily fall from his grasp. Another problem with shopping is the socialization aspect. People may have difficulty understanding him due to his speech deficit. He may also be ashamed to speak to others for fear of others not understanding him. For his medication routine this man may not
be able to open his prescription drugs that he takes four times a day. Once he actually opens the bottles he may drop the pills due to the tremors. If he were to need help he may not be able to call for help if his speech is too difficult for others to understand. If he is not able to drive anymore then he may have to call for a cab or other means of transportation. He might not be able to walk to a bus stop. There are many possibilities when it comes to deficits in complex ADL's.

Cindy Hale

ID of likely limitations in cognition: A patient with Parkinson's disease can exhibit memory and cognitive changes at any stage throughout the
progression of the disease. The following are some changes in cognition that may be observed:
1. reduced ability to concentrate on activity
2. may require additional time to express thoughts and ideas
3. may have difficulty thinking of a specific word that one wants to use
4. may lose train of thought while speaking
5. easily distracted by surroundings or others activities going on in their environment
6. may require an increased amount of time to process information
Be aware that some medications for Parkinson's disease can decrease memory and concentration. It may be necessary to adjust the dose or discontinue the medication. A physician may need to diagnose depression if that is suspected. If any of these characteristics are observed, it is important that the patient be seen by an SLP to be evaluated and provided with treatment if necessary. The SLP can help the patient (especially in the early stages of the disease) regain control over planning and preparing for daily routines and events, which can help the patient lead a more independent life with more self-confidence.

Heather Browning

Assessment of swallowing: As with many assessments, the swallowing assessment for this patient should begin with a thorough chart review and interview. The medical chart can provide important information regarding the patient's medical history including current status and medications. This also includes information on the patient's respiratory status, dysphagia symptoms, and general behavioral observations. An interview should be obtained from the patient, his caregiver, and/or the medical staff to further help the clinician understand the nature of the patient's swallowing difficulties. Patients who have Parkinson's disease are often able to accurately describe what is wrong with their swallow (i.e. "It feels like it gets stuck in my throat").

The next step in a swallowing assessment is usually to complete a bedside examination. However, due to the high incidence of silent aspiration in patients with Parkinson's disease, I feel it would be safe to forgo that portion of the assessment for this particular patient and request a Modified Barium Swallow evaluation via videoflouroscopy. A Modified Barium Swallow will help determine if and why the patient is aspirating. It will also show whether the patient's symptoms are alleviated with diet modifications and/or compensatory strategies. You would want to begin the examination using the least threatening consistency, which would probably be a liquid in this case (unless the chart indicated otherwise).

During the videoflouroscopy, you could expect to see swallowing difficulties in both the oral and pharyngeal phases. The repetitive rolling motion of the tongue will cause difficulty in bolus propulsion into the pharynx. Aside from seeing a delay in the triggering of the pharyngeal swallow, you could also expect to see reduced pharyngeal wall contraction, reduced laryngeal elevation, and incomplete laryngeal closure. This will result in residual material in the valleculae and pyriform sinuses which may enter the airway after the swallow when the patient inhales. And as noted earlier, it is very likely that the patient's aspiration will be silent.

Paige Ferguson

Assessment of language: Evidence has strongly linked the language deficits in Parkinson's patients to the presence of dementia. Therefore, I would assess this patient's language while informally assessing symptoms characteristic of dementia. The following assessments would be appropriate for this patient, regardless of the presence of dementia. 

First, I would talk to the patient's family about any concerns they had for "John Doe's" language. Next, I would obtain a language sample while engaging in natural conversation with John Doe. This would include questions about himself, his family, where he is, and what day it is, etc. I would look for both expressive language abilities and auditory comprehension. I would then present John Doe with a series of pictures and have him tell a narrative sample. I would use this sample to further analyze spontaneous oral-expressive language. Attention and memory skills would be observed throughout this assessment.  

I would finally assess John Doe's language using two standardized instruments, The Western Aphasia Battery (WAB) and The Functional Assessment of Communication Skills for Adults (FACS). The WAB provides a comprehensive evaluation of all 4 modalities of communication: auditory comprehension, reading comprehension, oral expression, and written expression. The WAB specifically assesses content, fluency, auditory comprehension, repetition and naming, reading and writing, and calculation of the patient. The aphasia classification system provided by the WAB would, of course, be unnecessary in this assessment, however, the diagnostic information provided would be valuable in determining John Doe's language strengths and needs.

The FACS would be administered to elicit and assess the patient's language as related to the everyday activities and social-communicative interactions he may be involved in. This, as well as the non-standardized, informal assessments previously mentioned, would be important in determining the functionality of John Doe's social-communicative language.

Olivia Herndon

Assessment of speech :When researching information about speech assessment for what I believe to be Parkinson's disease was a easier to find with the web site given by Kelli Black. Thanks

When assessing the speech characteristics of a Parkinson's patient, which is hypokinetic dysarthria, the information was easy to understand.
According to Duffy, Conversational speech and reading are useful for evoking the errors of prosody: monopitch, reduced stress, monoloudness, and inappropriate pauses. Connected speech samples would be good for evaluating short rushes of speech. Speech AMR's can give evidence of articulation errors: imprecise consonants, variable rates of articulation and the running together of syllables. Vowel prolongations would be helpful in assessing vocal quality. All of these assessment procedures would be helpful in detecting other characteristics of hypokinetic dysarthria such as decreased loudness, low pitch, and repeated phonemes. Also, an assessment of hearing loss would be helpful because if he can not hear what we are saying then it will be difficult to make gains from therapy.

Melissa Green

From the information that we have about this client, it seems that he may have hypokinetic dysarthria, similar to what would be present with Parkinson’s disease. However, it is still important to conduct a thorough examination of speech to gather all the information we might need to be sure that we provide the most appropriate treatment for this client.

First, we would want to get case history information from the client. Some of this information will be obtained from the medical record, without having to interview the client, but it will be important to talk to the client himself about his perception of this difficulty and how it is impacting his quality of life. Knowing accurate medical history and the client’s perception of the problem will assist us in making an accurate medical diagnosis as well as recommending appropriate treatment.

Next, it will be important to do a thorough oral-motor assessment. This assessment should include examination of the following: face and jaw muscles, and the tongue by looking at symmetry, range of motion, and asking the client to perform various jaw and tongue movements. The velum and pharynx should be examined by having the client sustain /a/ and by testing the client’s gag reflex. The oral-motor exam should also look at laryngeal function by having the client produce a cough, a glottal stop, and by listening to his breathing patterns for stridor. The exam should also include auditory-perceptual measures of respiration, phonation, articulation, prosody, and resonance. Additionally, we should examine the client for nonverbal oral apraxia and apraxia of speech to rule out those possibilities, even though the case history doesn't’t indicate that apraxia is likely the problem.

We will need to use some type of standardized test for this client, in addition to our own observations, in order to be able to get a more accurate picture of his performance in relation to other individuals with motor speech disorders. The Frenchay Dysarthria Assessment might be a good test to use, since it is commonly used. Other options include the Dysarthria Profile and the Dysarthria Examination Battery.

Since it seems that this client has hypokinetic dysarthria, we should pay close attention to conversational and reading tasks, in which prosodic variations may be abnormal. The client will likely have reduced pitch, loudness, and stress, and short rushes of speech. As far as articulation is concerned, the client will probably be imprecise. Additionally, we should pay close attention to the client’s vocal quality, which may sound harsh or breathy in the case of hypokinetic dysarthria. Pitch may also be reduced. AMR and SMR tasks should reveal reduced range of motion.

Meredith Glover

Assessment of basic ADL's:In order to asses this individuals limitations in simple ADL's, an observation of his ADL routine would be best. In particularly, you could use the FIM scale. You are likely to find that he needs minimal assistance to setup. He may need setup with grooming products, such as opening toothpaste, or minimal assistance with combing his hair. With dressing, he may need assistance with fasteners and retrieving the clothing. Bathing would likely require setup and the use of a shower bench. He may need moderate assistance with feeding due to difficulty retrieving and bringing food to his mouth secondary to tremors. These FIM scores would give the baseline of deficits and show the direction in which treatment should follow.

Stacy McCraw

Assessment of complex ADL's: Since this gentleman has potential for difficulties in basically all his complex ADL's, a variety of assessment options are necessary and available. To being,an interview is necessary to truly identify present and past roles, interests and habits. The Canadian Occupational Performance Measure (COPM) can be useful in identifying some of these areas. It is important to find out his priorities. In order to assess some of his home management abilities such as clothing care, cleaning, and meal preparation, it is necessary to look at his muscle tone, speed and reaction of voluntary movements, postural movements, and his sensory motor skills. Some evaluation tools that may be useful for these areas include the Modified Ashworth Scale and Nine Hole Peg Test. Meaningful and functional observations may give a better idea of his abilities, however observations can not be considered standardized assessments. A handwriting sample will be helpful in addressing his ability to sign checks or complete paperwork (whether it be personal or business related).

The Assessment of Motor and Process Skills (AMPS) is specifically designed to look at complex ADL skills. This assessment is aimed at
assessing an individuals performance of complex ADL tasks along with the motor and process performance components that contribute to the
completion of these tasks. (Trombly, 4th ed.) Unfortunately, a therapist must be specially trained in order to complete this evaluation and use the computer system that scores it.

The Kohlman Evaluation of Living Skills (KELS) is another assessment that addresses areas involved in complex ADL's such as money management, safety, and using the telephone.

There are many options available for assessing this gentleman's complex ADL status. Selecting the tool that the therapist has access to and is
most comfortable with is probably going to help in obtaining an accurate outcome.

Assessment of cognition: When thinking about cognition, it is good to think about it in four major areas: attention, memory, reasoning &/or problem solving, and executive functioning such as resources/planning, implementing/adjusting goals. To begin, observe the client. While observing, think about these areas and look for characteristics of each of the areas. It is important to use both informal and formal assessment procedures when assessing cognition. I believe the RIPA (Ross Information Processing Assessment) would be a great tool to use with this client. However, while researching, I found an assessment tool that I had never heard of but thought was a great because it is specific to Parkinson's and the dementia that can accompany the disease. It is called the Mini-Mental Status Examination, abbreviated MMSE, devised
by Drs. Folstein and Folstein. It consists of a series of questions including: 1. Orientation: the day of the week, the day of the month, the month, the year. 2. General Information: the name of the President, the Vice President, the Governor 3. Immediate Recall or Short Term Memory. This
includes the ability to remember 3 objects such as Red Shoes, Black Box, $300 4. Attention Span. 5. Delayed Recall. This includes the ability to
remember the 3 objects asked under Immediate Recall. 6. Language and Left-Right Discrimination: The patient is asked to name objects such as a hand, a thumb, an ear, The patient is asked to repeat a phrase such as: "No ifs, ands, or buts about it, "The patient is instructed to follow a complex command such as: "Take your Right Hand, place it upon your Head, and comb your Hair." 7. Reading, Writing 8. Visual Orientation

Jamie Davis

Prognosis: With the information provided thus far, this prognosis is based upon a diagnosis of Parkinson's disease. If the most recent comprehensive reevaluation reveals the patient is in the late stages of Parkinsonism with severe deficits in functioning, the most appropriate recommendation is either home health care with visits from occupational and speech therapists or a nursing home placement which will offer the same services. However, if the reevaluation reveals the patient is still in the early stages of Parkinsonism, immediate rehab placement for a period of 3-6 weeks would be beneficial in providing short term improvements in independent functioning as well as the education and resources needed to return home. Due to the degenerative nature of Parkinson's disease and the possibility of dementia, the long term
prognosis for independent functional status is poor. However, optimal functioning should be maintained through pharmacological and therapeutic
interventions for as long as possible.

Maureen Ritter & Jennifer Williamson

Swallowing targets and activities: Regarding treatment and therapy targets for swallowing: One of the first things that should be addressed is client and family education regarding dysphagia and the progressive effects of the client's condition. Additional resources such as information about support groups could also be offered.

The exact targets for this client's treatment rely on the symptoms and severity of his dysphagia. Pending on the severity of his condition, different treatment goals may be addressed.

Two functional goals for the client include:

1.. The client will perform a functional swallow of medications utilizing necessary compensatory strategies and postural techniques.
*Sinemet must be swallowed without chewing or crushing.

2. The client will use compensatory strategies and postural techniques to manage a 3-5 mL bolus.
The following are general compensatory strategies that are commonly used for individuals with Parkinson's disease:

a.. The use of specialized utensils to control the amount of food eaten and to compensate for problems with hand-mouth coordination (i.e. weighted utensils, etc). May need to consult with the occupational therapist.
b.. Eating small nutritious meals more frequently.
c.. Avoid dry crumbly foods (i.e. potato chips, crackers) and replace with moist, cohesive foods (i.e. yogurt, over-cooked rice).
d.. A modified diet of soft or pureed foods may be incorporated to compensate for problems with chewing and swallowing if the client is not aspirating on these consistencies.

The following are postural and therapeutic techniques that are commonly used for individuals with Parkinson's disease:

a.. Chin Tuck--The client can raise and narrow the entrance of the larynx by tucking the chin down towards the chest.
b.. The supraglottic swallow -- (client holds their breath while swallowing then immediately coughs) can be utilized to clear residual residue from pharyngeal cavity.
c.. The Mendelssohn maneuver -- may be utilized with every swallow to assist with transit of bolus through the cricopharyngeal opening, if necessary.
d.. Supraglottic swallow -- An additional technique that achieves these same goals is the supraglottic swallow, where the client holds their breath while swallowing and then immediately coughs.
e.. The client can be instructed to clear throat by coughing approximately every 2-3 sips to clear potential penetration or tracheal aspiration. It is also recommended that the client cough at end of every meal.
f.. Instruct the client to alternate purees and liquids to clear residue from pharyngeal cavity.

In the late stages of this disease, the client may be at great risk for aspiration due to an inability to perform a functional swallow. Alternative means for nutrition/hydration should be recommended at this time. The nasogastric (NG) tube or the percutaneous endoscopic gastrostomy (PEG) tube are alternative means that should be discussed with the client and the client's physician. Medication should also be administered through a tube unless the medication requires oral intake (as with Sinemet).

Angie Halter

Basic ADL targets and activities: All of this clients basic ADL's could be affected due to the tremors in the hands. Some functional goals and treatment focus is listed below.

Functional Goals
Client will write a shopping list / letter with modified independence.
Client will open medication containers with mod I.
Client will demo ability to open toothpaste with mod I.
Client will feed with supervision.

Of course treatment ideas for those goals (which would be formulated around the patients desires for improvement and his interests) would include working on those specific ADL tasks as well as components of those functional activities such as reaching for the object, maintaining grasp of the object, and in hand manipulation of those objects once they are controlled. A good part of the treatment sessions organizational form in the beginning would be to adequately evaluate and assess the clients abilities as to the degree of the tremor, and how it effects his ADL’s currently, and his ability to adapt and to utilize different associated techniques and/or equipment to aid him in safe and timely completion of functional tasks. Treatment could also be focused around educating the client about his own body and how he can utilize it towards the completion of daily tasks, for example, that he may be more capable of doing fine motor tasks early in the morning, or late at night. And that those are the times of the day that those tasks would be suggested to be completed.

Complex ADL targets and activities: List at least two functional goals and list those treatment activities (including compensatory strategies and therapeutic techniques) which would be utilized.

Language targets and activities:Patient will receive individual language therapy for 2 50- minute sessions weekly.

LTG1: Mr. Doe will improve receptive language skills to a more functional level.

STG1: Mr. Doe will answer oral Yes/No questions about a paragraph orally read to him at 80% accuracy.

Procedures: Clinician will read a paragraph of the client's interest and will ask basic questions, relating to content.
Cues: Re-read paragraph, Re-read/state questions
Reinforcement: Praise
Materials: Reader's Digest

STG2: Mr. Doe will follow 2-step oral commands on the first try with 80% accuracy.
Procedures: Role-playing doing laundry
Cues: Simplify into one-part command(s), Ask client to repeat the instructions, Model the behavior
Reinforcement: completing the task and praise
Materials: clothing

LTG2: Mr. Doe will improve naming skills to a more functional level.

STG1: Mr. Doe will name common items with no semantic cues with 80% accuracy.
Procedures: Clinician will show picture cards of items and ask patient to name each one.
Cues: Saying the target word while pointing to a picture, Matching a printed word to the corresponding picture, prior to naming it, Making semantic judgments about a target word such as (Is an icebox a freezer?)
Reinforcement: praise
Materials: Reminiscence cards

STG2: Mr. Doe will name common items with no phonemic cues with 80% accuracy.
Procedures: Clinician and client will look at a magazine and clinician will point to pictures of common knowledge or interest to the client, and ask
client to name each.
Cues: Client gesture the use of item, Sentence completion, Providing the initial phoneme
Reinforcement: Praise
Materials: Good Housekeeping, November 2002

Speech targets and activities: It is believed that this patient has a Hypokinetic Dysarthria, specifically Parkinson's Disease. These patients typically exhibit monoloudness, monopitch, decreased vocal loudness, decreased facial expression with low mouth movements, rapid bursts of speech, increased respiratory rate, reduced vital capacity, and imprecise articulation.

The Lee Silverman Voice Treatment protocol will be implemented to achieve the following goals:

1. Increase vocal loudness.
2. Increase breath support for speech.
3. Improve articulation skills.

Activities include following the LSVT protocol of intensive training for 16 sessions meeting 4 times per week. The frequency of treatment contributes to generalization of skills outside of the therapy room. The main idea of this protocol is "Think loud/ Think shout!" The theory is that focusing on vocal loudness automatically improves breath support for speech and intelligibility.

Some specific activities include:

1. 10 trials of sustained "ah": the patient is timed and over the course of therapy the times should increase

2. 10 trials of pitch glide both rising and falling: the patient starts at comfortable pitch and increases/decreases to highest/lowest pitch
possible...use of keyboard to match the note.

3. 10 commonly used sentences: patient states the sentences with loud voice while clinician uses calibration device to determine level of loudness.

4. conversational speech: patient and clinician engage in conversational speech with use of calibration device while clinician gives feedback regarding patient's loudness.

During speech tasks it is important for the clinician to give a non-verbal cue letting the patient know if they need to increase their loudness level, so they may make necessary adjustments.

Erin Nelson
Tressa Murrell

Cognitive targets and activities: Often times Parkinson's patients (depending on severity) experience decreased attention and difficulty with remaining on task. Their ability to plan and use strategies to execute the plan may also be impaired. Therefore targeting his sustained attention and keeping him on task would be the first goal. Heather Browning mentioned that he may become distracted by the noises and the environment around him so if you gave him an activity such as a list of letters and make him go through and mark all the "B"s then he would have to use that sustained attention to make it through the activity (may need verbal or physical prompting to get him back on task). The other thing that may need to be targeted is his executive functioning skills for his ADLs. By working on helping him understand the steps needed in carrying out an activity the patient may gain the ability to work through these and self-monitor on his own. Step by step instructions could be printed out to remind the patient on what procedures need to be completed to obtain that certain goal. Since Parkinsons is a degenerative disease reassessment will always need to be done to determine what targets will need to be changed or when therapy may no longer be successful.

Ashley Jones

Review and question: It looks like everyone did a great job of researching materials to find the appropriate answers. For language it is difficult to determine the diagnosis for the patient. The idea that dementia could possibly be present with this patient was relevant depending on the severity of the problem. Swallowing seems to be a consistent problem in patients with Parkinson's Disease. It is very important to remember that these patients do silently aspirate. I feel that a clinical bedside examination should be warranted for anyone who complains of swallowing difficulty especially if the diagnosis is unknown then proceed with an MBSS. The discussion on ADL's were very detailed and appropriate for this patient. Especially impairment in fine motor skills interfering with ADL's. Thank you for introducing website information to the group. These sites seem to be very helpful with your answers. Questions of my own include: Why target receptive language in therapy? Why not attempt Deep Pharyngeal Neuromuscular Stimulation in swallowing therapy? Why not target memory in cognitive rehabilitation if the patient has dementia?

Kellan Williams

The responses to all of the facets of this patient's disorder seemed very well thought-out by everyone involved. When reviewing the information, I found it difficult to come up with many questions because most were answered! I agree with the overall diagnosis of Parkinson's disease and the statements made regarding treatment for this patient were excellent! Just some comments and questions on a few of the responses:

-The web-sites that were given by Kelli Black were mentioned several times by others working on the assignment and they proved to be very helpful. Thank you, Kelli! It's important to keep in mind that the website is an accredited National Foundation, so I assume that there would be minimal chance of incorrect information, unlike other sites on the web. I'm sure most of you all know to be cautious about what you find on the web and make sure to check the source before giving information to clients, families, or other professionals.

-Language Limitations: Is it possible to have a mixed dysarthria and also have Parkinson's or is it confined to only hypokinetic dysarthria?

-Swallowing Limitations: One issue that was not brought up often was family counseling. I think this is an important aspect of treatment (although his family was not mentioned in the Case Intro.) It would be important to bring up feeding issues with the pt's family if they were involved. They should be made aware of what the pt.'s swallowing limitations and what the pt. can and can not consume after the dx.

-Assessment of Language: I understand the reasoning behind giving the WAB to this pt. to assess the 4 modalities of communication. However, is it necessary to give this pt. an Aphasia Battery when we are almost certain of hypokinetic dysarthria or is there a better test to assess his language abilities?

I thought all of the responses were informative and thoughtfully written.

Julie Stiffler

Summarize: Provide a brief summary of the case, highlighting the most pertinent issues for speech, language, swallowing, cognition, and ADL's

In response to one of the questions posed by Billy Irwin... "How could participation and quality of life issues be addressed more directly in assessment?" I agree that this is a critical factor to consider. I think obtaining personal and background information on the patient is the first place to begin looking at quality of life issues. Some questions need to be direct, but in a tactful way. What I may view as key factors to quality of life could be very different from my patients perceptions. Assumptions are dangerous territory. It is also important to gather a full picture of the patients "regular schedule" and activities. They may find that they need to use energy conservation techniques, compensatory techniques, or allow for extra rest at certain times of day to prepare for something personally meaningful later in the day. Although we are not qualified to make medication recommendations of any sort, we may want to refer the patient back to the MD to address time of day for certain medications to allow for maximal performance in prioritized activities. Overall, what I am saying is that in my opinion, the quality of life issues addressed in assessment from an OT perspective come in the interview and information gathering portion more than anything else. Every patient is an individual... not a diagnosis!

Kara