Therapy must take place where people are

Can you tell us about your professional background and what inspired you to become a speech therapist, especially with a focus on Parkinson’s patients?

I was originally a professional musician and played the double bass with great passion. Unfortunately, a serious hand injury ended my career. While teaching, I began to audition vocal lines for my students and became aware of my own voice. By a lucky coincidence, I was referred to a renowned expert in speech therapy for Parkinson’s – this sparked my interest. I realized that with my musical ear and technical understanding, I was ideally suited to training as a speech therapist. So I began my studies in speech therapy, worked with digital aids and specialized in Parkinson’s early on.

In a care facility, I noticed how many residents suffered from Parkinson’s disease. That was the trigger for me to set up interdisciplinary Parkinson’s teams. I later met my wife Josefa Domingos – she is a physiotherapist – and together we developed a comprehensive training concept. Today we live in Lisbon and work with Parkinson’s patients worldwide – and I am grateful that I chose this path.

How did you come to offer online training for Parkinson’s patients? What challenges did digitalization bring with it, and why is the online format particularly suitable for speech therapy?

Online training initially arose from practical considerations: Face-to-face courses are effective, but geographically and logistically very limited. Many people do not have the opportunity to travel to us. With the advent of digital tools – especially during the pandemic – we were able to develop our courses further. Zoom suddenly became an everyday tool.

We began to offer regular interactive courses in which cameras and microphones are deliberately left switched on. This enables direct feedback and individual adjustments. Today, we offer nine online training sessions per week. My focus is on language exercises and communication, while Josefa takes on movement training and dual-task exercises. Online formats not only create access – they also promote motivation, structure and social interaction.

You work in North America, the UK and Europe. Have you noticed any regional differences in Parkinson’s care, particularly in terms of exercise and support?

Yes, the differences are clear. The Netherlands has developed an impressive model with “ParkinsonNet”: nationwide care by networked, specialized professionals. There have been similar approaches in Germany, but the structure of the healthcare system makes nationwide implementation difficult. In the USA, something like this usually only works within large hospital groups.

The culture of exercise also varies from region to region. In Colorado, for example, movement is firmly anchored in everyday life – meetings are often held while hiking. In Portugal, this is less pronounced, which means that we have to be creative to get people moving. The important thing is: the path is different, but the goal – an active, independent lifestyle – remains the same.

What role do technology and digital tools play in your work with Parkinson’s patients? How do you see the future of digital applications in Parkinson’s care?

Technology has long been an integral part of my work. It helps us to design training sessions flexibly, document progress and also support diagnostics. I find the voice particularly exciting as a biometric measurement tool. It can provide indications of motor and cognitive changes – an approach that I am working on together with colleagues in research.
Digital tools such as wearables, apps or machine speech analysis enable a much more differentiated picture of the course of the disease. It is important that these technologies are not complicated, but intuitive to use. In this way, they can help to close gaps in care – even in regions with limited access to specialists.

From your experience – how effective are speech therapy exercises via an app, and what should Parkinson’s patients pay attention to?

Apps are a valuable addition to therapy, especially if they are simple, motivating and flexible to use. A good app should provide individual feedback, make progress visible and, ideally, also be a bit of fun. People with Parkinson’s often experience a lack of motivation – an app that is too complex quickly remains unused.

That is why we have placed great emphasis on a user-friendly design in our online courses: The exercises are clearly structured, there is no complicated navigation. It’s easy to get started – which is exactly what many of those affected need. Of course, an app is no substitute for personal contact, but it can help to integrate regular exercises into everyday life.

In your opinion, what are the most common misunderstandings you encounter when dealing with Parkinson’s?

One of the biggest misconceptions is that Parkinson’s is automatically equated with cognitive impairment. Many people see someone with visible motor symptoms and wrongly assume that their mental performance is also severely impaired. Unfortunately, this leads to stigmatization – in everyday life, at work and even in the medical environment. I know many Parkinson’s patients who continue to work in highly qualified jobs, in international companies or with complex technology. These skills don’t suddenly disappear.

In addition, many sufferers struggle with a feeling of isolation. When their voice becomes quieter or their facial expressions diminish, social interaction changes – this is often not sufficiently noticed. It is so important to provide support at an early stage and not just react when the person has already withdrawn.

Parkinson’s also affects the ability to speak and communicate. How do you see the connection between physical and speech therapy in this area?

The connection is central for me. Communication is almost never a purely cognitive task – it is embedded in movement, in everyday actions. We speak while walking, cooking, shopping. In therapy, we therefore often work with so-called dual-task exercises in which speech and movement are trained simultaneously. One example of this is an exercise in using your voice while moving or reacting to visual stimuli.
This combination is both practical and effective. After all, what good is a strong voice in a quiet therapy room if it cannot be called upon in real life? That’s why we attach great importance to embedding the exercises in realistic contexts. After all, language is not detached from life – it is right in the middle of it.

What role does speech therapy play overall in the care of Parkinson’s patients?

Speech therapy is an important component of Parkinson’s care – but is often not sufficiently in focus. Around 90% of Parkinson’s patients develop speech or voice changes during the course of the disease. These have a massive impact on quality of life because they make communication in everyday life, at work and in the family more difficult. Unfortunately, many people only start treatment when the limitations are already very clear.

An early start would be ideal. Even at an early stage, targeted exercises can strengthen the voice, improve articulation and – very importantly – boost self-confidence. After all, people who no longer have the confidence to speak out loud often withdraw. Speech therapy is not only functionally effective here, but also emotionally.

What challenges do you see in the area of motivation? How do you manage to motivate Parkinson’s patients to exercise regularly?

This is a very important question. Many people with Parkinson’s experience a lack of motivation – this is not a question of willpower, but often a direct consequence of the neurobiological changes. A lack of dopamine, but also reduced levels of other neurotransmitters such as serotonin or noradrenaline, have a strong influence on motivation.

This is why the hurdle to exercise must be as low as possible. It’s about creating habits that can be easily integrated into everyday life. Small units, visible progress and positive feedback – all this helps. In our app or our courses, we make sure that success is noticeable after the first session. When someone realizes: “This works!”, motivation comes from within.

What specific exercises or techniques do you recommend for improving voice and communication in Parkinson’s patients?

The LSVT LOUD method is very well researched and has proven itself in many cases. It is based on increasing the volume of speech, which has a positive effect on articulation, vocal strength and body language. We combine these approaches with cognitive elements, for example through reactions to visual or acoustic stimuli.

This results in exercises that not only train the voice, but also the interplay of attention, reaction and speech. The aim is not only to make the voice stronger, but above all to make it suitable for everyday use. After all, a loud, clear voice that also works in conversation with others is crucial for quality of life.

What developments in research give you particular hope, especially with regard to treatment and coping with everyday life?

I find the use of the voice as a biomarker particularly exciting. In research, we are working on using artificial intelligence and machine learning to analyze changes in the voice – and draw conclusions about motor and cognitive symptoms. This can help to detect Parkinson’s earlier and monitor its progression more accurately. So it’s not just about diagnosis, but also about fine-tuning therapy.

Added to this are wearables that record movement patterns and the analysis of video data – so-called machine vision methods. Together, these technologies provide a multi-layered picture of a person’s state of health. This also makes it easier to understand individual reactions to medication or exercise. The resulting opportunities are enormous – especially for personalized, flexible care.

How do you see the future of Parkinson’s care in the digital age, particularly with regard to platforms and virtual services?

I am convinced that digital care will play a decisive role. Virtual services are already giving many people access to specialized therapy – even in rural regions or countries with limited care. That is a huge step forward.

At the same time, digital platforms offer the opportunity to customize therapy content. For example, anyone who can only exercise at certain times of the day needs a service that can be flexibly integrated into their daily routine. Online offers also promote networking – many of our participants feel part of a community. This not only boosts motivation, but also emotional well-being.

What do you personally find most rewarding about working with Parkinson’s patients?

I consider it a great privilege to be able to work with this group of patients. Many of them show enormous commitment – they want to stay active, shape things and give something back. That impresses me time and time again. They are often people who have been curious, willing to learn and responsible all their lives – and who remain so even with the diagnosis.

What makes me particularly happy is that we often see progress quickly in speech therapy. When someone hears better, speaks more clearly or feels more confident after just a few sessions, that’s the best feedback for me. This direct effect, combined with long-term support, is what makes my work so special.

How do you implement a holistic approach in your work – both physically and mentally?

Our work is based on an interdisciplinary approach. Speech therapy, exercise, motivation and psychosocial support are intertwined. My wife Josefa is an expert in movement therapy for Parkinson’s – together we design courses that combine physical and speech exercises. We make sure that it remains varied and relevant to everyday life.

The emotional component also plays an important role. Many Parkinson’s patients experience uncertainty, anxiety or withdrawal. That’s why it’s important for us to create a positive, supportive atmosphere – both in therapy and in the digital space. Because people who feel comfortable are also more open to change.

What advice would you give to speech therapists who want to work more intensively with Parkinson’s patients?

First: familiarize yourself with the basics of the disease – neurological, functional and psychosocial. Then I recommend networking across disciplines. The International Parkinson and Movement Disorder Society (MDS) offers excellent training and access to the latest research findings. I myself lead the Allied Health Professionals group there, in which therapists from all over the world work together.

Practice is also important: seek contact with experienced colleagues, visit them, exchange ideas. And above all – listen carefully to your patients. After all, they are the ones who know best what really helps in everyday life.

You are Chair of the Allied Health Professionals Special Interest Group and Co-Chair of the Web Editorial Board of the International Parkinson and Movement Disorder Society. What are the goals and priorities of these organizations?

The MDS was founded to promote knowledge about movement disorders such as Parkinson’s worldwide. Our focus is on research, training and networking of professionals. What has changed in recent years: We are increasingly including the perspectives of patients and relatives. This is an important step towards making care truly patient-centered.

Another focus is our collaboration with start-ups that develop digital or technical solutions. Many of these innovations emerge directly from the Parkinson’s community – and we see it as our task to offer them a platform. In the long term, we want to create a global network that combines expertise, research and practical support – and thus make a real difference to people’s lives.

Thank you very much for the interview and all the best for the future!