Ask the Expert: Michael S. Okun, M.D.

People have trouble hearing me when I speak. Is this common? What can I do to make this better? I've tried singing, or just talking louder, but nothing seems to work.

One of the most common symptoms of Parkinson's is hypophonia, a type of dystonia. This can result in very soft speech. The interesting thing is that the person perceives that he or she is speaking at a normal volume. A type of speech therapy called the LSVT LOUD program can be effective in training you to speak louder. A few sessions with a speech-language pathologist may also be useful - talk to your doctor about a referral.

Are there exercises I can do to help with balance problems?

Balance problems are very difficult to address. Physical therapy and medications can sometimes help, but as the disease progresses, balance issues usually get worse. You need to remain vigilant about how your condition is changing, and may need to use assistive devices such as a walker to prevent falls.

I've heard that Botox injections can help with my dystonia. Should I give them a try?

Medications can often help with dystonia, and botulinum toxin (commonly called Botox) can be very useful as well. It can improve toe-curling, and when injected in the neck can help with cervical dystonia and also reduce the pain caused by unusual posture and muscle tightness. It also can be helpful for excessive drooling - though you need to be careful not to let your mouth get too dry, because that can result in cavities.

My handwriting has changed because of my tremors, and I'm worried that my bank won't accept my signature as legal. Do you have a suggestion for me?

Many Parkinson's patients have what's called micrographia - their handwriting gets smaller and smaller as time goes on. Signatures often trail off or become illegible. You can see this, for example, in the autograph of Muhammad Ali, who suffered from Parkinson's. Occupational therapy can be helpful in learning to write larger. Also, you might go to your bank and explain that you have Parkinson's. They have several ways, other than handwriting, to accept official signatures.

It seems to me that my symptoms are worse when I'm under stress. I've tried anti-anxiety medications and talk therapy, but they haven't solved the problem. Can you suggest anything else?

Anxiety, stress, and sleep deprivation all can make Parkinson's worse. Talk to your doctor if you are not sleeping well; you may have an underlying sleep disorder that should be addressed. As for anxiety and stress, I tell my patients to live a life of Zen: Do your best to avoid people and experiences that make you feel anxious or stressed.

Michael S. Okun, M.D.
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Michael S. Okun, M.D.

Michael S. Okun, M.D. is professor and chair of neurology at the Fixel Center for Neurological Diseases at the University of Florida, and the national medical director for the Parkinson's Foundation.