Specialist article on Parkinson’s
Parkinson’s and the basic functionsSwallowing, speaking, head balance
When it comes to Parkinson’s, many people first think of shaking hands. In everyday life, other things are often more of a burden: choking, saliva at the corner of the mouth, a quieter voice, a head that sinks forward. Here you can find out what studies show about this and why we see breathing, swallowing and head balance as trainable functions, without treating the disease itself.
Does this sound familiar?
Parkinson’s is more than tremor, everyday life shows it when eating and speaking
What applies to you or your relative?
Tap whatever applies to you.
If several points apply, raise them at your next neurological check-up, because swallowing problems in Parkinson’s often go unmentioned. The disease is treated by medicine. In our view, the functions behind it can also be practised in addition.
Where the saliva at the corner of the mouth comes fromWhat has been tested and what has notThe key points at a glance
- Parkinson’s does not only change gait and hands. Swallowing, voice and head balance are also affected in many people with the condition.
- The disease is treated by medicine. In our view, breathing, swallowing and head balance can be practised in addition, ideally already in the early stage, as a supporting lever, not as a remedy for Parkinson’s.
- There is no study on FaceFormer therapy in Parkinson’s. However, independent studies on other forms of training show that swallowing and speech functions in Parkinson’s can respond to training.
Video
Swallowing: why the swallowing pattern matters
Das Video lädt erst nach dem Klick. Dann werden Daten an YouTube (Google) übertragen.
The disease
Parkinson’s is more than tremor
Parkinson’s is known for trembling hands. What is decisive in everyday life, however, is often functions that hardly anyone talks about.
In Parkinson’s disease, also known as Morbus Parkinson, nerve cells in the brain that produce the messenger substance dopamine gradually die off. Why this happens has still not been clarified. The dopamine deficiency changes the control of movements in deep-lying brain regions, the basal ganglia. This affects not only the arms and legs, but many movements that the body calls up automatically.
Rigidity
Increased muscle tension; the muscles feel stiff
Bradykinesia
Slowed movements that become smaller over time
Tremor
Trembling, typically at rest
Postural instability
Unsteady balance and a stooped posture
These also include breathing, swallowing and balancing the head. We swallow many hundreds to a thousand times a day, and breathe far more often. If these sequences become slower and smaller, you notice it when eating, when speaking and in your posture. These functions are what this is about.
Diagnosis and treatment of Parkinson’s disease belong in the hands of a neurologist. Never change prescribed medication, speech therapy or physiotherapy on your own initiative. The training addresses the functions, not the disease.
Swallowing
Swallowing disorders in Parkinson’s: common and often unnoticed
Choking seems like a minor matter. In Parkinson’s, it is one of the most common changes, and yet it is often missing from the conversation with the practice.
Specialists call a swallowing disorder dysphagia. A research group from Nijmegen in the Netherlands compiled how often it occurs in Parkinson’s. It analysed twelve studies and distinguished between two approaches: what those affected report themselves, and what examinations of the act of swallowing measure1.
of people with Parkinson’s reported swallowing difficulties themselves, pooled from ten studies1
showed a swallowing disorder when the act of swallowing was measured, pooled from four studies1
higher was the risk of a swallowing disorder than in people of the same age without Parkinson’s1
The gap between the first two figures is the real message. Many do not notice the change or do not mention it, so the authors advise asking about it specifically. The swallowing sequence is described in detail in the article Swallowing and swallowing disorders.
Unnoticed does not mean harmless. If saliva or food gets into the airways, pneumonia can result, and people with Parkinson’s are among those particularly at risk12. That is why swallowing should be looked at early, even before it becomes noticeable in everyday life, and in our view also practised.
When you swallow, the muscles of the floor of the mouth pull the hyoid bone, and with it the larynx, upwards and forwards. The epiglottis folds over the entrance to the windpipe, and the food passage opens. This happens in fractions of a second and has to be timed precisely.
If this movement becomes slower or smaller, the airway stays open a moment too long, and liquid more easily gets to the wrong place. This shows up as coughing, but sometimes not at all.
Saliva
Saliva at the corner of the mouth: a question of swallowing
Many people with the condition have the impression that they produce too much saliva. The measurements show something different.
Loss of saliva from the mouth, technically sialorrhoea, is common in Parkinson’s and distressing for many. The obvious assumption would be that the body produces too much saliva. Three investigations point to a different explanation.
of people with Parkinson’s reported loss of saliva in eight studies, compared with 14 % of healthy people2
was produced by 44 people with Parkinson’s compared with 44 people of the same age without Parkinson’s4
people with loss of saliva showed changes in the oral phase of swallowing on X-ray video3
So saliva collects because it is swallowed less often and less effectively. A British investigation of 18 people with the condition also showed how much swallowing depends on attention. When they solved a distracting language task on a computer at the same time, they swallowed less often, and saliva ran out more frequently. As further factors, the authors name an unintentionally open mouth and a forward-bent posture5.
Swallowing becomes less frequent
The automatic control works more slowly, especially when attention is elsewhere.
Saliva collects
It stays in the mouth instead of being swallowed regularly.
The mouth is open
The lips no longer close by themselves, and the mouth is no longer sealed.
The head sinks forward
With the stooped posture, saliva flows forward, following gravity.
Saliva runs out
In our view, all three basic functions come together here: swallowing, lip closure with nasal breathing, and head balance.
The mouth is sealed when the lips are loosely closed, the back teeth briefly touch when swallowing, and the tongue rises from the tongue reference position to the palate. If, on the other hand, the lower jaw drops, the swallow lacks its starting point.
That some people also complain of a dry mouth is not a contradiction, because an open mouth dries out; see dry mouth.
Voice and speech
Quiet voice, unclear pronunciation
Often others notice it first. The voice becomes quieter and more monotonous, and people ask you to repeat yourself more often on the phone.
In Australia, the speech of 200 people with Parkinson’s was assessed. The voice itself, i.e. loudness and sound quality, was affected most often and earliest. Pronunciation and fluency of speech changed later and were predominant in the most severe stage6. The technical term for this is hypokinetic dysarthria, a speech disorder caused by movements that are too small.
The voice comes from the breath.The vocal folds vibrate in the airflow of exhalation. How loud and resonant the voice is therefore also depends on breathing and on the upright alignment of the head and trunk.
That the voice can be trained in Parkinson’s is well researched. In a randomised study from the USA, people with the condition practised loud speech intensively for one month according to the LSVT LOUD programme. Their loudness increased more than in a group with articulation training and in a group without training, and this was still the case seven months later. According to the study, up to 89 % of people with Parkinson’s develop a speech disorder7.
Voice and speech therapy by speech and language therapists is an established treatment in Parkinson’s. Training the basic functions does not replace it; it addresses breathing and head balance, on which the voice builds.
Head balance
When the head sinks forward: posture and swallowing
The stooped posture is one of the well-known signs of the disease. Less well known is that the position of the head changes the swallowing passage from within.
The head, neck and throat form a unit. If the head tilts forward, the larynx moves under the base of the tongue, and the entrance to the airway becomes narrower. If the head is tilted back, it opens wider. The external alignment therefore changes the internal geometry of the swallowing passage.
The head does not balance on its own; it rests on the trunk. If the trunk slumps, the head moves forward with it. If it balances upright over the pelvis, in our view the jaw, hyoid bone and larynx are in their most favourable position, and the diaphragm and ribcage have room for breathing.
If, on the other hand, the head sinks forward, the neck muscles perform compensatory work; see neck and back. How the diaphragm and pelvic floor work together in breathing is shown in the article Pelvic floor training.
How strong the effect of head position is was examined in a large US study of 711 people with dementia or Parkinson’s who choked on thin liquids. Under X-ray monitoring, all of them tried three aids: tilting the chin to the chest, and drinks thickened to a nectar-like or honey-like consistency. Honey-like thickened drinks most often prevented choking, followed by nectar and the chin posture. The participants liked the chin posture best8.
According to the authors, only a swallowing examination can show which aid offers the best protection in an individual case. For us, there is something else in this. A consciously adopted head position changes the swallowing passage for the moment, but does not replace swallowing motor function that works by itself.
Try it with your saliva, not with water. In which posture is it easiest to swallow?
The triad
Breathing, swallowing and head balance: a shared rhythm
Swallowing disorders, a quiet voice and a stooped posture are often looked at separately by different specialities. In our view, they are connected.
Breathing and swallowing share the throat and therefore have to coordinate their timing, because breathing briefly stops during swallowing. In healthy adults, the swallow followed the pattern exhale, swallow, exhale in 62 % of cases9. The control for this lies in the brainstem, where the vagus nerve, which also supplies the throat and larynx, originates.
Breathing
Provides the airflow for the voice and the rhythm into which the swallows fit. In Parkinson’s, in our view, breathing coordination changes, and with it the scope for swallowing.
Swallowing
Many hundreds to a thousand times a day. It clears saliva, protects the airways and needs a sealed mouth with the tongue against the palate.
Head balance
Determines how the jaw, hyoid bone and larynx are positioned relative to each other. If the head sinks, the swallowing passage, lip closure and voice change at the same time.
A disturbance is never local.Breathing, swallowing and head balance run on shared circuits in the brainstem. If one function changes, the others change with it.
This does not imply a promise, but it does give a direction. The brain does not automate individual parts, but whole sequences. That is why we practise breathing, swallowing and head balance in the same sequence, just as the body needs them in everyday life.
Explanatory model
Function instead of symptom: where the training comes in
The training does not treat Parkinson’s disease. It addresses the functions through which the disease makes itself felt in everyday life.
The disease
- Nerve cells that produce dopamine die off
- Diagnosis and monitoring of progression in neurology
- Treatment with medication and other medical procedures
- Speech therapy and physiotherapy as prescribed
The basic functions
- Breathing, swallowing and head balance as the basic sequences of everyday life
- Become slower and smaller in Parkinson’s
- Can be practised in the same sequence several times a day
- Are to a large extent in your own hands
The two sides do not replace each other. In our view, the training is a supporting adjusting screw alongside medical treatment, not a remedy for the disease. How it works is described in How does FaceFormer therapy work?, and how it fits alongside other approaches in FaceFormer and other treatments.
Our explanatory model is simple. Muscles that are not involved in their function are used less and lose tension. In Parkinson’s, there is the additional factor that the control system executes movements smaller and more slowly. In our view, the two processes reinforce each other. If you swallow, speak and straighten up less often and less fully, you give the body less reason to maintain these sequences with vigour.
Like an instrument that is played
An instrument goes out of tune if it is not played for a long time. The strings are still there, but the sound and the fingering are lost. Regular playing keeps it in tune. That is how we see the basic functions. The training takes nothing away from the disease; in our view, it helps ensure that existing capabilities are used.
Especially in the early stage, as long as swallowing, voice and posture are still working well, in our view it is worth starting to practise and keeping these sequences large and precise. This does not replace any treatment; it makes use of the scope that the body still has. It does not promise any particular course. Stage, course and daily condition set the framework, and what changes in one person says something about that person, not about the disease.
Nose and smell
Smell and nasal breathing: an open question
One sign of Parkinson’s disease often appears years before the movement disorders: a declining sense of smell.
A study led by the University of Dresden tested the sense of smell of 400 people with Parkinson’s in Germany, the Netherlands and Australia. Only 3.3 % had a normal sense of smell. Compared with young healthy people, 96.7 % had a marked loss of smell; compared with people of the same age, 74.5 %. The authors see this as a reliable feature of the disease10.
Nasal breathing
- With every breath, odorants reach the olfactory mucosa in the upper nasal cavity
- The signals travel a short route to the brain
- The olfactory pathway receives a constant stimulus, many thousands of times a day
Mouth breathing
- The airflow takes the route through the mouth
- Hardly any air flows over the olfactory mucosa
- The constant scent stimulus is largely absent
Smelling requires nasal breathing. How the nose directs the airflow is described in the article Deviated nasal septum.
The book “Trust the Triad” raises a question about this. If loss of smell is an early sign, could, conversely, an olfactory pathway that has been little used for years be involved in the development of the disease? Nerve connections that are rarely used become weaker. However, such a connection with Parkinson’s has not been demonstrated.
Protection against Parkinson’s cannot be inferred from nasal breathing. We mention the question because it suggests itself, not because it has been answered.
Research
What has been tested and what has not
There is no study on FaceFormer therapy in Parkinson’s. There are, however, independent studies showing that swallowing and speech functions in Parkinson’s can be influenced by training.
The most important one on swallowing comes from Florida. 60 people with Parkinson’s practised for four weeks, on five days a week for 20 minutes each, breathing out forcefully against the resistance of a handheld device. The comparison group practised blinded with a sham device. Only in the training group did swallowing safety improve on X-ray video, and the hyoid bone and larynx moved better11.
Tested
Targeted expiratory and voice training measurably improves swallowing safety and loudness in Parkinson’s, as shown in randomised studies with a comparison group.
Not tested
Whether FaceFormer training changes swallowing, voice or posture in Parkinson’s. There is no investigation on this.
What exists on the FaceFormer
A randomised study in children, a peer-reviewed paper with a comparison group on jaw complaints, plus pilot observations; see Studies and science.
The absence of an investigation does not mean that the connection does not exist. It means that it has not been tested.The studies on expiratory and voice training do not examine the FaceFormer. They show that functions in Parkinson’s can respond to training.
For voice and exhalation, there are well-studied exercise programmes for Parkinson’s. In our experience, exercises that address the lips, tongue, palate and throat in the interplay of breathing and swallowing are rare. FaceFormer training addresses this interplay and can be built into the day in a few short sessions.
The training could only be tested fairly under three conditions. It must be performed correctly, it needs intermediate goals such as the swallowing sequence and lip closure before the symptom, and it needs several months. We would support an independent investigation in Parkinson’s, without influence on its conduct and analysis.
Safety
Limits and consultation
Parkinson’s progresses differently in every person. That is why clear limits apply to the training.
Advanced Parkinson’s
In degenerative neuromuscular diseases at an advanced stage, only start the training after medical consultation.
Known swallowing disorder
If you choke frequently, have had pneumonia or are losing weight unintentionally, have your swallowing examined first, for example in a swallowing assessment by a speech and language therapist or a doctor.
Prescriptions stay
Never change or stop medication, speech therapy or physiotherapy on your own initiative. The training can be combined with them.
Acute complaints
In the case of acute inflammation in the mouth, throat or airways, a completely blocked nose or recent surgery in the mouth, take a break.
Choking while practising
If you cough during training or saliva remains in your throat, stop the session and practise with fewer repetitions next time.
Typical feedback at the start includes muscle fatigue, pressure on the teeth or irritated mucous membranes. In that case, take a short break and continue with fewer repetitions.
Training
What the training can look like
You practise sitting down, in short sessions and with a sequence that combines breathing, swallowing and head balance.
In FaceFormer training, the FaceFormer sits in the oral vestibule, behind the lips and in front of the teeth. You sit upright, your head balanced over your body, the tip of your tongue resting on the small ridge behind the upper front teeth, and you breathe through your nose. In the basic exercise, you press the lip wedge together with your lips, bite down briefly with your back teeth and swallow once.
From around week 3, the pull exercise is added. You press the lip wedge while gently pulling it forward with your thumb and index finger, bite down briefly and swallow. The lips, tongue, floor of the mouth and upright head balance work together in this exercise.
In Parkinson’s, in our view, regularity counts more than strength, i.e. short sessions several times a day, ideally at a good time of day for you.
- From day 1
Basic exercise with the ZERO
Three times a day for a few minutes with the FaceFormer ZERO made of softer material. Adjust the number of repetitions to how you are feeling on the day.
- From around week 3
Pull exercise
The pull exercise is added, sitting upright. Relatives can help with counting.
- Later
Breathing and head balance
The breathing exercise and the head balance rotation link the training with nasal breathing and head balance, ideally in consultation with a practice.
- Over months
Keeping at it
The exercise manual expects six to twelve months until new sequences run by themselves. Parkinson’s changes over time, which is why, in our view, practising is an ongoing task here.
- After
Maintenance training
After the build-up phase, a short maintenance training that you keep up is enough. You have to keep at it, and it can be worth it.
Eat and drink sitting upright
Sit upright to eat, with your head balanced over your body. Take small sips and bites, without talking at the same time.
Swallow consciously
When distracted, the body swallows less often. A brief thought about lip closure and swallowing, for example while watching TV or reading, can help to clear saliva.
Lips closed, nose open
At rest, the lips lie loosely together and the tongue rests against the palate. This keeps the mouth sealed.
Speak upright
Speak sitting or standing with your head upright. This gives your voice more breath.
With a practice or on your own
The free FaceFormer app guides you through the basic exercises, and all modules are on the exercise pages. If you train with a practice, you can find addresses in the practitioner directory.
Questions
Frequently asked
Can swallowing be trained in Parkinson’s?
Swallowing functions respond to training in Parkinson’s, as independent studies show, for example on expiratory muscle training. FaceFormer training practises swallowing together with breathing and head balance, but it has not been investigated for Parkinson’s. If you have a known swallowing disorder, have a doctor clarify whether you can start beforehand.
Where does the increased saliva flow in Parkinson’s come from?
As a rule, not from too much saliva; people with Parkinson’s tend to produce less. The saliva is swallowed less often, the mouth is open more often, and the head tilts forward. In our view, swallowing, lip closure and head balance all come together here.
Why does the voice become quieter in Parkinson’s?
The movements with which breathing and the vocal folds produce the voice become smaller. The voice is often the first thing about speaking to change. In a randomised study, intensive voice training according to LSVT LOUD improved loudness over months.
Does the FaceFormer help against Parkinson’s?
No. The training does not treat the disease. It practises breathing, swallowing and head balance, i.e. functions that are also affected in Parkinson’s. How this affects an individual case cannot be predicted, and there is no study on the FaceFormer in Parkinson’s.
May I train with advanced Parkinson’s?
Only after medical consultation. In degenerative neuromuscular diseases at an advanced stage, the training is not indicated without further ado. Together with your practice, you clarify whether and to what extent you practise.
Which FaceFormer do I start with?
With the FaceFormer ZERO. It is exactly the same size and shape as the ONE, just made of softer material. If inserting it is difficult because of tremor or stiffness, relatives can help.
More articles from the knowledge section
Where to go next
Sources
- Kalf JG, de Swart BJ, Bloem BR, Munneke M (2012). Prevalence of oropharyngeal dysphagia in Parkinson’s disease: a meta-analysis. Parkinsonism and Related Disorders 18(4):311-315. PMID 22137459. Source
- Kalf JG, de Swart BJ, Borm GF, Bloem BR, Munneke M (2009). Prevalence and definition of drooling in Parkinson’s disease: a systematic review. Journal of Neurology 256(9):1391-1396. PMID 19288042. Source
- Nóbrega AC, Rodrigues B, Torres AC, Scarpel RD, Neves CA, Melo A (2008). Is drooling secondary to a swallowing disorder in patients with Parkinson’s disease? Parkinsonism and Related Disorders 14(3):243-245. PMID 17892967. Source
- Proulx M, de Courval FP, Wiseman MA, Panisset M (2005). Salivary production in Parkinson’s disease. Movement Disorders 20(2):204-207. PMID 15389996. Source
- Reynolds H, Miller N, Walker R (2018). Drooling in Parkinson’s Disease: Evidence of a Role for Divided Attention. Dysphagia 33(6):809-817. PMID 29785679. Source
- Ho AK, Iansek R, Marigliani C, Bradshaw JL, Gates S (1998). Speech impairment in a large sample of patients with Parkinson’s disease. Behavioural Neurology 11(3):131-137. PMID 11568413. Source
- Ramig L, Halpern A, Spielman J, Fox C, Freeman K (2018). Speech treatment in Parkinson’s disease: Randomized controlled trial (RCT). Movement Disorders 33(11):1777-1791. PMID 30264896. Source
- Logemann JA, Gensler G, Robbins J et al. (2008). A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson’s disease. Journal of Speech, Language, and Hearing Research 51(1):173-183. PMID 18230864. Source
- Hiss SG, Treole K, Stuart A (2001). Effects of age, gender, bolus volume, and trial on swallowing apnea duration and swallow/respiratory phase relationships of normal adults. Dysphagia 16(2):128-135. PMID 11305223. Source
- Haehner A, Boesveldt S, Berendse HW et al. (2009). Prevalence of smell loss in Parkinson’s disease: a multicenter study. Parkinsonism and Related Disorders 15(7):490-494. PMID 19138875. Source
- Troche MS, Okun MS, Rosenbek JC et al. (2010). Aspiration and swallowing in Parkinson disease and rehabilitation with EMST: a randomized trial. Neurology 75(21):1912-1919. PMID 21098406. Source
- Hoecker RN, Schweiger J, Prunier J, Dua A (2026). Aspiration Risk. In: StatPearls. Treasure Island (FL): StatPearls Publishing. PMID 29262188. Source
Get started
Ready for the training?
The free FaceFormer app guides you through the basic exercises, counts along and reminds you of your sessions. If you wish, a practice from the practitioner directory can support you.
FaceFormer ZERO + ONE
Both material hardnesses for getting started, day and night. The set for adults.
FaceFormer ZERO
The softer FaceFormer for getting started, for children and for the night.
FaceFormer ZERO Children’s Set
ZERO with hygiene box, plush bag and success book with stamp.
FaceFormer training aims to restore the physiological setting of the basic functions of breathing, swallowing and head balance, with lip closure and the tongue reference position, thereby creating the conditions under which symptoms can improve. It does not replace a medical assessment. You can find practitioners near you in the practitioner directory.
