LSVT LOUD Professional Webinar...

LSVT LOUD® Professional Webinar Series

Title: LSVT LOUD in Pediatric Motor Speech Disorders

Presenters: Cynthia Fox, PhD, CCC-SLP

Carol Boliek, PhD

Date Presented: May 16, 2018

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5/16/2018

Copyright© LSVT Global, Inc. 2018 1

LSVT LOUD in Pediatric Motor Speech Disorders

Cynthia Fox, PhD, CCC-SLPNational Center for Voice and Speech

LSVT Global, Inc.

Carol Boliek, PhDDepartment of Communication Sciences and Disorders

University of Alberta

Plan for Webinar

Logistics-Handout attached in webinar menu

Discuss pediatric application of LSVT LOUD

We encourage your participation and questions

Complete survey at the end of the webinar (5 minutes or less to complete)

Information to Self-Report Activity

• This LSVT Global webinar is NOT ASHA or state registeredfor CEUs, but it may be used for self-reported CEUcredit as a non-registered CEU activity.

• If you are a speech, physical or occupational therapy professional and would like to self-report your activity, e-mail [email protected] to request a certificate aftercompletion of the webinar which will include your name,date and duration of the webinar.

• Licensing requirements for CEUs differ by state. Check withyour state licensing board to determine if your state acceptsnon-ASHA registered CEU activities.

• Attendance for the full hour is required to earn a certificate.

Instructor Biographies

Cynthia Fox, Ph.D, CCC-SLPDr. Fox is a research associate at the National Center for Voice and Speech and Co-Founder of LSVT Global. She is an expert on rehabilitation and neuroplasticity and the role of exercise in the improvement of function consequent to neural injury and disease. Dr. Fox is among the world’s experts in speech treatment for people with Parkinson disease. She has multiple publications in this area of focus, as well as numerous national and international research and clinical presentations. Dr. Fox pioneered the application of LSVT LOUD pediatric populations.

Carol Boliek, PhDDr. Boliek, is a professor in the Department of Communication Sciences and Disorders, University of Alberta. She has investigated breathing and vocalization in infants and young children who are typically developing and those with motor speech disorders. She is currently examining activity-dependent neuroplasticity and speech motor control in children with and without neurogenic communication disorders. Dr. Boliek is also evaluating the effects of non-invasive neuro-stimulation on speech motor control.

Disclosures

All of the LSVT LOUD faculty have both financial and non-financial relationships with LSVT Global.

Non-financial relationships include a preference for the LSVT LOUD as a treatment technique.

Financial Relationships include:

Dr. Fox is an employee and Co-Founder of LSVT Global, Inc. She receives honorarium and has financial interest in the company.

Dr. Boliek receives honorarium and travel reimbursement from LSVT Global, Inc.

This work was funded by :• The Cerebral Palsy International Research

Foundation

• LSVT Global, Inc.

• The Stollery Children’s Hospital Foundation

• The Edmonton Oilers Community Foundation

• The National Institutes of Health RO1 DC01150

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Presentation Objectives• Present the rationale for intensive voice therapy

in children who have motor speech disorders secondary to cerebral palsy and Down syndrome

• Discuss Phase I research: discovery and findings

• Present the LSVT LOUD treatment protocol with audio examples

• Explain Phase II research: discovery and findings

Polling Question

• Who is in our audience today?– LSVT LOUD Certified Clinicians– Speech-language pathologists (not LSVT

LOUD)– Allied Health (PT/OT/Nursing)– Family member of child with speech disorder– Physician– Other

Communication is Important

• Want to be socially accepted so their first choice is to use oral communication

• Continue to communicate orally in the absence of success

• Extremely frustrated when peers or adults fail to wait to understand the message and simply walk away

Common communication themes from child and parent interviews:

There is a great need!

Parkinson’s Treatment to CP?

What if?

Case StudyAge: 3 year, 11 months old male

Diagnosis: Cerebral Palsy

Type: Dyskinetic

Physical involvement: All four limbs

Cognition: Normal, delayed language development

Pre-treatment Voice and Speech Characteristics

• Throaty and strained talking• Limited respiratory support• Breathy sometimes

• Variability in vocal loudness• Severely reduced intelligibility• Strained/breathy vocal quality

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Pre-treatment: “I don’t know”

0 2739

Post-treatment: “I don’t know”

0 2538

Post-treatment voice and speech changes

• Improved stability of phonation• Increased frequency of voice/speaking• Not so breathy, not so strangled• “He understands using his voice and what

that means”• Increased confidence with speaking

Motivation Rationale

Next Step?

Target of Treatment: Voice

Why?

Perceptual characteristics of voice and speech in children with CP and children with DS

• Consistent hypernasality• Breathy voice quality• Voice quality changes• Monotone• Uncontrolled rate and rhythm of voice• Imprecise articulation

Clement & Twitchell, 1959; Heltman & Peacher, 1943; Hixon & Hardy, 1964; Keesee, 1976; Kent & Vorperian, 2013; Kumin, 1994; Mahler & Jones, 2012; Roberts, Price, and Malkin, 2007; Solomon & Charron, 1998; Venail, Gardiner, and Momdain, 2004; Wolf, 1950; Workinger & Kent, 1994

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Voice may be a good“POINT of ENTRY” -Boliek

Establish a PHONATION foundation through respiratory/phonatory training

Strand, 1995

Training target of Voice MODE of Treatment: Intensive and High Effort

Why?

Treatment-dependent Neuroplasticity occurs in Pediatric Context When:

• Intensive task repetitions• Progressive challenges to the learner with

increasing difficulty• Presence of motivators and rewards (internally

driven) • Active participation • Skill acquisition of a functional goal• Practice must be structured

Schertz & Gordon, 2008

CP

• Benefit from treatment programs with intensive frameworks

• Number of sessions matter

• Specificity of training matters

• Increasing task difficulty matters

DS

• Benefit from treatments occurring more than once per week

• Can handle intensive and physically difficult interventions

Efficacious Approaches to Overall Rehabilitation in Pediatrics: Evidence from Physical Therapy

Deitz-Curry, 2001; Garvey, Giannetti, Alter, & Lum, 2007; Lewis & Fragala-Pinkham, 2005; Mahoney, Robinson, & Perales, 2004; Pisani, Centonze, Bernardi, & Calabresi, 2005; Schertz and Gordon, 2008

Traditional Approaches to Speech Treatment for Children with Motor Speech Disorders

• Systems approach to address multiple targets versus singular target: • respiration • phonation• articulation • resonance

• Low to moderate intensity, low repetitions of tasks, limited focus on effort

• Limited efficacy dataDeitz-Curry, 2001; Pennington et al., 2009

What about in speech treatment? Best Practices for Pediatric Motor Speech Disorders

The majority of speech-language pathologists specializing in pediatric motor speech disorders agree that ---

intensive motor speech treatment, regardless of subsystem(s) targeted, is the preferable mode of delivery

Hodge & Wellman, 1999; Love, 1992; Pennington et al., 2010; Strand, 1995; Yorkston et al., 1999

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Why LSVT LOUD?

LSVT LOUDEstablished Treatment Approach

???Develop New

Treatment Approach

25+ year journey from invention to scale-up1987-89: Initial invention; Pilot data (Lee Silverman Center)1989-91: Treatment development OE-NIDRR

1991-94: Treatment follow-up OE-NIDRR1990-95: Treatment Efficacy NIH R01 RCT1995-00: Underlying Mechanism NIH R01 RCT 2002-07: Distributed effects NIH R01 2007-12: Target/mode NIH R01 RCT

2001-02: PDA; LSVTC Coleman Institute 2002-04: LSVTC NIH & MJ FOX Foundation NIH R212002-04: LSVTVT Coleman Institute 2004-06: LSVTVT NIH R212004: LSVT Down Syndrome Coleman Institute2006: Technology Enhanced Clinician Training NIH SBIR2009: Telehealth Delivery of Software Enhanced LSVT NIH SBIR2010: Independent Delivery of Software Enhanced LSVT NIH

SBIR

Alternative delivery, new populations, implement ‘real world’ clinical practice

Phas

e I,

IIPh

ase

IIIPh

ase

IV, V

Pediatric Work Began

LOUD

Loudness Target: Source and Trigger of Distributed Effects

Single treatment target with limited cognitive load encourages distributed effects to optimize speech production

Healthy Vocal Loudness

SOFT

Treatment delivered 4 consecutive days a week for 4 weeks

Individual 1 hour sessions ( repetitions)

Daily homework practice(all 30 days of the month)

Daily carryover exercises (all 30 days of the month)

Develop a life-long habit of practice

Training mode of LSVT LOUD:

Mode is consistent with principles that drive activity-dependent neuroplasticity

Focus on Function in LSVT LOUD

Goal: Child automatically uses improved voice in daily living and the improved voice lasts over time.

SaliencyFunctional

Phrases

Progressive

Hierarchy

Carryover

Exercises

Calibration

Trial• To detect the presence of a therapeutic effect

Phase I : DiscoveryDetect presence of therapeutic effect; population, protocol, dosage;Single case designs, small groups, no controls, no comparative treatment, no blinding(Robey & Schultz, 1998; Robey, 2004)

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• Single subject• Multiple baselineDesignDesign

• Speech acoustics• Listener Perceptions• Parent Ratings

MeasuresMeasures

• 5 children with spastic CP and dysarthria

• Ages 5 – 7 yearsParticipantsParticipants

Listener Perception

1 2 3 4 5

Male7 yrs,

10 mosModerate

Female5 yrs,

10 mosMild-

moderate

Male6 yrs, 1 mos

Moderate

Male7 yrs,7 mos

Moderate-severe

Female6 yrs,7 mos

(Un Tx)Mild

Participant Patterns in Results

• Greatest improvements in maximum performance tasks

• Strong listener preference for treated speechsamples

• Favorable ratings from parents of treatment approach

Fox, C.M., & Boliek, C.A. (2012). Intensive voice treatment (LSVT LOUD) for children with spastic cerebral palsy and dysarthria. Journal of Speech Language Hearing Research, 55, 930-945.

Therapeutic Effect

Do listeners prefer treated speech samplesover baseline speech samples of

children with CP?

Yes

Next Step: Phase II Small Group design, but before we go there….

A different way of doing therapy

• Can you really get a kid to do an hour session?

• No way we can do four days a week!• Can kids with CP give that much effort?• Loudness will cause vocal hyperfunction.

Minimum Repetitions and Time Spent on Treatment Exercises in LSVT LOUD

Task Total Minimum Repetitions in one month

Total Minimum Repetitions in one month

Long Ah 504 repetitions

High ah 504 repetitions

Low Ah 504 repetitions

Functional phrases 1680 repetitionsStructured reading 440 minutesConversational speech 440 minutes

All tasks increase in complexity and difficulty across the 4 weeks of treatment

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Daily Exercise #1 Long “ah”

• Train respiratory/laryngeal coordination• Improve vocal fold adduction, loudness

with good quality, and duration of phonation

• Stepping stone for good loud voice into conversation

“Ah” is a tool to facilitate improved loudness, not the end goal of therapy

Treatment Goal:louder voice in conversation

Treatment Exercise: “ah”

Daily Exercise #2High/Low “ah”

• Improve range of motion in laryngeal muscles (e.g., cricothyroid)

• Improve control of intonation

• Modulate loudness/control of loudness

Daily Exercise #3Functional Phrases

• Child generates 10 phrases/sentences used every day in his/her life

– “Can I have the IPad”– “I gotta pee”– “I need help”

• Overlearn these key phrases child says everyday in life

• Cues/reminds them to use louder/stronger voice

Gradually Increase Complexity and Endurance

Week 1: Words/phrases

Week 2: Sentences

Week 3: Paragraphs

Week 4: Conversation

Mystery books

Choose topics of interest to child

Video Example of LSVT LOUD Treatment

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Family School Social Activities

Calibration requires individualization“Real-World” Long-term Goals – Child Driven!

• Improving voice for school activities • Being understood at home• Being understood on the telephone • Communicate with teachers or aides at school• Confidence to initiate and participate in conversations at

home and school

Explain Phase II research: discovery and findings

Phase IIDefine and refine protocol, outcomes, valid and reliable measurementsSmall groups, no controls, no comparative treatments(Robey & Schultz, 1998; Robey, 2004)

Phase I and Phase II Research: Small Group Pediatric Studies

Number of participants

Parent Ratings

ListenerPerception

Acoustic Physiology Imaging

Phase I: Single subject multiple baseline designCerebral Palsy

5-7 yeas5

Phase I: Pre-PostDown Syndrome

4-8 years9

Phase II: Cohort-ControlCerebral Palsy

6-10 yearsTypically Developing

6-10 years

9

9

Phase II: Cohort-ControlCerebral Palsy

8-16 yearsTypically Developing

8-16 years

9

9

Example: Acoustic Measure in DS

Robinson et al., 2004; Petska et al., 2006

60

65

70

75

80

Pre-Treatment Post-Treatment

dB

SP

LLoudness Changes on Picture Description Tasks

*

*

= p < 0.004

Example: Listener Perception in DS

Boliek, et al., in preparation

0

10

20

30

40

50

60

70

80

Pre-treatment Post-Treatment

Per

cen

t

Percent Intelligibility

*

* = p < 0.08

Pre-LSVT LOUD“I need help.”

Down syndromeFemale; 5 years

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ˇ¸

Post-LSVT LOUD“I need help”

Down syndromeFemale; 5 years Phase II: Children with Cerebral Palsy

Small group design: Cohort-Control (experimental vs. control)

Robey & Schultz, 1998

Physiologic, Perception & Neurologic Measures: Pre- Post- and Follow-up

Boliek, et al., 2012

LSVT LOUD Pre/Post-treatment Respiratory Changes

Boliek, Fox, Norton, Gan, Arichibald, Knuttila, Rosborough, & L'Abbe, 2009

*

*

*

Phase II: Small group design Small group design: Cohort-Control (experimental vs. control)

Participant Sex Age Speech Diagnosis GMFCS Cognitive Level

LSVTF1 F 13 Mixed Dysarthria Moderate

III Above Average

LSVTM2 M 11 Mixed DysarthriaMild

II Average

LSVTF3 F 12 Mixed Dysarthria; AOSMild-Moderate

II Average

LSVTM4 M 12 Mixed DysarthriaMild

V Below Average

LSVTM5 M 8 Spastic-type DysarthriaMild-Moderate

V Average

LSVTM6 M 13 Mixed Dysarthria; AOSModerate-Severe

IV Below Average

LSVTF7 F 16 Mixed Dysarthria ;AOSSevere

III Average

LSVTM8 M 8 Mixed Dysarthria Moderate-severe Dysfluency-Mild

II Below Average

LSVTM9 M 13 Mixed DysarthriaModerate-Severe

IV Average

Selected Results - Structural

Reed, Cummiine, Bakhtiari, Fox, & Boliek, 2017

Acoustic, intelligibility, perceptual measures and parent ratings were comparable to previous studies

12 weeks post-treatment (with well-documented maintenance practice) we see large increases in corticospinal tract integrity (impt. for speech motor control)

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Graphical Model of the Mechanisms of Change: Speech Networks

Bakhtiari, Cummine, Reed, Fox, Chouinard, Cribben, & Boliek, 2017

ACG = Anterior Cingulate g.

SMA = Supplementary Motor AreaIFG = Inferior Frontal g.

PCG = Precentral g.STG = Superior Temporal g. MTG = Middle Temporal g. SMG = Supramarginal g. Crb = Cerebellum

3 sessions in FMRI, phonation and speech tasks, functional changes, rare data

Summary of Research• Therapeutic effect

• Physiological effects

• Neurobiological changes

• All of which support and justify the use of LSVT LOUD in select children with cerebral palsy and Down syndrome, with potential application to other pediatric motor speech disorders

Reed, A., Cummine, J., Bakhtiari, R., Fox, C.M., Boliek, C. (2017). Changes in white matter integrity following intensive voice treatment (LSVT LOUD®) in children with cerebral palsy and motor speech disorders. Developmental Neuroscience, 39, 460-471. doi: 10.1159/000478724.

Bakhtiari, R., Cummine, J., Reed, A., Fox, C.M., Chouinard, B., Cribben, I., Boliek, C.A. (2017). Changes in brain activity following intensive voice treatment in children with cerebral palsy. Human Brain Mapping, 38(9): 4413-4429. doi: 10.1002/hbm.23669.

Boliek, C.A. & Fox, C.M. (2016). Therapeutic Effects of Intensive Voice Treatment (LSVT LOUD®) for Children with Spastic Cerebral Palsy and Dysarthria: A Phase I Treatment Validation Study. International Journal of Speech-Language Pathology, Oct 5:1-15. [Epub ahead of print] DOI:10.1080/17549507.2016.1221451

Boliek, C.A. & Fox, C.M. (2014). Individual and environmental contributions to treatment outcomes following a neuroplasticity-principled speech treatment (LSVT LOUD) in children with dysarthria secondary to cerebral palsy: a case study review. International Journal of Speech-Language Pathology, 16(4): 372–385.

Fox, C.M., & Boliek, C.A. (2012). Intensive voice treatment (LSVT LOUD) for children with spastic cerebral palsy and dysarthria. Journal of Speech Language Hearing Research, 55, 930-945.

Select References LSVT TEAMCynthia Fox, Ph.D., CCC-SLPLorraine Olson Ramig, Ph.D., CCC-SLPAngela Halpern, M.S., CCC-SLPJill Cable, M.A., CCC-SLPJessica Galgano, PhD, CCC-SLP Leslie Mahler, Ph.D., CCC-SLPJennifer Spielman, M.M., M.A., CCC-SLPElizabeth Peterson, M.S., CCC-SLP

U of AlbertaCarol Boliek, Ph.D.

Carly Nickerson Reyhaneh Bakhtiari, PhDNahal Namdaran Jacqueline Cummine, PhDBarrie Gardner Haley GynaneChrista Piccott Alesha ReedJill Hilstad Lauren PedersenErin Archibald Andrea ChangJulie Smith Aamn JaswalLeanne Wilson Brea ChouinardHeather Elliott Teresa HardyHeather Pennycook Brianna BoronJenna Teyke Clare WolffNancy Eason Katie Stevens

Online Pediatric Course: Implementation of LSVT LOUD in Pediatric Motor Speech Disorders. This is an advanced course for LSVT LOUD Clinicians to learn more about applying this treatment to pediatric populations. Available online and offered for 0.35 ASHA CEUs. Learn more or purchase at www.lsvtglobal.com.

To find LSVT LOUD Certified Clinicians:Search our Directory at www.lsvtglobal.comCall Us: 1-888-438-5788; 1-520-867-8838Email Us: [email protected]

Next Webinar: Wednesday, June 20th, 20188:00 P.M. EDT in the United States!

Introduction to LSVT LOUD® and LSVT BIG®: Speech, physical and

occupational therapies for Parkinson’s

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