Webinar handout- evidenced-based speech treatment lsvt loud an ...

3/8/2016

Copyright LSVT Global, Inc. 2016 1

Evidenced-based Speech Treatment (LSVT LOUD): An

Informational Webinar for Speech-Language Pathology

Students

Supported by NIH grants: NIH-NIDCD R01 DC-01150, R21 DC-006078, R21 NS-0437111, SBIR R43 DC-010956, SBIR R43 DC-010498, SBIR R45 DC-010956, OE-NIDRR, Michael J. Fox Foundation, Davis Phinney Foundation, Parkinson Alliance, Family of Lee Silverman

Disclosures: Drs. Fox and Ramig are employees of and have ownership interest in LSVT Global, Inc.

Lorraine Ramig, PhD, CCC-SLP

Professor University of Colorado, Boulder and Columbia, NY

National Center for Voice and Speech, Denver, CO

LSVT Global, Inc., Tucson, AZ

Cynthia Fox, PhD, CCC-SLP

National Center for Voice and Speech, Denver, CO

LSVT Global, Inc., Tucson, AZ

Plan for Webinar

Logistics (questions, handouts, CEUs)

Present webinar

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Information on CEUs- This webinar is offered for 0.1 CEUs.

- Attendance for the full hour is required to earn CEUs.

- The LSVT Global webinars for 2016 are not registered for ASHA CEUs.

- You will receive a certificate after completion of the webinar which will include your name, date of the webinar and the number of hours earned.

- Completion of the webinar cannot be reported to the ASHA CE registry by us and cannot be added to the ASHA CE registry by you. Pleas retain documentation for proof of completion.

- For more information on including non-ASHA registered CEUs for certification maintenance, visit ASHA’s website: http://www.asha.org/Certification/Certification-Maintenance-Frequently-Asked-Questions--Earning-Professional-Development-Hours/#earnASHA

- Licensing requirements for CEUs differ by state. Check with your state licensing board to determine if your state accepts non-ASHA registered CEU activities.

Instructor BiographiesCynthia Fox, PhD, CCC-SLP

Dr. Fox received her doctorate degree in Speech and Hearing Sciences from the University of Arizona, Tucson. Dr. 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 has worked closely with Dr. Ramig for the past 18 years on studies examining the efficacy of LSVT LOUD, the underlying mechanisms of speech disorders in PD, and the application of LSVT LOUD to other disorders (children and adults) and other motor systems (e.g., limb). She is an expert on rehabilitation and neuroplasticity and the role of exercise in the improvement of function consequent to neural injury and disease.

Lorraine Ramig, PhD, CCC-SLP

Dr. Ramig received her doctoral degree at Purdue University and master’s degree at the University of Wisconsin-Madison in communication disorders. Dr. Ramig is a Professor in the Department of Speech-Language and Hearing Science at the University of Colorado-Boulder, a Senior Scientist at the National Center for Voice and Speech (NCVS), a division of the Denver Center for the Performing Arts (DCPA), located in Denver, Colorado, and an adjunct professor at Mt. Sinai School of Medicine and Columbia Teacher’s College in New York City. Dr. Ramig is an internationally recognized scientist with an established research record in the areas of aged and neurological voice disorders. She has been investigating neurological voice disorders for over 20 years and has authored numerous refereed journal articles and book chapters. She has been awarded Honors of the American Speech Language Hearing Association.

DisclosuresAll of the LSVT Global 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 and equipment which will be discussed as a part of this workshop.

Drs. Ramig and Fox receive lecture honorarium and travel reimbursement and have ownership interest in LSVT Global, Inc.

Ms. Halpern and Ms. Peterson are employees of and receive lecture honorarium and travel reimbursement from LSVT Global, Inc.

Dr. Mahler, Dr. Galgano and Ms. Gustafson receive consulting fees, lecture honorarium and travel reimbursement from LSVT Global, Inc.

STATEMENT ON DISCLOSURE AND CONFLICT: All members of this research teamhave fully disclosed any conflict of interest. The conflict of interest management plan has been approved by the Office of Conflict of Interest and Commitment at the University of Colorado, Boulder (Ramig, Fox and Halpern).

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All clients shown in videos during this presentation have given consent for their videos

to be used for educational purposes. Any copying of videos or viewing outside of this

course is strictly prohibited.

These videos represent work from 25+ years of research. Although some of the footage is from older studies (i.e. not shot in high definition), it has been chosen for demonstrating key points

important for learning LSVT LOUD.

Presentation Objectives1) Briefly explain advances in neuroscience that

have had a positive impact on the field of rehabilitation for individuals with PD

2) Discuss the development and data on LSVT LOUD

3) Explain key principles of LSVT LOUD treatment

4) Highlight innovative technology to enhance accessibility of treatment for all people with PD who can benefit

5) Summarize the ability of students to learn and use LSVT LOUD in their clinical practicum and clinical fellowship year

Poll Question 1

• Who are you?– Undergraduate Student

– Graduate Student

– University faculty, clinical supervisor

– Professional SLP

– Other

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Polling Question 2

• How did you learn about LSVT LOUD?– From a lecture on LSVT LOUD in school

– Observation of LSVT LOUD treatment in action

– Through research

– LSVT Global Website

– Word of mouth

1990-1999: The Decade of the BrainRecognition of the adaptive capacity of the central

nervous system: Activity-dependent Neuroplasticity

It is a “Stunning Time” to be in rehabilitation today

Basic science evidence for the value of exercise in PD (classically drugs, surgery)

Identified key principles of exercise that drive activity-dependent neuroplasticity (intensity, repetition, salience, complexity, timing matters)

Demonstrated that exercise can improve brain functioning (neural plasticity) and may slow symptom progression

Exercise is Medicine!Kleim & Jones, 2008; Kleim et al, 2003; Zigmond et al, 2009

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Intensity mattersIntensive practice is important for maximal plasticity

Complexity mattersComplex movements or environmental enrichment have been shown to promote greater structural plasticity

Repetition MattersInduction of plasticity requires sufficient repetition (Kliem et al, 2004)

Salience mattersPracticing rewarding tasks (success/emotionally salient) activates basal gangliacircuitry

Timing matters Injury creates fertile field for plasticity - need behavior to make it happen.

Specificity matters -Train the deficits (target hypokinesia in PD)

(Alexander et al., 1990; Fox et al., 2002; Graybiel 1998; Kliem et al., 2003; Kleim and Jones, 2005; Joneset al. 1999; Saint-Cyr JA, 2003; Tillerson et al., 2002; Vergara-Aragon et al., 2003; Black et al. 1990; Comery 1995;

Fisher et al, 2004; Kleim et al., 2001; 1996; Perez et al. 2004; Pisani et al., 2005 Plautz et al., 2000 )

Principles that Drive Activity Dependent Neuroplasticity

LSVT Programs Adhere to principles of neural plasticity

Rehabilitation (ST, PT, OT) is becoming a routine part of management in PD

To provide symptomatic relief; improve function

Pharmacological(L-dopa)

Speech, PhysicalOccupational Tx

(Empower)

Neurosurgical(DBS-STN)

Kleim & Jones, 2008; Kleim et al., 2003; Zigmond et al, 2009

Our work – LSVT Protocols:based on 25 years of NIH funded research and clinical experience

• LSVT LOUD is a speech therapy – Delivered by LSVT LOUD Certified

Speech-Language Pathologists

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Video Pre to Post LSVT LOUD

Speech disorders and development of LSVT LOUD

treatment in PD

Over 89% of the nearly 6 million individuals with Parkinson disease worldwide suffer from voice and speech disorders.

• Reduced vocal loudness• Hoarseness• Monotone voice • Imprecise articulation

(e.g., Logemann et al., 1978; Sapir et al., 2001)

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These voice and speech disorders contribute to lifelong frustration, embarrassment and social isolation (e.g., Miller et al, 2006).

“If I have no voice, I have no life.”-Natalie, individual with PD

Classic Medical Treatments Alone do not Consistently or Significantly Improve

Speech in PD

Pharmacological Tx:“…no evidence of systematic improvement in dysarthria owing to dopamine replacement therapy.” (e.g., Pinto et al, 2004)

Surgical Tx:Neurosurgical interventions do not consistently or effectively improve speech in PD ( e.g., Freed et al., 1992; Goberman, 2005; Pinto et al., 2004; Rousseaux et al., 2000; Tripoliti et al., 2008; Astromet et al., 2010)

1987 no effective voice and speech treatments for PD

“If only we could hear and understand her”Family of Mrs. Lee Silverman 1987

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20+ year journey from invention to scale-upOver 8 million dollars in NIH funding

1987-89: Initial invention; Pilot data (Scottsdale)1989-91: Office of Education OE-NIDRR

1991-94: OE-NIDRR1990-95: NIH funded RCT Efficacy1995-00: NIH funded EMG, Kinematics2002-07: NIH funded RCT Spread of effects2007-12: NIH funded RCT, imaging

2001-02: Coleman Institute (PDA; LSVTC)2002-04: NIH and M J FOX Foundation PDA (R21)2002-04: Coleman Institute (VT; LSVTVT)2004-06: NIH LSVTVT (R21)2004 : Coleman Institute (LSVT Down Syndrome) 2004-07: LSVT –Dissemination2006: Technology-enhanced Clinician Training (SBIR)2010: Technology-enhanced LSVT LOUD delivery (SBIR)

Ph

ase

I, II

Pha

se II

IP

hase

IV, V

Poll Question 3

• Are you already LSVT LOUD Certified?– Yes

– No

LSVT LOUD: Data

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Conducted TWO Randomized Clinical Trials (RCT) to Test

Efficacy of Treatments to improve Vocal Loudness

Among the first and most pervasive symptoms in PD (e.g., Logemann et al., 1978)

Respiratory (RESP) vs. voice (LSVT) (N=45)

Pre to post (Ramig et al., 1995) e.s. 1.81-1.20

Pre to 12 months follow-up (Ramig et al., 1996) e.s. .85-.65

Pre to 24 months follow-up (Ramig et al., 2001) e.s. 1.03-1.03

Voice (LSVT) vs. Untreated Control groups (PD, Healthy) (N=44)

Pre to Post to 6 months follow-up (Ramig et al., 2001)

e.s. 1.77-1.45, 1.50-1.03

Average SPL effect size 1.23 (.65-1.81)

Novel: intensive dosage (16 sessions/month), high effort designed to target physiology underlying reduced loudness, had a single treatment target enhance feasibility of generalization and addressed PD sensory challenges

(motor learning muscle training literatures)

Ramig et al., 2001; J Neurol, Neurosurgery, PsychiatryLevel 1 Evidence Goetz,2003

60

65

70

75

-2 0 2 4 6 8 10 12 14 16 18 20 22 24

Months

SP

L R

ain

bo

w (

50 c

m)

LSVT R

LSVT® LOUD

RESP

N=45

Blinded, no med changeSame time med

Established Clinical Efficacy(Ramig et al, 1995; 1996; 2001a; 2001b; Goetz, 2003)

Cross-system effects, Neural changes

Spielman, Borod (2003)

(facial expression)

El-Sharkawi, Logemann

(2002)

(swallowing)

Smith, M. (1995)

(adduction)

Ramig & Dromey(1996)

(aerodynamics)

Baker (1998),

Luschei (1999) (EMG)

P. Fox, Liotti (2003)Narayana (2010)

(PET)

Dromey, (1995) (articulation)

Sapir (2007; 2010)

(articulatory acoustics)

Smith,A. (2001)(STI)

Taskoff (2001)

(perceptual)

Huber, Stathopoulos, (2003)

(respiratory kinematics)

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Pre to Post Vocal Folds

3.8 3.6

7.0

4.2

3.3

5.26.3

3.2

1

2

3

4

5

6

7

8

9

Art LSVT NC UPD

Event

Number

Variability of Facial Movement

before

after

The Effect of LSVT on Facial Movement in PD

*

┼

Variability significantly increased from before to after treatment for the LSVT LOUD group, but did not significantly change for any other group.

Dumer, Borod, Oster, Spielman, Rabin, & Ramig (2011)

Facial Action Coding System (Ekman et al., 2002); 44 PD patients and 11 age-matched controls

┼

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Methods

• 84 Subjects (4 Groups)– Two groups received intensive treatment

(LSVT or ARTIC)

– Two groups remained untreated (PD and non PD)

– Sample Size 20 Statistical Power.80

• 3 PD groups reported here today (64 Ss)

LSVT LOUD New Research

• Neurology• ENT• Neuro-

psychology • Swallow • Speech lab

(repeated twice)

Stratification/minimization

Pre-tx

16 sessions of treatment in one month

Daily homeworkCarryover

Month

Tx

• Speech lab assessment (repeated twice)

• Swallow

Post-tx

• 6-month speech lab assessment (repeated twice)

Follow-up

Over 400 Screened

64 Subjects Enrolled

Enroll

1 Month 6 Months

NO TX

Study Progression

*No statistically significant difference among groups pre-treatment

*

**

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***

To a patient……major life impact

“My voice is alive again”

“I can talk to my grandchildren!”

“I feel like my old self”

“I am confident I can communicate!”

Poll Question 4

• Do you plan to work predominately with– Adults

– Pediatrics

– Combination

– Don’t know

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Impact beyond PD• Parkinson Plus (Countryman et al., 1994)

• Post Surgery, Fetal cell (Countryman, et al., 1993)

• Stroke (Fox et al, 2002; Mahler et al., 2009; Mahler et al., 2012)

• Multiple Sclerosis (Sapir et al., 2001)

• Ataxia (Sapir et al., 2003)

• Cerebral palsy (Fox et al, 2012; Boliek et al., 2014)

• Down Syndrome (Boliek et al., 2016; Petska et al, 2006; Mahler et al., 2012)

• Aging (Ramig et al., 2001)

Video Pre to Post LSVT LOUD Stroke

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

LSVT LOUD: Key Concepts

SOFT

LOUD

Drive amplitude to override bradykinesia/hypokinesia

Loss of motor energyMovements underscaled

Berardelli et al, 1986; Hallett, 2011

Healthy Vocal Loudness

Target

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Intensity across sessions:

Treatment delivered 4 consecutive days a week for 4 weeks

Daily homework practice(all 30 days of the month)

Daily carryover exercises (all 30 days of the month)

Life-long habit of continuous practice

Intensity within sessions: High effort

Mode

Fox et al, 2002; Sapir et al, 2011

CALIBRATION Addresses Barriers to Generalization

Sensory disorder: People with PD have soft speech, but they think it is within normal limits (world needs a hearing aide).

Internal cueing: Physiological substrate for movement is present – not being activated.

Neuropsychological: Slow thinking, slow learning, problems sustaining attention, problems shifting cognitive set, problems internally cueing, and problems in procedural memory.

LSVT LOUD: Protocol

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LSVT LOUD Treatment Session

Daily Exercises1. Maximum Duration of

Sustained Vowel Phonation (Long Ahs) –15+ reps

2. Maximum Fundamental Frequency Range (High/Low Ahs) – 15 reps each

3. Maximum Functional Speech Loudness (Functional Phrases) – 5 reps of 10 phrases

Hierarchy ExercisesStructured reading – multiple reps, 20+ min.Off the cuff – bridge the gap to conversationBuild complexity across 4 weeks of treatment towards your long-term communication goal

HomeworkIncludes all daily exercises and hierarchy exercisesAssigned all 30 days

Carryover ExercisesUse loud voice in real life situations outside of the treatment roomAssigned all 30 days

LSVT LOUD Goal!

Treatment Goal: louder voice in conversationTreatment Exercise: “long ah”, “high/low ah”

MISMATCH between internal perception of vocal loudness and how others perceive it in people with PD.

“I’m not too soft.”“I can’t speak like this, I am shouting!!”

Fox et al, 2002; Sapir et al, 2011

Calibration

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“Intervention That Challenges the Nervous System Confronts the Challenge of Real-World

Clinical Practice” (Fisher, B., 2011, JNPT)

Maintain treatment fidelity: accessibility, technology, change management

LSVT eLOUD™ LSVT Companion®

Funded by: NIH-NIDCD &Michael J. Fox Foundation

Telemedicine

Accessibility for Patients

Accessibility for CliniciansAccessibility for Clinicians

Pre, Post, 6 month dB SPL (p< 0.001)

Changes consistent with those reported in previously published data Halpern et al, 2012

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Accessibility for Patients

• Standardized maintenance programs:LOUD for LIFE™

• Free Webinars-PD Community • “Ask the Expert”[email protected]• LSVT Companion Home Edition• LSVT LOUD Homework Helper DVDs

Implementation of Intensity

• Is it Reimbursable?

• Is it Practical and Feasible?

• Is it Applicable to Varied Practice Settings?

YES!• Eminently reimbursable

– Patients make significant progress

– Medical necessity readily proved in PD

– People with progressive disease get better!

– Real world experience with 1000+ patients

• Practical and feasible – Use of technology

– May require education of admin and scheduling change in clinic

• Applicable to varied practice settings– Successful implementation in home health, out patient, skilled

nursing facilities, private practice, etc.

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Accessibility for Clinicians

LSVT LOUD Training and Certification

CourseFree webinars

Discussion forumAsk the clinical expert

LSVT Global Clinician Database

Materials for facilitating referrals

LSVT LOUD global standard for Speech Treatment for PD (Pinto et al., 2004) NICE Great Britain

Over 16,000 LSVT LOUD Certified Clinicians in 69 countriesOver 10,000 LSVT BIG Certified Clinicians in 38 countries

Data as of January, 2016

LSVT LOUD Online Certification 2016

• Individual Learning: www.lsvtglobal.com/loud-certification/online-courses

• Group Learning: email [email protected]• University Learning: email [email protected]

“I found the online training to be an excellent learning experience. I was initially concerned that the content

would be difficult to learn without the live hands on experience, however, the video clips coupled with the

organized, comprehensive presentation style were very effective. I am excited to begin my practice of

LSVT LOUD!”

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LSVT LOUD Live Trainings 2016Full schedule at www.lsvtglobal.com

Updates as year progresses

April 1 - 2, 2016 Minneapolis, MNApril 9 - 10, 2016 São Paulo, BRApril 21 - 22, 2016 Dallas, TXMay 13 - 14, 2016 Cherry Hill, NJJune 17-18, 2016 Berlin, GermanyJune 24 - 25, 2016 London, UKAugust 4-5, 2016 New York, NYJuly 16-17, 2016 Tokyo, JapanAugust 4-5, 2016 New York, NYAugust 26-27, 2016 Mainz, GermanyDecember 1 - 2, 2016 New York, NY

Post-Training Information• Students may use LSVT LOUD under the

supervision of LSVT LOUD Certified clinical instructors before graduation in accordance with state and federal practice regulations pertaining to students

• Students must contact LSVT Global upon graduation to be upgraded to professional status and to be listed on the website

• LSVT LOUDG Certification Renewal every 2 years from certification date

Speech Grants 2016

• Two $1,500 grants will be awarded

• Treatment research in a neurological population (does NOT have to be LSVT LOUD related research)

• Letters of intent was DUE February 16, 2016

• We will offer again next year! Announcement at ASHA 2016

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Public Webinars 2016

Use of LSVT LOUD® and LSVT BIG® in Advanced ParkinsonDate/Time: 2/10/16, 2:00 p.m. EST

LSVT BIG® and LSVT LOUD®: Evidence-Based Physical and Occupational Therapy for Parkinson’s DiseaseDate/Time: 3/16/16, 2:00 p.m. EST

Addressing Difficulties with Voice and Activities of Daily Living in Parkinson DiseaseLOUD Date/Time: 4/13/16, 2:00 p.m. EST

Turn up the Gain: Are you getting what you should be getting out of LSVT LOUD and LSVT BIG? Date/Time: 5/11/16, 2:00 p.m. EST

Atypical Parkinsonian Disorders: Can LSVT LOUD® and LSVT BIG® be effective? Date/Time: 6/8/16, 2:00 p.m. EST

Certified Clinician Webinars 2016

New in 2016: Office Hours!If you are already certified, or while you are talking the Online LSVT LOUD course.

Date/time: 2/18/16, 8:00 p.m. ESTDate/time: 3/24/16, 8:00 p.m. EST Date/time: 4/21/16, 8:00 p.m. EST Date/time: 5/19/16, 8:00 p.m. EST Date/time: 6/16/16, 8:00 p.m. EST

“If my possessions weretaken from me with one

exception, I would chooseto keep the power of

communication, for by itI would soon regain

all the rest”Daniel Webster

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