Evidenced-based Speech Treatment (LSVT LOUD): An Informational Webinar for Speech-Language Pathology Students

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 Survey will automatically launch at the conclusion of the webinar (less than 5 minutes to complete) Copyright LSVT Global, Inc. 2016 1

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 Biographies Cynthia 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. Disclosures All 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 team have 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). Copyright LSVT Global, Inc. 2016 2

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 Objectives 1) 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 Copyright LSVT Global, Inc. 2016 3

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 Brain Recognition 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 activitydependent 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 Copyright LSVT Global, Inc. 2016 4

Principles that Drive Activity Dependent Neuroplasticity Intensity matters Intensive practice is important for maximal plasticity Complexity matters Complex movements or environmental enrichment have been shown to promote greater structural plasticity Repetition Matters Induction of plasticity requires sufficient repetition (Kliem et al, 2004) Salience matters Practicing rewarding tasks (success/emotionally salient) activates basal ganglia circuitry Timing matters Injury creates fertile field for plasticity - need behavior to make it happen. Specificity matters -Train the deficits (target hypokinesia in PD) LSVT Programs Adhere to principles of neural plasticity (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 ) Rehabilitation (ST, PT, OT) is becoming a routine part of management in PD To provide symptomatic relief; improve function Pharmacological (L-dopa) Neurosurgical (DBS-STN) Speech, Physical Occupational Tx (Empower) 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 Copyright LSVT Global, Inc. 2016 5

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) Copyright LSVT Global, Inc. 2016 6

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 Copyright LSVT Global, Inc. 2016 7

20+ year journey from invention to scale-up Over 8 million dollars in NIH funding Phase I, II Phase III 1987-89: Initial invention; Pilot data (Scottsdale) 1989-91: Office of Education OE-NIDRR 1991-94: OE-NIDRR 1990-95: NIH funded RCT Efficacy 1995-00: NIH funded EMG, Kinematics 2002-07: NIH funded RCT Spread of effects 2007-12: NIH funded RCT, imaging Phase IV, V 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 Dissemination 2006: Technology-enhanced Clinician Training (SBIR) 2010: Technology-enhanced LSVT LOUD delivery (SBIR) Poll Question 3 Are you already LSVT LOUD Certified? Yes No LSVT LOUD: Data Copyright LSVT Global, Inc. 2016 8

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, Psychiatry Level 1 Evidence Goetz,2003 75 N=45 SPL Rainbow (50 cm) LSVT LOUD 70 65 RESP 60-2 0 2 4 6 8 10 12 14 16 18 20 22 24 Months LSVT R Blinded, no med change Same time med Established Clinical Efficacy (Ramig et al, 1995; 1996; 2001a; 2001b; Goetz, 2003) Cross-system effects, Neural changes P. Fox, Liotti (2003) Narayana (2010) (PET) Spielman, Borod (2003) (facial expression) El-Sharkawi, Logemann (2002) (swallowing) Smith, M. (1995) (adduction) Ramig & Dromey (1996) (aerodynamics) Baker (1998), Luschei (1999) (EMG) Dromey, (1995) (articulation) Sapir (2007; 2010) (articulatory acoustics) Smith,A. (2001) (STI) Taskoff (2001) (perceptual) Huber, Stathopoulos, (2003) (respiratory kinematics) Copyright LSVT Global, Inc. 2016 9

Pre to Post Vocal Folds The Effect of LSVT on Facial Movement in PD Facial Action Coding System (Ekman et al., 2002); 44 PD patients and 11 age-matched controls E v e n t 9 8 7 6 5 N u m b e r 4 3 2 1 Variability of Facial Movement * 3.8 3.6 3.3 Art LSVT NC UPD 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) 5.2 7.0 6.3 4.2 before after 3.2 Copyright LSVT Global, Inc. 2016 10

LSVT LOUD New Research 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) Study Progression 1 Month 6 Months Enroll Pre-tx Tx Post-tx Followup Over 400 Screened 64 Subjects Enrolled Neurology ENT Neuropsychology Swallow Speech lab (repeated twice) Stratification/ minimization 16 sessions of treatment in one month Daily homework Carryover Month Speech lab assessment (repeated twice) Swallow NO TX 6-month speech lab assessment (repeated twice) *No statistically significant difference among groups pre-treatment * * * Copyright LSVT Global, Inc. 2016 11

* * * 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 Copyright LSVT Global, Inc. 2016 12

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 Syndrome Female; 5 years Copyright LSVT Global, Inc. 2016 13

Post-LSVT LOUD I need help Down Syndrome Female; 5 years ˇ LSVT LOUD: Key Concepts Target Loss of motor energy Movements underscaled Drive amplitude to override bradykinesia/hypokinesia LOUD Healthy Vocal Loudness SOFT Berardelli et al, 1986; Hallett, 2011 Copyright LSVT Global, Inc. 2016 14

Mode 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 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. Fox et al, 2002; Sapir et al, 2011 LSVT LOUD: Protocol Copyright LSVT Global, Inc. 2016 15

LSVT LOUD Treatment Session Daily Exercises 1. 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 Exercises Structured reading multiple reps, 20+ min. Off the cuff bridge the gap to conversation Build complexity across 4 weeks of treatment towards your long-term communication goal Homework Includes all daily exercises and hierarchy exercises Assigned all 30 days Carryover Exercises Use loud voice in real life situations outside of the treatment room Assigned all 30 days LSVT LOUD Goal! Treatment Exercise: long ah, high/low ah Treatment Goal: louder voice in conversation Calibration 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 Copyright LSVT Global, Inc. 2016 16

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 Accessibility for Patients Accessibility for Clinicians LSVT eloud LSVT Companion Telemedicine Funded by: NIH-NIDCD & Michael J. Fox Foundation Pre, Post, 6 month db SPL (p< 0.001) Changes consistent with those reported in previously published data Halpern et al, 2012 Copyright LSVT Global, Inc. 2016 17

Accessibility for Patients Standardized maintenance programs: LOUD for LIFE Free Webinars-PD Community Ask the Expert -info@lsvtglobal.com 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. Copyright LSVT Global, Inc. 2016 18

Accessibility for Clinicians LSVT LOUD Training and Certification Course Free webinars Discussion forum Ask 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 countries Over 10,000 LSVT BIG Certified Clinicians in 38 countries Data as of January, 2016 LSVT LOUD Online Certification 2016 Individual Learning: www.lsvtglobal.com/loudcertification/online-courses Group Learning: email info@lsvtglobal.com University Learning: email info@lsvtglobal.com 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! Copyright LSVT Global, Inc. 2016 19

LSVT LOUD Live Trainings 2016 Full schedule at www.lsvtglobal.com Updates as year progresses April 1-2, 2016 April 9-10, 2016 April 21-22, 2016 May 13-14, 2016 June 17-18, 2016 June 24-25, 2016 August 4-5, 2016 July 16-17, 2016 August 4-5, 2016 August 26-27, 2016 December 1-2, 2016 Minneapolis, MN São Paulo, BR Dallas, TX Cherry Hill, NJ Berlin, Germany London, UK New York, NY Tokyo, Japan New York, NY Mainz, Germany 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 Copyright LSVT Global, Inc. 2016 20

Public Webinars 2016 Use of LSVT LOUD and LSVT BIG in Advanced Parkinson Date/Time: 2/10/16, 2:00 p.m. EST LSVT BIG and LSVT LOUD : Evidence-Based Physical and Occupational Therapy for Parkinson s Disease Date/Time: 3/16/16, 2:00 p.m. EST Addressing Difficulties with Voice and Activities of Daily Living in Parkinson Disease LOUD 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. EST Date/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 were taken from me with one exception, I would choose to keep the power of communication, for by it I would soon regain all the rest Daniel Webster Copyright LSVT Global, Inc. 2016 21

QUESTIONS??? www.lsvtglobal.com info@lsvtglobal.com Please complete the survey that will automatically launch at close of webinar. Copyright LSVT Global, Inc. 2016 22