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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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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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