public webinar series - lsvt globalblog.lsvtglobal.com/.../public-webinar-lsvt-beyond... · beyond...

Public Webinar Series

Title: LSVT LOUD® and LSVT BIG® Beyond Parkinson

Disease: Could They Be Helpful for My Condition?

Presenters: Cynthia Fox, PhD, CCC-SLP

Beth Marcoux, PhD, DPT

Date Presented: June 14, 2017

Disclaimer:

The information provided in this webinar and handout is not a substitute for

medical or professional care, and you should not use this information in

place of a visit, call consultation or the advice of your physician, speech,

physical or occupational therapist, or other healthcare provider.

Copyright:

The content of this presentation is the property of LSVT Global and is for

information purposes only. This content should not be reproduced without

LSVT Global’s permission.

Contact Us:

Web: www.lsvtglobal.com Email: [email protected]

Phone: 1-888-438-5788 (toll free), 1-520-867-8838 (direct)

http://www.lsvtglobal.com/

mailto:[email protected]

Copyright© LSVT Global, Inc. 2017 1

www.lsvtglobal.com [email protected]

LSVT LOUD® and LSVT BIG®

Beyond Parkinson Disease: Could they be helpful for my

condition?Cynthia M Fox, PhD, CCC-SLP

VP Operations and Co-Founder

LSVT LOUD and LSVT BIG Training and Certification Faculty

LSVT Global, Inc.

Beth Marcoux, PhD, DPT

LSVT BIG Training and Certification Faculty

LSVT Global, Inc.

Greetings from….

Plan for WebinarLogistics

-Handout attached in webinar menu-Videos (lag time and permissions)

Discuss application of LSVT LOUD and LSVT BIG beyond Parkinson disease

We encourage your participation and questions

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

INFORMATION ON CEUS

- This webinar is offered for 0.1 self-reported CEUs. CEUs available only for Live version of webinar, not the On-demand version.

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

- Details required for self-reported CEU credit for speech, physical and occupational therapy professionals are included in the handout at the end of the webinar slides (author biographies, disclosures, etc.).

- Certificates for self-reported CEU credit must be requested by professional participants. If you are a professional and would like a certificate of attendance, you must email your request to [email protected] 48 hours of attending.

Learning ObjectivesUpon conclusion of this webinar, participants will be able to:

• Describe which conditions may be most appropriate for LSVT LOUD and LSVT BIG

• Outline what to expect during assessment and treatment for LSVT LOUD and LSVT BIG in other conditions

• Discuss research cases on the application of LSVT LOUD to populations other than Parkinson disease

• Discuss clinical cases on the application LSVT BIG to populations other than Parkinson disease

Who are you?

-Person with a condition what may benefit from LSVT-Family member of a person who may benefit from LSVT-Non LSVT-certified therapist-LSVT Certified Clinician-Other

Polling Question


What condition do you represent or are you most interested in learning about?

Multiple SclerosisStrokePediatricsParkinson or Atypical PDOther

Polling Question Describe which conditions may be most appropriate for LSVT LOUD and LSVT BIG

Designed to address underlying pathophysiology of Parkinson disease (PD)

• Bradykinesia/hypokinesia

• Problems with sensory processing

• Subtle neuropsychological deficits

Key Features of LSVT Treatments• Target: Amplitude

• Mode: Intensive and High Effort

• Calibration: Addresses barriers to generalization (sensory, cueing, neuropsychological deficits)

Goal in LSVT LOUD or LSVT BIG Secondary Benefits

LSVT LOUD• Intonation

• Voice Quality

• Articulation

• Speech intelligibility

• Facial Expression

• Swallowing

• Strengthening

• Aerobic Conditioning

• Active Stretching

• Balance

• Trunk Rotation

• Posture/Alignment

LSVT BIG

• Intensity - across and within treatment sessions

• Repetition – increased number of repetitions of exercises and tasks

• Complexity – increasing difficulty of exercises and tasks as treatment progresses, including dual tasking

• Salience – individualize functional and long-term goals to be meaningful to each person

• Specificity – train the deficit you want to improve

These principles are important when treating many neurological and non-neurological conditions!

LSVT Includes Key Treatment Principles that Drive Activity-Dependent Neuroplasticity

When deciding whether LSVT LOUD or LSVT BIG is appropriate

for conditions beyond PD….

Two Groups of Possible Candidates…caveat - there are not always clear boundaries

between the these groups


Symptoms with similarity to what we see in PD:

• Is there a muscle activation deficit affecting voice, speech, mobility, gait, balance?

• Are there problems with sensory processing?

• Are there changes in neuropsychological functioning?-atypical Parkinsonisms

-multiple sclerosis

-stroke

-children with cerebral palsy or Down syndrome

-normal pressure hydrocephalus

Symptoms dissimilar to what we see in PD:

• A problem with muscle function that may not be a reduced activation problem (affecting voice, speech, gait, balance)

• Minimal sensory processing deficits or primary sensory deficits (pain, tingling, loss of proprioceptive input)

• Normal neuropsychological functioning or advanced cognitive deficits-hyperkinetic disorders (e.g., Huntington’s disease, dystonia)

-ataxia

-aging

-paralysis (e.g., vocal fold paralysis)

-autism

Ultimate decision whetherLSVT LOUD or LSVT BIG

is appropriate is Based upon:

• Assessment with stimulability testing• A trial of treatment • Clinical decision making skills of the

therapist

Don’t under estimate the potential to improve!

Everyone deserves a reasonable chance

Unexpected outcomes may await

Outline what to expect during assessment and treatment for LSVT LOUD and LSVT BIG in other conditions

Can the patient increase and/or stabilize amplitude of movement with your model and drive?

• Louder voice/Bigger movement

What is the impact across multiple motor functions?

• Speech – vowel durations, functional speech

• Movement – Gait, fine motor tasks, balance

What is the difference between cued and uncued speech/movements?

Can the patient follow the cues and directions?

• Assess cognitive abilities to follow directions

• May be an issue with really young children

Stimulability Testing


Consider very short clip of CP stimulability in speech video of cued and uncued gait (in PD, but we could use as an example of the type of difference we are looking for

Stimulability Considerations

• Don’t be discouraged if client is minimally stimulable in the initial testing session

• Consider a week of trial treatment as extended stimulablity testing – some clients takes a few days

• Follow your clinical intuition – give it a chance• Many times these are clients where nothing else has

worked• Sometimes clients may need some preconditioning

before they are ready for LSVT LOUD or LSVT BIG-E.g., establish sensory tolerance in children with autism

before LSVT LOUD; address orthopedic issues prior to LSVT BIG

• Try four consecutive initial treatment sessions and evaluate impact

• Can the client understand and approximate instructions

• Does the client show signs of motivation and engagement

• At then end of the week – evaluate progress

• If no progress or anything gets worse – stop• If good progress, continue with treatment

Initial Treatment Process

Factors that may influence stimulability for

LSVT LOUD or LSVT BIG

• Motivation• Timing• Saliency• Ability to benefit from intrinsic rewards (e.g.,

improved communication, mobility)• Family, social, facility or school support

• Buy-in• Opportunities for practice• Time and effort from family members, care

facility, or school personnel

Who benefits may depend upon:


Preparing as if you will proceed with all 16 sessions of LSVT LOUD or LSVT BIG

• Scheduling• One month of treatment blocked off. Expectations of daily

homework practice established

• Transportation• Line up help as needed for getting to/from clinic

• Cleared for Exercise• If needed, get medical clearance from other physicians for this

type of treatment

• Laryngeal Exam• For LSVT LOUD, get medical clearance the voice disorder

does not have a contra-indication or organic pathology that may need to be treated first

Discuss research cases on the application of LSVT LOUD to populations other than Parkinson disease

• 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, 2016; Bakhtiari, et al., 2017)

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

• Aging (Ramig et al., 2001)

(Single-subject, case study and small group designs)

LSVT LOUD Applications Reading Rainbow Passage

60

65

70

75

80

85

90

95

Brainstem Stroke MS Parkinson Group

SP

L d

b (

30

cm

)

Pre 1

Pre 2

Pre 3

Post 1

Post 2

FU 1

FU 2

Conversation

60

65

70

75

80

85

90

95

Brainstem Stroke MS Parkinson Group

SP

L d

b (

30

cm

)

Pre 1

Pre 2

Pre 3

Post 1

Post 2

FU 1

FU 2

Sapir et al, 2003;Sapir et al, 2001;Ramig et al, 2001

BACKGROUND INFORMATION

Age: 46 year old female

Diagnosis: Progressive MS with superimposedexacerbations

Time since diagnosis: 12 years sinceinitial diagnosis

Physical involvement: Motorized cart

Cognition: Within normal limits

PRE-TREATMENT VOICEAND SPEECH SIGNS

• Weak voice

• Intermittent breathy voice

• Observed deterioration of vocal loudness with extended use

• “No laryngeal anomalies, good speech production, no lesions”


Audio pre/post MS Case 2

POST-TREATMENT VOICEAND SPEECH CHANGES

• Increased loudness• Decreased fatigue• Improved singing strength• Confidence

• “Marked improvement in both the strength of voice and the adductor tone”

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

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

Discuss clinical cases on the application LSVT BIG to populations other than Parkinson disease

LSVT BIG for Stroke

A community dwelling, 52 year old female 2 years post stroke received LSVT BIG Independent in all activities of daily living and mobility with mild/moderate left upper extremity hemiparesis.

Outcome measures: increased active range of motion left shoulder forward flexion and abduction to within normal limits and active thumb extension; time improvements on the Wolf Motor Function test (7.78 sec pre; 4.14 sec post)

Proffitt R, Henderson W. et al. (2016) LSVT-BIG in Stroke: A Case Study. Arch Phys Med Rehab, Volume 97 , Issue 12 , e17.

• Multiple Trauma following a motor vehicle accident (MVA)

• 20 yo in MVA with cervical & thoracic fractures, head injury, internal injuries

• Hierarchy: climbing 12 foot ladder with tool box

• Functional Component Tasks: sit to stand; climbing up stairs as if on ladder; step up & down on stool, balance on 1 foot on step stool, place objects on overhead self from step stool

LSVT BIG Post Multiple Trauma

OUTCOMES

Assessment Tool

Pre‐treatment Post‐treatment

MiniBest Test 23/28 27/28

FTST 11 sec 8 sec

TUG 9,63 7 sec

ABC 55.62% 100%

Test Pre LSVT BIG Post LSVT BIGTUG ﴾Timed up and Go﴿

28 sec with walker

25 sec ﴾with walker﴿

FTST ﴾five times sit to stand﴿

Unable to complete

40.78 seconds

Berg Balance Scale

25 39

Standing independently

3 minutes 15 minutes

Case Presentation: MSA


FREQUENTLY ASKED QUESTIONS

• Is LSVT LOUD or LSVT BIG covered if I don’t have a diagnosis of Parkinson’s?

• Is it “true” LSVT if it is used for another diagnosis?

• Can the protocol be modified if it is used for another diagnosis?

Summary• We are not suggesting that LSVT LOUD or LSVT BIG is

for all conditions or diagnoses

• At this time, there is limited research beyond PD, but some promising results

• Ask your therapist about these treatments if you (or a family member) is interested in stimulability testing or trial treatment

• Don’t underestimate the power to change – everyone deserves a chance

• Ultimate decision is based on stimulability test, results of a trial of treatment & clinical decision making skills of the therapist

• We are here to help if you have any questions or concerns

Come with prepared questions or email [email protected]

NEXT Webinar: Wednesday, August 23rd

2:00 P.M. EDT in the United States!

Exercise versus Therapy for Parkinson Disease: How do I decide?

How to ask questions LIVE:

1. Type in the QUESTION BOX on your control panel

2. Raise your hand! (Click on the hand icon.)• Your name will be called out• Your mic will be unmuted (make sure your mic

is unmuted as well)• Then ask your question out loud

3. Email [email protected] if you think of questions later

Additional Information- www.lsvtglobal.com

- Patient Resources

- Free On Demand Webinars

- Scroll through the topics, available 24/7

- Advanced Parkinson Disease and Deep Brain Stimulation (DBS): How can LSVT LOUD® and LSVT BIG® help?

- Atypical Parkinsonian Disorders: Can LSVT LOUD® and LSVT BIG® be effective?

On Demand Webinars


- This webinar is offered for 0.1 self-reported CEUs.

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

- The LSVT Global webinars are not registered for state-approved CEUs (PT), ASHA approved (SLP) or AOTA approved (OT).

- You must request a certificate of completion. The certificate will include your name, date of the webinar and the number of hours earned.

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

- 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

Information on CEUs Instructor BiographiesCynthia Fox, Ph.D, CCC-SLPDr. 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.Beth Marcoux, DPT, PhDDr. Marcoux holds a BS in Physical Therapy from Russell Sage College, an advanced Master’s degree in Physical Therapy Education from the University of Alabama, Birmingham, a Ph.D. in Public Health (Health Behavior and Health Education) from the University of Michigan and a Doctor of Physical Therapy from the Massachusetts General Hospital Institute for Health Professions. She has served on physical therapy faculties at the University of Vermont, the University of Michigan, and University of Michigan-Flint, Henry Ford Community, Oakland University and the University of Rhode Island where she was Professor and Chair of Physical Therapy for seven years. She is certified in LSVT BIG and for the past several her clinical experience has focused on the treatment of patients with Parkinson’s disease.

DisclosuresAll 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. Marcoux receives lecture honorarium and consulting fees from LSVT Global, Inc.

public webinar series - lsvt globalblog.lsvtglobal.com/.../public-webinar-lsvt-beyond... · beyond...

Documents