public webinar series - lsvt...

Public Webinar Series

Title: Improving communication and movement through evidence-based speech, physical, and occupational therapies in Parkinson disease

Presenters: Laura Guse, MPT, MSCS

Cynthia Fox, PhD, CCC-SLP

Date Presented: March 16, 2016

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

Improving Communication and Movement through Evidence-based Speech, Physical, and Occupational

Therapies in Parkinson Disease

Supported, in part by research grants: R01 DC01150, R21 RFA-NS-02-006, R21 DC006078, R21 NS043711

Presented byCynthia Fox, PhD, CCC-SLP

LSVT BIG/LSVT LOUD Faculty

Co-Founder, VP of Operations

LSVT Global, Inc.

Laura Gusé, MPT, MSCSLSVT BIG Faculty

Chief Clinical Officer – LSVT BIG

LSVT Global, Inc.

Plan for WebinarLogistics (questions, handouts)

Present Webinar

Question/Answer Session

Survey will automatically launch at the conclusion of the webinar (less than 5 minutes to complete)

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.

Dr. Fox and Ms. Guse are employees of and receive lecture honorarium and travel reimbursement from LSVT Global, Inc. Dr. Fox has ownership interest in 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).

Objectives of Presentation

• Discuss development and data on an efficacious speech treatment LSVT LOUD®

• Highlight LSVT LOUD treatment concepts and increased treatment accessibility through technology-supported delivery

• Describe development and key aspects of limb motor treatment LSVT BIG®

• Provide a list of additional resources to learn more about LSVT LOUD and LSVT BIG

Polling Question 1

• Is this your first LSVT Global webinar?– Yes

– No


Poll Question 2

• Who are you?– Professional SLP, PT, or OT

– Graduate Student in Speech, PT, or OT

– Person with Parkinsons

– Caregiver or loved one of someone with PD

– Other

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

• LSVT BIG is a physical/occupational therapy– Delivered by LSVT BIG Certified Physical

or Occupational Therapists

Video Example:

• 59 year old female• 2.5 years post-diagnosis• On-meds pre and post video

Pre/post LSVT (Lee Silverman Voice Treatment)Intensive physical exercise of speech mechanism

LSVT LOUD Pre and Post Treatment Video

http://www.lsvtglobal.com/news/video

Patient case: Bernie

• 71 year-old, diagnosed with Parkinson’s disease in 1994

• Reason for referral: slowness and difficulty walking, history of falls, freezing

• Optimized on PD medications

• Hoehn & Yahr 3


LSVT BIG Pre and Post Treatmenthttp://www.lsvtglobal.com/news/video

Bernie’s Outcomes:

Falls 1-2/month 0/month

Assistive device Cane None

Confidence 37.5% 56.8%

Gait Velocity 0.35 m/s 1.17 m/s

% of age matched norm 29.6 % 100%

Endurance 730 ft 1200 ft

Bernie’s Goals: To improve his walking

To go to the movies

To play with his grandchildren

To go out to dinner with friends and family

PRE POST

Where did we begin…

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

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)

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

Surgical Treatment:

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

LSVT LOUD Treatment Concepts

Evidence-based Practice

SOFT

LOUD

HEALTHY LOUDNESS

Loud is more than a laryngeal event – spread of effects

TARGET

• Treatment delivered 4 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)

LIFE LONG HABIT OF PRACTICE!

Consistent with practice principles that drive activity-dependent neuroplasticity.

MODE: Intensive and High Effort

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

LSVT LOUD ExercisesDaily Exercises

Sustained “ah” (15+ repetitions)High/Low “ah” (15+ repetitions)Functional phrases (50+ repetitions)

Hierarchical speech Exercises

Week 1 – words, phrasesWeek 2 – sentencesWeek 3 – readingWeek 4 - conversation

Shorter, simple

Longer, complex

If you don’t feel like you are talking “too loud” you

are not talking loud enough!!

CALIBRATION

Fox et al, 2002; Sapir et al, 2011

Retrain sensory perception of the amount of effort and loudness needed to speak with a normal loudness level.


LSVT LOUD DATA

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

cm

)

LSVT R

LSVT® LOUD

RESP

N=45

Blinded, no med changeSame time med

Advances in 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)

LSVT eLOUD LSVT Companion

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

www.LSVTGlobal.com

Telemedicine

LSVT BIG

LSVT LOUD LSVT BIG

(Ebersbach et al, 2010; Farley & Koshland, 2005; Fox et al, 2012)


BIG (Large amplitude whole body movement)Single Target - Triggers Activation across motor systems

SMALLBIG

NORMAL “BIGNESS“

TARGET

Delivery– Certified LSVT BIG™ Physical/Occupational

Therapist• 1:1 intervention

Time of Practice– 4 consecutive days per week for 4 weeks

– 16 sessions in one month

– 60 minute sessions

– Daily carryover assignments (30 days/entire month)

– Daily homework (30 days/entire month)

MODE

MISMATCH betweenon-line perception ofoutput and how others perceive it

“I had no idea how small my world had become”

“I can’t move like this, people will think I am crazy!!”

CALIBRATION

LSVT BIG DATA

Comparing Exercise in Parkinson’s Disease —The Berlin BIG Study (2010, Movement Disorders)

Georg Ebersbach,1* Almut Ebersbach,1 Daniela Edler,1 Olaf Kaufhold,1 Matthias Kusch,1

Andreas Kupsch,2 and Jo¨rg Wissel3

Comparing Exercise in Parkinson’s Disease —The Berlin LSVT BIG Study (2010, Movement Disorders)

Georg Ebersbach,1* Almut Ebersbach,1 Daniela Edler,1 Olaf Kaufhold,1 Matthias Kusch,1

Andreas Kupsch,2 and Jo¨rg Wissel3

FIG. 2. UPDRS motor score (blinded rating), mean change from baseline (vertical bars 5 standard deviations). Change between baseline and follow up at week 16 was superior in BIG (interrupted line) compared to WALK (dotted line) and HOME (solid line), P <0.001. ANCOVA did not disclose significant differences between in intermediate and final assessments.


LSVT BIGExercises

Treatment SessionDaily Exercises1.Floor to Ceiling 2.Side to Side 3.Forward step 4.Sideways step 5.Backward step 6.Forward Rock and Reach 7.Sideways Rock and Reach

Functional Component Tasks

5 EVERYDAY TASKS– 5 reps each For Example:

-Sit-to-Stand

-Pulling keys out of pocket

-Opening refrigerator door

Walking BIG distance/time may vary

Hierarchy TasksPatient identified tasks:

Getting out of bed

Playing golf

In and out of a car

Build complexity across 4 weeks of treatment towards long term goals

Maximum Sustained Movements

Floor to Ceiling Side to Side

Multidirectional Repetitive MovementsStep and Reach

Forward Step Sideways Step Backward Step

Multidirectional Repetitive MovementsRock and Reach

Sideways Rock and Reach Forward/Backward Rock and Reach

-Stepping stones for use of good big

movements in daily life-


-Tools to facilitate improved movements, not the end goal of therapy-

Examples:

• Rolling in bed

• Sit to stand

• Reach for something

• Stir

• Pull pants up

Functional Component TASKS

Simple Movements– Patient DRIVEN!

Sit to stand BIG

5 tasks; 10 repetitions per day each x 30 days = 300 BIG repetitions of each task in one month!

Daily Hierarchical Tasks

“Real-World” Complex BIG Tasks – Patient DRIVEN!

• Bed to Bathroom• In/Out of Car• Walk and Talk• Tennis• Chores• Golf• Hiking• Gardening

BIG Walking- Big arm swings, Big steps

Goal: Normalize amplitude, stride length, posture, arm swing so

walking is more normal and safer in a variety of real world situations and

settings.

Carryover Exercises

Daily assignments to useBig movements

in real life situations outside of the treatment room

LSVT BIG TREATMENT GOAL

People with Parkinson disease will use their bigger movements

“automatically” in everyday living –

and there will belong-term carryover

of increased amplitude use!


“My voice is alive again!” - Lucy R.

“LSVT BIG has changed my life. I can free walk, arise from any armless chair, in or out of a car in a flash, the impact on my life is beyond a miracle.” - Charles H.

Our patients…living proof

Resources for You

For Therapy Professionals: How to get started with

LSVT BIG and LSVT LOUD Training

• For ONLINE LSVT BIG or ONLINE LSVT LOUD, go to www.lsvtglobal.com and click on LSVT BIG or LSVT LOUD and then “Online Courses” . Same content, certification, and CEUs as live course!

• For IN-PERSON LSVT BIG or IN-PERSON LSVT LOUD go to www.lsvtglobal.com and click on LSVT BIG or LSVT LOUD to find course locations.

For People with Parkinson’s:How to get started with

LSVT BIG and LSVT LOUD• Ask your doctor for a referral and a prescription for a speech

or physical/occupational therapy evaluation and treatment

• Visit www.lsvtglobal.com and click on “find a clinician” to find an LSVT LOUD or LSVT BIG Certified Clinician in your area

• DVDs available to introduce you to movement exercises used in LSVT BIG and voice exercises used in LSVT LOUD: www.lsvtglobal.com/products or www.amazon.com/shops/LSVTGlobal SOON available for Download or Streaming!!

Other Resources

1. LSVT Training: Live workshops and patient symposiums

2. Professional Meetings

3. Parkinson Events

4. Webinars

5. LSVT LOUD App for clinicians and patients

6. BIG for LIFETM and LOUD for LIFETM

7. New Video resources and streaming

How to ask questions1. Type in the question box on your control panel

2. Raise your hand! (click on the hand icon in your control panel)

• Your name will be called out• Your mic will be unmuted, then you can ask your

question out loud

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


Thank you!

Questions???

[email protected]

Please complete the survey that will automatically launch at close of webinar.

Additional Resources More details

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, UKJuly 16-17, 2016 Tokyo, JapanAugust 4-5, 2016 New York, NYAugust 26-27, 2016 Mainz, GermanyDecember 1 - 2, 2016 New York, NY

Every live workshop (LSVT BIG and LSVT LOUD) offers free patient symposiums on day 2! To register please go to www.lsvtglobal.com → Patient Resources → Patient Symposium

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

Updates as year progressesMarch 17 - 18, 2016 East Midlands, UKApril 9 - 10, 2016 St Louis (Creve Coeur), MOApril 16 - 17, 2016 Columbus, OHApril 30 – May 1, 2016 Minneapolis, MNApril 30 – May 1, 2016 Beelitz, GermanyMay 14- 15, 2016 Orlando, FLMay 21-22, 2016 Crown Point, INJune 10 - 11, 2016 Cherry Hill, NJJune 17-18, 2016 Berlin, GermanyJuly 9-10, 2016 Tokyo, JapanAugust 6-7, 2016 New York City, NYAugust 20 - 21, 2016 Traverse City, MIAugust 27– 28, 2016 Austin, TXOctober 1 - 2, 2016 Cherry Hill, NJOctober 29-30, 2016 Beelitz, GermanyNovember 19-20, 2016 Nuremburg, GermanyDecember 2-3, 2016 New York City, NY

Parkinson Events 2016• National Participating Partner in Partners in Parkinson’s:

Michael J Fox Foundation www.partnersinparkinsons.orgMarch 19: Birmingham, AlabamaMay 14: Oakland, CaliforniaJune 4: Cincinnati, OhioOctober 1: New York, New York

• Corporate Sponsor for the Victory Summit Symposia Series: Davis Phinney Foundation

• www.davisphinneyfoundation.org/victory-summit/April 30: Vancouver, BC, CanadaOctober 8: Sacramento, CA

Parkinson Events 2016

• Sponsor for the Parkinson’s Unity Walk www.unitywalk.orgSaturday, April 23, 2016

• World Parkinson Congress http://www.wpc2016.org/Portland, OR from September 20 – 23, 2016


Webinars 2016Use 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 DiseaseDate/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

www.lsvtglobal.com → Patient Resources → FREE Live or FREE On Demand Webinars

LSVT LOUD App (Free)

• Patient App • What happens when you get loud?• Homework reminder

• Clinician App• Clinical tools• Treatment guide

COMING SOON!

BIG for LIFE™ and LOUD for LIFETM

• Post discharge maintenance groups for people that received LSVT BIG and/or LSVT LOUD

• Pilot Launch of Test Group: July 2015-ongoing• Phase 1: Live training for LSVT BIG and LSVT

LOUD Clinicians in Spring of 2016• Phase 2: Assess results and expand access to

all LSVT BIG and LSVT LOUD Clinicians either live or online TBD

• Will be able to search the clinician directory to find a group near you – late 2016

LSVT BIG Homework Helper DVD Volume 2: Seated and Supine Adaptations

• Includes special chapter for caregivers!• New Exercise pictures• Coming 3rd Quarter 2016!

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