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July speaker summary

Our BIG thanks to Lewis for not only organizing our speakers but writing this detailed summary for us all!

The speakers were Kimberly McPhee and Jennifer Katzen from Washington Speech in Fairfax.
Both are Certified Speech-Language Pathologists and Certified LSVT LOUD Clinicians.

LSVT LOUD is a treatment program that was designed specifically for people with Parkinson’s Disease (PwP). (For more information about the program, see What is LSVT LOUD?) The LSVT LOUD talk was prepared by Kim and Jennifer and presented by Jennifer. She based the talk on 15 slides that are summarized below.

Speech Characteristics in Parkinson’s Disease (PD)
It is common for people with Parkinson’s (PwP) to experience several speech impairments. Among these are reduced loudness, hoarse voice quality, monotonic speech, imprecise articulation and a vocal tremor. Some PwPs report that low volume, a hoarse voice, and monotonic speech are their first PD symptoms.

Reduced loudness should be seen to be more than just a laryngeal event. Together with other speech impairments that are correlated with PD, reduced loudness can create awkwardness in many communicative situations such as phone conversations, discussions at the grocery store and restaurants, and in conversations with your spouse or your children or grandchildren.

With PD there is often a mismatch between the PwP’s own perception of vocal output and the perception that others have of the person’s vocal output. PwP often think to themselves, “I’m not speaking too softly” when, in fact, they really are speaking too softly. And when they’re asked to speak louder, they often feel uncomfortable like they’re shouting. One of the goals of LSVT LOUD treatment program is for the participant to calibrate how much vocal effort is associated with normal speech.

Unexpected Outcomes
During an LSVT LOUD treatment, it is common for several systems to improve including the PwP’s volume and rate of speech, articulation, swallowing, and even facial expressions. Jennifer showed a chart from a research study by El-Sharkawi et al. (2002) (El-Sharkawi abstract) that demonstrates improved ability to swallow after LSVT LOUD treatment, and she showed a second chart that was adapted from a study by Ramig et al. (2001) (Ramig paper) that shows LSVT LOUD to be significantly more effective than respiratory therapy alone at maintaining vocal loudness over time.

Unexpected Outcomes Continued
In order for speech to happen, three subsystems must work together:
–  respiration – the way we breathe,
–  phonation – the way we make sounds with our voice, and
–  resonation – where the sound vibrates in our head.
Some people have to really work on respiration before they can start an LSVT program. Your speech language pathologist can work with your respiration.

Relative Vocal Loudness (a chart)
On a 5-point scale of relative vocal loudness that ranges from very soft to shouting with normal loudness in the middle, the typical vocal loudness level of a PwP is between very soft and soft, well below normal loudness. PwPs must use more vocal effort to have a voice within normal loudness limits.

What to Expect at the Evaluation
Before beginning an LSVT LOUD program, you will be evaluated by an ear, nose and throat (ENT) doctor to assess your vocal folds and to clear you for voice treatment. The evaluation will include a review of your case history, a review of your list of medications, a discussion with your caregiver and a discussion of vocal hygiene. Also, measurements may be taken of your breath support, your sustained phonation, your pitch range and your vocal quality. You may also need to obtain a prescription for the LSVT treatment.

What to do after Evaluation
Once you are cleared for LSVT LOUD treatment, you should come up with a list of at least 10 functional phrases that you use frequently throughout the day. These phrases will be used throughout the treatment program.

What are the Daily Exercises?
The first half of each treatment session will consist of three core exercises. All three will be monitored by tools that measure loudness and pitch. The first exercise is a sustained “ah” for a minimum of 15 repetitions. The second exercise is an “ah” that ascends in pitch from a middle tone to your highest tone, for 15 repetitions. This is followed by an “ah” that descends in pitch from a middle tone to your lowest tone, for 15 repetitions.

At this point in the presentation Jennifer had Lewis, a member of the Fair Oaks PD group who had completed the LSVT LOUD program, demonstrate both these two exercises.

The third daily exercise consists of saying the 10 functional phrases a minimum of 50 times.

Exercises Continued
After the three daily, core exercises, the second half of every treatment session consists of using the amplitude from the core exercises in context-specific situations and variable speaking activities. In week one this is done with single words and short phrases. In week two the core exercises are followed by full sentences. In week three the core exercises are followed by reading out loud. And in week four the exercises are followed by conversation with the therapist. As the weeks pass, clearly, each task in the second half of the session increases in difficulty as the sessions approach closer and closer to normal discussions.

How does Therapy Work?
Therapy sessions take place four days a week for four consecutive weeks.
During the therapy period of four weeks, you will complete all the exercises twice each day, one time during a session with the therapist and the other time at home, or two times at home on days when there is no session.

It’s About Calibration
One of the goals of LSVT LOUD treatment is for you to learn how much vocal effort you will need to produce normal speech. The other big goal of the treatment is for you to develop the physical capability to speak intelligibly and comfortably at that level of vocal effort. As a patient in LSVT LOUD, you can expect to learn quickly that unless you feel like you are talking too loudly you are not talking loudly enough. But, eventually, normal speech volume will come to feel normal. And then, you will be able to avoid most or all of the awkwardness in social situations (and at home) that your impaired voice caused before the treatment.

After completing the LSVT LOUD program, the three core exercises (all 15 repetitions each) should be completed one time each day for the foreseeable future. In addition, some people should return to an LSVT LOUD therapist for a “tuneup” after about six months.

New Programs
LSVT BIG a is a new program that focuses on gross motor movements. BIG is LOUD applied to limb movement.

LSVT BIG follows the same principles as LSVT LOUD and applies them to gross motor movements like walking, bending, reaching and so forth. For many PwPs, “if you don’t feel like you are moving too big you aren’t moving big enough.”

After Jennifer finished the LSVT talk, Kim gave a short talk on cognitive impairments associated with PD.

Kim’s major point was that cognitive exercises and games can reduce the risk of getting some of the impairments. She led the group through an example using Sudoku. And she told the group something that we have heard from other speakers as well, that routines can help to mitigate impairments. She concluded her talk by going through the following list of tips for caregivers:
1. Offer help only when your loved one asks for it.
2. Prompt the person – for example, instead of asking “did anyone call?” ask, “did Linda call?”
3. Say the name of the person and make eye contact when speaking to them, to gain and hold their attention.
4. Put reminder notes in a prominent place.
5. Keep things in routine places.
6. To ensure medications are taken on time, provide the person with a dispenser, perhaps with a built-in alarm.
7. Use photos on cell phone contact entries to prompt face-name association.
8. Write lists and keep them in a routine place.
9. If the person is searching for a word, provide a cue, such as, “the word you were looking for probably begins with ‘d’.”
10. Do not finish the sentences of a person who needs more time to put them together.
11. When presenting the person with a list of actions, first verbalize them, then write them down.
12. Ask the person questions in order to moderate the pace of conversation and allow them an opportunity to pause, catch up, think and reinforce.

Click here for bios for Jennifer and Kim

Click here for more information about Washington Speech available on their website.

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