Background Developed by Parkinson Voice Project in Richardson, Texas Similar to LSVT, but uses latest and relevant research Central concept: bypasses the automatic system Long-term results driven by maintenance program (LOUD Crowd and refreshers)

Parkinson’s Characterized by reduced amplitude of movement Smaller walking, writing, and voicing Muscles become weak, because they’re not used to their full capacity Four cardinal symptoms: Resting tremor Slowness of movement Impaired balance Rigidity (stiffness)

DaTscan: imaging technology that reveals the levels of dopamine in the brain, confirms clinical suspicion of Parkinsonism Neurons that produce a chemical called dopamine die or become impaired 80% of dopamine-producing cells are lost by the time motor symptoms appear

Dopamine Dopamine is a neurotransmitter that transmits impulses from one neuron to the next for the planning and controlling of automatic muscle movements Without enough dopamine, automatic movements are disrupted Ex: walking, talking, swinging arms, swallowing, blinking, getting out of a chair, etc. The production of speech is a highly automatic behavior

Dopamine and Neurons

Early Signs of a Speech Disorder Reduced vocal volume Hoarse sounding vocal quality Frequent throat clearing Trailing off at the end of sentences Inconsistent production of the voice

Motor Systems Humans are blessed with two motor systems: Extrapyramidal Pyramidal

Extrapyramidal System “Automatic System”

Pyramidal “Intentional System”

Examples of Using Intent First job interview Driving down the freeway when it’s raining Exercising Basketball, baseball, tennis Giving this presentation!

SPEAK OUT! SPEAK OUT!® teaches pts with Parkinson’s to use INTENT instead of relying on automatic speech production When we speak with intent or deliberation, we use a system that is less dependent on dopamine

SPEAK OUT! & LOUD Crowd

SPEAK OUT! 12 individual sessions (3 days per week) Sessions are 40-45 minutes long Exercise 2x daily using SPEAK OUT! Workbook Cognitive exercises embedded Speak with INTENT at all times!

Components of the Program 1) Assessment: Completed by SLP and student Baseline data taken Stimulability testing Video recording of pre-therapy interview Call Parkinson’s Voice Project 2) Therapy: Completed by student with SLP assistance when needed Complete one lesson per session, 1x Client completes one lesson per day, 2x per day; therapy and LOUD Crowd count as 1x 3) LOUD Crowd Every week starting in their third week 4) Follow-up, Refreshers Six week follow up/check-in Refresher at 3 or 6 months, depending on follow-up results if come in morning, they do again in afternoon... **review HO?

Assessment Brief interview Screen for swallow and cognitive decline Complete brief oral mech exam and motor speech tasks/analysis Record pre-interview questions Complete baseline data tasks using the data sheet Conversation average dB Sustained /a/ average Reading Grandfather Passage average

Assessment continued Document severity of speech domains and choose vocal quality descriptors Educate on intent using the motor tract diagram Model all stimulability tasks and provide cueing Sustained /a/ average dB Reading of Phrases average Document improvement in any speech domains Write recommendations

Discharge Complete components (hopefully of lesson 25) Record post-interview questions Watch the pre and post interviews to compare Provide them with the Discharge Summary Make sure to take discharge data the session prior (session 11 in the calendar) Give them their diploma (in InfoCDS)and celebrate! Schedule the 6 week follow-up

Follow-up Scheduled 6 weeks after original discharge Brief interview Document frequency of lesson completions and what components, if they have assistance, how many LOUD Crowds attended, etc. (these are listed on document) Complete a lesson (of their or your choosing based on perceived level of competence) Use prior goals Document level of cueing needed during lesson Write recommendations and determine when they come back for a refresher

Refresher Refreshers follow the same protocol as a follow-up and assessment combined It does not include the stimulability testing

Calendar Use the calendar that provides you with each session’s detailed lesson plan Read the calendar ahead to prepare for the session

Important Notes Educate pts on importance of daily practice Parkinson’s Voice Project drops pts from therapy who do not keep up with the homework It is a requirement, but also makes a difference For pts who are behind, attempt to have them make up lessons Lessons get increasingly challenging Remind pts about LOUD Crowd so that they go in week three

To Do You can adjust the tasks to manage time Verbal cues: E.g., if slow processing time on cognitive tasks, only do a few Slow them down if they speed through Verbal cues: Give frequent reinforcement (“Very strong” or “Stronger”), this reorients their internal feedback system Some pts like to hear what the dB level is, this can be a good reinforcement cue Typical phrases: “With intent!”, “Through the wall!” “Speak out”, “Throw it out”, “Say it over my head”, “Yell it across the room” “More powerful” “Stronger”, “Use your CEO voice”, “That was 85” Visual cues: Use your hands to guide the glides Cup ear, wave forward like when you gesture “come here”, point hand up, over your head "That's what it feels like to be at an understandable level." Some clients have SLM or dB apps at home.

To Avoid Explanations, do not talk about breath support, over-articulation, etc. Idea is to model and rehearse instead of analyzing, which increases cognitive load Allowing them to go consistently into the 90 dBs, this is damaging and will wear out the voice Allowing them to either not do daily practice or overuse their voice and do too much

Documentation Use the provided data sheet Only take averaged dB data of the conversation task All other data is a plus or minus Can fill in the dB goals for several data sheets at once Adapt the goals r/t difficulty Attempt to fill in the % accuracy as you go However you take data, make sure to keep it consistent across sessions E.g., always taking the first and last lines of sequences Due to supervisor: SOAP with data and pertinent information E.g., what cueing helped, homework completed, vocal quality descriptions, independence in self- cueing or correction, medical changes that affect performance, etc. I make sure to always get ending data to see intent endurance.

Daily Data Sheet Make goals prior to the first therapy session and write them in blank spots on the left The warm up is completed 5 times ahs, and glides are completed 10 times each They are only completed 5x in the home practice (home practice takes 15 minutes) There are 10 boxes in the row, each box is for one repetition i.e., the first /a/ data goes in the first box, the second /a/ data goes in the second box, 10x For the conversation task, do not cue, just take dB data throughout until you have 10 data points For all other components, use a plus or minus in reference to the goal; write the % when the component is completed and the level of cuieng

Goal Writing Use the PVP examples, but ensure they are SMART E.g., “SCMA will produce “ah” at 90 dB with 90% accuracy independently.” or “SCMA will produce paragraphs at 71 dB with 80% accuracy when given minimal cueing.” Write attainable goals based on the stimulability data Write goals based on pts PD severity Do they have deep brain stimulation (DBS) or Progressive Supranuclear Palsy (PSP) diagnosis? Conversational goal is most challenging to meet, make it achievable

Goal Writing Goal ranges for each component: Warm up: 85-90 Ahs: 85-90 Glides: 85-90 Number sequences: 80-85 Reading: 75-85 Cognitive: 72-78

Scheduling If pt misses a session, attempt to make it up or have them complete the exercises independently that day Best practice to schedule with two consecutive sessions, one day break, then a third session. This allows us to provide feedback and training so that they are using intent correctly when outside the clinic 12 sessions is average, however, can be less or more as needed

The LOUD Crowd® Dopamine is also responsible for our motivation and drive People with PD need to actively find ways to motivate themselves to exercise daily Attend LOUD Crowd It provides: Weekly review of SPEAK OUT! exercises Peer support and encouragement Provides accountability and motivation to regularly complete SPEAK OUT! exercises

The LOUD Crowd® Hosted by Hilyard Community Center, Tuesdays at 2:30 p.m. Students arrive by at least 2:15 p.m. to set-up Use chairs with arms and provide water Use the LOUD Crowd workbooks, organized by month and week Students set-up and take down, prepare water for members, and lead the components Complete the components, include an out-of-the book group activity at end Should take 30-40 minutes Document how many members were present in the log Use the group as an opportunity to occasionally check-in on if they are doing the daily exercises Strive for pt to pt interaction and encouragement Make them accountable to each-other (e.g., “Sara, do you think Tom is using his intentional voice?”) Ask for their opinion (e.g., how to switch up the sequences to make it more intentional) During workbook, use the SLM or ask if they think someone is using intent in-between tasks; game that includes them talking to each-other

Leading The LOUD Crowd® Group Use the same cueing techniques that are used in individual therapy Use opportunities to increase the intent During sequences have them shout out the third number extra loud/long, have them get progressively louder in each line, count backwards, yell “Ole!” at the end of each line, etc. Take an answer from each of them (e.g., favorite father’s day gift) and have the group spell it forwards then backwards. Join the Facebook SPEAK OUT! Providers group for game ideas

Leading The LOUD Crowd® Game Ideas Out-of-the book game ideas Scattagories or Head Bandz (in the Hilyard treatment room) (Note-adjust the complexity) Print out pages to practice writing and have them play 2 truths 1 lie, write a fond summertime memory, write a letter to their young selves, write about who they were in 1970 Use the Ice breakers and Conversation topics HO when a new client comes to group, split them up to ask each other questions then have them state (with intent!) one thing they learned about their partner to the group Split them up and have them plan a volunteer outing that they actually do Group discussion on topics important to them (e.g., how PD has changed their lives, falls, medication, swallowing changes, changing social lives, what they are grateful for, etc.) Get creative! Making it seasonally themed is always fun 