2. 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)

3. 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)

4. 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

5. 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

6. Dopamine and Neurons

7. 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

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

9. Extrapyramidal System
“Automatic System”

10. Pyramidal
“Intentional System”

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

12. 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

13. SPEAK OUT! & LOUD Crowd

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

15. 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

16. The LOUD Crowd® Maintenance Program
Weekly review of SPEAK OUT! exercises
Peer support and encouragement
Provides accountability and motivation to regularly complete SPEAK OUT! exercises

17. 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
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?

18. Calendar PVP provides a calendar with each session lesson plan
Read the calendar ahead to prepare for the session

19. 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
Pts who are behind, try to make up lessons
Lessons get increasingly challenging
Remind pts about LOUD Crowd
adjust time: people who speed through exercises or who take longer

20. To Do You can adjust the tasks to manage time Verbal cues:
E.g., slow processing time on cognitive tasks, only do a few
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”
Visual cues:
Use your hands to guide the glides
Put hand by hear, 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.

21. To Avoid
Explanations, do not talk about breath support, over-articulation, etc.
Idea is to keep modeling and rehearse instead of analyze
Allowing them to go consistently into the 90s, 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

22. 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.

23. Daily Data Sheet
Make goals prior to the first therapy session and write them in blank spots on the left
The warm up, 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
For the conversation task, do not cue, just take dB data throughout until you have 10
For all other components, use a plus or minus in reference to the goal; write the % when the component is completed

24. Goal Writing
Use the PVP examples, but ensure they are SMART and show growth progression
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 moderate cueing.”
Write different dB goals for phrases, sentences and paragraphs, because they are different levels of difficulty
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?
Conversation goal is most challenging to meet, make it achievable

25. 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

26. 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

27. LOUD Crowd Hosted by Hilyard Community Center, Fridays at 2:00 p.m.
Students arrive by at least 1:45 p.m. to set-up
Use chairs with arms and provide water
Use the LOUD Crowd workbooks, organized by month
Students set-up and take down, prepare water, and extra activities
Complete the components, include an out-of-the book group activity
Should take minutes
Strive for pt to pt interaction and encouragement
Both during workbook and in extra game
E.g. during workbook components “Sara, do you think Tom is using intent?” E.g. during extra game have them ask each other questions
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