EPISODE 76

[INTRODUCTION]

[00:00:05] MBH: Thanks for joining us at Keys for SLPs, opening new doors for speech-language pathologists to better serve clients throughout the lifespan. A weekly audio course and podcast from speechtherapypd.com. I'm your host, Mary Beth Hines, a curious SLP who embraces lifelong learning.Ê

Keys for SLPs brings you experts in the field of speech-language pathology as well as collaborative professionals, patients and caregivers to discuss therapy strategies, research, challenges, triumphs and career opportunities. Engage with a range of practitioners, from young innovators to pioneers in the field, as we discuss a variety of topics to help the inspired clinician thrive.Ê

Each episode of Keys for SLPs has an accompanying audio course on speechtherapypd.com available for .1 ASHA CEUs. We are offering an audio core subscription special coupon code to listeners of this podcast. Type the word KEYS for twenty dollars off. With hundreds of audio courses on demand and new courses released weekly, it's only $59 per year with the code word KEYS. Visit speechtherapypd.com and start earning ASHA CEUs today.Ê

[INTERVIEW]Ê

[0:01:24] MBH: Welcome to this episode, episode 76 of Keys For SLPs. Keys to Communication with Parkinson's Disease with SPEAK OUT! I am Mary Beth Hines. Before we get started, we have a few items to mention. Here are the financial and non-financial disclosures. I am the host of Keys for SLPs and receive compensation from speechtherapypd.com. I am employed by Life Speech Pathology and Voices for Parkinson's. I am a SPEAK OUT! provider. No non-financial relationships exist.

Samantha Elandary is the founder and Chief Executive Officer of Parkinson Voice Project. She received an honorarium for this presentation from speechtherapypd.com. Samantha is a volunteer on the Board of Directors for Parkinson Voice Project.

Caitline Fattore received an honorarium for this presentation from speechtherapypd.com. She is a co-founder and operator of Voices for Parkinson's. Caitline is a SPEAK OUT! provider. Caitline is a participant of the SIG 15 Professional Development Committee. And she is a volunteer on the Board of Directors of Voices for Parkinson's.Ê

Now we'll go into our learning objectives. Okay. Number one, describe how Parkinson's disease impacts communication, specifically biofeedback and perception. And how SPEAK OUT! addresses communication challenges? Two, identify three tools and objective measures that can be utilized to measure success by the SLP and the client with Parkinson's disease. Three, identify three methods that are utilized to promote patient success with the SPEAK OUT! program.Ê

And now we welcome our guests today. Samantha Elandary, MA, CCC-SLP. And Caitline Fattore, MS, CCC-SLP. Both our guests run nonprofit organizations that help people with Parkinson's communicate. Samantha Elandary and her team at Parkinson Voice Project developed SPEAK OUT! therapy. The program consists of individual and group speech therapy combined education and daily home practice.Ê

Parkinson Voice Project is a nonprofit organization dedicated to helping people with Parkinson's regain and retain their speech and swallowing. Elandary founded the organization in 2005. In 2012, Parkinson Voice Project began training other speech-language pathologists from across the country and abroad in SPEAK OUT! therapy. The goal is to make this effective speech treatment accessible to patients worldwide.Ê

Caitline became a SPEAK OUT! provider in 2018 and co-founded the nonprofit Voices for Parkinson's in March of 2020. Both Caitline and Samantha are passionate about educating and serving the Parkinson community. For complete bios, please visit this course listing on speechtherapypd.com.Ê

Samantha and Caitline, we are honored to have you both here today.Ê

[0:04:19] SE: Thank you for the opportunity.

[0:04:19] CF: Thank you.

[0:04:20] MBH: Thank you to both of you for all that you do for people with Parkinson's disease. Let's talk about both of your journeys. Samantha, will you tell us about your journey as an SLP that led you to have expertise in working with people with Parkinson's?Ê

[0:04:34] SE: Sure. Actually, in 1997, I was working in a Dallas hospital and we were treating individuals with Parkinson's. And as all SLPs know, around that time in 1998, Medicare came out with the therapy caps. And it was just devastating for the patients that I was treating. I was noticing that they were getting better and stronger. I had the idea of having my patients come back for group therapy after the individual speech treatment. And I noticed how much it helped them to keep up with their home practice and it provided the support and encouragement. But with the Medicare therapy caps, everything started to kind of fall apart.Ê

I left the hospital. I started treating individuals with Parkinson's out of my home. And then it took me six years to develop what is now Parkinson Voice Project. I finally came to realize that it needed to be we needed the nonprofit model. The private practice wasn't going to work at least for what I had had in mind. And so, now it's a nonprofit organization.Ê

And I do want to mention, I will be giving my honorarium to Parkinson Voice Project. I appreciate that, but I'll be donating that to Parkinson Voice Project. And now we have an organization. We're located in Richardson, Texas. We developed SPEAK OUT! therapy in 2010. In 2012, we started training speech-language pathologist and graduate students. And now the program is across the US and abroad. And it's pretty exciting. But our goal is to make SPEAK OUT! therapy accessible to people with Parkinson's and related neurological disorders worldwide.Ê

[0:06:27] MBH: Well, wonderful. Well, thank you for all you have done. And it's so exciting for us as other SLPS to see someone who had an idea and just made it bloom. Thank you for blooming that Parkinson Voice Project.

[0:06:41] SE: It was hard, I'm going to say. At the beginning, it was very difficult trying to figure out the best way to do it and thought I could do a private practice. And then just kept running into obstacles. I'm not saying that a private practice wouldn't work. But it is challenging when your specialty is Parkinson's. And it's very different from other SLPs that might treat maybe children and adults.

[0:07:09] MBH: Well, we do say we grow from our challenges. And if you hadn't had those challenges, you may not have grown it into what it is today. Thank you for sticking with it.

[0:07:19] SE: Thank you.

[0:07:20] MBH: And, Caitline, can you tell us a little bit about your journey?Ê

[0:07:24] CF: Absolutely. I actually went into undergraduate thinking I wanted to be a pediatric speech therapy model. And I started working with the older adults and fell in love with the medical side of things. After graduate school, I started a position with a big rehab company in the skilled nursing facilities. Did some acute rehab and had the opportunity.Ê

One of my co-workers said, "Hey, there's this really great program called SPEAK OUT! Have you heard of it? We have an opportunity to get one of our speech therapists trained. We'd love to have you."Ê

And I had a little a little bit of experience through graduate school. And, unfortunately, it was mostly, if this person with Parkinson's is having trouble swallowing, let's leave it be because we're going to fatigue the muscles. It was almost this old-school ideal that we just kind of let it be. We don't want to aggravate. I never learned anything about how it affects the communication.Ê

I was so lucky and got to go down to the Lead With Intent Symposium down in Texas and left so energized. Okay. This is so different from what I learned. We're really missing out on a huge population here. I was really excited by the work, the model and coming from a big corporate kind of healthcare model and seeing some of those challenges that Samantha just spoke about. I thought, "How neat is this?"Ê

And she's done all the groundwork. And how cool that she is so willing to share her ideas and to make it accessible? I came back to Cincinnati, Ohio, to my employer, and I said, "Let's hit the ground running." We started to build the caseload. And since then, I have co-founded a nonprofit model similar to Samantha's. Much smaller, but follow her guidance.Ê

And so, I do the nonprofit work on the side. I still work as a speech therapist and all the other kind of settings. But since 2000, I think we got our nonprofit status in 2019. And since then, have worked through COVID and seeing people. And the telehealth aspect of it.Ê

I've just grown into learning more about the Parkinson's community. How do we do the best therapy for them? And kind of just found that niche in that population. That's my journey so far.

[0:09:48] MBH: Well, wonderful. Well, thank you for sharing and thank you for creating that nonprofit as well. All right. Samantha, will you summarize the SPEAK OUT! program and tell us how this program helps communication for those with Parkinson's? And address the biofeedback and perception that can be the most challenging thing for people with Parkinson's disease.Ê

[0:10:10] SE: Sure. We know that humans have two motor systems. We have the pyramidal system and the extrapyramidal system. And we like to refer to them as the intentional motor system or the automatic motor system.Ê

Well, speaking and swallowing are automatic behaviors. Normally, we could Ð I like to give the example that, normally, we can walk down the street with our friend, have a conversation and eat an ice cream cone all at the same time. It's all automatic.Ê

But the problem is that automatic movements are highly dependent on dopamine. And people with Parkinson's, by the time they have any symptoms of Parkinson's, they've already lost about 80% of their dopamine-producing cells. Because they do not have enough dopamine, any movements that used to be automatic or anything that they would do without conscious effort now has to be intentional.Ê

They need to learn how to speak with intent, but also swallow with intent, walk with intent. Anything that was automatic now needs to be purposeful, deliberate and intentional. And we learned all about this from the late Daniel R. Boone. He actually first recognized this, if you can believe it, in the late 1950s.Ê

In the late 1950s, Dr. Boone was working with a neurologist at Highland View Hospital in Ohio and they had these Parkinson patients. And they said, "Will you please count from 1 to 20?" And when they counted, they could barely be understood. Their voices were soft. They were mumbly, flat, no expression.Ê

And then they said, "Well, would you count backwards?" And Dr. Boone tells the story so beautifully of how, right away, the patients were saying, 20, 19, 18. He's like, "Huh? What's going on here?" Well, when they were counting forward, they were using their automatic motor system, which it needs dopamine. So it wasn't working. And when they were counting backward, they were using intent. They were using the pyramidal motor system.Ê

And something interesting is that Dr. Boone said that they had to have patients count to at least 20 backward. They couldn't do 10. Because when you count backward from 10, 9, 8, it's automatic. They would not see the benefit in this speech until they would ask them to count 15 or 20. They had to do that.Ê

And that's the basis of the SPEAK OUT! therapy program, is to do exercises to strengthen the muscles that we use for speaking and for swallowing and the premise is to learn how to speak with intent. And I really love that. Because you can go into a quiet environment and speak with intent. And you can go into a noisy restaurant and speak with intent.Ê

And it's something also that can generalize to other areas of their life. Again, walking with intent and putting their seat belt on with intent. But the biggest thing about SPEAK OUT! therapy is that it's not just one-on-one therapy. It is one-on-one therapy and then patients transition to group therapy. They stay in the program for the rest of their lives. And it also requires daily home practice.Ê

In fact, when patients enroll in SPEAK OUT! therapy, if they are not committed to doing the daily home practice, then we will ask them to please come back when you're ready to make that commitment. Because speech therapy for Parkinson's without the daily home practice will not work.Ê

But I also want to say there is a business side to this too. The reason that we developed SPEAK OUT! is we were trying to find a program that would fit with the Medicare rules. That was the big challenge. When I first got into this, I recognized that people with Parkinson's need so much therapy. But we couldn't get Medicare to pay for as much as they need.Ê

We worked very hard at developing a protocol that could be where the treatment sessions were short and we could help them. I can tell you right now that most of our patients Ð now that we are doing teletherapy, most of our patients are reaching their treatment goals in 8 to 10, 30-minute sessions. And I think that's pretty amazing.Ê

And my staff, we work. We are continually working to figure out how to be more efficient and how Ð when the Medicare therapy caps came out, people would say, "Oh, we only have this much money." So, "Sorry. We can't provide the treatment." And the way I wanted to look at it was, "Okay, we only have this much money. Now how can we do it?"Ê

And so, we developed a workbook that we ship to every US patient. That saves the speech pathologists a lot of time. They're not having to develop materials. Every patient has their own workbook. Now we have an e-library. It's got photo cards, and word cards and these other therapy workbooks.Ê

We're trying to Ð our nonprofit is supplementing the care that speech-language pathologists are giving at the hospitals, are providing at their hospitals or other clinics. We're supplementing what you're giving so that people with Parkinson's will receive the best care. It's really hard to do it all in one model. But if the nonprofit sector jumps in, and helps and provides the workbooks, and takes the time to study and figure out, "How can we be more efficient?" then all patients are going to be helped.Ê

[0:15:55] MBH: Well, that is an excellent model. It is so surprising to tell a patient, "Well, yeah, you don't Ð" or it's surprising for the patient, "Yeah, you don't have to pay for the workbook. Yes, you actually get it for free." If you want to make a donation down the line, that's fine. But I think just that demonstrates the way that Parkinson Voice Project really cares for the patients and families. And you've really thought it through to make it inclusive and the best.Ê

Speaking of which, I think we're going to get into it a little bit later. But you've also really expanded your offerings for home practice through not teletherapy, but tele Ð what would we call it? Telegroup?

[0:16:35] SE: Well, with the pandemic, we had to shut down our clinic in March of 2020. And I was so concerned at that time. Because people with Parkinson's, if they don't do their exercises for even two days, they usually can tell a difference. They can start to tell a difference in their voice and their swallowing.Ê

And at that time, in March of 2020, we were conducting 15 groups every week in our clinic. And then, all of a sudden, we had to shut the doors. We went on Facebook live and started doing SPEAK OUT! exercises. And I was terrified to do that. I mean, now it's no problem. But back then, I was doing it from my home, from my living room airing.Ê

And we had 30 people, 30 participants practicing and doing their home practice at that time. Now these exercises are now on our website, Facebook, YouTube. They're hosted live five days a week. We have more than 3,000 patients practicing with us every day. And we also record so that people in other countries where, when we do it live, it might be the middle of the night for them, they can practice it at any time. And those are all offered at no charge.Ê

In fact, since 2008, Parkinson Voice Project has not charged for any of its patient care services. Our clinic is very unique. Not only do we provide the workbooks in the e-library, but we don't charge for therapy. Our program is funded through the pay-it-forward model where patients receive whatever treatment they need. And then if they're able to, they can pay it forward. Make a donation to help the next patient who needs help.

[0:18:27] CF: And if I may interject, some pieces coming from a speech therapist who's a SPEAK OUT! provider, those Facebook live sessions and the recordings help keep the patient engaged. Because they're new every time. When you think of the limited time we have to do resources as speech-pathologist, we're passing out a handout of, "These are your exercises. And go and do them." Well, you do that page over and over again, it, A, becomes automatic. And so, you're not thinking about it anymore. And, B, bored. I've done this. I've said this sentence 6,000 times. I'm kind of done with it.Ê

And so, a lot of my clients do the Facebook with Samantha and her team. And they come back and love it and talk to our groups like, "Oh, try this one. This one's really good and functional." There's an out-and-about workbook that is specific to different scenarios that a person may encounter. Being at the airport. being at the pharmacy. And so, it's these functional scenarios where you get the buy-in and like, "Oh, I could see where I'd be using this."Ê

And so, also, the point of, when you have a workbook, there's really no excuse. Okay. I know having that structure there I think helps provide that carryover from the client and their family is I don't have to do any guessing. I go right to this book. I look through it. I go to the next lesson. This is how it goes.Ê

And the fact that they have responsibility. I'm not the magic speech therapist with a wand who's going to make it all better. The fact that this program shows, "Okay. You come into me. We tweak. We work together." But then, in between, what are you doing? It's not just a passive approach. And so, I think those are some points that just that you guys were talking that I wanted to make sure I relayed.Ê

[0:20:12] MBH: Well, thank you. Those are really good points. Yeah, it's the daily home practice and that commitment to, "I'm not going through the speech therapy. And after eight or 12 weeks, I'm going to be done. I'm going to be fixed. And that's it." I'm going to commit to working on this for the rest of my life because it is important.

[0:20:30] SE: Yeah. We like to tell our patients, "We're in it with you for the long haul." But I think that's also where the nonprofit can help the for-profit. Because speech pathologists in hospitals and other clinics where they might have 90% productivity standards, well, they don't have the time to develop the materials. And so, that's where we come in.Ê

We're going to take the time to develop the materials. And we're even developing new workbooks now. We have one for young onset population. We have a group called The Parkinson Voice Advocates. These are our patient volunteers. And they are helping us to create this workbook.Ê

And so, think about the things that somebody in their 30s or 40s what they need to practice saying. Someone the other day said, "Can I find you on Instagram? Would you like to go have a drink?" We are creating this workbook that will have different lessons in it for things that if you're raising kids, working, dating.Ê

And we're also creating a workbook for people with Parkinson plus disorders. We know it's more challenging for them. Some of the sentences are way too long. We're going to modify that. But because we're nonprofit, we are able to take and spend that time to develop the materials and then share them with everybody. And all these materials can go into the e-library. And we now this year have a setup where all SPEAK OUT! providers, the speech pathologists and all their patients have free access to the e-library.Ê

It's just about doing absolutely everything that we can to help people with Parkinson's regain and retain their speech and swallowing for a lifetime. And we'll do everything we can to help speech pathologists to be able to do that.

[0:22:24] MBH: Well, thank you for doing that. As a new provider, I was not aware that the patients had access to the library as well.

[0:22:32] SE: They do now.

[0:22:33] MBH: They do now. Okay. I know I did not get full access until I completed my Ð it's not really a certification. It's a ÐÊ

[0:22:41] SE: You're licensed. You're licensed in SPEAK OUT!Ê

[0:22:44] MBH: Mm-hmm. Okay. Do they have to go through to individual sessions before they get access to the library? How does that work?Ê

They do. We will ship a hard copy of the SPEAK OUT! workbook to any patient in the United States for free. Pretty soon, it's going to become available for outside the US. They can get workbooks too. But they're going to have to pay a fee, unfortunately. Because it's just too expensive to ship it out of the country.Ê

But any SPEAK OUT! provider, when they log into their account now, they have a link to give to their patients. We do not give workbooks or the e-library access to any person with Parkinson's who is not working one-on-one with a SPEAK OUT! provider. Because we know that is not the best care. It's not that we want to hold on to it. We don't even sell it. If we sold the book or the e-library, I bet we would have lots of patients and families who would love to pay for it. But that's not the best care for them. They need the one-on-one treatment and they need group and the daily home practice.Ê

Of course, the home practice sessions, anybody can participate. Anybody. But now we restrict the workbook. And that way, I'm not going to say it forces them, but they need to connect one-on-one with a SPEAK OUT! provider. They will not make the same Ð as much progress as they could if they're not working one-on-one and then doing the groups.

[0:24:12] MBH: Really getting that individualized feedback.Ê

[0:24:17] SE: They need it. Because of the sensory deficit, which is what you were talking about before. Where people with Parkinson's, the way that they are speaking, they think they are speaking louder and clearer than they really are. And so many times they say, "Well, I sound too loud." And I say, "You don't sound too loud. You feel like it's too loud. You feel like it's too loud, but it actually sounds good." And so, we have to do a lot of recording during the treatment session so that they can hear themselves. It's not their hearing. It's the way it feels.

[0:24:54] MBH: Exactly. And how many patients come to you with a complaint about their significant others' hearing?Ê

[0:25:00] CF: I just had that today.Ê

[0:25:04] MBH: Oh, okay. All right. Well, thank you. One more question for you, Samantha. Can you touch upon the research and the supportive evidence for SPEAK OUT! therapy?

[0:25:14] SE: Absolutely. On our website under education and training there is a link in the drop down that says research. You can go there to see the research studies that have been published on SPEAK OUT! And it's good. We certainly don't have as much research as let's say the LSVT LOUD program. Of course, that started in the 80s. In the 80s.Ê

But the reason Ð really, SPEAK OUT! and LSVT, the results, if you look at just the one-on-one treatment, they're very similar. The biggest difference is the emphasis on maintenance. That is really Ð because, honestly, Parkinson Voice Project would probably still be using LSVT. But there's a couple things. So many treatment sessions that maybe Medicare won't follow and lots of therapists maybe modifying or changing it. And we don't want to do that.Ê

Because once you change the program, it's not evidence-based anymore, right? if it was researched for 16 1-hour sessions and you're only doing eight 45-minute sessions, well, then we're not following it. I think it's important when therapists think about evidence-based research. Yes, we have the research, but we Ð also, your patient may not fit, or your situation, or what you're able to do may not fit into that model.Ê

But I am excited to tell you that we are establishing a SPEAK OUT! therapy and research center right now. One in every state. We are collaborating with universities across the United States. And these university clinics will be treating patients and utilizing SPEAK OUT! And they will be designing and conducting research studies on Parkinson's, speech and swallowing issues and SPEAK OUT! In the future, we will have more research to clinically prove what we know to be true.Ê

And if there are any university faculty participating in this session, they might want to check out our SPEAK OUT! grant program and the grant that deals with the SPEAK OUT! therapy and research centers. Because we're working very closely with these universities. They also receive $50,000 over five years to help them, especially as we transition to telehealth and we need to upgrade our computers and microphones. And so, that funding that our donors are providing can help the universities to get that equipment that they need so they can provide top-notch therapy. But anyway, you can go to our website and learn about those therapy and research centers. I'm pretty excited about it.

[0:28:00] MBH: Well, that is exciting. Well, thank you for sharing that. Okay, Caitline. Can you tell us how do you engage and then reinforce the strategies you teach to support your clients' success?Ê

[0:28:11] CF: Yeah. We kind of touched based on that, the whole aspect of people walking in the doors and saying, "I'm here because my spouse says they can't hear me." "I'm here because the doctor said I should be here."Ê

And so, the first portion and really why I got excited about this program is how underserved the Parkinson's community is. When I went to the Lead With Intent and learned like only 4% of people get the services they need and neurologists and doctors aren't really explaining what Parkinson's can do in terms of the swallowing, the speech, the cognition.Ê

And so, part of my mission was we have to get this education. And so, I'm excited to see more people coming in those doors and being prompted by other people and not just writing it off as, "Well, that's just Parkinson's," or "that's just me," or "that's just me getting older," or "she can't hear me." "He can't hear me."Ê

The first step is getting to know them. Why are you here? Okay. If there's blame on other people, then we kind of talk about, "Okay. Well, what are some situations you're finding difficult?" And what I love about this program and this approach is there's subjective, there's objective. There are so many different tools you can use, which is the question you asked.Ê

One of the things is a decibel reader. I have a lot of gentlemen who really need the numbers. They want to know, "Okay. I get that you say I sound good. But that doesn't mean much. What are my numbers?" And so, we have normative data of conversation should be 72 to about 78. There's fluctuation in the settings.Ê

And so, we start off with going through the protocol. We talk about, "Okay. Well, do you think you maybe met those numbers? Let's talk about what your numbers were." "No. No. There's no way I could be that low. There's something wrong with your machine." "Okay. Well, what if we talk and we go through the protocol of a pre-treatment video and I say, "Okay. Well, let's listen." And the reaction of, "That's not me," or, "Can you turn that up, please? That must be really low." Or I've had people say, "My poor wife." Like, "That's me?" And they say, "Okay." They kind of get that buy-in of maybe it is a little bit of hearing impairment of other people. But it's probably I didn't realize that my numbers were this low. That I sounded this low. The perception that we've been talking about this entire course. That biofeedback.Ê

And so, we use the decibel reader, audio recordings. A lot of self-awareness. How did that feel? Samantha brought up, "Okay. Someone says I'm too loud." "No. You feel too loud. And one of the cues in the book, the SPEAK OUT! workbook, is being comfortable with being uncomfortable.Ê

When you're using intent, you're going to feel a little uncomfortable because your brain's going to be telling you too loud. And so, what we do is all that feedback of how do people respond when you use intent? Have you noticed they've asked you less questions or you've had to repeat less? Yeah, I've noticed that. Okay. Well, don't you think if you were too loud they would be backing away?

Reading the people around you. That self-awareness. And really, okay, this is what I feel like. This is that intentional voice. And this is the body feeling I have. These are the cues I have to have and feel to know I'm at that correct volume. Or when I'm using my intentional voice, I know when I hear it. Okay, I know it feels loud, but I know that it's appropriate.Ê

Another thing is the comparison. Sometimes I'll record just me talking with them and I'll say, "Okay. Well, do I sound too loud when we talk?" "No, you sound okay. Well, let's listen to this." If you know that my voice is comfortable and then your voice is quite soft compared to mine, you know I'm not making this up.Ê

A lot of those tools of assessing with the objective, the body feelings, the cues that their brain's telling them. When I know my brain is saying, "Oh, I'm too loud." I actually know that's probably a good volume. And when I'm not thinking about my voice, I'm not being intentional and I'm not getting those brain cues, I know I'm reverting back down here in that soft speech.Ê

We did talk a lot about to the carryover, the Facebook daily group practice from Samantha, caregiver groups, the speech groups that we offer. And then there's also sing out and sing along. There's all these variety of ways to keep your voice involved. And so, I think that's part of reinforcing the strategies, is they're doing it in ways that are fun functional and that they enjoy. Singing, joining a group.Ê

I think the peer interaction is very big too. In those speech groups, those weekly maintenance groups, "Okay. Great, Caitline. You're my speech pathologist. You have to say I'm doing well." First of all, I don't have to say that. And second of all, it means more when their peers are saying, "Wow. that was great. I really understood you there. That was such good intent." And they're talking back and forth and interjecting on how well each other's doing and like, "That's the clearest I've heard him be." And talking.Ê

And so, you get that collaboration, camaraderie. And you learn to use it in a functional way. Therapy happens outside of those four walls. What happens outside? Another reinforcement or strategy is getting the caregivers involved. Just touching again on that biofeedback. And what Samantha was touching on, that if someone doesn't connect with a speech pathologist, they're never going to learn Ð I don't want to say never. But they're less likely to learn that change.Ê

And so, if I think I'm talking loud, I'm going to continue to talk this way because I've known to tell me that's not loud enough or it's not being projected. I liken it to people's physical therapy. Because everybody knows physical therapy is great. Physical exercise for Parkinson's. And they're all gung-ho about that. But, darn it, to get them in a speech therapy clinic.Ê

I liken it to have you ever had someone tell you take bigger steps? And you think you're taking big steps. And I liken it to that's the same thing. Your voice is small. People are telling you to have a big voice. And it's that disconnect. And so, that feedback of really retraining what is a good intentional voice? What is a good normative? You're not too loud. Not too soft.Ê

And just meeting them where they are. Finding functional goals for them. I think that's such a piece that we lose. And we've gotten so much better as a field. But with the Medicare, it all has to be this measurable Ð we're so stuck in that loop. But to find something functional.Ê

For example, a gentleman always came to me and before he would have his lunch. And so, he'd go through the drive-thru. His goal was to be able to go through a drive-thru and not have someone ask to repeat, or say what's that, or to give him just whatever they thought he said. And so, that's so functional. I mean, yeah. And that's kind of what lights my fire. And then I think I had one other thought and it completely went away.

[0:35:30] MBH: Well, that's okay. I have a question for you. Can you both touch upon the caregiver groups? What's the structure of those? And what are your goals for the caregiver groups? Is it more support? Or are you training them on the exercises to be a care partner?Ê

[0:35:47] SE: At Parkinson Voice Project, we include the care partners in the treatment. We do not have separate care partner groups. There are a number of other Parkinson organizations like the Davis Phinney Foundation that has a care partner, monthly meetup. And they have lots of good educational materials for care partners. And I think that is one really important thing for nonprofits.Ê

For anyone maybe thinking about starting a nonprofit, is that if there is another nonprofit that is doing what you're doing, well, then it would be better for us to refer. Unless we can find it. We've always had a hard time finding the right psychologist or counselor that knew enough about Parkinson's.Ê

Caitline, I'm not sure if y'all offer care partner groups. You might. But ours are mostly just focused on the speech and swallowing and educating them about that. Educating them about the sensory deficit and educating them about the motivation.Ê

The lack of dopamine affects the patient's motivation and drive. And, unfortunately, care partners will think, "My husband is just lazy. Or he's stubborn. He knows what he needs to do. He knows he sounds better when he does this SPEAK OUT! exercises, but he won't do them."Ê

And, unfortunately, some care partners just kind of throw their hands up and say, "Well, he's an adult. If he doesn't want to do it, he doesn't have to." And that's a big mistake. Part of ours in working with the care partners is to help them to understand that struggle with motivation. And I usually tell them, "We all make New Year's resolutions. And how long does it take us to stop doing them?" Right? I mean, if I say I'm going to eat right. And then by the afternoon when somebody brings out some cake, it's gone.Ê

[0:37:43] MBH: Uh, tomorrow.Ê

[0:37:43] SE: Yeah. And I have all my dopamine or supposedly. I think I do. And so, imagine, if they don't have it, how hard it is for them. We do a lot of educating. But there is something new since the pandemic. We are updating our SPEAK OUT! course. Because our current course doesn't have teletherapy in it. But something else that we've noticed since patients are spending more time at home, something we've added to our Ð it was always part of the protocol, but we've emphasized it, is that we need to train the care partner on the best cue for every patient.Ê

Intent means different things to different people. Some people, when you tell, "Say it with intent." Oh, they sound so much better immediately. But other people, it's speak out more. And they do better. I mean, if they have a gravelly voice, speak out more is usually the cue that works for them. Or if they're speaking too quickly, it's usually speak out more. Or every single word with intent.Ê

Part of our care partner group is training the care partner in what the best cue is. We're trying to get the care partners to stop saying, "What? Huh? Stop mumbling. Sit up straight. Maybe if you took a deeper breath you could talk better." We want to cue them, so that what we are queuing them, how we're queuing them in therapy, they are doing the same thing and their children are doing the same thing.Ê

And that's why I love teletherapy. Because children are participating in the therapy sessions even if they live in other states. And we can train everybody so that they're all saying be more deliberate or whatever the best cue is.Ê

[0:39:29] MBH: And I find when family members actually participate in the therapy, then they don't feel like they are being critical when they're giving those cues. Everyone's on the same page. The patient doesn't feel picked on. Because they've all learned it together in therapy.Ê

[0:39:45] SE: And I love that we can give the patients the e-library. Because now they can work with their kids. I have one patient who lives in one state and his three children live in different states. And he practices every morning online with the online SPEAK OUT! practice sessions. But every afternoon or evening, the kids take turns. And they work for 15 to 20 minutes using the tools in the e-library. Or they might talk about something else. But it kind of gives them some structure. And they can access it. And it's great.

[0:40:20] MBH: Well, what a great way to connect. And, Caitline, I know your structure is a little bit different. Is your f with care partners similar?Ê

[0:40:28] CF: Yes. I agree. The fact of having the care partners involved. Because, again, therapy happens outside of the four walls as well. That's where the gains happen. And if it's a drop so and so off and I'm going to go do my errands, they're not learning the cues and they're not seeing those small steps where, "Okay. Well, look at the way he corrected himself here or she corrected herself." And engaging in that home practice.Ê

Again, if the caregiver doesn't know what they're looking for or can't cue the client to speak out or to use intent and they're doing their warm-ups just "ahhh". And the spouse or caregiver say, "Great. You did your workbook. Awesome." But they're not getting the most out of it.Ê

The caregivers have to know and the communication partners have to know what's going on in the education piece. And as Samantha touched on the difference Ð I have a lot of couples that come in and it's a strain on their marriage. I'm sick of asking him/her to repeat. I'm sick of her/him telling me to repeat. And it's this functional goal of how do we step in?Ê

And, again, if they're just saying, "What? Huh? I can't hear you." That's not the cue that's registering. And they can also see just from a skilled standpoint of a speech therapist some of that education that we have. And if this doesn't work, what can we try differently? How can we cue differently and get a different result?Ê

We don't have specific caregiver groups either. But we do encourage the family to come in. And we've always encouraged on telehealth, "Have someone near you as many caregivers as you can have." I'm working with a donor right now and he has a morning aid. And she sits in on the sessions. Because she's helping him get ready. If she can't hear and understand him, granted he has PSP. So it's the plus. He needs a lot more physical help and he's declining a little bit more rapidly. And it's okay she can't understand me. And those are my most intimate moments and what I need to stay healthy and functional.Ê

She sits in on the sessions. And it's a very just involved. This is a community thing. Communication takes two people. It's not just myself talking. And so, we need both partners. We need both ends of that continuum.

[0:42:49] MBH: Well, that is great. Well, thank you. All right. I know we touched on it a little bit before. We want to get into some case studies in a minute here. But, Samantha, can you tell us a little bit about Medicare and insurance coverage for SPEAK OUT!

[0:43:02] SE: We don't bill Medicare at Parkinson Voice Project or any insurance. But when you Ð yes, it definitely covers it. There is no CPT code for SPEAK OUT! therapy just like other treatments. You ask for the order for speech evaluation and treatment.Ê

I wish I could tell you more about that. I can't, since we don't bill Medicare. But other providers, our billing insurance, not having a problem. We also do what Ð we call them refreshers. But they're really evaluations that every six months, at least every six months, you bring the patient back for another evaluation. And haven't heard any problems with that not being billed or paid for. It's just speech therapy. And so, it's fine. Yeah. I wish I could tell you more. I don't. We haven't billed Medicare since 2007.Ê

[0:43:59] CF: And if I may interject real quickly. I have the nonprofit donation-based pay-it-forward model similar to Samantha. But I also do the SPEAK OUT! protocol. I've done it with home health, and outpatient and in the hospital. And so, I've never had trouble Ð I'll say with the SPEAK OUT! protocol or the model, sure, the barriers of insurance. And I'm sharing the Medicare funds of the PT and ST. How much have they used for this year come into those? Well, they don't have Medicare. They have [inaudible 0:44:32] give you four sessions. Do what you can with it.Ê

As Samantha said it is a billable service. It's just finding the healthcare and navigating that system, which is why I love what Samantha started with the pay it forward and then donation-based, that there's really no restrictions. You get to give the client what they need and what's beneficial. You don't have to worry about explaining why you should be able to do your job. You just do your job. You provide the services.Ê

[0:45:03] SE: I think the home practice sessions are really helping therapists who are in that situation where an insurance company is saying, "We're only going to pay for five therapy sessions." Because the home practice sessions that we're doing five days a week, online and no charge, they go through all six of the SPEAK OUT! exercises. And so, the patients can learn them faster.Ê

They're getting the model from me. It's not therapy. And I think that's one of the biggest benefits since the pandemic. Offering these practice sessions. I thought they were going to be temporary when I started them three years ago. I didn't know I would still be doing them. But we do 260 a year. And they're all different. Different topic every day. But following the six SPEAK OUT! exercises. And I think it's a great benefit to the patients going through it. Because they can learn how to do the exercises accurately. And they can learn them faster. And this is a big help, especially to the young-onset population. Because I think they are the ones that have the insurance plans that may not cover that many sessions.

[0:46:14] MBH: Oh, that's a good point. All right. Let's get into some case studies. Let's check our time. Okay. Let's just go Ð I know you guys have both prepared a few. Why don't we just go back and forth? And, Caitline, you want to start with one of your favorite case studies?Ê

[0:46:30] CF: Yeah. Mine, I didn't bring much numerical data because I really find the results in, again, the functional setting. My first one, and just to kind of reiterate how important the speech group is, the client had the basics in those sessions. He understood what intent was, but he wasn't quite there yet. And he was one who didn't quite believe me in my feedback. I'm the speech therapist. Of course, I'm saying you sound good.Ê

And so, he continued to come to the speech groups weekly and he's been Ð I mean, never misses one. And I start to see continued progress. It's not even that. He's maintaining he's making further progress in getting that feedback from his peers. And, "Hey, that was a lot more intentional. So I understood what you said."Ê

And so, seeing him continue to make that progress and maintain the skills has been one of the best that I look back and I'm like, "This is why this model works." Yeah. And he was one that was a little bit more Ð he has DBS. And so, the speech pattern is a little bit different. It's a little bit more sped-up. And so, he uses the intent to take his time and say every word with intent.Ê

And so, he's really gotten much better and feels more confident in it in his ability to self-assess and say, "Yeah, that was good." Or, "Oop. That wasn't as intentional as I could have been," has grown so much over the past year of him being within the groups.Ê

[0:47:59] MBH: Oh, that's exciting. It's so exciting to see that progress. That's what it's all about.Ê

[0:48:04] CF: He's got a long Ð he needs to be engaged in these social activities. And he was pulling away. And then he came to the program and just kind of blossomed.

[0:48:13] MBH: That's awesome. That's awesome. Okay, Samantha. I know you've had years of this. It's probably very hard to pick a favorite or a few favorites.Ê

[0:48:23] SE: Yeah. There are so many of them. When patients come in, it is very typical. They're not usually aware of the problem that they're having. I would say that's most people that come in. They really Ð some of them are dragged in by their spouses, kicking and screaming. And they only came to the speech evaluation to prove to their spouse that they were the ones with the hearing problem.Ê

Patients will come in with Ð if it's idiopathic Parkinson's, it's not uncommon for them to be speaking with glottal fry. They describe it as hoarseness. But it's really just glottal fry. Also, not articulating as well mostly due to the small movements. We think of the small movement, small handwriting, small walking. Well, their facial expression. Those facial muscles and are not moving as much. And so, their articulation is not as good.Ê

I will say that people with Parkinson's make very quick progress. Some people, after they have the evaluation and they come for their first session, they're already speaking better. Because they've started to use intent. And it usually doesn't take much.Ê

When we're doing the SPEAK OUT! therapy program, what we're really working on is teaching them the exercises. How to do them? And that's why those online sessions are so helpful. How to do them the right way? We want them to establish a consistent home practice routine. We want to train the caregiver in the best cue. What is the best cue for this particular patient? And then the other goal is to transition to a group. It's something that they're going to have to do for a lifetime.Ê

On our website, under our program, we have some video testimonials. If you go to parkinsonvoiceproject.org, under our program and in the dropdown there's testimonials. And there are a number of videos there. And I encourage the SLPs to go and see them when you're looking at case studies.Ê

And the neat thing is every patient is different. And some of these patients, what we did was we brought them back 10 years later. We are Ð you will see them not just when they Ð before they started SPEAK OUT! therapy and right afterwards. But you will see them several years later.Ê

There's one gentleman there who's been in the program for 15 years. And so, you'll get to see what he's like. And so, I encourage everyone to go look at those videos. Because you'll see all the typical symptoms of Parkinson's. Whether it's low volume, gravelly voice, breathy voice, in coordination of the breath support for speech, flat, affect. But then you'll see what it's like afterwards.Ê

I would say anybody treating people with Parkinson's, they need to take videos. That is crucial for this patient population. They're important for the patient to be able see the progress they're making. It's important for the family to see it. It's important for us SLPs. It makes us feel good too.Ê

But also, to share those testimonials with physicians. We have a lot of educating to do with the physicians. I think sharing those video testimonials with the doctors will help a lot too. I don't know if I answered your question, but there are just so many.

[0:51:52] MBH: That's okay. That's very good information. Can you think of a client who kind of stands out as someone who SPEAK OUT! therapy really changed their life?

[0:52:04] SE: There is a particular patient. And his Ð well, I call him Frank, even though we won't say his last name. But I think the neat thing about Frank, he found out about the program when he was at his doctor's office and there was a brochure sitting there. And Frank is a Salesman. And on the back of it there was a communication screening and he was like, "What? 90% of people with Parkinson's can lose their voice? I can't lose my voice." So he called us.Ê

Sure enough, he went through the program. And even though he thought that Parkinson's had not affected his voice yet, it had. When he heard it, "Wow. That just is not as vibrant as it used to be."Ê

He's been in our program now for six years. But what is neat about him is that he really has generalized intent to other areas of his life. Six years ago, he was actually in a wheelchair and he went to physical therapy. And I think he thought at the time, "Well, Parkinson's, it's a progressive disease. And I'm just going to get worse and worse."Ê

And so, we referred him for physical therapy. He got better and then was walking with a walker for several years now. And during the pandemic, he went back and had another round of physical therapy and now is walking with a cane. But if you talk to him, he talks about doing everything with intent. Talking with intent. Walking with intent. Even being intentional about his exercise and managing his Parkinson's. And being intentional about when he takes his medications and when he eats. And being intentional about not filling up his schedule too much. I mean, there's so much that people with Parkinson's need.Ê

I love it, we say speak with intent and live with intent. I think that's also one of the benefits of the program is never-ending. Sometimes there's too much information at the beginning for the patient. But as they're in the program for a while, then they're able to start, "Okay. I have a handle on this. Now I can Ð let me see if I can start using intent in this area."Ê

[0:54:14] MBH: Oh, that's great. What a great story. Now is he a patient advocate? I know you spoke about it.Ê

[0:54:19] SE: Yes. He's a Parkinson Voice advocate. And he is in our intentional singers. And he gives presentations. And he sings at his church. And he's now giving those brochures out to other people. And I think this patient volunteer program that we have, all SPEAK OUT! providers can recommend a SPEAK OUT! graduate to be a Parkinson Voice advocate. A patient volunteer.Ê

And this is something else that also changed during the pandemic. We have our in-house volunteer group, but we also have a virtual group. And I will say that the people on the advocates, the first part of being an advocate is being a role model. And that means doing your physical exercise. Doing your SPEAK OUT! exercises. Staying consistent and working one-on-one.Ê

And so, if there are SPEAK OUT! providers there that have patients that they think would benefit from being in this group with other people who are learning how to live with intent and then help others, it can be very motivating to do that. And it gives them a purpose. I need to keep my voice strong because I'm going to be going to that health fair.Ê

And it also can help the local clinics. Even though we are train Ð this is another example how the nonprofit sector can help other providers. We will train the advocates. We will teach them the statistics. We will teach them how to go out there and educate others. But they are meant Ð and when they live Ð we have advocates from all different states. They are supposed to be helping the SPEAK OUT! providers in their area. They can greet the group members. They can go out and distribute brochures to the local physicians. There's just so many people that need help.Ê

We have over six million people with Parkinson's in the world. We know that number is not even accurate. Because there are so many people that probably have Parkinson's who haven't been officially diagnosed. 90% will struggle with speech and swallowing. The main cause of death in Parkinson's is aspiration pneumonia caused by swallowing disorders.Ê

In fact, it's been documented that aspiration pneumonia accounts for 70% of the mortality rate in this patient population. That is not the case that way at Parkinson Voice. So it doesn't need to be that way. And we just have so much work. And I'm really grateful to you for making this a topic. And I can't tell you how proud I am to hear Caitline and really excited about all of the patients.Ê

And I know how many patients she's treated. Because we've shipped workbooks out. But there's a lot. Dozens of patients that she has helped already and will help. And it's just really exciting to see. And I'm happy for those patients.Ê

[0:57:20] MBH: Well, that's so nice of you to say. Yes, Caitline, you are a shining example. Can you tell us Ð both of you kind of weigh-in. I just had a question that popped up. For someone who's newly diagnosed who may have no or very minimal voice symptoms yet, when would you tell them that the best time for Parkinson's for SPEAK OUT! therapy would be?Ê

[0:57:43] CF: Right now.Ê

[0:57:44] MBH: I've said to people it's kind of like an insurance policy that you're giving yourself. When you do start to have physical changes, you already have these skills in place and you're really in tune to that biofeedback. But I would love to get your thoughts on that.Ê

[0:58:01] CF: I used to be under the umbrella coming out of graduate school that if there's "no impairment" we don't treat them. But you think about this disease, it's progressive. And I think you make a great point of let's be proactive versus reactive. Because when things start to tumble or progress, you're probably having more memory issues, more cognitive, more physical. And so, you're battling a bigger set of symptoms.Ê

And I typically tell people, again, kind of with the physical. But like, okay, it's a lot easier to lose five pounds than it is 50 pounds. And same with your voice. If you're coming to us as speech therapist and your voice is already so deteriorated, we have to build those muscles back up and teach you how to speak with intent. Whereas if you come in and you learn these premises, and, "Okay, what does intent mean?" you can maintain those vocal muscles. And then you also have Ð and you're in more of a routine and feeling more comfortable and confident in intent.Ê

And so, it's not learning when you're in the middle of a fall. And so, then we just tumble into this whole it's a reactive. We kind of Ð as a society, we react in chaos versus, like you said, being in an insurance policy. Let's keep and maintain that communication and those skills. And let's learn what can maybe happen. How do we prevent that? Instead of just waiting till it happens and then coming in and saying, "Well, here we are."Ê

[0:59:37] MBH: That's great.Ê

[0:59:38] SE: I'm not sure I've ever evaluated a patient who would not benefit from treatment. There's always something to work on. But some patients we've treated Ð the first part of our program is that patients and families attend a learn about Parkinson's webinar. I do want to mention that. And it's on the homepage of our website. Anybody that wants to learn about Parkinson's and wants to learn about the difference between the automatic and intentional motor systems is invited to come attend that webinar.Ê

But what I will say is Ð usually, patients have something to work on. But maybe some patients only need four therapy sessions. And so, they will tend to learn about Parkinson's webinar. Well, we'll evaluate them first and get a baseline. I love to get a baseline. That's what I tell new people, "Maybe you don't need treatment. But let's go ahead and get a baseline so we have something to compare."Ê

And then, usually, they do need treatment. They go to the learn about Parkinson's webinar and they get their workbook and they learn their exercises. But maybe they only need four treatment sessions. Not everybody needs 10 or 12. Some people need 25 treatment sessions. And that's okay too. We'll provide that too. But some only need maybe four or five treatment sessions and then they can transition to the group and then they get all of those benefits that Caitline was talking about. That camaraderie.Ê

And the groups I will say Ð SPEAK OUT! groups, people are grouped according to, I guess, their levels. If you have somebody who's struggling with single words and phrases, they will not be in the same group as somebody who can carry on a conversation and tell a joke. That is something that's very important with the SPEAK OUT! protocol. Because if somebody is very mild and then you put them in a group with somebody who's having severe issues, that can be very upsetting to them.Ê

But do a little therapy. Teach them the exercises. Get them to start practicing online. They'll have fun. And then they'll participate in their group. And then six months later, we bring them back just to see how they're doing. And maybe later on they'll need more.Ê

I love what you said, Caitline, about it's easier to lose five pounds than 50. I'm going to use that from now on. That is so good. And I wish everybody Ð I wish every patient, considering DBS, would go have an evaluation and treatment if they need it before DBS. Because it can be a real shock. The speech deficits after DBS can just Ð it's just not something that's talked about a lot and can be very devastating.Ê

But if they've already gone through the program or they've already learned the exercises, it will not be as much of a shock. And then after the surgery, we're fine-tuning it. But at least they're not having to start from scratch.

[1:02:36] MBH: Good information. Thank you so much. And we are just about at our time. We do have a question here. As I look Ð let me look at that question. Is Parkinson's plus for more severe patients?Ê

[1:02:51] SE: People diagnosed with Parkinson plus disorder. Sometimes they refer to them as the alphabet soup. It's PSP, MSA, CBD. Very often, patients are diagnosed with idiopathic Parkinson disease first. And then after about five years of assessing the patient,Ê
they go back to the neurologist every six months, they find that maybe the medications aren't working as well. The disease is progressing more rapidly.Ê

And so, Parkinson plus, yes, it is more severe. The patients have a harder time. They really have to practice every day. Maybe even twice a day. Shorter sessions. But they need treatment right away. And the coordination of the breathing, that can become severe. And for them, the ability to cough.Ê

And that's what I really talk to people about when Ð sometimes for somebody with Parkinson plus, they are really struggling to speak with intent in conversation without any cues. Oftentimes, they need a cue and then they can do it. And that's much better than repeating themselves four, five, six times. Or just throwing their arms up and go, "Forget it. I'm not going to talk anymore." If they only have to repeat once, that's good.Ê

But sometimes care partners can be frustrated and think that speech therapy isn't helping. And we really need to show them that the muscles we use for speaking are the muscles we use for swallowing. They're the muscles we use in order to produce a good cough.Ê

And so, for these patients, it is essential that they do the treatment and that they practice every day and that we train the care partners. You're not just trying to preserve the speech and try to get their conversational speech better. You're trying to preserve their ability to be able to cough. Because so many of these patients will hold their breath when they try to cough and go, "Ahh," which is we don't want to hear that.Ê

As you're doing the SPEAK OUT! exercises, you're taking that air in and out. And it just helps with so many other features also. Not just for Parkinson plus, but the saliva. So many patients come in and say, "I feel like I have more saliva than everybody else in the world." And so, "Well, you don't." But swallowing our saliva is an automatic function. And automatic functions or movements require dopamine. And you don't have enough dopamine.Ê

It goes back to what Caitline said about becoming very aware. Aware of when the saliva is accumulating in your mouth and intentionally, purposefully swallowing. And that can be very important for people with Parkinson plus disorders also.

[1:05:37] MBH: Thank you for that clarification. And so, true. When we're swallowing our saliva, if we have an adequate amount of dopamine, it's very automatic. We don't even know that we're swallowing and it just kind of happens.Ê

[1:05:48] SE: I will say a trick that helps my patients, if they don't have a problem with aspirating if they choose sugar-free gum, it just makes them swallow more often. And so, that seems to help them. I mean, think about it. The posture with Parkinson's is also to lean forward. If that saliva is accumulating in your mouth, I mean, you're going to have a problem. But I will say that chewing, a lot of my patients choose sugar-free gum. And that helps them to swallow. And the more we swallow, the better our swallowing is.Ê

[1:06:20] MBH: Exactly. Exactly. Well, thank you so much. I really appreciate it. Samantha and Caitline, it's been so wonderful to spend this time with you. And you both had such interesting perspectives. Samantha, you've been doing this Ð you're one of the founders. You are the founder. I know you didn't want to take all the credit for SPEAK OUT! But I'd like to give you credit. And thank you for everything that you have done for people with Parkinson's and for speech-language pathologists who are working with people with Parkinson's.Ê

And, Caitline, it's been so fun to get to know you as well and learn about how you started this nonprofit and all that you are doing for people with Parkinson's in your world here in Cincinnati.Ê

[1:07:03] CF: Thank you.

[1:07:03] MBH: Well, do you guys have anything else that you would like to add?Ê

[1:07:07] CF: I would just like to thank you for the opportunity. And, Samantha, I mean, I don't know where I'd be. Walking into your doors and learning about SPEAK OUT! just Ð I mean, it's been such a pleasure. And all that you do for this population, it's been groundbreaking. I appreciate it.Ê

[1:07:23] SE: I think you're doing a wonderful job. And I just want to say that, for any speech pathologists, if they have questions about starting a nonprofit or so, I love to work with people on that and talk that through. Because it's hard. It's hard. And we all got into this field because we want to help people. And it's difficult. It's hard. But there is a way to do it. And, Caitline, you're doing it now. And I'm glad got to see the clinic. It is amazing. She got to meet a lot of the Parkinson Voice Advocates. And just when you meet them in person too, it's pretty amazing.Ê

But Mary Beth, what you're doing too is amazing in educating speech-pathologists about all sorts of topics. Thank you for choosing Parkinson's and SPEAK OUT! therapy. We appreciate it.Ê

[1:08:16] MBH: Well, thank you. Well, I appreciate it. And I do make it down to Texas from time to time. I might just happen ÐÊ

[1:08:22] SE: Come visit.Ê

[1:08:23] MBH: I would love to. I would love to.Ê

[1:08:25] SE: We would love to have you. You can meet the advocates. They would love to talk to you. And, yes, you could be part of our online practice sessions.Ê

[1:08:34] MBH: I would love that. We'll talk.Ê

[1:08:37] SE: Okay.

[1:08:37] MBH: Thank you, everyone. Have a great day.

[1:08:39] CF: Thank you.

[OUTRO]

[1:08:41] MBH: Thanks for joining us here at Keys for SLPs, providing keys to open new doors to better serve our clients throughout the lifespan. Remember to go to speechtherapypd.com to learn more about earning ASHA CEUs for this episode and more.Ê

Thanks for your positive reviews and support. I would love for you to write a quick review and subscribe. Keep up the good work.Ê

[END]

 
KFSP 76		Transcript

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