EPISODE 81

[INTRODUCTION]

[0:00:05.7] 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.

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.

Each episode of Keys for SLPs has an accompanying audio course on SpeechTherapyPD.com, available for 0.1 ASHA CEUs. We are offering an audio course subscription special coupon code to listeners of this podcast. Type the word Keys for $20 off. With hundreds of audio courses on demand and new courses released weekly, it's only $59 per year with the codeword Keys. Visit SpeechTherapyPD.com and start earning ASHA CEUs today.

[INTERVIEW]

[0:01:24.1] MBH: Welcome to this episode of Keys for SLPs, Keys to Treating a Variety of Speech and Voice Disorders with LSVT LOUD. I am Mary Beth Hines. Before we get started, we have a few items to mention. Here are the required financial and non-financial disclosures. I am the host of Keys for SLPs and receive compensation from SpeechTherapyPD.com. 

For my nonfinancial disclosure, I am LSVT LOUD certified. Cynthia Fox is Chief Executive Officer and cofounder of LSVT Global, and a faculty member for both LSVT LOUD and LSVT BIG Training and Certification Courses. She receives an honorarium from SpeechTherapyPD.com for her podcast appearance. 

And here are our learning objectives for today. One, describe the evolution of LSVT LOUD, two, define five parameters that research has shown evidence of improvement with LSVT LOUD, and three, identify five speech and/or voice disorders that research supports using LSVT LOUD for treatment. 

And now, we welcome our guest today, Dr. Cynthia Fox, Ph.D., CCC, SLP. Dr. Fox received her doctorate degree in Speech and Hearing Sciences from the University of Arizona Tucson. Her training included a focus in the areas of Neuroscience and Motor Control. She is an expert on rehabilitation and neuroplasticity and the role of exercise in the improvement of function consequent to neural injury and disease.

She has over 25 years of experience working in collaboration with expert colleagues, conducting efficacy research on the Lee Silverman Voice Treatment, LSVT LOUD Program, in people with ParkinsonÕs disease as well as studying the underlying mechanisms of speech disorders and ParkinsonÕs disease. Dr. Fox is a world leader in the administration of LSVT LOUD treatment. 

She was the first to apply LSVT LOUD to disorders other than ParkinsonÕs disease. She pioneered the application to pediatric populations including children with cerebral palsy, and Down syndrome. She worked closely on the development of a physical and occupational therapy program, LSVT BIG, that was modeled after the LSVT LOUD Speech Treatment Protocol.

Dr. Fox is the Chief Executive Officer and co-founder of LSVT Global and a faculty member for both LSVT LOUD and LSVT BIG Training and Certification Courses. Welcome, Dr. Fox. It is an honor to have you here.

[0:03:59.9] CF: Thank you, itÕs really wonderful to be here and I appreciate the invitation to talk with you here today.

[0:04:06.5] MBH: Well, thank you for accepting it, it really is an honor. I know it took us a little while to make it happen and IÕm so happy that you're here. So, tell us a little bit about yourself and your journey as an SLP.

[0:04:19.2] CF: Sure. So, I live now, in beautiful Tucson, Arizona, and my journey got me here through my journey as a speech-language pathologist. So, I graduated with my undergraduate degree from Southeast Missouri State University in Cape Gerardo. Crossed the Mississippi, I headed out to University of Colorado Boulder where I studied for my master's degree. It was at that time that I took Dr. Lorraine RamigÕs Voice Class. 

I got very interested in voice. I volunteered at her lab at that time, where she was doing the research on initial Š some of the initial work on LSVT LOUD for people with Parkinson's, and when I graduated I really didnÕt know where I was going to go. I was excited to have some kind of focus and voice, really loved the neurological, and Dr. Ramig rang me up one day before I had a job and said, ŅHey, I have a research position open in Tucson Arizona, would you be interested?Ó And I was like, ŅYes, IÕm interested, IÕll goÓ.

I had no idea where Tucson was, I remember looking at the map and kind of going, ŅWoah, thatÕs way far south.Ó But that began really, what will this August be 30 years of work specifically with LSVT LOUD and the work in Parkinson's. So, I came to Tucson. I was the onsite research clinician, this was actually my CF position to be able to do this and I would recruit subjects for the study. Dr. Ramig would fly in, sheÕd collect data, leave, I would stay, treat the participants in the study. 

She would fly back, collect data and we did this cadence for just over a year and then I ended up staying in Tucson for my Ph.D., which led to the application to children pediatric populations with LSVT LOUD. So, really, my career as a speech-language pathologist has been rooted in Parkinson's disease and expansion of that to pediatric populations, the fiscal and occupational therapy, itÕs really all IÕve ever done in my adult life.

[0:06:43.1] MBH: Well, what an exciting journey and such a contribution to our field for sure. Just a little note, I did not know because it was not in your bio that you went to college in Missouri. Are you from Missouri?

[0:06:54.4] CF: I actually grew up in Southern Illinois. So, not too far, a little town called Mount Vernon, Illinois. So, Southeast Missouri wasnÕt too far away and then headed out west.

[0:07:04.9] MBH: Yes, I know Mount Vernon. I grew up in Saint Louis.

[0:07:08.0] CF: Oh, no way. Oh okay, yes, I have many friends and colleagues and both from when my grade school as well as college who are still in the Saint Louis area. So, thatÕs great.

[0:07:20.1] MBH: Yeah, that is great. Well, small world, right?

[0:07:23.1] CF: Yup, yup.

[0:07:24.5] MBH: All right. So, you kind of went over it a little, you touched upon it, but take us through a timeline of the history of LSVT LOUD.

[0:07:32.5] CF: Absolutely. So, LSVT first of all, stands for, Lee Silverman Voice Treatment, and Mrs. Lee Silverman was a woman living with Parkinson's disease, and back in the late 1980s, her family had helped fund a center at Scottsdale Memorial Hospital in Arizona called the Lee Silverman Center for ParkinsonÕs and it was really a facility, I think ahead of its time. Patients would come and they would spend a month. 

They would get daily physical therapy, speech therapy, occupational therapy, exercise, nutrition, and it was at the center that they were looking for a person to come in and build the speech therapy program, and Dr. RamigÕs line of research had been in neurological voice and so they reached out to her and she came in along with one of her former students, Carolyn MeadŹBonitati. And they, together at that center, developed what really today is known as LSVT LOUD. 

So, once it got to a point, it really was a protocol, we were doing research on it and needed a name. It was named in honor of Mrs. Silverman, and one of the hallmark features of the treatment, which really, thereÕs several but one of them is its intensity and really, that intensity came out of that center where, at that time, patients were seeing up to five days a week, an hour each day, across four weeks. 

[0:09:05.5] MBH: Wow, wow, and I imagine people from all over the world came to that center or was it more of a local center?

[0:09:12.4] CF: Yeah, thatÕs a good question. I know that many people from Arizona. I had to go back and do a little research on that, how global it was, and individuals coming but like I said, it was really ahead of the time. It no longer exists today but different elements of work came out of that center and of course, the work of Dr. Ramig. She used the data she collected there, kind of as initial clinical research data that formed the foundation for her scientific career, 30 years of NIH funding, RO1 research grants, to really understand the treatments study, its efficacy, and all the work thatÕs been done.

[0:09:54.5] MBH: Wow, wow, that is great, and then, okay, so then, at what point did Š was LSVT BIG developed?

[0:10:01.0] CF: LSVT BIG came about. I think that collaboration probably started in the late 90s, probably early 2000s and that was a function of me getting my Ph.D. at the University of Arizona. I was in the laboratory, the lab of Dr. Jenny Hoi and Dr. Tom Hickson, which was a respiratory lab. Dr. Becky Farley was getting her Ph.D. she was a physical therapist in the neuroscience department. 

But she was actually Š came from pediatrics and she was interested in respiration and movement coordination and children. Well, just through cross-collaboration, I got interested in her work, she was interested in what we were doing in Parkinson's and when she finished her Ph.D., she really went Š made kind of the switch into Parkinson's and attended some of our lectures, attended LSVT LOUD training courses, and then wrote a grant. 

And so, we worked together to take all the elements of LSVT LOUD and transition them into a movement therapy and so it was really exciting and that was the beginning of that work, which of course has grown over the years.

[0:11:14.3] MBH: Absolutely. Now, does LSVT BIG follow the same protocol and intensity over the course of four weeks?

[0:11:21.0] CF: Yes, it follows all the exact same parameters, the three key features, which is the first one, we focus on amplitude for speech thatÕs voice, vocal loudness. For movement, itÕs bigger, so bigger movements. Then, it's intensive and high effort. So, both treatments are delivered in one-hour individual treatment sessions, four days a week across four weeks, daily homework exercise, daily carry-over, and then the third one is really focusing on sensory recalibration.

So, people with Parkinson's oftentimes, when they speak with a softer voice, they donÕt realize theyÕre as soft as they are. When we get them to speak louder, it oftentimes feels like theyÕre shouting or talking too loud and thatÕs something we have to retrain them to accept through treatment that when they feel too loud, itÕs within normal limits.

What was really fascinating is that when we began the work transitioning LOUD to BIG, we found the same phenomenon. Many people, they may know theyÕre moving smaller and slower but not to the extent that they are, and when we stimulate bigger movements that you and I would perceive as completely normal, they would say, ŅOh my gosh, I canÕt move like that, IÕm moving too big, people think IÕm crazy.Ó So, that sensory mismatch that Kinesthetic sensory mismatch during speech or during movement was really a hallmark feature that I think before LSVT LOUD, oftentimes limited some of the carryover of treatment effects because people would do what you want in the treatment room, ŅSure, IÕll speak louderÓ but walk up the door and say, ŅThat lady is crazy, that sounds ridiculous.Ó So, we reeled that down Š 

[0:13:15.4] MBH: IÕm not comfortable with that, yeah.

[0:13:17.1] CF: And that time to retrain those perceptions.

[0:13:20.4] MBH: Okay. All right, very interesting. Okay, so, neuroplasticity, itÕs based on the principles of neuroplasticity and intensive, holistic, and personalized. Would you agree those are the key features of both LSVT and LSVT LOUD? I mean, LSVT LOUD and LSVT BIG?

[0:13:41.4] CF: Yes, yes they are, and actually, so, the protocol, LSVT LOUD really came about predating some of the neuro Š you know, the Neuroplas literature as we know it today.

[0:13:52.6] MBH: Oh really?

[0:13:53.6] CF: Yeah. So, Dr. Ramig, CarolynŹBonitati. You know, that intensity was partly, initially as part of the nature of the facility they were in but they really recognized how important that is. They also recognized you know, the principles of motor learning, and so having sufficient repetitions, having task specificity. Those were very much a part of the protocol from very early on.

It was in the early 2000s, mid-2000s that some of the seminal work on plasticity and exercise in animal models of Parkinson's was starting to come out. You know, the 90s were the decade of the brain, where really neuroplasticity became something that the world got excited about and those publications came about and we could look at those principles, intensity, repetitions, specificity, saliency, complexity. 

And we had many of those components already, which I think was part of the reason the treatment was successful. While the core tenants didnÕt change, I do believe we made the treatment better with that knowledge. ThereÕs elements of it that we put more emphasis on and we continue to do that over time as science evolves, as our knowledge evolves, we can tweak the treatment how we teach it to therapists, how we deliver it to patients, to maximize all of those principles of plasticity that we know are so important for brain change.

So, I mentioned the dosage of intensity already but repetitions as well. So, even within each of the tasks that we do in therapy, whether they be the voice task, like sustaining vowel phonations, pitch glides, functional phrases, thereÕs many, many repetitions. So, we do lots of practice and then we take that and train it into functional speech because obviously, vowel phonations arenÕt really how we communicate.

[0:16:03.2] MBH: No, absolutely not.

[0:16:05.3] CF: Yeah, but we use that effort and loudness that we scale up in those exercises and then train it systematically into speech and thatÕs where we build complexity and difficulty. So, we start simple, short length of utterances, words, phrases, move to sentence level, paragraph level, conversational speech but we also then can make the communication situation more complex. 

So, it might be repetition or reading things off of a page but by the end, we may be outside of the treatment room, you know unfamiliar environments, background noise, dual tasking. So, depending upon the patientÕs ability, we continue to challenge them through all 16 sessions of treatment. The other big one is saliency. So, we know that the more salient, be it meaningful, be it something that youÕre successful at, materials are, activities are, they drive more plasticity.

So, even though the protocol, letÕs say, the core ingredients of LSVT LOUD are standardized, which is necessary because you canÕt study a protocol if you donÕt have elements that you can replicate across participants, across studies, we tailor and personalize many of the activities within that. So, for example, one of the functional phrase or one of the daily exercises are functional phrases. 

These are 10 words or phrases, a person says every day and we repeat that so itÕs very patient-driven, and we spend time to make sure, ŅDo you really say this every day? Is this something in your communication?Ó And we over-learn those as a cure trigger. So, when IÕm at home and IÕm like, ŅWhere are my glasses?Ó That may have been one of my functional phrases and that triggers me, ŅOh, IÕm supposed to Š did I say that 15 times in therapy every day? IÕm supposed to use my loud voice.Ó

And then, in the hierarchy practice, you're spending a lot of time either reading or doing structured speech tasks, and I honestly, in the beginning, we might have used more kind of dysarthria workbooks, materials like that, and now we say, absolutely not. Find out what the person loves to talk about. What are their functional goals? Are they related to work, are they related to hobbies, do they love hiking?

Do they love golf? What do they love? And we tailor all the materials that we use to their likes and interests so that, as theyÕre having to do all that motor practice, itÕs really about something thatÕs meaningful to them.

[0:18:59.7] MBH: Yeah, and as you said, saliency leads to neuroplasticity.

[0:19:04.6] CF: Right, right, and even when we add dual tasks. Now, not all patients can actually get to dual-tasks because it takes everything they have just to have that focus on LOUD, to be able to drive that effort for communication but when we get our early patients, they can get the kind of motor exercises pretty quickly but they need the challenge of, ŅWell, what happens in my daily life?Ó 

So, even for dual-tasking, ŅWell, what are your activities at work? Are you typing on the computer as you talk? Are you on the phone, what is it?Ó And then weÕll add that salient dual-tasking even within our treatment sessions.

[0:19:45.5] MBH: Wonderful. Well, that makes a lot of sense. All right. So, letÕs now talk about the five parameters that research has shown evidence of improvement with LSVT LOUD.

[0:19:56.9] CF: Yes, well, thereÕs lots of things. So Š 

[0:19:59.9] MBH: I know there are more than five but our learning objectives say, we have to cover five.

[0:20:04.3] CF: Five. All right, letÕs do it. 

[0:20:06.1] MBH: But we can go beyond five, we can go to 500 but letÕs at least cover five.

[0:20:11.0] CF: And yes, I will give you a good, solid five. I think the one that we have the most data on in almost every study, looking at LSVT Lab Quantifies, is vocal loudness typically measured through sound pressure level and obviously, thatÕs a target of treatment. People with Parkinson's disease are softer than healthy aging comparisons or non-Parkinson comparisons. 

So, measuring that through things like vocal sound pressure level, and across different tasks. So, we measure it through targeted tasks like sustained vowel phonation, things like that but also, un-targeted tasks. So, monologues, picture descriptions, things that we didnÕt actually practice within the treatment room. Across our studies, which there are many, we consistently see a statistically significant increase in vocal sound pressure level across most all of those tasks. 

We see those changes immediately post-treatment and weÕve actually documented up to six months, 12 months, and one initial study actually followed patients out to 24 months. So, two years after the initial dosage, and for some of them, their sound pressure level was still above their pretreatment levels. So, thatÕs very common. With vocal loudness, we also often times and had documented improvements in voice quality. 

So, many patients in addition to being soft, they may be a little hoarse, strained, instability and so through studies both measuring acoustic measures, harmonic to noise ratio, the vowel A, V, Q, I, the new voice index, and other measures weÕve measured quantitatively, improvements in vocal quality, and the many studies have also done listener perception, you know, do listeners perceive improvements in voice quality? 

So, thatÕs voice, the third IÕd say in that voice parameter is improvements in porosity. Some studies, the outcomes are a little bit variable, some of it is maybe what task-dependent or measure-dependent but for the most part, we see at least some improvement in fundamental frequency variability during speech because many patients are also quite monotone so they donÕt have that pitch inflection.

Now, what many of the exciting kind of serendipitous findings, after Dr. Ramig was publishing some of this initial work, putting it out there, we were training clinicians, they would say or they watch videos and presentations and theyÕd say, ŅYeah, but, what about their articulation? It sounds so much better. What about their face? Oh my gosh, their face is so much more expressive. What about swallowing?Ó

And so, in another phase of research, started to look systematically at what we call kind of cross-system effects, and what we found is, really, the voice and vocal loudness serves as a global variable, and when we drive that effort, even in a non-disordered system, we can get spill over to other elements of speech. So, weÕve documented improvements in things like speech articulation through things like vowel triangles, and seeing an increase where there was pretreatment, more centralization.

WeÕve documented it in speech intelligibility and in fact, recently, two studies were published that were both randomized control trials, and what was interesting in these studies are really novel was that noise was added, both pre and post, to the speech intelligibility ratings. So, it added a little more real-world context because sometimes, when we rate speech intelligibility, we turn up volume, we make everything audible and then rate the intelligibility of speech. 

But for people with ParkinsonÕs, their lack of audibility, their soft voice, is what contributes to their lack of intelligibility. So, when you kind of correct for that in some way, I think it better unmasked the pretreatment deficits and then allowed us to look at how those changes occurred post-treatment and Dr. Ramig, Dr. Erika Levy published some of this work that was really Š as I said, quite a novel way to look at speech intelligibility.
 
[0:24:57.7] MBH: So, are you saying you added background noise?

[0:25:00.5] CF: To the listener, so in the speech intelligibility task, not while they were speaking but as the listeners were listening to the samples, that kind of noise was added. There was a second study that looked at, it was the diagnostic rhyme test. So, a little bit more words, but very systematic way, they add background noise in different kinds of background noise like babble noise, mall noise, and again, had listeners rate speech intelligibility. 

So, we were able to show as compared to an equally intensive speech treatment for ParkinsonÕs, LSVT LOUD, which focused on voice, LSVT Artic, which put all the effort into annunciation and articulation, and when we looked at speech intelligibility, the one that focused on voice had greater outcomes, more improvements in speech intelligibility in those conditions post-treatment.

[0:26:02.5] MBH: Okay. So, your LSVT Artic was your control.

[0:26:06.4] CF: It was a comparison.

[0:26:08.1] MBH: Specifically designed comparison protocol.

[0:26:10.4] CF: Yup. And we didnÕt know, we expected because in some of the studies before we did that, that level of comparison that we saw these changes in articulation, facial expression, that maybe if we drive all the effort there, we can see greater improvement. So, itÕs really trying to tease apart, ŅIs it just intensity and you do anything intensity at any subsystem, will you see these kinds of changes or is it intensity and the target is special?Ó

So, our research to date because weÕve done a comparison voice, which really is respiratory and laryngeal, versus respiratory only, that was the first randomized control trial, and for ParkinsonÕs, the voice was the superior treatment, and then the next round was the voice compared to high effort artic. So, thatÕs the kind of science that Dr. Ramig really drove, where systematically, unraveling the onion to say, ŅWhat is the most important piece of treatment for this population to get the effects that weÕre seeing?Ó

And, thereÕs still more to unravel, you know? WeÕve got as far as weÕve gotten but thereÕs still studies ongoing and I think things we can learn. So, back to your initial question. So far, we have vocal loudness, we have intonation, we have voice quality, articulation, speech intelligibility. We have actually, documented in a very systematic way, facial expression and these were studies where we followed a protocol of Dr. Joan Borod at Queens College New York, who is a facial expression expert and the process was the facts which is facial action coding.

So, the data weÕre collected in Denver in our lab, all the videos were blinded, mixed, et cetera, their laboratory analyzed it, and again, it was the comparison of LSVT LOUD, LSVT Artic, ParkinsonÕs with no treatment, over time, and then I believe, people without ParkinsonÕs and in those, we saw all the ParkinsonÕs group had reduced facial expression, compared to non-ParkinsonÕs pretreatment but only the group that got LSVT LOUD had improvement in facial expression post-treatment.

[0:28:37.1] MBH: ThatÕs amazing. I wouldnÕt have guessed that LSVT Artic, because when weÕre Š just like what you said now, when youÕre focusing on your articulation, your facial expression almost automatically becomes more intense, brighter.

[0:28:53.2] CF: Yeah, and so the thought there and I think what the authors describe was really, the voice is a very Š itÕs tied to emotion. ItÕs phylogenetically old and when you target the voice and youÕre driving that, youÕre driving effort, emotion, and I think thatÕs really what drove those facial expression changes that you canÕt fake in a sense, you know?

And you know how people study and theyÕre like, ŅWell, you can fake certain expressions, others you canÕt.Ó And I think when it was coming from the voice and the voice driving was really what resulted in those changes we saw.

[0:29:31.0] MBH: Well, that is just fascinating. What fascinating work. I love hearing about all of this research.

[0:29:36.1] CF: Yeah. The other one that I will mention, and then we can move on.

[0:29:40.7] MBH: No, keep going.

[0:29:42.3] CF: And we could share links to all the studies because it really is a wide body of work for many, many people have contributed over the years but itÕs the neural imaging and this really has gone through evolution from the first small study through the most recent study, which looked for the first time at a comparative treatment group. So, LSVT LOUD versus LSVT Artic, versus people with ParkinsonÕs who did not receive treatment, and it looked at them pre, immediately, post, and six months later.

So, this was PET imaging. Again, we wanted to see, did the changes we saw in the previous imaging studies with LSVT, was that a function of just activity, right? Or, was it something specific to the target? In post-treatment, we saw changes kind of what you would expect in motor areas with both LOUD, both Artic, but the uniqueness with LSVT LOUD was this recruitment of right-sided areas, really related to monitoring prosodic aspects of speech, and weÕve seen that right side shift in every imaging study. 

WeÕve even seen it in the kids with cerebral palsy that we treated and so we see that as potentially neurophysiological phenomenon of calibration, where weÕre retraining people to really monitor how it hears, how it sounds to them when we hit that target louder voice.

[0:31:17.7] MBH: Well, that is just fascinating.

[0:31:19.5] CF: Yeah, the other interesting thing of the speech imaging study in the untreated group is that from pre to post, from that post to six months, they saw continued deterioration of the speech motor network. So, even in six monthsÕ time, changes are happening related to speech, and so that is our big marquee point early, early, early treatments. Even sometimes maybe before itÕs so perceptible because changes are happening. 

And the sooner we can improve the system, perhaps make it more resistant to the deterioration that is happening, patients may have better outcomes than may be able to maintain that over time.

[0:32:06.6] MBH: I love the way that you said resistance, because Š or resistant because IÕve said, well, to earlier onset or newly diagnosed, ŅWell, this is, even though you havenÕt experienced voice changes now, this is kind of an insurance policy.Ó And that seems to be Š they seem to be relatable. Like that seems to be relatable to them but I really like the term resistant, making it resistant to the vocal changes that are part of the disease process, yeah. 

[0:32:35.8] CF: Yeah. 

[0:32:36.2] MBH: ThatÕs wonderful. Okay, so probably most of the SLPs listening are familiar with LSVT LOUD for ParkinsonÕs but in conversations with some different people who have said, ŅOh, IÕm meeting interviews at the Dr. Cynthia Fox, IÕm so excited!Ó Did you know that LSVT can be used for a lot of other diagnoses and most people were not aware of that? So, I am really excited to dive into that. 

[0:33:04.8] CF: Absolutely. Well, itÕs an evolution, right? So, also as you go through phases of treatment research, you have phase one, phase two where youÕre sort of seeing, ŅIs there any treatment effect?Ó YouÕre kind of fine-tuning your research protocol. Stage three really is the randomized controlled trial, ŅCan you establish efficacy?Ó And part of stage four in addition to clinical implementation is oftentimes, once a treatment has been found to be efficacious, safe, is looking at it for other diagnoses. 

And I think that weÕre very familiar with this, for example, in the neuropharmacological work. In fact, oftentimes, the best treatment for something didnÕt start with the research looking at it for that specific purpose. So, we began this work really back in the early 90s just looking at case studies of people who have different diagnoses, however, as components of their dysarthria, thereÕs a respiratory laryngeal component and almost every dysarthria has some voice component. 

It may not be always soft voice but it might be soft voice, breathy voice, sometimes itÕs instability, and not even that the voice is too soft but itÕs not stable. I know some in our pediatric populations, itÕs sometimes too loud or too soft, and so really the target of LSVT LOUD is always healthy vocal loudness. For ParkinsonÕs, that means weÕve got to scale it up but for other diagnoses, it may be stabilizing, it may be strengthening. We began to look at some of these other diagnoses. All of these other diagnoses do not have yet randomized controlled trials, so our levels of evidence are different but we do have case studies, really well-structured single-subject designs, and in some cases, small group designs. In a range of things such as dysarthria, secondary to multiple sclerosis, a really interesting one is ataxic dysarthria and I think that one is so interesting because we tend to think of that in a very articulatory sense. 

You know, thereÕs slurred speech, we should be working on that and thereÕs not good modulation, too loud, too soft but by focusing on the voice, we were able to get stability and improve not only voice but also in some cases, speech intelligibility, parameters of articulatory function. There is a really interesting case study looking at laryngeal dystonia or spasmatic dysphonia. 

This case was led by Mindy, I know Š oh gosh, I feel terrible, theyÕre about to publish it I believe. The videos are on YouTube but it was a woman with laryngeal dystonia, interesting case, she was referred. SheÕd had Botox, so she was getting kind of the traditional medical treatments, Mindy Schnell, thank you. I was going to Š 

[0:36:17.5] MBH: DonÕt you love it? Now, we can move on. 

[0:36:19.9] CF: Yes, yes but the case is so interesting, so had the Botox and wasnÕt getting as much improvement as she would like, so it was her neurologist who referred her to LSVT LOUD, and her neurologist had said she had other clients with laryngeal dystonia who she had seen have some benefit from it. So, the client reached out, I believe to several people. Some people were not LSVT clinicians, weÕre really sure, werenÕt ready to take that on. 

But Mindy and students at her university did and it was really a beautiful outcome. They continued to follow up, do tune-up sessions and she really had a wonderful voice, not full recovery but improvement in her voice that she was able to go back to work and really reengage in communication in her life. So, sometimes, with we say, you know, LSVT is a great tool in your clinical bag. 

If you have people with ParkinsonÕs, it is the speech treatment with the most research and the highest level of evidence but when these other sort of cases come your way, it may be a tool that could be helpful. In our training and certification courses, we walk people through you know, how to do sting and ability testing, kind of what are the decision-making parameters, how to do trial treatment, and kind of go through that process. 

In some cases, it doesnÕt work. In other cases, weÕve had some outcomes that have really helped different patients with different diagnoses improve their voice and improve their communication. 

[0:38:04.0] MBH: And has this spasmatic dysphonia, that case that you mentioned and the research, has that been replicated? 

[0:38:09.9] CF: In a research context, I donÕt believe so but in a clinical context, yes. WeÕve had other therapists, you know certainly report back to us that in certain individuals theyÕve also seen some improvement, and many times, itÕs co-treatment in the sense that it may be Botox injections plus the behavioral treatment. In some cases, it may be the behavioral treatment as a monotherapy. So, we would take it on a case-by-case basis in those situations for sure. 

[0:38:45.3] MBH: Okay, how fascinating. Okay, well, we have a whole list of different diagnoses here, so do you want me to just yell out a diagnosis and you can tell us about it or do you want to go through the list yourself? 

[0:38:56.9] CF: Yeah. Yeah, well, so stroke, dysarthria, secondary to stroke, weÕve had Š thereÕs Dr. Leslie Mahler has published two studies, again series of case studies and single subject design. Most of them had not just dysarthria but also maybe some apraxia and also aphasia and weÕve seen some nice outcomes in the dysarthria component. I know one of the patients I treated early on, he was three years post-stroke. 

So, this is not a chronic or an acute treatment, right? ThereÕs a lot of other things to be dealt with first, cognition, language, oftentimes swallowing, but he was three years post-stroke and he was in an aphasia group of Dr. Audrey Holland at that time at the University of Arizona and was making nice gains in his language so that now, the dysarthria was actually becoming a barrier to communication. 

So, when the aphasia clinic went on break for the summer, he came and we did a month of LSVT LOUD and it was fascinating and he got a great voice, didnÕt fix the other, the aphasia, he went back to the aphasia groups but he could say his confidence improved, his loudness, his voice quality, and he had a little bit of that spill over to articulation as well. Multiple sclerosis, we published from our research group some case studies. 

ThereÕs been a group in Italy that actually recently has published some group data and maybe one of those might be a randomized controlled trial showing some you know, so a larger dataset Italian Italian-speaking individuals with MS showing some improvement. I mentioned ataxia, we have one detailed case, a single-subject design. Anja Lowit, out of the UK, recently published another paper and is doing continued research with ataxia. 

I mentioned laryngeal dystonia, thereÕs a publication on just aging voice, presbyphonia, and thereÕs been some case studies presented with the traumatic brain injury as well. 

[0:41:09.8] MBH: Okay, as far as presbyphonia goes, I think thereÕs really a strong application there. 

[0:41:14.2] CF: Yes, absolutely. Absolutely and you know, we know that aging voice can get softer and so when you take something that has an intensive exercise, motor learning-based protocol to it, it can definitely make a difference. I recall one of our studies when we began to look at aging voice, I actually had a couple. 

They were both in the study, so one of them had ParkinsonÕs, one of them didnÕt but they both came, and I do one hour and another hour and it was great because theyÕd go home, theyÕd practice together, theyÕd calibrate each other, and both came out with some nice improvements. 

[0:41:54.2] MBH: Yeah, thatÕs great, so fun. Okay, well, how about TBI?

[0:41:57.7] CF: Yeah, TBI would definitely also be a case-by-case basis. So, we would look again, there was a case study or maybe a single Š a couple of case studies published a number of years ago. I think [Wenky 0:42:11.3] is the first author, Dr. Elizabeth Ward out of Australia, and so in that case, it would be, once again, assessing the dysarthria secondary to the TBI. Most likely, the dysarthria treatment is probably in the chronic phase, probably not acute. 

In terms of determining whether it would be appropriate, again, it would be going through stimulability type of assessment and some trial treatment but we would expect to see for seeing results improvement in vocal loudness, vocal quality, as well as some improvements in articulation. Then weÕve also had some publications in adults with Down syndrome and adults with cerebral palsy. 

So, we think about those in our pediatric application but many of these individuals have communication challenges, dysarthria into adulthood as well and those were some interesting case studies.

[0:43:09.0] MBH: Yes, can you tell us a little bit about either of those? 

[0:43:11.9] CF: Yeah. Again, looking at the dysarthria associated with each of them. You know, the individuals with down syndrome wanted the things that we see. It was published in the study but we were seeing as therapists today do it is the improvement in speech clarity. So, even though again, that focuses on voice, establishing that good respiratory laryngeal coordination. When have that vocal effort, we get that spillover into that speech clarity, which can help some of these individuals when theyÕre in their occupation, doing their jobs, communicating at home. 

ItÕs where really those ten functional phrases, in particular for some of them who are working come into play. TheyÕre so over-learned, we get very good at without cues to be able to implement those phrases using the stronger voice and improvements in that speech clarity and so much I think across all of these individuals we see that improvement in confidence with communication as well. 

[0:44:17.3] MBH: Which is really what this is all about, right? 

[0:44:20.0] CF: Right, yeah. 

[0:44:21.1] MBH: Yeah, have you had or have any of your studies have you examined confidence from a research perspective? 

[0:44:28.3] CF: Right, so we have looked at from our ParkinsonÕs studies also at some of these single subject design case studies a range of patient-reported outcomes. Probably the most common one that was used in ParkinsonÕs was the voice handicap index and many studies have reported improvements in that. The most recent randomized controlled trial, which was Artic versus LOUD, with our primary outcome variable being vocal sound and pressure level. 

But the secondary outcome variable was the modified communicative effectiveness index showing improvements and what was interesting was in that study, both LOUD and Artic had statistically significant improvements immediately post-treatment but when we looked at the six-month-later mark, the artic group had gone back almost to baseline and only the LOUD group maintained that improvement. 

So, both treatments had an immediate effect but the LSVT LOUD group had that lasting effect. In some of our pediatric studies, we have parent ratings, parent perceptual ratings of their perception of how much their child participates in conversation, initiates conversation, and so through some of those perceptual measures for some of the children we see higher ratings or improvements there. 

[0:46:00.2] MBH: ThatÕs great and how does the pediatric protocol differ from the adult protocol? 

[0:46:06.1] CF: Right, so the pediatric work in general came about through another collaboration also at the University of Arizona. So, the University of Colorado, it was Dr. Ramig's home base, and the National Center for Voice and Speech, which really housed the ParkinsonÕs studies, and then in Arizona was some of our offshoots to other populations, LSVT BIG and the pediatric work. 

And so, once again, back in my lab, my dissertation lab, Dr. Carol Boliek was there and she was doing respiratory speech breathing studies in children without cerebral palsy, children with cerebral palsy, and also looking at infants and babies at risk for cerebral palsy and following them over time. So, we were talking and sheÕs like, ŅYou know, so many of these kids have just such reduced respiratory drive, soft voices.Ó 

And so we started talking about, ŅI donÕt know. How would children respond to something like intensive voice treatment. Would they do the exercises?Ó And so in the spirit of research, she came to me one day. SheÕs like, ŅI think I have the kiddo, we should give it a try.Ó So, did our pre-treatment data collection, he actually had Š he was three years eleven months. 

[0:47:28.4] MBH: Young. 

[0:47:28.8] CF: Yeah, young, predominantly dyskinetic type of CP and we just gave it a try. I honestly thought, ŅHmm, I donÕt know.Ó You know, when I sat down, I was like, ŅDo what I do, ahh.Ó I figured theyÕd just kind of look at me but it was amazing. We did that pilot study and then that was the data that I then used. So actually, my dissertation work was looking at LSVT LOUD in five children with predominantly spastic cerebral palsy in a very Š in a systematic, single-subject design. 

But to your question, the treatment is exactly the same, all the same ingredients. We do the daily exercises, long ahs, high-low ahs, functional phrases, we then train that loudness systematically into speech. Some of these kids, the length of utterance may not get longer and longer but we can get more complex in the type of communication situations. They do individual one-hour treatment sessions four days a week for four weeks.

They have the daily homework, daily carryover, which involves family to help, you know facilitate that at home and itÕs impressive how hard these kids will work. I think some of the Š and not every day. Anybody who works in pediatrics, not every day. 

[0:48:55.3] MBH: Not every day. 

[0:48:56.6] CF: The beauty of the intensity is weÕre gradually building upon day after day so we see outcomes more quickly because itÕs not like one day, a whole week goes by and then we see them again. The kids see the outcome, the family sees the outcomes quickly, and that becomes self-motivating. ItÕs very tailored again, personalized. So what does it that the kid likes, the children want to talk about? 

Things like that, those are incorporated into the session. ItÕs very, very, very much intrinsic motivation, so we really try to drive that saliency, ŅOh my gosh, feel how that feels? Oh, your voice is beautiful. Listen to how your voice sounds, listen to your speech when you use those.Ó So, they do buy in and I think all the clinicians who have done LSVT with kids are surprised by it, like surprised how hard the kids will work and the buy-in that we get to the intensity of the protocol. 

ThereÕs also a finite time, a beginning, and an end. So, itÕs more the model of intensive bouts of therapy, then take a break. Maybe we do tune-up sessions or then they reconvene some other types of speech therapy but to have that intensive bout of treatment and then being able to take breaks with it has been great. 

[0:50:27.5] MBH: Now, do you ever have patients who do the intensive bout and you know because children are growing, right? And changing, developing, so do the intensive bout, take a six-month break, and then do a second one month both protocol intensive treatment? 

[0:50:43.8] CF: Right, they may not need a whole month again. They may just need some tune-up sessions. You know, theyÕve grown, their physiology has changed, or an emotional motivation has changed. TheyÕre more motivated to communicate now and so that gets them back into therapy and this is true actually for anybody who receives LSVT LOUD, ParkinsonÕs, non-ParkinsonÕs, adult, pediatric. 

Our goal with that one month of treatment is that voice habits last at least six months without any additional treatment. We have a homework routine, we try to establish that very rigidly. Maybe rigid is the wrong word, very intensely, so that after treatment they continue. Our research has shown up to two years but realistically, we say, ŅHey, they should last at least six months.Ó And then it becomes kind of a check-in. 

You know, itÕs six months check-in, that could be a simple phone call, a, ŅHow are you doing?Ó Okay, some people are great, they may be even better than they were post-treatment. ŅGreat, IÕll check in again in six months.Ó Other people may slip a little bit and we say, ŅOkay, letÕs come back in, letÕs do a quick reassessment, letÕs do some tune-up sessions.Ó And the tune-ups can be you know, two sessions, six sessions. 

If weÕve lost touch with the patient and maybe a couple of years have gone, maybe we do need to redo that entire one month of therapy. 

[0:52:14.8] MBH: Okay, what are your Š especially with pediatrics, do you have any suggestions on getting insurance to cover one full hour of therapy in this intensive program for four weeks?

[0:52:27.4] CF: ItÕs not been there as long as we have in the adult but the therapists who have been using it have had some pretty good success with multiple levels. It is a hard question as you know always because it depends. There can be state-to-state variability, there can be you know, insurance plan variability but we always recommend checking, getting pre-authorization, sometimes the referral from the pediatrician or ENT. 

It may come from either and then also providing the documentation of changes so we could document improvements that are ongoing as well as being able to provide the research and while we donÕt have the randomized controlled trials, for the pediatrics we have research at the acoustic physiological perceptual and neural level, so we have a depth of research even if we donÕt have the large groups and comparative studies yet. So, using all those tools can increase the likelihood of getting reimbursement for the treatment. 

[0:53:40.6] MBH: Okay, and as far as pediatrics go, have you had anyone do this in a school setting, at a school-based SLP? 

[0:53:48.6] CF: Yes, we have and weÕve actually had again, these are case-by-case basis. In one case, it was written into the IEP and the school district actually paid for the therapist to get the training and they were able to deliver the treatment. Now, because of its intensity, it does not work in all school settings and I know when we went in the research setting into the schools, some of the kids we did early in the morning, sometimes we did it at kind of in the afternoon, lunch break.

The other way many people have done it is during summer break and they kind of do a camp. While the treatment is individual still, itÕs like, ŅOkay, weÕre doing a bunch of kids during this one month, during summer break they come in and get the treatment during the times off.Ó So, weÕve had a range, weÕve had a range of success. Not always but we certainly have had some implementation in the school settings. 

[0:54:48.4] MBH: Excellent, that is really exciting work. All right, well, what is the future direction of LSVT LOUD? 

[0:54:55.4] CF: Yes, well, always research. I mean, there is Dr. Ramig has data from the last RO1 grant that is still being analyzed, so thereÕs levels of that that is ongoing. WeÕre continuing to look towards technology and how can technology help us in the implementation of intensive protocols and I think this is not just for LSVT but we see across all disciplines, speech PTOT in neuro intensity really drives change. 

But it comes against, ŅOh, youÕve got effective intensive treatments.Ó Traditionally in our clinic, we havenÕt done that way and so how can we utilize technology to facilitate that, both through telepractice and Dr. Deborah Theodoros at the University of Queensland in Australia published many studies, her and her colleague, Dr. Liz Ward, an LSVT delivered via telepractice showing itÕs equivalent in outcomes to all in-person, face to face. 

WeÕve developed a software program, the LSVT Coach. In a research study led by Angela Halpern on our team, we showed that nine of the 16 sessions were done in the clinic face to face, seven of the sessions, they used the software program at home on their own to make the 16 sessions and outcomes were comparable as good immediately post-treatment and at the six-month mark. 

So, technology is a really wonderful tool when developed in a way that is tailored to the treatment program, that may help us with the implementation barrier. So, weÕre excited about that. We continue to develop the multidisciplinary treatment working collectively with PTs, OTs, and SLPs to deliver both LOUD and BIG, as well as training, and so our training continues to expand both in the US but also internationally. 

We have our first fully translated online LSVT training and certification course and of course, we do virtual live in-person training courses all around the world. In fact, weÕre doing one this weekend thatÕs coming up with Germany but IÕll be in the US and weÕll do translation through Zoom and the outreach to help as many people in the world who would benefit from access to this treatment. 

[0:57:33.2] MBH: Okay, so fascinating. So, you will be conducting the class and then youÕll have an interpreter?

[0:57:39.0] CF: Yes. 

[0:57:39.5] MBH: Interpreting, okay, and then using all German language protocols. 

[0:57:44.1] CF: Yes. So, the slides, all of our materials are translated into German and we actually have a very large German team both for LSVT BIG and LSVT LOUD. Germany is one of the countries when we started training there, I believe in 2001, it had that same type of initial implementation barrier, insurance only paid for 30-minute sessions. Fast forward to now, the LSVT protocol for speech is fully reimbursed, the one-hour treatment, and that was really driven by the science, the research data, the published outcomes, and so that was an evolution over time that has been very positive in implementing it effectively in a different country. 

[0:58:34.4] MBH: Now, if someone only was covered for 45-minute sessions, what is your suggestion to an LSVT-trained clinician? 

[0:58:42.8] CF: Right. The decision of 45-minute sessions is typically an administrative decision, be it for scheduling, be it for whatever reason, and we typically go to the powers that be and make our case for the one-hour treatment session. The research data, the power of the science when weÕve been effective we oftentimes tell clinicians, ask for, ŅGive me two patients. Let me show you what this treatment can do in terms of positive outcomes.Ó 

ŅWhat that does for our organization, in terms of quality of care, and these individuals are going to be coming back because they may need PT, OT, other speech services.Ó And this successful scheduling bit was oftentimes, itÕs a block. So, maybe thereÕs one one-hour block thatÕs always for LSVT LOUD in the morning and maybe a one-hour block thatÕs always for the LSVT clients in the afternoon. 

So, there are facilities who successfully utilize it per protocol one-hour sessions, so it just Š it takes sometimes a little bit of education, a little bit of persistence to give the patients the dosage that has data that says going to improve facial expression, your neuro functioning, your articulation, thereÕs so much about it that patients deserve to be able to have access to. 

[1:00:17.3] MBH: They certainly do deserve to have access to it. All right, weÕre about out of time and then you said you would share some resources. So, we can put those in the show notes or we can put those as a handout for people when they take the course. 

[1:00:31.7] CF: Absolutely. I have links to all of the research. So, if youÕd like to look at the research and anything thatÕs open access, you can download the PDF files so you can have those studies with you. Also links to some videos and just where you can learn more and explore more about any aspects of LSVT LOUD for ParkinsonÕs, LSVT BIG, or you know, our LSVT LOUD for kids. We call it for kids but like I said, itÕs the same protocol. We just adapt the activities to be kid-friendly. 

[1:01:07.8] MBH: Okay. Okay, now, I am LSVT LOUD certified but I am not certified for children, for pediatric. So, what would be the process for someone like me? 

[1:01:18.2] CF: You can once Š the certification is the same. So, in the past, we, if you took the course, the LSVT LOUD training course, itÕs really geared towards ParkinsonÕs and adult populations and then we developed a short two-and-a-half, three-hour pediatric course that if youÕve taken the adult course, this just gives you tips, ideas on how to, again, do those adaptations for pediatric populations. So, thatÕs one route to be able to do that.

Honestly, if you didnÕt even take the pediatric course, you can treat kids. You know, a lot of people treat adults and kids and make those adaptations to the activities. We did though start having a lot of therapists who never worked with adults and theyÕre like, ŅI donÕt really want to take that adult course.Ó So, I believe two years ago or a year and a half ago, we developed an LSVT LOUD for Kids training and certification course. 

So, for those individuals who fully come at treatment from a pediatric perspective, that would be one option and so all the example videos have children, adolescents in them, and we just teach it through a pediatric lens. So, we say the training and certification is the same. One course teaches it through the adult lens, one course teaches it through the pediatric lens. The skills you learn in either are transferable. 

[1:02:48.7] MBH: Okay. 

[1:02:49.2] CF: So, I hope that makes sense. 

[1:02:50.5] MBH: Yes, it does, absolutely. Thank you for that clarification. Well, I hate to say it but we are about out of time. It was so wonderful to talk with you, Dr. Cynthia Fox, and we really appreciate your contributions to our field. I mean, they are immeasurable when you think of all the people with ParkinsonÕs and other diagnoses who have benefited from LSVT LOUD and BIG, it truly is amazing. So, thank you for all the work that youÕve done, and keep up the good work. 

[1:03:21.1] CF: Well, thank you for having me, and thank you to all the listeners out there. Thank you for all the work that you do and I really appreciate you giving me the opportunity to share in more detail some of the work weÕve done and the journey that weÕve had. 

[1:03:36.6] MBH: Well, wonderful, and we look forward at SpeechTherapyPD.com to having you back. So, until the next time, keep up the good work. 

[1:03:44.7] CF: Thanks. 

[1:03:45.3] MBH: Okay, take care. Bye-bye. 

[END OF INTERVIEW]

[1:03:47.5] 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. Thanks for your positive reviews and support. I would love for you to write a quick review and subscribe. Keep up the good work.

[END] 
KFSP 81		Transcript

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